OcToBER,
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TOMOGRAPHY DURING
OF PELVIC-ABDOMINAL INTRAVENOUS UROGRAPHY* ADDED
AN ANTHONY
By
MASSES
DIMENSION
G. PECK,
M.D.,t
RICHARD
C.
and
1975
BOSTON,
ISABEL
C. YODER,
PFISTER,
M.D.,
M.D.
MASSACHUSETTS
ABSTRACT:
Experience quality
with
a wide
tomography
variety
during
high
cystic lesions in almost all of surface contour, absence cification,
and
mass.
of
the
above
diagnosis,
other
cystic
Since tion
masses
can
pausal
used
the and
an
added
female
dimension
to
routine
to separate
cystic
its
exposure
necessity
for
from
lesions.
solid
pelvic-abdominal has, until
recently,
intravenous
masses been
urography;
AND
the Departments Address:
durlim-
and
METHOD
of Radiology,
University
Hospital,
Harvard University
etc.),
While
independent
of
a probable
from calthe
titration
the
clinical
abscess
Medical
With
5chool
of Washington,
322
roentgenologic the
from
the
vided preoperative terization of the tients
had
“pelvic,
of
exception
ultrasound
of
investiga-
addition
is a consideration,
subsequent
Twenty-five masses in 22 patients are presented in which tomography of the pelvic-abdominal mass during urography proFrom
solid
of
separately.
preoperative
usefulness.
radiation
demonstra-
MATERIAL
*
of
good
characterization
in separating
exclusion,
we concur with Love et al.3 that the addition of tomography to the urographic study provides an added dimension since it permits a more accurate assessment of such a mass, in addition to the usual evaluation of the urinary tract.
t Present
assessment
to be a pivotal kidney
in whom the
during
for
evaluated
accurate
ited to secondary signs and inferences. Contrast enhancement of pelvic and abdominal masses has been shown to be a useful technique,”3-6 and recently infusion tomography of the female pelvis has been described.3 Since 1973, we have studied 25 proved pelvic-abdominal masses by tomography
separation
that
mass opacification. Evaluation its features, opacification,
framework
is important
continues pe’vic
OENTGENOGRAPHIC ing
an
permits
indicates
lesions. status,
tion of urography
urography
identified
information
urography
preclude
be
masses
with minimal of a wall and
provides
permits
latter
(ureteral
provides to
status
criteria
the
dose
cases, even or presence
uterine
Multiple
of pelvic-abdominal
of the
premeno-
tomography study
appears
which
has
definition mass. Most
a preoperative
adnexal,
TOMOGRA
been
and characof these pa-
clinical
or
TABLE PELVIC-ABDOMINAL
tomography
diagnosis
abdominal
mass.”
I PHIC
UROGRAPHY
Technique I. Preliminary anteroposterior film of pelvic-abdominal area Determine size pelvic mass: 8 cm. or less: 6 cm. tomogram 10 cm. or more: 12 cm. tomogram 2. Preliminary anteroposterior tomogram of pelvicabdominal area 3. Intravenous urogram (bolus or infusion) 4. Early tomography of mass a. Imm. (bolus) 3-5 mm. (infusion) b. small mass: 4-I cm. levels
.
larger mass: 8-17 cm. levels Standard urography of urinary tract
and Massachusetts Seattle,
General
Washington.
Hospital,
Boston,
Massachusetts.
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VOL.
No.
125,
FIG.
.
(
leiomyoma
tioned No
single
medium
Tomography
2
Case
.,
14
thin-walled of
adhered
tomographic level showing An i8 cm. tomographic level cystic ovarian mass (dermoid)
delivery
to;
Masses
of
were
contrast
patients
re-
(arrows).
dilated
uteri
abscess
was
a 300 ml. infusion urogram, i received a Too ml. bolus of contrast medium, and received a 50 ml. bolus. While tomography was done at times ranging from i to 25 minutes, the present technique is described in Table . Both a preliminary plain film of the abdomen and a preliminary tomogram of the pelvic-abdominal area should be obtained to evaluate subsequent opacification of the mass. Following injection of contrast medium, early tomography is suggested to study the pelvis prior to significant bladder filling. The level of the tomogram generally depends on the size of the mass (Table i). Standard urographic filming completes the examination. These 22 patients with 25 masses (, patients with 2 distinct masses) include 13 ovarian neoplasms, 9 uterine masses, I pelvic abscess, I ectopic pregnancy, and I mesenteric tumor (Table ii). Of the 13 ovarian tumors, 6 were benign cystadenomas, 3 were malignant cystadenocarcinomas, 3 were cystic dermoids, and i was a
ectopic fected,
pregnancy and the
malignant
density (Fig. solid tumors
17
ceived
uterine
solid
masses,
dysgerminoma. 7 were
leiomyomas
Of
the
9
and
2
tumor
323
enlarged posteriorly positioned opacified demonstrating a separate anteriorly posi-
cm.
