AJR 2004; 183:933-943
© American Roentgen Ray Society
CT Appearances of Intraabdominal and Intrapelvic Fatty Lesions
Luis Méndez-Uriburu1,
Jorge Ahualli,
Julio Méndez-Uriburu,
Martín Méndez-Uriburu,
Luis Fajre,
Federico Méndez-Uriburu and
Ramón Carabajal
1 All authors: Centro Radiológico "Luis Méndez
Collado," Muñecas 444, San Miguel de Tucumán,
Tucumán 4000, República Argentina.
Received November 6, 2003;
accepted after revision April 15, 2004.
Address correspondence to L. Méndez-Uriburu
(luismu{at}mendezcollado.com).
Introduction
CT allows determination of the density of all tissues with fat measurements
ranging from 40 to 100 H. Often, recognition of low density within a lesion
allows a definitive diagnosis to be made. The purpose of this pictorial essay
is to review intraabdominal fatty lesions with an emphasis on the role of CT
in their detection and diagnosis.
Liver
Fatty hepatic neoplasms include angiomyolipoma, lipoma, myelolipoma,
liposarcoma, and metastases from other primarily fatty tumors
[1]. Angiomyolipomas consist of
fat and blood vessels and present as well-defined masses, with attenuation
values associated with fat and more dense areas of angiomuscular tissue that
may enhance with IV administration of contrast material (Figs.
1 and
2A,
2B). Lipomas are encapsulated
tumors composed of adipose tissue that present as well-defined round masses
with a visible and homogeneous wall and, unlike angiomyolipomas, show an
absence of enhancement after contrast administration
[1].
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Fig. 1. —40-year-old woman with echogenic nodule that was detected on
sonography and suspected of being hemangioma. CT scan reveals well-defined
oval mass (arrow) with attenuation values of fatty tissue (–57
H) and consistent with angiomyolipoma, which was confirmed by percutaneous
fine-needle biopsy.
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Fig. 2A. —71-year-old woman who presented with nonspecific abdominal
pain. Contrast-enhanced CT scan incidentally reveals intrahepatic focal fatty
lesion (–27 H) containing thin septa that was interpreted as hepatic
angiomyolipoma.
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Fig. 2B. —71-year-old woman who presented with nonspecific abdominal
pain. Contrast-enhanced CT scan obtained 2 years later shows no changes from
previous scan (A). Fine-needle biopsy confirmed diagnosis of hepatic
angiomyolipoma.
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Liver liposarcomas are extremely rare tumors
[1]. To our knowledge, only a
few cases of liver liposarcoma have been reported in the literature. Imaging
of a documented case showed a 11 x 12 x 14 cm mass in the hilum of
the liver that extended to the retroperitoneum. The mass had well-defined
borders and an inhomogeneous structure. Fatty areas had attenuation values of
less than –20 H on CT scans. Other components of the mass had
attenuation values in the intermediate range. No evidence of surrounding
soft-tissue edema or contrast enhancement was present
[2]. Rarely, metastases to the
liver can contain fat. One possible primary site would be a teratoma
(metastatic teratomatous hepatic implantations)
[1].
Pancreas
The major histologic finding of pancreatic lipomatosis is the presence of
fatty deposits in the parenchyma. Pancreatic lipomatosis may occur in obese
and diabetic patients with varying levels of pancreatic insufficiency. It may
also manifest in patients with cystic fibrosis or diseases such as Shwachman
syndrome and Johanson-Blizzard syndrome. In advanced stages of pancreatic
lipomatosis, the whole parenchyma is replaced by fat, and the pancreatic duct
is identified as a linear density
[3]
(Fig. 3).
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Fig. 3. —45-year-old obese man with diabetes and pancreatic
lipomatosis. Abdominal CT scan reveals pancreatic parenchyma has been
completely replaced by fatty tissue with marked glandular atrophy. Note dense
acini (arrows) separated by increased fatty tissue.
