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MR imaging of atypical polypoid adenomyoma
Computerized
Medical
Pergamon
Imaging and Graphics, Vol. 19, No. 4, pp. 351-355, 1995 Copyright 0 1995 Else&r Science Ltd Printed in the USA. All rights reserved 0895611 l/95 $9.50 + .oo
0895-6111(95)00017-8
MR IMAGING
OF ATYPICAL
POLYPOID
ADENOMYOMA
Yasuyuki Yamashita,*t Miyuki Torashima,* Yoshimi Hatanaka,* Mutsumasa Takahashi,” Koreatsu Fukumatsu,$ Nobuyuki Tanaka,? Kohji Miyazakil and Hitoshi Okamurai Departmentsof *Radiology and SObstetricsand Gynecology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan (Received
2 December
1994)
Abstract-The magnetic resonance (MR) appearances of three cases of atypical polypoid adenomyoma are reported. The signal intensity of the tumor was similar to that of adenomyosis on T&weighted MR Imaging (MRI). On contrastsnhanced study, irregular enhancement was seen in hype&tense areas on T2-weighted images. Atypical polypoid adenomyoma can he characterized as a hypointense polypoid mass with hyperintense foci on TZ-weighted MR images, resembling the appearance of adenomyosis. Key
Words:
Atypical
polypoid
adenomyoma,
MR,
Cd-DTPA
cavity (Fig. 3). Contrast-enhanced study showed irregular enhancement of the tumor. Hyperintense areas within the tumor on T2-weighted images appeared to correspond to well enhanced areas on contrast-enhanced study. The pattern of enhancement of the hyperintense areas was similar to that of endometrium (Fig. 1). On histologic examination of three cases, the polypoid masseswere characterized by an intimate admixture of endometrial glands with varying degrees of hyperplasia and atypia separated by swirling fascicles of cellular smooth muscle cells, consistent with atypical polypoid adenomyoma (Fig. 1). Hyperintense areas on TZweighted images corresponded to islands of metaplastic endometrial foci within the tumor. In Cases1 and 2, adenomyosis was seenin the myometrium. Carcinoma in situ was seenin the localized area of Case 3.
INTRODUCTION
Endornetrial polyps, having smooth muscle fibers in addition to the customary glands and stroma, are designated as polypoid adenomyomas, and an important variant, which is more common than the basic type, is the recently described atypical polypoid adenomyomas (APAs) (l-3). They typically occur in premenopausal women who are first seenbecause of abnormal genital bleeding. They usually present as an intrauterine polypoid mass. Adenocarcinoma is occasionally found in the resected specimen. To our knowledge, the MR appearance of APA has not been reported previously. We describe three cases of APA that developed in the endometrial cavity. CASE
REPORTS
The summary of patients is shown in Table 1. At transvaginal sonography, all cases had a polypoid mass in the uterine cavity. On TZweighted MRI, a polypoid mass mixed with hypointensity and hyperintensity was seen in all patients. On Tl-weighted MRI, the tumors were isointense with myometrium. In Cases 1 and 2, the tumors extend from the endometrial cavity to the myometrium (Figs 1 and 2). In case 3. the mass was localized in the endometrial
DISCUSSION
An APA is a benign form of mixed epithelial and mesenchymal tumors observed in the uterus, most frequently in the endometrial cavity. Some APAs are associatedwith Turner’s syndrome (4). Histologically APA is characterized by an intimate admixture of benign endometrial glands with structural atypia and a stroma consisting predominantly of benignappearing smooth muscle. The tumors may be pedunculated or sessileand are usually well demarcated from the underlying myometrium (l--3). Squamous or morular metaplasia is found in most
tcorrespondence should be addressed to Yasuyuki Yamashita, M.D., Department of Radiology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan. Tel.: 096344-21 11; Fax: 096-362-4330. 351
Computerized Medical Imaging and Graphics
352
July-August/l995,
Table 1. Summary of cases with atypical polypoid
Volume 19, Number 4 adenomyoma
No.
