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Imaging of Transposed Ovaries in Patients with Cervical Carcinoma

¹ Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021.
² Present address: Department of Radiology, Hadassah University Hospital, Jerusalem, Israel.

View larger version (115K): [in a new window]   Fig. 1. —Photograph from open laparotomy shows left ovary being transposed out of pelvis into left lateral paracolic gutter in 33-year-old woman with stage IB cervical adenocarcinoma. Note rectum (straight arrow), uterus (asterisk), and transposed ovary (curved arrow).

View larger version (35K): [in a new window]   Fig. 2. —Schematic drawing shows common locations for ovarian transposition: laterally within pelvis, in lower paracolic gutters (), anterior to psoas muscles (), and in intraabdominal paracolic gutters ().

View larger version (109K): [in a new window]   Fig. 3A. —28-year-old woman 2 years after hysterectomy and transposition of ovaries for stage IB squamous cell carcinoma of cervix. Sonogram shows hypoechoic oval structure located anterior to psoas muscle with adjacent surgical clip (arrow), representing normal transposed ovary.

View larger version (142K): [in a new window]   Fig. 3B. —28-year-old woman 2 years after hysterectomy and transposition of ovaries for stage IB squamous cell carcinoma of cervix. Axial (B and C) and coronal (D) T2-weighted images show ovaries as ovoid structures with cystic follicles of high signal intensity (arrows, B and C) located in lower abdomen, anterior to psoas muscles (asterisk). Dominant follicle in left ovary (curved arrow, D) represents physiologic changes and confirms that ovary is functioning.

View larger version (125K): [in a new window]   Fig. 3C. —28-year-old woman 2 years after hysterectomy and transposition of ovaries for stage IB squamous cell carcinoma of cervix. Axial (B and C) and coronal (D) T2-weighted images show ovaries as ovoid structures with cystic follicles of high signal intensity (arrows, B and C) located in lower abdomen, anterior to psoas muscles (asterisk). Dominant follicle in left ovary (curved arrow, D) represents physiologic changes and confirms that ovary is functioning.

View larger version (166K): [in a new window]   Fig. 3D. —28-year-old woman 2 years after hysterectomy and transposition of ovaries for stage IB squamous cell carcinoma of cervix. Axial (B and C) and coronal (D) T2-weighted images show ovaries as ovoid structures with cystic follicles of high signal intensity (arrows, B and C) located in lower abdomen, anterior to psoas muscles (asterisk). Dominant follicle in left ovary (curved arrow, D) represents physiologic changes and confirms that ovary is functioning.

View larger version (95K): [in a new window]   Fig. 4. —34-year-old woman 6 months after laparoscopic lymph node dissection and ovarian transposition for stage IB squamous cell carcinoma of cervix. CT scan shows ovaries (circled) as bilateral symmetric ovoid structures in paracolic gutters adjacent to loops of bowel. Small cystic follicle (asterisk) in left ovary and adjacent metallic clips (arrows) confirm that these are transposed ovaries, with normal CT appearance.

View larger version (141K): [in a new window]   Fig. 5A. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Sonogram shows well-defined cystic structure with thin walls and through-transmission, representing simple cyst in transposed ovary.

View larger version (90K): [in a new window]   Fig. 5B. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. CT scan again shows well-defined simple cyst (arrow) that is exhibiting no enhancement.

View larger version (103K): [in a new window]   Fig. 5C. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Follow-up CT scan obtained 1 month after B shows nearly complete resolution of this cyst and normal right transposed ovary (arrow). Resolution over short period of time confirms this to be simple follicular cyst.

View larger version (121K): [in a new window]   Fig. 5D. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Sonogram obtained 1 year after C shows round complex cystic mass (arrow) with fine septations and low-level internal echoes ("fish-net" appearance), representing hemorrhagic cyst.

View larger version (85K): [in a new window]   Fig. 5E. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. CT images obtained 1 year after C show that same cyst within left transposed ovary has fine septations (curved arrow, E) and subtle internal high attenuation (asterisk), representing blood. Right ovary now has normal appearance (arrow, F).

View larger version (84K): [in a new window]   Fig. 5F. —33-year-old woman 5 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. CT images obtained 1 year after C show that same cyst within left transposed ovary has fine septations (curved arrow, E) and subtle internal high attenuation (asterisk), representing blood. Right ovary now has normal appearance (arrow, F).

View larger version (131K): [in a new window]   Fig. 6A. —Histologic specimen obtained from resection of peritoneal inclusion cyst in 40-year-old woman. Low-power-field (A) and high-power-field (B) microscopic images show that cyst is lined by single layer of mesothelial cells that appear flattened due to distention (arrows). Cells are uniform and bland. On gross examination, cyst contained clear fluid that appears as pink secretion under microscope.

View larger version (111K): [in a new window]   Fig. 6B. —Histologic specimen obtained from resection of peritoneal inclusion cyst in 40-year-old woman. Low-power-field (A) and high-power-field (B) microscopic images show that cyst is lined by single layer of mesothelial cells that appear flattened due to distention (arrows). Cells are uniform and bland. On gross examination, cyst contained clear fluid that appears as pink secretion under microscope.

View larger version (74K): [in a new window]   Fig. 7A. —40-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Sonogram shows irregular-shaped large fluid collection with thick septations. Embedded within this collection is an ovoid structure (arrow).

