Female reproductive system Flashcards
@# 6. Regarding yolk sac tumours of ovary:
A. Are the most common malignant germ cell tumour of the ovary
B. Account for 5% of all ovarian malignancy
C. Carry a poorer prognosis than any other ovarian germ cell tumour
D. Haemorrhagic change is very rare
E. Are slow growing tumours
C. Carry a poorer prognosis than any other ovarian germ cell tumour
Yolk sac tumours are well-enhanced tumours consisting of mixed solid and cystic tissue with some area of haemorrhage.
A ‘bright dot’ sign is recognised; a well-enhanced dilated vessel on the post-contrast image.
Yolk sac tumours have a poor prognosis.
They account for 1% of ovarian malignancies.
They are the second most common malignant germ cell tumour after dysgerminomas.
- Granulosa cell ovarian tumour is diagnosed following removal of a complex pelvic mass. Which is the single best answer?
A. Account for 15% of ovarian tumours
B. The juvenile subtype is more common
C. Has a rapid rate of growth
D. Recurrent disease is almost always in the frst two years after treatment
E. Variable imaging appearances are recognised from uniloculated cystic masses to solid masses
E. Variable imaging appearances are recognised from uniloculated cystic masses to solid masses
Represent 70% of malignant sex cord stromal tumours, but only 2-5% of all ovarian tumours have an unpredictable and indolent course with relapse occurring up to several years after initial diagnosis. The adult subtype accounts for 95% of all GCTs.
- Involvement of which of the following indicates the poorest prognosis in recurrent endometrial cancer?
A. Spleen
B. Vagina
C. Lung
D. Bladder
E. Well-differentiated tumour at original surgery
A. Spleen
Splenic, liver and multiple sites of disease are independent predictors of poor outcome.
- Regarding endometrial carcinoma on MR:
A. Normal zonal anatomy is best demonstrated on T1
B. Tumour is typically higher signal compared with endometrial lining on T2
C. Tumour is typically higher signal intensity than myometrium
D. Enhances faster than myometrium on dynamic contrast enhancement
E. Usually low SI than brightly enhancing normal myometrial tissue after contrast
E. Usually low SI than brightly enhancing normal myometrial tissue after contrast
Endometrial tumours are usually isointense to myometrium on T1 and lower SI to endometrial lining on T2. Tumours demonstrate slower enhancement on DCE than myometrium. Normal zonal anatomy is clear on T2.
- Which of the following ovarian masses appear more cystic than solid?
A. Arrhenoblastoma
B. Metastases
C. Fibroma
D. Lymphoma
E. Endometriosis
E. Endometriosis
Cystadenocarcinoma, dermoid abscess, endometriosis and ectopic pregnancy are examples of cystic ovarian masses.
- MRI shows two separate normal sized uteri and cervices with a septum extending into the upper vagina. The two uteri are widely separated, with preservation of the endometrial and myometrial widths. What name is given to this abnormality?
A. Uterus didelphys
B. Mullerian agenesis
C. Unicornate uterus
D. Uterus bicornuate
E. Septate uterus
A. Uterus didelphys
When partial fusion of the Müllerian ducts occurs, myometrium forms the dividing septum. This abnormality is known as a bicornuate uterus. A septate uterus arises when there is only partial resorption of the final fbrous septum dividing the two horns of the uterus. The latter defect results in further reproductive comp
- HSG shows small diverticular outpouchings in the isthmic portion of the right fallopian tube with distal tube occlusion. What is the diagnosis?
A. Tubal polyps
B. Salpingitis isthmica nodosa (SIN)
C. Adenomyosis
D. Asherman’s syndrome
E. Ectopic pregnancy
B. Salpingitis isthmica nodosa (SIN)
SIN is associated with pelvic inflammatory disease and a higher risk of ectopic pregnancy
@# 44. Regarding clear cell tumour of the ovary:
A. Are rarely invasive
B. Represents > 20% of ovarian carcinomas
C. Most patients present at stage 2 disease
D. Frequently occurs as a unilocular cyst with mural nodule
E. Has a poorer survival rate compared with other ovarian cancers
D. Frequently occurs as a unilocular cyst with mural nodule
50% of patients have a 5-year survival rate; it presents in stage I in 75% of cases and accounts for up to 10% of all ovarian cancers.
- Regarding mucinous ovarian tumours:
A. Are most commonly mucinous cystadenocarcinomas
B. Account for the most common benign epithelial neoplasias of the ovary
C. Are most common in the post-menopausal population
D. Rupture may lead to pseudomyxoma peritoneii
E. When mucinous, cystadenomas are unilocular cysts with few septa
D. Rupture may lead to pseudomyxoma peritoneii
20 % of ovarian tumours are mucinous.
These are the second most common benign epithelial neoplasm after serous ovarian neoplasias.
Mucinous cystadenomas account for 80% and are multiloculated cysts with numerous septae, occurring in the third to fifth decades.
- Regarding ovarian fbromas:
A. Demonstrate rapid enhancement on CECT
B. Commonly present as Meigs’ syndrome
C. Are usually bilateral
D. Usually hyperechoic on ultrasound
E. Low on T1 and T2, less or equal to myometrium
E. Low on T1 and T2, less or equal to myometrium
Well-defned solid masses in patients > 40.
Low SI on T1+T2, with poor delayed contrast enhancement.
Bilateral in 4-8% and associated with Meigs’ syndrome in 1%.
Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor
3) A 30-year-old woman has a well-circumscribed, cystic, adnexal mass with areas of dense focal calcification, small enhancing soft-tissue elements, fluid–fluid levels and bright regions on T1W MRI that become dark on fat-saturated sequences. Which of the following pathologies is most likely?
a. ovarian cyst with proteinaceous contents
b. endometrioma
c. mature cystic teratoma of the ovary
d. ovarian cyst adenofibroma
e. ovarian adenocarcinoma
c. mature cystic teratoma of the ovary
The main differentials for an ovarian mature cystic teratoma (dermoid cyst) are endometriomas and proteinaceous ovarian cysts, which can also have fluid–fluid levels.
Fat is frequently demonstrated in a dermoid cyst, but not in these differentials.
Fat can be proven by a significant negative attenuation value on CT, or on MRI with chemical shift artefact in the frequency-encoding direction, a gradient echo sequence in which fat and water are in opposite phase or frequency-selective fat saturation sequences.
Mature cystic teratoma contains mature tissues of germ cell (pleuripotent) origin. At least two of the three germlines should be represented.
Mean patient age is 30 years, younger than for epithelial ovarian neoplasms, and it is the commonest ovarian mass in children.