Age
Symptom
Macroscopic appearance
Comments
I
30
Hypermenorrhea
Adenomyosis in the myometrium
2
38
Hypermenorrhea
3
28
Five yrs history of infertility
Extended from endometrial cavity to myometrium Extended from endometrial cavity to myometrium Localized in endometrial cavity
of the cases and is often extensive. Central necrosis may be present in these large metaplastic foci. The glands occurring between the endometrial stroma and smooth muscle exhibit varying degrees of hyperplasia and atypia. Carcinoma may be seen, as in our Case 3. Thus, recognition of this disease is very important. In our three cases, TZweighted MR images showed a polypoid mass in the uterine activity. The signal intensity of the polypoid mass was similar to that of adenomyosis (5). Multiple hyperintense areas were seen, corresponding to islands of metaplastic endometrial foci. On contrast-enhanced MRI, the pattern of enhancement of these areas was similar to that of the endometrium (6). The differential diagnosis include various pathologic conditions occurring in the endometrium. They include endometrial polyp, endometrial hyperplasia, submucous myoma or superficial endometrial carci-
Adenomyosis in the myometrium Carcinoma in situ +
noma. Whether or not an APA can be differentiated from these diseases on MRI is unknown. However, if a hypointense polypoid mass with hyperintense foci on TZweighted MR images, resembling the appearance of adenomyosis, is seen, then APA should be included in the differential diagnosis. SUMMARY
The MR appearance of three cases of atypical polypoid adenomyoma are reported. On T2-weighted MRI, a polypoid mass mixed with hypointensity and hyperintensity was seen in all patients. The signal intensity of the tumor was similar to that of adenomyosis. On Tl-weighted MRI, the tumors were isointense with myometrium. Contrastenhanced study showed irregular enhancement of the tumor. Hyperintense areas on TZweighted images showed contrast enhancement, as did the
Fig. l(a)
Atypical polypoid adenomyoma
l
Y. YAMASHITA
et al.
(b)
woman with amenorrhea. (a) Sagittal T2-weighted MRI (2000/80) shows Fig. 1. Case 1: a 30-yr-old heterof seneous lesion of similar signal intensity with thickened myometrium. Hyperintense areas are seen within the tumor (arrowheads). (b) Gd-DTPA enhanced MRI reveals irregular enhancement of the tumor. Hyperi ntense areas of T2-weighted images showed contrast enhancement as did endometrium (arrowheads). (c) Phc )tomicrograph of the tumor obtained from an island of endometrial metaplastic foci. On histologic examir iation, the polypoid masses were characterized by an intimate admixture of atypical endometrial glands separated by swirling fascicles of cellular smooth muscle cells, consistent with atypical polypoid adenomyoma. Adenomyosis was separately seen in the myometrium.
Computerized
Medical
Imaging
and Graphics
July-August/l995,
Volume
19, Number
4
Sagittal T2-weighted MRI (2000/80) shows lesion of Fig. 2. Case 2: a 38-yr-old woman with amenorrhea. simi lar signal intensity with myometrium. Hyperintensity foci are see;. .:- 5%: tumor (arrowheac 11. Adenomyosis was seen at the base of the polypoid mass, which was histologically confirmed.
Fig. 3. Case 3: a 28-yr-old woman ma6 ;s compared with myometrium.
with sterility. Sagittal T2-weighted MRI (2000/80) shows hypointer me Hyperintensity foci are seen in the tumor (arrowhead). The tumor is localized in the endometrial cavity.
Atypical
polypoid
adenomyoma
endometrium. If a hypointense polypoid mass with hyperintense foci on TZweighted MR images, resembling the appearance of adenomyosis is seen, APA should be included in the differential diagnosis. REFERENCES 1. Young, R.H.; Treger, T.; Scuhy, R.E. Atypical polypoid adenomyoma of the uterus. A report of 27 cases. Am. J. Clin. Pathol. 86:139-145; 1986. 2. Mazur, M.T. Atypical polypoid adenomyoma of the endometrium. Am. J. Surg. Pathol. 5:473482; 1981. 3. Silverberg, S.G.; Kurman, R.J. Tumors of the uterine corpus and gestational trophoblastic disease. In: Mixed epithelialnonepithelial tumors. Washington, DC: Armed Forces Institute of Pathology, 1992: 153-l 57. 4. Clement, P.B.; Young, R.H. Atypical polypoid adenomyoma of the uterus associated with Turner’s syndrome. A report of three cases, including review of ‘estrogen-associated’ endometrial neoplasms and neoplasms associated with Turner’s syndrome. 1987:6. 5. Togashi, K.; Nishimura, K.; Itoh, K.; Adenomyosis: diagnosis with MR imaging. Radiology 166: 11 l-l 14; 1988. 6 Hricak, H.; Finck, S.; Honda, G.; Goranson, H. MR imaging in the evaluation of benign uterine masses: value of gadopentetate dimeglumine-enhanced Tl-weighted images. AJR 158:10431050; 1992.
