Cross-sectional Imaging of Ovarian and Isolated Fallopian Tube

Cross-sectional Imaging of Ovarian and Isolated Fallopian Tube Torsion
Leah E. Binkovitz1, James Naprawa M.D.2, Larry A. Binkovitz M.D.1
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e Ch dren
Th
Ovarian torsion is a rare cause of acute lower quadrant pain in girls. Because the
symptoms are non-specific, the correct pre-operative diagnosis is made in less than half of
patients. Clinicians need to have a high index of suspicion for ovarian torsion when
evaluating these patients. However, often these girls are referred for imaging to "rule out
appendicitis."
te
Department of Radiology,
2
Department of Emergency Medicine
Children's Hosptial, Columbus, Ohio
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R
ad
sti
iolo
gic al In
With the increasing use of CT, rather than US, as the initial imaging study used to evaluate
lower abdominal pain in girls, especially with limited "R/O Appendicitis" CT protocols,
radiologists need to have a high index of suspicion of ovarian torsion when interpreting
studies in this patient population.
Fallopian Tube Torsion
Pathologic Findings
Introduction
Isolated torsion of the fallopian tube, ITFT, was first described pathologically in 1890. It
is a relatively rare condition estimated to occur in about 1 in 1,000,000 women. It has
been associated with several factors including redundancy of the mesosalpinx, dilatation
of the fallopian tube with fluid, blood or pus, adhesions related to prior infection or
surgery, and adnexal masses. These factors are generally rare in premenarchal girls and
isolated tubal torsion is extremely rare in this age group.
It has a strong right-sided predominance likely reflecting the protective effects of
the left-sided sigmoid colon and the increased frequency of imaging and surgery for right
lower quadrant pain.
The purpose of this exhibit is to present the cross-sectional imaging findings of ITFT and
to distinguish this entity from ovarian torsion.
Patients
Retrospective review CCH clinical charts identified 9 patients with the diagnosis of
isolated tubal torsion between 1/1995 and 8/2006, who had preoperative imaging.
Age range: 12 -17yr, mean age 14yr
Presenting symptom was pain (8) and mass (1)
Frequency of ITFT
Side
Size
Viability
Right 7
The purpose of this poster is to review the imaging findings in pediatric ovarian torsion
and to present our imaging experience in a large pediatric series.
Left 2
*
2cm-16cm
8 resected
Ovarian Torsion
Introduction: Ovarian Torsion
s
1
1 cyst excised
Patients
bladder
8 of 9 patients had ipsilateral paratubal cysts associated with the ITFT. Two
patients had contralateral paratubal cysts.
Discussion
Figure 6:
Left hydrosalpinx (arrows) with paratubal cyst (*)
superior to bladder
The age range was newborn to 17 years with nean age of 10.6 years. A bimodal
frequency was observed
Frequency of Ovarian Torsion
12
10
8
Number
of
Patients
8
4
0
5
21 patients
16 patients
5 patients
The diagnosis of ovarian torsion was suggested based on the first imaging study findings in 21
of 42 cases (50%); 12/27 with US, 8/14 with CT and 1/1 with MRI. A second study was
obtained in 10 cases; the diagnosis of torsion was suggested in 2/5 with US, 0/4 with CT and
1/1 with MRI. Overall, the diagnosis of torsion was suggested based on the imaging findings in
14/32 US, 8/18 CT and 2/2 MRI.
*
*
Pathologic Findings
Side:
Right 28
Left 14
Figure 5:
Fourteen year old with left ovarian torsion (*) in located
in the midline posteriorly. There was no ovarian flow
demonstrated with Doppler. Surgery confirmed
hemorrhagic infarction of the torsed ovary.
