MRI of the Female and Male Pelvis

290 Pages·2015·28.023 MB·English

by  Riccardo Manfredi, Roberto Pozzi Mucelli (eds.)

Riccardo Manfredi
Roberto Pozzi Mucelli
Editors
MRI of the Female
and Male Pelvis
123
MRI of the Female and Male Pelvis

Riccardo Manfredi (cid:129) Roberto Pozzi Mucelli

Editors
MRI of the Female
and Male Pelvis
Editors
Riccardo Manfredi Roberto Pozzi Mucelli
Department of Radiology Department of Radiology
University of Verona University of Verona
“G.B. Rossi” University Hospital “G.B. Rossi” University Hospital
Verona Verona
Italy Italy
ISBN 978-3-319-09658-2 ISBN 978-3-319-09659-9 (eBook)
DOI 10.1007/978-3-319-09659-9
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014957394
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Contents
1 Magnetic Resonance Imaging of Congenital
Malformation of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Valerio Di Paola , Eugenio Oliboni , Daniela Avolio ,
Riccardo Manfredi , and Roberto Pozzi Mucelli
2 MRI of Endometrial Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . 19
Matteo Bonatti , Lisa Zantedeschi , Flavia Dal Corso ,
Riccardo Manfredi, and Roberto Pozzi Mucelli
3 Uterine Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Claudia Schenk , Federica Spagnolli , Arianna Rossi ,
Riccardo Manfredi , and Roberto Pozzi Mucelli
4 Endometriosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Simona Mautone , Salvatore Belluardo , Valerio Di Paola ,
Luigi Romano , Giovanni Foti , Riccardo Manfredi ,
and Roberto Pozzi Mucelli
5 Fibroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Laura Pavanello , Stefano Cesari , Carlo Biasiutti ,
Riccardo Manfredi , and Roberto Pozzi Mucelli
6 Neoplasms of the Ovary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Maria Chiara Ambrosetti , Livia Bernardin ,
Riccardo De Robertis Lombardi , Stefano Crosara ,
Federica Castelli , Andrea Rockall , Riccardo Manfredi ,
and Roberto Pozzi Mucelli
7 Benign Prostatic Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Teresa Milazzo , Federica Castelli , Beatrice Pedrinolla ,
Emanuele Demozzi , Riccardo Manfredi ,
and Roberto Pozzi Mucelli
8 Adenocarcinoma of the Prostate. . . . . . . . . . . . . . . . . . . . . . . . . 183
Ugolino Alfonsi , Anna Ventriglia , Riccardo Manfredi ,
and Roberto Pozzi Mucelli
9 MR Imaging of the Scrotum. . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Michele Bertolotto , Francesca Cacciato ,
Matilde Cazzagon , and Lorenzo E. Derchi
v
vi Contents
10 Magnetic Resonance Urography. . . . . . . . . . . . . . . . . . . . . . . . . 249
Maria Assunta Cova , Gabriele Poillucci ,
Luca De Paoli , and Maja Ukmar
11 Fetal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Alessia Adami , Sara Mehrabi ,
Alessandro Zaccarella , Anna Ventriglia , Riccardo Manfredi ,
and Roberto Pozzi Mucelli
1
Magnetic Resonance Imaging
of Congenital Malformation
of the Uterus
Valerio Di Paola , Eugenio Oliboni , Daniela Avolio ,
Riccardo Manfredi , and Roberto Pozzi Mucelli
1.1 Introduction 1.2 E pidemiology
Female genital tract anomalies are common C ongenital malformations of the uterus f requency
deviations from normal anatomy with an esti- vary widely owing to different patient popula-
mated prevalence of 1–3 % in the general popula- tions, non-standardized classifi cation systems,
tion and even higher in selected populations such and differences in diagnostic data acquisition.
as recurrent aborters [1 , 2 ]. Because normal pregnancies can occur in women
Their occurrence could be associated with a with MDA and the anomalies are discovered in
variety of clinical presentations ranging between most cases of patients presenting with infertility,
life-threatening complications, severe health the reported prevalence of MDA in the general
problems in the adolescence, and reproductive population is probably underestimated. The over-
problems, although in most of them they are all published data suggest a prevalence range of
