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Mri of cervical adenocarcinoma with cystic components
MRI OF CERVICAL ADENOCARCINOMA WITH CYSTIC COMPONENTS MANABU TAKAMURA, MD, TAKAMICHI MURAKAMI, MD, PHD, HIROHISA KURACHI, MD, PHD, YOSHIFUMI NARUMI, MD, PHD, KYO TSUDA, MD, TAKAYUKI ENOMOTO, MD, PHD, YUJI MURATA, MD, AND HIRONOBU NAKAMURA, MD
We encountered two cases of endocervical well-differentiated adenocarcinoma with cystic components. Magnetic resonance findings of the first case showed cystic lesion with enhanced mural nodule in the uterine cervix. The second case showed multicystic lesion in the uterine cervix. The cystic walls were thickening in the postcontrast T1-weighted image. The cervical adenocarcinoma with cystic components should be added to one of differential diagnosis of the uterine cervical cystic lesion. Elsevier Science Inc., 1999 KEY WORDS:
Uterine cervix; Adenocarcinoma; Magnetic resonance imaging
INTRODUCTION While well-differentiated adenocarcinoma of the uterine cervix is usually a solid mass (1), it rarely presents with cystically dilated glands and it may contain eosinophilic secretion (2). We encountered two patients with well-differentiated endocervical adenocarcinoma with cystic components, who underwent magnetic resonance (MR) examinations. We re-
port the MR findings of the cystic adenocarcinoma of the uterine cervix. To our knowledge, there is no report of MR findings of such cases. CASE 1 A 40-year-old woman had abnormal vaginal bleeding. Findings from cytologic smear suggested cervical adenocarcinoma. Results of blood laboratory tests and levels of tumor makers were unremarkable. MR examination was performed. T1-weighted spin-echo images (TR/TE msec, 500/32) showed a cystic hypointense lesion of 4 cm in diameter. T2-weighted spinecho images (4500/85) showed hyperintense lesion with intermediate intense mural nodule (Figure 1A). Postcontrast T1-weighted spin-echo images (500/32) with intravenous administration of 0.1 mmol/kg of gadopentetate dimeglumine showed enhancement of the mural nodule (Figure 1B). We interpreted the cystic lesion with mural nodule as malignancy. Radical hysterectomy was performed. The dilated glands were lined in benign epithelial cells, which contained mucin. In mural nodule, the enlarged irregular shaped glandular cells were present (Figure 1C). CASE 2
From the Department of Radiology (M.T., T.M., Y.N., K.T., H.N.) and Obstetrics and Gynecology (H.K., T.E., Y.M.), Osaka University Medical School, Osaka, Japan. Address correspondence to: Manabu Takamura, MD, Department of Radiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 5650871 Japan. Tel: 81-6-879-3434; Fax: 81-6879-3439: e-mail: [email protected] Received September 30, 1998; accepted October 20, 1998. CLINICAL IMAGING 1999;23:40–43 Elsevier Science Inc., 1999. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
A 55-year-old woman had postmenopausal vaginal bleeding. Findings from cytologic smear suggested cervical adenocarcinoma. Results of blood laboratory tests were unremarkable, but the levels of tumor makers CA19-9 and CA125 elevated to 141 U/ml and 72 U/ml (normal range: CA19-9, 0–37 U/ml; CA125, 0899-7071/99/$–see front matter PII S0899-7071(98)00089-8
JANUARY/FEBRUARY 1999
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0–65 U/ml), respectively. The level of CEA was normal. MR examination was performed. T1-weighted spin-echo images (500/32) and T2-weighted spin-echo images (4500/85) showed multicystic lesion (Figure 2A). The cystic walls were thickening, but mural nodule was not seen. Postcontrast T1-weighted spinecho images (500/32) showed enhanced thick cystic walls, however the solid mass was not detected in the uterine cervix in MR images (Figure 2B). The patient underwent radical hysterectomy. The histological findings revealed cystic dilation of endocervical glands with normal epithelium, but well-differentiated endocervical adenocarcinoma in the surrounding stroma. DISCUSSION Cervical malignant tumors of the uterus have many histological subtypes, (i.e., squamous cell carcinoma, adenocarcinoma, adenosquamous carcinoma). There are no significant differences between the histological type with MR images, however the location of tumor may suggest histological type. Adenocarcinoma of the uterine cervix presently accounts for 10% to 20% of neoplasms of the uterine cervix (2). Adenocarcinoma are