MRIMRI ofof thethe UterusUterus BENIGNBENIGN
Jeffrey C. Weinreb, M.D. FACR [email protected] Yale University School of Medicine NormalNormal AnatomyAnatomy
MM JunctionalJZ Zone EE
Junctional Zone is the inner layer or the myometrium RoutineRoutine GYNGYN ProtocolProtocol
•• PrepPrep –– VoidVoid priorprior toto examexam –– IVIV lineline –– NPONPO xx 44 hrshrs –– GlucagonGlucagon RoutineRoutine GYNGYN ProtocolProtocol
•• SagSag T2WT2W FSEFSE – Respiratory trigger and/or anterior sat bands •• ShortShort axisaxis T2WT2W (uterus(uterus oror cervix)cervix) •• CorCor oror AxialAxial T2WT2W •• AxialAxial T1WT1W IP/OPIP/OP •• AxialAxial FatFat SatSat T1WT1W •• PostPost--CC FatFat SatSat T1WT1W withwith SubtractionsSubtractions •• DelayedDelayed SagSag T2WT2W FSEFSE NormalNormal Uterus/CervixUterus/Cervix UterineUterine LeiomyomaLeiomyoma
•• MostMost commoncommon uterineuterine neoplasmneoplasm •• OccurOccur inin womenwomen ofof reproductivereproductive ageage andand areare underunder hormonalhormonal influenceinfluence –– EnlargeEnlarge duringduring pregnancypregnancy oror BCPBCP useuse –– RegressRegress afterafter menopausemenopause •• SymptomsSymptoms –– DysmenorrheaDysmenorrhea –– MenorrhagiaMenorrhagia –– InfertilityInfertility –– PressurePressure sensationsensation MRIMRI ofof UterineUterine LeiomyomaLeiomyoma
•• LowLow signalsignal onon T2WIsT2WIs •• RoundRound •• MassMass effeceffec •• WellWell defineddefined marginsmargins oftenoften withwith pseudocapsulepseudocapsule •• LacyLacy oror confluentconfluent hyperintensityhyperintensity UterineUterine LeiomyomaLeiomyoma
•• AsAs theythey grow,grow, theythey maymay outgrowoutgrow theirtheir bloodblood supply,supply, resultingresulting inin variousvarious typestypes ofof degenerationdegeneration –– HyalineHyaline (homogeneous eosinophilic proteinaceous material) –– MyxoidMyxoid (hyaluronic acid-rich mucopolysccharide gelitenous material) –– CysticCystic –– HemorrhagicHemorrhagic (red or carneous, occurs in pregnancy or with BCPs) –– CalcificCalcific UterineUterine LeiomyosarcomaLeiomyosarcoma
•• SarcomatousSarcomatous transformationtransformation ofof preexistingpreexisting leiomyomaleiomyoma isis rarerare –– DiagnosisDiagnosis usuallyusually mademade asas anan incidentalincidental pathologicpathologic diagnosisdiagnosis inin 0.5%0.5% oror resectedresected fibroidsfibroids •• MostMost arisearise independentlyindependently fromfrom myometrialmyometrial smoothsmooth musclemuscle cellscells UterineUterine LeiomyomaLeiomyoma
•• EdemaEdema isis commoncommon –– ScatteredScattered oror diffusediffuse –– FrequentlyFrequently prominentprominent atat peripheryperiphery –– WithWith extensiveextensive edema,edema, getget markedmarked enhancementenhancement duedue toto retentionretention ofof contrastcontrast materialmaterial withinwithin thethe abundantabundant interstitialinterstitial spacesspaces
Okizuka H, et al. J comput Assist Tomogr 1993;17:760-766 SuspectSuspect LeiomyosarcomaLeiomyosarcoma
• Lyphadenopathy, ascites, or peritoneal seeding are unusual • Rapid growth of leiomoyoma is not useful – <3% of sarcomas have rapidly growing uterus – <1% of rapidly growing leiomyomas contain leiomyosarcomas • Hemorrhage is not useful – Hemorrhage is not uncommon in fibroids but unusual in leiomyosarcomas • High signal on T2WIs in >50% of mass is not useful – Not uncommon in fibroids • High signal on T2WIs and intense enhancement is not useful – Seen with cellular leiomyomas (composed of compact smooth muscle cells with little or no collagen) • Irregular or indistinct margin is suggestive UterineUterine LeiomyomaLeiomyoma
• Differential Diagnosis – Uterine sarcoma • Leiomyosarcoma • Mixed mullerian tumor • Endometrial stromal sarcome – Adenomyosis – Solid ovarian masses (fibroma, fibrothecoma, Brenner tumor) – Myometrial contractions – Endometrial cancer – Endometrial polyp – Gestational Trophoblastic Disease – Retained products of conception OvarianOvarian Fibromas/FibrothecomasFibromas/Fibrothecomas
