RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE, KARNATAKA

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1 |Name of the Candidate and Address (in Block Letters) |Dr. AFAQ AHMED |

| | |H. No. 101/10, 9th CROSS, |

| | |WILSON GARDEN, |

| | |BANGALORE-560027 |

| | |KARNATAKA. |

|2 |Name of the Institution |J.J.M. MEDICAL COLLEGE |

| | |DAVANGERE – 577 004, KARNATAKA |

|3 |Course of Study and Subject |Post-graduate |

| | |M.D. IN RADIO-DIAGNOSIS |

|4 |Date of Admission to Course |30TH MAY, 2011 |

|5 |Title of the Topic |“ROLE OF MRI IN THE EVALUATION OF CLINICALLY SUSPECTED UTERINE |

| | |AND ADNEXAL MASSES.” |

|6 |Brief Resume of the intended work: |

| |Need for the study: |

| |Ultrasound remains the first line of imaging for the female pelvis with high diagnostic accuracy rates for uterine and |

| |ovarian abnormalities. However, the shortcomings with this modality includes limited field of view, obscuration of pelvic |

| |organs by the presence of bowel gas, inherent limitation dependant on patient size and its dependence on the skill and |

| |experience of the operator. |

| |Since MRI is more expensive and potentially less readily available than USG, it is important to know when patients should |

| |undergo MRI. MRI because of its superb soft tissue contrast and direct multiplanar capabilities, can better delineate and |

| |characterize normal uterine anatomy and focal and diffuse uterine conditions. MRI is non-invasive, has no risk of |

| |radiation, requires no anesthesia and is less operator dependant. In patients with infertility, MRI can confirm the |

| |presence and extent of a septate uterus and define the fibrous and muscular components. In patients with pelvic pain, MRI |

| |is more sensitive and specific than USG for the findings of Adenomyosis. |

| |MRI should be considered for the evaluation of uterine and adnexal pathology when sonographic characteristics are not |

| |definitive to determine the origin of the mass and to determine the likelihood of malignancy. |

| |Sonographically indeterminate adnexal masses of uncertain origin and solid or cystic content benefit from further |

| |evaluation with MRI, which is highly accurate for identifying the origin of a mass and characterizing its tissue content. |

| |Thus, use of MRI will prove to be cost-effective in that it reduces unnecessary surgical procedures by its ability to |

| |differentiate benign and malignant lesions accurately. |

| |MRI can assist sonographic assessment of adnexal masses in pregnancy by depicting the characteristic findings of red |

| |degeneration of leiomyoma, endometrioma, decidualized endometrioma and massive ovarian edema. Accordingly, MRI should be |

| |considered as a useful adjunct when sonography is inconclusive or insufficient to guide management of adnexal masses |

| |discovered in pregnancy. |

| |Thus, MRI can be very useful in characterization and origin of uterine and adnexal masses, staging of known endometrial and|

| |cervical cancers, evaluation of suspected mullerian ductal anomalies, differentiating benign from malignant lesions where |

| |other imaging modalities (like ultrasonography and CT scan) are not conclusive. |

| |Review of Literature |

| |With its high contrast resolution, its ability to provide good tissue characterization, and its multiplanar imaging |

| |capabilities, magnetic resonance imaging (MRI) is increasingly used to evaluate pelvic pathology. There is a significant |

| |difference, however, in the inherent costs of MRI and ultrasound. The dilemma for referring physicians and general |

| |radiologists is to decide when it is appropriate to refer patients for MRI.  |

| | |

| |Leiomyomas |

| |Transvaginal ultrasound has been shown to be as efficient as MRI in the detection of the presence of myomas; however, MRI |

| |is superior in terms of mapping individual myomas[1].  This is especially true with larger uteri and with the presence of a|

| |large number of myomas. |

| |On MRI, a uterus containing leiomyomas will be enlarged and will have an abnormal contour. On T2W images, leiomyomas appear|

| |as sharply marginated lesions of low signal intensity relative to the myometrium. Often, a high-signal-intensity rim can be|

