CT - Anatomy and Pathology of
Uterus and Ovaries
Migdalia Ordonez
OHSU
Summer 2012
Purpose of this Presentation
• Review Pelvic anatomy on CT.
• Review common Pelvic pathologies on CT.
Topics to review:
(use hyperlinks to jump to different sections)
• CT basics
• Normal Anatomy
• Non-neoplasm
• Neoplasms
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
First, some basic CT Principles you will
need for this learning module.
http://www.nowhow.nl/nederlands/images/CT-scanner.jpg
CT Basics
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
http://www.babalublog.com/archives/ToeTag.jpg
View the image is as if you were looking up from the patient’s feet.
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CT Basics
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Metal
+500 to +1000 HU
Bone
+300 to -500 HU
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Water
(tissue and blood)
0 HU
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Fat
0 to -50 HU
Air
-200 to -1000 HU
•Things appear whiter according to their relative densities.
•This property is called “Attenuation” and it is quantified in Hounsfield Units
(HU), which can be measured on CT viewing software.
Quick review
Is it metal, bone, water, fat, or air
C.
D.
A. _______
B. _______
C. _______
D. _______
B.
A.
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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Answers
Is it metal, bone, water, fat, or air
A.
B.
C.
D.
C.
D.
Muscle
Bone
Air
Fat
B.
A.
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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Normal Pelvic Anatomy
Uterus
Ovary
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Identify structures in next slide:
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Identify structures
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Landmarks: Ovaries usually lateral to uterus and inferior to bifurcation of Iliac vessels C
A
F
C
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G
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Identify structures
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B.
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Bladder
Piriformis muscle
Right ovary
Rectum
Left ureter
Psoas muscle
Uterine body
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D
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Another look:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Side note: This is a…
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Hysterosalpingogram
Radio-opaque material is
injected into the cervical canal.
Procedure is used to investigate
the shape of uterine cavity and
shape and patency of fallopian
tubes.
Included here to review anatomy
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Pathology
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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Pathology – Non-neoplasm
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #1
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 28 year old female presents with fever, lower abdominal
pain, new vaginal discharge and complaints of painful
intercourse.
• Physical exam: Febrile and cervical motion tenderness.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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Enlarged uterus of soft-tissue attenuation, flanked at the
posterior aspects by tortuous, thick-walled oviduct Left
greater than Right filled with material of fluid-attenuation.
Pelvic Inflammatory Disease
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #2
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 36 year old female presents with sudden onset bilateral
pelvic pain, left side worse than right. History of pelvic
inflammatory disease a year ago treated with antibiotics.
• Physical exam: Tender to palpation in bilateral lower
abdomen, L greater than R. Entire pelvis tender to
palpation.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Coronal view - Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Left pelvis there is a cystic lesion with heterogeneous enhancement.
The lesion appears to be contiguous with the uterus, likely representing…
Tubo-ovarian abscess
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Tubo-ovarian abscess
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #3
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 23 year old female presents with fever, chills, lower
abdominal pain, recent history of PID treated with
antibiotics.
• Physical exam: Febrile and cervical motion tenderness.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Uterus has large, heterogeneous mass with areas of soft-tissue
attenuation and areas of fluid attenuation
Tubo-ovarian abscess
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #4
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 23 year old female presents to ED by ambulance due to
motor vehicle accident. She is complaining of lower
abdominal / pelvic pain.
• Physical exam: Pelvis tender to palpation.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Highly attenuated object in uterus,
otherwise normal pelvic CT
IUD
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #5
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 21 year old female with 2 days of progressively
worsening pelvic pain. She missed last period. She has
been feeling nauseated for past 3 weeks.
• Physical exam: right pelvic tenderness, breast
tenderness.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Contrast enhanced axial CT image shows strong
enhancing ring-like mass (arrow) that represents
gestational sac without hemoperitoneum
Ectopic pregnancy
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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Pathology - Neoplasm
CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Case #6
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 13 year old female presents with abdominal discomfort
and feeling bloated. Stomach seems to be growing
wider.
• Physical exam: Increased abdominal girth
• A computed tomography (CT) was done, see next slide.
Describe what you see:
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
•Mid pelvis there is large, thin-walled, cystic structure of fluid-attenuation.
•At the periphery of this structure are a few distinct regions of heterogeneous tissue.
•Within the right lateral aspect lies a foci of bone-density material.
•Within the left lateral aspect lies a heterogeneous foci of fat and soft-tissue densities
Teratoma
(Mature dermatoid cyst)
Case #7
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 48 year old female was involved in motor vehicle
accident. She is shaken up from accident but otherwise
feeling fine.
• Physical exam: Pt is in no acute distress. No signs or
symptoms of pain. Patient insisted having a CT to rule
out bleeds.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
Clue: this arises from the ovary
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Posterior aspect of the pelvis lies a well-circumscribed,
thin-walled, non-septated cystic structure containing
fluid-density material
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Clue: this arises from the ovary
Serous Cystadenoma
(benign)
Incidental finding on CT
Case #8
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
• 58 year old female presents to clinic with bloating, back
pain, urinary urgency, constipation, and tiredness for 6
months. Recently she developed pelvic pain, vaginal
bleeding, and unintentional weight loss.
• Physical exam: Abdomen tender to palpation throughout.
Pelvic tenderness.
• A computed tomography (CT) was done, see next slide.
Describe what you see:
Clue: This arises from the ovary
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
The pelvic cavity is grossly distended by multiple well-circumscribed,
thin-walled, septated, lobular structures of fluid-density.
These structures are compressing but don’t seem to invade surrounding
pelvic tissues
Note: Septations and lobulated surface
Cystadenocarcinoma
(Malignant)
Sources
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CT basics
Normal Anatomy
Non-neoplasm
Neoplasm
Siddall KA. Multidetector CT of the female pelvis. Radiol Clin North Am. 01-NOV-2005; 43(6): 1097-118
Casillas J, Joseph RC, Guerra JJ Jr. CT appearance of uterine leiomyomas. Radiographics. 1990 Nov;10(6):999-1007.
Foshager MC, Walsh JW. CT anatomy of the female pelvis: a second look. Radiographics. 1994 Jan;14(1):51-64;
Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 2001 MarApr;21(2):475-90.
Pannu, HK, et al. MD CT Evaluation of Cervical Cancer: Spectrum of Disease. Radiographics 2001; 21:1155–1168
Rha SE, et al. CT and MR imaging features of adnexal torsion. Radiographics. 2002 Mar-Apr;22(2):283-94.
Roberts JL, Dalen K, Bosanko CM, Jafir SZ. CT in abdominal and pelvic trauma. Radiographics. 1993 Jul;13(4):735-52.
Roobolamini, SA. Imaging of Pregnancy-related Complications. Radiographics 1993; 13:753-770.
Saksouk FA, Johnson SC. Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics. 2004 Oct;24
Suppl 1:S133-46.
Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. Radiographics.
2002 Nov-Dec;22(6):1327-34.
Yang DM. Retroperitoneal cystic masses: CT, clinical, and pathologic findings and literature review. Radiographics. 2004 SepOct;24(5):1353-65.
Buy, J-N, et al. Cystic Teratoma of the Ovary: CT Detection. Radiology 1989; 171:697-701
As well as
IMPAX, EPIC, and
WIKIPEDIA