asymptomatic [1 – 3 ]. uterovaginal anomalies of 1–3 % in the general
D ue to their high prevalence and possible population, among women with normal and
impact on the reproductive health of women, abnormal fertility [5 – 7 ].
congenital uterine malformations of the female While conceiving is a minor problem for the
genital tract are a challenge for the therapeutic majority of women with MDA, the risk of preg-
decision-making process. nancy loss is truly associated with MDA, and its
The diagnosis of Mullerian duct anomalies prevalence in women with repeated miscarriage
(MDA) is based upon the clinical presentation, is considered to be in the order of 3 %. No racial
physical examination, and subsequent imaging predilection is reported in the literature [5 , 8 , 9 ].
work-up with different imaging methods avail-
able, namely, sonography and magnetic reso-
nance (MR) imaging, among them MR imaging 1.3 Clinical Presentation
takes a leading role, especially in complex uter-
ine malformation [1 – 4 ]. MDA may become clinically evident at different
ages depending on their specifi c characteristics
and associated disorders. In the newborn/infant
V. Di Paola (*)(cid:129) E. Oliboni age, an initial presentation of a palpable abdomi-
D. Avolio (cid:129) R. Manfredi (cid:129) R. P. Mucelli nal or pelvic mass due to a utero and/or vaginal
Department of Radiology , University of Verona ,
obstruction causing intraluminal fl uid retention
Piazzale Scuro , Verona , Italy
e-mail: [email protected] can be discovered.
R. Manfredi, R. Pozzi Mucelli (eds.), MRI of the Female and Male Pelvis, 1
DOI 10.1007/978-3-319-09659-9_1, © Springer International Publishing Switzerland 2015
2 V. Di Paola et al.
I n adolescent age group a delayed menarche Mullerian ducts develop in medial and caudal
or primary amenorrhea with/without a fl uid directions, and the cranial part remains non-fused
retention in the uterus (hematometra) and/or and forms the fallopian tubes. The caudal part
vagina (hematocolpos) may present as a painful fuses to a single canal forming the uterus and the
intra-abdominal tumor. Some patients also have upper two thirds of the vagina. This is called lat-
cyclical pain. eral fusion.
I n childbearing age, MDA can present with In a process called vertical fusion, the inter-
various problems of infertility, repeated sponta- vening midline septum of both ducts undergoes
neous abortions, premature delivery, fetal intra- regression. The caudal part of the vagina arises
uterine growth retardation, and diffi culties during from the sinovaginal bulb and fuses with the
delivery. The defective embryological develop- lower fused Mullerian ducts.
ment can also be associated with congenital mal- The ovaries originate from the gonadal ridge,
formations of other organ systems. Most a completely different tissue than the mesoderm,
frequently, renal malformations like renal agene- forming both the urinary and genital systems.
sis or ectopia can occur. Much less frequent are Hence, associated malformations of the kidney,
bony malformations – most of them occur in a but not of the ovaries, are frequently observed
complex of varying symptoms – like abnormal together with MDA.
scapula, supernumerary or fused ribs, vertebral Pathogenesis of MDA can be basically classi-
malsegmentation, fusion of the vertebral column fi ed into the presence of agenesis, hypoplasia,
(i.e., Klippel-Feil syndrome), and radiocarpal and defects in vertical and lateral fusion of the
hypoplasia. paired ducts [5 ].
Other malformations such as cardiac defects
have been described, but it remains unclear if
some of the associated malformations are caused 1.5 C lasses of Mullerian Duct
in the same development fi eld or if early expo- Anomalies (MDA)
sure to teratogenic agents was causative [7 , 9 ].
The literature does not show increased mortal- The fi rst attempt to classify female congenital
ity for patients carrying an MDA compared to the anomalies goes back to the beginning of the nine-
