CASE DISCUSSION

1. CASE DISCUSSION Dr. Harsha K J DEPT OF RADIODIAGNOSIS SSG Hospital & Medical College Baroda 28/07/06

2. Case-1 • 28-year-old woman presents with infertility, menstrual disorders, and pain.

4. DIAGNOSIS • Tuberculosis of endometrium & both fallopian tube (Endometrial biopsy).

5. Discussion • Female genital tuberculosis is invariably secondary to tuberculosis elsewhere, and spread may be hematogenous (most common), via the lymphatic system, or by direct spread from adjacent organs. • Patients usually present with infertility, menstrual irregularity, and pain. • Pregnancy is rare in the presence of genital tuberculosis and is often complicated by ectopic pregnancy or spontaneous abortion. • Clinical features of female genital tuberculosis, if any, are nonspecific and diagnosis may be difficult.

6. A definitive diagnosis of endometrial involvement can be made using endometrial biopsy. • The endometrial cavity may be obliterated by adhesions and thick synechia. In end-stage disease, the endometrial cavity may be completely obliterated. • Tubal obstruction is common, as are hydrosalpinx and pyosalpinx. • In end-stage disease, the tubes become rigid and pipelike, because of fibrosis, and they lack peristalsis.

7. Pathology • Genital tuberculosis is mostly acquired by haematogenous spread from an extragenital source. • The primary focus of genital tuberculosis is the fallopian tubes, which are almost always affected bilaterally but not symmetrically. • The tubes are thickened and show a rough external surface with adhesions. • Caseous ulceration of the mucosa produces ragged contours and diverticular outpouchings of both the isthmus and ampulla.

8. As tuberculosis heals, the entire tube become encased in heavy connective scar tissue and the lumen develops a beaded, rigid pipe stem appearance. • The obstruction of the tube most frequently occurs in the region of transition between the isthmus and the ampulla. • Although hydrosalpinx is very uncommonly noted in the western literature, it is a common finding in India. • Tubal tuberculosis spreads to the endometrium in approximately one half of the cases. • Therefore a negative culture from uterine curetting does not exclude the diagnosis of genital tuberculosis.

9. Tubal tuberculosis • Calcifications • Plain films of the pelvis may show calcification of the fallopian tubes or ovaries. • This calcification must be differentiated from calcified pelvic nodes, calcified uterine myomas, pelvic phleboliths and calcification in an ovarian dermoid. • Tubal calcification can take the form of linear streaks, which lie in the course of the fallopian tube or appear as faint or dense tiny nodules.

11. Tubal outline • Caseous ulceration of the mucosa of the tube produces an irregular contour of the lumen of the tubes. • Diverticular cavities may surround the ampulla and give it a characteristic "tufted" appearance. • Isthmic diverticula resembling those seen in Salphingitis isthmica nodosa. • Blind ending sinus tract or occasionally fistula to adjacent bowel may be seen.

12. 30-year-old woman with genital tuberculosis. Hysterosalpingogram frontal projection shows occlusion of bilateral tubes in the ampullary region with multiple diverticula bilaterally (small arrows). The thick arrow indicates terminal hydrosalpinx.

13. Tubal occlusion • Tubal occlusion in tuberculosis occurs most commonly in the region of isthmus and ampulla. • Multiple constrictions along the course of fallopian tube can form because of scarring and give rise to "beaded" appearance. • Scarring also leads to a "rigid pipe stem" appearance of the tubes. • Tubal occlusion is the most common HSG finding encountered in genital tuberculosis.

14. Cornual occlusion is the most common site of tubal occlusion of any cause followed by obstruction in the ampullary segment. • However, cornual occlusion is not so common in tuberculosis. • Other causes of tubal occlusion include pelvic inflammatory diseases due to Chlamydia and gonococci, prior pelvic surgery, Crohn's disease, ulcerative colitis, endometriosis, and the use of intrauterine contraceptive device

15. 25-years-old woman with genital tuberculosis. Hysterosalpingogram frontal projection shows ampullary obstruction of both fallopian tubes. The tubes appear rigid "pipe-stem" and are beaded. There is a lucent filling defect in the lower uterine segment suggestive of adhesion (arrow).

