Aust. Radiol. (1976), 20, 239
Bolus Intravenous Injection of Contrast and Sequential Opacification in the Diagnosis of Pelvic Masses Dr. INDRAN DEVADASON, M.B.B.S. (Sydney), D.M.R.D. (London), M.R.C.P. (U.K.), F.R.C.R. Radiologist, District Hospital, Taiping (Perak), Malaysia INTRODUCTION The critical evaluation of the excretory urogram of the gynaecological patient with a pelvic mass was advised first by Dr. Jasen C. Birnholz, 1972"', when he reported the hysterogram sign. The new large bolus technique (I.V.U.) has been very useful in the diagnosis of pelvic masses besides being physiological (modern contrast excreted by glomerular filtration-Sherwood, 197 l'), cheaper than drip infusion, faster, and safer than slow injection, Davies e t a / . , 1975'21. & METHODS MATERIALS Of the many women during a period of 12 months who were investigated in our department by I.V.U. for conditions such as hypertension and urinary tract infection, there were also 52 obstetric and gynaecological conditions. 1 to 2 ml/kg ( =300 to 600 mg lodine/kg) body weight of contrast medium (Conray 280 o r 325, Urovision or Urografin 60%) were used depending on whether blood urea levels were above normal and the size of pelvic mass. After control films. the contrast medium was
injected intravenously very quickly (bolus technique), that is 20 to 30 seconds. Immediate, 5, 10 and 20 minutes (17 in. X 14 in.) abdominal films were taken. Sometimes coned pelvic and renal area films were taken to get a better view of the tumour or kidneys. In a few cases delayed films were also taken. RESULTS 19 cases of leiomyoma (5 not confirmed by surgery-because patients declined or postponed operation-but suggestive on vaginal examination) showed the hysterograrn sign of homogenous persistent opacification ( Figures 1 to 3 ) in all films and the mass was better defined than on the control film. The 2 calcified fibroid cases showed less dense opacification (Figure 4 ) following contrast injection. F I G U R2-Control, ~ immediate, 10 and 70 minute iibdomen films showing persistent opacification and margination during I.V.U. of uterine myoma.
7. a 37-year-old Malay with primary inferA-Case tility 9 years and growing abdominal mass X months.
F I G U R EI--C'ontrol and after-micturition pelvic films of case 15. a 43-year-old Chinese with irregular menses and menorrhagia for 2 years. Note persistent opacification in uterine myoma. A u.vtru/miciii R u d i o I q ~ y .V d . X X . ho. 3. Septczniher. I976
&Case
25. a 51-year-old Malay with abdominal swelling and hypertension 9 months.
239
DR. INDRAN DEVADASON
FIGURE 3 S e q u e n t i a l pelvic films (control, immediate, 10 and 20 minutes) of Case 41, who was a 34-year-old Chinese lady with dyspareunia for 6 months and infertility. She was found to have a bulky uterus and myomectomy was performed. FIGURE 5-Case 29. This 45-year-old Chinese lady had a gradually increasing abdominal mass for 4 months and it turned out to be a left hydrosalpinx. T h e 10-minute radiograph on the right shows the rim sign when compared to the control film.
FIGURE 4-Cbntrol and after-micturition films of Case 2, a 45-year-old Indian woman with 3 months amenorrhoea and 1 month intermittent vaginal bleeding. Persistent opacification in calcified fibroid seen. FIGURE &Case 17, a Chinese girl aged 15 years who presented with a lower abdominal mass and recent pain due to twisted dermoid cyst with 2 teeth. Rim sign very clear, probably due to contrast between wall and fat contents of cyst.