Usually asymptomatic, they can cause abdominal pain or other nonspecific symptoms. They are bilateral in 10% of cases
8) A general practitioner performs a vaginal examination prior to intended removal of an intrauterine contraceptive device. The locator device cannot be seen or palpated. What is the most appropriate initial investigation for this patient?
a. abdominal radiograph
b. pelvic ultrasound scan
c. pelvic CT
d. pelvic MRI
e. hysteroscopy
b. pelvic ultrasound scan
The device should be seen within the endometrial cavity on ultrasound scan as an echo-bright structure casting an acoustic shadow. If it is not identified in the uterus on ultrasound scan, then a plain abdominal film is indicated to exclude perforation and migration.
12) A 40-year-old woman with a history of prior pelvic radiotherapy for cervical cancer has an ultrasound scan for cyclical pelvic pain. The endometrium is distended by predominantly echo-poor material, and both ovaries have moderately large cysts containing low-level echoes. On MRI, the cervix returns low T2 signal and the ovarian cysts return high signal on fat-suppressed T1W sequences. Which of the following is the most likely diagnosis?
a. recurrent cervical tumour with bilateral ovarian metastases
b. recurrent cervical tumour and synchronous bilateral ovarian teratomas
c. cervical stenosis and bilateral endometriomas
d. cervical stenosis and bilateral ovarian cystadenocarcinomas
e. new primary endometrial carcinoma with bilateral ovarian secondaries
c. cervical stenosis and bilateral endometriomas
Cervical stenosis can be congenital or acquired. When it is acquired, causes include cervical (after the menopause) or endometrial (before the menopause) carcinoma.
Radiation and curettage can also produce cervical stenosis.
On imaging, the endometrial cavity is distended by secretions and blood products.
Reflux endometriosis can complicate cervical stenosis
@# 13) A postmenopausal patient has a hysterectomy and bilateral salpingo-oophorectomy for bilateral ovarian masses. Histological examination confirms bilateral ovarian tumours and reveals concomitant endometrial adenocarcinoma. What is the most likely histological diagnosis of the ovarian lesions?
a. benign serous cystadenoma
b. benign mucinous cystadenoma
c. malignant serous cystadenocarcinoma
d. malignant mucinous cystadenocarcinoma
e. endometrioid tumour
e. endometrioid tumour
Benign serous cystadenoma is bilateral in 20% of cases, benign mucinous cystadenoma in 5%, malignant serous cystadenocarcinoma in 50% and malignant mucinous cystadenocarcinoma in 25%. However, not only are endometrioid ovarian tumours frequently bilateral (30–50%) but they are also often (30%) found with concomitant endometrial adenocarcinoma.
25) A 65-year-old female with biopsy-proven ovarian cancer has a staging CT scan. It reveals a left basal pleural effusion that after aspiration contains no malignant cytology. There is a large, complex, abdominopelvic mass, with ascites and peritoneal deposits outside the pelvis measuring over 2 cm in diameter. Pelvic and para-aortic lymph nodes are enlarged. There are liver surface and parenchymal deposits. Which of the described features results in a classification of stage IV disease?
a. ascites
b. pleural effusion
c. liver surface deposits
d. liver parenchymal deposits
e. 2 cm deposits outside the pelvis
d. liver parenchymal deposits
Liver capsule deposits are stage T3/III. The pleural effusion cannot be regarded as M1/IV, because it requires positive cytology for this. Any involved regional nodes give stage IIIc and include obturator, common, internal and external iliac, laterosacral, inguinal and para-aortic.
28) An imaging request is received with the clinical information, ‘biopsy-proven adenocarcinoma of the cervix, for local staging’. Which of the following is the most appropriate technique?
a. transvaginal ultrasound scan
b. endoanal ultrasound scan
c. CT abdomen and pelvis with intravenous and oral contrast
d. MRI with pelvic phased-array coil
e. 18FDG PET
d. MRI with pelvic phased-array coil
MRI is the technique of choice for local staging of cancer of the uterine cervix. CT is less useful for staging of the primary tumour but has value in detecting involved lymph nodes and distant metastases. 18FDG PET may be useful in some cases for detection of distant metastases or the identification of recurrent disease. Its value will vary with the histological diagnosis on account of varying radiotracer avidity, with squamous cell carcinomas typically being avid
32) A 23-year-old nulliparous woman is examined for dyspareunia. Biopsy confirms a clinically small but malignant-looking cervical lesion to be adenosquamous carcinoma. In such cases, local imaging staging must indicate which of the following?
a. tumour size and distance from the internal os plus the cervix length
b. tumour size and distance from the external os plus the uterine length
c. tumour size and distance from the vaginal introitus plus length of the vagina
d. tumour size and vascularity
e. ovarian position
a. tumour size and distance from the internal os plus the cervix length
Trachelectomy may be considered to conserve the uterus and preserve fertility in young women with small tumours.
Tumour size, distance from the internal os, cervix length and size of the uterus are required from the imaging.
Surgery, radiation and chemotherapy are treatment options for cervical cancer dependent on stage.
From 85% to 90% of cervical carcinomas have squamous cell histology, the remainder being mostly adenocarcinoma or adenosquamous.
33) A patient has a squamous cell carcinoma of the vulva. An MRI is performed for locoregional staging. There are significantly enlarged inguinal lymph nodes ipsilateral to the primary tumour, but none contralaterally. A short axis, ipsilateral, 1.2 cm external iliac node is also identified that has signal characteristics identical to the primary tumour throughout. Which of the following is the most accurate nodal staging?
a. Nx
b. N0
c. N1
d. N2
e. N3
c. N1
NX is used when regional nodes cannot be assessed, and N0 when there are no involved regional nodes.
N1 denotes ipsilateral involved femoral or inguinal lymph nodes.
N2 signifies bilateral regional nodal involvement.
All intrapelvic nodes are regarded as metastases and therefore do not influence the N stage.