16. 27-year-old woman with genital tuberculosis. (a) Hysterosalpingogram shows isthmic obstruction of both the tubes. The left tube shows "beaded" appearance (small arrows). Also seen are irregularity of the endometrial cavity and intravasation of the contrast medium. (b) Hysterosalpingogram next film shows multiple diverticula in the isthmic portion of the right tube (arrowheads) giving salpingitis isthmica nodosa like appearance.

17. Tubal dilatation • Tuberculous hydrosalpinx is common in India, hydrosalpinx is usually moderate or slight with a club like appearance to the ampulla. • Thickened mucosal folds in the dilated tubes are the commonly seen feature in tuberculosis. • Other causes of tubal dilatation include other pelvic inflammatory diseases, adhesions and obstruction of any cause.

18. Peritubal adhesion • Distal tubal disease usually appears secondary to peritubal adhesions. • These adhesions disrupt the delicate anatomical relationship between the tube and the ovary, interfering with normal ovulation. • The presence of a convoluted or corkscrew fallopian tube, peritubal halo, tubal fixation and loculated spillage of contrast material is suggestive of peritubal adhesions. • Other causes of pelvic adhesions include other chronic pelvic inflammatory conditions, previous surgery and endometriosis.

19. 28-year-old woman with genital tuberculosis. Hysterosalpingogram shows bilateral tubes convoluted and fixed. There is a loculated spill (small arrows) on the right side suggestive of adhesions.

20. 33-year-old woman with genital tuberculosis. (a) Hysterosalpingogram shows bilateral isthmic block. Both the tubes are vertically oriented and appear fixed. The right tube shows "cork screw" appearance (small arrows). (b) On injecting more contrast hysterosalpingogram shows intravasation of contrast medium (arrowheads). At laproscopy lots of adhesions were seen in the pelvis with multiple tubercles on the uterine surface.

21. Endometrial tuberculosis • Endometrial tuberculosis has been reported to have a non-specific appearance on HSG, commonly characterized by synechiae, a distorted uterine contour, and venous and lymphatic intravasation. • A characteristic HSG feature suggestive of tuberculosis has been described in which irregular contrast distribution occurs resembling a cotton-wool plug appearance. • The synechiae and intrauterine adhesions in tuberculosis are characteristically irregular, angulated and stellate shaped with well-demarcated borders. • Other causes of intrauterine adhesions include dilatation and curettage, trauma, surgery and other infections.

22. Unilateral scarring may lead to obliteration of the uterine cavity on one side giving rise to a unicornuate like appearance called "pseudounicornuate" uterus. • Scarring in tuberculosis may result in conversion of the triangular uterine cavity into a T-shape. • These T-shape uteri are very similar to those seen in Diethylstilbestrol uteri. • An asymmetric small sized uterine cavity is usually due to tuberculosis.

23. Venous and lymphatic intravasation is a good indicator suggesting endometrial tuberculosis. • It is not specific for tuberculosis and can be seen in HSGs done early in the menstrual cycle, shortly after endometrial instrumentation and in any condition causing obstruction to the flow of contrast such as intrauterine adhesions and tubal obstruction of any aetiology. • Although the various features described are not specific for genital tuberculosis, they are highly suggestive of it.

24. The diagnostic criteria established by Klein et al is very useful for this purpose: • Calcified lymph nodes or smaller, irregular calcifications in the adnexal area. • Obstruction of the fallopian tube in the zone of transition between the isthmus and the ampulla. • Multiple constrictions along the course of the fallopian tube. • Endometrial adhesion and or deformity or obliteration of the endometrial cavity, in the absence of curettage or surgical termination.

25. 32-year-old woman with genital tuberculosis. Hysterosalpingogram frontal projection shows two lucent defects (large arrows) in the lower uterine segment suggestive of intrauterine synechiae. There is contour defect of the left side of the fundus (small arrows).

26. 40-year-old woman with genital tuberculosis. Hysterosalpingogram shows isthmic obstruction of both the tubes (large arrows). The uterine cavity is deformed and shows "T" shaped configuration (small arrows). Also note the intravasation of the contrast medium. There is fundal impression on the uterine cavity (black arrow).

