Riccardo Manfredi Roberto Pozzi Mucelli Editors MRI of the Female and Male Pelvis 123 MRI of the Female and Male Pelvis Riccardo Manfredi (cid:129) Roberto Pozzi Mucelli Editors MRI of the Female and Male Pelvis Editors Riccardo Manfredi Roberto Pozzi Mucelli Department of Radiology Department of Radiology University of Verona University of Verona “G.B. Rossi” University Hospital “G.B. Rossi” University Hospital Verona Verona Italy Italy ISBN 978-3-319-09658-2 ISBN 978-3-319-09659-9 (eBook) DOI 10.1007/978-3-319-09659-9 Springer Cham Heidelberg New York Dordrecht London Library of Congress Control Number: 2014957394 © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Contents 1 Magnetic Resonance Imaging of Congenital Malformation of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Valerio Di Paola , Eugenio Oliboni , Daniela Avolio , Riccardo Manfredi , and Roberto Pozzi Mucelli 2 MRI of Endometrial Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . 19 Matteo Bonatti , Lisa Zantedeschi , Flavia Dal Corso , Riccardo Manfredi, and Roberto Pozzi Mucelli 3 Uterine Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Claudia Schenk , Federica Spagnolli , Arianna Rossi , Riccardo Manfredi , and Roberto Pozzi Mucelli 4 Endometriosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Simona Mautone , Salvatore Belluardo , Valerio Di Paola , Luigi Romano , Giovanni Foti , Riccardo Manfredi , and Roberto Pozzi Mucelli 5 Fibroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Laura Pavanello , Stefano Cesari , Carlo Biasiutti , Riccardo Manfredi , and Roberto Pozzi Mucelli 6 Neoplasms of the Ovary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Maria Chiara Ambrosetti , Livia Bernardin , Riccardo De Robertis Lombardi , Stefano Crosara , Federica Castelli , Andrea Rockall , Riccardo Manfredi , and Roberto Pozzi Mucelli 7 Benign Prostatic Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Teresa Milazzo , Federica Castelli , Beatrice Pedrinolla , Emanuele Demozzi , Riccardo Manfredi , and Roberto Pozzi Mucelli 8 Adenocarcinoma of the Prostate. . . . . . . . . . . . . . . . . . . . . . . . . 183 Ugolino Alfonsi , Anna Ventriglia , Riccardo Manfredi , and Roberto Pozzi Mucelli 9 MR Imaging of the Scrotum. . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Michele Bertolotto , Francesca Cacciato , Matilde Cazzagon , and Lorenzo E. Derchi v vi Contents 10 Magnetic Resonance Urography. . . . . . . . . . . . . . . . . . . . . . . . . 249 Maria Assunta Cova , Gabriele Poillucci , Luca De Paoli , and Maja Ukmar 11 Fetal MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Alessia Adami , Sara Mehrabi , Alessandro Zaccarella , Anna Ventriglia , Riccardo Manfredi , and Roberto Pozzi Mucelli 1 Magnetic Resonance Imaging of Congenital Malformation of the Uterus Valerio Di Paola , Eugenio Oliboni , Daniela Avolio , Riccardo Manfredi , and Roberto Pozzi Mucelli 1.1 Introduction 1.2 E pidemiology Female genital tract anomalies are common C ongenital malformations of the uterus f requency deviations from normal anatomy with an esti- vary widely owing to different patient popula- mated prevalence of 1–3 % in the general popula- tions, non-standardized classifi cation systems, tion and even higher in selected populations such and differences in diagnostic data acquisition. as recurrent aborters [1 , 2 ]. Because normal pregnancies can occur in women Their occurrence could be associated with a with MDA and the anomalies are discovered in variety of clinical presentations ranging between most cases of patients presenting with infertility, life-threatening complications, severe health the reported prevalence of MDA in the general problems in the adolescence, and reproductive population is probably underestimated. The over- problems, although in most of them they are all published data suggest a prevalence range of asymptomatic [1 – 3 ]. uterovaginal anomalies of 1–3 % in the general D ue to their high prevalence and possible population, among women with normal and impact on the reproductive health of women, abnormal fertility [5 – 7 ]. congenital uterine malformations of the female While conceiving is a minor problem for the genital tract are a challenge for the therapeutic majority of women with MDA, the risk of preg- decision-making process. nancy loss is truly associated with MDA, and its The diagnosis of Mullerian duct anomalies prevalence in women with repeated miscarriage (MDA) is based upon the clinical presentation, is considered to be in the order of 3 %. No racial physical examination, and subsequent imaging predilection is reported in the literature [5 , 8 , 9 ]. work-up with different imaging methods avail- able, namely, sonography and magnetic reso- nance (MR) imaging, among them MR imaging 1.3 Clinical Presentation takes a leading role, especially in complex uter- ine malformation [1 – 4 ]. MDA may become clinically evident at different ages depending on their specifi c characteristics and associated disorders. In the newborn/infant V. Di Paola (*)(cid:129) E. Oliboni age, an initial presentation of a palpable abdomi- D. Avolio (cid:129) R. Manfredi (cid:129) R. P. Mucelli nal or pelvic mass due to a utero and/or vaginal Department of Radiology , University of Verona , obstruction causing intraluminal fl uid retention Piazzale Scuro , Verona , Italy e-mail: [email protected] can be discovered. R. Manfredi, R. Pozzi Mucelli (eds.), MRI of the Female and Male Pelvis, 1 DOI 10.1007/978-3-319-09659-9_1, © Springer International Publishing Switzerland 2015 2 V. Di Paola et al. I n adolescent age group a delayed menarche Mullerian ducts develop in medial and caudal or primary amenorrhea with/without a fl uid directions, and the cranial part remains non-fused retention in the uterus (hematometra) and/or and forms the fallopian tubes. The caudal part vagina (hematocolpos) may present as a painful fuses to a single canal forming