There is no N3 for vulval cancer
35) A patient with endometrial cancer previously treated with surgery has an 18FDG PET scan to look for recurrence. A false-negative result could be caused by which of the following scenarios?
a. peritoneal deposits smaller than 1 cm
b. bladder diverticulum
c. post-surgical inflammation
d. abscess
e. bowel avidity
a. peritoneal deposits smaller than 1 cm
False positives can occur with PET because 18FDG is a metabolic tracer, and activity is seen in normal bowel, ovaries (cyclical), endometrium (cyclical), blood vessels, bone marrow and skeletal muscle. 18FDG is renally excreted; hence, focal accumulation can be seen in ureters, bladder diverticula, pelvic kidneys and urinary diversions. Benign processes can also take up this tracer, including abscesses, uterine fibroids, endometriosis, post-surgical inflammation, post-radiotherapy inflammation and sacral fractures. Fusion of the PETwith a CT scan can reduce these common pitfalls. However, using CT for attenuation correction can introduce other artefacts, such as apparently increased activity around metal prostheses. The PET acquisition is considerably longer than the CT one, allowing movement of bowel or bladder wall (with distension over time) and hence misregistration of PETactivity on the anatomical CT data. False-negative PET scans can be caused by small tumour deposits close to the urinary bladder, where they cannot be resolved from each other
43) A 45-year-old female has imaging to stage a cervical carcinoma. The primary tumour is 5 cm in longest dimension, is seen to involve the uterine corpus, and has small-volume parametrial spread that does not reach the pelvic side wall. Parametrial lymph nodes are significantly enlarged. There is no hydronephrosis. Vaginal involvement is also seen, with the caudal extent of the tumour being below the level of the urethral orifice into the bladder base. Which of the described features causes the local stage to be T3a?
a. size over 4 cm
b. uterine corpus invasion
c. parametrial spread
d. vaginal invasion
e. parametrial nodal involvement
d. vaginal invasion
The urethra is used as a landmark for the lower third of the vagina.
Cervical cancer involvement of the upper two-thirds of the vagina is T2a.
When the lower third is involved, it becomes T3a.
T3b disease denotes disease that reaches the pelvic side wall or has caused hydronephrosis.
Extension of disease into bladder or rectal mucosa is T4, as is disease extending out of the true pelvis.
Extension into the corpus only is disregarded.
T1b1 disease and T1b2 disease differ in being less or greater than 4cm respectively.
Parametrial lymph nodes are regional nodes and represent N1 disease; they do not influence the T stage
@# 47) A postmenopausal patient is investigated for ascites. Cytology from the ascites reveals cells in keeping with an epithelial ovarian malignancy. Which of the following is the most appropriate staging investigation?
a. CT of the abdomen and pelvis with oral and intravenous contrast
b. CT of the chest, abdomen and pelvis with oral and intravenous contrast
c. MRI of the pelvis
d. 18FDG PET
e. PET/CT
a. CT of the abdomen and pelvis with oral and intravenous contrast
Plain chest radiograph may be added to this as a routine, but chest CT would be requested only with an additional reason to do so. MRI of the ovaries can be helpful in characterizing ovarian masses where ultrasound scan and CA-125 are equivocal. There may be a role for PET/CT in defining disease extent, but cystic tumour deposits, particularly when they may be on or close to bowel or associated with ascites, present a challenge for this technique.
55) Lymphatic drainage from the lower third of the vagina is normally first to which of the following LN groups?
a. obturator
b. internal iliac
c. external iliac
d. inguinal
e. retroperitoneal
d. inguinal
The upper two-thirds of the vagina drain to the pelvic nodes, which is of relevance when imaging vaginal cancer. This cancer is uncommon, representing 1–2% of gynaecological malignancy. Eighty-five per cent of cases of vaginal cancer are squamous and 15% are adenocarcinoma. Clear-cell carcinoma is a rare form of adenocarcinoma found in young patients with in utero diethylstilbestrol exposure. Even less common are melanoma, sarcoma and adenosquamous carcinoma occurring as vaginal primaries. The two commonest cell types have different natural histories. Adenocarcinoma tends to involve pelvic and is more likely to involve supraclavicular lymph nodes, while squamous carcinomas are more likely to give rise to liver metastases. They are equally likely to metastasize to the lungs.
59) A 25-year-old female undergoes ultrasound scan of the pelvis for low abdominal pain. A gas reflection is seen within the uterine cavity. Which of the following is the likely cause of the pain?
a. endometriosis
b. adenomyosis
c. endometritis
d. endometrial carcinoma
e. tubo-ovarian abscess
c. endometritis
Endometritis is the commonest cause of gas in the uterus. Gas is also seen in the uterus when a submucosal fibroid becomes infected, when necrotic neoplastic tissue is metabolized by bacteria, because of fistula to the gastrointestinal tract, in pyometra secondary to cervix obstruction by cancer, or in cases of gas gangrene due to clostridial infection following septic abortion. Ovarian gas can be seen with infection within an ovarian neoplasm. Numerous gas-filled spaces in the vaginal submucosa and exocervix can occur in pregnancy; this is termed ‘vaginitis emphysematosa’.
@# 60) MRI is performed for locoregional staging of vaginal cancer. Which of the following descriptions is the most likely appearance on a T2W sequence, given a small primary tumour confined to the vagina?
a. central high signal within the vagina; focal homogeneous, low-signal mass not breaching the surrounding ring of intermediate-signal vaginal wall
b. central high signal within the vagina; focal homogeneous, high-signal mass not breaching the surrounding low-signal vaginal wall
c. central high signal within the vagina; focal homogeneous, intermediate-signal mass breaching the surrounding low-signal vaginal wall
d. central high signal within the vagina; focal homogeneous, intermediate-signal mass not breaching the surrounding low-signal vaginal wall
e. central intermediate signal; focal homogeneous, high-signal mass contained by low-signal vaginal wall
d. central high signal within the vagina; focal homogeneous, intermediate-signal mass not breaching the surrounding low-signal vaginal wall
The vaginal epithelial layer and mucus are bright on T2W images. This is normally surrounded by low-signal (fibromuscular) vaginal wall. Tumours are typically intermediate signal on T2W images. If gadolinium is used, cancers often have early phase enhancement. Large tumours may have central necrosis.
T1 tumours do not breach the low-T2-signal vaginal wall,
whereas T2 tumours do and extend into the paracolpal fat.
T3 tumours reach the pelvic side wall
while T4 tumours extend beyond the true pelvis or involve bladder or rectal mucosa
61) A 30-year-old, nulliparous woman with Stein–Leventhal syndrome is being treated for subfertility with clomiphene. She develops abdominal pain, distension, nausea and vomiting. Ultrasound examination of the abdomen reveals both ovaries to be larger than 7 cm in length and packed with large follicles, and also reveals an ovarian cyst 12 cm in diameter. Ascites and a pleural effusion are also seen. What is the most likely diagnosis?
a. endometriosis
b. ovarian cyst torsion
c. ovarian hyperstimulation syndrome
d. ovarian serous cystadenoma
e. corpus luteum of menstruation
c. ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome is more commonly seen with human menopausal gonadotrophin therapy but can also be seen with clomiphene. Severe complications relate to volume depletion, such as hypovolaemia, oliguria, electrolyte imbalance and thromboembolic events. Intra-abdominal haemorrhage is also reported.
