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,

Tomography of pelvic-abdominal masses during intravenous urography. An added dimension.

Experience with a wide variety of pelvic-abdominal masses indicates that good quality tomography during high dose urography permits separation of soli...
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