Gynecologic Pelvic Mass:

Gynecologic Pelvic Mass:

• Large uterine fibroid.
• Ovarian mass.
  • Coelomic epithelial tumors: These tumors, which originate from the coelomic epithelium, constitute 80-85% of all ovarian tumors.
    • Serous cystadenoma and mucinous cystadenoma: Fifteen to 20% are malignant.
    • Endometrioid type and clear cell: Ninety-five to 98% are malignant.
    • Brenner tumor: Two percent are malignant.
  • Germ cell tumors: These tumors originate from the germ cell and constitute 10-15% of all ovarian tumors. All are malignant except mature teratomas and gonadoblastomas, which are always benign.
    • Mature teratoma.
    • Immature teratoma.
    • Dysgerminoma.
    • Gonadoblastoma.
    • Endodermal sinus.
    • Embryonal carcinoma.
    • Nongestational choriocarcinoma.
  • Gonadal-stromal cell tumors constitute 3-5% of all tumors.
    • Granulosa cell.
    • Fibroma: Fewer than 5% are malignant.
    • Thecoma: Fewer than 5% are malignant.
    • Sertoli-Leydig cell: Fewer than 5% are malignant.
    • Lipid cell type: Thirty percent are malignant.
    • Gynandroblastoma: One hundred percent are malignant.

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Meigs syndrome:

Meigs syndrome:

• Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. The ovarian tumor in Meigs syndrome is a fibroma.
• Pseudo-Meigs syndrome consists of pleural effusion, ascites, and benign tumors of the ovary other than fibromas. These benign tumors include those of the fallopian tube or uterus and mature teratomas, struma ovarii, and ovarian leiomyomas.
• Pseudo-pseudo Meigs syndrome includes patients with systemic lupus erythematosus and enlarged ovaries.
• Tumor marker serum levels of CA125 can be elevated in Meigs syndrome, but the degree of elevation does not correlate with malignancy.
• Etiology of ascitic fluid: Pathophysiology of ascites in Meigs syndrome is speculative: considerations include irritation of the peritoneum, secretion form the mass itself, direct pressure on surrounding lymphatics or vessels, hormonal stimulation, and tumor torsion.
• Origin of pleural effusion: The etiology of pleural effusion is unclear. Current theory is that ascitic fluid is transferred via transdiaphragmatic lymphatic channels.
• Ascitic fluid and pleural fluid in Meigs syndrome can be either transudative or exudative.
• Ovarian tumors are more prevalent in upper socioeconomic groups. Ovarian fibroma is found in 2-5% of surgically removed ovarian tumors, and Meigs syndrome is observed in about 1%. Ascites is present in 10-15% of those with ovarian fibroma and hydrothorax in 1%, especially with larger lesions.
• Although Meigs syndrome mimics a malignant condition, it is a benign disease and has a very good prognosis if properly managed. Life expectancy after surgical removal of the tumor mirrors that of the general population.
• The incidence of ovarian tumor begins to increase in the third decade and increases progressively to peak in the seventh decade. Meigs syndrome in prepubertal girls with benign teratomas and cystadenomas has been reported.

References:

1. Jones OW, Surwit EA: Meigs syndrome and elevated CA 125. Obstet Gynecol 1989 Mar; 73(3 Pt 2): 520-1[Medline].
2. Lacson AG, Alrabeeah A, Gillis DA et al: Secondary massive ovarian edema with Meigs syndrome. Am J Clin Pathol 1989 May; 91(5): 597-603[Medline].
3. Lin JY, Angel C, Sickel JZ: Meigs syndrome with elevated serum CA 125. Obstet Gynecol 1992 Sep; 80(3 Pt 2): 563-6[Medline].
4. Meigs JV, Cass JW: Fibroma of the ovary with ascites and hydrothorax: with a report of seven cases. Am J Obstet Gynecol 1937; 33: 249-267.

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Extrahepatic biliary atresia:

Extrahepatic biliary atresia:

• Extrahepatic biliary atresia is obliteration or discontinuity of the bile ducts, usually in the region of the porta (i.e., hepatic or common bile ducts).
• Usually acquired postnatally at approximately 2 – 8 weeks of age.
  • Progressive inflammation of biliary system associated with infections such as CMV, EBV, reovirus, rotavirus.
• Less often congenital and seen with other anomalies such as asplenia or situs inversus.
• Cholestasis leads to jaundice in baby several weeks old. Differential at this age is neonatal hepatitis versus biliary atresia.
• On ultrasound, may see the following:
  • No gallbladder or small, irregular gallbladder.
  • Triangular fibrous (hyper echoic) remnant measuring at least 4 mm in the region of the porta hepatis. This represents the obliterated bile duct.
  • Ultrasound is not very sensitive.
• On nuclear hepatobiliary imaging, see normal prompt homogeneous uptake in the liver (ruling out hepatitis) and NO excretion into the biliary system, even on delayed imaging.
• Patients undergo portoenterostomy (Kasai procedure).
  • If bile duct involved in anastomosis is large, greater chance of success.
  • Greater success if performed before ten weeks of age.
  • Complications include cholangitis, stenosis, and complete failure, which ultimately requires liver transplantation.