(B)
(arrows).
method
was
(A) A
i i.)
of uterus multiloculated
of Pelvic-Abdominal
was
of
(hydrometria).
In our
initial of
group and and
The
pelvic-abdominal
raphy
in
1-40
of
patients,
22
pelvic-abdominal
alone.
7) mm.
and inmesenteric
APPEARANCE
made: and
i
the
a fibrosarcoma.
characterized greater clarity
;
origin,
was ruptured abdominal
ROENTGEN
raphy
The
tubo-ovarian
identified detail
following cystic
tomog-
masses
observations tomographic
ovarian
has
lesions with than urography
masses
showed a smooth thick and a lucent
can be urog(Fig.
opacified center
I;
3;
wall in ii of
12 cases (92 per cent), and a separate normal uterus in those cases in which it was evaluated. The I solid malignant ovarian mass presented no wall or opacification, and a smooth surface. In the 2 dilated uterine masses (hydrometria) both (2 of 2) showed the following:
opacified cm.) lucent
wall
of
uniform
with a smooth center, without 2;
(Fig.
and I;
thickness
(i.5
rounded surface and a separate uterine 3). 4;
Of
and
the
6),
7 uterine all (‘ of 7)
A. G. Peck,
324
I. C. Yoder
and
OF
PELVIC-ABDOMINAL
MASSES
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Tomographic Case
Age
Sex
(I)
2!
MW.
F
Tomography
Clinical Diagnosis
Level; Dose Time
Pelvicabdominal mass
z cm. ml. DIP
43
Pelvic
io cm,
F
mass
o ml. bolus indn.
(3) L.M.
34 F
Pelvic mass,
PID
52
cm.
o
ml, bolus mm.
‘5
L adnexal
33
F
(5) C.L.
6 F
Pelvic
(6) V.P.
53 F
Pelvic
mass
cm. lao ml, bolus 52
mass
(8) B.N.
7 F
Pelvicabdominal
(9) E.K.
57 F
Pelvicabdominal mass
(so) MG.
63 F
Patholor
-
-
Round smooth no opacification
surface,
N.E.
Ovarian
mass
Ovarian
dysgerminonia
(solid tumor)
8 cm.
-
+
5 cm.
-
+
i6 cm, oo nil. DIP S mmn, i
mass
I
smooth
mm, smooth
wall and
+
Ovarian
cyst
Ovarian
cyst
wall and
+
Ovarian
cyst
Ovarian
cyst
Ovarian
cyst
Ovarian
cyst
Ovarian
cyst
Ovarian
cystadenonia
surface
4
fli.
-
+ +
I
mm. smooth
wall and
N.E.
surface
z
cm.
+
-
cm,
cm.
+
-
mm. smooth
and
wall
+
(mucinous)
3-c
mm. smooth
and
surface
wall
cm.
-
-
Round
smooth
surface
i8 cm.
-
+
z mm. surface
smooth
wall
26 cm.
-
+
3 funi. smooth wall and lobulated surface
i6 cm.
-
25
ml, DIP
300
i
surface
i z cm. so ml. bolus 25 mm.
mass
i mm. surface
fun.
57 cm.
mass
Pelvicabdominal
50
Uterus
Wall
ml, DIP S mm.
F
Roentgen Diagnosis
ste
Features
300
F.S.
(7)
cm,
20
UROGRAPHY
Findings
Opacifi cation Central
197$
OCTOBER,
S mlii.
(2)
(4)
Size Mass
DURING
.
300
B.J.
J.R.
.
C. Pfister
II
TABLE TOMOGRAPHY
R.
+
Ovarian
cyst
Ovarian
mass
Ovarian
cyst
Ovarian oma
cystadenocarcin-
+
Ovarian
cyst
Ovarian oma
cystadenocarcin.
+
Ca9’ovarian cyst (dermoid)
N.E.
and
N.E.
Ovarian cystadenoma (mucinous)
Ovarian (serous)
cystadenoma
S !nin. ‘7
Cm
ml, DIP
300
5 mmn.
Ovarian
tumor
cm. niL DIP S mit,. i
++
Curvilinear 3 YT., 5-40mm.
300
for
Ca wall
i.