@# 63) On transvaginal ultrasound scan, an ovary measures 5 X 3 X 2 cm. Regarding the volume of this ovary, which of the following statements is most accurate?
a. it is large for pre- and postmenopausal ovaries
b. it is normal for pre- and postmenopausal ovaries
c. it is normal for a premenopausal ovary but large for a postmenopausal ovary
d. it is normal for a postmenopausal ovary but large for a premenopausal ovary
e. not enough information is given to assess the volume
c. it is normal for a premenopausal ovary but large for a postmenopausal ovary
Normal ovarian volume is less than 18 cm3 before the menopause and less than 8 cm3 after.
The volume can be estimated by multiplying the three diameters and dividing by two.
65) A transvaginal ultrasound scan is performed on a premenopausal woman on day 21 of the menstrual cycle. Given that her endometrium is normal, which of the following measurements of endometrial thickness is most likely?
a. 2 mm
b. 2–4 mm
c. 4–8 mm
d. 7–14 mm
e. greater than 14 mm
d. 7–14 mm
The menstrual endometrium is under 4mm.
After menstruation and up to date 14, the proliferative endometrium is 4–8mm.
Days 14–28 are secretory with the endometrium 7–14mm.
On ultrasound scan, the endometrium is seen as an echo-bright stripe. Unless the patient is taking tamoxifen or hormones, the postmenopausal endometrium should be less than 4mm.
A cut-off of 3mm when performing screening for endometrial cancer has a 99% negative predictive value.
69) A 68-year-old female patient has a pelvic ultrasound scan for a palpable mass. Arising within the left ovary is a 15 cm cyst with an irregular thick wall, frond-like solid elements, multiple septations over 2 mm thick and a pulsatility index of 0.5. These sonographic appearances are most in keeping with which of the following ovarian cystic structures?
a. corpus luteum cyst
b. follicular cyst
c. polycystic ovaries
d. benign ovarian neoplasm
e. malignant ovarian neoplasm
e. malignant ovarian neoplasm
Features of an ovarian cyst that suggest malignancy are thick irregular walls and thick septations (.2mm), large overall size, solid elements and, on Doppler scan, a high peak systolic velocity and low-impedance diastolic flow. Together, these give a resistive index (RI) of ,0.4 and a pulsatility index (PI) of ,1.
@# 70) A 17-year-old female with primary amenorrhoea is found on clinical examination to have a hypoplastic upper/middle vagina. MRI shows an absent uterus but normal tubes and ovaries. Which of the following is the most likely diagnosis?
a. uterus didelphys
b. unicornuate uterus
c. Mayer–Rokitansky–Kuster–Hauser syndrome
d. uterine agenesis
e. septate uterus
c. Mayer–Rokitansky–Kuster–Hauser syndrome
The uterus, fallopian tubes and upper vagina arise from the paired paramesonephric (mullerian) ducts. The caudal parts fuse and ultimately form the uterus and upper vagina with resorption of the midline septum. The cranial parts remain unfused and form the fallopian tubes. Congenital uterine abnormalities arise with failure of development or fusion of this duct, or failure of midline resorption following fusion. Mayer–Rokitansky–Ku¨ster–Hauser syndrome describes uterine agenesis accompanied by hypoplastic proximal/middle third of the vagina but normal tubes and ovaries. Forty per cent of patients with the syndrome have pelvic kidneys and other urinary tract anomalies are also associated. They have a normal genotype.
72) A postmenopausal woman is found on MRI to have a multicystic adnexal mass that contains fluid–fluid levels and does not show any fat suppression. In addition, her uterus shows a widened junctional zone containing small bright foci on T2W images. For which of the following diseases is she most likely to be receiving oral treatment that can account for these findings?
a. urinary tract infection
b. deep venous thrombosis
c. endometrial cancer
d. breast cancer
e. bipolar disorder
d. breast cancer
The patient is receiving tamoxifen. Side effects include subendometrial cystic atrophy, endometrial hyperplasia and endometrial polyps. Less frequent side effects are endometriosis, polypoid endometriosis, adenomyosis and cervical polyps. There is an increased risk of endometrial carcinoma. On MRI, an endometrioma can appear as a multicystic adnexal mass of high T1 and both hypo- and hyperintense T2 signal, but without the fat suppression that would be expected with a mature cystic teratoma. Adenomyosis on MRI may manifest as a uterus with a thickened, low-signal, junctional zone on T2W images, containing small foci of high T2 signal.
73) An 80-year-old female is found incidentally to have a unilateral, unilocular, echo-free, thin-walled ovarian cyst of diameter 4 cm. There are no papillary projections or solid parts, and the CA-125 is less than 30 U/ml. Which of the following is the most appropriate management?
a. pelvic exenteration
b. total abdominal hysterectomy and bilateral salpingo-oophorectomy
c. bilateral oophorectomy
d. laparoscopic staging
e. repeat transvaginal ultrasound scan in 4 months
e. repeat transvaginal ultrasound scan in 4 months
The Risk of Malignancy Index (RMI) is used to stratify the likelihood of an incidentally identified ovarian cyst being malignant. The RMI is the product of the ultrasound score, the CA-125 level and the score assigned according to menopausal status. Low-risk cysts can be managed conservatively. A cyst below 5cm in diameter that is unilocular, unilateral and echo-free, and has no solid parts or papillary formations has a risk of malignancy of less than 1%, and a 50% chance of resolving spontaneously in 3 months.
(Ped) 73) An incidental finding made in a 13-year-old girl is of unilateral ovarian atrophy. The atrophic ovary has stippled calcification. Given these features, which is the most likely explanation?
a. ovarian teratoma
b. amputated ovary
c. follicular ovarian cyst
d. ovarian leiomyoma
e. ovarian vein thrombosis
b. amputated ovary
An amputated ovary occurs as the result of ovarian torsion and infarction. Both an ovarian teratoma and leiomyoma will enlarge the affected ovary rather than appear atrophic. A follicular cyst will usually be a simple cyst, although it may have internal echoes produced by haemorrhage.