•• GonadalGonadal stromalstromal cellcell originorigin •• MostMost commoncommon solidsolid primaryprimary ovarianovarian tumortumor •• BenignBenign •• FibromasFibromas consistconsist ofof intersectingintersecting bundlesbundles ofof spindlespindle cellscells thatthat produceproduce largelarge amountamount ofof collagencollagen •• FibrothecomasFibrothecomas alsoalso containcontain thecatheca cellscells •• CysticCystic degenerationdegeneration andand edemaedema •• OnOn MRIMRI resembleresemble fibroidsfibroids •• DiffDiff DxDx includesincludes intraligamentousintraligamentous leiomyomaleiomyoma,, endometriomaendometrioma,, ovarianovarian fibromatosisfibromatosis,, andand BrennerBrenner tumortumor BridgingBridging VascularVascular SignSign
• Vessels that extend from the uterus to supply a pelvic mass indicate the uterine origin of a juxtauterine mass • Caused by feeding vessels that arise from the uterine arteries • In one study, it was present in in 20/26 exophytic leiomyomas and absent in all other adnexal masses, resulting in a diagnostic accuracy of 80% Kim JC, et al. J Comput Assist Tomogr 2000;24:57060
• But, ovarian malignancies that invade the uterus may also show this sign Kim SH, et al. J Comput Assist Tomogr 2001;25:36-42 Exophytic fibroid or fibroma? Fibroid
A mass may originate from the periphery of the ovary, so the identification of an apparently normal adjacent ovary does not exclude an ovarian origin OvarianOvarian VascularVascular PediclePedicle SignSign
•• IfIf youyou cancan tracetrace asymmetricallyasymmetrically enlargedenlarged gonadalgonadal veinsveins anterioranterior toto psoaspsoas musclemuscle andand commoncommon iliaciliac vesselsvessels intointo aa pelvicpelvic mass,mass, itit indicatesindicates thatthat thethe ovaryovary isis thethe organorgan ofof originorigin – Identified in 92% of ovarian masses •• AlsoAlso seenseen inin 13%13% ofof subserosalsubserosal uterineuterine myomasmyomas – The ovarian veins form a plexus in the broad ligament that communicates with the uterine plexus
Lee JH, et aal.l. AJR 2003;181:131-137 AdenomyosisAdenomyosis • Hormonally resistant endometrial glands (basalis type) and stroma deep within the myometrium • Smooth muscle hyperplasia and hypertrophy induced around glands • Histologically present in >40% women
Tamai K, e tal. RadiolGraphics 2005;25:21-40 MRMR FindingsFindings inin AdenomyosisAdenomyosis • Broadening of junctional zone • Poorly defined low signal contiguous with junctional zone • Low signal myometrial mass (adenomyoma) • Punctate high signal on T2WIs (glandular cystic changes) •high resolution images helpful AdenomyosisAdenomyosis •• >> 1212 mmmm == adenomyosisadenomyosis •• 88 -- 1111 mmmm == c/wc/w adenomyosisadenomyosis ifif clinicalclinical findingsfindings •• << 77 mmmm == nornalnornal PitfallsPitfalls
•• JunctionalJunctional zonezone maymay widenwiden (focally(focally oror diffusely)diffusely) onon daysdays 11--22 ofof menstrualmenstrual cyclecycle •• JunctionalJunctional zonezone maymay widenwiden withwith dysmenorrheadysmenorrhea •• UterineUterine contractionscontractions –– FocalFocal –– StriatedStriated SummarySummary LeiomyomaLeiomyoma AdenomyomaAdenomyoma •• RoundRound •• OvalOval withwith longlong axisaxis parallelingparalleling uterusuterus •• MassMass effecteffect •• RelativelyRelatively littlelittle massmass effecteffect • Indistinct margins •• WellWell defineddefined marginsmargins • Indistinct margins oftenoften withwith pseudocapsulepseudocapsule •• LacyLacy oror confluentconfluent •• PunctatePunctate hyperintensityhyperintensity hyperintensehyperintense focifoci
Leiomyoma coexist in 35-55% of cases if adenomyosis AdenomyosisAdenomyosis andand EndometriosisEndometriosis
•• MostMost ofof thethe majormajor authorsauthors ofof thethe firstfirst halfhalf ofof thethe pastpast centurycentury dealingdealing withwith thethe diseasedisease consideredconsidered pelvicpelvic endometriosisendometriosis andand uterineuterine adenomyosisadenomyosis asas variantsvariants ofof thethe samesame diseasedisease processprocess •• AdenomyosisAdenomyosis usedused toto bebe knowknow asas ““endometriosisendometriosis internainterna”” oror ““insideinside--outout endometriosisendometriosis”” •• TheyThey areare nownow thoughtthought toto bebe differentdifferent diseases,diseases, butbut therethere isis aa highhigh associationassociation betweenbetween endometriosisendometriosis andand adenomyosisadenomyosis,, andand vicevice versaversa LeyendeckeLeyendeckerr G (2000) EndometriosEndometriosisis is an entity wwithith extreme pleiomorphism. Hum Reprod 15, 4–7