“37 years old female, had a normal delivery 4 months ago. During pregnancy had right sided mild hydro-nephrosis which resolved after child birth. No past history of abdominal/pelvic surgery. Now presented with right iliac fossa pain for 2 days. RIF was tender but no definite palpable lump. Blood tests normal esp WBC/ESR. Her G.P. thought of Renal stone & asked for Ultrasound. When I did the U.S, the kidneys were normal but there was a vascular & tender lesion in the RIF. After discussing with the G.P, I did a 3 phase CT scan.
Following are some relevant images:
1)Doppler US of RIF
2)Axial, Coronal & Sagittal CT images of Abdo/Pelvis.
Can you identify the pelvic organs & the pathology ? ”
Seelan
Posted 2/22/18
Its unfair to wait too long.
Discussion:-
US showed vascular mass of 4x5cm diameter in the RIF. All the blood
path including the pregnancy test were normal.
CT showed part of the appendix & terminal ileum. They were normal.
Uterus is shifted to the right towards the RIF & appears slightly
twisted. There is a cauliflower shaped mass( as identified by Eddie)
on the right side of the uterus which is more anterior owing the
“twist” & is vascular. It is the swollen right ovary which showed
patchy density. On the left side of this, there is a cyst (6-7cm
diameter). In between the ovary & the cyst, a little fluid is seen in
the CT. The cyst is arising from the right ovary. This indicates that
the right ovary is a complicated ovary.
Because the uterus & right ovary appeared twisted & the swollen ovary
is vascular, I thought that it may be “Acute torsion of inflamed
dermoid cyst”.(About 50% of torsion occurs in ovaries with some lesion
& 50% of this are due to Dermoid cysts).
The posterior lesion noted by Eddie is a partly calcified Fibroid of
abt 7-8 cm diameter.
Patient underwent emergency surgery & the Gynecologist thought that it
is “Torsion of right ovarian Tumor”- “Borderline tumor”
The Path report:- Sero-mucinous tumor of ovary.
I have provided an annotated(CT) answer with numbers. Please zoom to
read the letters.
1=Ovarian mass
2=Right Ov Cyst
3=Uterus
4=Fibroid
5= Bladder
Thanks for participating. Even if you(some) have retired, don’t waste
the medical knowledge you gathered so far in your life.
Seelan
News, Views and More from Batch'64, Faculty of Medicine, Colombo, SriLanka 
Dear Seelan,
It can be a unruptured ectopic pregnancy.
LikeLike
Dear Indragee,
That is one of the DD but the pregnancy test was normal.-
Seelan
LikeLike
I agree with Indragee-
Unruptured Ectopic / Ovarian Pregnancy .– this is my Pathological DX .
I am not familiar with the Radiology Imaging- .
I will leave the explanation of the Radiological findings to the Radiology Experts in the Class of 64- after all Iam just a plain old Late Bloomer Locum GP – that retired 17 yrs ago !
LikeLike
Hi Seelan, I do not know why I am attempting this quiz as I am neither an O&G or a Radiologist.However it is great to keep the conversation going.My impression is that the pelvic organs are unusual in arrangement.For a woman 4 months post partum, her uterus has not involuted back to it’s pre graviid state.There also appears to be a rounded mass in the pelvis posteriorly,quite apart from the uterus and the urinary bladder.There is a further abnormality in continuity with uterus which may be the area on the right where the U.S shows a possible A/V . aneurysm..We do not know whether she had any post partum bleeding to raise the possibility of RPOC etc.
We do not know the result of her pregnancy test which will be useful for interpretation.The normal haematology excludes an inflammatory mass.
I cannot clearly identify the ovaries.On the right side there is a suggestion of a cauliflower like shadow. This could be the area where the US abnormality has been noted.
Hence I am reluctant to offer a possible diagnosis.One abnormality that is reliable is the BARTmap on colour Doppler indicating a very vascular lesion suggestive of anA.V aneurysm.?
I hope that does not have anything more sinister.!
Thank you for sharing this interesting case.Eddie.
LikeLike
Dear Eddie,
This is a Gyne case but I show these to GPs as well for education. Most cases are initially referred for Radiology by GPs.
You have correctly identified that there is a mass posterior to the uterus & there is a vascular “cauliflower” like lesion on the right which is the same as in the US.
Hope some of our Gynaecology mates look at these images too.
LikeLike
Message from Rani
Sorry Seelan ..I
I have no clue?.?
Rani
LikeLike
Dear Seela,
Sorry I do not have a clue, but it is very interesting to read the discussion. Praxy
LikeLike
Dear Seelan,
Is it too unrealistic to consider lithopaedian possibly of undeveloped second of twin of the previous pregnsncy?
Ariya
LikeLike
Rare possibility but not in this case.
Clue: After emergency surgery, she now symptoms free.
I am going to KL tomorrow. I am posting the answers to Sam.
LikeLike
I have been following the comments. I have no clue. Will wait for the final answer.
