Sex: female
Age: 35 years
History
Remitted with lower abdominal pain, diarrhoea, and weight loss of 5kg in the last 3 months. During sonography a cystic mass in the pelvis was found, the patient was admitted to the hospital.
Laboratory data
Wbc 12/nl, Platelets 180.000/ccm, Hb 103 g/l, CRP negative.
Physical findings
Palpable lower abdominal mass.
Case text
Sonography was performed and a cystic mass in the pelvis was found, the patient was admitted to the hospital.
Image 1
Colon-contrast-enema with barium.
Lateral view in monocontrast (double contrast with air was not tolerated by the patient due to discomfort).
Image 2-5
MRI of the pelvis with intravenous and rectal contrast agent.
Image 1: Sagittal T2-weighted image (TR 2176, TE 80).
Image 2: Axial T2-weighted image (TR 2400, TE 80)
Image 3: Axial contrast-enhanced T1-weighted image (Selective Partial Inversion Recovery =
SPIR fatsat, TR 450, TE 12)
Image 4: Axial contrast-enhanced T1-weighted image (SPIR fatsat, TR 450, TE 12)
Image 1
1. What is the abnormality present in this examination?
A dorsal convex slight impression of the rectosigmoid was seen. Infiltration of the rectum was not seen, but can not be excluded.
2. What is the next diagnostic step?
CT scan or MRI of the pelvis with rectal contrast media.
Image 2-5
3. What is the abnormality present in this examination?
A partly solid and partly cystic mass between the bladder and rectum cranial of the uterus was found. The tumour was enhanced using contrast media, and best-seen in fat saturated imaging. The cystic parts could be distinguished from bowel loops due to their strong hypointensity.
4. Was the rectum infiltrated or not?
This question can clearly be answered with yes. The rectal lumen was very hypointense due to the superparamagnetic ironoxide particles, and therefore the contrast to the mural structures of the rectum was high. The ventral face of the rectum was thickened and enhanced using contrast media.
5. Were there therapeutic consequence?
The rectum had also to be resected. The operation was planned by both gynaecologists and abdominal surgeons.
Final diagnosis
Endometriosis
Differential diagnosis
- Ovarian carcinoma
- Cystic sarcoma
Discussion
The evaluation of the degree of infiltration of neighbouring organs, like the bladder and rectum, is of major importance in the therapy and prognosis in ovarial carcinoma and endometriosis. Especially the differentiation of adherence of the tumour to, or infiltration into, the rectal wall can be very difficult to determine. MRI as the best imaging method in the pelvis is often hampered by artifacts through the bowel tract and its content. The contrast between bowel wall and content is often too low to make an exact diagnosis of tumour wall infiltration. When the rectal lumen is filled with negative contrast media particles = Abdoscan), the lumen is distended and a good contrast from the wall is achieved. Infiltration can clearly be depicted, especially when an intravenous contrast media is given (the infiltrated wall is enhancing stronger than normal bowel wall). For these types of gynaecological questions the use of a negative contrast media for the bowel is a major advantage. In our patient the diagnosis was surgically proven.