Radiological imaging of uterine lesions.

Dr/ ABD ALLAH NAZEER. MD.

Congenital Uterine Anomalies.

The true incidence of congenital uterine anomalies in the general population and among women with RPL is not known accurately. Although incidences of 0.16 to 10% have been reported, the overall data suggest an incidence of 1% in the general population and 3% in women with RPL and poor reproductive outcomes. In a comparative study of women with and without a history of RPL using three-dimensional ultrasound, Salim et al found major congenial anomalies in 6.9% of women with RPL compared with 1.7% in low-risk women. Overall, the prevalence of major congenital anomalies appears to be three-fold higher in women with RPL compared with women without a history of recurrent miscarriage.

Class I: Müllerian agenesis or hypoplasiaClass II: Unicornuate uterusClass III: Didelphys uterusClass IV: Bicornuate uterusClass V: Septate uterusClass VI: Arcuate uterusClass VII: Diethylstilbestrol (DES)-exposed uterus

Bicornate Uterus.

Unicornuate Uterus.

Uterus Didelphys.

DES-related uterine anomaly. Hysterosalpingogram demonstrates a hypoplastic T-shaped uterus. The patient had been exposed to DES while in utero.

Arcuate uterus. Three-dimensional coronal US image (26) and coronal oblique T2-weighted MR image (27), obtained in different patients, show a smooth, broad-based, shallow endometrial impression (arrow) with a normal external contour of the uterine fundus (arrowhead).

PELVIC INFLAMMATORY DISEASE (PID) DEFINITION Pelvic inflammatory disease is an infection of the female upper genital tract that involves any combination of the uterus, endometrium, ovaries, fallopian tubes, pelvic peritoneum and adjacent tissues. PID consists of ascending infection from the lower to upper genital tract.

PREDISPOSING RISK FACTORS • Sexual contact in which exchange of body fluid may occur • History of STI • Multiple sexual partners • Upper female genital tract instrumentation: o dilatation & curettage (D&C) . Recent intrauterine device (IUD) insertion . Therapeutic abortion (T/A).

PID is a common medical problem, affecting nearly 1 million women each year distributed worldwide.

Etiology:PID usually results from ascending infection by Neisseria gonorrhoeae or Chlamydia trachomatis, although 30% of cases are polymicrobial. In addition, aerobic and anaerobic, gram positive and negative organism, normal vaginal flora, viruses, tuberculosis, mycoplasma, and other atypical organism have been implicated as causative agents Dissemination routes: PID may disseminate to neighboring organs or even affect abdominal organs across three primary routes:1. - Extension to parametrials structures2. - Direct ascent of microorganisms to upper genital tract: Pyosalpinx, salpingitis, endometritis3. - Primary vaginal or cervical infection: endocervical inflammation.4. - Less frequent: Direct spread from a nearby infection such as appendicitis or diverticulitis. Hematogenous, peritoneal or lymphatic spread: Salpingitis secondary to tuberculosis.

Transvaginal ultrasound. a and b) Mild enlargement of the uterus with an irregular contour and presence of fluid accumulation within the cervical canal and inside the endometrial cavity. c) Enlarged ovaries with increased numbers of cyst. d) Fluid in cul de-sac

Contrast-enhanced CT scan obtained in venous phase. a) Endometritis andoophoritis. Fluid accumulation inside the endometrial cavity, enlarged ovaries with increased number od cyst (arrowheads) and abnormal enhancement. b) Initial salpingitis, CT image shows not dilated fallopian tubes with wall thickening (> 5 mm), enhancement and underlying inflammation (white arrow)

Contrast-enhanced CT scan obtained in venous phase. a and b) Mild pelvicedema: thickening of the uterosacral ligaments and haziness of the pelvic fat with obscuration of the pelvic fascial planes (white arrows).

Advanced stages of salpingitis. a and b) Transvaginal US shows Elongated and dilated fallopian tube with echogenic contents ("string sign")c and d) Contrast-enhanced CT scan shows dilated fallopian tube with wall thickening and enhancement.

