Role Of MRI In Diagnosing Ectopic Endometrium

Transcription

1 Role Of MRI In Diagnosing Ectopic Endometrium Thesis Submitted for partial fulfillment of the Master Degree in Diagnostic Radiology By Marwa Mohamed Mohamed Onsy (M.B.B.CH. Cairo University) Supervisors Dr. Rasha Mohamed Kamal Professor of Radiology Faculty of Medicine Cairo University Dr. Sahar Mahmoud Mansour Lecturer of Radiology Faculty of Medicine Cairo University Dr. Rasha El koumy Lecturer of Gynecology and Obstetrics Faculty of Medicine Cairo University FACULTY OF MEDICINE CAIRO UNIVERSITY 2012

2 Abstract This study entails evaluation of 25 female patients who were suspected to have endometriosis/ adenomyosis, for MRI evaluation. Their ages were ranging between 21 and 50 years. Their main complaints were infertility (36% of cases), pelvic pain (40% of cases), and irregular uterine bleeding (24% of cases). MRI proved the presence of endometriosis / adenomyosis in 20 out of 25 cases (80%). Endometriosis was diagnosed in 14 cases (70%), adenomyosis was diagnosed in 4 cases (20%), and mixed endometriosis and adenomyosis were diagnosed in 2 cases (10%). Key words adenomyosis- Radiology- Endometrium-MRI

3 Acknowledgment It is the faith and belief in almighty Allah that gave me the strength all through that work till it is finished. I would like to express my profound thanks, sincere and deep gratitude to Dr. Rasha Kamal Professor of Radiology, Cairo University for her valuable suggestions, kind guidance, encouragement, valuable time and effort in making this study possible. I would like also to thank Dr. Sahar Mansour Lecturer of Radiology, Cairo University who gave me much of her time, effort and care. I would like also to thank Dr. Rasha El-Koumy Lecturer of Gynecology and Obetetrics, Cairo University for her kind assistance and support. I would like to thank my family for their patience and support without which the completion of this work would have not been possible.

4 Table Of Contents Introduction Aim of the work Review of literature Anatomical background... Pathology.... Diagnosis of endometriosis. Diagnosis of adenomyosis.. Patients and methods Results Case presentation... Discussion Summary.. References Arabic Summary Page

5 List Of Abbreviations ADC CT DCBE DIE DWI FOV 1H MR LG-ESS MHz mm MRI NPV PPV Ppm Sec/ mm2 SHG TE TR TVS TVUS US apparent diffusion co-efficient computed tomography double-contrast barium enema deeply infiltrating endometriosis diffusion weighted images field of view Spectroscopy Hydrogen 1 magnetic resonance spectroscopy low-grade endometrial stromal sarcoma mega hertz millimeter magnetic resonance imaging negative predictive value positive predictive value part per million second per square millimeters sonohysterography time of echo time of repetition transvaginal sonography transvaginal ultrasound ultrasound

6 List of Tables No. Table1 Table 2 Table 3 Table 4 Table 5 Most common sites for endometriotic implants and adhesions MR imaging protocol of female pelvis Summary of patients complaints Pattern of MRI signals of endometriotic cysts Associated MRI findings in patients with endometriosis Page Table 6 Table 7 Table 8 Table 9 Table 10 MRI findings in suspected adenomyosis patients Associated MRI findings in patients with adenomyosis Results of MRI examination compared to histopathology MRI final diagnoses Sensitivity, Specificity, PPV, NPV and accuracy of MRI