21 cases of cysts (dermoid, broad ligament and ovarian cysts) and one case of hydrosalpinx (Figure 5 ) did not opacify but most of them unless very large, showed the rim sign, Phillips, 1974(6’ of peripheral opacification (Fieures 6 and 7). A little blotchy opacification within the cyst in early films suggested malignancy (Figure 8 ) . There were 8 obstetric patients studied-5 cases of moles/choriocarcinoma (Figure 9), one post-partum case with hypertension, and 2 cases of foetal deaths (Figure 10). one an abdominal pregnancy due to obstructed tubes and the other a 47-year-old patient with inevitable abortion. These vascular uteri opacified well on the immediate film but the opacification faded away on subsequent films. One case each of solid teratoma. ovarian and uterine carcinoma hardly opacified at all. 240
FIGURE 7-This Chinese patient (Case 45) complained of increasing abdominal swelling for 6 months. Rim sign (arrowed) on 5-minute I.V.U. film. Pathologymucinous cystadenorna.
Australasian Radiologv. Vol. X X . N o . 3. September. 1976
BOLUSINTRAVENOUS
INJECTION
OF
CONTRAST A N D SEQUENTIAL OPACIFICATION
FIGURE 8-Blotchy opacification within the rim sign in ('me 13. This Malay lady, aged 31, had an abdominal mass for 8 months and frequency of micturition one month. H istopathology confirmed malignancy-mucinoils cyst adenocarcinoma.
DISCUSSION The sequence and density of opacification seem to indicate the type of vascularity of pelvic tumours. The blood supply of myomas, Faulkner, 1944'::', is obviously related to the cxtent of degeneration. Before necrosis myomas contain a large number of proliferating arteries with hardly any veins in the tumour substance. Myomas do not have only one nutrient artery. The frequent arteriolar tufts seen in corrosion specimens are pointed out as evidence that a rich capillary bed probably exists, emptying towards the periphery of the tumour. There is no evidence of blood entering and leaving a myoma by arterial channels. The peculiar vascularity of myonias is confirmed by radionuclide scans, Rosenthall 1968'7',and pelvic angiography, Lang 1967"', and probably results in interstitial accumulation o f contrast media-causing persistent dense opacification, the hysterogram sign, except in calcified o r necrotic parts. In cystic masses, except very large ones, marginal curvilinear opacification o r the "rim sign", seen in the 5 minute and some subsequent films was probably due to the difference bztween the radiographic density of the opacified wall and cyst contents. Oblique and lateral films or tomography can assist definition of the cyst wall but are not usually necessary. Patchy opacification within the cyst contents especially in the early films probably indicates capillary perfusion of malignant tissue. The rim sign in our single case of hydrosahinx was probably due to the fact that the wall had not become too fibrotic and the bolus technique produces an early high Dlasma concentration; unlike the reports by Phillips ef. al., 1974"j). Transient opacification of uterine masses is
FIGURE 9A-This case 10 of molar pregnancy demonstrates dense opacification on immediate film which fades away o n later films.
FIGURE 9B-Amniogram showing filling defects caused by grape-like vesicles of hydatidiform mole.
FIGURE I0-!Sequential I.V.U. films show early opacification (maximum in immediate injection film ) which fades away on later films in Case 2 8 - d e a d foetus and inevitable abortion. This 41-year-old Chinese woman with 7 children subsequently had her tubes ligated.
due to the total body opacification effect of highly vascular organs such as liver and spleen. Martin, 1972'". 4 further cases not included in this series with persistent opacification of normal uteri were probably due to premenstrual hyperaemia.
DR. INDRAN DEVADASN
A-Persistent
opacification in sequential films.
FIGUREI I--Case 44, a 47-year-old Malay lady with 2 months’ menorrhagia due to interstitial leiomyoma of the uterus.
In a few cases we have given faster bolus injections through large bore (blood donor) needles into both arms to obtain a “poor man’s arteriogram effect” for a direct picture of the vasculature of these pelvic tumours. Figure 11 shows the correlation between this and the contrast injection into the uterine arteries of a resected uterus with interstitial leiomyoma. ABSTRACT/SUMMARY Sequential changes in opacification of pelvic masses occur in women during intravenous urography performed using a large bolus technique. These changes are helpful in diagnosis and include: (1) Persistent dense opacification in myomas, (-2) Immediate Opacification which fades in vascular masses and (3) Rim Sign in Cystic Tumors.
