AJR 2005; 184:1602-1610
© American Roentgen Ray Society
Imaging of Transposed Ovaries in Patients with Cervical Carcinoma
Tamar Sella1,2,
Svetlana Mironov1 and
Hedvig Hricak1
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.
Received July 27, 2004;
accepted after revision September 30, 2004.
Address correspondence to S. Mironov
(mironovs{at}mskcc.org).
Abstract
OBJECTIVE. Lateral ovarian transposition is a surgical procedure
performed in premenopausal women with pelvic malignancies in which the ovaries
are surgically displaced from the pelvis, before radiation therapy. In this
article, we present the imaging features of normal transposed ovaries as well
as the spectrum of abnormalities associated with lateral ovarian
transposition.
CONCLUSION. After lateral ovarian transposition, it is important to
recognize the ovaries to avoid confusing them with peritoneal implants. In
addition, benign ovarian lesions must be distinguished from primary and
secondary malignancies.
Introduction
Lateral ovarian transposition is a surgical procedure in which the ovaries
are displaced from the pelvis before pelvic radiation therapy, with the goal
of maintaining ovarian function. It is performed in premenopausal women with a
variety of pelvic malignancies, including rectal cancer, lymphoma, and, most
commonly, cervical cancer
[1].
After lateral ovarian transposition, the incidence of functional ovarian
cysts and peritoneal inclusion cysts is increased
[2]. There is no additional
risk for primary and secondary malignant lesions
[3]. Recognition of imaging
characteristics of transposed ovaries and their associated abnormalities may
prevent them from being misinterpreted as peritoneal implants. In this
article, we present the imaging features of normal transposed ovaries and the
spectrum of lesions associated with ovarian transposition in patients with
cervical cancer.
Surgical Technique
Displacement of the ovaries may be performed at the time of hysterectomy or
as a separate procedure. It can be performed using open surgical technique or
laparoscopically. In brief, the ovary and fallopian tube are dissected from
the uterus along with a long vascular pedicle. The ovaries are then mobilized
out of the pelvis and ligated to the peritoneum in as high and lateral a
location as possible, preferably above the level at which the vascular pedicle
crosses the ureter. The transposed ovaries may be sutured anywhere within the
lateral paracolic gutter, up to the level of the lowest rib
(Fig. 1). Additional locations
include anterior to the psoas muscle above the pelvic brim or within the
pelvis in a far lateral position (Figs.
2 and
3A,
3B,
3C,
3D). The procedure is performed
unilaterally or bilaterally. Only ovaries that appear normal on inspection are
transposed. The transposed ovaries are commonly marked with metallic surgical
clips [1,
4]
(Fig. 4).
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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).
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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.
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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.
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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.
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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.
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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.
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Ovarian Cysts
Cyst formation in a transposed ovary is common. The pathogenesis is thought
to be the surgery itself. Placement of the ovaries high in the paracolic
gutters predisposes the patient to cyst formation because extensive
mobilization of the ovarian pedicle may result in compromise of the ovarian
vascular supply. Other factors reported to predispose the patient to ovarian
cyst formation are the presence of endometriosis, adhesions, and pelvic
inflammatory disease.
Symptomatic ovarian cysts are defined as benign entities, causing pain and
requiring the use of analgesics or surgical intervention. In patients with
cervical cancer who have undergone lateral ovarian transposition, the
incidence of symptomatic ovarian cyst formation has been reported at up to
24%; this constitutes a threefold increase compared with patients who have
undergone hysterectomy without lateral ovarian transposition, who have an
incidence of only 7% [5].
However, most of the patients with cystic alteration of transposed ovaries
remain asymptomatic, and the incidence of reoperation after lateral ovarian
transposition for benign adnexal disease is only 1–4%.
Functional ovarian cysts include follicular cysts (Figs.
5A,
5B,
5C), corpus luteum cysts, and
hemorrhagic cysts (Figs. 5D,
5E,
5F). The imaging
characteristics of these lesions in transposed ovaries follow the same
guidelines as in normal ovaries
[6]. Because of their complex
nature, hemorrhagic cysts may be confused with malignant masses.
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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.
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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.
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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.
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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.
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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).
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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).
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Simple ovarian cysts are managed conservatively with observation and serial
follow-up ultrasound examinations. Hemorrhagic and corpus luteum cysts may
have a confusing appearance on imaging; however, both undergo relatively rapid
transformation and resolve within 2–3 months. Follicular cysts may
persist, but they usually have a benign appearance.
