Exercises: Pelvic Calcifications

EXERCISES 8-2. PELVIC CALCIFICATIONS

8-5. What is the most likely diagnosis in Case 8-5 (Figure8-11)?

A.         Appendicolith

B.         Ectopic gallstone

C.         Pelvic phlebolith

D.         Right ureteral calculus.

8-6. What is the most likely diagnosis in Case 8-6 (Figure8-12)?

A.   Calcified ovarian tumor

B.   Multiple phleboliths

C.   Multiple ureteral calculi

D.   Uterine fibroid calcification

8-7. What is the most likely diagnosis in Case 8-7 (Figure8-13)?

A.   Bladder calculus

B.   Chondrosarcoma of the sacrum

C.   Cystadenoma of the ovary

D.   Uterine fibroid calcifications

8-8. What is the most likely diagnosis in Case 8-8 (Figure8-14)?

A.         Bladder calculi

B.         Calcified vas deferens

C.         Ovarian dermoid cyst

D.         Uterine fibroid calcification.

Radiologic Findings

8-5. This case is that of a boy with acute appendicitis (A is the correct answer to Question 8-5). An oval calcifi-cation measuring 0.8 cm in diameter projects over the iliac bone and laterally to the right sacroiliac joint with a distended appendiceal lumen filled with gas. At surgery, gangrenous appendicitis with perforation and an obstructing appendicolith were found.

8-6. This case demonstrates 5 5 mm and 4 4 mm cal-cified densities (arrows) along the expected course of the right distal ureter. These densities were formerly identified in the right kidney and have migrated infe-riorly to the current position, indicating right ureteral calculi. With the history of hematuria, the most likely choice would be right ureteral calculi (C is the correct answer to Question 8-6).

8-7. This case shows large, 2-cm-diameter mottled and curvilinear calcifications in the midpelvis. These cal-cifications overlie the sacrum and are consistent with calcification in uterine fibroids (D is the correct an-swer to Question 8-7).

8-8. This case shows several “teeth-like” calcifications in the right side of the pelvis. With a palpable pelvic mass, the most likely diagnosis is ovarian dermoid cyst. (C is the correct answer to Question 8-8.)

Discussion

Calcified appendiceal stones are present in only about 10% of patients with appendicitis; however, in a symptomatic child, an appendicolith indicates at least a 90% chance ofacute appendicitis. Prophylactic appendectomy has been recommended in the child with an incidentally discovered appendicolith because of a high incidence of gangrene and perforation. CT or ultrasound are better choices in evaluat-ing appendicitis.

Ureteral calculi are always a consideration in patients with hematuria. About 50% of urinary calculi are radiographically opaque and shown on the plain abdominal radiograph. Close scrutiny of the abdominal film is crucial because ureteral cal-culi may be elusive when they project over the lumbar trans-verse processes or the sacroiliac region. To confirm a ureteral calculus, CT is often needed to localize the density to the ureter. CT is more sensitive in evaluating ureteral calculi. Phleboliths are thrombi within the pelvic veins, and this loca-tion accounts for their circular shape. Calcification within these thrombi starts peripherally with a typical radiolucent center that is seen radiographically. Phleboliths have little clinical significance except that they can be confused with other pelvic densities, particularly distal ureteral calculi. In general, ureteral stones lie above and medially to the ischial spines, and they lack a radiolucent center.

Most uterine leiomyoma calcifications appear as multiple mottled or speckled calcifications or as dense, smooth, curvi-linear calcifications around the mass. The real soft-tissue mass is often larger than the area of calcification. Other calcifications in the pelvis include calcified ovarian tumors (Figure 8-15), foreign material, lymph nodes, or prostate.

Ovarian dermoid cyst accounts for about 10% of ovar-ian neoplasms. Ovarian dermoid cyst range from 6 to 15 cm in diameter and contain teeth, abortive bone, and curvilin-ear capsular calcification, which may be seen on plain radi-ograph. Dermoid cyst may contain sebaceous material simulating low-density fat compared to surrounding soft tissue.

Bladder stone is often seen in association with bladder outlet obstruction. Bladder calculi are composed of mixed calcium oxalate and phosphate salts that are radiopaque. Other calcifications in the bladder include foreign body, transi-tional cell carcinoma, urachal carcinoma, Schistosoma infesta-tion, tuberculosis, or alkaline encrusting cystitis. Calcifications in the same area include prostatic calculi (Figure 8-16) and calcified vas deferens (Figure 8-17). The prostate gland may be calcified. If enlarged, it may protrude into the bladder.