B-“Poor
ACKNOWLEDGEMENTS I wish to thank the Director of Medical and Health Services of Malaysia, Tan Sri Datuk (Dr.) Abdul Majid bin Ismail for permission to publish this paper, Professor W. S. C. Hare for his valuable comments, the Taiping Obstetrics and Gynaecology Unit under Dr. J. Sabaratnam for referring cases and providing clinical data, the Ipoh Pathologist, Dr. Chan Choe Fatt, for prompt reports, a n d my Radiographers who took the excellent films and photographs and typed this manuscript.
C R a d i o g r a p h s of resected specimen showing calcification and arterial supply after injection of contrast.
REFERENCES ‘Birnholz, J. C. (November, 1972) :“Uterine Opacificatioq During Excretory Urography.” Radiology,
l@S, 303-307.
‘Davies, P., Roberts, M. B., Roylance, J. (1975): “Acute Reactions to Urographic Contrast Media.” Br. Med. 1..2. 434-437. ’Faulkner. R. L. (February, 1944): “The blood vessels of the myomatous uterus.” Amer. I . Obstet. Gynec.. 41, 185-197.
‘Lang, E. K. (April, 1967) : “Arteriography i i gynecO10gy.’‘ Radiol. Clin. North America. 5, 133-149.
242
Man’s Arteriogram” from intravenous bolus.
“Martin, D. J. Griscom, N. T., Neuhauser, E. B. D. (March, 1972) : “A further look at the total body opacification effect.” Br. J. Radiol., 45, 185-192. ‘Phillips, J. C., Easterly, J. F., Langston, J. W. (July. 1974) : “Contrast Enhancement of Pelve-Abdominal Masses: The Rim Sin.” Radiology, 112, 17-21. ‘Rosenthall, L. (April, 1968) : “Radionuclide imaging of the uterus with special reference to pregnancy.” Radiology, 90, 750-755.
”Sherwood, T. (1971): The Physiology of Intravenous Urogaphy.” Scienr. Basis Med.. A Review. pp. 336-348. Australasian Radiology. Vol. XX,No. 3 , September. 1976
Bolus Intravenous Injection of Contrast and Sequential Opacification in the Diagnosis of Pelvic Masses Dr. INDRAN DEVADASON, M.B.B.S. (Sydney), D.M.R.D. (London), M.R.C.P. (U.K.), F.R.C.R. Radiologist, District Hospital, Taiping (Perak), Malaysia INTRODUCTION The critical evaluation of the excretory urogram of the gynaecological patient with a pelvic mass was advised first by Dr. Jasen C. Birnholz, 1972"', when he reported the hysterogram sign. The new large bolus technique (I.V.U.) has been very useful in the diagnosis of pelvic masses besides being physiological (modern contrast excreted by glomerular filtration-Sherwood, 197 l'), cheaper than drip infusion, faster, and safer than slow injection, Davies e t a / . , 1975'21. & METHODS MATERIALS Of the many women during a period of 12 months who were investigated in our department by I.V.U. for conditions such as hypertension and urinary tract infection, there were also 52 obstetric and gynaecological conditions. 1 to 2 ml/kg ( =300 to 600 mg lodine/kg) body weight of contrast medium (Conray 280 o r 325, Urovision or Urografin 60%) were used depending on whether blood urea levels were above normal and the size of pelvic mass. After control films. the contrast medium was
injected intravenously very quickly (bolus technique), that is 20 to 30 seconds. Immediate, 5, 10 and 20 minutes (17 in. X 14 in.) abdominal films were taken. Sometimes coned pelvic and renal area films were taken to get a better view of the tumour or kidneys. In a few cases delayed films were also taken. RESULTS 19 cases of leiomyoma (5 not confirmed by surgery-because patients declined or postponed operation-but suggestive on vaginal examination) showed the hysterograrn sign of homogenous persistent opacification ( Figures 1 to 3 ) in all films and the mass was better defined than on the control film. The 2 calcified fibroid cases showed less dense opacification (Figure 4 ) following contrast injection. F I G U R2-Control, ~ immediate, 10 and 70 minute iibdomen films showing persistent opacification and margination during I.V.U. of uterine myoma.
