DOI:10.2214/AJR.05.2032
AJR 2007; 188:1564-1567
© American Roentgen Ray Society
Detection of the Gonadal Veins in the Diagnosis of Transposed Ovaries in Patients with Cervical Carcinoma: A Useful Sign on MDCT
Masakazu Hirakawa1,
Kengo Yoshimitsu,
Daisuke Kakihara,
Hiroyuki Irie,
Yoshiki Asayayama,
Kousei Ishigami and
Hiroshi Honda
1 All authors: Department of Clinical Radiology, Graduate School of Medical
Sciences, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka
812-8582, Japan.
Received November 20, 2005;
accepted after revision February 28, 2006.
Address correspondence to M. Hirakawa
(mahira{at}radiol.med.kyushu-u.ac.jp).
Abstract
OBJECTIVE. The purpose of our study was to evaluate the
detectability of the gonadal vein of transposed ovaries in patients with
uterine cervical cancer on MDCT.
CONCLUSION. Gonadal veins and surgical clips of transposed ovaries
can be shown with high consistency on MDCT. Tracking the gonadal veins and
detecting the surgical clips may prevent the transposed ovaries from being
misinterpreted as peritoneal implants.
Keywords: cervical carcinoma • CT • gonadal veins • ovaries • pelvic imaging • women's imaging
Introduction
Ovarian transposition was first proposed in 1958 as a method for
maintaining ovarian function in patients receiving irradiation for cervical
cancer [1]. This procedure is
now being performed in premenopausal women who have a variety of pelvic
malignancies, including rectal cancer and lymphoma
[2]. The ovaries are frequently
transposed laterally at the paracolic gutter outside the radiation field. They
are typically seen as multi- or monocystic masses with a varying amount of
interstitium at this location. The placement of surgical clips around these
masses has been reported to be useful for recognizing the transposed ovaries
on CT [3]. These ovaries could
easily be misinterpreted as one of various disorders, including appendiceal
mucocele, lymphocele, or peritoneal implants
[4] if the history of ovarian
transposition is not given. The detection of gonadal veins on MDCT is useful
in the differential diagnosis of pelvic masses by determining the ovarian
origin of the masses [5,
6]. We recently encountered a
case in which no surgical clip was detected around the transposed ovary,
probably because of dislodgement and migration. This prompted us to examine
whether the detection of gonadal veins on MDCT is useful as an adjunctive or
secondary sign in the identification of transposed ovaries.
Materials and Methods
Patient Population
From January 2000 to June 2005, 30 patients at our institute underwent
ovarian transposition during surgical treatment of stage IB squamous cell
cervical cancer (radical hysterectomy with lymphadenectomy). Twenty-six of the
30 patients underwent contrast-enhanced MDCT after surgery, and these 26
patients formed the study population. The patients ranged in age from 21 to 48
years old (mean age, 36.2 years). Four ovaries were resected and two ovaries
were not transposed. A total of 46 ovaries were thus transposed in the 26
patients. None of the patients had clinical evidence of pain or hormonal
dysfunction.
The time interval between MDCT and ovarian transposition was 1–18
months (mean, 6.6 months). In 22 patients, MDCT scans (two to 13, median,
four) were obtained. The interval change of the size in the 39 transposed
ovaries of 22 patients was evaluated (follow-up period, 6–48 months;
median, 24 months).
Surgical Technique
Lateral ovarian transposition was performed by laparotomy in all patients.
When the ovaries were macroscopically normal, both ovaries were transposed.
For the transposition, the uteroovarian ligament was ligated and cut and the
Fallopian tube was separated from the ovary. The ureter was identified and the
peritoneum incised along the infundibulopelvic ligament to mobilize the
ovaries. The ovaries were laterally transposed and fixed to the peritoneum in
paracolic gutters by metallic surgical clips for later radiographic
localization. In all cases, the transposed ovaries were outside the external
beam irradiation volume.
CT Technique
MDCT of the abdomen and pelvis was performed in all cases. We used two CT
scanners, an Aquillion scanner (Toshiba) and a Somatom Volume Zoom scanner
(Siemens Medical Solutions), which together formed a 4-MDCT scanner. The
parameters for the scanning were 2.5- or 3-mm collimation, 5-mm
reconstruction, and a pitch of 5.5. Scanning was begun 60 and 240 seconds
after the IV injection of contrast medium containing 300 mg I/mL of iodine
(Iopamiron 300 [iopamidol], Nihon Shering) with a total volume of 100 mL at a
rate of 2 mL/s, covering from the top of the liver to the pubis with oral
contrast material.
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Fig. 1A —31-year-old woman 2 years after hysterectomy and lateral
transposition of bilateral ovaries because of stage IB squamous cell carcinoma
of uterine cervix. Arrows and arrowheads indicate surgical clips and gonadal
veins, respectively. Bilateral gonadal veins were fully visible and given
detectability score of 5 (totally detectable) by two reviewers. Early-phase CT
scans through levels of S1–S2 (A), L5–S1 (B), and
L4–L5 (C).