Resected 38 Detorsed 4
ovarian cyst (Fig 5, 6)
teratoma (Fig. 8, 9)
serous cystadenoma (Fig. 12, 13)
paratubal cyst (Fig. 12)
none*
8 (19%)
8 (19%)
4 (10%)
3 (7%)
19 (45%)
Figure 6:
Three year old with uterine
deviation to the right and
large cystic mass anteriorly
in the pelvis. The left
fallopian tube is
straightened (arrows) and
the normal left ovary is
demonstrated (arrow).
*
Discussion
Ovarian torsion is a relatively rare condition in childhood and it is estimated that 0-4 cases/yr
will be encountered at large pediatric centers. It typically presents with severe lower quadrant
pain, right side more frequently than left and, when right-sided, can be confused with
appendicitis. The clinical presentation is often non-specific and the pre-operative diagnosis is
made in less than 50% of cases even with pre-operative cross-sectional imaging. Imaging
findings have been described in case reports and small series.
*
Figure 12:
Eleven year old with torsion of a left ovarian serous
cystadenoma with an associated paratubal cyst (*). Note normal
right ovary (arrowhead).
*
5
yr
yr
yr
2
yr
yr
yr
Figure 7:
Fifteen year old with rightward deviation of
uterus and straightening of the left fallopian
tube (arrowhead). Large cystic mass
anterior to uterus was found to be torsed
right ovary with cystic necrosis.
Figure 8:
Eight year old with right ovarian
teratoma with hemorrhagic infarction (*)
in the midline. Note normal left ovary
(arrow).
*
*
Imaging Studies
yr
yr
+
18
7
-1
15
yr
5
-1
13 r
y
2
-1
10
yr
6-8
3-5
0-2
US
CT
MR
1st
27*
14
1
2nd
5
cyst
Figure 11:
Nine year old with septated cystic lesion in cul de sac and with normal right
ovary (arrowhead) and leftward deviation of the uterus (* on fundus).
Surgery demonstrated a torsed left ovary with serous cystadenoma.
*pathology often showed necrosis and hemorrhage replacing the torsed ovary
+
8
16
5
-1
2
Age
u
*
1
0
13
6-
LT
-1
3-
bladder
RT
2
10
0-
b
3
Uterine
37 patients
4 patients
1 patient
Ovarian torsion is associated with other ovarian pathology in approximately 50%-85% of cases.
These abnormalities include cysts (25%), benign germ cell tumors (20%), and serous
cystadenoma (8%). Torsion of normal ovaries is associated with elongated ovarian ligaments,
hydrosalpinx, or abrupt abdominal movements or changes in pressure.
6
4
Torsed Ovary
Imaging with US has traditionally been the initial study for evaluation of pelvic pain in girls;
however, with increased utilization of CT, radiologists need to be aware of the CT findings of
ovarian torsion in order to make a timely diagnosis and to increase the chances of ovarian
salvage. It should be noted that a hemorrhagic ovarian cyst can give similar grayscale and
color doppler findings as an ovarian torsion.
6
2
7
Number
of
Patients
midline
ipsilateral
contralateral
Associated Mass (23/42, 55%)
Retrospective review identified 42 patients with the diagnosis of ovarian torsion between
1/1995 and 3/2007 who had preoperative cross-sectional imaging studies and surgical
findings available for review at Columbus Children's Hosptial.
The chief complaint was pain in all patients but the primary clinical impression before
imaging included appendicitis (9), urolithiasis (2), intussusception (2).
Fallopian tube torsion is a rare cause of acute pelvic pain in peri-menarchal girls. It may occur with a
normal fallopian tube but often is associated with hydrosalpinx, adnexal masses, especially paratubal
cysts, or pelvic adhesions. Within the limitations of a retrospective review, none of our patients were
shown to have a risk factor for fallopian tube torsion other than paratubal cysts. These cysts are rare in
prepubertal girls and were present in nearly all of our patients. The pre-operative diagnosis is rarely made
and was suggested in only one of our patients. All but one of the torsed tubes in our series were resected;
contralateral paratubal cysts were drained when identified at laparoscopy. Nearly all patients were imaged
with US and adnexal pathology was commonly idenfied as a cyst or complex cyst. The recognition of the
dilated fallopian tube was confirmed in a single case only. The identification of the normal ovary on the
affected side, in the presence of an adnexal cystic mass should suggest the possibility of tubal torsion. CT
and MRI may be beneficial in demonstrating the fallopian tube abnormalities more clearly, but surgical
exploration is often required despite lack of a firm pre-operative diagnosis.