7. a 37-year-old Malay with primary inferA-Case tility 9 years and growing abdominal mass X months.
F I G U R EI--C'ontrol and after-micturition pelvic films of case 15. a 43-year-old Chinese with irregular menses and menorrhagia for 2 years. Note persistent opacification in uterine myoma. A u.vtru/miciii R u d i o I q ~ y .V d . X X . ho. 3. Septczniher. I976
&Case
25. a 51-year-old Malay with abdominal swelling and hypertension 9 months.
239
DR. INDRAN DEVADASON
FIGURE 3 S e q u e n t i a l pelvic films (control, immediate, 10 and 20 minutes) of Case 41, who was a 34-year-old Chinese lady with dyspareunia for 6 months and infertility. She was found to have a bulky uterus and myomectomy was performed. FIGURE 5-Case 29. This 45-year-old Chinese lady had a gradually increasing abdominal mass for 4 months and it turned out to be a left hydrosalpinx. T h e 10-minute radiograph on the right shows the rim sign when compared to the control film.
FIGURE 4-Cbntrol and after-micturition films of Case 2, a 45-year-old Indian woman with 3 months amenorrhoea and 1 month intermittent vaginal bleeding. Persistent opacification in calcified fibroid seen. FIGURE &Case 17, a Chinese girl aged 15 years who presented with a lower abdominal mass and recent pain due to twisted dermoid cyst with 2 teeth. Rim sign very clear, probably due to contrast between wall and fat contents of cyst.
21 cases of cysts (dermoid, broad ligament and ovarian cysts) and one case of hydrosalpinx (Figure 5 ) did not opacify but most of them unless very large, showed the rim sign, Phillips, 1974(6’ of peripheral opacification (Fieures 6 and 7). A little blotchy opacification within the cyst in early films suggested malignancy (Figure 8 ) . There were 8 obstetric patients studied-5 cases of moles/choriocarcinoma (Figure 9), one post-partum case with hypertension, and 2 cases of foetal deaths (Figure 10). one an abdominal pregnancy due to obstructed tubes and the other a 47-year-old patient with inevitable abortion. These vascular uteri opacified well on the immediate film but the opacification faded away on subsequent films. One case each of solid teratoma. ovarian and uterine carcinoma hardly opacified at all. 240
FIGURE 7-This Chinese patient (Case 45) complained of increasing abdominal swelling for 6 months. Rim sign (arrowed) on 5-minute I.V.U. film. Pathologymucinous cystadenorna.
Australasian Radiologv. Vol. X X . N o . 3. September. 1976
BOLUSINTRAVENOUS
INJECTION
OF
CONTRAST A N D SEQUENTIAL OPACIFICATION
FIGURE 8-Blotchy opacification within the rim sign in ('me 13. This Malay lady, aged 31, had an abdominal mass for 8 months and frequency of micturition one month. H istopathology confirmed malignancy-mucinoils cyst adenocarcinoma.
DISCUSSION The sequence and density of opacification seem to indicate the type of vascularity of pelvic tumours. The blood supply of myomas, Faulkner, 1944'::', is obviously related to the cxtent of degeneration. Before necrosis myomas contain a large number of proliferating arteries with hardly any veins in the tumour substance. Myomas do not have only one nutrient artery. The frequent arteriolar tufts seen in corrosion specimens are pointed out as evidence that a rich capillary bed probably exists, emptying towards the periphery of the tumour. There is no evidence of blood entering and leaving a myoma by arterial channels. The peculiar vascularity of myonias is confirmed by radionuclide scans, Rosenthall 1968'7',and pelvic angiography, Lang 1967"', and probably results in interstitial accumulation o f contrast media-causing persistent dense opacification, the hysterogram sign, except in calcified o r necrotic parts. In cystic masses, except very large ones, marginal curvilinear opacification o r the "rim sign", seen in the 5 minute and some subsequent films was probably due to the difference bztween the radiographic density of the opacified wall and cyst contents. Oblique and lateral films or tomography can assist definition of the cyst wall but are not usually necessary. Patchy opacification within the cyst contents especially in the early films probably indicates capillary perfusion of malignant tissue. The rim sign in our single case of hydrosahinx was probably due to the fact that the wall had not become too fibrotic and the bolus technique produces an early high Dlasma concentration; unlike the reports by Phillips ef. al., 1974"j). Transient opacification of uterine masses is
FIGURE 9A-This case 10 of molar pregnancy demonstrates dense opacification on immediate film which fades away o n later films.
