Pelvis

Question 1

Pelvis major anatomic compartments (3)

Answer 1

1. Peritoneal Cavity.
2. Extra-peritoneal space:
   a) Retropubic space of Retzius
   b) Presacral space
3. Ischiorectal fosa.

Question 2

Fondos de saco en hombres y mujeres

Answer 2

• Hombres: Rectovesical y receso vesical anterior.
• Mujer: Douglas, vesico-uterino y receso vesical anterior.

Question 3

Vasos linfáticos de pelvis

Answer 3

• Linfonodos iliacos comunes, internos, externos y obturadores.
• > 10 mm se considera adenopatía.

Question 4

Ligamentos del ovario y útero (4)

Answer 4

• Ligamento ancho.
• Ligamento cardinal.
• Ligamento redondo.
• Ligamento uterosacro.

Question 5

Bladder carcinoma types and %

Answer 5

• 95% are TCC.
• 4-5% are squamous cell carcinoma.
• <2% Adenocarcinomas

Question 6

Bladder carcinoma CT findings

Answer 6

• Focal thickening of the bladder wall or soft-tissue mass projecting into it’s lumen.
• Mass might be: plaque-like, polypoid or papillary.
• Multicentric tumor in 30-40% of cases.
• Tumor upper tract 2-5%.
• Perivesical spread = soft-tissue density in the perivesical fat.
• Metastases: Liver, lung, bones and adrenal glands.

Question 7

Bladder Diverticulum

Answer 7

• Cystic pelvic mass with communication with the bladder lumen.
• Urine stasis may produce stone formation and recurrent infections.

Question 8

Cystitis types (6)

Answer 8

• Acute bacterial cystitis.
• Cystitis cystica and cystitis glandularis.
• Interstitial cystitis.
• Emphysematous cystitis.
• Tuberculosis of the bladder.
• Schistosomiasis.

Question 9

Cystitis cystica and cystitis glandularis

Answer 9

• Inflammatory disorders secondary to chronic irritation of the bladder by recurrent bacterial cystitis or bladder stones.
• CT shows multiple hypervascular enhancing polypoid masses.

Question 10

Uterus Leiomyomas

Answer 10

• 40% of women >30 years old.
• Homogeneous or heterogeneous masses, may be hypo-iso-hyper dense relative to enhanced myometrium.
• Lobulation and diffuse enlargement of the uterus is common.
• Calcifications are common.
• May suffer cystic degeneration.
• Pedunculated leiomyomas may appear as an adnexal mass.
• Parasitic leiomyomas, detached from the uterine pedicle.
• Lipoleiomyoma as a subtype
• Cannot be differenciated from leiomyosarcomas.

Question 11

Carcinoma of the Cervix

Answer 11

• 85% squamous cell carcinomas and 15% adenocarcinomas.
• Direct invasion, lymphatic metastases and hematogenous spread to lung, bone and brain (uncommon, occurs late in the course of the disease).
• Hypoattenuating (50%), iso-attenuating (50%).
• Fluid collection in the uterine cavity is common.
• Extension to the pelvic sidewall is seen when nodules are seen <3 mm from the obturator internus or piriformis muscle.
• Recurrence appear as a soft-tissue mass anywhere in the pelvis.

Question 12

Endometrial malignancy

Answer 12

• The most common invasive gynecologic malignancy.
• 90% endometroid adenocarcinomas.
• Clear cell, papillary serous subtypes are more agressive.
• Iso-attenuating with uterine tissue.
• Post-contrast: heterogeneous diffuse thickening of the endometrium or as a hypodense polypoid mass.
• Tumor spreads by direct invasion of the endometrium, then lymphatic channels or direct extension to the parametrial tissues.
• Diffuse peritoneal spread may occur.
• Metastases: lung, bone, liver and brain is more common than cervical cancer.
• Recurrence: soft-mass tissue local or nodal enlargement. Generally <2 years.