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Differential for acquired causes of intestinal obstruction in children (older) is described in Practical Pediatric Imaging: Diagnostic Radiolog

Differential for acquired causes of intestinal obstruction in children (older) is described in Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children as follows: (Take AAIIMM) Adhesions (from surgery) Appendicitis (often with abscess formation) Incarcerated inguinal hernia Intussusception Malrotation with volvulus Miscellaneous causes Meckel's diverticulum Duplication Ingested foreign body Causes of pneumoperitoneum in older infants and children include the following: Bowel perforation (Meckel's, appendix, ulcer, trauma) Perforation of other organ (uterus, vagina, bladder) Iatrogenic causes (dissection from pneumomediastinum, surgery, paracentesis, biopsy, resuscitation) CT evidence of appendicitis includes the following: Enlargement of the appendix Wall enhancement Periappendiceal fat stranding Appendicolith Wall thickening of the cecum or terminal ileum Check for associated abscess. References: Donnelly, LF. Fundamentals of Pediatric Radiology. First Edition. 2001. W.B. Saunders Company. Incesu, L, Taylor, CR, et al: Appendicitis. Emedicine. June 2004. Accessed May 12, 2007. Kirks, DR; Griscom, NT. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. Third Edition. 1998. Lippincott-Raven Publishers.

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Radiographic appearance in Osteomyelitis

• Periosteal reaction
• Thin, linear periosteal reaction
• Thick periosteal reaction
• Laminated—"onion peel"
• Codman's triangle—periosteum forms bone only at the margins of the periosteal triangle
• Bone destruction
  • Permeating bone lesion
  • Punched-out bone
  • Moth-eaten
  • Geographic
  • Aggressive osteolysis
  • Well-defined osteolytic lesion with thick sclerotic border
• Localized cortical thickening
• Involucrum
  • Reactive new bone surrounding sequestrum
• Ground-glass
• Diffusely dense bones
• CT—for evaluation of
  • Chronic disease
  • Soft tissue expansion
  • Sequestra
  • Sinus tracts
• MR—relative to X-ray
  • Increased sensitivity
  • Decreased specificity
• Nuclear Medicine
  • Tc99m-MDP bone scan
    • More sensitive than plain film
    • Negative rules out osteomyelitis
    • Phases (osteomyelitis positive through all 3 phases, cellulitis is negative on delayed)
      • Flow
      • Blood pool
      • Delayed
  • If underlying bone abnormal (i.e. diabetic foot, fractures, nonunion, pseudoarthroses, hardware) use multiple isotope scintigraphy (Tc99m-MDP combined with the agents listed below)
    • Sulfur colloid
      • Defines extent of red marrow
    • Labeled WBC's (Indium-111 or Tc99m-HMPAO)
      • Infection suggested by
        • Activity in absence of sulfur colloid activity
        • Greater activity than that of sulfur colloid
      • If activity of labeled WBC's and sulfur colloid ~equal, probably just marrow not infection
    • Gallium
      • Used in place of labeled WBCs
      • Less effective
• Risk factors
  • Penetrating trauma
  • Immunocompromised
  • IV drug abuse
  • Diabetes mellitus
  • Sickle cell disease
• Sequestrum and/or abscess
  • Antibiotics and surgical drainage
• In patients <>

References:

1. Weissleder et al, Primer of Diagnostic Imaging, 4th edition, 2007.
2. Bookstein, Medical Student's Pocket Reference, 4th edition, 2002.
3. Brant & Helms, Fundamentals of Diagnostic Radiology, 3rd edition, 2006.
4. STATdx, url: my.statdx.com (by Amirsys, Inc.).

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Thoracic outlet syndrome:

• Thoracic outlet syndrome is a clinical constellation of symptoms secondary to neurovascular compression at the level of the thoracic outlet.
• These symptoms are often exacerbated by abduction of the arms. Patients may complain of worsened symptoms when their arms are raised.
• Neurologic symptoms can include pain, numbness, paresthesias, or weakness, usually in a radicular pattern. C8 and T1 are most commonly involved.
• Vascular symptoms can include pain, no pulse, and pallor.
• Physical examination maneuvers to elicit thoracic outlet syndrome include Adson's test and the elevated arm stress test (EAST).
• The Adson's test involves abducting the arm to 90 degrees, and having the patient take a deep breath and turning his/her head away from the affected arm. A positive Adson's test results in a decrease or absence of the affected arm's radial pulse.
• The EAST test involves abducting the upper arms to 90 degrees, and flexing the elbows to 90 degrees. The patient is then asked to open and close the hands vigorously. Affected patients will be unable to continue for three minutes as this arm positioning will elicit the clinical symptoms of thoracic outlet syndrome.
• Imaging studies include a chest radiograph to evaluate for thoracic bony abnormalities, such as cervical ribs. Upper extremity dopplers and angiography are used to confirm the diagnosis.
• Patients should be anticoagulated to an INR of 2-3 to minimize the chance of subclavian artery or vein thrombosis.
• Surgical treatment includes anterior and middle scalenectomy, first rib resection, and removal of a cervical rib if present.

References:

1. Emedicine. "Thoracic Outlet Syndrome" http://www.emedicine.com/emerg/topic578.htm

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Useful link to description of Imaging exams and Prep required

Copy & Paste url to browser
http://www.qdi.com.au/webpages.cfm?pagenumber=4

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