About the Author-YASUYUKI YAMASHITA, M.D., specialized in angiography and abdominal radiology as a member of staff of the Department of Radiology, Kumamoto University Hospital. His main interest is angiography and MRI of the gastrointestinal tract and urologic radiology.
l
Y. YAMASHITA
355
et al.
About the Author-MIYuKI TORASHIMA, M.D., specialized urologic radiology as a member of staff of the Department Radiology, Kumamoto University. Her main interest is MRI the female pelvis.
in of of
About the abdominal Radiology, angiography
in of is
HATANAKA, M.D., specialized radiology as a member of staff of the Department Kumamoto University. His recent main interest and interventional radiology.
Author-YOSHIMI
About the Author-MUTSUMASA TAKAHASHI, M.D., is a Professor and Chairman of the Department of Radiology, Kumamoto University School of Medicine. He has made many contributions in neuroradiology and interventional radiology. His recent interest is MRI of the central nervous system. About the Author-KoaEATsu FUKUMATSU, of staff of the Department of Obstetrics Kumamoto University Hospital. His main logic pathology.
M.D., is a member and Gynecology, interest is gyneco-
About the Author-NosuYuKI TANAKA, M.D., is a member of staff of the department of Obstetrics and Gynecology, Kumamoto University Hospital. He has made many contributions in this field. About the Author-KoHn MIYAZAKI, M.D., is a member of staff of the Department of Obstetrics and Gynecology, Kumamoto University Hospital. His main interest is gynecologic oncology. About the Author-HIToSHI OKAMURA, M.D., is a Professor and Chairman of the Department of Obstetrics and Gynecology, Kumamoto University Hospital. He has made many contributions in this field.
Medical
Pergamon
Imaging and Graphics, Vol. 19, No. 4, pp. 351-355, 1995 Copyright 0 1995 Else&r Science Ltd Printed in the USA. All rights reserved 0895611 l/95 $9.50 + .oo
0895-6111(95)00017-8
MR IMAGING
OF ATYPICAL
POLYPOID
ADENOMYOMA
Yasuyuki Yamashita,*t Miyuki Torashima,* Yoshimi Hatanaka,* Mutsumasa Takahashi,” Koreatsu Fukumatsu,$ Nobuyuki Tanaka,? Kohji Miyazakil and Hitoshi Okamurai Departmentsof *Radiology and SObstetricsand Gynecology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan (Received
2 December
1994)
Abstract-The magnetic resonance (MR) appearances of three cases of atypical polypoid adenomyoma are reported. The signal intensity of the tumor was similar to that of adenomyosis on T&weighted MR Imaging (MRI). On contrastsnhanced study, irregular enhancement was seen in hype&tense areas on T2-weighted images. Atypical polypoid adenomyoma can he characterized as a hypointense polypoid mass with hyperintense foci on TZ-weighted MR images, resembling the appearance of adenomyosis. Key
Words:
Atypical
polypoid
adenomyoma,
MR,
Cd-DTPA
cavity (Fig. 3). Contrast-enhanced study showed irregular enhancement of the tumor. Hyperintense areas within the tumor on T2-weighted images appeared to correspond to well enhanced areas on contrast-enhanced study. The pattern of enhancement of the hyperintense areas was similar to that of endometrium (Fig. 1). On histologic examination of three cases, the polypoid masseswere characterized by an intimate admixture of endometrial glands with varying degrees of hyperplasia and atypia separated by swirling fascicles of cellular smooth muscle cells, consistent with atypical polypoid adenomyoma (Fig. 1). Hyperintense areas on TZweighted images corresponded to islands of metaplastic endometrial foci within the tumor. In Cases1 and 2, adenomyosis was seenin the myometrium. Carcinoma in situ was seenin the localized area of Case 3.
