MRI of the UterusMRI of the Uterus

Jeffrey C. Weinreb, M.D. FACRJeffrey C. Weinreb, M.D. FACRjeffrey.weinreb@yale.edujeffrey.weinreb@yale.edu

Yale University School of MedicineYale University School of Medicine

BENIGNBENIGN

Normal AnatomyNormal Anatomy

Junctional Zone is the inner layer or the myometrium

Junctional Zone

E

MJZ

E

M

Routine GYN ProtocolRoutine GYN Protocol

•• PrepPrep–– Void prior to examVoid prior to exam–– IV lineIV line–– NPO x 4 hrsNPO x 4 hrs–– GlucagonGlucagon

Routine GYN ProtocolRoutine GYN Protocol

•• Sag T2W FSESag T2W FSE–– Respiratory trigger and/or anterior sat bandsRespiratory trigger and/or anterior sat bands

•• Short axis T2W (uterus or cervix)Short axis T2W (uterus or cervix)•• CorCor or Axial T2W or Axial T2W •• Axial T1W IP/OP Axial T1W IP/OP •• Axial Fat Sat T1W Axial Fat Sat T1W •• PostPost--C Fat Sat T1W with SubtractionsC Fat Sat T1W with Subtractions•• Delayed Sag T2W FSEDelayed Sag T2W FSE

Normal Uterus/CervixNormal Uterus/Cervix

Uterine Uterine LeiomyomaLeiomyoma•• Most common uterine neoplasmMost common uterine neoplasm•• Occur in women of reproductive age and are Occur in women of reproductive age and are

under hormonal influenceunder hormonal influence–– Enlarge during pregnancy or BCP useEnlarge during pregnancy or BCP use–– Regress after menopauseRegress after menopause

•• SymptomsSymptoms–– DysmenorrheaDysmenorrhea–– MenorrhagiaMenorrhagia–– InfertilityInfertility–– Pressure sensationPressure sensation

MRI of Uterine MRI of Uterine LeiomyomaLeiomyoma

•• Low signal on T2WIsLow signal on T2WIs•• RoundRound•• Mass Mass effeceffec•• Well defined margins Well defined margins

often with often with pseudocapsulepseudocapsule

•• Lacy or confluent Lacy or confluent hyperintensityhyperintensity

Uterine Uterine LeiomyomaLeiomyoma

•• As they grow, they may outgrow their blood As they grow, they may outgrow their blood supply, resulting in various types of supply, resulting in various types of degenerationdegeneration–– Hyaline Hyaline (homogeneous (homogeneous eosinophiliceosinophilic proteinaceousproteinaceous material)material)–– MyxoidMyxoid ((hyaluronichyaluronic acidacid--rich rich mucopolysccharidemucopolysccharide gelitenousgelitenous

material) material) –– CysticCystic–– Hemorrhagic Hemorrhagic (red or (red or carneouscarneous, occurs in pregnancy or with , occurs in pregnancy or with

BCPsBCPs))–– CalcificCalcific

Uterine Uterine LeiomyosarcomaLeiomyosarcoma

•• SarcomatousSarcomatous transformation of preexisting transformation of preexisting leiomyomaleiomyoma is rareis rare–– Diagnosis usually made as an incidental Diagnosis usually made as an incidental

pathologic diagnosis in 0.5% or pathologic diagnosis in 0.5% or resectedresectedfibroidsfibroids

•• Most arise independently from Most arise independently from myometrialmyometrialsmooth muscle cellssmooth muscle cells

Uterine Uterine LeiomyomaLeiomyoma

•• Edema is common Edema is common –– Scattered or diffuseScattered or diffuse–– Frequently prominent at peripheryFrequently prominent at periphery–– With extensive edema, get marked With extensive edema, get marked

enhancement due to retention of contrast enhancement due to retention of contrast material within the abundant interstitial spaces material within the abundant interstitial spaces OkizukaOkizuka H, et al. J H, et al. J computcomput Assist Assist TomogrTomogr 1993;17:7601993;17:760--766766

Suspect Suspect LeiomyosarcomaLeiomyosarcoma

•• LyphadenopathyLyphadenopathy, , ascitesascites, or peritoneal seeding are unusual, or peritoneal seeding are unusual•• Rapid growth of Rapid growth of leiomoyomaleiomoyoma is not usefulis not useful

–– <3% of sarcomas have rapidly growing uterus<3% of sarcomas have rapidly growing uterus–– <1% of rapidly growing <1% of rapidly growing leiomyomasleiomyomas contain contain leiomyosarcomasleiomyosarcomas

•• Hemorrhage is not usefulHemorrhage is not useful–– Hemorrhage is not uncommon in fibroids but unusual in Hemorrhage is not uncommon in fibroids but unusual in

leiomyosarcomasleiomyosarcomas•• High signal on T2WIs in >50% of mass is not usefulHigh signal on T2WIs in >50% of mass is not useful

–– Not uncommon in fibroidsNot uncommon in fibroids•• High signal on T2WIs and intense enhancement is not usefulHigh signal on T2WIs and intense enhancement is not useful

–– Seen with cellular Seen with cellular leiomyomasleiomyomas (composed of compact smooth muscle (composed of compact smooth muscle cells with little or no collagen) cells with little or no collagen)

•• Irregular or indistinct margin is suggestiveIrregular or indistinct margin is suggestive

•• Differential DiagnosisDifferential Diagnosis–– Uterine sarcomaUterine sarcoma

•• LeiomyosarcomaLeiomyosarcoma•• Mixed Mixed mullerianmullerian tumortumor•• Endometrial Endometrial stromalstromal sarcomesarcome