76) A 70-year-old woman is known to have uterine fibroids. There has been a clinically apparent increase in the uterine size. Transvaginal ultrasound appearances are in keeping with a large myometrial fibroid. Which of the following diagnoses must be considered in this patient?
a. lipoleiomyoma
b. endometrial hyperplasia
c. adenomyoma
d. leiomyosarcoma
e. Bartholin’s gland tumour
d. leiomyosarcoma
Uterine fibroids are oestrogen dependent and should involute following the menopause. Increase in size of a fibroid after the menopause should raise the possibility of sarcomatous degeneration. On ultrasound scan, the appearance of leiomyosarcoma may be indistinguishable from that of a benign fibroid
78) A 28-year-old female has a hysterosalpingogram for infertility. Both fallopian tubes distend progressively with contrast injection but without peritoneal spill of contrast. A delayed plain abdominal radiograph shows continued distension of both tubes by dense collections of contrast and no peritoneal spill. Given these findings, which of the following is the most likely predisposition to infertility for this patient?
a. tuberculosis
b. endometriosis
c. pelvic inflammatory disease
d. submucosal uterine fibroids
e. Asherman’s syndrome
c. pelvic inflammatory disease
The patient’s fallopian tubes are occluded, giving bilateral hydrosalpinx. The commonest cause of proximal or distal tubal occlusion is pelvic inflammatory disease. Endometriosis, infection following birth or abortion, and tuberculosis are other causes. Indications for hysterosalpingogram include infertility, recurrent miscarriage, assessment of the tubes after surgery and assessment of the integrity of a post-caesarean uterine scar. Contraindications are pregnancy, purulent vulval or cervical discharge, pelvic inflammatory disease in the preceding 6 months and contrast sensitivity. Historical contraindications include the immediate post-menstruation phase and recent dilatation and curettage, because of the risks associated with intravasation of oily contrast media.
83) A 28-year-old female is investigated for infertility. She has raised androgen levels and a higher than normal luteinizing hormone: follicle-stimulating hormone ratio. Pelvic ultrasound scan demonstrates bilaterally large ovaries with multiplesmall follicles. Which of the following is the most likely reason for the patient’s infertility?
a. cervical fibroids
b. hostile cervical mucus
c. ovarian torsion
d. polycystic ovarian disease
e. bilateral ovarian endometriosis implants
d. polycystic ovarian disease
Polycystic ovarian disease is diagnosed by clinical, biochemical and ultrasound findings. Clinically, oligomenorrhoea, hirsutism and obesity are features. Luteinizing hormone is increased as is the luteinizing hormone: follicle-stimulating hormone ratio. Androgen levels are increased. Sonographic findings vary from normal-looking ovaries through hypoechoic ovaries without individual cysts to multiple, 5mm or more, peripherally located cysts in bilaterally larg
86) A 79-year-old female has a 6-month history of vaginal bleeding. Transvaginal ultrasound scan demonstrates an ill-defined endometrium measuring 20 mm in thickness. Outpatient clinic endometrial biopsy confirms endometrial adenocarcinoma. MRI stage is T4. Which of the following MRI features supports this stage?
a. disease limited to the endometrium
b. cancer invasion evident into the outer half of the myometrium
c. vaginal involvement
d. rectal serosal involvement
e. bladder mucosal involvement
e. bladder mucosal involvement
Endometrial carcinoma is the commonest gynaecological malignancy, and the fourth commonest site of female malignancy. It is very unlikely if the endometrial thickness on transvaginal ultrasound scan is less than 4mm. Endometrial carcinoma becomes stage T4 when bladder or bowel mucosa is involved, whereas the stage remains T3 if other layers of bowel or bladder are invaded. On MRI, endometrial carcinoma has homogeneous signal intensity, isointense to myometrium on T1W images and hypointense to endometrial lining on T2W images. Endometr cancers shows slower contrast enhancement to a lower peak of enhancement than normal myomet.
89) On a midline sagittal T2W MR image of the uterus of a 25-year-old female, the endometrium, junctional zone and outer myometrium of the corpus are clearly identified. From innermost to outermost, which of the following signal intensities best describes the normal uterus?
a. high, intermediate, low
b. high, low, intermediate
c. intermediate, high, low
d. intermediate, low, high
e. low, intermediate, high
b. high, low, intermediate
The premenopausal uterus normally has a bright endometrium within a dark junctional zone and an intermediate outer myometrium on T2W images. Cancer disrupts the zonal anatomy seen on T2W MRI. T1W sequences do not demonstrate uterine zonal anatomy. On T2W images, the uterine cervix has a distinct zonal signal pattern that is particularly well seen on sequences acquired perpendicular to the long axis of the cervix. These are especially useful for cervical cancer staging. The cervix lumen is bright, the cervical mucosa is intermediate to bright, and the fibromuscular cervical stroma is dark and surrounded by the intermediate signal outer layer of cervical stroma. With age or radiation treatment, the uterus involutes and loses this zonal appearance on T2W MRI. Notably, the outer corpus and especially the cervical muscles return a lower signal.
90) A 60-year-old female with urinary retention and pelvic pain is investigated with MRI of the pelvis. On sagittal T2W images, the bladder is seen to be 2 cm below the pubococcygeal line. What is cause of patient’s symptoms?
a. anterior rectocele
b. enterocele
c. cystocele
d. rectal prolapse
e. bladder intussusception
c. cystocele
Suspected pelvic floor prolapse can be investigated with MRI. Usually, there is minimal movement of pelvic organs even on maximal strain. When the pelvic floor is lax, the organs descend below the pubococcygeal line by 1–2cm. When descent exceeds 2cm, the prolapse may require surgical intervention. An enterocele describes small bowel descending 2cm or more between vagina and rectum. Anterior bulging of the rectal wall is known as a rectocele, while bladder descent of more than 1cm is a cystocele.
91) Regarding normal pelvic floor anatomy, which of the following is contained within the middle compartment of the female pelvic floor?
a. bladder
b. urethra
c. vagina
d. rectum
e. anus
c. vagina
The pelvic floor is supported by the endopelvic fascia and the levator ani muscle complex. This complex consists of three muscle groups, iliococcygeal, pubococcygeal and puborectalis. The anterior compartment of the female pelvic floor contains the bladder and urethra. The middle compartment contains the vagina and the posterior compartment the rectum.
99) Which of the following is the strongest indication for a PET/CT scan?
a. cervical cancer staging
b. endometrial cancer staging
c. ovarian cancer staging
d. prostate cancer staging
e. bladder transitional cell carcinoma staging
a. cervical cancer staging
In the pelvis, 18FDG PET/CT is recommended for use in staging colorectal cancer, cervical cancer and non-Hodgkin’s lymphoma. It is also indicated for detecting recurrence of colorectal, cervical, endometrial and ovarian cancers. It is not recommended for primary urothelial malignancy or prostate cancer. Usefulness is limited in the renal tract by urinary excretion of FDG. It is less than satisfactory in prostate cancer because of the poor sensitivity for osseous metastases
9 A 26 year old, otherwise fit and well female patient is referred for a pelvic US as part of her routine investigations for infertility. US shows an 8 cm right complex adnexal mass with echogenic and anechoic components. CT shows a inass of fat density floating in an interface between two water density components. MRI shows a hyperintense mass on T2W lesionwith a fluid-fluid level. What is the likeliest diagnosis?
