MRI of the Uterus

BENIGN
BENIGN

Jeffrey C. Weinreb, M.D. FACR

jeffrey.weinreb@yale.edu
Yale University School of Medicine

Normal Anatomy
MM
Junctional
JZ
Zone
EE

Junctional Zone is the inner layer or the myometrium

Routine GYN Protocol

Prep
Void prior to exam
IV line
NPO x 4 hrs
Glucagon

Routine GYN Protocol

Sag T2W FSE
Respiratory trigger and/or anterior sat bands

Short axis T2W (uterus or cervix)

Cor or Axial T2W
Axial T1W IP/OP
Axial Fat Sat T1W
Post-C Fat Sat T1W with Subtractions
Delayed Sag T2W FSE

Normal Uterus/Cervix

Uterine Leiomyoma
Most common uterine neoplasm
Occur in women of reproductive age and are
under hormonal influence
Enlarge during pregnancy or BCP use
Regress after menopause

Symptoms

Dysmenorrhea
Menorrhagia
Infertility
Pressure sensation

MRI of Uterine Leiomyoma

Low signal on T2WIs

Round
Mass effec
Well defined margins
often with
pseudocapsule
Lacy or confluent
hyperintensity

Uterine Leiomyoma
As they grow, they may outgrow their blood
supply, resulting in various types of
degeneration
Hyaline (homogeneous eosinophilic proteinaceous material)
Myxoid (hyaluronic acid-rich mucopolysccharide gelitenous
material)

Cystic
Hemorrhagic (red or carneous, occurs in pregnancy or with
BCPs)

Calcific

Uterine Leiomyosarcoma
Sarcomatous transformation of preexisting
leiomyoma is rare
Diagnosis usually made as an incidental
pathologic diagnosis in 0.5% or resected
fibroids

Most arise independently from myometrial

smooth muscle cells

Uterine Leiomyoma
Edema is common
Scattered or diffuse
Frequently prominent at periphery
With extensive edema, get marked
enhancement due to retention of contrast
material within the abundant interstitial spaces
Okizuka H, et al. J comput Assist Tomogr 1993;17:760-766

Suspect Leiomyosarcoma

Lyphadenopathy, ascites, or peritoneal seeding are unusual

Rapid growth of leiomoyoma is not useful
<3% of sarcomas have rapidly growing uterus
<1% of rapidly growing leiomyomas contain leiomyosarcomas

Hemorrhage is not useful

Hemorrhage is not uncommon in fibroids but unusual in

leiomyosarcomas

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

Not uncommon in fibroids

High signal on T2WIs and intense enhancement is not useful

Seen with cellular leiomyomas (composed of compact smooth muscle

cells with little or no collagen)

Irregular or indistinct margin is suggestive

Uterine Leiomyoma
Differential Diagnosis
Uterine sarcoma

Leiomyosarcoma
Mixed mullerian tumor
Endometrial stromal sarcome

Adenomyosis
Solid ovarian masses (fibroma, fibrothecoma, Brenner tumor)
Myometrial contractions
Endometrial cancer
Endometrial polyp
Gestational Trophoblastic Disease
Retained products of conception

Ovarian Fibromas/Fibrothecomas

Gonadal stromal cell origin

Most common solid primary ovarian tumor
Benign
Fibromas consist of intersecting bundles of
spindle cells that produce large amount of
collagen
Fibrothecomas also contain theca cells
Cystic degeneration and edema
On MRI resemble fibroids
Diff Dx includes intraligamentous leiomyoma,
endometrioma, ovarian fibromatosis, and
Brenner tumor

Bridging Vascular Sign

Vessels that extend from the uterus to supply a pelvic
mass indicate the uterine origin of a juxtauterine mass
Caused by feeding vessels that arise from the uterine
arteries
In one study, it was present in in 20/26 exophytic
leiomyomas and absent in all other adnexal masses,
resulting in a diagnostic accuracy of 80%
Kim JC, et al. J Comput Assist Tomogr 2000;24:57060

But, ovarian malignancies that invade the uterus may

also show this sign
Kim SH, et al. J Comput Assist Tomogr 2001;25:36-42

Exophytic fibroid or fibroma?

Fibroid

A mass may originate from the periphery of the ovary,

so the identification of an apparently normal adjacent ovary
does not exclude an ovarian origin

Ovarian Vascular Pedicle Sign

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

Also seen in 13% of subserosal uterine myomas

The ovarian veins form a plexus in the broad ligament
that communicates with the uterine plexus
Lee JH, et al. AJR 2003;181:1312003;181:131-137

Adenomyosis
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 Adenomyosis
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

Adenomyosis
> 12 mm = adenomyosis
8 - 11 mm = c/w adenomyosis if clinical findings
< 7 mm = nornal

Pitfalls
Junctional zone may widen (focally or
diffusely) on days 1-2 of menstrual cycle
Junctional zone may widen with
dysmenorrhea
Uterine contractions
Focal
Striated

Summary
Leiomyoma
Round

Mass effect

Well defined margins

often with
pseudocapsule
Lacy or confluent
hyperintensity

Adenomyoma
Oval with long axis
paralleling uterus
Relatively little mass
effect
Indistinct margins

Punctate
hyperintense foci

Leiomyoma coexist in 35-55% of cases if adenomyosis

Adenomyosis and Endometriosis

Most of the major authors of the first half of the
past century dealing with the disease considered
pelvic endometriosis and uterine adenomyosis as
variants of the same disease process
Adenomyosis used to be know as endometriosis
interna or inside-out endometriosis
They are now thought to be different diseases, but
there is a high association between endometriosis
and adenomyosis, and vice versa
Leyendecker G (2000) Endometriosis is an entity with extreme pleiomorphism.
47
pleiomorphism. Hum Reprod 15, 4