MR Imaging in Corpus Neoplasia: Spectrum of MR Findings

MR imaging is a noninvasive and a useful modality for depicting a wide variety of uterine tumors with excellent tissue contrast. In case malignant uterine neoplasms are suspected, contrast-enhanced image is useful to delineate the tumor extent and internal architecture of the tumor. In cases of endometrial carcinomas, dynamic enhanced imaging is utilized for evaluating the depth of myometrial invasion. In differentiating malignant uterine tumors from benign conditions, in addition to filtration into the surrounding tissues, the presence of necrosis that is usually better demonstrated on postcontrast images is important imaging finding. Diffusion-weighted imaging is an emerging technique that depicts tissue contrast based on restricted diffusion of water molecules and demonstrates increased intensity in the malignant tumors. The recognition of typical MR imaging features in a wide variety of endometrial tumors may facilitate differentiation, thus better determining appropriate patient management.     

子宫肌腺症的临床病理特点及手术指征的探讨

目的:探讨子宫肌腺症的临床病理特点及手术指征。方法:2004年1月至12月手术治疗且病理证实为子宫肌腺症340例,其中全子宫切除284例,保守手术(子宫肌腺症病灶切除术)56例,回顾分析其临床病理特点并探讨手术方式及指征。结果:340例子宫肌腺症中合并子宫内膜异位囊肿95例(27.94%),合并子宫肌瘤148例(43·5%),合并贫血95例(27.9%),合并子宫内膜息肉20例(5.9%)。痛经组与无痛经组患者合并不孕症差异无统计学意义(P>0.05),两组合并内膜息肉有显著的统计学差异(P<0.01),痛经者合并内膜息肉是非痛经组的5倍,95%CI为0.079~0.509。两组合并子宫内膜异位囊肿有显著的统计学差异(P<0.01)。痛经患者合并卵巢子宫内膜异位症的风险是无痛经患者的3.369倍,95%CI为1.699~6.681。多因素Logistic回归分析表明,绝经前、月经量多和子宫大的患者易并发卵巢子宫内膜异位囊肿;年轻、分娩次数多和痛经重的患者易并发子宫内膜息肉;绝经前年轻女性和子宫体积大的患者易并发子宫肌瘤。分析不同手术途径表明:腹腔镜组年龄偏低,贫血、不孕比例明显增高。结论:对年轻合并性交痛、肛门坠痛等症状,伴有贫血或不孕患者首选腹腔镜检查/手术;子宫较大、B超提示合并肌瘤或既往有剖宫产史,估计盆腔粘连重者选择开腹手术;合并子宫脱垂、尿失禁等盆底组织缺陷性疾病选择阴式途径完成。保留子宫的手术可以根据患者主要症状、手术医师的技能和仪器来选择术式。对年龄大且无生育要求,合并贫血、子宫肌瘤,服药有严重副作用或无明显疗效的可行全子宫切除术。     

Progression of adenomyosis magnetic resonance imaging features under ulipristal acetate for symptomatic fibroids

Research questionWhat is the evolution of adenomyosis on magnetic resonance imaging (MRI) after a 3-month treatment course of daily 5 mg doses of ulipristal acetate (UPA) for symptomatic fibroids?DesignA monocentric prospective pilot study on patients who underwent a 3-month treatment course of UPA for symptomatic fibroids between January 2014 and December 2017. Patients underwent pelvic MRI shortly before (pre-MRI) and after treatment (post-MRI). The diagnosis of adenomyosis on MRI was defined by the observation of intramyometrial cysts and/or haemorrhagic foci within these cystic cavities and/or a thickening of the junctional zone >12 mm. The progression of adenomyosis was defined by the presence of at least one of the aforementioned criteria of adenomyosis on the pre-MRI and by at least one of the following on the post-MRI: (i) increased thickness of the junctional zone ≥20% and/or (ii) increased number of intramyometrial cysts. The appearance of adenomyosis was defined by the absence of the aforementioned criteria of adenomyosis on the pre-MRI and the presence of at least one of these criteria on the post-MRI.ResultsSeventy-two patients were included. The MRI features of adenomyosis progressed for 12 of 15 patients (80.0%) for whom adenomyosis was identified on the pre-MRI. An appearance of adenomyosis was identified after treatment for 15 of 57 patients (26.3%) for whom adenomyosis was not identified on the pre-MRI.ConclusionsA 3-month treatment course of daily 5 mg doses of UPA could provoke a short-term progression or an emergence of typical adenomyosis intramyometrial cysts on MRI examinations.     