View larger version (26K): [in a new window]   Fig. 7B. —40-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Doppler image shows internal blood flow within septations (arrow).

View larger version (36K): [in a new window]   Fig. 7C. —40-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IB adenocarcinoma of cervix. Spectral Doppler image shows nonspecific waveform in central mass; because this waveform does not show low resistive index, as would be found in ovarian mass or in septation, it helps to confirm diagnosis of normal ovary trapped within cyst.

View larger version (94K): [in a new window]   Fig. 8A. —35-year-old woman 3 years after radical hysterectomy for stage IIB squamous cell carcinoma of cervix. CT scans show cystic structure with thick enhancing walls and septations (arrows) with central focus of enhancing soft-tissue (asterisk, B). Round configuration made diagnosis confusing, and structure was originally interpreted as complex cyst. Pathology confirmed benign peritoneal inclusion cyst.

View larger version (101K): [in a new window]   Fig. 8B. —35-year-old woman 3 years after radical hysterectomy for stage IIB squamous cell carcinoma of cervix. CT scans show cystic structure with thick enhancing walls and septations (arrows) with central focus of enhancing soft-tissue (asterisk, B). Round configuration made diagnosis confusing, and structure was originally interpreted as complex cyst. Pathology confirmed benign peritoneal inclusion cyst.

View larger version (99K): [in a new window]   Fig. 9. —35-year-old woman 1.5 years after laparoscopic lymph node dissection and ovarian transposition for stage IIIB squamous cell carcinoma of cervix. CT scan shows 4.5 x 4.1 cm predominately solid mass (asterisk) with small cystic component arising from left ovary. This mass was pathologically proven to be metastasis from cervical cancer. Normal-appearing transposed ovary is seen on right, marked by surgical clip (arrow).

View larger version (93K): [in a new window]   Fig. 10A. —32-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IIB adenocarcinoma of cervix and 4 months after complete pelvic exenteration for pelvic recurrence. CT scan shows cystic mass in left transposed ovary with enhancing mural nodule (curved arrow). Adjacent surgical clip (straight arrow) is noted, confirming that origin of lesion is transposed ovary. Colonic urinary reservoir (asterisk) is seen on right.

View larger version (95K): [in a new window]   Fig. 10B. —32-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IIB adenocarcinoma of cervix and 4 months after complete pelvic exenteration for pelvic recurrence. Axial T1-weighted (B) and axial (C) and coronal (D) T2-weighted images show multiloculated nature of this cystic mass and also show number of soft-tissue mural nodules (arrows), best seen on T2-weighted images. Fine-needle aspiration of cyst revealed cells suspicious for malignancy. Surgical pathology confirmed cystic metastasis of cervical cancer.

View larger version (79K): [in a new window]   Fig. 10C. —32-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IIB adenocarcinoma of cervix and 4 months after complete pelvic exenteration for pelvic recurrence. Axial T1-weighted (B) and axial (C) and coronal (D) T2-weighted images show multiloculated nature of this cystic mass and also show number of soft-tissue mural nodules (arrows), best seen on T2-weighted images. Fine-needle aspiration of cyst revealed cells suspicious for malignancy. Surgical pathology confirmed cystic metastasis of cervical cancer.

View larger version (147K): [in a new window]   Fig. 10D. —32-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage IIB adenocarcinoma of cervix and 4 months after complete pelvic exenteration for pelvic recurrence. Axial T1-weighted (B) and axial (C) and coronal (D) T2-weighted images show multiloculated nature of this cystic mass and also show number of soft-tissue mural nodules (arrows), best seen on T2-weighted images. Fine-needle aspiration of cyst revealed cells suspicious for malignancy. Surgical pathology confirmed cystic metastasis of cervical cancer.

View larger version (86K): [in a new window]   Fig. 11A. —35-year-old woman 1.5 years after laparoscopic ovarian transposition, before radiation therapy, for stage IIIB squamous cell carcinoma of cervix (same patient as in Fig. 9). CT scan shows three enhancing nodules in abdominal wall (arrows). Location of these nodules correlates to sites of laparoscopic trocar placement. Patient also had ovarian metastasis on left (Fig. 9). Retroperitoneal fluid collection is a persistent lymphocele from prior lymph node dissection (asterisk).

View larger version (45K): [in a new window]   Fig. 11B. —35-year-old woman 1.5 years after laparoscopic ovarian transposition, before radiation therapy, for stage IIIB squamous cell carcinoma of cervix (same patient as in Fig. 9). FDG PET image confirms abnormal metabolic activity in abdominal nodules (straight arrows) and in left ovary (curved arrow). Surgical pathology proved all of these sites to be metastatic cervical cancer.

View larger version (93K): [in a new window]   Fig. 12A. —28-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage II squamous cell carcinoma of cervix. CT scan of mid abdomen shows heterogeneous enhancing solid mass in right transposed ovary (curved arrow), located adjacent to surgical clip (straight arrow), suspicious for an ovarian metastasis.

View larger version (103K): [in a new window]   Fig. 12B. —28-year-old woman 2 years after radical hysterectomy and ovarian transposition for stage II squamous cell carcinoma of cervix. CT scan of chest shows multiple scattered well-defined nodules that are consistent with pulmonary metastases.

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