2.
39 F
(I I)
R.C.
64 F
(52)
J.M.
Pelvicabdominal mass
Ovarian
14
300
5
cancer
is
and i8 cm, ml. DIP
zg cm.
-
+ +
IS cm.
+
23X
-
++
-
++
-
++
cm
ml. DIP
52
-
cm.
5 mm.
(‘3) MM.
69 F
Recurrent tumor-carcinonia cervix
300
(‘4) N.H.
35 F
Pelvic mass,
so cm. o ml. bolus
cm.
52
cm.
mm.DIP
5 mm.
PID
MUItilOCUIaT ovarian cyst
i.
i.
Ovarian
-
a. Lelomyoma uterus
2.
Leiomyoma
a contiguous lesions, R: ‘3 cm. IBaSS with i, cm. smooth wail and surface L: io cm. mass with I mm. smooth wall and surface
-
Multilocular ovarian cyst
Is cm. smooth surface
wall and
-
3 mm. surface
wall
-
dermoid
cyst
IBm.
300
i
Superior: multiloculated mass 2 mm. wall
L: ovarian dermoid cyst with squamous cell carcinoma R: ovarian dermoid cyst with carcinoid
cm.
-
+
-
++
Inferior: fication surface
uniform and
smooth
opacilobular
and
i.
2.
N.E.
Hydrometrium
Ovarian
cyst
uterus
R: hematometrium s to obstructing adenocarcinoma endometrium L: ovarian carcinoma
Pyometrium tO fibrosis
cystoadeno-
(sterile)
of cervical
Abscess,
subacute
Infected pregnancy
ruptured
2’
os
I mm.
(Is)
22
D.D.
F
m DIP
-Pelvic -Drip
NA. -Not
Pelvic mass, possible abscess or ectopic pregnancy
inflammatory
Ix cm. 300
mm.DIP
z8 cm.
s-so mm multilocular smooth walled mass
8 mmn.
disease.
infusion pyelogram. applicable.
N.E.
-Not R -Right
evaluated. side.
L -Left side. 2’ “Secondacy.
-
Hemorrhagic ovarian cyst
ectopic
II
(continued)
Tomographic
Findings
TABLE
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Case
Age Sex
.
Clinicai Diagnosis
Ovarian
(z6) CD.
62
(57)
46 F
Pelvic
MS.
Pelvic
cancer
F
57
oo
mass
cm. ml. DIP mm.
.
Size Mas
22
cm.
Opacification
(i8)
4!
F
mass
(ig)
48 F
Pelvic
MT.
(20)
82
Ovarian
A.W.
F
Central +
+
(2’)
6 F
Abdominal mass
(22)
so
Abdominal
S.H.
M
Wall -
-
opacification lobular sur-
Uniform and lobular
opacification surface
N.E.
Pathology
Leiomyoma uterus
Leiomyoma
uterus
-
Leiomyoma uterus
Leiomyoma
uterus
cm. ml. 5 mm.
25
cm.
+
-
Uniform and lobular
opacification surface
-
Leiomyoma uterus
Leiomyoma
uterus
23
cm.
++
-
Uniform and lobular
opacification surface
-
Leiomyoma uterus
Leiomyoma
uterus
13
cm.
+ +
-
Uniform opacification, lobular surface, and broid calcification
-
Leiomyoma uterus
Leiomyoma
uterus
-
Leiomyoma uterus
Leiomyoma
uterus
DIP
57 cm.
ml. 5 mm.
300
DIP
8 cm. 300 ml. mi
DIP
is cm. ml. DIP so mm.
3ocm.
++
17X cm.
+ +
Uniform and slightly face
-
300
pain
Uniform and slightly face
oentgen Diagnosis
7 cm.
17
cancer
Separate Uterus
Features
so cm. ml. DIP 5 mm.
300
mass
.
-
300
E.H.
AM.
Tomographic Level; Dose Time
ii cm. ml. DiP 5 mm.
300
52
-
Uniform
6-
opacification lobular sur-
opacification
NA.
Solid mesenchyFibrosarcoma mal tumor of je- tery junum
of
mesen-
A. G. Peck,
326
I. C. Yoder
and
R.
C. Pfister
5975
DISCUSSION
#{149} f%I Total
body
method
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OCTOBER,
opacification
for
pelvic masses, O’Connor and
then, or
being
of pelvic cation
in solid
opacifying
dose urography. Birnholz,’ reported the as
other
success
in the but
by Since
have cystic
had
lesions
during
structures
masses,
and
in children I963.
authors”2’6
from this “adventitious
present
in
outlining
useful was
accepted
abdominal
first observed Neuhauser
in adults,
variable
is an
demonstrating
high
department, hysterogram” differential
noted in
12
“no. cases
first
diagnosis
. - opacifiof
ovarian
r.