27. DES exposure. HSG image shows T configuration of endometrial cavity (arrow).

28. 27-year-old woman with genital tuberculosis. She had completed 9 months of antitubercular treatment. Hysterosalpingogram shows isthmic obstruction of bilateral tubes (curved arrows). The calcification (large arrow) is seen in the path of the right tube. The uterine cavity is deformed with indentation of the fundus (black arrow). There is a lucent area (arrowheads) in the uterine cavity suggestive of intrauterine adhesion. Also seen is a small diverticulum from the fundus on the right side (small arrows).

29. 32-year-old woman with genital tuberculosis. Hysterosalpingogram shows small contracted uterus with irregular outline.

30. Reference • eMedicine November 5, 2004. • British Journal of Radiology (2004) 77, 164-169.

31. Case-2 • Elderly male presents with epigastric pain & vomiting.

33. D/D Cystic Pancreatic Lesions • PSEUDOCYST • Common cystic pancreatic neoplasm- A- Serous cystic neoplasm B- Mucinous cystic neoplasm C- IPMN (Intraductal papillary mucinous tumor)

34. Morphologic Classification of Cystic Pancreatic Lesions Unilocular cysts Microcystic lesions Macrocystic lesions Cysts with a solid component

36. Unilocular Cysts • Unilocular cysts include pancreatic cysts without internal septa, a solid component, or central–cyst wall calcification. • Pseudocyst is the most common and the most frequently encountered cystic lesion in this group. • Other less commonly encountered unilocular cysts include IPMNs, unilocular serous cystadenomas, and lymphoepithelial cysts. • These lesions can be differentiated from pseudocysts on the basis of lack of clinical, laboratory, and imaging evidence of pancreatitis.

37. A unilocular cyst in a patient with a clinical history of pancreatitis is almost always a pseudocyst. • Communication of the pseudocyst with the pancreatic duct may be seen at MRCP or CT, especially on curved reformatted images. • Cyst communication with the pancreatic duct can also be seen in IPMNs ; however, IPMNs demonstrate a narrow neck at the cyst-duct junction on CT scans or MRCP. • Precise characterization of a unilocular cyst on the basis of imaging findings alone can be difficult in the absence of pancreatitis or obvious cyst communication with the pancreatic duct. • When there is a unilocular cyst with a lobulated contour located in the head of the pancreas, one should consider a unilocular macrocystic serous cystadenoma.

38. Asymptomatic thin-walled unilocular cysts can be monitored with CT or MR imaging, especially when they are small. • Usually small (<3-cm) unilocular cysts are almost always benign, so in these cases a conservative approach using imaging follow-up is appropriate. • Follow-up schedule, • At 6-month intervals for the 1st year, • Followed by annual imaging for a period of 3 years. • If cyst stability has been established at this point and the patient remains symptom free, no further work-up may be needed. • When present, multiple unilocular cysts are most often pseudocysts resulting from prior pancreatitis. Other causes of multiple cysts include von Hippel–Lindau disease and, rarely, IPMN. • In von Hippel–Lindau disease, the pancreas is otherwise healthy and cysts may also be present in the kidneys or liver.

39. Pseudocyst. CECT scan shows a well-defined unilocular cyst (arrow) in the head of the pancreas. Endoscopic US image helps confirm the unilocular nature of the cyst.

40. Pseudocyst in a patient with a recent history of pancreatitis. (a, b) Axial CT scan (a) and coronal contrast-enhanced T1-weighted MR image (b) depict a well-defined unilocular cyst (arrow) in the tail of the pancreas. (c) T2-weighted MR image shows the cyst (arrow) with homogeneously bright signal intensity, a finding that confirms the unilocular nature of the cyst.

41. Side-branch IPMN manifesting as a unilocular cyst. (a) Contrast-enhanced CT scan demonstrates a small cyst (arrow) in the head of the pancreas. (b) Coronal oblique single-shot fast spin-echo MRCP shows communication of the cyst (arrow) with the main pancreatic duct (arrowheads), a finding that helped establish the diagnosis.