histologically classified into seven types: endocervical, endometroid, clear cell, serous, mesonephric, intestinal, and signet-ring cell. Of these types, endocervical type accounts for approximately 70% (2). Endocervical adenocarcinoma has a variety of histological differentiation, ranging from well differentiated to poorly differentiated. The MR appearances of cervical cancers show usually solid lesion of the uterine cervix (1). On T1-weighted images, tumor has no contrast to cervical normal structure. On T2weighted images, tumor shows high intense solid lesion compared to the cervical stroma (1). Previous reports mainly described the staging of cervical carcinoma (3–6). Adenoma malignum and nabothian cysts are well known as the cystic lesion of uterine cervix. While the features of MR images of these diseases have been reported (7–9), the differential diagnosis of these diseases on MR imaging is sometimes difficult. The nabothian cyst represents cystically dilated endocervical gland which show medium to low intensity on T1-weighted images and high intensity on T2weighted images (7). The locations of the nabothian cysts are usually the superficial cervical wall, however they occasionally penetrate deeply into the wall of the cervix. In such a case, it is difficult to distinguish nabothian cysts from adenoma malignum (7, 10, 11). Adenoma malignum are extremely welldifferentiated adenocarcinoma. They are a rare cervi-
FIGURE 1. (A) T2-weighted sagittal image (TR/TE msec, 4500/85) demonstrates intermediate intense mural nodule within high intense cystic lesion. (B) Postcontrast T1weighted sagittal image (500/32) with gadopentetate dimeglumine shows well enhanced mural nodule. (C) Low power microscopic specimen. The mural nodule is seen (arrow). (H&E stain, magnification 3 5.)
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cal neoplasm arising from the endocervical glands. Histological finding is dilated glands that vary from small to large, and the glands are often irregular in size and shape (5). Ultrasound shows hyperechoic mass with hypoechoic cystic components (12). Computed tomography (CT) shows low attenuated mass with thin septa (8, 12). MRI shows multicystic mass with solid parts located in deep cervical stroma (9). The prognosis of adenoma malignum are poor. Be-
CLINICAL IMAGING VOL. 23, NO. 1
cause the gland of the tumor mimics the benign glands, test of smear and cystological test are misinterpreted. The diagnosis of the tumor is usually detected in advanced stage (8). We experienced two cases of well-differentiated endocervical adenocarcinoma with cystic components. In the first case, cystic mass with mural nodule was observed. The cystic wall was constructed by benign single layer epithelium. The mural nodule
FIGURE 2. (A) T2-weighted sagittal image (4500/85) shows the high intense multicystic lesion in the cervix. The myoma is shown as the low intense lesion in uterine posterior wall. (B) Postcontrast T1-weighted image (500/ 32) shows enhanced thick cystic walls, however the solid mass is not detected in the uterine cervix. (C) Low power microscopic specimen. The multiple dilated endocervical glands and irregular glands are seen. (H&E stain, magnification 3 5.)
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histologically showed atypical glandular cells, with partially papillary formation. We were able to interpret this lesion as malignancy, because of the mural nodule. In the second case, multicystic lesion was present. The cysts were dilated endocervical glands with normal epithelium, and there were adenocarcinomas in the surrounding stroma (Figure 2C). We initially diagnosed adenoma malignum on MR imaging. In MR images, the enhanced walls corresponded to adenocarcinoma in endocervical stroma and in the cystic walls (Figure 2B). It is difficult to distinguish this case from adenoma malignum. We need to add cervical adenocarcinoma with cystic components to the differential diagnosis of the uterine cervical cystic lesion including adenoma malignum and nabothian cyst. Mural nodule in the cystic cervical adenocarcinoma seen in the first case may be helpful for correct diagnosis. REFERENCES 1. Worthington JL, Balfe DM, Lee JK, et al. Uterine neoplasms: MR imaging. Radiology 1986;159:723–730. 2. Robert H, Robert E. Invasive adenocarcinoma and related tumors of the uterine cervix. Semin Diagn Pathol 1990;7:205–227.
