Roentgen diagnosis of adenomyosis uteri

ROENTGEN

DIAGNOSIS

OF ADENOMYOSIS

UTERI

MORRIS A. C~OLDBERGER,M.D., RICEIARD H. MARSHAK, M.A., MORTIMER HERMEL, M.D., NEW YORK, N. Y. (From

the Depnrtment

of

Gynecology

nnd~ Rndiology,

A

Mount

Sinai

M.D., -ISI) Hospitnl)

DENOMYOSIS of the uterus is a condition characterized by benign invasion of the endometrium into the uterine musculature associated with an overgrowth of the 1atter.l It differs from pelvic endornetriosis in that whatever is responsible for the abnormal endometrial growth affects the uterine musculature as well. On section through such a uterus, the striking feature is this marked musculature overgrowth. A frequent, although not constant, feature on examination of the extirpated uterus is the presence of dark, hemorrhagic areas,,varying in size from 1 to 4 mm. in diameter and scattered discretely throughout the musculature. The latter represent islands of endometrium in which menstrual hemorrhage has occurred. This invasion of endometrium into muscle forms tubelike structures into which the radiopaque media may penetrate, producing according to our findings a rather characterisbic roentgen film. Short, spiculelike structures extend especially from the superior surface of the uterus varying in size from 1 to 4 mm. and ending in very tiny sacs. This roentgen finding was noted in approximately 15 per cent of the cases of adenomyosis. A possible cause for failure of the dye to enter the endometrial channels in the other cases is the marked overgrowth of muscle which may act as a pinchcock preventing the dye from going into the endometrial channels. Another possibIe cause for failure is the presence of clotted blood within the endometrial We have made the diagnosis of adenomyosis by the above means channels. twelve times in a series of three hundred hysterograms performed because of menst,rual irregularity. ThePe cases were confirmed by hysterectomy. Some of the cases of adenomyosis found at operation which did not reveal the tiny sacs on review of the roent.genograms revealed an irregularity of the uterine border. This irregularity was more marked than was usually noted with hyyerplasia of the endometrium. On pelvic examination, the uterus in these cases was’usually globular and slightly enlarged. These findings would therefore suggest adenomyosis when the t.iny sacs were not, visualized. Adenomyosis can, on occasion, produce a fillin, n defect wit.hin the uterus which simulates a submucous fibroid. Two such cases were encountered. The uterine walls, in these cases, were unusually thick and probably only permitted the dye to outline the periphery of the uterine cavity. Recently we have visualized the tiny sacs more frequently. A possible explanation may be the use of Skiodan acacia in preference to Lipiodol. Skiodan acacia is less viscous and probably cntclrs the endometrial channels more readily than Lipiodol. 563

564

I.-Uterine defects.

Fig.

any

Ailing

Fig. jections

uteri.

are

Z.-The seen

Fig. J.-The la e sacs extending dm.4 ely above the

cavity Several

uterine extending

uterine from cervical

is nurmi~l tiny sacs

cavity from

shalw, and itI size, sern extfnrlinfi are

is norulal in size, tht. left side of the

shape, uterine

position. fronl

the

There superior

is

no evidence surface of

and position. Several Impression: cavity.

cavity is normal in size, shape, and position. There the superior surface of the uterine cavity. Others are Imprmsiota: adenomyosis uteri. n?i.

of the

smsil proadenomyosis

are seen

several imme-

Volume

57

Number

3

hI)ENOMYOSIS

UTERI

56.5

Case Reports (:ASE I.-S. H., a -W-year-old woman, entered +int of profuse menstrual bleeding lasting eight to illness started six months ago with an increase in very severe, lasting ten days and passing numerous essentially negative.

Mount Sinai Hospital with a chief corn nine days and passing clots. Her present her periods. Her last two periods were clots. The remainder of the history was.

Physical examwnation : The uterus was slightly enlarged, not tender. Both adnexa were not palpable. The cervix was not smooth. The remainder of the physical examination was negative. Hysterography revealed no evidence of any filling defects. Several tiny sacs h diagnosis of were seen extending from the superior surface of the uterine cavity. :i(lenornyosis was made which was confirmed by the pathologic sections (Fig. I).

Fib-. Fig. Fig. Several

4.

I.-Same case as above, revealing the sacs in the injected 5.-Hysterography reveals the uterine cavity to be normal sacs are seen extending from the uterine border.

