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A 53-year-old woman presented with a 3-month history of left inguinocrural and lumbar pain and anorexia with weight loss. No fever was reported. The patient had no prior pelvic surgery. Physical examination revealed a palpable nontender mass in the left groin area. There was no bloody or purulent discharge. Laboratory findings revealed inflammation with an increased C-reactive protein level (127 mg/L [1209 nmol/L]), leukocytosis (13 800/mm(3)), and microcytic anemia (hemoglobin level, 7.2 g/dL). Computed tomography (CT), fluorine 18 ((18)F) fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, and magnetic resonance (MR) imaging were performed.

Institutional review board approval and written informed consent were obtained. Patients with newly diagnosed prostate cancer and patients suspected of having recurrent prostate cancer were prospectively evaluated with fluorine 18 fluorocholine (FCH) combined in-line positron emission tomography (PET) and computed tomography (CT). In 19 patients (mean age, 67 years +/- 8; range, 57-85 years), standardized uptake values of FCH in 17 different tissues were determined by using volumes of interest. In nine patients evaluated at initial staging, histologic findings of the resected prostate were compared to FCH uptake. Only small variations of physiologic tracer accumulation were measured in all organs but the kidneys. Differentiation of benign hyperplasia from cancerous prostate lesions was not possible with FCH PET/CT. However, in patients with recurrent prostate cancer, FCH PET/CT is a promising imaging modality for detecting local recurrence and lymph node metastases., ((c) RSNA, 2005.)

Purpose: To prospectively evaluate the accuracy of magnetic resonance (MR) imaging for the preoperative diagnosis of deep pelvic endometriosis and extension of the disease., Materials and Methods: One hundred ninety-five patients (mean age, 34.2 years; range, 20-71 years) who were suspected of having pelvic endometriosis were recruited at two institutions. Two experienced radiologists evaluated the MR images independently. Deep pelvic endometriosis was defined as implants or tissue masses that appeared as hypointense areas and/or hyperintense foci on T1- or T2-weighted MR images in the following locations: torus uterinus, uterosacral ligaments (USLs), vagina, rectovaginal septum, rectosigmoid, and bladder. MR imaging results were compared with surgical and pathologic findings. Sensitivity, specificity, predictive values, and accuracy of MR imaging for prediction of deep pelvic endometriosis were assessed., Results: Pelvic endometriosis was confirmed at pathologic examination in 163 (83.6%) of 195 patients. Endometriomas, peritoneal lesions, and deep pelvic endometriosis were diagnosed on the basis of surgical findings, alone or combined with pathologic findings, in 111 (68.1%), 83 (50.9%), and 103 (63.2%) of 163 patients, respectively. Torus uterinus and USL were the most frequent sites of deep pelvic endometriosis. The sensitivity, specificity, positive and negative predictive values, and accuracy of MR imaging for deep pelvic endometriosis were 90.3% (93 of 103), 91% (84 of 92), 92.1% (93 of 101), 89% (84 of 94), and 90.8% (177 of 195), respectively. The sensitivity, specificity, and accuracy, respectively, of MR imaging for the diagnosis of endometriosis in specific sites were as follows: USL, 76% (57 of 75), 83.3% (100 of 120), and 80.5% (157 of 195); vagina, 76% (16 of 21), 95.4% (166 of 174), and 93.3% (182 of 195); rectovaginal septum, 80% (eight of 10), 97.8% (181 of 185), and 96.9% (189 of 195); rectosigmoid, 88% (53 of 60), 97.8% (132 of 135), and 94.9% (185 of 195); and bladder, 88% (14 of 16), 98.9% (177 of 179), and 97.9% (191 of 195)., Conclusion: MR imaging demonstrates high accuracy in prediction of deep pelvic endometriosis in specific locations., (Copyright RSNA, 2004)