| |identified, more commonly in intramural or subserosal leiomyomas. Leiomyomas may contain calcifications, especially in |

| |older women. Calcified myomas can cause significant artifact on ultrasound and can obscure adjacent tissues. While similar |

| |calcification appears as a signal void on MRI, it typically does not limit the evaluation of adjacent tissues. On MRI, |

| |myomas larger than 3 to 5 cm are often heterogeneous because of various degrees of degeneration. Although varied, |

| |enhancement tends to be heterogeneous and less than that of the myometrium. |

| | |

| |Adenomyosis |

| |Although adenomyosis is typically a diffuse process, focal areas of involvement are also seen. It is these focal lesions |

| |that are often mistaken for leiomyomas. It is important to differentiate between them, as their treatments vary greatly. |

| |Studies have shown that MRI is superior to ultrasound for the diagnosis of adenomyosis[2].  The characteristic appearance |

| |of adenomyosis on MRI is diffuse thickening (>12 mm) of the junctional zone. This is most evident on T2W sequences and |

| |corresponds to the smooth muscle hyperplasia associated with the ectopic tissue. A junctional zone ≤ 8 mm virtually |

| |excludes the disease, whereas a width of 9 to 11 mm is equivocal. Other findings that may suggest the diagnosis include |

| |poorly defined margins of the junctional zone and foci of high signal intensity on T1W or T2W sequences that indicate the |

| |presence of endometrial cysts. The foci of high signal may represent ectopic endometrium, cystically dilated endometrial |

| |glands, or hemorrhage. Contrast administration has been shown to be of very little benefit in the diagnosis of adenomyosis.|

| |Distinguishing between focal adenomyosis and leiomyomas is reliably achieved with MRI, and we now know that these |

| |conditions often coexist[3].  Unlike leiomyomas, a focal area of adenomyosis will have indistinct margins and extend |

| |subjacent to the myometrium. The signal characteristics will otherwise be the same as with the diffuse form of the disease.|

| |Treatment implications for focal adenomyosis and leiomyoma differ however, so accurate diagnosis is important. |

| | |

| |Uterine endometrial pathology: |

| |Endometrial thickening seen at ultrasound is a nonspecific finding.  For years, endometrial biopsy was the diagnostic |

| |standard for differentiating benign causes, such as polyps and leiomyomas, from endometrial carcinoma. However, benign |

| |abnormalities far outnumber cancer in these situations.  Other problems with biopsy include vaginal or cervical stenosis |

| |and difficulty in obtaining an adequate specimen. MRI can be helpful in further differentiating these lesions. |

| | |

| |Endometrial carcinoma: |

| |MRI is not recommended as a screening procedure in the diagnosis of endometrial carcinoma. However, MRI has proven to be an|

| |important tool for the staging of known endometrial carcinoma[4].  MRI can differentiate between superficial and |

| |deep-muscle-invasive tumors by using a combination of T2W imaging and contrast-enhanced MRI. This can significantly alter |

| |surgical management. The presence of cervical invasion also alters preoperative and surgical management. MRI has been shown|

| |to be superior to both CT and ultrasound in assessing myometrial invasion, cervical extension, and nodal involvement. |

| |Endometrial carcinomas appear isointense to the myometrium and endometrium on T1W images. On T2W images, their signal |

| |intensity is commonly hyperintense; however, this is quite variable[4]. Endometrial carcinomas usually enhance less than |

| |the myometrium does, with the difference less marked on delayed images. Myometrial invasion is best visualized on T2W |

| |images, where it appears as a disruption or an irregularity of the junctional zone by a mass of intermediate signal |

| |intensity. |

| |Transmyometrial extension of tumor is identified by interruption of the normal low signal intensity of the serosal surface.|

| |However, early serosal invasion may be difficult to detect. Parametrial involvement is best depicted on T1W images with a |

| |signal intensity change in the parametrial fat. T1-weighted images are also better for identifying tumor involvement of the|