the uterus and the intra-abdominal tumor. Some patients also have upper two thirds of the vagina. This is called lat- cyclical pain. eral fusion. I n childbearing age, MDA can present with In a process called vertical fusion, the inter- various problems of infertility, repeated sponta- vening midline septum of both ducts undergoes neous abortions, premature delivery, fetal intra- regression. The caudal part of the vagina arises uterine growth retardation, and diffi culties during from the sinovaginal bulb and fuses with the delivery. The defective embryological develop- lower fused Mullerian ducts. ment can also be associated with congenital mal- The ovaries originate from the gonadal ridge, formations of other organ systems. Most a completely different tissue than the mesoderm, frequently, renal malformations like renal agene- forming both the urinary and genital systems. sis or ectopia can occur. Much less frequent are Hence, associated malformations of the kidney, bony malformations – most of them occur in a but not of the ovaries, are frequently observed complex of varying symptoms – like abnormal together with MDA. scapula, supernumerary or fused ribs, vertebral Pathogenesis of MDA can be basically classi- malsegmentation, fusion of the vertebral column fi ed into the presence of agenesis, hypoplasia, (i.e., Klippel-Feil syndrome), and radiocarpal and defects in vertical and lateral fusion of the hypoplasia. paired ducts [5 ]. Other malformations such as cardiac defects have been described, but it remains unclear if some of the associated malformations are caused 1.5 C lasses of Mullerian Duct in the same development fi eld or if early expo- Anomalies (MDA) sure to teratogenic agents was causative [7 , 9 ]. The literature does not show increased mortal- The fi rst attempt to classify female congenital ity for patients carrying an MDA compared to the anomalies goes back to the beginning of the nine- general population, whereas the morbidity may teenth century; Strassmann described septate and be increased in some specifi c types of MDA bicornuate uterus and some subgroups of the dis- causing obstructed Mullerian systems with the orders in 1907. However, the fi rst classifi cation presence of hematosalpinx (retention of blood in system for categorization of congenital uterine the fallopian tubes), hematocolpos (retention of malformations was that of the American Fertility blood in the vagina), and retrograde menses caus- Society (AFS) published in 1988, mostly based on ing the potential problem of endometriosis [5 ]. the previous work of Buttram and Gibbons [3 , 4 ]. Then other classifi cation systems followed, but the AFS classifi cation is still the most broadly 1.4 Embryology used, widely accepted among specialists. The American Fertility Society introduced a The understanding of the embryogenesis of the classifi cation system that stratifi es MDA into urogenital female tract is of paramount impor- seven different classes of uterine anomalies tance to understand the pathogenesis of the dif- (Fig. 1.1 ). ferent types of MDA. The female reproductive system develops from the two-paired Mullerian ducts (synonym: 1.5.1 Class I Anomalies: Dysgenesis paramesonephric duct) that start off in the embry- onal mesoderm lateral to each Wolffi an duct D ysgenesis (segmental agenesis and variable (synonym: mesonephric duct). The paired hypoplasia) of the Mullerian ducts (uterus and 1 Magnetic Resonance Imaging of Congenital Malformation of the Uterus 3 I Hypoplasia/agensis II Unicornuate III Didelphus (a) Vaginal (b) Cervical (a) Communicating (b) Non Communicating IV Bicornuate (c) Fundal (d) Tubal (e) Combined (c) No cavity (d) No horn (a) Complete (b) Partial V Septate VI Arcuate VII DES drug related (a) Complete (b) Partial Fig. 1.1 Classifi cation system of Mullerian duct anomalies by the American Fertility Society upper 2/3 of the vagina) (Fig. 1 .1 ). Mayer- 1.5.3 Class III Anomalies: Uterus Rokitansky- Küster-Hauser syndrome is the most Didelphys common form of Class I anomaly and includes agenesis of uterus and vagina [5 , 9 , 10 ] . U terus didelphys is a result of complete non- fusion of the Mullerian ducts forming a complete uterine duplication with no communication 1.5.2 Class II Anomalies: between each other (Fig. 1 .1 ). Unicornuate Uterus Uterus didelphys may be associated with a longitudinal (75 %) or, more rarely, with a trans- U nicornuate uterus is the result of partial or com- verse vaginal septum, the latter causing obstruc- plete hypoplasia of one Mullerian duct (Fig. 1 .1 ) tive hematometrocolpos. [ 11 ]. Unicornuate uterus may be isolated (35 %) or Endometriosis as a result of retrograde men- associated with a contralateral rudimentary horn. struation may also occur in these conditions. A The rudimentary horn presents with or without nonobstructive uterus didelphys is usually communication to the endometrial cavity and may asymptomatic [5 ]. be associated with or without endometrium, which is also called no cavity rudimentary horn. In patients with cavity non-communicating rudimen- 1.5.4 Class IV Anomalies: tary horn, dysmenorrhea and hematometra may Bicornuate Uterus occur. Surgical resection either to relieve symp- tomatic pain or to reduce the risk of potential ecto- B icornuate uterus is the result of incomplete pic pregnancy is justifi ed. As with every obstructed fusion of the cranial parts of the Mullerian ducts system, the risk of endometriosis is also increased (Fig. 1 .1 ) [5 – 9 , 1 2] . Two uterine cavities with with a non-communicating rudimentary horn. normal zonal anatomy can be depicted. The lead- Renal malformations are common with unicornu- ing imaging feature is a fundal cleft greater than ate uterus and occur mostly on the same side as the 1 cm of the external uterine contour that helps to rudimentary horn could be found [5 ]. distinguish bicornuate uterus from septate uterus.