3. G.M., Case 12.) (A) Large oval pelvic mass with thick wall inferolateral on right (arrows) at infusion urography. (B) Urographic tomography demonstrates 2 adjacent cystic lesions: right, /1,drometrium (double tailed arrows) and leJt,ovarian cystadenocarcinoma (solid arrows).
FIG.
had uniform opacification, lobular surface, no wall and no separate uterine density. The i tubo-parametrial mass (abscess, subacute) had an opacified wall 3 mm. thick, a smooth round surface, and lucent center (Fig. 8). The ruptured infected ectopic
pregnancy mm. thick
1-10 i
solid
had with
mesenteric
surface,
multiple
smooth
a lobular neoplasm
uniform
walls
surface. had
The
a lobular
and
opacification
.
no
wall
(Fig. io). Indications examination
diation
and are
exposure
contraindications given
in
data
are
Table listed
to III
and
in Table
the ra-
iv.
FIG.
.
(M.T.,
Case
19.)
pelvic mass on preliminary defined diffusely opacifying at urographic tomography.
(A)
Large,
nondescript
tomogram.
(B)
leiomyoma
of
Welluterus
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VOL.
FIG.
No.
325,
(B.N., mass
.
cystic
Tomography
2
of Pelvic-Abdominal
Case 8.) (A) Large, ill-defined, nonopacified at urographic tomography (arrows) indicate
Masses
mass at infusion urography, probable ovarian etiology
327
and
(B) thin-walled
(cystadenocarcinoma
of ovary).
Fic.
6.
(A.M.,
Case
21.)
on urographic
(A) Opacified
mass
tomogram
arising
on
infusion from
uterus
urogram,
(arrows)
and
(B) opacified mass (/eiomyoma of uterus).
without
wall
A. G. Peck,
328
I. C. Yoder
and
C. Pfister
OCTOBER,
Imray,2
however,
cent cent
of cystic of uterine
ovarian fibroids,
abscesses.
These
per per Downloaded from www.ajronline.org by 50.1.141.206 on 06/22/16 from IP address 50.1.141.206. Copyright ARRS. For personal use only; all rights reserved
R.
of pelvic to
our
own
Recently, small the
Love series
demonstrated
7. (J.R.,
FIG.
pelvic
Case
mass
tomography
Small,
.)
thin-walled, cystic by urographic ovarian cyst) above the
clearly
demonstrated
(corpus
luteum
tomography
during to
solid,
non-
cent
closer
experience. their initial tomography
experience indicates
permits sions the
are
of
in 9 patients.
Our concurrent abdominal masses one (ovarian,
figures
infusion
pelvis
3 8
only
tumor walls, and 33 per
non-tomographic et al.3 presented
with
female
1975
in that
high
dose
the
pelvicuse of
urography
differentiate the uterine, abscess, or poorly
25
cystic leetc.) from
opacifying
tumors
bladder. cystic
masses.”
sented
et al.6
Phillips
excellent
results
in
the “rim sign” in 8o per cent mixed (solid and cystic) ovarian and
homogeneous
cent
of
able
to
masses
distinguish of
was
but
uterine
remaining
none
abscesses graphic
in
leiomyomas,
in the
their
8o
were
from per
20
per un-
ovarian
cent.
Addi-
tubo-ovarian
50
identified
pre-
of cystic and neoplasms,
opacification
uterine
tionally,
have
demonstrating
by
non-tomo-
urography.
9.
FIG.
bowel
absent Ftc.
8.
(N.H.,
(solid
arrow)
Case
with
14.)
A
12 cm.
thick-walled
second thin opacified gin (double tailed arrow) at urographic raphy (subacute abscess).
inner
mass martomog-
Urographic
(A)
showing
uterus
lateral
tomogram
end-on
(arrows)
(post
total
hysterectomy
(B)
salpingo-oophorectomy).
tient
at
mal
uterus
arrows).
urographic (white
of deep and
tomography arrow)
and
pelvis but and biDifferent pabladder
illustrating
sigmoid
colon
nor-
(black
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VOL.
Tomography
No.
TO.
(A) Infusion urogram (B) urographic tomogram (mesenteric fibrosarcoma).
FIG.