7 List of Figures Figure Content Page Number Figure 1 Diagram showing the anatomy of female reproductive 4 system Figure 2 Diagram showing the layers of the uterus 10 Figure 3 Diagram showing the ligaments of the uterus 12 Figure 4 Diagram showing the blood supply of the uterus 13 Figure 5 Diagram showing the anatomy of a normal fallopian tube 15 Figure 6 Diagram showing the anatomy of ovary and follicles 17 Figure 7 Diagram showing the location of endometriomas and 21 implants of endometriosis Figure 8 Laparoscopic view showing endometriotic implants 25 Figure 9 Intraoperative view showing endometriotic implants in the 25 cul-de-sac Figure 10 (a) Transabdominal US scan and (b) Photograph of gross specimen of left ovarian endometrioma in a 30-year-old woman 27 Figure 11 (a) Transvaginal US scan and (b) Photograph of right 28 ovarian endometriotic cyst in a 25-year-old woman Figure 12 Microscopic appearance of an endometriotic implant 29 Figure 13 Drawing illustrating ectopic endometrial glands located 35 deep in the myometrium, surrounded by smooth muscle hyperplasia Figure 14 Diagrammatic illustration of the pathology of adenomyosis 36 Figure 15 (a) Photograph and (b) microscopic appearance of 37 adenomyosis in a 47-year-old woman

8 Figure 16 Transvaginal sonogram showing classic ovarian 42 endometrioma Figure 17 Axial T1-weighted fat-suppressed MR image and T2-44 weighted MR image of left ovarian endometrioma Figure 18 Transvaginal sonogram and Sagittal T2-weighted MR image 45 of endometrioma associated with hematosalpinx Figure 19 Axial T2-weighted MR image and Axial fat-suppressed T1-47 weighted MR image of bladder endometriosis Figure 20 Sagittal T2-weighted MR image and axial fat-suppressed 48 T1-weighted MR image of endometriotic involvement of the vesicovaginal septum in a 37-year-old woman Figure 21 MRI of ureteral endometriosis in a 31-year-old woman 49 Figure 22 MRI of sigmoid endometriosis in a 30- year-old woman 51 Figure 23 T1-weighted MR image showing endometriotic involvement 53 of the uterine ligaments in a 31-year-old woman Figure 24 Sagittal T2-weighted MR image and axial fat-suppressed 54 T1-weighted MR image showing endometriotic involvement of the retrocervical area in a 33-year-old woman Figure 25 TVUS image of the uterus showing adenomyosis 57 Figure 26 Sagittal oblique sonohysterogram showing focal 59 adenomyosis Figure 27 Hysterosalpingogram showing numerous large lollipop 59 diverticula in a 40-year-old woman with surgically proven adenomyosis Figure 28 Sagittal T2 FSE image showing widespread thickening of the junctional zone with numerous high signal foci in a patient with adenomyosis. 60

9 Figure 29 Sagittal T1-weighted spin-echo MR image showing highsignal-intensity spots in a patient with adenomyosis Figure 30 Axial T2-weighted fast spin-echo MR image showing adenomyosis in a 50-year-old woman before and after hormonal therapy with gonadotropin-releasing hormone analog. Figure 31 Sagittal T2-weighted fast spin-echo MR image and sagittal diffusion-weighted echo-planar MR image showing adenomyosis with focal edema in a 54-year-old woman. Figure 32 Axial T2-weighted fast spin-echo MR image, axial fatsaturated T1- weighted spin-echo MR image and axial susceptibility-weighted gradient-echo MR image showing adenomyosis in a 46-year-old woman. Figure 33 Sagittal high-resolution T2-weighted fast spin-echo MR image and MR spectroscopy in a patient with LG-ESS. Figure 34 Coronal T2-weighted fast spin-echo MR image showing subserosal polypoid adenomyoma. Figure 35 Sagittal T2-weighted fast spin-echo MR image showing an adenomyotic cyst. Figure 36 Sagittal T2-weighted fast spin-echo MR image, axial T1- weighted spin-echo MR image and a photograph of the cut surface of the gross specimen of an adenomyotic cyst. Figure 37 Sagittal T2-weighted fast spin-echo MR image showing subserosal adenomyosis-like lesion (invasive solid endometriosis) in a 33-year-old woman during different phases of the menstrual cycle. Figure 38 Sagittal T2-weighted fast spin-echo MR image showing physiologic transient myometrial contraction