Transvaginal US in patient with follicular rupture shows large amount of fluid with debris posterior to the uterus. b) Power Doppler US in patient with ovarian torsion shows enlarged ovary with peripheral cysts on sonogram with complete absence of blood flow in the ovary and c) Contrast-enhanced CT scan in the same patient revealed the enlarged ovary in the midline of the pelvis with no central enhancement. d and e) Transvaginal US and Pelvic MR revealed complex and loculated cystic masses in adenxial region and the MR images confirm the diagnosis of Tarlov Cyst.

Complications of PID. Tubo-ovarian abscess. a) Transvaginal ultrasoundrevealed a heterogeneous cystic mass in adnexal region. b) Axial contrast-enhanced CT scan revealed solid-cystic mass with thicked and hyperenhanced wall and septum. c) Axial contrast-enhanced CT scan in patient with tubo-ovarian abscess shows cystic tubular structure with enhanced wall.

MR findings in TOA. Tubaric morphologic changes (Beak sign) representing tubal and peritubal adhesions with fimbrial obstruction.

Reliable signs of hydrosalpinx. a) Transvaginal US. Axial image shows cyst tubular structure with C shaped. b) Pelvic MR. Axial T2-weighted image shows incomplete septations secondary to distension and tubaric folding (waist sign). c) Transvaginal US. Axial image shows round projections and thicked longitudinal folds (cogwheel appearance).

Advanced stages of salpingitis. a and b) Transvaginal ultrasound in woman patientwith hydro-pyosalpinx: axial and longitudinal images shows cystic mass containing mixedechogenicity areas. c) Pelvic MR. Axial fat-suppressed T1-weighted MR image, revealeda cystic tubular structure (white arrows) with variable signal intensity depending of theprotein content of the fluid. d) Pelvic MR. Axial gadolinium-enhanced fat-suppressedT1-weighted MR image. Enhancement of the thickened fallopian tube wall and pelvicstranding. e and f) Pelvic MR. Coronal T2-weighted image shows cystic tubular structurewith high signal intensity which is lower than a pure cyst (white arrows).

Tubo-ovarian abscess with gas. Enhanced computed tomography shows bilateral, gas-containing, tubo-ovarian abscesses (arrows).

Uterine Leiomyomas:Leiomyomas, or fibroids, are the most common benign tumors of the uterus. The incidence of fibroids is difficult to estimate and frequencies reported in the literature range between 25% and 50%. In autopsy studies, leiomyomas of the uterus have been found in up to 77% of women. Only about one third of affected women have fibroids that become clinically apparent before menopause. Fibroids may cause abnormal menstrual bleeding (menorrhagia with secondary anemia, dysmenorrhea) or pelvic pressure due to their mass effect (urinary frequency, constipation, pelvic pain, dyspareunia). Finally, leiomyomas of the uterus are also implicated in female infertility and are the most common indication for hysterectomy in western industrialized countries.

Transvaginal ultrasound (TVUS) of uterine leiomyoma. TVUS demonstrates a well defined subserosal leiomyoma (arrow) distorting the outer contour of the uterine wall. The leiomyoma shows a heterogeneous echotexture and is hypoechoic compared to the adjacent myometrium and endometrium. The endometrium is seen as a hyperechoic stripe.

Transvaginal ultrasound of leiomyoma. Transvaginal color-coded duplex ultrasound demonstrates the perifibroid plexus vessels surrounding the leiomyoma.

MRI of leiomyoma , locations. Trans-axial T2-weighted image depicts multiple, mainly subserosal uterine leiomyoma. There is mild distortion of the uterine cavity by a transmural (full thickness) leiomyoma (arrow).

CT of uterine leiomyoma. Contrast-enhanced CT of the pelvis in a 39-year-old women with a known uterine leiomyoma shows a large oval mass within the uterus with heterogeneous enhancement (asterisk) which displaces the hypodense right ovary (arrow) and distends the abdomen.

Acute torsion of a uterine leiomyoma.

Correlation of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in a patient with leiomyoma and adenomyosis of the uterus. a TVUS of a 48-year-old women with menorrhagia and dysmenorrhea. Two leiomyoma were reported to be present, one in a subserosal location (black arrow) of the posterior wall and a second intramurally in the anterior uterine wall (white arrow).

