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TEXTBOOK READING OF SUTTON

Textbook of Radiology and Imaging 7th Edition, Volume 2, page 1095-1097

CHAPTER 34:

GYNECOLOGICAL IMAGING

Presented by: Yessi Oktiari

Consultant: dr. Yana Supriatna, Ph.D, Sp.Rad(K)RI

CHAPTER 34: GYNECOLOGICAL IMAGING

Ultrasound

Plain Film Radiology

Contrast Studies

Computed Tomography

Interventional Radiology

Magnetic Resonance Imaging

Uterus, Cervix and Vagina

Congenital Uterine Abnormalities

Uterine Tumours

Cervical Carcinoma

Ovaries

UTERUS ANATOMY

Source: Atlas of Human Anatomy 6th Ed

Source: Diagnostic Imaging 7th Ed

LEIOMYOMA (UTERINE FIBROID)

Most common solid uterine tumour

Composed of smooth muscle, varying amount of fibrous tissue

Single or multiple

Estrogen dependent

Location

Submucosal

Intramural

Subserosal Source: mayoclinic.org

LEIOMYOMA

MRI

Accurate assesment of the site, number, size as small as 3 mm diameter

IV gadolinium-chelate does not improve the detection

LEIOMYOMA

Non degenerating

T1: uniform signal intensity T2: low signal intensity

Degenerating

T1: intermediate-high signal intensity T2: high signal intensity


Sagittal T2-weighted MRI demonstrating several uterine fibroids (white arrows), which are of low signal intensity. The endometrial cavity is normal (black arrow). B, bladder; C, cervix

LEIOMYOMA

USG

• Useful in demonstrating subserosal and submucosal lesion on pedicle

• Precludes the use of uterine artery ablation

MRI

• Limited in the presence of retroverted displaced uterus

• Difficult in discriminating a uterine & adnexal mass

• False negative up to 20%

ADENOMYOSIS

http://www.emedicinehealth.com/adenomyosis-health/article_em.htm

The presence of endometrial glandular cells and cells of the

chorion more than 2.5 mm from the endometrium-myometrium

interface

Risk factor: 1. Prior endouterine surgery 2. Multiparity 3. Women between 40-50

tahun

Signs and symptoms: 1. Menorrhagia 2. Dysmenorrhea 3. Recent onset of menstrual

cramping that is gradually getting worse

MRI Characteristics of the Uterine Junctional Zone: From Normal to the Diagnosis of Adenomyosis, Novellas et al., 2011

ADENOMYOSIS

Can’t be distinguished from leiomyomas on clinical findings or by ultrasound

Similar pelvic pain & menorraghia with uterine enlargement

Different treatment

Adenomyosis vs leiomyoma on MRI

MRI findings Adenomyoma Leiomyoma

1. Diffuse or focal thickening of junctional zone

Yes No

2. Ill-defined margin Yes No

3. Signal intensity Low Low but often high

4. Periphery large vessels No Yes

JUNCTIONAL ZONE

MRI is the first imaging technique to reveal this structure

Innermost layer of myometrium

A distinct low signal on T2-weighted sequences separating the endometrium in high signal intensity from the outer myometrium in intermediate signal

Looser extracellular matrix, lower water content

The upper limit of normal for the junctional zone thickness: up to 5–8 mm (midsagital image through the long axis of uterus)


JUNCTIONAL ZONE


ADENOMYOSIS ON MRI

Direct sign Indirect sign

1. Microcysts 2. Adenomyoma

Thickness of the junctional zone exceeding 12 mm Diagnostic accuracy 85% and spesificity of 96%

Advantages Limitation

• Less interoperator variability • More specific diagnosis

• Only 50% cases detecting mycrocysts • From 20% to 30% of patients will not have

a measurable junctional zone during their reproductive cycle, 50% in postmenopausal women


Sensitivity: 70% to 86% and a specificity of 86–93% These numbers are similar to ultrasound

ADENOMYOSIS


RESUME

Uterus anatomy

Leiomyoma

Pathology

MRI

Adenomyoma

Definition

Junctional Zone

MRI

QUIZ

What is the most likely diagnosis on the following MRI:

a. Endometriomas

b. Adenomyosis

c. Leiomyosarcoma

d. Uterine fibroids

e. Cervical carcinoma

TERIMA KASIH MOHON ASUPAN