TEXTPUT
This is Page 1 of 1
Search Journal
VALUE OF IMAGING IN DIFFERENTIAL DIAGNOSIS OF PATHOLOGIC FINDINGS IN THE UTERUS. S Taïeb, F Bonodeau, A Chevalier, E Leblanc, A Delobelle, P-E Besson Department of Radiology - Centre Oscar Lambret - Lille - France
n INTRODUCTION n Some benign lesions of the uterus could be taken for malignant on clinical data. This exhibit illustrates various imaging findings of such benign lesions in 19 patients compared with 23 malignant lesions. The imaging study includes data of sonography (n=37), hysterography (n=3), hysterosonography (n=15), CT (n=7), and MRI (n=32). They will be retrospectively analyzed with hysteroscopy (n=19) and histological correlations (n=42) in order to determine their respective indications. There were atypical leiomyomas (n=9), polyps and subendometrial lesions with Tamoxifen (n=10), compared to sarcomas (n=8), adenocarcinoma of the endometrium (n=14), and one rare lesion: uterine PNET (Peripheral primitive neuroectodermal tumor). All the patients had been referred for uterine examination because of pain, pelvic mass or abnormal uterus bleeding. Transvaginal sonography (TVS) is the procedure of choice, in these symptomatic patients, for differentiate myometrium or endometrium abnormalities.
n MYOMETRIUM PATHOLOGY n UTERINE MYOMAS are the most common solid uterine neoplasm: 20-40% of all women during their reproductive years. They are estrogen dependent and regress after menopause. According their location, myomas are classified as submucous (1), mural (2) or subserosal (3). An intramural location of well-circumscribed benign lesion is the most common. The variability of echogenicity depends on relative ratio of components: smooth muscle with various amounts of fibrous connective tissue. Circumferential calcification of the lesion may occur. The most common sonographic appearance is of a hypoechoic or heterogeneous uterine mass. They are usually multiple. Some subserosal or pedunculated myomas may be missed because of a limited field of view with transvaginal sonography alone. It should be used in conjunction with transabdominal sonography. TVS appearance of submucous myoma
DIFFERENTIAL DIAGNOSIS: With increasing size of the mass, the organ of origin of a pelvic mass may become unclear. Sonographic appearance may strongly change in case of degenerative myomas. There are no reliable sonographic criteria that allow differentiation between degenerative myoma, sarcomas, or rare neoplasm. MR Imaging provides localization and may be helpful for differential diagnosis. MR Imaging of myomas shows well-circumscribed lesion with a medium-intensity signal on T1-weighted (T1-w.) images, homogeneous low-intensity signal on T2-weighted (T2-w.) images, and homogeneous contrast enhancement following myometrium enhancement. è BIG SIZE MYOMAS: How to prove the myometrium origin? Most often MR Imaging with multiple plan study and contrast image make diagnosis.
? 51-year-old woman with abdominal mass. Homogeneous low signal intensity well limited mass with homogeneous enhancement for a large part of the lesion from myometrium origin. ? a - T1-w. axial image.
? b - Enhanced T1-w. sagittal image.
è DEGENERATIVE MYOMAS: Degenerative changes correspond to: hyaline degeneration (60%)', edema (50%)ƒ, hemorrhage (10%),cystic degeneration (4%), calcification (4%).
' 50-year-old woman. T2-w. coronal image shows. One large mural myoma: mixed signal intensity due to hyaline degeneration. Two low signal intensity masses in subserous location. One submucous myoma impinges on endometrial signal.
ƒ 25-year-old woman. Axial images. ƒ a - Mixed signal on T2-w.image.
ƒ b - Homogeneous signal on T1-w.
ƒ c - Homogeneous enhancement after contrast administration.
UTERINE SARCOMAS are rare (less than 3% of uterine malignancies). It is a post menopause pathology. There are 3 main groups: carcino-sarcomas (50%), leiomyosarcomas (35%) and endometrial stromal sarcomas (15%). The treatment is based on surgery and radiotherapy. Chemotherapy is used in case of high histological grade. An overall actuarial median survival of 30% is found in major series. Nearly 70% of patients relapsed with local recurrence, intraabdominal disease and chest metastases. MR imaging is the main modality after nonconclusive sonography. Differential diagnosis with degenerative myomas must be approached based on menopause status, extension of the lesion and contrast enhancement. Compare ƒ with " , and . with + .