The torsed ovarain maxium diameter ranged between 3 and 15 cm and averaged 7 cm.
Imaging Studies
US
CT
1st
8
1
2nd
1
1
Figure 2:
Longitudinal transabdominal US shows large paratubal
cyst (*) superior to bladder (b) and uterus (u).
sc
Imaging Findings
The dilated fallopian tube occasionally may be demonstrated (Fig. 6) with thickened
walls and complex fluid indicating hematosalpinx. Beaking of the fallopian tube at the
uterine infindubilum may be identified indicating torsion. Non-enhancement of the
fallopian tube has been reported with CT and MRI. Doppler waveforms may show a
high resistance pattern (Fig. 7).
adnexal cyst
complex mass
normal exam
6 patients
2 patients
1 patients
cyst
cyst
Imaging studies typically demonstrated a midline cystic structure. It may have a simple
cystic appearance (Fig. 1) or show signs of hemorrhage (Fig. 2, 3). Identification of the
normal ipsilateral ovary is a key finding and can permit the preoperative diagnosis of
isolated fallopian tube torsion to be suggested (Fig. 4, 5).
Figure 4:
Transverse image from a transabdominal US
demonstraes normal ovaries bilaterally (arrows). A
small paratubal cyst was demonstrated at surgery
with a cyst torsion. A cyst excision was performed.
Figure 3:
Longitudinal transabdominal ultrasound image of a
right paratubal cyst with torsion. Note internal
echoes within cyst found to represent hemorrhagic
fluid at surgery.
Marked asymmetry of adnexal Doppler signal in 2/3 patients
Torsed Tube/Cyst Position
midline
ipsilateral
contralateral
5 patients
3 patients
0 patients
cyst
cyst
u
u
Uterine position
4 patients
2 patients
3 patients
u
Summary
bladder
u
Figure 5:
Right sided paratubal cyst with torsion
of the fallopian tube noted superior to
bladder. The uterus is deviated
rightward (u) with the normal ovary
noted adjacent to the uterine fundus on
the right (arrow). The normal left ovary
is identified as well (arrow).
4 1
*Before 2003, 19 of 24 first studies were US. A fast appendicitis CT protocol was
introduced in late 2002; afterwards 8 of 18 first scans were US.
Figure 7:
Doppler Evaluation of the right adnexa demonstrates
high resistance waveform; a right ITFT was confirmed
surgically. Note normal waveform on the left.
Though rare, radiologists should consider fallopian tube
torsion in peri-menarchal and post-menarchal girls who
present with lower quadrant pain when imaging findings
demonstrate normal ovaries but a dilated and tortuous
fallopian tube, especially when an extra-ovarian adnexal cyst
is demonstrated.
Hematosalpinx, as demonstrated with MRI, or lack of
fallopian tube wall enhancement, as demonstrated with MRI
or CT, also suggest the diagnosis of fallopian tube torsion.
Rapid diagnosis may permit urgent surgical intervention and
tube salvage with preservation of fertility.
References
1.
2.
3.
4.
5.
6.
7.
Bondini, Pediatric Radiology 2002
Orazi, Pediatric Radiology 2006
Low, Australasian Radiology 2005
Okada, Journal of Pediatric Surgery 2002
Genardy, Am J of Obstetrics and Gynecology 1977
Athey, American Journal of Radiology 1985
Kim, American Journal of Radiology 1995
*
bl
Age
Figure 1:
Transabdominal US demonstrates normal right and
left ovaries (RT, LT respectively). The uterus is
deviated toward the side of torsion (arrow). There is
a large oval cystic mass in the cul de sac extending
toward the left adnexal proven to be a torsed right
fallopian tube with a 9cm paratubal cyst.