(a) Tubo-ovarian abscess
(b) Endometrioma
(c) Ovarian carcinoma
(d) Dermoid cyst
(e) Haemorrhagic cyst
(d) Dermoid cyst
Dermoid cysts are common congenital benign germ cell tumours that usually present in the reproductive age range. 15% are bilateral. They have a spectrum of appearances ranging from the classic fat or bone containing lesions to (less commonly) a predominantly cystic lesion with a fluid-fluid level. They can be diagnosed on plain radiographs in up to 40% of cases when the presence of fat, teeth or bone can be identified. They can be complicated by malignant degeneration (in 1-3%), torsion (4-16%) and rupture (rarely).
12 A 24 year old female patient with a regular 28 day menstrual cycle undergoes a transvaginal US examination as part of her investigations for dyspareunia. She cannot recall when her last menstrual period began. US shows bright central line, with a markedly echogenic smooth endometrium measuring 14 mm. Mild echogenic posterior acoustic enhancement is seen with a thin hypoechoic halo of inner myometrial zone. Which is correct?
(a) She should be referred for biopsy/dilation and curettage
(b) She is in the proliferative phase of her menstrual cycle
(c) She is in the secretory phase of her menstrual cycle
(d) The report should not mention her unknown LMP
(e) She is in the ovulatory phase of her menstrual cycle
(c) She is in the secretory phase of her menstrual cycle
An endometrial thickness of up to 16 mm may be seen in the secretory phase of the menstrual cycle. This is maximal during the mid-secretory phase. It is imperative to include the LMP, whether known or unknown as part of the report. In the proliferative phase (day 6-14), endometrial thickness is 5-7 mm and in the periovulatory phase, endometrial thickness up to 11 mm is seen.
14 A 45 year old woman undergoes a PET-CT as part of her investigations for cervical cancer. Which of the following is the least likely to cause a false positive result?
(a) Physiological uptake in bowel
(b) Bladder diverticulum
(c) Uterine fibroids
(d) Endometriosis
(e) Ovarian cyst
(e) Ovarian cyst
18FDG shows physiological uptake in brain, myocardium, liver, spleen, bone marrow, GI tract, testes, and skeletal muscle and is excreted by the kidneys. Increased uptake is also seen in healing fractures, inflammatory and granulomatous disease and infectious processes.
16 A 32-year-old woman with a history of multiple previous basal cell carcinomas of the skin undergoes a pelvic US. This shows a 5 cm solid-looking hypoechoic left ovarian mass. MRI shows the mass is well circumscribed, relatively homogeneous and of low signal intensity on T1 and T2. What is the most likely diagnosis?
(a) Ovarian adenocarcinoma
(b) Cystadenocarcinoma
(c) Brenner tumour
(d) Ovarian fibroma
(e) Endometrioma
(d) Ovarian fibroma
Ovarian fibroma is a well defined tumour containing extensive collagen. It is associated with Gorlin’s syndrome (fibromas seen in 17%) and occasionally presents as Meig’s syndrome.
17 A 19 year old female patient presents with a history of amenorrhoea. On examination she is noted to be overweight, hirsute, the blood sugar is raised on pin-prick testing. An underlying endocrine disorder is suspected. Which of the following features would not be in keeping with this diagnosis?
(a) Bilateral ovarian volumes of 20 m/s
(b) Bilateral ovarian volumes of 5 m/s
(c) 10 sman peripheral 5-8 mm cystic lesions on either side
(d) Asymmetrical ovarian size
(e) Patient’s age
(d) Asymmetrical ovarian size
The diagnosis of polycystic ovary syndrome is made on the basis of clinical and biochemical findings in conjunction with the sonographic findings, which alone are non-specific. Similar sized ovaries is a key finding. The classic finding of bilaterally enlarged ovaries with multiple small peripheral follicles is seen in 50%. Hyperechoic central stroma is also usually seen. Normal ovaries are seen in 25%.?
18 With regards to MRI protocols for the assessment of endometriosis, which of the following statements is incorrect?
(a) A pelvic surface coil improves image quality
(b) T1 W sequences post gadolinium administration is employed
(c) T2W spin echo sequences are routinely employed
(d) A smooth muscle relaxant improves image quality
(e) T2W gradient echo sequences are not routinely employed
(b) T1 W sequences post gadolinium administration is employed
T1W imaging after the administration of intravenous gadolinium is not routinely employed for the assessment of endometriosis.
28 A 34 year old woman presents with left lower abdominal pain. US shows a complex adnexal lesion which cannot be fully characterised. MRI shows a 5 cm fluid filled structure with incomplete non-enhancing plicae crossing it and with areas of focal narrowing and peripheral small low signal intensity nodules on T2W. Amorphous shading of the lesion is also seen on T2W. Enhancement of the wall of the lesion after gadolinium administration is noted. Normal ovarian tissue is seen stretched around the lesion. What is the likely diagnosis?
(a) Endometriosis
(b) Ovarian mucinous carcinoma
(c) Fallopian tube carcinoma
(d) Pyosalpinx
(e) Lymphangioma
(d) Pyosalpinx
Pyosalpinx is characterized by dilatation of the fallopian tube with pus within it. It characteristically demonstrates amorphous or geographic shading on T2W
37 A 37 year old female patient with suspected pelvic malignancy undergoes an MRI with diffusion weighted imaging. There is an area of slight T2 hyperintensity which shows high signal intensity on high b-value source images and decreased signal on the ADC map. What is the most likely diagnosis?
(a) Liquefactive necrosis
(b) Fibrous tissue
(c) T2.:.shine through
(d) Cyst
(e) High-cellularity tumour
(e) High-cellularity tumour
Diffusion-weighted MRI is increasingly being used in body MRI and offers functional information over and above conventional morphological images. These features are typical of tumour.
50 A 14 year old girl presents with lower abdominal pain. Transabdominal ultrasound shows a partially solid/partially cystic midline mass. Which of the following radiological features would not support a diagnosis of ovarian torsion?