general population, whereas the morbidity may teenth century; Strassmann described septate and
be increased in some specifi c types of MDA bicornuate uterus and some subgroups of the dis-
causing obstructed Mullerian systems with the orders in 1907. However, the fi rst classifi cation
presence of hematosalpinx (retention of blood in system for categorization of congenital uterine
the fallopian tubes), hematocolpos (retention of malformations was that of the American Fertility
blood in the vagina), and retrograde menses caus- Society (AFS) published in 1988, mostly based on
ing the potential problem of endometriosis [5 ]. the previous work of Buttram and Gibbons [3 , 4 ].
Then other classifi cation systems followed,
but the AFS classifi cation is still the most broadly
1.4 Embryology used, widely accepted among specialists.
The American Fertility Society introduced a
The understanding of the embryogenesis of the classifi cation system that stratifi es MDA into
urogenital female tract is of paramount impor- seven different classes of uterine anomalies
tance to understand the pathogenesis of the dif- (Fig. 1.1 ).
ferent types of MDA.
The female reproductive system develops
from the two-paired Mullerian ducts (synonym: 1.5.1 Class I Anomalies: Dysgenesis
paramesonephric duct) that start off in the embry-
onal mesoderm lateral to each Wolffi an duct D ysgenesis (segmental agenesis and variable
(synonym: mesonephric duct). The paired hypoplasia) of the Mullerian ducts (uterus and
1 Magnetic Resonance Imaging of Congenital Malformation of the Uterus 3
I Hypoplasia/agensis II Unicornuate III Didelphus
(a) Vaginal (b) Cervical (a) Communicating (b) Non Communicating
IV Bicornuate
(c) Fundal (d) Tubal (e) Combined
(c) No cavity (d) No horn (a) Complete (b) Partial
V Septate VI Arcuate VII DES drug related
(a) Complete (b) Partial
Fig. 1.1 Classifi cation system of Mullerian duct anomalies by the American Fertility Society
upper 2/3 of the vagina) (Fig. 1 .1 ). Mayer- 1.5.3 Class III Anomalies: Uterus
Rokitansky- Küster-Hauser syndrome is the most Didelphys
common form of Class I anomaly and includes
agenesis of uterus and vagina [5 , 9 , 10 ] . U terus didelphys is a result of complete non-
fusion of the Mullerian ducts forming a complete
uterine duplication with no communication
1.5.2 Class II Anomalies: between each other (Fig. 1 .1 ).
Unicornuate Uterus Uterus didelphys may be associated with a
longitudinal (75 %) or, more rarely, with a trans-
U nicornuate uterus is the result of partial or com- verse vaginal septum, the latter causing obstruc-
plete hypoplasia of one Mullerian duct (Fig. 1 .1 ) tive hematometrocolpos.
[ 11 ]. Unicornuate uterus may be isolated (35 %) or Endometriosis as a result of retrograde men-
associated with a contralateral rudimentary horn. struation may also occur in these conditions. A
The rudimentary horn presents with or without nonobstructive uterus didelphys is usually
communication to the endometrial cavity and may asymptomatic [5 ].
be associated with or without endometrium, which
is also called no cavity rudimentary horn. In
patients with cavity non-communicating rudimen- 1.5.4 Class IV Anomalies:
tary horn, dysmenorrhea and hematometra may Bicornuate Uterus
occur. Surgical resection either to relieve symp-
tomatic pain or to reduce the risk of potential ecto- B icornuate uterus is the result of incomplete
pic pregnancy is justifi ed. As with every obstructed fusion of the cranial parts of the Mullerian ducts
system, the risk of endometriosis is also increased (Fig. 1 .1 ) [5 – 9 , 1 2] . Two uterine cavities with
with a non-communicating rudimentary horn. normal zonal anatomy can be depicted. The lead-
Renal malformations are common with unicornu- ing imaging feature is a fundal cleft greater than
ate uterus and occur mostly on the same side as the 1 cm of the external uterine contour that helps to
rudimentary horn could be found [5 ]. distinguish bicornuate uterus from septate uterus.