Mass effect of uterine leiomyoma. a T2-weighted sagittal image shows a multifibroid uterus with a large submucosal leiomyoma that exerts mass effect on the underlying endometrium (arrow). b T2-weighted a axial image at corresponding level.

Bridging vascular sign in a pedunculated leiomyoma. T1-weighted contrast-enhanced fat-suppressed sagittal image depicts a large pedunculated subserosal leiomyoma originating from the uterine fundus. Flow-voids are seen within the vessel stalk (arrow). A second intramural leiomyoma in the anterior wall is seen displacing the endometrial stripe.

MRI of cellular leiomyoma. a T2-weighted sagittal image of the uterus demonstrating a large intramural cellular leiomyoma with homogenous high signal intensity compared to surrounding myometrium. Two small intramural leiomyoma show the typical low intensity signal (arrows). b T1-weighted contrast-enhanced fat-suppressed sagittal image showing marked enhancement of the intramural cellular leiomyoma which appears hyperintense compared to surrounding myometrium

Signal intensity characteristics of leiomyoma. a T2-weighted transaxial image of theuterus (secretary phase of menstrual cycle) showing a subserosal leiomyoma with typical low signal intensity compared to adjacent myometrium. Note the bright signal of the endometrium and intermediate signal intensity of the junctional zone. b Corresponding T1-weighted transaxial image of the uterus showing intermediate signal intensity of the leiomyoma which can hardly be differentiated from the adjacent myometrium.

MRI of myxoid leiomyoma.

MRI of spontaneouslyinfarcted leiomyoma

MRI of rim calcification of a leiomyoma. T1-weighted fat-suppressed transaxial image showing a leiomyoma with a discontinuous, markedly hypointense rim corresponding to asymmetrical calcification.

Adenomyosis of the Uterus.Adenomyosis (endometriosis genitalis interna) of the uterus affects premenopausal women and is predominantly seen in multiparous women and women over 30 years of age. Because its symptoms are unspecific, adenomyosis rarely comes to clinical attention, which is why the incidence of this uterine condition is underestimated. Until recently, the diagnosis was established almost exclusively after hysterectomy. Histologic examination of hysterectomy specimens demonstrates adenomyosis in 19%–63% of cases. Adenomyosis often occurs in conjunction with fibroids and endometriosis (endometriosis genitalis externa et extragenitalis.

Adenomyosis is a common gynecologic condition, non-neoplastic, that causes substantial morbidity and that affects women of reproductive age.• The clinical symptoms of adenomyosis include: pelvic pain, uterine enlargement, dysmenorrhea, menorrhagia, or may be asymptomatic.• Diseases with symptoms similar to adenomyosis: dysfunctional uterine bleeding, endometriosis and leiomyomas.• Adenomyosis is rarely diagnosed before hysterectomy and commonly coexists with uterine leiomyomas.• Women undergoing hysterectomy with both adenomyosis and leiomyomas have a number of different clinical features compared with women with only leiomyomas at the time of hysterectomy.• Women with substantial pain despite a smaller fibroid burden may be more likely to have concomitant adenomyosis.

MRI of diffuse adenomyosis of the uterus. a T2-weighted transaxial image of a patient with diffuse adenomyosis of the uterus. The uterine wall is thickened, there is poor definition of the endomyometrial junction and the junctional zones blend with the myometrium. No focal mass is present. Cyst-like inclusions of hyperintense signal intensity are present (arrow). b Corresponding fat-suppressed T1-weighted transaxial image showing hyperintense spots within the myometrium indicating fresh blood related to the dislocated endometrial glands (arrows)

MRI of focal adenomyosis of the uterus. T2-weighted sagittal image of the uterus. The posterior wall of the uterus is thickened and a focally broadened junctional zone with hyperintense foci appearing as a globular lesion is seen (arrow). The uterus is enlarged but no mass effect is seen

MRI of diffuse adenomyosis of the uterus. T2-weighted sagittal image of the uterus. A broadened junctional zone (> 12 mm) is seen with poor definition of the endomyometrial junction. The junctional zone blends with the myometrium

Women 26 years. Bicornuate uterus with adenomyosis with focal nodular.T2- weighted MRI in coronal and axial.

