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MRI of Adnexal Masses in Pregnancy

¹ All authors: Department of Radiology, University of California, San Francisco, Box 0628, Rm. M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —36-year-old pregnant woman who presented for routine early pregnancy sonography. Routine early pregnancy transabdominal sonogram obtained at 7 weeks' gestation shows solid mass (arrow) of indeterminate origin and nature in pelvis posterior to uterus (UT).

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —36-year-old pregnant woman who presented for routine early pregnancy sonography. Sagittal single-shot RARE T2-weighted image shows large mixed solid and cystic pelvic mass inferoposterior to gravid uterus. Note that solid parts (arrow) of mass are of low T2 signal intensity.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —36-year-old pregnant woman who presented for routine early pregnancy sonography. Axial RARE T2-weighted image with fat saturation shows mass has beak- or clawlike interface with myometrium (arrows), consistent with uterine origin. Overall findings are those of cystic degeneration in exophytic uterine leiomyoma.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —34-year-old pregnant woman who presented with lower abdominal pain. Transvaginal sonogram obtained at 25 weeks' gestation shows solid 3.8-cm mass (between calipers) thought to be of right adnexal origin.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —34-year-old pregnant woman who presented with lower abdominal pain. Axial RARE T2-weighted image shows mass (arrow) arises from uterus and is of low T2 signal intensity; also, note "claw sign," similar to Figures 1A, 1B, and 1C. Findings are those of exophytic uterine leiomyoma.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —34-year-old pregnant woman who presented with lower abdominal pain. Axial spoiled gradient-echo T1-weighted MR image shows exophytic uterine leiomyoma (arrow) is of increased T1 signal intensity; this finding indicates red degeneration (i.e., spontaneous hemorrhagic infarction).

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Sagittal single-shot RARE T2-weighted image in 29-year-old woman with ectopic pregnancy at 22 weeks' gestation shows fetus in extrauterine location. Empty endometrial cavity (arrow) is seen anterior to large leiomyoma (Fibroid).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —Axial RARE T2-weighted image with fat saturation obtained at 24 weeks' gestation in 29-year-old woman shows complex mixed solid and cystic left adnexal mass (arrow). No increased signal was seen on T1-weighted images (not shown). MRI appearances are nonspecific, although diagnostic considerations include cystic malignancy. Mass was resected and found to be benign hemorrhagic cyst.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —37-year-old pregnant woman. Transvaginal sonogram obtained at 21 weeks' gestation shows uniformly hypoechoic left adnexal mass (arrow) of indeterminate nature.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —37-year-old pregnant woman. Axial spin-echo T1-weighted MR image shows mass (arrow) is of increased T1 signal intensity.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —37-year-old pregnant woman. Axial spin-echo T1-weighted MR image with fat saturation shows mass (arrow) remains of increased signal intensity, excluding macroscopic fat and suggesting blood.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —37-year-old pregnant woman. Axial single-shot RARE T2-weighted MR image shows mass (arrow) of reduced T2 signal intensity ("T2 shading"). Overall findings are consistent with endometrioma.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —34-year-old pregnant woman. Axial Doppler sonography image obtained at 21 weeks' gestation shows right adnexal mass (arrow) with smoothly lobulated mural nodules and prominent internal vascularity.

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —34-year-old pregnant woman. Axial T1-weighted spoiled gradient-echo MR image shows that fluid in cystic part of mass is of high T1 signal intensity (arrow), which is consistent with blood.

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —34-year-old pregnant woman. Axial RARE T2-weighted MR image shows solid component (white arrow) of mass is strikingly similar to decidualized endometrium (between black arrows) in uterus, both with respect to signal intensity and texture. Findings are considered consistent with decidualized endometrioma; postnatal resection confirmed diagnosis.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —Coronal single-shot RARE T2-weighted MR image obtained at 22 weeks' gestation in 31-year-old woman. Large bilateral multilocular adnexal masses (vertical arrows) are typical of theca lutein cysts, which in this case were associated with twin pregnancy; note two fetal heads (horizontal arrows) in uterus.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —32-year-old woman with persistent right-sided pelvic pain. Transvaginal sonogram obtained at 24 weeks' gestation shows enlarged right ovary with preservation of peripheral follicles.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —32-year-old woman with persistent right-sided pelvic pain. Sagittal RARE T2-weighted MR image shows right ovary (asterisk) is of markedly increased T2 signal intensity to degree that mass might be considered cystic if MRI findings had not been interpreted in conjunction with sonographic findings. Appearance is of massive ovarian edema. Cause of this condition is not well understood but may reflect chronic or subacute low-grade torsion. Beaklike pedicle (arrow) arising from superior aspect of ovary is compatible with this pathogenesis.

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —Axial RARE T2-weighted MR image obtained at 18 weeks' gestation in 29-year-old woman shows large predominantly cystic right adnexal mass with somewhat thickened internal septae (arrow). Resection showed benign cystadenofibroma.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —22-year-old pregnant woman. Axial spin-echo T1-weighted MR image obtained at 24 weeks' gestation shows adnexal mass is posterior to uterus and contains focus (arrow) of increased T1 signal intensity.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —22-year-old pregnant woman. Axial spin-echo T1-weighted MR image with fat saturation shows that focus of increased T1 signal intensity in A is now of low signal intensity (arrow), confirming presence of macroscopic fat and indicating diagnosis of mature cystic teratoma (dermoid cyst).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —24-year-old pregnant woman. Axial T1-weighted spoiled gradient-echo MR image with fat saturation obtained at 25 weeks' gestation shows bilateral cystic adnexal masses (arrows) with thick septations and stained-glass appearance due to variable signal intensity among different compartments of lesion.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —24-year-old pregnant woman. Axial RARE T2-weighted MR image shows internal complexity in masses (white arrows) with thick septations (vertical black arrow) and solid nodules (horizontal black arrow). Findings are considered suggestive of malignancy. Resection showed bilateral mucinous cystic tumors of low malignant potential (borderline tumors).

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —34-year-old pregnant woman. Axial RARE T2-weighted MR image obtained at 23 weeks' gestation shows bilateral solid adnexal masses (arrows).

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —34-year-old pregnant woman. Axial RARE T2-weighted MR image through upper abdomen shows large tumor deposit (arrow) abutting liver. Appearances are considered indicative of malignancy. Cesarean hysterectomy and bilateral salpingo-oophorectomy were performed at 28 weeks' gestation because of progression of subphrenic tumor with diaphragmatic irritation. Pathology results showed benign metastasizing leiomyoma. Masses spontaneously regressed after surgery and patient remains free of disease 3 years after surgery.

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