Surgery in adenomyosis

Introduction

Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium. The true prevalence is unknown and has been reported to range from 1 to 70%. It has a significantly negative impact on women’s quality of life, causing abnormal uterine bleeding, dysmenorrhea, and chronic pelvic pain. The definitive treatment for adenomyosis is hysterectomy, although it does not contemplate patients who wish to preserve their fertility. The aim of this paper is to discuss the latest evidence on the surgical techniques for the treatment of adenomyosis published in medical–scientific databases.

Method

A comprehensive literature search for articles published from 1996 to 2017 related to surgery for adenomyosis was made in Pubmed, Medline, the Cochrane Library, and Google Scholar, in English, by the following MeSH terms: adenomyosis, surgery, pathogenesis, dysmenorrhea and infertility.

Results

There is extensive evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

Conclusion

The management of adenomyosis is quite complex and controversial. Complications after extensive uterine reconstruction, such as uterine rupture, should be considered and discussed with the patient. There are still limited data to support surgery effectiveness, especially for infertility, and further well-designed studies are required.

     

Experimental adenomyosis

Adenomyosis has been reported in a number of different animal species, whereas endometriosis appears limited to humans and non-human primates. This suggests a different aetiology of the two conditions. Adenomyosis develops spontaneously in certain strains of laboratory mice. Its incidence in mice can be markedly enhanced by systemic exposure to various hormonal agents, including prolactin, progesterone, synthetic progestins, certain oestrogenic agents, as well as tamoxifen and toremifene. The precise hormonal changes necessary remain unclear, although the evidence suggests that adenomyosis in this model is not due to a simple oestrogenic effect. Study of the pathological and molecular alterations in this model indicates that disturbances to the uterine stroma, blood vessels and myometrium are also important factors in the development of adenomyosis.     

Uterine innervation in adenomyosis.

This study describes the innervation of the uterus with a histopathological diagnosis of adenomyosis in a retrospective survey of two groups of uteri. Group 1 consisted of 17 histologically-normal, parous uteri and eight nulliparous uteri. Group 2 consisted of 23 parous uteri with the histopathological diagnosis of adenomyosis. Tissue sections from the uterine isthmus were stained for nerves with PGP 9.5 using a standard immunohistochemical regimen. In group 1 (n = 25, normal histological report), normal innervation of the uterine isthmus included concentrations of nerves in the subserosal layers and at the endometrial-myometrial interface with sparse, neurovascular bundles distributed throughout the myometrial stroma. In group 2, (n = 23 with adenomyosis), there were no nerves in areas of adenomyosis and absence of nerves at the endometrial-myometrial nerve plexus. Focal proliferation of small-diameter nerve fibres was observed at the margins of adenomyosis in some uteri. Subserosal nerve fibres were still present in those sections that extended to include this region. Adenomyosis is associated with loss of nerve fibres at the endometrial-myometrial interface and absence of nerve fibres in the adenomyosis.     

Expression of CA 125 in adenomyosis

To investigate the histogenic and cytogenic localization of CA 125 in patients with adenomyosis, sections from 8 adenomyosis cases were expressed with monoclonal anti-CA 125 antibodies. Consequently, CA 125 proved to be present on the glandular epithelium localized in muscle layers of adenomyosis.     