| |vagina when there is disruption of the low signal intensity wall. Lymph node involvement is suggested on T1W images with |

| |nodes that have a diameter >1 cm in the short axis. MRI can also detect tumor extension outside the true pelvis as well as |

| |bladder and rectal invasion. |

| | |

| |Cervical carcinoma: |

| |Like the uterus, the cervix has a zonal anatomy that is well delineated on T2W images. MRI is not initially used to |

| |diagnose cervical cancer but is used to stage disease in women who have had a diagnosis established by a Pap smear or |

| |biopsy. T2-weighted images obtained in the sagittal plane and in a plane along the short axis of the cervix are the most |

| |useful for local staging. On T2W images, cervical cancer appears as a mass of higher signal intensity than the adjacent |

| |fibrous cervical stroma, but the mass is of lower signal intensity than the endometrium[5].  If the low signal intensity of|

| |the inner cervical stroma is preserved, stage IIB or higher disease is excluded, which indicates that the patient is likely|

| |a surgical candidate. Macroscopic extension of tumor into the parametrial fat establishes a diagnosis of stage IIB disease.|

| |MRI has an accuracy range of 75% to 95% in detecting parametrial invasion. MRI can accurately assess for more advanced |

| |disease such as pelvic sidewall invasion and obstruction of the distal ureter[5]. Localizing the tumor and determining the |

| |presence or absence of ureteral obstruction can provide a road map for radiation therapy. |

| | |

| |Mullerian duct anomalies: |

| |The incidence of müllerian duct anomalies is approximately 0.1% to 3%. Although they are often asymptomatic, obstetrical |

| |complications occur in up to 25% of these women, including spontaneous abortion, stillbirth, preterm delivery, and adverse |

| |obstetrical outcomes. Knowledge of the type and severity of the anomaly can significantly impact treatment, as the |

| |therapies vary greatly. With an accuracy approaching 100%, MRI has become the gold standard in identifying müllerian duct |

| |anomalies[6,7]. Various studies have shown that it is superior to sonography and hysterosalpingography[6].  In patients |

| |with primary amenorrhea, MRI can determine the presence or absence of the vagina, cervix, and uterus[7].  Bicornuate and |

| |septate uteri are the 2 most common types of mullerian ductal anomalies. Differentiating between these 2 entities is |

| |important because of their complications and different treatments. The evaluation of the external fundal contour is the key|

| |to differentiating between bicornuate and septate uteri. This can be best evaluated on a plane that passes through the long|

| |axis of the uterus. The outer contour of the septated uterus is convex or fat, with 10-mm concavity between the right and left uterine horns. |

| | |

| |Sonographically indeterminate adnexal masses: |

| |A perception in radiology is that MRI may be superfluous for a mass that is large (>5 cm), suspicious, or inconclusive for |

| |ovarian cancer on sonography[8,9,]. However, Outwater and Dunton[9] revealed that unnecessary surgery was performed in |

| |50–67% of benign cases because of suspicious sonography findings. Study done by Adusumilli et al., revealed 90 final benign|

| |diagnoses, 13 of which were actually normal MRI findings despite a sonographically questioned mass. The value of reassuring|

| |a patient that a sonographically detected ovarian mass is not a malignancy but a normal structure or a benign mass cannot |

| |be underestimated; patients avoid not only surgery but also unnecessary followup imaging and anxiety. These issues justify |

| |the need to recognize which sonographic features routinely result in an indeterminate or suspicious diagnosis and to |

| |determine whether MRI is the appropriate next step. Surprisingly, only 11 indeterminate diagnoses were the result of |

| |technically limited sonograms; rather, a specific imaging feature of a mass more commonly yielded an indeterminate |

| |diagnosis. |

| |The study reveals that sonography performs poorly for determining the origin of the mass, which is the essential first step|

| |in characterizing an adnexal mass. For example, although a solid intrauterine mass is likely a fibroid, a solid mass |

| |located adjacent to the uterus may be a pedunculated uterine fibroid or an ovarian mass. In this study (Adusumilli et al.,)|

