Gynecologic Adenomyosis and Endometriosis: Key Imaging Findings, Mimics, and Complications Saro B
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Volume 38 • Number 7 March 31, 2015 Gynecologic Adenomyosis and Endometriosis: Key Imaging Findings, Mimics, and Complications Saro B. Manoukian, MD, Nicholas H. Shaheen, MD, and Daniel J. Kowal, MD After participating in this activity, the diagnostic radiologist should be better able to utilize ultrasound and MR imaging to help differentiate between gynecologic adenomyosis and endometriosis given their divergent management despite their signifi cant overlap in symptoms. Adenomyosis of the Uterus CME Category: Women’s Imaging Subcategory: Genitourinary Adenomyosis of the uterus represents heterotopic endome- Modality: MRI trial glands and stroma in the myometrium with adjacent smooth muscle hypertrophy. The pathogenesis of uterine adenomyosis involves endometrial migration via a basement Key words: Adenomyosis, Endometriosis, Ovarian membrane defect or through lymphatic or vascular channels.1 Endo metrioma Women age 40 to 50 years usually are affected. Although patients with uterine adenomyosis are usually asymptomatic, Adenomyosis and endometriosis are gynecologic processes symptoms may include pelvic pain, menorrhagia, and dys- with characteristic pathophysiologic, clinical, and imaging menorrhea. Risk factors for uterine adenomyosis include prior differences. Although adenomyosis refers to the presence of uterine trauma or surgery, multiparity, and hyperestrogene- heterotopic endometrial glands and stroma within the myo- mia. Imaging is important because superfi cial uterine adeno- metrium, endometriosis involves the presence of endometrial myosis responds signifi cantly better to endometrial ablation glands and stroma outside of the uterus (Figure 1). Patients than does deep uterine adenomyosis. On ultrasound imaging, with either adenomyosis or endometriosis can have a similar pseudowidening of the endometrium with a poorly defi ned clinical presentation. Imaging can be of great utility in dif- endomyometrial junction often is seen in diffuse uterine ferentiating between these 2 gynecologic pathologic pro- adenomyosis because of heterotopic endometrium extending cesses, thereby guiding appropriate clinical management. into the inner myometrium2 (Figure 2). These heterotopic Accurate diagnosis also is important because endometriosis endometrial glands cause an appearance of subendometrial has potentially more signifi cant complications. Finally, dif- echogenic linear striations.2 Also, the uterus is often globular ferentiating an ovarian endometrioma from its mimics can and enlarged with heterogeneous myometrial echotexture. obviate the need for more invasive procedures, such as lapar- On MRI, diffuse uterine adenomyosis demonstrates oscopy or oophorectomy. thickening of the junctional zone of at least 12 mm. The junctional zone corresponds to the innermost layer of myo- metrium and is visualized as a distinct area of low signal Dr. Manoukian is Radiology Resident, Dr. Shaheen is Radiology Resident, and on T2-weighted MR images, separating the high-signal Dr. Kowal is CT Division Director, Department of Radiology, Saint Vincent endometrium from the intermediate-signal outer myo- Hospital, 123 Summer St, Worcester, MA 01608; E-mail: [email protected]. metrium3 (Figure 3). Although a junctional zone thickness The authors and all staff in a position to control the content of this CME activity greater than 12 mm is diagnostic of uterine adenomyosis and their spouses/life partners (if any) have disclosed that they have no relation- ships with, or fi nancial interests in, any commercial organizations pertaining to (Figure 4), a junctional zone thickness of 8 mm or less effec- this educational activity. tively excludes adenomyosis as a diagnostic consideration. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This continuing medical education activity expires on March 30, 2016. 1 CCDRv38n7.inddDRv38n7.indd 1 22/11/15/11/15 110:180:18 PPMM Figure 3. Sagittal, T2-weighted MR image of the uterus demon- strates its normal zonal anatomy. The outer myometrium (1) is intermediate signal intensity. The inner myometrium (2) (also Figure 1. Adenomyosis represents heterotopic endometrial known as the junctional zone) is hypointense and normally <12 mm glands and stroma in the myometrium. Endometriosis represents in thickness. The endometrium (3) is normally hyperintense. functional ectopic endometrial glands and stroma outside of the uterine cavity, commonly manifesting as an endometrioma. (see Figure 4), and T1-hyperintense punctuate foci indi- cating hemorrhage, all of which are fi ndings that add specifi city to the diagnosis. Because of its superior sensiti- vity and specifi city compared with ultrasound, MRI is the imaging modality of choice for the diagnosis of uterine adenomyosis.2 The defi nitive treatment for diffuse uterine adenomyosis is hysterectomy, particularly in women with debilitating symptoms. Endometrial ablation can be performed for more superfi cial disease, which is best evaluated on MRI.2 Mimics of Focal Adenomyosis. A myometrial contrac- tion could mimic focal adenomyosis, but myometrial con- tractions are transient and change in appearance over time.2 Although typically diffuse, uterine adenomyosis also can occur focally and even appear mass-like as an adenomy- oma. Uterine leiomyomas (fibroids) are well-defined, rounded lesions with mass effect on the endometrium, unlike focal uterine adenomyosis, which is poorly defi ned, elliptical, and without mass effect. Although both uterine Figure 2. Transvaginal ultrasound of the uterus demonstrates fi broids and adenomyosis are hypointense on T2-weighted endometrial pseudowidening (white arrow) with a poorly defi ned MR images, focal uterine adenomyosis contains punctate endomyometrial junction (dashed arrow). Heterogeneity of the hyperintense foci, signifying dilated cystic endometrial myometrium also is present. glands.2 Differentiating the two conditions is clinically rel- Additional MR fi ndings include poorly defi ned junctional evant because of divergent management: uterine conserva- zone margins, intrazonal T2-hyperintense punctate foci tion with myomectomy for leiomyomas versus hysterectomy representing cystic dilatation of heterotopic glands3 for uterine adenomyosis. The continuing education activity in Contemporary Diagnostic Radiology is intended for radiologists. EDITOR: Robert E. Campbell, MD, Clinical Professor of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Contemporary Diagnostic Radiology (ISSN 0149-9009) is published bi-weekly by Lippincott Williams & Wilkins, Inc., 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Customer Service: Phone (800) 638-3030; FOUNDING EDITOR: William J. 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Permission to reproduce in any way must be secured in writing; go to the journal website (www.cdrnewsletter.com), select the article, and click “Request Permissions” under “Article Tools,” or e-mail [email protected]. Reprints: For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 or under, e-mail [email protected], call 866-903-6951, or fax 410-528-4434. 2 CCDRv38n7.inddDRv38n7.indd 2 22/11/15/11/15 110:180:18 PPMM A Figure 4. T2-weighted MR image demonstrates a poorly