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Focal fatty infiltration of the pancreas refers to a focal region of
pancreatic parenchyma that on CT shows normal or lower density compared with
that of the surrounding pancreas. In focal pancreatic infiltration,
contrast-enhanced CT reveals low-attenuation tissue interposed between normal
pancreatic parenchyma that can mimic a hypoattenuating mass (cystic or solid
neoplasm) [4]
(Fig. 4).
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Fig. 4. —42-year-old man with focal fatty infiltration of pancreas.
Helical CT scan shows hypoattenuating pancreatic mass (arrow) that
does not deform border and has typical fatty density (–40 H), indicating
mass is composed of fat.
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Gastrointestinal Tract
Gastrointestinal lipomas are circumscribed tumors with a uniform fat
attenuation depicted on CT scans
[1]. The typical presentation
is as polypoid masses that are generally found in the submucosa of the
gastrointestinal tract, most frequently in the large and small intestines
[1]. Given their appearance and
features, gastrointestinal lipomas can be definitively diagnosed on CT in most
cases [5] (Figs.
5,
6,
7A,
7B,
8,
9A,
9B,
9C,
10).
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Fig. 5. —71-year-old man with anemia. CT scan shows well-defined
intragastric mass in pyloric segment. Mass has smooth margins
(arrows) and attenuation of –99 H, consistent with gastric
lipoma.
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Fig. 6. —57-year-old woman with bladder cancer. Contrast-enhanced CT
scan reveals polypoid lesion extending through proximal duodenum
(arrow), with typical fatty density (–43 H). Lesion is
surrounded by air (arrowheads) and duodenal walls. Endoscopy
confirmed transpyloric prolapse of gastric lipoma.
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Fig. 7A. —71-year-old man who presented with dyspepsia and vomiting. CT
scan was obtained using oral but no IV contrast agent with patient in dorsal
decubitus position. Fat-density mass (arrow) surrounded by air
(arrowheads) and intestinal fluid is revealed and cystic mass
(asterisk) is visible on outer margin of right kidney.
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Fig. 7B. —71-year-old man who presented with dyspepsia and vomiting. CT
scan was obtained with patient in right lateral decubitus position after
second administration of oral contrast agent and first administration of IV
contrast agent. Intraduodenal fatty lesion (arrow), surrounded by
second dose of oral contrast agent, can be clearly seen.
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Fig. 8. —65-year-old man with history of testicular tumor. CT scan
shows incidentally found oval fatty lesion (arrow) in third section
of duodenum in front of aorta and inferior vena cava. Lesion is of homogeneous
fat density, consistent with duodenal lipoma.
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Fig. 9A. —71-year-old woman with abdominal colic. Oral
contrast-enhanced CT scan reveals round intraluminal mass (arrow),
characterized by fat-attenuation mass (tip of lipoma) and thin halo
(arrowheads), which is suggestive of mesenteric fat resulting from
intestinal intussusception.
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Fig. 9C. —71-year-old woman with abdominal colic. CT scan obtained with
patient in right lateral decubitus position shows lesion (arrow)
involves different layers of small intestine and highlights its homogeneous
fat density.
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Fig. 10. —65-year-old woman with colonic lipoma. CT scan obtained with
oral and IV contrast material shows colonic mass (arrow) on proximal
part of transverse colon with density and characteristics identical to those
of adipose tissue.
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Liposarcomas are common soft-tissue neoplasms but are rarely present in the
gastrointestinal tract. They have a more inhomogeneous appearance than their
benign counterparts, lipomas, because of the presence of more solid and myxoid
elements besides fat. This mixed composition explains the variable appearance
of these tumors on CT [5,
6].
Mesentery
Mesenteric panniculitis is a rare condition characterized by a nonspecific
chronic disorder in the adipose tissue of the intestinal mesentery
[7]. The most characteristic CT
findings include superior mesenteric veins surrounded by a well-defined fatty
mass, movement of intestinal loops, well-differentiated nodules in the soft
tissue smaller than 5 mm in diameter
[7], and mass effect on the
adjacent organs. (Fig. 11) In
such cases, the term "misty mesentery" is often applied. This term
refers to increased attenuation in the mesentery, but this sign is not
specific for mesenteric panniculitis. Any process that infiltrates the
mesentery can result in a misty mesentery. Therefore, hemorrhage, edema, or
tumor (lymphoma) can have an appearance similar to that of mesenteric
panniculitis [8]
(Fig. 12).