| |48% of such masses were pedunculated fibroids and 34% were ovarian masses. Large mass size was an additional contributing |

| |factor to an indeterminate sonographic diagnosis in five cases. Unless specific features of fibroids can be identified, |

| |such as refractory shadowing, these large solid pelvic masses remain diagnostic dilemmas on sonography[10,11]. Unlike |

| |sonography, excellent agreement was seen between MRI and the final proven origin of a mass. This stresses the importance of|

| |MRI as the best next step in evaluating such a mass before subjecting a patient to surgery that might be unnecessary. The |

| |results of the study in accurately characterizing an adnexal mass as a pedunculated uterine fibroid (17/18 masses) are |

| |similar to those reported in prior MR studies[12,13]. |

| |Because fibrous tumors of the ovary have imaging features similar to those of fibroids, such as low signal intensity on |

| |T2-weighted images, the recognition of the stalk of the fibroid and the identification of separate normal ovaries can help |

| |confirm the diagnosis of a fibroid. In postmenopausal women, identification of atrophic ovaries can be problematic and the |

| |uterus may be small, which limits visualization of a stalk[13, 14]. In such cases, the identification of vessels bridging |

| |the mass and the uterus on T2-weighted and gadolinium-enhanced images (“bridging vascular” sign) has an accuracy of 80% for|

| |the diagnosis of pedunculated uterine fibroids[14]. |

| |This study (Adusumilli et al.,) also documented that eight indeterminate “masses” on sonography were not masses but a |

| |cervical remnant, mullerian anomaly, or low-lying bowel filled with feces. MRI is well suited to the characterization of |

| |uterine and cervical tissue and the evaluation of congenital uterine anomalies [15,7]. Extraovarian cystic masses can pose |

| |a diagnostic challenge on sonography and MRI. The advantage of MRI is its ability to reveal separate normal ovaries and to |

| |delineate the characteristic morphologic features of a mass on multiple imaging planes, such as the pathognomonic tortuous |

| |folded appearance of a hydrosalphinx[9]. |

| |The study (Adusumilli et al.,) showed that accurate tissue characterization, the second essential component of |

| |characterizing an adnexal mass, was poor for sonography and excellent for MRI. The entire spectrum of benign and malignant |

| |pelvic masses appeared solid on sonography in this study, and benign masses sometimes appeared complex on sonography, |

| |thereby mimicking a malignancy. Unenhanced T1- and T2-weighted imaging is important for accurate tissue characterization. |

| |Lipid and blood are readily detected on T1-weighted imaging with and without fat suppression[9,16, 17,18]. T2-weighted |

| |imaging helps to identify the relatively low signal intensity of endometriomas, reflecting blood degradation products from |

| |repeated cyclical bleeding[9] or the very low signal intensity of fibrous tissue in a fibrous tumor of the ovary (i.e., |

| |Brenner tumor, ovarian fibroma, fibrothecoma)[19,20,16]. Gadolinium is usually reserved for improved delineation of |

| |papillary projections, nodules, and thick enhancing septations in ovarian cancers[8,21,22]. |

| |Although in this study (Adusumilli et al.,) they correctly classified eight purely cystic unilocular ovarian masses as |

| |benign or probably benign, they could not distinguish between a functional ovarian cyst and a serous cystadenoma to prevent|

| |surgery in seven patients. Although MRI is sensitive for the detection of the fluid content of a mass[12, 9, 23], it may |

| |not add information beyond what is gleaned from a good-quality sonogram for a unilocular, purely cystic ovarian mass. |

| |Moreover, the size of a simple unilocular cyst has little correlation with the likelihood of malignancy[9]. Therefore, the |

| |more appropriate and cost-effective way of managing such a mass in a premenopausal woman is to perform follow-up sonography|

| |for interval resolution. |

| |The high specificity (94%) for establishing a benign diagnosis in this study (Adusumilli et al.,) is similar to that |