(a) Enhancement of the solid component on CT
(b) Free fluid in the cul-de-sac on US
(c) Multiple peripheral cysts on US
(d) High signal intensity on fat suppressed T1
(e) Wall thickness of 12 mm on MRI
(a) Enhancement of the solid component on CT
Lack of enhancement of the solid component of the mass is seen on CT and MRI. Other features include a whorled paraovarian structure on CT, representing the ovarian pedicle
21 A 30 year old woman presents with chronic pelvic pain and dyspareunia. PV examination reveals tenderness in ‘the right adnexa. Pelvic US shows a 4 cm cystic lesion arising from the right ovary with diffuse homogeneous low-levet internal echoes and echogenic wall foci. What is the likeliest diagnosis?
(a) Haemorrhagic ovarian cyst
(b) Endometrioma
(c) Dermoid
(d) Cystadenocarcinoma
(e) Tubo-ovarian abscess
(b) Endometrioma
The classic features of an endometrioma are described, others include wall nodularity, a fluid-fluid level and acoustic enhancement. A haemorrhagic ovarian cyst or a tubo-ovarian abscess wou1d present more acutely. A dermoid may have similar appearances but would usually have fat and/or calcium within. A cystic ovarian tumour is in the differential and typically appears as a multilocular cyst with large associated soft tissue component mass, sometimes with papillary excrescences into the cysts.
29 A 28 year old woman is referred for investigations for infertility. HSG and MRI demonstrate normal fundal contour but no division of the uterine horns and a single uterine canal with a saddle shaped fundus. What is the most likely diagnosis?
(a) Arcuate uterus
(b) Septate uterus
(c) Bicornuate uterus
(d) Uterus d)delphys
(e) Unicornuate uterus
(a) Arcuate uterus
Arcuate uterus is the most common uterine anomaly associated with reproductive failure. Uterus didelphys is a duplication defect with 2 vaginas, 2 cervices and 2 uterine horns. Bicornuate and unicornuate abnormalities demonstrate an abnormal fundal contour.
31 A 73 year old woman is referred to the post-menopausal bleed fast track clinic where she undergoes a transvaginal US. Which of the following statements is incorrect?
(a) Endometrial measurement should be of both opposed endometrial layers
(b) The normal endometrial thickness measurement should be less than 5 mm
(c) If she is taking HRT, normal endometrial thickness can be up to 20 mm
(d) Normal measurement limits can be increased by 1-2 mm in obese patients
(e) Biopsy/D+C is advisable if she is not on HRT and has an endometrial thickness of >8 mm
(c) If she is taking HRT, normal endometrial thickness can be up to 20 mm
HRT can increase the normal thickness of the post-menopausal endometrium up to 15 mm (depending on the HRT). Measurements should be of bi-layer thickness. For post-menopausal women not on HRT, 5 mm is the upper limit of normal.
35 A 26 year old woman who has a Mirena IUCD in situ presents with intermittent lower abdominal pain. Which of the following statements is correct?
(a) 3T MRI is contraindicated
(b) Mirena IUCDs are better visualised than copper IUCDs on transabdominal US
(c) Threads of a lost coil are not visible on ultrasound
(d) IUCDs increase the risk of ectopic pregnancy
(e) The Mirarla is commonly used for the treatment of dysfunctional uterine bleeding
(e) The Mirarla is commonly used for the treatment of dysfunctional uterine bleeding
The Mirena is a polyethylene IUCD and is well seen on MRI. Metal IUCDs are not a contraindication to 1.5T MRI examination although safety in a 3T machine has not been fully evaluated. Threads of a lost coil can ball up to form an echogenic mass on ultrasound. IUCDs do not increase the risk of ectopic pregnancy per se, but a higher percentage of ectopic pregnancies are seen in patients with IUCDs as endometrial implantation is restricted. The Mirena is commonly used for treatment of dysfunctional uterine bleeding with success rates of up to 70%.
@#e 36 A 30 year old woman with a previous history of pelvic inflammatory disease is undergoing investigations for infertility. With regards to assessment of tubal patency, which of the following statements is correct?
(a) Gadolinium enhanced MRI is the investigation of choice
(b) Normal fallopian tubes are visible on pelvic US
(c) Hysterosalpingography should be performed in the first half of the menstrual cycle
(d) Hysterosalpingo contrast sonography is as good as laparoscopy and dye instillation
(e) Iodine based contrast is used for hysterosalpingo contrast sonography
(c) Hysterosalpingography should be performed in the first half of the menstrual cycle
Laparoscopy and blue dye instillation (with spillage of dye into the peritoneal cavity indicating patency) is the gold standard, but requires a general anaesthetic. MRI and standard pelvic US do not clearly demonstrate the fallopian tubes. HSG provides an accurate indication of tubal patency but employs ionizing radiation. It should therefore be performed in the first half of the menstrual cycle to avoid irradiating a patient with possible early pregnancy. Hysterosalpingo-ContrastSonography uses microbubbles to demonstrate the fallopian tubes and has the advantage of not using ionizing radiation or requiring anaesthesia but is less accurate than the other methods.
37 A 34 year old woman with 2 previous unremarkable vaginal deliveries presents with a history of pelvic pain. TV US shows diffuse heterogeneous myometrial echotexture with multiple tiny myometrial cystic lesions and poor definition of the junctional zone. MRI shows an indistinct diffuse predominantly low signal intensity lesion with small foci of increased signal intensity on T2W along with diffuse widening of the junctional zone on T2W. What is the most likely diagnosis?
(a) Adenomyosis
(b) Leiomyoma
(c) Endometrial carcinoma
(d) Muscular hypertrophy
(e) Myometrial contraction
(a) Adenomyosis
Adenomyosis is a term relating to benign invasion of the myometrium by endometrium. It can exist in either focal or diffuse forms. The diffuse form is characterised by junctional zone widening. Dilated cystic glands or haemorrhagic foci can be seen within the myometrium in 40% of diffuse cases.
54 With regards to normal ovarian anatomy on US, which of the following statements is false?
(a) Normal ovarian volume in a woman of reproductive age is up to 12 mis
(b) Normal ovarian volume in a postmenopausal woman is up to 4 mis
(c) The broad ligament contains the round ligaments within it
(d) Resistance to flow on Doppler imaging of the ovary is greatest in the luteal phase of the menstrual cycle
(e) The ovarian ligaments are not normally seen
(d) Resistance to flow on Doppler imaging of the ovary is greatest in the luteal phase of the menstrual cycle
Highest resistance to flow on Doppler is seen on days 1-8 of the menstrual cycle, gradually reducing with follicular development until day 21
67 With regards to fallopian tube recanalisation, which of the following statements is incorrect?
(a) It is used in cases of infertility associated with proximal tubal obstruction
(b) It cannot be employed after reversal of sterilization surgery
(c) Technical success is achieved in 80-90%
(d) It is associated with increased rates of ectopic pregnancy
(e) Salpingitis isthmica nodosa is a contraindication
(b) It cannot be employed after reversal of sterilization surgery
Although primarily used in cases of proximal tubal obstruction, it can be used to treat mid tubal obstructions after reversal of sterilization surgery.