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Fig. 1B —31-year-old woman 2 years after hysterectomy and lateral
transposition of bilateral ovaries because of stage IB squamous cell carcinoma
of uterine cervix. Arrows and arrowheads indicate surgical clips and gonadal
veins, respectively. Bilateral gonadal veins were fully visible and given
detectability score of 5 (totally detectable) by two reviewers. Early-phase CT
scans through levels of S1–S2 (A), L5–S1 (B), and
L4–L5 (C).
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Fig. 1C —31-year-old woman 2 years after hysterectomy and lateral
transposition of bilateral ovaries because of stage IB squamous cell carcinoma
of uterine cervix. Arrows and arrowheads indicate surgical clips and gonadal
veins, respectively. Bilateral gonadal veins were fully visible and given
detectability score of 5 (totally detectable) by two reviewers. Early-phase CT
scans through levels of S1–S2 (A), L5–S1 (B), and
L4–L5 (C).
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Fig. 1D —31-year-old woman 2 years after hysterectomy and lateral
transposition of bilateral ovaries because of stage IB squamous cell carcinoma
of uterine cervix. Arrows and arrowheads indicate surgical clips and gonadal
veins, respectively. Bilateral gonadal veins were fully visible and given
detectability score of 5 (totally detectable) by two reviewers. Curved
multiplanar reconstruction image shows complete course of bilateral gonadal
veins as well as transposed ovaries (open arrows) and surgical
clips.
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Image Interpretation and Analysis
The axial MDCT images and curved multiplanar images done on a workstation
were retrospectively evaluated by two experienced abdominal radiologists, who
had been given the surgical information regarding the transposed ovaries, on a
monitor (Coronis 3MP, Barco) using the scrolling method. The gonadal veins
were tracked backward from the draining point at the inferior vena cava or the
left renal veins in a caudal direction to the transposed ovaries
[7]. The visibility of each
gonadal vein was scored individually on a 5-point scale (1, not detectable; 2,
partially detectable [< 50%]; 3, 50–75% detectable; 4, 75% or less
detectable; 5, totally detectable). We assessed and scored both early and late
contrast-enhanced images.
The interobserver difference for the detection of the gonadal veins was
evaluated using kappa statistics; detectability was then calculated by
defining confidence level ratings of 4 and 5 as positive and 3 or less as
negative after discrepancies between the two observers were resolved by
consensus. Kappa values greater than 0 were considered to be indicative of a
positive correlation. Values of 0.40 or less were considered to be indicative
of a positive but poor correlation; 0.41–0.75, a good correlation; and
greater than 0.75, an excellent correlation. The maximum diameters of the
gonadal veins were measured at the consensus interpretation. The presence or
absence of the surgical clips and interval change in the appearance of the
transposed ovaries on follow-up MDCT were also evaluated and recorded.
Discrepancies between the two observers were again resolved by consensus.
Results
All 46 transposed ovaries were visualized on MDCT. Forty-three ovaries were
located laterally to the lower paracolic gutter. Three ovaries were found at
the posterior intraperitoneal space in the upper pelvis, lateral or
anterolateral to the psoas muscle.
Detectability of the gonadal veins was 83.3% on the right side and 68.1% on
the left side on MDCT, with interobserver kappa values (
= 0.7000 on
the right and = 0.7905 on the left) showing good correlation for the
right gonadal veins and excellent correlation for the left (Fig.
1A,
1B,
1C,
1D). We could not find any
difference in detectability of the gonadal veins between ovaries transposed to
the lower paracolic gutter and those transposed to the posterior
intraperitoneal space in the upper pelvis. Detectability on the right side
tended to be higher than that on the left side, but the difference was not
statistically significant (p < 0.05, McNemar's test).
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Fig. 2A —48-year-old woman 3 years after hysterectomy and
transposition of right ovary for stage IB squamous cell carcinoma of uterine
cervix. Left ovary was resected. Delayed-phase CT scan through level of iliac
fossa reveals formation of cyst on transposed ovary (arrow). Surgical
clips could not be detected. Arrowhead indicates gonadal vein.
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Fig. 2B —48-year-old woman 3 years after hysterectomy and
transposition of right ovary for stage IB squamous cell carcinoma of uterine
cervix. Left ovary was resected. Curved multiplanar reconstruction image shows
complete course of right gonadal veins (arrowheads), as well as
transposed ovary with cyst formation (arrow). Right gonadal vein was
given detectability score of 5 (totally detectable) by both reviewers.