10 Figure 39 Sagittal T2-weighted fast spin-echo MR imaging 79 subserosal adenomyosis-like lesion (invasive solid endometriosis) in a 41-year-old woman. Figure 40 Sagittal T2-weighted fast spin-echo MR image showing 82 malignant lymphoma in a 59-year-old woman. Figure 41 Sagittal T2-weighted image and a photograph of the cut 83 surface of the gross specimen in a case of adenomyosis with leiomyomas. Figure 42 Example for planning of imaging slices for MRI examination 87 of the uterus Figure 43 Case one 99 Figure 44 Case two 101 Figure 45 Case three 104 Figure 46 Case four 105 Figure 47 Case five 107 Figure 48 Case six 108

11 List of charts No. Chart 1 percentage of bilateral & unilateral endometriomas Page 90 Chart 2 Chart 3 Chart 4 Chart 5 MRI signal pattern of endometriotic cysts Percentage of unilocular and multilocular cysts. MRI findings in suspected adenomyosis patients. MRI final diagnoses

12 Introduction INTRODUCTION Endometriosis is a condition where tissue similar to the lining of the uterus; the endometrial stroma and glands, is found elsewhere in the body (Kennedy et al., 2005). In older literature, endometriosis was further classified as endometriosis interna and endometriosis externa. Endometriosis interna referred to endometrial tissue within the uterine musculature, and endometriosis externa referred to endometrial tissue in all other sites (Woodward et al., 2001). Currently, the term adenomyosis has replaced endometriosis interna. Adenomyosis is considered a distinct and different clinical entity because its pathogenesis, symptoms, and epidemiology differ from those of endometriosis (Yantiss et al., 2000). Some patients being asymptomatic and others having disabling pelvic pain, infertility, or adnexal masses. Symptoms do not necessarily correlate with the severity of the disease. Others can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively). However, because the endometrial glands can be trapped in the myometrium, it is possible to have increased pain without profuse menses. This can be used to distinguish adenomyosis from endometrial hyperplasia; in the latter condition, increased bleeding is more common (Leyendecker et al., 2006). Endometriosis externa is now simply called endometriosis. In the typical patient, the ectopic implants are located in the pelvis 1

13 Introduction (ovaries, fallopian tubes, vagina, cervix, or uterosacral ligaments or in the rectovaginal septum) and manifest as severe dysmenorrhea, chronic pelvic pain, or infertility. The term deep endometriosis should be reserved for lesions in the retroperitoneal tissue (Vercellini et al., 2004). MRI provides better diagnostic capability due to the increased soft tissue differentiation, allowable through higher spatial and contrast resolution it has high specificity for identifying endometriomas, which are characterized by high signal intensity on T1-weighted images and low signal intensity on T2-weighted images (Chamié et al., 2011). MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.the uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences interspersed within foci of hyperintensity (brightness) noted on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage (Tamai et al., 2006). In addition to depicting adenomyosis, MRI can be used to distinguish a focal adenomyoma from a leiomyoma. Precise knowledge of the spectrum of MR features in adenomyosis greatly helps in determining an accurate diagnosis and appropriate management of the patients (Tamai et al., 2006). 2

14 Aim of work AIM OF WORK The aim of this study is to prove the ability of MRI to accurately diagnose endometriosis, adenomyosis and their complications. 3

15 Review of literature ANATOMICAL BACKGROUND Figure 1: Anatomy of female reproductive system (Gray, 2001). VAGINA ` This musculo-membranous structure extends from the vulva to the uterus and is interposed anteriorly and posteriorly between the urinary bladder and the rectum (fig.1). The upper portion of the vagina arises from the mullerian ducts, and the lower portion is formed from the urogenital sinus. Anteriorly, the vagina is separated from the bladder and urethra by connective tissue, often referred to as the vesicovaginal septum. Posteriorly, between the lower portion of the vagina and the rectum, there are similar tissues that together form the rectovaginal septum. The upper fourth of the vagina is 4