MRI OF CERVICAL ADENOCARCINOMA
43
3. Togashi K, Nishimura K, Itoh K, et al. Uterine cervical cancer: assessment with high-field MR imaging. Radiology 1986; 160:431–435. 4. Hricak H, Hamm B, Semelka RC, et al. Carcinoma of the uterus: use of gadopentetate dimeglumine in MR imaging. Radiology 1991;181:95–106. 5. Hricak H, Lacey CG, Sandles LG, et al. Invasive cervical carcinoma: comparison of MR imaging and surgical findings. Radiology 1988;166:623–631. 6. Togashi K, Nishimura K, Sagoh T, et al. Carcinoma of the cervix: staging with MR imaging. Radiology 1989;171:245–251. 7. Yasuyuki Y, Takahashi M, Katabuchi H, et al. Adenoma malignum: MR appearances mimicking nabothian cysts. AJR 1994;162:649–650. 8. Turuchi N, Tukamoto N, Kaku T, et al. Adenoma malignum of the uterine cervix detected by imaging methods in a patient with Peutz-Jeghers syndrome. Gynecol Oncol 1994;54:232–236. 9. Doi T, Yamashita Y, Yasunaga T, et al. Adenoma malignum: MR imaging and pathologic study. Radiology 1997;204:39–42. 10. Clement PB, Young RH. Deep nabothian cysts of the uterine cervix. A possible source of confusion with minimal devication adenocarcinoma (adenoma malignum). Int J Gynecol Pathol 1989;8:340–348. 11. Daya D, Young RH. Florid deep glands of the uterine cervix. Another mimic of adenoma malignum. Am J Clin Pathol 1995;103:614–617. 12. Choi CG, Kim SH, Kim JS, et al. Adenoma malignum of uterine cervix in Peutz-Jeghers syndrome: CT and US features. J Comput Assist Tomogr 1993;17:819–892.
We encountered two cases of endocervical well-differentiated adenocarcinoma with cystic components. Magnetic resonance findings of the first case showed cystic lesion with enhanced mural nodule in the uterine cervix. The second case showed multicystic lesion in the uterine cervix. The cystic walls were thickening in the postcontrast T1-weighted image. The cervical adenocarcinoma with cystic components should be added to one of differential diagnosis of the uterine cervical cystic lesion. Elsevier Science Inc., 1999 KEY WORDS:
Uterine cervix; Adenocarcinoma; Magnetic resonance imaging
INTRODUCTION While well-differentiated adenocarcinoma of the uterine cervix is usually a solid mass (1), it rarely presents with cystically dilated glands and it may contain eosinophilic secretion (2). We encountered two patients with well-differentiated endocervical adenocarcinoma with cystic components, who underwent magnetic resonance (MR) examinations. We re-
port the MR findings of the cystic adenocarcinoma of the uterine cervix. To our knowledge, there is no report of MR findings of such cases. CASE 1 A 40-year-old woman had abnormal vaginal bleeding. Findings from cytologic smear suggested cervical adenocarcinoma. Results of blood laboratory tests and levels of tumor makers were unremarkable. MR examination was performed. T1-weighted spin-echo images (TR/TE msec, 500/32) showed a cystic hypointense lesion of 4 cm in diameter. T2-weighted spinecho images (4500/85) showed hyperintense lesion with intermediate intense mural nodule (Figure 1A). Postcontrast T1-weighted spin-echo images (500/32) with intravenous administration of 0.1 mmol/kg of gadopentetate dimeglumine showed enhancement of the mural nodule (Figure 1B). We interpreted the cystic lesion with mural nodule as malignancy. Radical hysterectomy was performed. The dilated glands were lined in benign epithelial cells, which contained mucin. In mural nodule, the enlarged irregular shaped glandular cells were present (Figure 1C). CASE 2