INTRODUCTION
Endornetrial polyps, having smooth muscle fibers in addition to the customary glands and stroma, are designated as polypoid adenomyomas, and an important variant, which is more common than the basic type, is the recently described atypical polypoid adenomyomas (APAs) (l-3). They typically occur in premenopausal women who are first seenbecause of abnormal genital bleeding. They usually present as an intrauterine polypoid mass. Adenocarcinoma is occasionally found in the resected specimen. To our knowledge, the MR appearance of APA has not been reported previously. We describe three cases of APA that developed in the endometrial cavity. CASE
REPORTS
The summary of patients is shown in Table 1. At transvaginal sonography, all cases had a polypoid mass in the uterine cavity. On TZweighted MRI, a polypoid mass mixed with hypointensity and hyperintensity was seen in all patients. On Tl-weighted MRI, the tumors were isointense with myometrium. In Cases 1 and 2, the tumors extend from the endometrial cavity to the myometrium (Figs 1 and 2). In case 3. the mass was localized in the endometrial
DISCUSSION
An APA is a benign form of mixed epithelial and mesenchymal tumors observed in the uterus, most frequently in the endometrial cavity. Some APAs are associatedwith Turner’s syndrome (4). Histologically APA is characterized by an intimate admixture of benign endometrial glands with structural atypia and a stroma consisting predominantly of benignappearing smooth muscle. The tumors may be pedunculated or sessileand are usually well demarcated from the underlying myometrium (l--3). Squamous or morular metaplasia is found in most
tcorrespondence should be addressed to Yasuyuki Yamashita, M.D., Department of Radiology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan. Tel.: 096344-21 11; Fax: 096-362-4330. 351
Computerized Medical Imaging and Graphics
352
July-August/l995,
Table 1. Summary of cases with atypical polypoid
Volume 19, Number 4 adenomyoma
No.
Age
Symptom
Macroscopic appearance
Comments
I
30
Hypermenorrhea
Adenomyosis in the myometrium
2
38
Hypermenorrhea
3
28
Five yrs history of infertility
Extended from endometrial cavity to myometrium Extended from endometrial cavity to myometrium Localized in endometrial cavity
of the cases and is often extensive. Central necrosis may be present in these large metaplastic foci. The glands occurring between the endometrial stroma and smooth muscle exhibit varying degrees of hyperplasia and atypia. Carcinoma may be seen, as in our Case 3. Thus, recognition of this disease is very important. In our three cases, TZweighted MR images showed a polypoid mass in the uterine activity. The signal intensity of the polypoid mass was similar to that of adenomyosis (5). Multiple hyperintense areas were seen, corresponding to islands of metaplastic endometrial foci. On contrast-enhanced MRI, the pattern of enhancement of these areas was similar to that of the endometrium (6). The differential diagnosis include various pathologic conditions occurring in the endometrium. They include endometrial polyp, endometrial hyperplasia, submucous myoma or superficial endometrial carci-
Adenomyosis in the myometrium Carcinoma in situ +
noma. Whether or not an APA can be differentiated from these diseases on MRI is unknown. However, if a hypointense polypoid mass with hyperintense foci on TZweighted MR images, resembling the appearance of adenomyosis, is seen, then APA should be included in the differential diagnosis. SUMMARY
The MR appearance of three cases of atypical polypoid adenomyoma are reported. On T2-weighted MRI, a polypoid mass mixed with hypointensity and hyperintensity was seen in all patients. The signal intensity of the tumor was similar to that of adenomyosis. On Tl-weighted MRI, the tumors were isointense with myometrium. Contrastenhanced study showed irregular enhancement of the tumor. Hyperintense areas on TZweighted images showed contrast enhancement, as did the
Fig. l(a)
Atypical polypoid adenomyoma
l
Y. YAMASHITA
et al.
(b)
woman with amenorrhea. (a) Sagittal T2-weighted MRI (2000/80) shows Fig. 1. Case 1: a 30-yr-old heterof seneous lesion of similar signal intensity with thickened myometrium. Hyperintense areas are seen within the tumor (arrowheads). (b) Gd-DTPA enhanced MRI reveals irregular enhancement of the tumor. Hyperi ntense areas of T2-weighted images showed contrast enhancement as did endometrium (arrowheads). (c) Phc )tomicrograph of the tumor obtained from an island of endometrial metaplastic foci. On histologic examir iation, the polypoid masses were characterized by an intimate admixture of atypical endometrial glands separated by swirling fascicles of cellular smooth muscle cells, consistent with atypical polypoid adenomyoma. Adenomyosis was separately seen in the myometrium.