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Fig. 11. —67-year-old man with mesenteric panniculitis. Unenhanced
abdominal CT scan shows discrete increase (arrowheads) in density of
fatty tissue surrounding mesenteric vessels without displacement. Note thin
halo of normal fatty tissue surrounding mesenteric vessels.
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Fig. 12. —71-year-old man with history of treated lymphoma and
"misty mesentery." CT scan shows heterogeneous increase in fat
surrounding mesentery root (arrows) results in thin peripheral
capsule and mass effect on loops of adjacent small intestine
(arrowheads).
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Cavitating mesenteric lymph node syndrome is an uncommon and poorly
understood complication of celiac disease. Multiple cystic masses containing
thin and milky or thick and creamy material are present along the jejunoileal
mesentery. In some cases, very low attenuation is noted within these multiple
cystic masses, indicating fat
[9]
(Fig. 13). Lipomatous
neoplasms and lymphangiomas of the mesentery are quite uncommon.
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Fig. 13. —47-year-old woman with cavitating mesenteric lymph node
syndrome. Helical CT scan obtained after administration of oral and IV
contrast material shows multiple rounded fluid-attenuation (10 H) masses with
thin walls (arrows) in mesentery. Some masses have lower attenuation
values (–50 H) (arrowheads) indicating fatty material.
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Adrenal Gland
Adrenal myelolipomas are relatively rare tumors composed of mature fatty
tissue associated with proliferating hematopoietic cells. At biopsy, the
reported prevalence of this tumor has ranged from 0.08% to 0.4%
[9]. The most relevant CT
findings are of fatty tissue. The attenuation levels are higher than those
seen in the retroperitoneal fat on CT scans because of the presence of
hematopoietic tissue in the myelolipoma
[10] (Figs.
14 and
15A,
15B).
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Fig. 14. —33-year-old woman with adrenal myelolipoma. Helical CT scan
obtained without IV contrast agent shows right adrenal mass (long
arrow) with heterogeneous density in more dense central area (short
arrow) and fatty density in peripheral area (–102 H).
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Fig. 15A. —41-year-old man who presented with adrenal myelolipoma. CT
scan shows well-defined adrenal mass (arrow) characterized by
low-attenuation tissue (–84 H) reflecting fat in myelolipoma, mixed with
bone marrow elements.
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Fig. 15B. —41-year-old man who presented with adrenal myelolipoma. CT
scan obtained 7 years after A shows persistent right adrenal lesion
(arrow) with same appearance and size as in previous scan (A)
but with slight increase in its density, probably because of higher content of
hematopoietic tissue within it.
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Kidney
Renal angiomyolipomas are renal masses composed of abnormal blood vessels,
mature fat, and smooth muscle that may be associated with hemorrhage,
necrosis, and dystrophic calcification
[11]. CT findings of this
tumor reveal the presence of a well-defined heterogeneous renal mass
reflecting the amount of fatty, muscular, and vascular tissue within it. The
administration of a contrast agent contributes to enhancement of solid areas,
which is directly related to the existing vascular structures
[11] (Figs.
16,
17,
18). Bleeding may disguise the
areas of fatty density, consequently presenting difficulties to making the
diagnosis. We present a case that posed no such difficulty
[11] (Fig.
19A,
19B).
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Fig. 16. —71-year-old woman with occult blood in feces. Enhanced CT
scan shows tumor (4-cm diameter) (arrow) on outer margin of right
kidney with fatty density pattern (–81 H) and more dense lineal areas
characteristic of renal angiomyolipoma.