Question 13

Müllerian mixed tumor

Answer 13

• Sarcoma of the endometrium.
• Massive enlargement of the uterus, large areas of necrosis and hemorrage withing the tumor.
• Rapid growth of metastases

Question 14

Ovarian cancer

Answer 14

• 66% cystic. 25% bilateral. 15% endocrinally fuctional.
• Primary route of tumor spread is throughout the peritoneal cavity. 70% present at the time of the diagnosis.
• Direct extension: pelvic organs (uterus, colon, small bowel and bladder), lymphatic spread (renal lymphnodes) and hematogenous spread (lung, liver, bone).
• CT findings: Usually cystic with thick irregular walls, internal septations, prominent soft-tissue components. May be mixed cystic/solid, calcifications may be evident.
• Peritoneal implants: subtle thickening of peritoneum, soft tissue nodules, omental cake. Ascites = peritoneal spread.

Question 15

Normal ovaries

Answer 15

• 4 x 3 x 2 cm.
• Follicles < 3 cm.
• Normal corpus luteum.

Question 16

Ovarian benign adnexal findings

Answer 16

• Normal corpus luteum.
• Functional ovarian cyst.
• Hemorragic functional cysts.
• Benign cystic teratoma.
• Paraovarian cyst.
• Endometriomas
• Hydrosalpinx
• Spinal mengieal cyst.

Question 17

Pelvic inflammatory disease

Answer 17

• Infection by Neisseria gonorrhoeae or Chlamydia trachiomatis or polymicrobial.
• CT: Thickening of the fallpoian tubes and enlargement and abnormal enhancement of the ovaries.
• Advanced disease: Dilated fallopian tubes, filled with complex fluid collections with septa, debris, fluid-fluid levels or gas in the adnexa.
• Complication: Tubo-ovarian abscess.

Question 18

Adnexal torsion

Answer 18

• Ovary, fallopian tube or both.
• Types: Partial, impairing only venous drainage, complete, occluding arterial supply or intermittent.
• Unrelived torsion may result in a hemorragic infarction.
• CT findings: previus adnexal mass, thickening of the wall of the fallpoian tube (>3 mm), tubal distention, smooth thickening of the wall of the mass, pelvic ascites, deviation of the uterus to the affected side.
• DD: Tubo.ovarian abscess, ectopic pregnancy, ruptured memorrhagic ovarian cyst.

Question 19

Prostate ENLARGEMENT

Answer 19

• Enlarged, with a lobulated contour.
• Cystic degeneration and coarse calcifications are common.
• Bladder base is elevated, and the prostate projects it self to the bladder lumen.
• Bladder thickening and trabeculation result from chromic bladder outlet obstruction.

Question 20

Prostate cancer

Answer 20

• Second most common cancer in males.
• Spreads from direct extension from peripanreatic tissues and the seminal vesicles.
• Lymphatic spread is similar to bladder cancer.
• CT does not accurately demonstrate intraprostatic architecture and is poor at demonstrating intraprostatic tumor.
• Enlargement of the prostate is common and may be: benign or malign.
• Asymmetric size of the seminal vesicles and infiltration of fat between the bladder base, prostate and seminal vesicules are evidence of tumor involvement.
• Nodules >10 mm

Question 21

Cystic lesions of the prostate

Answer 21

• Prostate abscess.
• Prostatic utricle cysts.
• Müllerian duct cysts.
• Cysts associated with benign prostatic hypertrophy.
• Prostate retention cysts.
• Cystadenoma.
• Cystic appearance of prostate carcinoma is rare.

Question 22

Testicular cancer

Answer 22

• Seminomas 55%: Radical inguinal orchictomy and radiation, does not require retroperitoneal node dissection for staging. Highly curable.
• Non-seminomas 45%: germ tumors (embryonal cell carcinoma, yolk sac tumors, teratoma and choriocarcinoma. Treatment: QT + QX.

Question 23

Most common testicular malignancy in Males >60 years old

Answer 23

B-Cell Lymphoma

Question 24

Undescended Tests

Answer 24

• High risk of malignancy (48 fold risk) and torsion (10 fold risk).
• Appear as an oval soft-tissue density up to 4 cm, usually atrophic in the inguinal canal.