Computerized
Medical
Imaging
and Graphics
July-August/l995,
Volume
19, Number
4
Sagittal T2-weighted MRI (2000/80) shows lesion of Fig. 2. Case 2: a 38-yr-old woman with amenorrhea. simi lar signal intensity with myometrium. Hyperintensity foci are see;. .:- 5%: tumor (arrowheac 11. Adenomyosis was seen at the base of the polypoid mass, which was histologically confirmed.
Fig. 3. Case 3: a 28-yr-old woman ma6 ;s compared with myometrium.
with sterility. Sagittal T2-weighted MRI (2000/80) shows hypointer me Hyperintensity foci are seen in the tumor (arrowhead). The tumor is localized in the endometrial cavity.
Atypical
polypoid
adenomyoma
endometrium. If a hypointense polypoid mass with hyperintense foci on TZweighted MR images, resembling the appearance of adenomyosis is seen, APA should be included in the differential diagnosis. REFERENCES 1. Young, R.H.; Treger, T.; Scuhy, R.E. Atypical polypoid adenomyoma of the uterus. A report of 27 cases. Am. J. Clin. Pathol. 86:139-145; 1986. 2. Mazur, M.T. Atypical polypoid adenomyoma of the endometrium. Am. J. Surg. Pathol. 5:473482; 1981. 3. Silverberg, S.G.; Kurman, R.J. Tumors of the uterine corpus and gestational trophoblastic disease. In: Mixed epithelialnonepithelial tumors. Washington, DC: Armed Forces Institute of Pathology, 1992: 153-l 57. 4. Clement, P.B.; Young, R.H. Atypical polypoid adenomyoma of the uterus associated with Turner’s syndrome. A report of three cases, including review of ‘estrogen-associated’ endometrial neoplasms and neoplasms associated with Turner’s syndrome. 1987:6. 5. Togashi, K.; Nishimura, K.; Itoh, K.; Adenomyosis: diagnosis with MR imaging. Radiology 166: 11 l-l 14; 1988. 6 Hricak, H.; Finck, S.; Honda, G.; Goranson, H. MR imaging in the evaluation of benign uterine masses: value of gadopentetate dimeglumine-enhanced Tl-weighted images. AJR 158:10431050; 1992.
About the Author-YASUYUKI YAMASHITA, M.D., specialized in angiography and abdominal radiology as a member of staff of the Department of Radiology, Kumamoto University Hospital. His main interest is angiography and MRI of the gastrointestinal tract and urologic radiology.
l
Y. YAMASHITA
355
et al.
About the Author-MIYuKI TORASHIMA, M.D., specialized urologic radiology as a member of staff of the Department Radiology, Kumamoto University. Her main interest is MRI the female pelvis.
in of of
About the abdominal Radiology, angiography
in of is
HATANAKA, M.D., specialized radiology as a member of staff of the Department Kumamoto University. His recent main interest and interventional radiology.
Author-YOSHIMI
About the Author-MUTSUMASA TAKAHASHI, M.D., is a Professor and Chairman of the Department of Radiology, Kumamoto University School of Medicine. He has made many contributions in neuroradiology and interventional radiology. His recent interest is MRI of the central nervous system. About the Author-KoaEATsu FUKUMATSU, of staff of the Department of Obstetrics Kumamoto University Hospital. His main logic pathology.
M.D., is a member and Gynecology, interest is gyneco-
About the Author-NosuYuKI TANAKA, M.D., is a member of staff of the department of Obstetrics and Gynecology, Kumamoto University Hospital. He has made many contributions in this field. About the Author-KoHn MIYAZAKI, M.D., is a member of staff of the Department of Obstetrics and Gynecology, Kumamoto University Hospital. His main interest is gynecologic oncology. About the Author-HIToSHI OKAMURA, M.D., is a Professor and Chairman of the Department of Obstetrics and Gynecology, Kumamoto University Hospital. He has made many contributions in this field.