子宫结合带超微结构及间隙连接蛋白43的表达变化与子宫腺肌病发病的关系

目的 探讨子宫结合带的超微结构特点及间隙连接蛋白43(Cx43)在子宫结合带中的表达变化与子宫腺肌病发病的关系.方法 收集2008年11月至2009年11月在内蒙古医学院附属医院妇科住院的因子宫腺肌病行子宫全或次全切除术者30例为观察组(其中子宫内膜为增生期14例,分泌期16例),选择同期因宫颈上皮内瘤变(CIN)Ⅲ等行子宫全切除术者30例为对照组(子宫内膜为增生期、分泌期各15例).采用链霉素亲和素-生物素-过氧化物酶复合物(SABC)免疫组化法检测Cx43蛋白在子宫腺肌病患者子宫结合带中的表达水平,以吸光度(A)值表示;透视电镜观察两组中无诊断性刮宫(诊刮)史、剖宫产史、子宫手术史者(各4例)的子宫在位内膜、子宫结合带以及子宫肌层外1/3的超微结构特点.结果 (1)Cx43蛋白的表达:观察组增生期及分泌期子宫结合带中Cx43蛋白表达水平分别为0.133±0.018、0.137±0.021,对照组分别为0.154±0.016、0.141±0.018,两组同一期别子宫内膜比较,差异均有统计学意义(P＜0.05),但各组内增生期与分泌期子宫结合带中Cx43蛋白表达水平比较,差异无统计学意义(P＞0.05);观察组的在位内膜中增生期及分泌期Cx43蛋白表达水平(0.067±0.017,0.062±0142)低于对照组(0.094±0.005,0.080±0.005),差异也均有统计学意义(P＜0.05),但各组内增生期与分泌期比较,差异无统计学意义(P＜0.05);观察组和对照组增生期外肌层Cx43蛋白表达分别为0.184±0.022、0.188±0.028,差异无统计学意义(P＞0.05),分泌期外肌层Cx43蛋白表达分别为0.178±0.022、0.191±0.025,差异也无统计学意义(P＞0.05).(2)形态学变化:观察组子宫结合带平滑肌细胞核面积[(24.3±1.6)μm2]比对照组[(21.8±2.0)μm2]明显增加,差异有统计学意义(P＜0.01).细胞膜致密斑明显增长[(1.07±0.17)、(0.71±0.07)μm],差异也有统计学意义(P＜0.01);观察组子宫结合带肌细胞小凹结构减少,细胞增生肥大,排列紊乱,核表面呈圆齿状不规则外形,核染色质边集,异染色质多,细肌丝较少而中间丝较多,线粒体数量增加、体积增大、空泡化明显,粗面内质网扩张,高尔基体增加,肥大细胞与肌细胞紧密相邻;在位内膜的腺上皮细胞间呈桥粒连接,且表面绒毛增粗、致密.以上特点在观察组的外肌层也可见,但没有子宫结合带显著.结论 子宫结合带中超微结构的变化和Cx43蛋白的表达下调可能与子宫腺肌病的发病有关.     

子宫腺肌病影像学诊断

子宫腺肌病是常见的妇科疾病,严重影响妇女健康。如今无创的影像学技术已用于诊断子宫腺肌病。文章重点分析不同的影像学方法及指标在子宫腺肌病诊断中的优势及不足,以帮助妇科临床医生选择合适的诊断方法,提高疾病早期诊断率。     

The symptomatology of adenomyosis

Adenomyosis is a poorly understood condition which has been called 'elusive' or 'enigmatic' because of the difficulty in diagnosis, the lack of agreement on definition, and also because of the vague and ill-defined pattern of symptoms which may accompany it. There is little doubt that some women with adenomyosis may experience troublesome, heavy menstrual bleeding, troublesome dysmenorrhoea, and sometimes a tender uterus. However, the frequency and severity with which these symptoms occur, and the proportion of adenomyosis sufferers who are completely asymptomatic, are quite unclear. The common association of adenomyosis with other pelvic pathologies is an additional factor which confuses the understanding of related symptoms. It is clear that there is no specific combination of symptoms caused by adenomyosis, although many of these women will undoubtedly suffer from very heavy menstrual periods. Now that moderate to severe degrees of adenomyosis can be diagnosed preoperatively with a fair degree of reliability by good-quality ultrasound or magnetic resonance imaging (MRI), there is an urgent need for multicentre collaboration to prospectively define symptomatology in a uniform manner, and then correlate this with specific findings on imaging (and compare with later surgical and pathological findings).     

Endometriosis and adenomyosis

Peristaltic activity of the non-pregnant uterus serves fundamental functions in the early process of reproduction. Hyperperistalsis of the uterus is significantly associated with the development of endometriosis and adenomyosis. In women with hyperperistalsis fragments of basal endometrium are detached during menstruation and transported into the peritoneal cavity. Fragments of basal endometrium have an increased potential of implantation and proliferation resulting in pelvic endometriosis. In addition, hyperperistalsis induces the proliferation of basal endometrium into myometrial dehiscencies. This results in endometriosis-associated adenomyosis with a prevalence of about 90%. Adenomyosis results in impaired directed sperm transport and thus constitutes an important cause of sterility in women with endometriosis. The principal mechanism of endometriosis/adenomyosis is the paracrine interference of endometrial estrogen with the cyclical endocrine control of archimyometrial peristalsis exerted by the ovary thus resulting in hyperperistalsis. Minimal endometriosis of the fertile women, endometriosis and adenomyosis of the infertile women and adenomyosis of the parous peri- and postmenopausal women are considered as phenotypes of a pathophysiological continuum with uterine peristalsis playing a prominent role.     