From the Department of Radiology (M.T., T.M., Y.N., K.T., H.N.) and Obstetrics and Gynecology (H.K., T.E., Y.M.), Osaka University Medical School, Osaka, Japan. Address correspondence to: Manabu Takamura, MD, Department of Radiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 5650871 Japan. Tel: 81-6-879-3434; Fax: 81-6879-3439: e-mail: [email protected] Received September 30, 1998; accepted October 20, 1998. CLINICAL IMAGING 1999;23:40–43 Elsevier Science Inc., 1999. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
A 55-year-old woman had postmenopausal vaginal bleeding. Findings from cytologic smear suggested cervical adenocarcinoma. Results of blood laboratory tests were unremarkable, but the levels of tumor makers CA19-9 and CA125 elevated to 141 U/ml and 72 U/ml (normal range: CA19-9, 0–37 U/ml; CA125, 0899-7071/99/$–see front matter PII S0899-7071(98)00089-8
JANUARY/FEBRUARY 1999
MRI OF CERVICAL ADENOCARCINOMA
41
0–65 U/ml), respectively. The level of CEA was normal. MR examination was performed. T1-weighted spin-echo images (500/32) and T2-weighted spin-echo images (4500/85) showed multicystic lesion (Figure 2A). The cystic walls were thickening, but mural nodule was not seen. Postcontrast T1-weighted spinecho images (500/32) showed enhanced thick cystic walls, however the solid mass was not detected in the uterine cervix in MR images (Figure 2B). The patient underwent radical hysterectomy. The histological findings revealed cystic dilation of endocervical glands with normal epithelium, but well-differentiated endocervical adenocarcinoma in the surrounding stroma. DISCUSSION Cervical malignant tumors of the uterus have many histological subtypes, (i.e., squamous cell carcinoma, adenocarcinoma, adenosquamous carcinoma). There are no significant differences between the histological type with MR images, however the location of tumor may suggest histological type. Adenocarcinoma of the uterine cervix presently accounts for 10% to 20% of neoplasms of the uterine cervix (2). Adenocarcinoma are histologically classified into seven types: endocervical, endometroid, clear cell, serous, mesonephric, intestinal, and signet-ring cell. Of these types, endocervical type accounts for approximately 70% (2). Endocervical adenocarcinoma has a variety of histological differentiation, ranging from well differentiated to poorly differentiated. The MR appearances of cervical cancers show usually solid lesion of the uterine cervix (1). On T1-weighted images, tumor has no contrast to cervical normal structure. On T2weighted images, tumor shows high intense solid lesion compared to the cervical stroma (1). Previous reports mainly described the staging of cervical carcinoma (3–6). Adenoma malignum and nabothian cysts are well known as the cystic lesion of uterine cervix. While the features of MR images of these diseases have been reported (7–9), the differential diagnosis of these diseases on MR imaging is sometimes difficult. The nabothian cyst represents cystically dilated endocervical gland which show medium to low intensity on T1-weighted images and high intensity on T2weighted images (7). The locations of the nabothian cysts are usually the superficial cervical wall, however they occasionally penetrate deeply into the wall of the cervix. In such a case, it is difficult to distinguish nabothian cysts from adenoma malignum (7, 10, 11). Adenoma malignum are extremely welldifferentiated adenocarcinoma. They are a rare cervi-
FIGURE 1. (A) T2-weighted sagittal image (TR/TE msec, 4500/85) demonstrates intermediate intense mural nodule within high intense cystic lesion. (B) Postcontrast T1weighted sagittal image (500/32) with gadopentetate dimeglumine shows well enhanced mural nodule. (C) Low power microscopic specimen. The mural nodule is seen (arrow). (H&E stain, magnification 3 5.)