Multiple foci of hyperintensity on T2. Observe the correlation withhistopathology, which identify multiple dilated glands around the myometrium.

Endometriosis. Endometriosis is an inflammatory, estrogen-dependent disease that often results in substantial morbidity, pelvic pain, multiple surgeries, and infertility. Characterized by the existence of endometrial glands and stroma outside the uterine cavity, the disease represents a significant clinical challenge, commonly associated with significant morbidity and reduction in quality of life among reproductive-age females. Early symptoms may be underappreciated by caregivers, healthcare consumers, and clinicians alike, and timely diagnosis combined with effective management cannot be undervalued. The lack of reliable noninvasive detection methods may likely contribute to lengthy delays in diagnosis. Practitioners from all disciplines, particularly obstetricians and gynecologists, must understand not only the medical aspects of this disease but the tremendous psychosocial and cost burdens as well.

Symptomology: Symptoms vary considerably, often mimicking those of other conditions including pelvic inflammatory disease, adenomyosis, fibroids, and ovarian cancer.

The degree or stage at which endometriosis is present has no correlation with pain or symptomatic impairment. Symptoms are variable but typically reflect area of involvement and may include: • Dysmenorrhea • Heavy or irregular bleeding • Pelvic pain • Lower abdominal or back pain • Dyspareunia • Dyschezia, often with cycles of diarrhea/ constipation.

Endometrioma. Sagittal transvaginal US image obtained in a woman with a history of endometriosis shows an ovarian mass with multiple fine internal echoes (arrows) and several hyperechoic mural foci (arrowheads).

Endometriosis. Unenhanced axial T1- weighted fat-suppressed MR image shows dilatation of the right fallopian tube (arrow) with internal high signal intensity due to blood products, findings indicative of hematosalpinx. Smaller high-signal-intensity foci along the posterior uterine serosa (arrowhead) are indicative of endometrial implants.

Endometrial polyp.An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

Cause and symptoms:No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen. They often cause no symptoms. Where they occur, symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual bleeding (menorrhagia), and vaginal bleeding after menopause. Bleeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood "spotting" between menstrual periods, or after menopause. If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea) may result.

Endometrial polyps.

Endometrial polyps.

Endometrial polyps.

Polyp arising within the endometrium and filling most of the uterine cavity. On the US, it is well-defined, slightly echogenic relative to the surrounding the myometrium. On the MR, the differences in tissue contrast are clearer.

Endometrium hyperplasia.

Endometrial Carcinoma. Endometrial cancer (also referred to as corpus uterine cancer or corpus cancer) is the most frequently occurring female genital cancer; this condition was the fourth most common cancer among US women in 2012. In developed countries, adenocarcinoma of the endometrium is the most common gynecologic cancer.Signs and symptoms:Approximately 75% of women with endometrial cancer are postmenopausal. Thus, the most common symptom is postmenopausal bleeding.For the 25% of endometrial cancers in patients who are perimenopausal or premenopausal, the symptoms suggestive of cancer may be more subtle. The normal menstrual bleeding pattern during this period should become lighter and lighter and further and further apart. Heavy, frequent menstrual periods or intermenstrual bleeding must be evaluated.

Endometrial cancer histological typesThe most common type is endometrioid adenocarcinoma, which is composed of malignant glandular epithelial elements. Clear-cell and papillary serous carcinoma of the endometrium are tumours that are histologically similar to those noted in the ovary and the Fallopian tube, and the prognosis is worse relative to adenocarcinomas. Endometrioid (75%) (secretory, ciliated, papillary or villoglandular)Adenocarcinoma with squamous differentiation.Adenoacanthoma (benign squamous component)Adenosquamous (malignant squamous component).Uterine papillary serous (5%–10%)Clear cell (1%–5%).Malignant mixed Mullerian tumours or carcinosarcomas (1–2%).Uterine sarcomas (leiomyosarcoma, endometrial stromal sarcoma, undifferentiated) (3%).Mucinous (1%).Undifferentiated.

