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Second Trimester Pregnancy with Bilateral Adnexal Masses (Teratomas)

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This is an MRI of the abdomen and

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pelvis in a patient presenting in the

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early second trimester of pregnancy

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with acute left lower quadrant pain.

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We can see that there is significant respiratory

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motion artifact evident on this exam, which

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is another indicator that the patient is

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likely uncomfortable during this examination.

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These are T2-weighted images of the

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abdomen and pelvis, and before the gravid

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uterus comes into view, we begin to see an

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enlarged, predominantly T2 hyperintense

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mass that is in the left hemiabdomen.

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We can trace it down toward the left

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adnexa, and we can see that it communicates

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with the vascular pedicle, which

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arises from the lateral left uterus.

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So the vascular pedicle goes on to communicate

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with this lesion, which we can determine both

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because of the connection, but also because

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of the peripheral T2 hyperintense follicles

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that this is indeed of ovarian origin.

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A few other characteristics that

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we can use to describe this lesion

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in addition to being predominantly T2

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hyperintense, there are some septated

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or loculated components of this lesion.

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We see multiple T2 hyperintense

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locules, as well as the suggestion

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of some more independent or separate

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areas of nodularity within the lesion.

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This is the gravid uterus.

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We can see that this patient has multiple

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T2 hypointense uterine fibroids.

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In addition to a normal-appearing

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early placenta, we see the fetus

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suboptimally in these images.

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Posterior to the uterus, in the

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right hemipelvis, is a bilobed, mixed

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cystic and complex mass, which is

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in the region of the right ovary.

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We don't see the right ovary on these

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images, and so not seeing the organ of

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interest, but identifying a mass in its

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expected location is called the phantom

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organ sign, which you can use to imply that

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this lesion is of right ovarian origin.

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We can further evaluate these lesions by

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comparing their appearance on T1 non-fat

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saturated and T1 fat-saturated images.

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We can see that the subcutaneous fat is

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bright in the non-fat-saturated image and

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dark in the fat-saturated image.

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Let's start with the left ovarian lesion.

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This lesion is predominantly bright

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on the non-fat-saturated image and

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becomes dark on the fat-saturated image.

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Those areas of nodularity also become

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more apparent on the T1-weighted images

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than they were on the T2-weighted images.

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So we see a predominantly fat-containing

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mass with multiple areas of internal

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nodularity arising from the left ovary.

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When we evaluate the characteristics of

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the right ovarian mass, we can see that on

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the T1 pre-contrast image, there is almost

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a fat debris level within the lesion.

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There's a very clear demarcation between

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two types of material which are contained

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within this one component of the mass.

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In addition to a relatively T1 hypointense

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component of this overall

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lesion arising from the right ovary.

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On the fat-saturated images, we can see

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that what was bright in the anterior

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and dependent portion of this loculated

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component of the lesion saturates

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out and is indeed fat-containing.

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There is some drop in signal on the fat

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saturated images here, as well as here, and

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so this may be hemorrhage or proteinaceous

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debris within these other components.

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And so this is a patient

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who is coming in with bilateral adnexal masses,

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both of which exhibit characteristics of

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ovarian teratomas, mature ovarian teratomas.

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It's important to point out that the

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left ovarian lesion is quite large and

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in addition to connecting to the vascular

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pedicle that extends toward the left lateral

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aspect of the uterus, we do see a small

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amount of swirling in this region as well.

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And so it would be important in this patient

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who's having left lower quadrant pain to

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also do a pelvic ultrasound to evaluate

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the patency of the ovarian vasculature

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on the left and be sure that this patient

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is not experiencing ovarian torsion in

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the context of this large adnexal mass.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Ovaries

Neoplastic

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

Genitourinary (GU)

Body

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