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Unusual Causes of Tubo-ovarian Abscess: CT and MR Imaging Findings¹

¹ From the Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (S.H.K., S.H.K.); the Department of Radiology, Gachon Medical School, Gil Medical Center, Incheon, Korea (D.M.Y.); and the Department of Radiology, Korea University Guro Hospital, Seoul (K.A.K.). Presented as an education exhibit at the 2003 RSNA scientific assembly. Received February 11, 2004; revision requested March 19 and received April 23; accepted April 26. All authors have no financial relationships to disclose. Address correspondence to Seung Hyup Kim, Department of Radiology, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul 110–744, Korea (e-mail: kimsh@radcom.snu.ac.kr).

View larger version (144K): [in a new window]   Figure 1a.  Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).

View larger version (131K): [in a new window]   Figure 1b.  Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).

View larger version (132K): [in a new window]   Figure 1c.  Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).

View larger version (139K): [in a new window]   Figure 1d.  Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).

View larger version (134K): [in a new window]   Figure 2a.  Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.

View larger version (138K): [in a new window]   Figure 2b.  Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.

View larger version (145K): [in a new window]   Figure 2c.  Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.

View larger version (128K): [in a new window]   Figure 3a.  Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.

View larger version (136K): [in a new window]   Figure 3b.  Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.

View larger version (121K): [in a new window]   Figure 3c.  Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.

View larger version (141K): [in a new window]   Figure 3d.  Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.

View larger version (121K): [in a new window]   Figure 4.  Tubo-ovarian actinomycosis in a 45-year-old woman. Contrast-enhanced CT scan shows an ill-defined solid mass (arrows) in the left adnexal region. U = uterus.

View larger version (133K): [in a new window]   Figure 5a.  Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.

View larger version (127K): [in a new window]   Figure 5b.  Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.

View larger version (129K): [in a new window]   Figure 5c.  Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.

View larger version (147K): [in a new window]   Figure 6a.  Tubo-ovarian actinomycosis in a 48-year-old woman. The TOA has a solid and cystic appearance. (a) Axial T2-weighted MR image shows a solid and cystic mass in the right adnexal region (black arrows). Note the posterior extension by a solid lesion with low signal intensity (white arrows). (b) Axial contrast-enhanced fat-suppressed T1-weighted MR image obtained caudad to a shows good enhancement of the solid portion of the mass, which has multiple internal rim-enhancing lesions (black arrow). The linear, solid lesion extending posteriorly from the mass (white arrows) is also well enhanced.

View larger version (129K): [in a new window]   Figure 6b.  Tubo-ovarian actinomycosis in a 48-year-old woman. The TOA has a solid and cystic appearance. (a) Axial T2-weighted MR image shows a solid and cystic mass in the right adnexal region (black arrows). Note the posterior extension by a solid lesion with low signal intensity (white arrows). (b) Axial contrast-enhanced fat-suppressed T1-weighted MR image obtained caudad to a shows good enhancement of the solid portion of the mass, which has multiple internal rim-enhancing lesions (black arrow). The linear, solid lesion extending posteriorly from the mass (white arrows) is also well enhanced.

View larger version (122K): [in a new window]   Figure 7a.  Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.

View larger version (146K): [in a new window]   Figure 7b.  Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.

View larger version (93K): [in a new window]   Figure 7c.  Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.

View larger version (157K): [in a new window]   Figure 8a.  Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).

View larger version (127K): [in a new window]   Figure 8b.  Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).

View larger version (140K): [in a new window]   Figure 8c.  Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).

View larger version (154K): [in a new window]   Figure 9a.  Tuberculous TOAs with endometritis in a 63-year-old woman. (a) Sagittal contrast-enhanced T1-weighted MR image shows a well-enhancing, thickened endometrium (arrows) with hydrometra. (b) Axial contrast-enhanced T1-weighted MR image shows septate cystic masses (arrows) in both adnexal regions.

View larger version (150K): [in a new window]   Figure 9b.  Tuberculous TOAs with endometritis in a 63-year-old woman. (a) Sagittal contrast-enhanced T1-weighted MR image shows a well-enhancing, thickened endometrium (arrows) with hydrometra. (b) Axial contrast-enhanced T1-weighted MR image shows septate cystic masses (arrows) in both adnexal regions.

View larger version (140K): [in a new window]   Figure 10a.  Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.

View larger version (135K): [in a new window]   Figure 10b.  Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.

View larger version (129K): [in a new window]   Figure 10c.  Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.

View larger version (166K): [in a new window]   Figure 10d.  Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.

View larger version (113K): [in a new window]   Figure 10e.  Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.

View larger version (114K): [in a new window]   Figure 11a.  Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.

View larger version (120K): [in a new window]   Figure 11b.  Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.

View larger version (173K): [in a new window]   Figure 11c.  Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.

View larger version (167K): [in a new window]   Figure 11d.  Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.

View larger version (159K): [in a new window]   Figure 11e.  Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.

View larger version (143K): [in a new window]   Figure 12a.  Xanthogranulomatous oophoritis in a 44-year-old woman. (a) Axial T2-weighted MR image shows a left adnexal mass (white arrows) containing multiple round lesions with high signal intensity (black arrows). (b) Axial T1-weighted MR image shows that the internal lesions have low signal intensity (arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The nonenhancing lesions (arrows) in the mass correspond to the lesions with high signal intensity on the T2-weighted image (a). An IUD is visible as a nonenhancing area (arrowhead) in the endometrial cavity. (d) Photograph of the pathologic specimen of the mass shows multiple xanthogranulomas (arrows). (e) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows multiple lipid-containing foamy histiocytes (arrows).