| |reported by Scoutt et al.[12] (fibroids, 100%; dermoids, 99%; endometriomas, 91%). The specificity of this study is |

| |slightly higher than reported by Hricak et al.[8], which may be explained by their larger number of cystic ovarian masses |

| |(53/91 lesions), which are difficult to characterize as benign because of lack of tissue specificity. The study done by |

| |Adusumilli et al., also had mullerian anomalies and a larger number of uterine fibroids (17 V/s 3), which are more readily |

| |diagnosed as benign, than did Hricak et al. The radiologist’s subjective impression of malignancy versus benignity was |

| |highly accurate in this study, which supports prior conclusions that subjective assessment is one of the best |

| |discriminators in making such a diagnosis[24]. The false diagnoses of ovarian cancer occurred with cystic ovarian masses |

| |because of large mass size (> 4 cm) and lack of tissue specificity and with a solid adnexal mass that was a broad-ligament |

| |fibroid having intermediate signal intensity on T2-weighted images and avid enhancement, two features suggestive of |

| |malignancy. |

| |Pathologic adnexal mass is found in 1–2% of pregnancies. Sonography is the primary method of detection and evaluation, but |

| |findings may be nonspecific and then MRI may assist characterization[25]. The use of MRI in pregnancy has expanded because |

| |of improvements in rapid breath-hold sequences and because better imaging helps avoid the potential hazards of surgery |

| |during gestation. |

| |Gadolinium is teratogenic in animal studies and crosses the placenta where it is presumably excreted by the fetal kidneys |

| |into the amniotic fluid. In the era of nephrogenic systemic fibrosis, this characteristic of gadolinium raises theoretic |

| |concerns of toxicity related to disassociation and persistence of free gadolinium. Gadolinium is classified as a category C|

| |drug by the U.S. Food and Drug Administration (FDA) and can be used if considered critical—that is, to be administered only|

| |“if the potential benefit justifies the potential risk to the fetus.” More stable macrocyclic agents (e.g., gadoteridol or |

| |gadobutrol) may be preferable to gadolinium. In reality, contrast administration for adnexal masses is used primarily to |

| |assess for the presence of solid components in a cystic mass and is used to a lesser extent to evaluate nonenhancement in a|

| |torsed mass. Such information can generally be derived from gray-scale and Doppler sonography; thus, it is unlikely that IV|

| |gadolinium would be considered critical for MRI of an adnexal mass in pregnancy. |

| |Objectives of the Study: |

| |Characterization of uterine and adnexal masses as benign or malignant. |

| |To determine the origin, tissue content and characterization of sonographically indeterminate uterine and adnexal masses. |

| |Staging of cancer when a mass is noted to have malignant changes. |

| |To assist the surgeons in deciding on further line of management. |

| | |

|7. |MATERIALS AND METHOD |

| |Sources of Data |

| |The main source of data for the study are patients from the following teaching hospitals attached to Bapuji Education |

| |Association, J.J.M. Medical College, Davangere . |

| |Bapuji Hospital. |

| |Chigateri General Hospital. |

| |S.S. Institute of Medical Sciences and Research centre. |

| | |

| |Technique: Imaging will be done with 1.5 tesla Philips Achieva machine using abdominal surface coils. The following |

| |sequences will be selected as required. |

| |T1WI, T2WI AND STIR (in axial plane). |

| |T2WI and STIR (in coronal plane). |

| |T2WI and STIR (in sagittal plane). |

| |Contrast will be used as and when required. Gadolinium will be used as intravenous contrast material in a dose of 0.1 |

| |mmol/kg body weight. |

| |Post contrast study includes T1W FAT SUPPRESSED Sequence (in axial, coronal and sagittal planes). |

| | |

| |Method of collection of Data (including sampling procedures if any) |

| |All patients referred to the department of Radio diagnosis, J.J.M Medical college, Davangere with clinically suspected |

| |uterine and adnexal masses in a period of 2 years from Nov 2011 to November 2013 will be subjected for the study. |