L
LT
Imaging Findings
Gray scale US, findings included:
- asymmetric ovarian enlargement (Fig. 1)
- peripheral ovarian follicles (Fig. 2, 3)
- complex pelvic mass, often midline above bladder or in the cul de sac (Fig. 4, 5)
- cul de sac fluid
Figure 1:
Fifteen year old with enlarged right ovary
(calipers, 6.5 cm) with preserved blood flow
and normal Doppler waveform. Normal left
ovarian arterial waveforms for comparison.
At surgery, the right ovary was viable and
detorsed successfully.
Figure 2:
Twelve year old with hemorrhagic
right ovarian torsion. Note numerous
peripheral follicles in the torsed right
ovary (arrowheads), cul de sac fluid
and normal left ovary (arrow).
Figure 9:
Sixteen year old with torsed left ovarian dermoid centered posteriorly
just left of midline. Note small areas of fatty density (arrowhead) and
calcification. The right ovary was shown to be normal with US and CT
Figure 13:
Eleven year old with complex,
septated midline pelvic mass (*)
superior to bladder (bl) with thick
rim of tissue (crosshairs). Posterior
multiloculated mass (arrow). The
normal ovaries were not identified
with imaging. At surgery, the
anterior mass represented a torsed,
necrotic left ovary and the posterior
mass was found to be due to right
ovarian serous cystadenoma (sc).
Figure 14:
Twelve year old with large cul de sac mass
(*), absence of normal right ovary and
normal left ovary (L). Dopplar wavefr=orms
are asymmetric with higher resistance flow
on right. At surgery a hemorrhagic cyst was
noted but no torsion.
CT and MRI findings included:
Summary
- the findings at gray scale sonography
- lack of ovarian enhancement
- uterine deviation towards side of torsion with straightening of contralateral fallopian
tube (Fig. 6, 7)
The diagnosis of ovarian torsion remains elusive despite advances in imaging
techniques. US demonstration of a twisted vascular pedicle with the whirlpool
appearance with color imaging has increased the specificity of the imaging diagnosis.
However, clinicians tend to prefer to rule out a wide variety of diagnoses in patients
with lower quadrant pain, including appendicitis, intussusception and urolithiasis, and
use CT imaging for this purpose. Radiologists need to consider ovarian torsion in these
patients, especially if a midline pelvic mass is demonstrated and both ovaries can not be
reliable identified.
*
Doppler US findings include:
- asymmetric ovarian blood flow with reduced or absent diastolic flow in the affected
ovary (Fig. 5)
- twisted vascular pedicle with whirlpool appearance (Fig. 10)
- blood flow can be preserved due to dual blood supply of the ovary
In all patients, a pelvic abnormality was identified and nearly always attributed to adnexal
pathology. The pelvic abnormality was described as a cystic or complex cystic-solid mass in
all 41/42 cases. In one patient a cul-de-sac torsion of a benign ovarian teratoma was thought
to possibly represent as an over-distended rectum. Re-imaging later that day confirmed a culde-sac teratoma. Because many of the torsed ovaries were demonstrated as complex masses in
the midline, identification of the ovaries in normal position is a crucial imaging observation.
In one patient a "normal ovary" was demonstrated on the side later shown to be involved with
an ovarian torsion. In 9 cases normal contralateral ovaries could not be identified.
References
Figure 3:
Ten year old with large cul de sac mass
with low density peripheral follicles
(arrowheads). The normal left ovary
with normal enhanced appearance of the
fallopian tube (*).
Figure 4:
One month old with right-sided complex
mass found to be an infarcted right ovarian
torsion at surgery.
Figure 10:
Twisted vascular pedicle (arrow) with whirlpool configuration of the artery
and vein (color doppler).
reprinted from Vijayaraghavan, S, J Ultrasound Med, 2004
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