2
(S.H.,
colonic
Case
barium
tumor
tomography wall
of
etc.).
will variable
in many standard
The
Good
clearly
in
non-
or
poorly
be
to arise
from
the
sections
at
appropriate
6). Thus, nonopaci usually
with fying
will fail (Fig.
to
cystic
show and
IA;
masses
by 3;
be differentiated.
a wall, and
with that
provides
tomo-
the
evaluation greater
of can addi-
of the definition
and
increased diagnostic accuracy (Fig. 2). The differentiation of the cystic pelvicabdominal mass from nearby adjacent bowel
thickness,
is
not
difficult
change
(Fig.
in
shape,
)
since
and
mm.) showing cm.) demonstrating
left
329
midabdominal mass and residual sharply marginated opacified solid
character of the bowel become apparent serial tomograms. The opacified adjacent uterus is easily identifiable when appropriate
tomographic
levels
bladder
can
be
location
and
should
be TABLE
PELVIC-ABDOMINAL
are
segregated
obtained.
sought
for
of on
UROGRAPHY
wall
tubular
Indications Post menopausal female Known or suspected mass Premenopausal female Septicemia, suspected abscess Malignancy known or highly suspect Male Any age; gonadal shielding Con traindications Possible or known pregnancy History of serious reaction to contrast
its
later
III
TOMOGRAPHY
on
The
because
(Fig.
group masses
Further,
Masses
has may
levels
in the
mass
solid
),
uterus
tomography, pelvic-abdominal
of tomography
opacifying
a
opacified
fibroid surface
graphic
quality
not otherise delineated dose urography (Fig.
uterine a lobular seen
(30 (17
demonstrate
thickness
cases high
).
and
22.)
and
ovarian,
(uterine,
tion
of Pelvic-Abdominal
125,
medium
A. G.
330
Peck,
I. C. Yoder
and
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Standard
EXPOSURE
DURING
PELVIC-ABDOMINAL
Roentgenography
Tomography
*
Courtesy
t
2.o cm.
of Edward phantom
W.
Webster,
Ph.D.,
TOMOGRAPHY
in a male technique
evaluation
0.1
300
0.1
102
12.5
90
300
0.I
143
12.5
68
200
2.0
200
10
68
200
2.0
235
12.5
of Radiologic
of
C. Pfister,
(Fig. need female
io) not
demonstrates be limited
reported 2.
to
3.
General
4.
Hospital 021
I4
assistance Turner,
of and
Misses
Circhy
is 6.
cretory
San
Francisco, M.,
MELAMED,
R.,
and
305-307.
California,
of
female
COOPER,
H.
SCHWARTZ, pelvis.
&
THERAPY
1974,
AM.
NUCLEAR
R. A., MONInfusion tomog-
J.
ROENTGENOL.,
MED.,
1974,
122,
D. J., GRI5COM, N. T., and NEUHAUSER, E. B. D. Further look at total body opacification effect. Brim’. 7. Radiol., I972, 45, 185-192. O’CONNOR, J. F., and NEUHAIJSER, E. B. D. Total body opacification in conventional and high dose intravenous urography in infancy. AM. MARTIN,
ROENTGENOL.,
MED., REFERENCES
BIRNHOLZ,
105,
24-27.
L.,
LOVE,
J.
acknowledged.
I.
1972,
299-307.
technical Rivers,
Radiology,
Society,
CADA,
pelvic-abdominal
sign.
of pelvic masses during infusion excretory urography. Presented at the 75th Annual meeting of the American Roentgen Ray
.
Brown,
lO
J. Evaluation
T.
IMRAY,
Sept.
Office
Massachusetts
Superior
8o
Physics.
M.D.
Research
Massachusetts
(sec.)
Ovarian Level (cm.)t
300
RAD.
Radiology
Absorbed dose (mrads)t
8o
raphy
Richard
197$
ROENTGENOGRAPHY*
70
Section
Time
STANDARD
mA
masses.
Boston,
AND
kVp
urographic films to exclude a dilated bladder or a large bladder diverticulum which may simulate a pelvic mass. It should be noted that the case of fibrosarcoma of the
the
OCTOBER,
(mo cm. ovary). (12.5 cm. ovary).
25 cm. phantom
mesentery that this
C. Pfister
IV
TABLE RADIATION
R.
J. C. Uterine opacification during urography: definition of previously
exun-
1963,
RAD. 90,
63-7
THERAPY
&
NUCLEAR.
I.
J. C., EASTERLY, J. F., and LANGSTON, J. W. Contrast enhancement of pelvo-abdom-
PHILLIPS,
inal
masses:
ff2,
17-21.
rim
sign.
Radiology,
1974,
112,