Peritoneal Inclusion Cysts
Peritoneal inclusion cysts are intraperitoneal fluid collections contained
by mesothelial-lined thick adhesions. Additional names include benign cystic
mesotheliomas, peritoneal pseudocysts, and inflammatory cysts of the
peritoneum [7].
The pathogenesis of peritoneal inclusion cyst formation is nonneoplastic
reactive mesothelial proliferation, causing a decrease in absorption of
ovarian fluid. The prerequisites are a functioning ovary that secretes fluid
and peritoneal adhesions, which may be caused by prior surgery to the ovary,
trauma, pelvic inflammatory disease, or endometriosis
[7]. These cysts may be seen
after lateral ovarian transposition as a result of the formation of thick
postoperative peritoneal adhesions. Inclusion cysts may be asymptomatic or may
cause pain and discomfort. Although they may be small, peritoneal inclusion
cysts often grow to a very large size, at times filling the pelvis
[7].
On gross pathologic examination, peritoneal inclusion cysts are
multiloculated cystic masses filled with clear or yellow serous fluid. The
fluid contains a high concentration of ovarian hormones. The locules of the
cyst are lined by one or several layers of flat and cuboidal mesothelial cells
(Fig. 6A,
6B). Occasionally, these
cuboid cells can undergo squamous metaplasia
[8].
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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.
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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.
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The diagnosis of peritoneal inclusion cysts may be suggested by all
cross-sectional techniques, although sonography may have limited value because
of the large size of these cysts. On Doppler imaging, the septations may show
low resistive flow [9]. The
classic CT appearance of a peritoneal inclusion cyst is that of a complex
cystic mass with an eccentrically located ovary entrapped by thick enhancing
adhesions (the spiderweb appearance)
[7]. The ovary may be embedded
in the cyst (Fig. 7A,
7B,
7C). The cysts commonly
conform to the peritoneal cavity. MRI may have added value in helping to
identify the normal ovary within the loculated fluid collection
[10].
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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).
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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).
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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.
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If the diagnosis of a peritoneal inclusion cyst is highly suggested on
imaging, conservative management is an option. In cases of a painful
peritoneal inclusion cyst, attempts are made to relieve the symptoms with
suppression of ovulation or by imaging-guided per-cutaneous aspiration of the
cyst contents [11]. Because
functioning ovaries are present within peritoneal inclusion cysts, they have a
tendency to reaccumulate after aspiration; therefore, oophorectomy may be
necessary. Occasionally, the complex nature of these cysts makes it impossible
to distinguish them from malignant cystic ovarian neoplasms (Fig.
8A,
8B), thus requiring surgical
removal [12].
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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.
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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.
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Malignant Ovarian Lesions
Ovarian metastases from cervical cancer are rare, estimated at
approximately 2%. Risk factors include histologic type (more common in
adenocarcinoma), uterine corpus invasion, and blood vessel invasion
[13,
14]. They are highly uncommon
in early stage cervical cancer. Lateral ovarian transposition has not been
shown to increase the risk of ovarian metastases. Women with cervical cancer
have not been shown to be at added risk for developing primary ovarian
cancer.
As in the nontransposed ovary, a malignant lesion may appear as a solid
(Fig. 9), cystic (Fig.
10A,
10B,
10C,
10D), or complex cystic mass.
If a suspicious ovarian lesion is noted, careful evaluation for additional
sites of possible metastases should be performed (Figs.
11A,
11B and
12A,
12B).
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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).
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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.
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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.
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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.
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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.
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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).
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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.
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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.
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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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Conclusion
Lateral ovarian transposition as a surgical technique is gaining
popularity. From the radiologist's perspective, it is important to become
familiar with the appearance of normal transposed ovaries and to recognize
their different locations within the peritoneal cavity to avoid
misinterpreting them as peritoneal implants. It is also crucial to become
acquainted with various abnormalities in transposed ovaries and to recognize
the increased incidence of functional cysts and peritoneal inclusion cysts in
these ovaries.
Acknowledgments
We thank Yukio Sonoda from the Department of Gynecology and Carmen Tornos
from the Department of Pathology, Memorial Sloan-Kettering Cancer Center in
New York, for their assistance with clinical and pathologic images.
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T. Sella, S. Mironov, and H. Hricak
Reply
Am. J. Roentgenol.,
January 1, 2006;
186(1):
268 - 268.
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R. Zissin and E. Even-Sapir
18F-FDG Uptake on PET/CT in Transposed Ovaries
Am. J. Roentgenol.,
January 1, 2006;
186(1):
267 - 268.
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Top
Abstract
Introduction
),
anterior to psoas muscles (
), and in intraabdominal paracolic gutters
(
).