| |The study will be conducted on a minimum of 30 cases focussing mainly on sonographically indeterminate uterine and adnexal|

| |masses. However, the scope of increasing the number of cases exists depending upon the availability within the study |

| |period. |

| | |

| |Duration of study: 2 years. |

| | |

| |Data Analysis: By proportional scale. |

| | |

| |Inclusion criteria: |

| |All patients with clinically suspected uterine and adnexal masses with indeterminate diagnosis on sonography. |

| |For staging of known malignant conditions. |

| |Patients of all age groups. |

| | |

| |Exclusion criteria: |

| |Mimicks of adnexal masses such as exophytic uterine leiomyoma and ectopic pregnancy. |

| |All Patients having cardiac pacemakers, prosthetic heart valves, cochlear implants or any metallic implants. |

| |Patients having history of claustrophobia. |

| |All patients who do not consent to be a part of the study. |

| | |

| | |

| |Does the Study require any investigations or interventions to be conducted on patients or other humans or animals? If so |

| |please describe briefly. |

| |Yes |

| |The study is mainly based on investigations as Radiology itself is a tool of investigation. Interventions would be done |

| |as and when it is indicated alone. The study involves only humans. |

| |Informed consent would be taken after explaining about and before any procedure. |

| | |

| |Has ethical clearance been obtained from your institution in case of 7.3? |

| |Yes |

| |Ethical clearance has been obtained from the Research and Dissertation Committee/ Ethical Committee of the institution for|

| |this study. |

|8. |LIST OF REFERENCES |

| |Dueholm M, Lundorf E, Hansen ES. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, |

| |mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002; 186: 409-415. |

| |Ascher SM, Arnold LL, Patt RH. Adenomyosis: Prospective comparison of MR imaging and transvaginal sonography. Radiology. |

| |1994; 190: 803-806. |

| |Togashi K, Ozasa H, Konishi I. Enlarged uterus: Differentiation between adenomyosis and leiomyoma with MR imaging. |

| |Radiology. 1989; 171: 531-534. |

| |Yamashita Y, Mizutani H, Torashima M. Assessment of myometrial invasion by endometrial carcinoma: Transvaginal sonography |

| |V/s contrast-enhanced MR imaging. AJR Am J Roentgenol. 1993; 161: 595-599. |

| | |

| | |

| |Hricak H, Finck S, Honda G, Göranson H. MR imaging in the evaluation of benign uterine masses: Value of gadopentetate |

| |dimeglumine-enhanced T1-weighted images. AJR Am J Roentgenol 1992; 158: 1043-1050. |

| |Pellerito JS, McCarthy SM, Doyle MB. Diagnosis of uterine anomalies: Relative accuracy of MR imaging, endovaginal |

| |sonography, and hysterosalpingography. Radiology 1992;183:795-800. |

| |Carrington BM, Hricak H, Nuruddin RN. Mullerian duct anomalies: MR imaging evaluation. Radiology 1990; 176: 715-720. |

| |Hricak H, Chen M, Coakley FV. Complex adnexal masses: detection and characterization with MR imaging multivariate analysis.|

| |Radiology 2000; 214: 39–46 |

| |Outwater EK, Dunton CJ. Imaging of the ovary and adnexa: clinical issues and applications of MR imaging. Radiology 1995; |

| |194:1–18 |

| |Baltarowich OH, Kurtz AB, Pennell RG, Needleman L, Vilaro MM, Goldberg BB. Pitfalls in the sonographic diagnosis of uterine|

| |fibroids. AJR 1988; 151: 725–728 |

| |Caoili EM, Hertzberg BS, Kliewer MA, DeLong D, Bowie JD. Refractory shadowing from pelvic masses on sonography: a useful |

| |diagnostic sign for uterine leiomyomas. AJR 2000; 174: 97–101 |

| |Scoutt LM, McCarthy SM, Lange R, Bourque A, Schwartz PE. MR evaluation of clinically suspected adnexal masses. J Comput |