–– AdenomyosisAdenomyosis–– Solid ovarian masses (Solid ovarian masses (fibromafibroma, , fibrothecomafibrothecoma, Brenner tumor), Brenner tumor)–– MyometrialMyometrial contractionscontractions–– Endometrial cancerEndometrial cancer–– Endometrial polypEndometrial polyp–– Gestational Gestational TrophoblasticTrophoblastic DiseaseDisease–– Retained products of conceptionRetained products of conception

Uterine Uterine LeiomyomaLeiomyoma

•• GonadalGonadal stromalstromal cell origincell origin•• Most common solid primary ovarian tumorMost common solid primary ovarian tumor•• BenignBenign•• FibromasFibromas consist of intersecting bundles of consist of intersecting bundles of

spindle cells that produce large amount of spindle cells that produce large amount of collagencollagen

•• FibrothecomasFibrothecomas also contain theca cellsalso contain theca cells•• Cystic degeneration and edema Cystic degeneration and edema •• On MRI resemble fibroidsOn MRI resemble fibroids•• Diff Diff DxDx includes includes intraligamentousintraligamentous leiomyomaleiomyoma, ,

endometriomaendometrioma, ovarian , ovarian fibromatosisfibromatosis, and , and Brenner tumor Brenner tumor

Ovarian Ovarian Fibromas/FibrothecomasFibromas/Fibrothecomas

Bridging Vascular SignBridging Vascular Sign•• Vessels that extend from the uterus to supply a pelvic Vessels that extend from the uterus to supply a pelvic

mass indicate the uterine origin of a mass indicate the uterine origin of a juxtauterinejuxtauterine massmass•• Caused by feeding vessels that arise from the uterine Caused by feeding vessels that arise from the uterine

arteries arteries •• In one study, it was present in in 20/26 In one study, it was present in in 20/26 exophyticexophytic

leiomyomasleiomyomas and absent in all other and absent in all other adnexaladnexal masses, masses, resulting in a diagnostic accuracy of 80%resulting in a diagnostic accuracy of 80%Kim JC, et al. J Kim JC, et al. J ComputComput Assist Assist TomogrTomogr 2000;24:570602000;24:57060

•• But, ovarian malignancies that invade the uterus may But, ovarian malignancies that invade the uterus may also show this signalso show this signKim SH, et al. J Kim SH, et al. J ComputComput Assist Assist TomogrTomogr 2001;25:362001;25:36--4242

Exophytic fibroid or fibroma?Fibroid

A mass may originate from the periphery of the ovary,A mass may originate from the periphery of the ovary,so the identification of an apparently normal adjacent ovaryso the identification of an apparently normal adjacent ovarydoes not exclude an ovarian origindoes not exclude an ovarian origin

Ovarian Vascular Pedicle SignOvarian Vascular Pedicle Sign

•• If you can trace asymmetrically enlarged If you can trace asymmetrically enlarged gonadalgonadal veins anterior to veins anterior to psoaspsoas muscle and muscle and common iliac vessels into a pelvic mass, it common iliac vessels into a pelvic mass, it indicates that the ovary is the organ of origin indicates that the ovary is the organ of origin –– Identified in 92% of ovarian massesIdentified in 92% of ovarian masses

•• Also seen in 13% of Also seen in 13% of subserosalsubserosal uterine uterine myomasmyomas–– The ovarian veins form a plexus in the broad ligament The ovarian veins form a plexus in the broad ligament

that communicates with the uterine plexusthat communicates with the uterine plexus

Lee JH, et al. AJR 2003;181:131Lee JH, et al. AJR 2003;181:131--137137

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

MR Findings in MR Findings in 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•• >> 12 mm = 12 mm = adenomyosisadenomyosis•• 8 8 -- 11 mm = 11 mm = c/wc/w adenomyosisadenomyosis if if clinical findingsclinical findings•• << 7 mm = 7 mm = nornalnornal

PitfallsPitfalls

•• JunctionalJunctional zone may widen (focally or zone may widen (focally or diffusely) on days 1diffusely) on days 1--2 of menstrual cycle2 of menstrual cycle

•• JunctionalJunctional zone may widen with zone may widen with dysmenorrheadysmenorrhea

•• Uterine contractions Uterine contractions –– Focal Focal –– StriatedStriated

SummarySummaryLeiomyomaLeiomyoma

•• RoundRound

•• Mass effectMass effect

•• Well defined margins Well defined margins often with often with pseudocapsulepseudocapsule

•• Lacy or confluent Lacy or confluent hyperintensityhyperintensity

AdenomyomaAdenomyoma•• Oval with long axis Oval with long axis

paralleling uterusparalleling uterus•• Relatively little mass Relatively little mass

effecteffect•• Indistinct marginsIndistinct margins

•• PunctatePunctatehyperintensehyperintense focifoci

Leiomyoma coexist in 35-55% of cases if adenomyosis

AdenomyosisAdenomyosis and Endometriosisand Endometriosis

•• Most of the major authors of the first half of the Most of the major authors of the first half of the past century dealing with the disease considered past century dealing with the disease considered pelvic endometriosis and uterine pelvic endometriosis and uterine adenomyosisadenomyosis as as variants of the same disease process variants of the same disease process

•• AdenomyosisAdenomyosis used to be know as used to be know as ““endometriosis endometriosis internainterna”” or or ““insideinside--out endometriosisout endometriosis””

•• They are now thought to be different diseases, They are now thought to be different diseases, but but there is a high association between endometriosis there is a high association between endometriosis and and adenomyosisadenomyosis, and vice versa , and vice versa LeyendeckerLeyendecker G (2000) Endometriosis is an entity with extreme G (2000) Endometriosis is an entity with extreme pleiomorphismpleiomorphism. Hum . Hum ReprodReprod 15, 415, 4––77