Sagittal dynamic acquisition after gadolinium chelates injection shows heterogeneous enhancement with foci of avid enhancement on early acquisition (F). Delayed phase images (G) show diffuse myometrial enhancement, greater than that of the tumor.

Endometrial mass exhibits a heterogeneous pattern on sagittal T2 weighted images (A), with areas of avid enhancement (B) high signal intensity on diffusion weighted images and restriction on ADC map (C, D).

A 36 year-old woman presented with persistent vaginal bleeding. MR imaging shows on T2 weighted images on coronal (A) and sagittal (B) images a large and heterogeneous high intense endometrial mass, invading the outer half of the myometrium (white arrows).

63-year old woman previously treated for breast cancer, presenting for post-menopausal bleeding. Sagittal (A) and axial (B) T2-weighted images show a slightly hyperintense, large bulky mass enlarging the uterine cavity with a broad-based to the anterior uterine inner wall. Tumor exhibits high signal intensity on diffusion weighted images and restriction on ADC map (C, D)

62 year-old woman. Vaginal bleeding. Pelvic ultrasound showed an enlarged uterus. Speculum examination showed a mass protruding through a distended endocervical canal. Endometrial sampling showed an endometrial carcinosarcoma with a heterologous chondrosarcoma sarcomatous component. Myometrial invasion was inferior to 50%, no cervical stroma invasion was seen.

Endometrial carcinosarcoma in a 73 year-old woman. Sagittal (A) and axial (B), T2-weighted images show a large bulky mass distending the endometrial cavity, with a high T2 signal intensity and a heterogeneous pattern. Resection specimen (C) and H&E stain (D, E) show a tumoral proliferation containing both malignant epithelial and spindle cell components. Myometrial infiltration was superficial

62 year-old woman. Vaginal bleeding. Pelvic ultrasound showed an enlarged uterus. Speculum examination showed a mass protruding through a distended endocervical canal. Endometrial sampling showed an endometrial carcinosarcoma with a heterologous chondrosarcoma sarcomatous component. Myometrial invasion was inferior to 50%, no cervical stroma invasion was seen.

79 year-old woman previously treated for breast cancer, with vaginal bleeding. Speculum examination showed a mass protruding through the external os into the vagina. Sagittal T1 weighted and Sagittal T2 weighted images show a large carcinosarcoma (asterisk) invading the deep myometrium and the cervical stroma (white arrow), protruding into the vaginal lumen. Histological analysis shows a carcinosarcoma with a predominant clear cell sarcomatous component, invading the full thickness of the myometrium. Tumor extended to the uterine cornua and parametria. Histological analysis showed a large carcinosarcoma infiltrating the uterine corpus and the cervix. Tumor infiltrates the entire myometrium up to the serosa and the parametria. Lymphovascular extension was seen in adnexae.

Choriocarcinoma in uterus with lung metastasis.

Choriocarcinoma in uterus with lung metastasis.

Uterine lymphoma.Uterine lymphoma refers to involvement of the uterus with lymphoma.

It is rare condition with initial uterine involvement occurring in only 1% of patients with lymphoma . However, uterine involvement is more common as part of a generalized process, as shown in 40 - 50% of these patients at autopsy.

Pelvic MRIReported characteristic MR imaging findings include diffuse enlargement of the uterus may be presenthomogeneous intermediate signal intensity of an indistinct mass on T1- and T2-weighted images.T1 : involved regions slightly hypo-intense to rest of uterus.T2 : involved regions slightly hyper-intense to rest of uterus.

Primary lymphoma in a 62-year-old woman.

Primary diffuse large cell lymphoma of the uterus, in a 71 year old female (a) Axial unenhanced CT shows a mass (yellow arrow) in the uterine fundus with well defined borders. (b) Sagittal and (c) axial T2 weighted MRI shows a heterogeneous mass (yellow arrow), comparing to the muscle, in the uterine fundus, that shows well-defined contours and has in the interior areas with more signal intensity (orange arrow). (d) In Axial T1 weighted MRI, the mass is isointense to the muscle. (e) Axial T1 weighted image with gadolinium enhancing shows hypervascularity of the lesion.

Primary malignant Lymphoma of the uterine body.

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