Purpose: To evaluate the clinical and biologic safety of ultrasmall superparamagnetic iron oxide particles (AMI-227) as a contrast agent for magnetic resonance (MR) lymphography and to assess their efficacy for the differentiation of metastatic and benign nodes in patients with urologic and pelvic cancer., Materials and Methods: Thirty adults suspected of having lymph node metastases underwent MR imaging before and 22-26 hours after intravenous infusion of AMI-227 (1.7 mg Fe/kg). Sixty histopathologically proved lymph nodes were analyzed on MR images, and 29 of these nodes were also analyzed quantitatively., Results: AMI-227 was well tolerated with no major side effects. It allowed the detection of 10 additional nodes relative to those detected at MR imaging without AMI-227. None of the 27 metastatic nodes showed a decrease in signal intensity (SI) on AMI-227-enhanced images; nine of 27 metastatic nodes showed an increase in SI on T1-weighted images, probably resulting from altered capillary permeability in the tumor. A visually perceptible reduction in SI, indicating active AMI-227 uptake, was observed on postcontrast T2- and T2*-weighted images in 16 of 21 benign nodes. The SI ratio of benign nodes was lower than that of metastatic nodes on T2- and T2*-weighted images. The sensitivity of AMI-227-enhanced MR lymphography was 100%, and the specificity was 80%., Conclusion: AMI-227 is safe and may facilitate the differentiation of metastatic and benign nodes in patients with urologic and pelvic cancers.

Purpose: To compare dynamic contrast-enhanced subtraction (DCES) and T2-weighted spin-echo (SE) magnetic resonance (MR) imaging in the differentiation of fibrosis from recurrence during the follow-up of treated colorectal neoplasms., Materials and Methods: Forty-one patients with 39 malignant and 16 benign lesions confirmed by means of surgery (n = 23), biopsy (n = 24), or 12-month follow-up examination (n = 8) underwent DCES MR imaging and T2-weighted SE MR imaging. Enhancement of an abnormal pelvic structure within the first 90 seconds on DCES images or high signal intensity on T2-weighted SE images was considered indicative of malignancy., Results: Sensitivity, specificity, and positive and negative predictive values were, respectively, 97%, 81%, 93%, and 100% for DCES MR imaging and 77%, 56%, 81%, and 56% for T2-weighted MR imaging. The number of correctly classified lesions was significantly higher with DCES imaging compared with T2-weighted imaging (P < or = .006)., Conclusion: DCES imaging is more accurate than T2-weighted SE imaging for differentiating fibrosis from recurrence during the follow-up of treated colorectal neoplasms.

Purpose: To determine the accuracy of breath-hold gadolinium- and perflubron-enhanced magnetic resonance (MR) imaging, immunoscintigraphy with indium-111-CYT-103 (planar and single photon emission computed tomography [CT]), and contrast material-enhanced CT for the detection of ovarian cancer prior to laparotomy., Materials and Methods: Sixteen patients with primary (n = 3) or treated (n = 13) ovarian cancer underwent imaging of the abdomen and pelvis with each modality. All images were reviewed prospectively for tumor location, and results were compared with findings at surgery., Results: With CT or MR imaging, tumor was detected in 11 of 13 (85%) patients compared with 11 of 12 patients (92%) with immunoscintigraphy. Per patient accuracy for CT was 81% compared with 75% for MR imaging and 86% for immunoscintigraphy. For detection of individual sites of tumor, the sensitivity of MR imaging was highest (81%) compared with CT (51%, P < .001) and immunoscintigraphy (50%, P < .01). The combination of MR imaging and immunoscintigraphy depicted 89% of sites of tumor involvement confirmed at laparotomy., Conclusion: MR imaging and immunoscintigraphy show promise for the evaluation of patients with ovarian cancer.

Two phase 2 clinical trials of an oral superparamagnetic contrast agent for enhancement on magnetic resonance images of the intestine were performed. In trial 1, 31 male patients with cancer of the testis underwent follow-up examinations of the abdomen at 0.5 and 1.5 T after oral administration of magnetic particles. In trial 2, 31 female patients with pelvic and lower abdominal disease were examined at 1.5 T after administration of the contrast material. The patients each ingested 800 mL of contrast material over approximately 2 hours. Concentrations of 0.25 and 0.5 g/L did not induce blurring or metallic artifacts. Distribution was homogeneous through the gastrointestinal tract. In all patients, a loss of signal intensity was observed on proton density-, T1-, and T2-weighted images. The diagnostic information from postcontrast images in trial 2 was greater in 16 patients (52%). Contrast enhancement was independent of field strength; no major side effects were observed. Artifacts from moving bowels were less troublesome, and delineation of intraabdominal and pelvic organs was better with the use of oral magnetic particles.

Biplanar, transrectal ultrasound guidance was used in the transrectal aspiration of two pelvic abscesses, one recurrent tumor, and one sterile, nonmalignant fluid collection. This method provides an alternative path that allows precise localization for aspiration biopsy of pelvic masses.