42. Multiple unilocular cysts in a patient with von Hippel–Lindau disease. Contrast-enhanced CT scan shows multiple unilocular cysts (arrows) scattered throughout an otherwise healthy-looking pancreas.

43. Microcystic Lesions • The only cystic lesion included in the category of microcystic lesions is serous cystadenoma. • In 70% of cases, these benign tumors demonstrate a polycystic or microcystic pattern consisting of a collection of cysts (usually more than six) that range from a few millimeters up to 2 cm in size. • Fine, external lobulations are a common feature, and enhancement of septa and the cyst wall may be seen. • A fibrous central scar with or without a characteristic stellate pattern of calcification is seen in 30% of cases and, when present, is highly specific and is considered to be pathognomonic for serous cystadenoma.

44. In patients with indeterminate CT findings, further characterization with MR imaging or endoscopic US may be possible. • At MR imaging, the microcysts may be seen as numerous discrete foci with bright signal intensity on T2-weighted images. • Likewise, endoscopic US can help accurately depict these small microcysts as discrete small anechoic areas. • Because of the benign nature of serous cystadenomas, some surgeons recommend imaging surveillance of microcystic tumors as being sufficient in asymptomatic patients.

45. Serous cystadenoma. (a) Contrast-enhanced CT scan shows a classic serous cystadenoma (arrow) in the head and neck of the pancreas. The lesion has the appearance of a solid mass with numerous small cysts ("honeycomb" effect). The lobulated outlines and the calcified central scar (arrowhead) are typical findings in these tumors.

46. Serous cystadenoma (macrocystic variant). CECT scan demonstrates a variant of a serous cystadenoma in the pancreatic body. The mass appears as a septated lesion that contains a few macrocysts (arrow). Note the lobulated outlines of the lesion, a feature that is often seen in microcystic tumors. Serous cystadenoma was confirmed at surgery and histopathologic analysis.

47. Macrocystic Lesions • Macrocystic lesions include multilocular cysts with fewer compartments. In addition, the individual compartments (>2 cm) are larger than in serous cystadenomas. • The cystic tumors in this category include mucinous cystic neoplasms and IPMNs. • Mucinous cystic neoplasms (mucinous cystadenomas) predominantly involve the body and tail of the pancreas, and, although they do not communicate with the pancreatic duct. • At cross-sectional imaging, these neoplasms appear as multilocular macrocystic lesions. The cysts may occasionally contain debris or hemorrhage. • The complex internal architecture of the cyst, including septa and an internal wall, is best appreciated at MR imaging and endoscopic US, allowing differentiation from serous cystadenomas. • Although peripheral eggshell calcification is not frequently seen at CT, such a finding is specific for a mucinous cystic neoplasm and is highly predictive of malignancy.

48. IPMNs can be classified as main duct, branch duct (side-branch), or mixed IPMNs, depending on the site and extent of involvement. • Main duct IPMN is a morphologically distinct entity and cannot be included in the discussion of pancreatic cysts. • The side-branch IPMN or a mixed IPMN can have the morphologic features of a complex pancreatic cyst, making clear-cut distinction from a mucinous cystic neoplasm difficult. • Identification of a septated cyst that communicates with the main pancreatic duct is highly suggestive of a side-branch or mixed IPMN. However, it is important to be aware that lack of communication with the main pancreatic duct at imaging does not exclude an IPMN.

49. Currently, MRCP is considered the modality of choice for demonstrating the morphologic features of the cyst. • The occurrence of malignancy is significantly higher in main duct and mixed IPMNs than in side-branch IPMNs. • Therefore, in cases of side-branch IPMN, the treatment decision should be based on the risk-benefit ratio, taking into account the patient’s clinical presentation, age, and surgical risk and the size and imaging morphologic features of the cyst. • In one study small septated pancreatic cysts that is less than 3 cm in diameter have a low malignant potential, so that aggressive pancreatic surgery may not be appropriate for these patients.

50. Mucinous cystadenoma manifesting as a multiseptated cyst. Axial CT scan shows a cystic lesion with thin septa (arrow). Coronal reformatted image also depicts the lesion (arrow). High-resolution endoscopic US image demonstrates the septated internal architecture of the cyst.