FIGURE 9B-Amniogram showing filling defects caused by grape-like vesicles of hydatidiform mole.
FIGURE I0-!Sequential I.V.U. films show early opacification (maximum in immediate injection film ) which fades away on later films in Case 2 8 - d e a d foetus and inevitable abortion. This 41-year-old Chinese woman with 7 children subsequently had her tubes ligated.
due to the total body opacification effect of highly vascular organs such as liver and spleen. Martin, 1972'". 4 further cases not included in this series with persistent opacification of normal uteri were probably due to premenstrual hyperaemia.
DR. INDRAN DEVADASN
A-Persistent
opacification in sequential films.
FIGUREI I--Case 44, a 47-year-old Malay lady with 2 months’ menorrhagia due to interstitial leiomyoma of the uterus.
In a few cases we have given faster bolus injections through large bore (blood donor) needles into both arms to obtain a “poor man’s arteriogram effect” for a direct picture of the vasculature of these pelvic tumours. Figure 11 shows the correlation between this and the contrast injection into the uterine arteries of a resected uterus with interstitial leiomyoma. ABSTRACT/SUMMARY Sequential changes in opacification of pelvic masses occur in women during intravenous urography performed using a large bolus technique. These changes are helpful in diagnosis and include: (1) Persistent dense opacification in myomas, (-2) Immediate Opacification which fades in vascular masses and (3) Rim Sign in Cystic Tumors.
B-“Poor
ACKNOWLEDGEMENTS I wish to thank the Director of Medical and Health Services of Malaysia, Tan Sri Datuk (Dr.) Abdul Majid bin Ismail for permission to publish this paper, Professor W. S. C. Hare for his valuable comments, the Taiping Obstetrics and Gynaecology Unit under Dr. J. Sabaratnam for referring cases and providing clinical data, the Ipoh Pathologist, Dr. Chan Choe Fatt, for prompt reports, a n d my Radiographers who took the excellent films and photographs and typed this manuscript.
C R a d i o g r a p h s of resected specimen showing calcification and arterial supply after injection of contrast.
REFERENCES ‘Birnholz, J. C. (November, 1972) :“Uterine Opacificatioq During Excretory Urography.” Radiology,
l@S, 303-307.
‘Davies, P., Roberts, M. B., Roylance, J. (1975): “Acute Reactions to Urographic Contrast Media.” Br. Med. 1..2. 434-437. ’Faulkner. R. L. (February, 1944): “The blood vessels of the myomatous uterus.” Amer. I . Obstet. Gynec.. 41, 185-197.
‘Lang, E. K. (April, 1967) : “Arteriography i i gynecO10gy.’‘ Radiol. Clin. North America. 5, 133-149.
242
Man’s Arteriogram” from intravenous bolus.
“Martin, D. J. Griscom, N. T., Neuhauser, E. B. D. (March, 1972) : “A further look at the total body opacification effect.” Br. J. Radiol., 45, 185-192. ‘Phillips, J. C., Easterly, J. F., Langston, J. W. (July. 1974) : “Contrast Enhancement of Pelve-Abdominal Masses: The Rim Sin.” Radiology, 112, 17-21. ‘Rosenthall, L. (April, 1968) : “Radionuclide imaging of the uterus with special reference to pregnancy.” Radiology, 90, 750-755.
”Sherwood, T. (1971): The Physiology of Intravenous Urogaphy.” Scienr. Basis Med.. A Review. pp. 336-348. Australasian Radiology. Vol. XX,No. 3 , September. 1976