Findings from computed tomography (CT) and ultrasound (US) examinations of 74 patients who were clinically thought to have pelvic masses and of 110 patients who had possible recurrence of pelvic tumors were analyzed. There was no significant difference in the ability of the two modalities to identify masses or to predict disease extent. Although both CT and US failed to detect some examples of spread outside of the pelvis, overstaging (apart from two cases of unconfirmed parametrial spread) did not occur with CT and occurred only once with US. The sensitivity was 0.96 for CT and 0.91 for US in the detection of pelvic masses. Both modalities had an accuracy of 0.81 in the detection of recurrent disease.

A Clostridium infection occurred in an endometrioma following fine-needle aspiration. Fine-needle aspirations are clinically useful and safe. The authors conclude, however, that this procedure may rarely result in a secondary infection. Specific recommendations to avoid such complications are stated.

Ultrasonography was performed on 54 patients with lesions of the extremities and pelvic girdle. Computed tomography (CT) was employed in 8 patients. Focal space-occupying lesions such as tumors, abscesses, hematomas, aneurysms, and popliteal cysts (dissecting or otherwise) were delineated by ultrasound and their extent defined. Differentiation from diffuse changes such as lymphedema, cellulitis, or phlebitis and diagnosis of aneurysms were possible. Popliteal cysts were usually quite characteristic, while correlation with the clinical features suggested the correct diagnosis in the case of the other lesions. CT correlated well with ultrasound, except for one tumor of the forearm which was not shown by CT.

Ten patients with presacral tumors proved by histologic and computed-tomographic investigations underwent ultrasound scanning. The sound beam was directed through the ischial foramen along longitudinal, transverse, and oblique planes. Nine of 10 tumors localized in the sacral fossa were identified sonographically. In six of 10 instances, tumor demarcation was possible. Sonographic evaluation was impaired because of distance between the transducer and the target due to a patient's large volume and by the cranial location of the tumor. The transgluteal approach is suggested for sonographically guided percutaneous biopsy.

Four unusual pelvic masses, studied by CT and gray scale ultrasonography, demonstrate the comparative values of these modalities for this area of the body. In each instance a significant contribution to the diagnosis was made by one or both techniques. The ultrasound study provides a somewhat better differentiation of solid from cystic lesions, but the CT scan denotes to best advantage the anatomy of the area, and provides a means of viewing bone as well as soft tissue detail.

Multiplanar images of 62 pelvic lesions in 58 children and adolescents (aged 7 months to 19 years; mean, 10.6 years) were obtained with 0.3-T magnetic resonance (MR) imaging. Lesions were divided into three categories: congenital anomalies, cystic lesions and fluid collections, and neoplasms. MR demonstrated lesions well in all categories. Midline lesions were best imaged sagittally, and lesions of paired structures, axially. The coronal plane was useful in evaluating the superoinferior extent of lesions and in defining the extent of lymphadenopathy. T1-weighted sequences were sufficient to depict most congenital and cystic lesions. T2-weighted sequences were useful in demonstrating the extent of neoplasms and the position of ectopic gonads. Ultrasonography (US) was also performed in 45 cases. MR and US delineated lesions equally well in 25 cases (55.5%), MR was superior in 19 (42.4%), and US was superior in one (2.2%). Computed tomography (CT) was performed in 13 cases. MR and CT delineated lesions equally well in eight cases (61.5%), MR was superior in four (30.8%), and CT was superior in one (7.7%).

The posterior pelvic compartment, defined as consisting primarily of the rectosigmoid colon and peritoneal-lined cul-de-sac, was evaluated in 104 patients. Tumors and pseudotumors (fluid- and feces-filled loops of bowel) were ultrasonographically analyzed according to: (a) morphology and echo characteristics, and (b) location within either the cul-de-sac or rectosigmoid colon. On routine examination, a striking similarity between pathological processes and pseudotumors was demonstrated; these were diagnosed correctly only by the use of a technique in which the rectosigmoid colon is filled with water. Combined distension of the urinary bladder and rectosigmoid colon also enabled localization and differentiation of abnormalities within the cul-de-sac.

Pelvic fluid collections, solid masses, extrinsic or intrinsic vesicular masses, and abnormal distension of the bladder due to obstruction can be demonstrated by sonic scanning. Accurate diagnosis is based on the recognition of certain sonographic patterns, in addition to the clinical history and physical findings. These patterns include: (a) internal echo pattern, (b) external contour of the mass, (c) location within the pelvis, and (d) relationship to other pelvic structures.