16 Review of literature separated from the rectum by the recto-uterine pouch, also called the cul-de-sac of Douglas (Cunningham et al., 2005). Normally, the anterior and posterior vaginal walls lie in contact, with only a slight space intervening between the lateral margins. Vaginal length varies considerably, but commonly, the anterior and posterior vaginal walls are, respectively, 6 to 8cm and 7 to 10 cm in length. The upper end of the vaginal vault is subdivided into anterior, posterior, and two lateral fornices by the uterine cervix (Cunningham et al., 2005). Vascular supply The upper third is supplied by the cervico-vaginal branches of the uterine arteries The middle third is supplied by the inferior vesical arteries. The lower third by the middle rectal and internal pudendal arteries. The vaginal artery may branch directly from the internal iliac artery. An extensive venous plexus immediately surrounds the vagina and follows the course of the arteries (Cunningham et al., 2005) 5

17 Review of literature Lymphatics Lymphatics from the lower third of the vagina, along with those of the vulva, drain primarily into the inguinal lymph nodes. Those from the middle third drain into the internal iliac nodes. Those from the upper third drain into the iliac nodes (Cunningham et al., 2005). UTERUS The non-pregnant uterus is situated in the pelvic cavity between the bladder anteriorly and the rectum posteriorly. Size and Shape The uterus resembles a flattened pear in shape (fig.1). It consists of two major but unequal parts: 1- An upper triangular portion, the body, or corpus. 2- A lower, cylindrical, or fusiform portion, the cervix, which projects into the vagina. The isthmus is that portion of the uterus between the internal cervical is and the endometrial cavity. The oviducts, or fallopian tubes, emerge from the cornua of the uterus at the junction of the superior and lateral margins. The convex upper segment between the 6

18 Review of literature points of insertion of the fallopian tubes is called the fundus (Cunningham et al., 2005). The prepubertal uterus varies in length from 2.5 to 3.5 cm. The uterus of adult nulliparous women is from 6 to 8 cm in length as compared with 9 to 10 cm in multiparous women (Cunningham et al., 2005). Cervix The upper boundary of the cervix is the internal os, which corresponds to the level at which the peritoneum is reflected upon the bladder. The supravaginal segment is covered by peritoneum on its posterior surface. This segment is attached to the cardinal ligaments anteriorly, and it is separated from the overlying bladder by loose connective tissue. The other segment is the lower vaginal portion of the cervix, also called the portiovaginalis. The mucosa of the cervical canal is composed of a single layer of very high ciliated columnar epithelium that rests on a thin basement membrane (Cunningham et al., 2005). 7

19 Review of literature Layers of the Uterus: I. Perimetrium The serosal layer is formed by the peritoneum that covers the uterus. It is firmly adherent except at sites just above the bladder and at the lateral margins, where the peritoneum is deflected to form the broad ligaments (Cunningham et al., 2005). II. Myometrium The myometrium makes up the major portion of the uterus. It is composed of bundles of smooth muscle united by connective tissue in which there are many elastic fibers. The number of muscle fibers of the uterus progressively diminishes caudally such that, in the cervix, muscle comprises only 10 percent of the tissue mass. In the inner wall of the body of the uterus, there is relatively more muscle than in the outer layers; and in the anterior and posterior walls, there is more muscle than in the lateral walls (Cunningham et al., 2005). III. Endometrium This mucosal layer lines the uterine cavity. It is a thin, pink, velvet-like membrane that on close examination is found to be perforated by a large number of minute ostia of the uterine glands. The endometrium normally varies greatly in thickness, and measures 8

20 Review of literature from 0.5 mm to as much as 5 mm. It is composed of surface epithelium, glands, and interglandular mesenchymal tissue in which there are numerous blood vessels (Cunningham et al., 2005). The epithelium of the endometrial surface is made up of a single layer of closely packed, high columnar, ciliated cells. The tubular uterine glands are invaginations of the epithelium. The glands extend through the entire thickness of the endometrium to the myometrium, which is occasionally penetrated for a short distance (Cunningham et al., 2005). Histologically, the inner glands resemble the epithelium of the surface and are lined by a single layer of columnar, partially ciliated epithelium that rests on a thin basement membrane. The glands secrete a thin, alkaline fluid. The connective tissue of the endometrium, between the surface epithelium and the myometrium, is a mesenchymal stroma (fig. 2) (Cunningham et al., 2005). 9