Adenomyosis by myometrial Invasion of endometriosis: Comparison with typical adenomyosis Poster No.: C-1294 Congress: ECR 2010 Type: Scientific Exhibit Topic: Genitourinary Authors: S. Moon, H. K. Lim, J. Y. Cho, S. H. Kim; Seoul/KR Keywords: adenomyosis, endometriosis, MR DOI: 10.1594/ecr2010/C-1294 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 9
Purpose The purposes of this study were to compare the MRI features of uterine adenomyosis by myometrial invasion of endometriosis and the typical uterine adenomyosis. **Adenomyosis Nonneoplastic condition, characterized by benign invasion of ectopic endometrium into the myometrium with hyperplasia of adjacent smooth muscle. **Diagnosis of adenomyosis MRI : highly accurate noninvasive modality - high sensitivity (78%-88%) and specificity (67%-93%), - DDx of adenomyosis from other gynecologic disorders Biopsy or surgery **Endometriosis The presence of functional endometrial glands and stroma outside the uterine cavity In older literature, endometriosis was further classified as endometriosis interna : endometrial tissue within the uterine musculature # adenomyosis endometriosis externa : endometrial tissue in all other sites Adenomyosis is considered a distinct and different clinical entity because its pathogenesis, symptoms, and epidemiology differ from those of endometriosis. According to several literature, adenomyosis has been shown to be significantly associated with peritoneal endometriosis. In the patient with pelvic endometriosis, atypical serosal side location of adenomyosis Page 2 of 9
myometrial invasion of endometriosis ~ different from the typical uterine adenomyosis The purposes of this study were to compare the MRI features of uterine adenomyosis by myometrial invasion of endometriosis and the typical uterine adenomyosis. Methods and Materials Materials *Patients Inclusion criteria - Diagnosed as adenomyosis and endometriosis on MR - 2007.3 ~ 2009. 2 Exclusion criteria - s/p hysterectomy before MRI exam # 59 patients (25-52 years, mean 38.7 years) were included in this study. Methods *Evaluation of adenomyosis Location of adenomyosis in the uterus - inner, outer, and diffuse type Location of endometriosis related with adenomyosis Page 3 of 9
- separated, abutting Adhesion between uterus and endometriosis, and between endometriosis and surrounding other organs Size and internal feature of adenomyosis and endometriosis Results * Location of adenomyosis in the uterus Inner : 3 cases Outer : 31 cases Diffuse : 25 cases Among 31 outer cases, 29 cases showed adhesion between uterus and endometriosis, and 17 cases showed adhesion with bowel. The rest two cases with smooth margin of the serosal surface showed no significant adhesion with adjacent other structures. * Location of endometriosis related with adenomyosis Separated from adenomyosis : 18 cases Abutting adenomyosis : 41 cases We categorized adenomyosis into two groups - adneomyosis by invasion of endometriosis and adenomyosis with coincided endometriosis. Twenty-nine cases with outer adenomyosis showing adhesion were included in the group of adenomyosis by invasion of endometriosis. The rest 30 cases composed of 3 inner, 25 diffuse, and 2 outer adenomyosis without adhesion were included in the group of adenomyosis with coincided endometriosis. Page 4 of 9
Fig.: 1. Categorization of adenomyosis according to the location of adenomyosis in the uterus and the location of endometriosis related with adenomyosis References: S. Moon; Radiology, Seoul National University Hospital, Seoul, KOREA, Among 29 cases with adenomyosis by myometrial invasion of endometriosis, 19 cases underwent ovarian cystectomy or salpingo-oophorectomy and 7 cases underwent hysterectomy at the same time. In operation field, there were adhesions in the poserio clu-de-sac. Pathologic exams revealed multiple ectopic endometrial glands located not at the inner myometrium near the endometrium but at the outer myometrium. Page 5 of 9
Fig.: 2. The case of adenomyosis with conicided endometriosis References: S. Moon; Radiology, Seoul National University Hospital, Seoul, KOREA, MR images of a 45 year-old female with dymenorrhea. MR images show ill-defined, nonuniform thickening of the junctional zone subjacent to the endometrium that is diagnositic for adenomyosis (arrows). There is no evident adhesion between the endometriosis (E) and uterus (U). Fig.: 3. The case with adenomyosis by myometrial invasion of endometriosis Page 6 of 9
References: S. Moon; Radiology, Seoul National University Hospital, Seoul, KOREA, MR images of a 27 year-old female show ill-defined, low signal intensity lesion at serosal side of the retroverted uterus (arrows). There is multiple endometrial foci. This lesion looks like adenomyosis, but the junctional zone is separated from the this lesion, and intact without thickening. There are adhesion between endometriosis and adenomyosis. Fig.: 4. The microscopic findings of adenomyosis by myometrial invasion of endometriosis References: S. Moon; Radiology, Seoul National University Hospital, Seoul, KOREA, In pathologic review, there is endometriotic glands and stroma at sersal side of uterine wall in the case of adenomyosis by myometrial invasion of endometriosis (arrow). Page 7 of 9
Fig.: 5. The case of adenomyosis by myometrial invasion of endometriosis and adhesion between endometriosis and other surrounding organs References: S. Moon; Radiology, Seoul National University Hospital, Seoul, KOREA, Moreover, adenomyosis by invasion of endometriosis was often accompanied with adhesion with other surrounding organs. This case shows the adhesion between endometriosis, uterus and rectal wall (arrows). Conclusion Invasion of endometriosis may cause serosal sided adenomyosis and usually shows adhesion between uterus, endometriosis and surrounding organs. This information of invasion and adhesion may be helpful to determine the treatment plan of endometriosis. References Tamai, K., et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics 2005; 25:21-40. Tamai, K., et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006;20:583-602. Page 8 of 9
Grasso, RF. et al. Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography. Abdom Imaging 2009 Nov 19. [Epub ahead of print] Del Frate, C., et al. Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. Radiographics 2006;26:1705-1718. Zacharia, TT. and O'Neill, MJ. Prevalence and distribution of adnexal findings suggesting endometriosis in patients with MR diagnosis of adenomyosis. Br J Radiol 2006;79:303-307. Personal Information Moon, Sung Kyoung, MD. Department of Radiology, Seoul National University Hospital, Seoul, Korea E-mail: radmsk@hotmail.com Page 9 of 9