Seventeen cases of hemangiopericytoma of the retroperitoneum were retrospectively analyzed for demographic, morphologic, and radiologic features. These tumors were found in all age groups (2 months to 72 years) and occurred in similar numbers of male and female patients. The tumors tended to be large (11 were greater than 8 cm), were well encapsulated, and occurred less frequently in the pelvic retroperitoneal space (six cases) than in abdominal retroperitoneum (11 cases). All tumors were bulky enough to displace part of the gastrointestinal tract, with only two being inoperable. The most distinctive radiologic feature was hypervascularity (found on 11 of 11 angiograms). Other nondiscriminating radiologic features included well-defined margins and necrosis, with nondistinctive amorphous calcification identified in one case. Angiographic or computed tomographic demonstration of hypervascularity in a retroperitoneal tumor is more suggestive of hemangiopericytoma than of a liposarcoma or malignant fibrous histiocytoma, two of the more common tumors of this region.

Magnetic resonance (MR) images and computed tomographic (CT) scans of histologically characterized soft-tissue masses of the locomotor system in 35 patients were compared for image contrast, demonstration of bone destruction, and display of extent and anatomic relationships of the masses. Subjective criteria for predicting malignancy were tested. T1 measurements were made in a few cases. Intensities of masses relative to those of fat and muscle in spin-echo T1-weighted and highly T2-weighted images were evaluated for correlation with tissue type. Subjective value of using coronal and sagittal images was assessed. Because of its superior inherent image contrast and its ability to provide direct sagittal and coronal images, MR was better than CT in demonstrating size and extent of most tumors and their relationships to vascular and nonvascular structures. However, bone destruction was more difficult to see with MR. Except for fatty tumors, MR was not helpful in identifying tissue type. Subjective criteria were of limited value in distinguishing benign from malignant lesions. Moreover, there is currently no credible evidence that T1 or T2 measurements are helpful in this regard. Study results suggest that MR is superior to CT in evaluating soft-tissue masses of the locomotor system. If an MR examination is performed, CT may not be necessary in certain cases unless bone involvement is suspected.

The value of magnetic resonance (MR) imaging at 0.35 T in detecting, characterizing, and staging pelvic endometriosis was prospectively investigated in 30 consecutive women in whom this disease was clinically suspected. MR findings were correlated with the results of laparoscopy (13 women) and laparotomy (17 women). Surgical examination revealed a normal pelvis in five patients and endometriosis in 25. Three of the five normal cases and 16 of the 25 cases of endometriosis were correctly identified with MR imaging (sensitivity, 64%; specificity, 60%; accuracy, 63%). MR imaging demonstrated seven of eight endometriomas but only 14 of 29 adhesions and only six of 45 endometrial implants. While MR imaging demonstrated endometriomas, ovarian adhesions, and extraperitoneal endometrial implants, it could not accurately depict extraovarian endometrial adhesions and intraperitoneal endometrial implants. In addition, MR imaging findings did not correlate with the surgically determined severity of the disease. These limitations indicate that MR imaging cannot be used as the primary modality in the detection, characterization, and staging of endometriosis; laparoscopy remains the procedure of choice.

Endometriosis is a common cause of female infertility. It may affect as many as 40% of infertile women and may be the sole contributing factor to infertility in 15%. A study was undertaken to determine the usefulness of the routine pelvic ultrasound (US) examination in the detection of endometriosis by correlating pelvic US findings with laparoscopic findings in 85 patients who underwent both examinations. Forty-eight patients (56.5%) had no laparoscopic evidence of endometriosis, and 37 patients (43.6%) had endometriosis. Eight of the patients had abnormal sonograms; of these patients, only four had sonographic abnormalities that corresponded to laparoscopically identified endometriosis. Thus, US was successful in detecting endometriosis in only four (10.8%) of 37 patients. US is neither sensitive nor specific in diagnosing endometriosis. Furthermore, we believe that US does not have a significant role in the diagnosis or management of endometriosis in patients in whom a pelvic mass or other obvious pelvic abnormality is not suspected.

Three cases of rapidly growing leiomyomata uteri in young oligomenorrheic women are presented. The atypical ultrasonic and histologic findings are discussed. A spectrum of atypical ultrasonic findings including a high degree of transonicity and multiple areas of cystic degeneration is described. Histologic examination correlates well in explaining the sonographic characteristics. In addition, a possible relationship between the presumably anovulatory cycles present in these women and their rapidly growing leiomyomata is suggested.