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Fig. 17. —52-year-old woman with renal mass depicted on sonography. CT
scan obtained with oral and IV contrast material shows typical fatty mass
containing vessels and tissues located in front of left kidney (white
arrow), with defect present in renal parenchyma (black arrow)
that shows renal origin of lesion, thus differentiating renal angiomyolipoma
from retroperitoneal liposarcoma.
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Fig. 18. —64-year-old woman with tuberous sclerosis and large bilateral
renal angiomyolipomas. CT scan shows several lesions with fatty content
(long arrows) generously projecting to perinephric space. Thus,
serpentine vascular structures (short arrows) located within lesions
can be clearly seen.
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Fig. 19A. —55-year-old woman with hemorrhagic renal angiomyolipoma.
Helical CT scan obtained without contrast agent shows large heterogeneous
tumor mass (white arrow) measuring about 8 cm, with fatty content and
more dense areas suggestive of intratumoral hemorrhage (black arrow).
Note discrete hyperdensity compared with adjacent muscular structures.
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Fig. 19B. —55-year-old woman with hemorrhagic renal angiomyolipoma.
Contrast-enhanced helical CT scan shows that fatty lesion (white
arrow) is associated with renal parenchyma, which is laterally displaced
by lesion. Hemorrhage resulting from rupture of intratumoral aneurysm is more
clearly seen in sloping region (black arrow).
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Renal lipomas are unusual benign tumors of the kidney exclusively composed
of adipose tissue [11]
(Fig. 20). On CT, simple
lipomas display fat attenuation and do not enhance after contrast material
administration.
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Fig. 20. —56-year-old woman with malignant melanoma. Contrast-enhanced
CT scan of abdomen reveals lipoma (arrow) in left kidney resembling
simple renal cyst but with completely homogeneous fatty density (–99 H).
(Compare with density of intestinal air and subcutaneous fat.) Note absence of
vessels and tissue within lesion, findings that differ from those of
angiomyolipomas.
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Renal sinus lipomatosis is an excessive accumulation of fat in the renal
sinus that may occur in obese or normal-weight patients. On excretory
urography, this fatty tissue may resemble a peripyelic mass, with compression
of calyx structures. On CT, the origin of this condition can be determined
according to its characteristic density
[11]
(Fig. 21).
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Fig. 21. —71-year-old man with left renal sinus lipomatosis. CT scan
shows highly increased fatty deposit in left renal sinus (arrow) that
surrounds and compresses collecting system. Renal parenchyma thickness
(arrowheads) is slightly reduced, and thin calcifications are seen in
gallbladder.
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Replacement lipomatosis of the kidney is an advanced type of renal sinus
lipomatosis. This condition occurs with parenchymal atrophy associated with a
proliferation of the renal sinus fat
[1,
12]
(Fig. 22). The presence of
both a staghorn calculus and the atrophic renal parenchyma is easily depicted
on CT. The characteristic distribution of fat within the renal sinus and the
perinephric space is suggestive of this process. Replacement lipomatosis of
the kidney should be differentiated from xanthogranulomatous pyelonephritis
[12]. The latter may display
hydronephrosis and pyonephrosis surrounded by xanthogranulomatous tissue with
a watery density [13]. Other
entities less frequently found in the kidney but containing fat density are
renal capsule liposarcomas, [1]
Wilms' tumors, and renal cell carcinomas
[11,
14].
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Fig. 22. —Replacement lipomatosis in 50-year-old woman with uterine
cervix adenocarcinoma. CT scan obtained without IV contrast agent shows
changes in right renal parenchyma associated with generous fatty infiltration
(arrow) of both renal parenchyma and perinephric space. Renal pelvis
shows calcific staghorn lithiasis (asterisk).
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Ovary
Ovarian teratomas are the most frequent germ cell neoplasms. They are
tumors composed of different histologic types (mature cystic teratoma,
immature teratoma, and monodermal teratoma), containing mature or immature
tissue produced in the germ cells
[15]. On CT, fat attenuation
within a cyst, with or without wall calcification, is indicative of mature
cystic teratoma, which is the most common ovarian teratoma
[15] (Fig.
