Chaves, Paula

Cunha, Teresa Margarida

Ferreira, Joana

Horta, Mariana

English

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Case 11325 Uncommon pelvic mass: GIST mimicking adnexal tumourMariana Horta  , Teresa Margarida Cunha , Joana Ferreira , Paula Chaves  1 2 3 3 Genital (Female) Imaging Section: 2013, Nov. 22 Published: 66 year(s), femalePatient:Authors' Institution[1] Serviço de Radiologia, Centro Hospitalar Lisboa Ocidental, EPE, Lisboa; Email:mariana_horta@hotmail.com [2] Serviço de Radiologia, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE,Lisboa, Portugal[3] Serviço de Anatomia Patológica, Instituto Português de Oncologia de Lisboa Francisco Gentil,EPE, Lisboa, PortugalClinical HistoryA 66-year-old woman was referred to our Institute to define a sonographic finding of a pelvic mass.She presented with a history of pelvic pain, asthenia and weight loss. Gynaecological examination :Upper deflection of the cervix by a compressive lesion in the posterior cul-de-sac. CA125= normal.Imaging FindingsThe patient underwent a pelvic MR that showed a large, lobulated tumour localized in the pouch ofDouglas, measuring 15, 4x10, 6x11, 7cm.It did not invade the uterus or the sigmoid colon and it was in close relation with the intestinalloops. The ovaries were not visualized. The mass was heterogeneous, with focal areas of hypointensity on T1W1 showing high-signal onT2WI, and avid gadolinium uptake on fat-suppressed T1W1. These areas also demonstratedrestricted diffusion, suggesting solid malignant nature. Other areas showing intermediate signal onT1W1 were hyperintense on T2WI and did not enhance, which suggests hemorrhagic and necroticnature.The patient underwent a small bowel and rectal partial resection with total hysterectomy andbilateral anexectomy. The resected specimen contained, in a paraintestinal location, a 12cmpartially cystic and necrotic nodular tumour.The histopathologic diagnosis was small bowel malignant GIST.DiscussionGastrointestinal stromal tumours (GISTs) are mesenchymal tumours which account for less than 1%of all gastrointestinal tumours [1, 2]. They can occur throughout the GI tract, mesentery, omentumand retroperitonuem, with 20-30% arising in the small bowel [3, 4].They range from benign tumours to aggressive tumours (10-30%) [3].The majority of GISTs presents at ages above 40 years. Gastrointestinal hemorrhage due to mucosalulceration is a frequent symptom. Abdominal pain, vomiting, weight loss and intestinal obstructioncan also occur [4].Extraluminal and eccentric growth is frequently encountered in malignant small intestine GISTs,which can encase non contiguous segments [2, 4].The solid component of GISTs is typically hypointense on T1WI and shows intermediate/highsignal intensity on T2WI, enhancing avidly following the administration of gadolinium. Signalintensity of focal hemorrhagic areas varies according to the age of hemorrhage [1, 2, 5].Small bowel GIST's 5-year survival rate is 40-50% [1].Female pelvic masses commonly arise from reproductive organs, however non gynaecologicallesions originating from urinary and gastrointestinal systems, from the peritoneum, retroperitoneumand from adjacent soft tissues are important pitfalls that radiologists and gynaecologists must takeinto account [1].Identification of the location of the mass (intra or extraperitoneal) is based on anatomic landmarksand should also take into account the patient's age, clinical and gynaecological history [1].MRI is the modality of choice to evaluate US and CT indeterminate pelvic masses and hascapability to differentiate benign from malignant lesions [1, 6].In our case MR was performed to characterize an indeterminate adnexal mass that revealed to be ofgastrointestinal origin.Despite being an uncommon pelvic mass, GISTs must be considered in the differential diagnosis oflarge adnexal masses, since they may have similar imaging characteristics to ovarian cancer and itstherapy and prognosis are very different.Final DiagnosisSmall bowel malignant GISTDifferential Diagnosis ListDygerminoma , Adult Granulosa Cell Tumor, Mixed mullerian tumor, Ovarian solid metastasis,Leiomyossarcoma, Subserosal leiomyoma, Schwannoma, Neurofibroma, LymphomaFiguresFigure 1 Axial non-enhanced T1-weighted MR imageAxial non-enhanced T1-weighted MR image demonstrates a heterogeneous lobulated pelvicmass in the pouch of Douglas predominantly hypointense with focal areas of intermediatesignal and of remarkably hypointense signal. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 2 Axial T2- weighted MR imageAxial T2- weighted MR image shows a hyperintense mass with areas of strong hyperintensesignal. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 3 Axial non-enhanced T1-weighted MR imageTumour areas of hypointensity on T1W1 correspond to areas of hyperintensity on T2WI.Tumour areas of intermediate signal on T1W1 correspond to areas of strong hypersignal onT2WI. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 4 Axial non-enhanced T2-weighted MR imageTumour areas of hypointensity on T1W1 correspond to areas of hyperintensity on T2WI.Tumour areas of intermediate signal on T1W1 correspond to areas of strong hypersignal onT2WI. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 5 Sagittal T2-weighted imageThe tumour extends above the sacral promontory and displaces the uterus anteriorly and thesigmoid colon posteriorly. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 6 Sagittal fat-supressed gadolinium-enhanced T1-weighted imageSagittal fat-supressed gadolinium-enhanced T1-weighted image show avid contrast uptakeby the solid component of the tumour. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 7 a) Axial T2-weighted image. b) Sagittal T2-weighted image.Axial T2-weighted image. b) Sagittal T2-weighted image. The tumour was in close relationwith intestinal loops (arrow) , that crossed the tumour . © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 8 a) DWI sequence b) ADC mapThe tumour shows restricted diffusion. © Caldeira JP, Department of Radiology,Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 9 TumourThe tumor showed short intersecting fascicles of fusiform, pleomorphic cells with frequentmitotic figures (>10 mitosis/50HPF) (islet, H-E, 400x). (H-E, 200x). © Chaves P, Department of Pathology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 10 Neoplastic cellsThe neoplastic cells were positive for caldesmon © Chaves P,Department of Patholgy, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 11 Neoplastic cellsThe neoplastic cells were positive for CD117 © Chaves P, Department of Pathology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 12 Neoplastic cellsThe neoplastic cells were positive for DOG1 © Chaves P. Department of Pathology. Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 13 Neoplastic cellsThe neoplastic cells were negative for muscle markers namely actin and desmin © Chaves P. Department of Pathology.Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; References[1] Szklaruk J, Tamm E, Choi H, Varavithya V (2003) MR Imaging of Common and UncommonLarge Pelvic Masses Radiographics 23:403-424[2] Mass Elli G, Colaiacomo MC, Marcelli G, Bertini L, Casciani E, d'Amici P, Caprasecca S,Polettini E, Gualdi G. (2012) MRI of small bowel: how to differentiate primary neoplasms andmimickers Br J Radiol 85(1014):824-37[3] Webb WR, Brant W, Major N. (2006) Fundamentals of body CT Elsevier Health Sciences[4] Levy A, Remotti H, Thompson W, Sobin L, Miettinen M (2003) Gastrointestinal StromalTumours: Radiologic Features with Pathologic Correlation Radiographics 23:283-304[5] Caramella T, Schmidt S, Chevallier P, Saint Paul M, Bernard JL, Bidoli R, Bruneton JN (2005)MR Features of gastrointestinal stromal tumours Journal of Clinical Imaging 251-254[6] Spencer J, Forstner R, Cunha TM (2010) ESUR guidelines for MR imaging of thesonographically indeterminate adnexal mass: an algorithmic approach. Eur Radiol 20: 25-35CitationMariana Horta  , Teresa Margarida Cunha , Joana Ferreira , Paula Chaves  (2013, Nov. 22) 1 2 3 3 Uncommon pelvic mass: GIST mimicking adnexal tumour {Online}URL: http://www.eurorad.org/case.php?id=11325

Uncommon pelvic mass: GIST mimicking adnexal tumour

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Uncommon pelvic mass: GIST mimicking adnexal tumour

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