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cal neoplasm arising from the endocervical glands. Histological finding is dilated glands that vary from small to large, and the glands are often irregular in size and shape (5). Ultrasound shows hyperechoic mass with hypoechoic cystic components (12). Computed tomography (CT) shows low attenuated mass with thin septa (8, 12). MRI shows multicystic mass with solid parts located in deep cervical stroma (9). The prognosis of adenoma malignum are poor. Be-
CLINICAL IMAGING VOL. 23, NO. 1
cause the gland of the tumor mimics the benign glands, test of smear and cystological test are misinterpreted. The diagnosis of the tumor is usually detected in advanced stage (8). We experienced two cases of well-differentiated endocervical adenocarcinoma with cystic components. In the first case, cystic mass with mural nodule was observed. The cystic wall was constructed by benign single layer epithelium. The mural nodule
FIGURE 2. (A) T2-weighted sagittal image (4500/85) shows the high intense multicystic lesion in the cervix. The myoma is shown as the low intense lesion in uterine posterior wall. (B) Postcontrast T1-weighted image (500/ 32) shows enhanced thick cystic walls, however the solid mass is not detected in the uterine cervix. (C) Low power microscopic specimen. The multiple dilated endocervical glands and irregular glands are seen. (H&E stain, magnification 3 5.)
JANUARY/FEBRUARY 1999
histologically showed atypical glandular cells, with partially papillary formation. We were able to interpret this lesion as malignancy, because of the mural nodule. In the second case, multicystic lesion was present. The cysts were dilated endocervical glands with normal epithelium, and there were adenocarcinomas in the surrounding stroma (Figure 2C). We initially diagnosed adenoma malignum on MR imaging. In MR images, the enhanced walls corresponded to adenocarcinoma in endocervical stroma and in the cystic walls (Figure 2B). It is difficult to distinguish this case from adenoma malignum. We need to add cervical adenocarcinoma with cystic components to the differential diagnosis of the uterine cervical cystic lesion including adenoma malignum and nabothian cyst. Mural nodule in the cystic cervical adenocarcinoma seen in the first case may be helpful for correct diagnosis. REFERENCES 1. Worthington JL, Balfe DM, Lee JK, et al. Uterine neoplasms: MR imaging. Radiology 1986;159:723–730. 2. Robert H, Robert E. Invasive adenocarcinoma and related tumors of the uterine cervix. Semin Diagn Pathol 1990;7:205–227.
MRI OF CERVICAL ADENOCARCINOMA
43
3. Togashi K, Nishimura K, Itoh K, et al. Uterine cervical cancer: assessment with high-field MR imaging. Radiology 1986; 160:431–435. 4. Hricak H, Hamm B, Semelka RC, et al. Carcinoma of the uterus: use of gadopentetate dimeglumine in MR imaging. Radiology 1991;181:95–106. 5. Hricak H, Lacey CG, Sandles LG, et al. Invasive cervical carcinoma: comparison of MR imaging and surgical findings. Radiology 1988;166:623–631. 6. Togashi K, Nishimura K, Sagoh T, et al. Carcinoma of the cervix: staging with MR imaging. Radiology 1989;171:245–251. 7. Yasuyuki Y, Takahashi M, Katabuchi H, et al. Adenoma malignum: MR appearances mimicking nabothian cysts. AJR 1994;162:649–650. 8. Turuchi N, Tukamoto N, Kaku T, et al. Adenoma malignum of the uterine cervix detected by imaging methods in a patient with Peutz-Jeghers syndrome. Gynecol Oncol 1994;54:232–236. 9. Doi T, Yamashita Y, Yasunaga T, et al. Adenoma malignum: MR imaging and pathologic study. Radiology 1997;204:39–42. 10. Clement PB, Young RH. Deep nabothian cysts of the uterine cervix. A possible source of confusion with minimal devication adenocarcinoma (adenoma malignum). Int J Gynecol Pathol 1989;8:340–348. 11. Daya D, Young RH. Florid deep glands of the uterine cervix. Another mimic of adenoma malignum. Am J Clin Pathol 1995;103:614–617. 12. Choi CG, Kim SH, Kim JS, et al. Adenoma malignum of uterine cervix in Peutz-Jeghers syndrome: CT and US features. J Comput Assist Tomogr 1993;17:819–892.