23A,
23B). On occasion, a floating
hairy mass is found in a fat–water interface. The presence of fat is
reported in 93% of the cases, whereas teeth and other calcifications are found
in 56% [15]
(Fig. 24).
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Fig. 23A. —52-year-old woman with palpable mass in pelvis. CT scan
obtained with patient in supine decubitus position reveals large tumor mass
with two well-defined areas with different densities. Higher area
(asterisk) has density of –90 H (slightly lower than adjacent
fat), whereas sloping portion (arrow) has intermediate density
ranging between that of fat and that of soft tissues. Compare density with
that of psoas major. Presence of floating hairy mass is seen as wave on
horizontal level.
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Fig. 23B. —52-year-old woman with palpable mass in pelvis. On CT scan
obtained with patient in prone decubitus position, septa can be seen inside
mass (arrow), with mobility of the fluid–fatty content due to
presence of fatty tissues of different weights.
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Fig. 24. —47-year-old woman referred for suspected dermoid cyst. CT
scan shows typical appearance of mature cystic teratoma (dermoid cyst), with
components of three germinative layers consisting of low-density fatty tissue
(straight arrow), teeth (curved arrow), and structures with
attenuation similar to that of abdominal musculature
(arrowheads).
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Nonteratomatous lipomatous ovarian tumors (ovarian lipoleiomyoma and
ovarian lipoma) are extremely rare tumors. An ovarian lipoleiomyoma is a
predominantly solid leiomyomatous mass of intermediate density with a
scattering of multiple focal (1–3 cm) fat-density nodules. The
differential diagnosis of a pure lipomatous mass of obvious ovarian origin
includes benign cystic ovarian teratoma and ovarian lipoma
[16]
(Fig. 25).
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Fig. 25. —48-year-old woman with ovarian lipoma. Helical CT scan shows
well-defined tumor in right adnexal region with smooth margins
(arrow) and attenuation of –47 H. Surgery confirmed
diagnosis.
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Uterus
Lipomatous uterine tumors are rare benign neoplasms. The histologic
spectrum includes pure lipomas, lipoleiomyomas, and fibromyolipomas.
Histologically, they are composed of smooth muscle, fat cells, and fibrous
tissue in various ratios. Although pure lipomas have been reported, most of
these tumors contain various compositions of mesodermal tissues. A lipomatous
pelvic mass of obvious uterine origin may be diagnostic for this entity. The
masses may be endophytic or exophytic to the uterus. When a mass is exophytic,
the diagnosis is more difficult because its appearance mimics those of ovarian
fatty tumors that are more common
[16,
17].
Retroperitoneum
Retroperitoneal liposarcoma is the most frequently retroperitoneal
neoplasia found in adult patients, with a variable appearance on CT
[1]. It can be classified into
differentiated, pleomorphic, myxoid, and poorly differentiated. Differentiated
liposarcomas present a generous amount of fat easily depicted on CT that,
combined with heterogeneity, allows differentiating this condition from
retroperitoneal lipoma. The latter is a very rare condition that, unlike
liposarcoma, presents a homogeneously fatty density with scarce mass effect on
the adjacent structures [18]
(Figs. 26 and
27).
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Fig. 26. —66-year-old man with hematuria. CT scan shows well-defined,
homogeneous mass (arrow) with generous fatty content (–107 H)
and discrete mass effect on loops of adjacent small intestine, which are
characteristic of retroperitoneal lipoma. Absence of more dense areas within
lesion allows differentiation from liposarcoma.
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Fig. 27. —57-year-old woman with retroperitoneal liposarcoma. CT scan
obtained with oral and IV contrast materials shows huge retroperitoneal tumor
mass (long arrows) with heterogeneous fatty density that has septa
(short arrows) and well-defined lobulated contours. Mass effect on
adjacent structures is evident, but no infiltration is seen. Left kidney is in
contact with but is not infiltrated by tumor.
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