| |Assist Tomogr 1994; 18: 609–618 |

| |Weinreb JC, Barkoff ND, Megibow A, Demopoulos R. The value of MR imaging in distinguishing leiomyomas from other solid |

| |pelvic masses when sonography is indeterminate. AJR 1990; 154: 295–299 |

| |Kim JC, Kim SS, Park JY. Bridging vascular sign in the MR diagnosis of exophytic uterine leiomyoma. J Comput Assist Tomogr |

| |2000; 24: 57–60. |

| |Imaoka I, Wada A, Matsuo M, Yoshida M, KitagakiH, Sugimura K. MR imaging of disorders associated with female infertility: |

| |use in diagnosis, treatment, and management. Radio Graphics 2003; 23: 1401–1421. |

| | |

| |Siegelman ES, Outwater EK. Tissue characterization in the female pelvis by means of MR imaging. Radiology 1999; 212: 5–18. |

| |Kier R, Smith RC, McCarthy SM. Value of lipid and water-suppression MR images in distinguishing between blood and lipid |

| |within ovarian masses. AJR 1992; 158: 321–325. |

| |Stevens SK, Hricak H, Campos Z. Teratomas versus cystic hemorrhagic adnexal lesions: differentiation with proton-selective |

| |fat-saturation MR imaging. Radiology 1993; 186: 481–488. |

| |Outwater EK, Siegelman ES, Talerman A, Dunton C. Ovarian fibromas and cystadenofibromas: MRIfeatures of the fibrous |

| |component. J Magn Reson Imaging 1997; 7:465–471 |

| |Outwater EK, Siegelman ES, Kim B, Chiowanich P, Blasbalg R, Kilger A. Ovarian Brenner tumors: MR imaging characteristics. |

| |Magn Reson Imaging 1998; 16:1147–1153. |

| |Outwater EK, Huang AB, Dunton CJ, Talerman A, Capuzzi DM. Papillary projections in ovarian neoplasms: appearance on MRI. J |

| |Magn Reson Imaging 1997; 7: 689–695. |

| |Van Vierzen PB, Massuger LF, Ruys SH, Barentsz JO. Borderline ovarian malignancy: ultrasound and fast dynamic MR findings. |

| |Eur J Radiol 1998; 28: 136–142. |

| |Jain KA, Jeffrey RB Jr. Evaluation of pelvic masses with magnetic resonance imaging and ultrasonography. J Ultrasound Med |

| |1994; 13: 845–853. |

| |Sohaib SA, Sahdev A, Van Trappen P, Jacobs IJ, Reznek RH. Characterization of adnexal mass lesions on MR imaging. AJR 2003;|

| |180: 1297–1304. |

| |Bromley B, Benacerraf B. Adnexal masses during pregnancy: accuracy of sonographic diagnosis and outcome. J Ultrasound Med |

| |1997; 16: 447–452. |

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|9. |Signature of the Candidate | |

| | | |

| | | |

|10. |Remarks of the Guide | Study will conclude near possible diagnosis with near possible |

| | |accuracy leading to better surgical management and welfare of |

| | |the patients. |

|11. |Name & Designation | |

| |Guide |Dr. KIRAN KUMAR HEGDE S. M.D. |

| | |PROFESSOR, |

| | |DEPARTMENT OF RADIO-DIAGNOSIS, |

| | |J.J.M. MEDICAL COLLEGE, |

| | |DAVANGERE – 577 004. |

| | | |

| | | |

| | | |

| |Signature | |

| | | |

| | | |

| |Co-Guide (If any) | |

| | | |

| |Signature | |

| | | |

| | |Dr. J .PRAMOD SETTY M.D., |

| |Head of the Department |PROFESSOR AND HEAD, |

| | |DEPARTMENT OF RADIO-DIAGNOSIS, |

| | |J.J.M. MEDICAL COLLEGE, |

| | |DAVANGERE – 577 004. |

| | | |

| | | |

| | | |

| | | |

| |Signature | |

| | | |

|12 |Remarks of the Chairman & the Principal | |

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| | | |

| |Signature | |

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