72 A 69 year old woman presents with PV bleeding. US shows a normal sized uterus with an AP endometrial bilayer thickness of 16 mm. The maximally thickened endometrium is predominantly echogenic with scattered hypoechoic areas within it. At MRI a lesion of lower signal intensity than surrounding endometrium but higher signal intensity than myometrium on T2W is seen. Which of the following is the likeliest diagnosis?
(a) Adenomatous hyperplasia
(b) Submucosal leiomyoma
(c) Endometritis
(d) Endometrial carcinoma
(e) Benign endometrial hyperplasia
(d) Endometrial carcinoma
Other features to suggest malignancy include a resistive index of <0.7, disruption of the junctional zone or other evidence of myometrial invasion
- A 40 year old mother of three presents with menorrhagia and dysmenorrhoea. Transvaginal ultrasound shows an enlarged uterus with focal heterogeneous myometrial echotexture. The endometrium appears widened. T2-weighted MR imaging demonstrates focal widening of the junctional zone. There is a hypointense elongated myometrial mass with ill-defined margins. The mass contains foci of high signal on both T1- and T2-weighted imaging. The mass demonstrates contrast enhancement but to a lesser degree than the surrounding myometrium. What is the most likely diagnosis?
a. Leiomyoma
b. Endometrial carcinoma
c. Adenomyosis
d. Fibroma
e. Haematoma
- c. Adenomyosis
Adenomyosis is a focal or diffuse benign invasion of myometrium by endometrium, which incites reactive myometrial hyperplasia. It is associated with endometriosis (20–40%). It typically presents in multiparous women in the late reproductive years. Symptoms include pelvic pain, menorrhagia and dysmenorrhea, although adenomyosis it may be an incidental finding.
Adenomyosis may be diffuse or focal. Ultrasound appearances are variable but usually there is slight enlargement of the uterus with loss of homogeneity of the myometrium. There may be pseudo-widening of the endometrium due to increased myometrial echogenicity. MRI is more specific and demonstrates thickening of the junctional zone. When diffuse, a widened low-intensity junctional zone >12 mm confirms the diagnosis whereas <8 mm excludes the disease. For indeterminate sizes, further findings may aid the diagnosis, such as high-signalintensity linear striations extending out from the endometrium into the myometrium on T2 and high signal foci on T1 – representing ectopic endometrial tissue/haemorrhagic foci. When focal (adenomyoma), there is typically an oval/elongated mass with ill-defined margins residing within the myometrium which is in continuity with the junctional zone. Distinction from leiomyomas may be difficult but these tend to be round, sharply marginated masses occurring anywhere in the myometrium and they may contain calcifications.
- A 42 year old woman presents with post-coital bleeding. Transvaginal ultrasound shows the cervix to be enlarged, irregular and hypoechoic. MRI demonstrates a large cervical cancer with involvement of multiple pelvic lymph nodes. The left kidney is hydronephrotic. What is the most appropriate staging based on these findings?
a. T1
b. T2b
c. T3a
d. T3b
e. T4
- d. T3b
Cervical neoplasms are staged according to the TNM/FIGO classification. Stage I tumours are confined to the uterus. In stage IIA, there is involvement of the upper two-thirds of the vagina. Stage IIB shows parametrial invasion without pelvic sidewall involvement. Stage IIIA demonstrates invasion into the lower third of the vagina, and IIIB includes pelvic sidewall invasion with or without hydronephrosis. Tumour invasion into the bladder and rectal mucosa or distant metastasis accounts for stage IV disease. Pelvic nodal metastases do not alter the FIGO stage but para-aortic or inguinal node metastases are classified as stage IVB.
- A 50 year old woman presents with pelvic pain and abdominal fullness. Ultrasound reveals ascites and a large hypoechoic ovarian mass with posterior acoustic enhancement. CT demonstrates a well-defined solid pelvic mass which shows poor contrast enhancement. There is also a right-sided pleural effusion. Follow-up imaging postsurgical resection shows no residual tumour and resolution of ascites. What is the most likely diagnosis?
a. Serous cystadenocarcinoma
b. Mucinous cystadenocarcinoma
c. Ovarian fibroma
d. Brenner tumour
e. Massive ovarian oedema
- c. Ovarian fibroma
The condition described is Meigs syndrome. This occurs in about 1% of ovarian fibromas but is characterised by a large fibroma, ascites and a pleural effusion (typically right-sided). Ascites and effusion resolve after tumour resection. Fibromas are benign stromal tumours composed of fibrous tissue. On ultrasound they are typically solid hypoechoic lesions with posterior acoustic enhancement.
- A 28 year old woman presents with a dull ache in her pelvis. Ultrasound shows a 7 cm well-defined ovarian cyst. A distinct echogenic nodule which causes dense acoustic shadowing is seen projecting into the cyst’s lumen. What is the most likely diagnosis?
a. Mature cystic teratoma
b. Tubo-ovarian abscess
c. Endometrioma
d. Ovarian carcinoma
e. Corpus luteum cyst
- a. Mature cystic teratoma
Mature cystic teratomas (dermoid cysts) account for approximately 15% of all ovarian tumours. They are benign germ cell tumours containing tissues from all three germ cell layers. They most commonly present in younger women of reproductive age (20–40 years) and may be bilateral in up to 25%. They are generally cystic masses that may contain a pathognomonic distinct hyperechoic mural nodule (dermoid plug/Rokitansky nodule) which projects into the cystic lumen and causes posterior acoustic shadowing. This nodule represents in-growth of solid tissue such as hair or teeth from the tumour wall.
36 A 60-year-old female patient presented with post-menopausal bleeding and was found to have endometrial carcinoma. An MRI of her pelvis is performed for staging of the endometrial carcinoma. What signal would you expect normal myometrium, junctional zone and endometrium to return on T2 -weighted images
36 Answer C
On T2-weighted images three distinct layers can be seen: the endometrium is high signal, junctional zone is low signal and myometrium medium signal. On T1-weighted images the uterus is medium to low signal intensity