" 61-year-old woman with carcinosarcoma. " a - The gross specimen shows quite well circumscribed lesion involving all myometrium .
" b - T1-w. image to large mass with low signal intensity. On T2-w. image (not shown) the signal of lesion was mixed.
" c - The enhancement on third slide is heterogeneous with central zone of necrosis (no enhancement corresponding to high signal intensity on T2-w. image and Grey matter on gross specimen). Such Heterogeneous enhancement due to necrosis must referred diagnosis to uterine sarcomas.
. 49-year-old woman. . a - Homogeneous lesion on T1w.image.
. b - Dynamic contrast sequences: The signal of the lesion follows myometrium signal. The endometrium is clearly distinguishable from the lesion: myoma . b1 - 30 sec
. b2 - 3 mn.
+ 64-year-old woman menopaused for 16 years: leiomyosarcoma. + a - Heterogeneous lesion on T2-w. image.
+ b - Homogeneous lesion on T1-w.image.
+ c - Heterogeneous enhancement 3mn after contrast administration.
+ d - Gross specimen: G10
n ENDOMETRIUM PATHOLOGY n TVS is highly sensitive for detecting endometrial thickening. Such thickening is nonspecific. It can be due to hyperplasia, polyps, submucosal myomas or carcinoma. TV hysterosonography (TVHS) may assist in the workup of these endometrial process. UTERINE POLYPS
? 47-year-old-woman. Abnormal bleeding. Examination at 7th day of cycle. ? a - TVS shows endometrium thickening: 12mm.
? b - TVHS shows a well-circumscribed hyperechoic mass that does not interrupt the endometrial lining: benign pedunculated endometrial polyps
ENDOMETRIAL CARCINOMA is the 4th most frequent cancer in women. 75% occur in post menopause women with particular risk factors: excessive estrogen produce, obesity, Tamoxifen. Surgery is the primary treatment. Postoperative radiotherapy depends on recurrence risk. The superiority of staging with MR Imaging to clinical and CT scan is an established fact.
' 57-year-old woman. Postmenopausal bleeding. ' a - TVS shows endometrium thickening: 21mm.
' b - The midsagittal TVHS shows an irregular, and heterogeneous mass: a carcinoma could not be excluded.
' c - Sagittal T2-w. image shows a large medium signal intensity in the endometrium cavity.
' d - Dynamic contrast sequences (30'' and 3') show enhancement of junctional zone and myometrium without enhancement of endometrium: stage Ia. Limited to endometrium
' e - Gross specimen.
' f - G2.5: Microscopic examination revealed a stage Ib. (Invasion of less than half of myometrium width)
ƒ 70-year-old woman. Postmenopausal bleeding. ƒ a - TVS shows endometrium thickening.
ƒ b - TVHS shows irregular lesion.
ƒ c - Sagittal T2-w. image shows subnormal endometrium and ƒ d - Gadolinium-enhanced T1-w. image shows the lack of large low signal intensity of junctional zone. enhancement of lesion: stage Ic.
ƒ e - Gross specimen (inferior and posterior part of lesion).
ƒ f - Microscopic examination revealed a stage Ic. (Invasion of more than half of myometrium width)
In our fourteen cases, there were no pathological findings in one stage Ia, a Gadolinium enhancement of the lesion in one stage Ic. For all others cases (two Ia, four Ib, three Ic, two IIa and one IIb) the MRI patterns were the same: mixed signal intensity on T2-w., no difference between endometrium, lesion or myometrium on T1-w.image, and no contrast enhancement.
" 59-year-old woman. Stage Ia. " a - T2-weighted image.
" b - Gadolinium-enhanced T1-weighted image
. 68-year-old woman. Stage Ic. . a - T2-weighted image.
. b - Gadolinium-enhanced T1-weighted image
+ 49-year-old woman. Stage IIb. (Cervical stromal invasion) + a - T2-weighted image.
+ b - Gadolinium-enhanced T1-weighted image
TAMOXIFEN AND ENDOMETRIAL PATHOLOGY. Tamoxifen is clearly an inhibitor of breast cancer growth. It has been reported the association between tamoxifen treatment and hyperplasia, polyps and endometrial cancer. In our institution, we follow the recommendations of the American College of Obstetricians and Gynecologists published in February 1996. All our patients presented abnormal bleeding. There is not screening procedure.
+ 61-year-old woman. Tamoxifen 20mg since 2 years. + a - HSG shows enlarged cavity with irregular defects mimicking malignant lesions.