Nisantha
LikeLike
I am clutching on straws here.
Is it haematocolpos?
Ariya
LikeLike
Gynecology Point Of View—- Mass ,posterior to uterus, , could be a twisted ovarian mass, ?pseudo mucinous Cystadenoma. Partially involuted uterus.
WIMAL FERNANDO.
LikeLike
Dear Wimal,
The mass posterior to the uterus is not twisted ovary, but you are getting warmer. I have already posted the answer to Sam.
We just arrived in KL. it’s very hot & humid.
LikeLike
Hey Wimal Dostara- well done Wimal , you just about ‘nailed the quiz ‘ !
Very interesting quiz from Seelan .
The Pregnancy was a ‘red herring ‘
I wonder if these tumors are affected by the hormonal effects of pregnancy ? .
eaglemd .
LikeLike
Hi Seelan
Is this an extra uterine pregnancy . The one in the womb successfully delivered . The second twin is now undergoing disintegration and the highly vascular structure you described is the placenta which received its blood supply from the branches of the mesentric vessels.
What is the nationality of this patient. Is she of African origin as extra uterine pregnancies have been described among them.
LikeLike
On second thought the patient had two large fibroids one from the posterior wall of uterus and the other on right side . The later was pressing on the right ureter during pregnancy causing mild hydronephrosis. Once the baby was delivered the right fibroid must have undergone red degeneration resulting in RIF pain and relieving the pressure symptoms on the right ureter
Surgery either Myomectomy or hysterectomy.
LikeLike
I hope Path Cooray is listening .
And, Visva/ Ranaya, and Prof Nava ( Surgery ) are examining us all over again on the Long Case !!
Seelan– All of them will be very proud of your ‘case ‘ – and give you Full Marks at the Exam !
Have that ‘bottle ‘ready to celebrate – and share it with —-‘ And The Winner Is — ‘ !!–
Not me for sure !!!!
eaglemd
LikeLike
My dear Seelan,
Encouraging to see mates are tickling their few neurones, left
Facinating to note Deepthie, reminding Seelan Chivas Regal
There is an old saying it is not the victory but the participation
In which case our striving batch mates, certainly are a winning lot
Ariya
LikeLike
Dear Marina,
Patient is a white Australian.
Ranaya would have been happy to see the way you have analysed. – Even after retirement.
Unfortunately the pathology was different.
Sam will post it soon
Dear Deepthie,
Thanks for the comments.
My diagnosis from imaging was almost correct ,but I couldn’t get the exact pathology. Unfortunately,we Radiologists have to come out with diagnosis or DD before surgery & histology!!!
Seelan
LikeLike
Is it aAV malformation of the fallopian tube
LikeLike
Good thought like Eddie but the path was different. Hope Sam posts the answer/
LikeLike
Rani- you may be right – since emergency surgery was performed, I too suspect a vascular lesion- about to bust !
eaglemd .
LikeLike
Dear Sam,
I am now in KL. I sent you the answers before I left Sydney. Can you pl. Publish it. Thanks.
Seelan
LikeLike
Hey Seelan-
Sam is a very busy man- I know it first hand , having stayed with him/ Kathy for 4 days last week !!
Has many things waiting ‘to go ‘ down the pipe line, !
We just have to ‘wait and see ‘ !
eaglemd
LikeLike
Sam has already posted the answer – in red – above,at the beginning .
LikeLike
Oh Well- I guess, I ‘went through the Red Light ‘ !
Great quiz Seelan.
Send us more !
eaglemd
LikeLike
Thanks Seelan. A super demonstration of the CT findings in the pelvis of this woman.Yes, I did note the calcification in the fibroid, like a string of pearls but did not entertain the idea in view of her recent pregnancy..Keep these radiology cases coming to keep our ageing brains alert.I miss the radiology consultations since my retirement.Often, I used to take the whole team to the radiology service to acquaint the juniors of the need for multidisciplinary consultations.There is a lot that can be learned from a visit to the radiology service.Have a great holiday in K.L.Regards.Eddie.
LikeLike
Dear friends,
Thanks for taking part in this quiz.
Our medical knowledge gained over the years is valueless. We must keep learning whenever we get a chance, as part of our hobby . As Ariya pointed out, quiz at our age is not for winning – it’s to keep our memory active.
Eddie & Deepthie suggested more radiology quiz. Many years ago I used to have weekly presentation of interesting cases at the hospital where all doctors, relevant specialists & pathologists attend and discuss. Owing to tremendous improvement in technology, imaging has become more & more relevant in the diagnosis & management of diseases.
In private practise, collection , preparation & presentation takes time. I will try to send interesting cases now & then. It may be boring for some!!
Seelan
LikeLike
A n excellent case,
Thank you my dear Seelan, your radiological challenge was very good
Many septuagenarians’ including mine senile neurones got exhausted
The plethora of efforts and suggestions of our batch mates shows the attitude
Of our class, right or wrong had a good go at your extremely interesting case
Ariya
LikeLike