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Fig. 3A —33-year-old woman 2 years after hysterectomy and
transposition of right ovary for stage IB squamous cell carcinoma of uterine
cervix. Left ovary was resected. Early-phase CT scan through level of iliac
fossa shows high-density spot at anterolateral aspect of ascending colon
(arrow), mimicking contrast-filled colonic diverticulum. Dense region
was subsequently identified as surgical clip by consensus. Arrowhead indicates
right gonadal vein.
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Fig. 3B —33-year-old woman 2 years after hysterectomy and
transposition of right ovary for stage IB squamous cell carcinoma of uterine
cervix. Left ovary was resected. Curved multiplanar reconstruction image shows
complete course of right gonadal vein (arrowhead) as well as
transposed ovary (open arrow) and surgical clip (solid
arrow). Right gonadal vein was given detectability score of 5
(totally detectable) by both reviewers.
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The maximum diameters of the gonadal veins on the left side (2.3–4.6
mm; mean, 3.1 ± 0.55 mm) tended to be smaller than those on the right
side (2.4–5.0 mm; mean, 3.8 ± 0.63 mm); again, the difference was
not significant (p < 0.05, Student's unpaired t
test).
Surgical clips of transposed ovaries were found in 98% (45/46) of cases. In
one patient in whom surgical clips could not be detected, probably because of
dislodgement and migration, gonadal veins were well shown (Fig.
2A,
2B). In two other patients,
although one radiologist interpreted high densities around the right
transposed ovaries as residual gastrointestinal contrast material in the
diverticula of the ascending colon, the densities were identified as surgical
clips at the consensus interpretation (Fig.
3A,
3B). In these two cases, the
gonadal veins were well shown and could be tracked back to the transposed
ovaries.
Interval changes in the appearance of the 39 transposed ovaries in 22
patients, in whom multiple MDCT scans were obtained, were observed in 33%
(13/39) of cases and included both interval increases (10/13) and decreases
(3/13) in size.
Discussion
Ovarian transposition is an effective procedure that enables preservation
of ovarian function in patients younger than 40 years who are treated with a
combination of radiation therapy and surgery for early-stage cervical cancer
and in patients with pelvic malignancies before irradiation to the pelvic
lymph nodes. The ovaries are commonly repositioned laterally, either to the
lower paracolic gutters close to the lateral aspect of the colon above the
iliac fossa level, or to the posterior intraperitoneal space in the upper
pelvis, lateral or anterolateral to the psoas muscle outside the radiation
field [6]. The procedure
involves mobilizing the ovary, the suspensory ligament, and the contained
ovarian vessels [3,
8].
According to our data, gonadal veins were successfully detected and tracked
back along the anterior surface of the psoas major muscle to the transposed
ovary in most patients (83% on the right, 68% on the left side). Thus, gonadal
veins continuous to the cystic mass at the paracolic gutter can be a useful
adjunct sign in identifying transposed ovaries. In our study, surgical clips
marking the ovarian location were detected around the transposed ovaries in
all patients but one. Therefore, detecting gonadal veins may not be necessary
in diagnosing transposed ovaries in most cases; however, it increases the
confidence level of the diagnosis, particularly when an appropriate clinical
history of previous surgery is not provided.
In only one patient were surgical clips not detected around the right
transposed ovary, possibly because of dislodgement and migration. In this
particular case, we tracked the right gonadal veins back to the transposed
ovary and thereby correctly identified the transposed ovary. In two other
patients in whom the surgical clips mimicked residual gastrointestinal
contrast material in the colonic diverticula, the gonadal veins again could be
tracked back to the transposed ovaries, leading to a correct identification of
the surgical clips and the transposed ovaries.
Asayama et al. [7] reported
a slightly higher detection rate of the gonadal veins in patients with large
pelvic masses (84.6% on the right side and 92.3% on the left) compared with
our study. The mean diameter of the gonadal veins in their study was also
larger than that in our patients. We speculate that this difference may have
been due to the history of hysterectomy in our patients. The diameter of the
gonadal vein may be affected by various factors: The gonadal vein conveys
venous blood not only from the ovaries, but also from the uterus; there may
even be a bidirectional flow, particularly on the left side, where the gonadal
veins drains into the left renal vein
[9]. Because hysterectomy was
performed in all of our patients, the volume of venous blood conveyed through
the gonadal veins may have been less than that of normal women who have not
undergone hysterectomy, leading to smaller-diameter gonadal veins.
To evaluate more precisely the usefulness of gonadal veins in the
identification of transposed ovaries, a blinded interpretation test should be
performed using both positive (patients with transposed ovaries) and negative
(patients without transposed ovaries but with other pathology at the paracolic
gutter) cases. However, to do this was beyond the scope of our study.
In conclusion, gonadal veins were detected on MDCT and tracked back to the
transposed ovaries in 70–80% of the cases; this information could be
used as an adjunct sign in diagnosing this entity. This may be particularly
useful when appropriate clinical information is not available regarding the
previous surgery, and when there are no detectable surgical clips around the
lesions.
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Abstract
Introduction