+ b - TVS shows endometrium thickening: 40mm.
TVHS and Hysteroscopy were not possible: no cavity distention obtained. + c - Axial T2-w. and
+ d - Axial Gadolinium-enhanced T1-w. show large and multicystic cavity.
+ e - Gross specimen
+ f - Microscopic view (G5) show glandulocystic aspect of endometrium with endometrial atrophy.
^ 72-year-old woman. Tamoxifen 20mg since 18 months. Similar lesions than case + affected the endometrium. ^ a - Axial T2-w.
^ b - Sagittal Gadolinium enhanced T1-w.
No surgery were done, the patient is monitored with TVHS since 2 years. Nine of our ten patients had glandulocystic endometrial atrophy with same pattern than patients + and ^ . One was different: %
% 67-year-old woman. Tamoxifen 20mg since 3 years. % a - TVHS shows polyps with cystic formation.
% b - Sagittal T2-w.
% c - Axial Gadolinium enhanced T1-w. show the polyps (cross): Well-differentiated endometrial carcinoma.
RARE UTERINE NEOPLASME UTERINE PNET: Peripheral primitive neuroectodermal tumor are a group of unusual malignancies arising in the bone and soft tissue, representing only 4% of all tissue neoplasm. They probably develop from embryonal migrating cells of the neural crest. Neuroectodermal differentiation is a very unusual finding in uterine tumors. Only ten cases of pure uterine neuroectodermal tumors have been reported. A 36-year-old woman presented with an enlarged uterus, which appeared in 2 months. She had been treated eight years previously by chemotherapy for a non-Hodgkin lymphoma (grade IV). MR Imaging with axial T1-w., post-contrast, and sagittal T2-w. show a well-circumscribed lesion in the anterior wall of the myometrium with low signal intensity on T1 images, high signal on T2 images separated by irregular septas. The signal of the septas was enhanced by contrast. Gross specimen shows a necrotic white tumor measuring 11cm totally embedded in the anterior wall of the myometrium. Microscopic examination revealed a dense proliferation of solid sheets with round or spindle cells in the myometrium. On frozen tissue, the translocation t(11;22) (q24;q12) was detected. axial T1-w
post-contrast
Gross specimen
sagittal T2-w.
Microscopic examination
REFERENCES: * Imaging of uterine leiomyomas. S.Karasick, A.S.Lev-Toaff, M.E.Toaff. AJR 1992; 158:799-805. * Survival, patterns of spread and prognosis factors in uterine sarcoma: a study of 76 patients. E.Moskovic, E.Macsweeney, M.Law, A.Price. BJR 1993; 66:1009-1015. * Trans-vaginal hysterosonography: Comparison with biopsy in the evaluation of postmenopausal bleeding. T.J.Dubinski, H.R.Parvey, G.Gormaz, M.Curtis, N.Maklad. J Ultrasound Med 1995;14:887-893. * Endometrial carcinoma. P.G.Rose. N Engl J Med 1996;335:640-649. *Carcinoma of the uterus: use of gadopentate dimeglumine in MR imaging. H.Hricak, B.Hamm, R.C.Semelka et al. Radiology 1991;181:95-106.
* MR imaging appearance of the uterus in postmenopausal women receiving Tamoxifen therapy for breast cancer: histopathalogic correlation. S.M.Ascher, J.C.Johnson, W.A.Barnes, C.J.Bae, R.H.Patt, R.K.Zeman. Radiology 1996;200:105-110. * A realistic clinical perspective of tamoxifen and endometrial carcinogenesis. V.J.Assikis, P.Neven, V.C.Jordan, I.Vergote. Eur J Cancer 1996;32:1464-1476. * Primitive neuroectodermal tumor of the uterus. S.Taïeb, V.Cabaret, F.Bonodeau, E.Leblanc, P.Besson. JCAT 1999 in press. This is Page 1 of 1 VALUE OF IMAGING IN DIFFERENTIAL DIAGNOSIS OF PATHOLOGIC FINDINGS IN THE UTERUS: S Taïeb — Published November 28, 1999 E-mail the author Tell a Colleague about this Article Join JRAD Mailing List | Search our archives ©2000 Journal of Radiology, LLC
[email protected]
http://207.51.84.224/page_display.asp?article_id={3A682B1D-92C0-11D3-86B8-00902745F158} [6/7/2000 11:23:13 AM]