Ulipristal acetate therapy increases ultrasound features of adenomyosis: a good treatment given in an erroneous diagnosis of uterine fibroids

Ulipristal acetate (UPA) is used for medical treatment of uterine fibroids. The aim of this study was to describe the effects on painful symptoms and the sonographic uterine modifications in patients with adenomyosis erroneously treated with UPA. This is an observational study on six women affected by adenomyosis and treated with three months of UPA (5?mg/24h). The baseline ultrasonography (US) was not performed at out center nor was the diagnosis of fibroids. The patients came to our attention after the treatment with UPA, prescribed by an external physician. During our post-treatment scan we found aspects of adenomyosis, while no fibroids were detected. Symptoms, myometrial and endometrial ultrasound features were evaluated. All patients reported an increase in pelvic pain. At US evaluation intramyometrial cystic areas were found in all six cases (100%). All patients showed an enhancement of adenomyosis features.The intra-myometrial cysts appeared enlarged and the vascularization enhanced when compared to the images of the pretreatment scan. In patients with adenomyosis treated with UPA due to an erroneous diagnosis of uterine fibroids we observed a worsening of the US features of adenomyosis and of the painful symptoms.     

Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice?

Uterine adenomyosis is a benign lesion but a serious disease for women, because the symptoms are characterized by abnormal bleeding, pain, cramps, and sterility. Thus elucidation of the mechanisms involved in the development of the disease would contribute to improved management and treatment and prophylaxis of this lesion. A mouse model, in which ectopic pituitary isografting is associated with an increase in the plasma level of prolactin, is useful for a rapid and frequent induction of uterine adenomyosis and can be used to study the origin of this lesion.     

Intramural ectopic pregnancy implanting in adenomyosis

The clinical course of this 33-year-old gravida presenting at 16 weeks' gestation with hemoperitoneum was typical for suspected uterine rupture. Pathologic examination of the hysterectomy specimen supports the diagnosis of intramural pregnancy, representing the 15th case reported to date in the literature. Furthermore, there was histologic evidence of adenomyosis both within the sinus tract leading to the implantation site and throughout the myometrium. Documentation of implantation and development of ectopic pregnancy in adenomyotic myometrium should alert the clinician to the possibility of this rare pregnancy complication.     

Increased microvessel density in adenomyosis uteri

OBJECTIVE: To investigate microvessel density in adenomyosis compared to the endometrium in patients with adenomyosis and in normal controls. DESIGN: Uterine paraffin-embedded histologic specimens were immunostained for CD34. The area with the highest microvessel density in adenomyosis and in the endometrium was evaluated. All microvessels in a specific field of view (x200 magnification) were counted. SETTING: The Department of Gynecological Endocrinology and the Institute of Clinical Pathology, Department of Gynecopathology, in an university hospital. PATIENT(S): Specimens of 53 patients with adenomyosis, who had undergone hysterectomy. Endometrial specimens of 17 women without uterine pathology were investigated as normal controls. MAIN OUTCOME MEASURE(S): Microvessel density in adenomyosis and in the endometrium. RESULT(S): The mean microvessel density was significantly higher in adenomyosis than in the endometrium of the same patients (33.5 +/- 14.6 vs. 19.5 +/- 12.5 microvessels/field; P<.001 sign test). No significant difference between the endometrium of patients and of normal controls was observed (P=.805). CONCLUSION(S): Adenomyosis exhibits angiogenic properties. However, the endometrium of patients with adenomyosis is not more prone to express angiogenic activity compared to the endometrium of normal controls.     

Hormonal treatments for adenomyosis

Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. The medical treatment of adenomyosis is based on the hormonal dependency of the disease and its strongly debated similarities with endometriosis. Infact, despite the evident differences between the two conditions, the therapies that treat endometriosis effectively have also been successful for the treatment of adenomyosis. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis. Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.     

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD).A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE).This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.