Gynecological Masses: Tips for Determining their Site of Origin
Gynecological Masses: Tips for Determining their Site of Origin
Luís Maduro
The identification of the origin and nature of gynecological pelvic masses can be challenging. This work aims to provide tips to determine the site of origin of these lesions. For the purpose of this work, there are not included intra-peritoneal lesions or extra-peritoneal non-gynecological lesions.
The most common origin of lesions of the upper female reproductive tract lesions is the ovaries. Radiological clues are utilized to identify an ovarian origin: - Phantom Ovary Sign: absence of a normal ipsilateral ovary (Fig 1A, Fig 3D); - Ovarian Vascular Pedicle Sign: dilated ovarian veins with connections to the ovary (Fig 1C); - Beak Sign: sharp angles between the mass and ovary; - Ovarian Crescent Sign: compressed or encircling normal ovarian tissue (Fig 1B); - Posterior displacement of extraperitoneal structures such as the uterus, rectum, sigmoid, or ureter (Fig 1D). In cases where an ovarian origin is ruled out, attention is directed to consider a fallopian tube origin based on characteristic morphological signs: - Cogwheel Sign: dilated loops with infolding projections; - Waist Sign: indentations along the walls of the tubular-shaped tube (Fig 2); - "C" or "S" shaped configuration (Fig 2). Furthermore, the possibility of a uterine origin can be suspected by: - Claw Sign: uterine tissue embedding the mass (Fig 1A and 1B); - Bridging Vessel Sign: between the uterus and the mass (Fig 3C). There is also the possibility of broad ligament origin, for lesions with no clue signs for ovarian or uterine origin. Lesions of the cervix and vagina should be suspected when their epicenter is located in these organs.
Figure 1: Fibrotechoma A - Phatom Ovary Sign: only the right ovary (circle) is seen; B - Ovarian Crescent Sign: compressed ovarian tissue (crescent); C - Ovarian Vascular Pedicle Sign: dilated ovarian veins (arrows) connected to the ovary / lesion; D - Posterior displacement of the uterus
Figure 2: Hydrosalpinx - note the "C" shaped configuration and the Waist Sign (arrows)
Figure 3: Cellular Leiomyoma A and B - Claw Sign (dash line): uterus tissue embedding the mass; C - Bridging Vessel Sign (circle), independent from the left ovary (arrow); D - Negative Phantom Ovary Sign (circles marking both ovaries that are independent from the lesion))
Radiological features, along with clinical information, aid in narrowing the differential diagnosis. However, in some cases, a definitive diagnosis may not be achievable, and radiologists should provide a limited list of the most likely entities to facilitate treatment management.
