Borderline epithelial ovarian tumors: what the radiologist should know.

Ovarian borderline tumors are neoplasms of epithelial origin that are typically present in young patients and tend to have a less aggressive clinical course than malignant tumors. Accurate diagnosis and staging of borderline tumors has important prognostic and management implications (like fertility-sparing procedures) for women of child-bearing age. This article will review the sonographic, CT, and MRI features of borderline epithelial ovarian tumors with histopathologic correlation. Borderline tumors have less soft tissue and thinner walls/septations than malignant tumors. Serous borderline tumors more commonly have papillary projections, which can simulate the appearance of a sea anemone. Mucinous borderline tumors often are larger, multi-cystic, and more commonly unilateral. The borderline mucinous tumors may also present with pseudomyxoma peritonei, which can make it difficult to distinguish from malignant mucinous carcinoma. Ultrasound is usually the first-line modality for imaging these tumors with MRI reserved for further characterizing indeterminate cases. CT is best used to stage tumors for both locoregional and distant metastatic disease. Overall, however, the imaging features overlap with both benign and malignant ovarian tumors. Despite this, it is important for the radiologist to be familiar with the imaging appearances of borderline tumors because they can present in younger patients and may benefit from different clinical/surgical management.

A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn's perianal fistulas.

BACKGROUND & AIMS: To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. METHODS: Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for > or =85% of patients. RESULTS: Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was > or =85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. CONCLUSIONS: EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.

Hysterosonography: a key to what is inside the uterus.

The pursuit of endometrial histology is often prompted by postmenopausal or dysfunctional endometrial bleeding, a pathologically-thickened central endometrial complex on ultrasound, infertility, or routine screening caused by risk factors for underlying pathology. If a focal endoluminal process is responsible, it can remain undiagnosed when a blind method of biopsy is used. Transvaginal ultrasound coupled with hysterosonography can provide the necessary information to triage these patients to the most appropriate tissue sampling technique and avoid the common problem of a false-negative biopsy result. In many circumstances, a focal process can be more specifically characterized and localized during hysterosonography, information which could also help direct subsequent hysteroscopic biopsy if needed.

Focal intracavitary masses recognized with the hyperechoic line sign at endovaginal US and characterized with hysterosonography.

In 42 women, endovaginal ultrasonography (US) was performed because of an abnormal central endometrial complex. Retrospective review of the endovaginal US scans and subsequently obtained hysterosonograms with histopathologic correlation showed a hyperechoic line surrounding the central endometrial complex in 25 patients, all of whom had focal intracavitary processes. Cystic spaces within the central endometrial complex in 17 of these patients reflected polyps; this finding was associated with a hyperechoic line in 15. At hysterosonography, all polyps (n = 29) had a narrow attachment to the endometrium. All five fibroids were broadly attached and had a rim of overlying endometrium. These focal abnormalities were easily distinguished from global endometrial processes amenable to a blind biopsy procedure. This initial experience showed that a hyperechoic line circumscribing the central endometrial complex at endovaginal US allows prediction of focal intracavitary disease, particularly when the line is associated with cystic spaces within the central endometrial complex. The presence of a hyperechoic line can be used to direct the patient to a visually guided hysteroscopic procedure rather than a potentially unsuccessful blind biopsy procedure. Alternatively, absence of a hyperechoic line can prompt management appropriately directed by hysterosonographic characterization of the uterine contents as focal or diffuse.