View larger version (130K): [in a new window]   Figure 12b.  Xanthogranulomatous oophoritis in a 44-year-old woman. (a) Axial T2-weighted MR image shows a left adnexal mass (white arrows) containing multiple round lesions with high signal intensity (black arrows). (b) Axial T1-weighted MR image shows that the internal lesions have low signal intensity (arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The nonenhancing lesions (arrows) in the mass correspond to the lesions with high signal intensity on the T2-weighted image (a). An IUD is visible as a nonenhancing area (arrowhead) in the endometrial cavity. (d) Photograph of the pathologic specimen of the mass shows multiple xanthogranulomas (arrows). (e) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows multiple lipid-containing foamy histiocytes (arrows).

View larger version (116K): [in a new window]   Figure 12c.  Xanthogranulomatous oophoritis in a 44-year-old woman. (a) Axial T2-weighted MR image shows a left adnexal mass (white arrows) containing multiple round lesions with high signal intensity (black arrows). (b) Axial T1-weighted MR image shows that the internal lesions have low signal intensity (arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The nonenhancing lesions (arrows) in the mass correspond to the lesions with high signal intensity on the T2-weighted image (a). An IUD is visible as a nonenhancing area (arrowhead) in the endometrial cavity. (d) Photograph of the pathologic specimen of the mass shows multiple xanthogranulomas (arrows). (e) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows multiple lipid-containing foamy histiocytes (arrows).

View larger version (93K): [in a new window]   Figure 12d.  Xanthogranulomatous oophoritis in a 44-year-old woman. (a) Axial T2-weighted MR image shows a left adnexal mass (white arrows) containing multiple round lesions with high signal intensity (black arrows). (b) Axial T1-weighted MR image shows that the internal lesions have low signal intensity (arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The nonenhancing lesions (arrows) in the mass correspond to the lesions with high signal intensity on the T2-weighted image (a). An IUD is visible as a nonenhancing area (arrowhead) in the endometrial cavity. (d) Photograph of the pathologic specimen of the mass shows multiple xanthogranulomas (arrows). (e) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows multiple lipid-containing foamy histiocytes (arrows).

View larger version (179K): [in a new window]   Figure 12e.  Xanthogranulomatous oophoritis in a 44-year-old woman. (a) Axial T2-weighted MR image shows a left adnexal mass (white arrows) containing multiple round lesions with high signal intensity (black arrows). (b) Axial T1-weighted MR image shows that the internal lesions have low signal intensity (arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows irregular enhancement of the mass. The nonenhancing lesions (arrows) in the mass correspond to the lesions with high signal intensity on the T2-weighted image (a). An IUD is visible as a nonenhancing area (arrowhead) in the endometrial cavity. (d) Photograph of the pathologic specimen of the mass shows multiple xanthogranulomas (arrows). (e) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows multiple lipid-containing foamy histiocytes (arrows).

View larger version (133K): [in a new window]   Figure 13a.  Tubo-ovarian xanthogranulomatous inflammation in a 72-year-old woman. (a) Contrast-enhanced CT scan shows a solid and cystic mass (arrows) adherent to the sigmoid colon in the left adnexal region. Barium study of the colon showed invasion of the sigmoid colon. (b) Contrast-enhanced CT scan obtained caudad to a shows that the mass has a septate cystic appearance (arrows).

View larger version (130K): [in a new window]   Figure 13b.  Tubo-ovarian xanthogranulomatous inflammation in a 72-year-old woman. (a) Contrast-enhanced CT scan shows a solid and cystic mass (arrows) adherent to the sigmoid colon in the left adnexal region. Barium study of the colon showed invasion of the sigmoid colon. (b) Contrast-enhanced CT scan obtained caudad to a shows that the mass has a septate cystic appearance (arrows).

View larger version (117K): [in a new window]   Figure 14a.  Tubo-ovarian xanthogranulomatous inflammation in a 52-year-old woman. (a) Axial T2-weighted MR image shows a large cystic mass (white arrows) in the pelvic cavity. The right posterior portion of the mass (black arrows) has a more complex appearance. (b) Axial T1-weighted MR image shows high signal intensity in the right posterior portion of the mass (white arrows). Hemorrhage is noted in the main cystic portion (black arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the wall of the right posterior portion of the mass; internal linear solid lesions in that portion also enhance well. At pathologic examination, the mass was composed of a large abscess and a region of xanthogranulomatous inflammation in the left ovary and salpinx.

View larger version (104K): [in a new window]   Figure 14b.  Tubo-ovarian xanthogranulomatous inflammation in a 52-year-old woman. (a) Axial T2-weighted MR image shows a large cystic mass (white arrows) in the pelvic cavity. The right posterior portion of the mass (black arrows) has a more complex appearance. (b) Axial T1-weighted MR image shows high signal intensity in the right posterior portion of the mass (white arrows). Hemorrhage is noted in the main cystic portion (black arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the wall of the right posterior portion of the mass; internal linear solid lesions in that portion also enhance well. At pathologic examination, the mass was composed of a large abscess and a region of xanthogranulomatous inflammation in the left ovary and salpinx.

View larger version (109K): [in a new window]   Figure 14c.  Tubo-ovarian xanthogranulomatous inflammation in a 52-year-old woman. (a) Axial T2-weighted MR image shows a large cystic mass (white arrows) in the pelvic cavity. The right posterior portion of the mass (black arrows) has a more complex appearance. (b) Axial T1-weighted MR image shows high signal intensity in the right posterior portion of the mass (white arrows). Hemorrhage is noted in the main cystic portion (black arrows). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the wall of the right posterior portion of the mass; internal linear solid lesions in that portion also enhance well. At pathologic examination, the mass was composed of a large abscess and a region of xanthogranulomatous inflammation in the left ovary and salpinx.