Fig. in

5. specimen. size, shape,

and

position

CASE Z.-M. P., was a 36year-old woman with the chief complaint of dysmenorrhea am1 menorrhagia of many years’ duration. Pelvic examination disclosed an enlarged, globular uterus the size of an orange. h adnexa were thickened and not tender. Numerous small nodules were palpated in the Hysterography revealed many small projections ;\ (lia~oxis of adenomyonis was confirmed extending from the left side of the uterine csavity. by the pathologic sections (Fig. 2). CASE S.--L. F. was a 43.year-old woman with the chief complaint of dysmenorrhe:\ since the onset of her periods anal menorrhHgia during the last four years. Pelvic examination disclosed the uterus to be enlarged to a two months’ gestation due to multiple fibroids. Hysterography revealetl several large sacs extending from the superior surface of the uterine Others were seen immediately above the cervical OS. Hysterectomy and sections cavity. confirmed the diagnosis of a fibroid uterus with adenomyosis (Fig. 3). Fig. -i reveals the sacs

in

the

injecated

specimen.

CASE 4.-T. L. was a 32-year-old woman with the chief complaint of menorrhagia of six months’ duration. Pelvic examination revealed the uterus to be enlarged to the size of a three months gestation by multiple fibroids. Hysterography reveal&A several tiny sacs extending from the uterine border. (Fig. 5). One fairly large sac was seen above the cervical OS on the right side. Hysterectomy and section confirmed the above diagnosis.

Fig. the uterine TIOI-tllally. cavity.

filling cavity.

T.--The cavity Several

Wig. S.-The defects within Impressiolz:

uterine which snx~ll

cavity ii s~n:~ll. There can be du? tu an intranlural *ilc,s i~rrv ,3v’n vxkntlinl:

uterine cavity the uterine adenomyosis.

is slightly cavity and

enlarpe(1. tiny sacs

is

:L ,.oT vltv on the superior surface of flbro (1 but which is occasionally seen tht, superior surface of the uterine

l’r~>ru

dextrovc&
from

There are the border

several of the

small uterine

Volume

Number

57

ADENOMYOSIS

5

CASE 5.-A. S. was and a feeling of weight in the uterus to be enlarged sacs extending from the firmed the diagnosis.

UTERl

567

a 36year-old woman with the chief complaint of dysmenorrhea Pelvic examination revealed her pelvis. Her periods were normal. Hysterography revealed several small to the size of a grapefruit. superior surface of the uterine cavity (Fig. 6). Operation con-

CASE 6.-R. R., a 48-year-old woman, was admitted with abdominal pain, menorrhagia, Endometrid biopsy dysmenorrhea, and anemia. The uterus was enlarged and nodular. revealed a proliferative endometrium. Hysterography revealed several tiny sacs in the superior portion of the uterine cavity (Fig. 7). Dilatation and curettage were done and the pathologic report revealed fragments of endometrium in a proliferative stage. She was admitted again one year later with a severe metrorrhagia for two months after four months after amenorrhea. Pelvic examination was similar to t,he previous admission. Hysterectomy was performed which revealed adenomyosis ant1 small fibromyomas.

%ig. defect

uterine

%-The uterine cavity within the uterine musculature rather than

is noted

is normal in size, cavity. At operation, to submucous flbroid.

shape,

this

and

was

position.

found

A

circular

filling

to be due to thickened

CASE 7.-L. G., a 42.year-old woman, was admitted with the chief complaint of vaginal spotting for the last six weeks. Pelvic examination revealed the uterus to be slightly enlarged. Hysterography performed with Lipiodol revealed several tiny sacs extending from the border of the uterine cavity. In addition, numerous small filling defects were seen within the uterine cavity. Hysterectomy revealed adenomyosis (Fig. 8).

CASE 8.-S. A., a 28.year-old woman, was admitted with the diagnosis of menometrorRecently the bleeding had become severe and the patient rhagia of two years’ duration. passed numerous clots. Pelvic examination revealed the uterus to be slightly enlarged. Roth adnexa were not palpated. Hysterography revealed (Fig. 9) a filling defect occupying practically the entire uterine cavity. A diagnosis of a submucous fibroid was made. Dilatation and curettage were performed and, although the operator could feel a tumor, he was unable to remove it. Hysterectomy revealed a uterus that was slightly enlarged. The muscular layer was extremely thickened and bulged into the uterine cavity. Except for a very small endometrial polyp in the left upper quadrant of the uterine cavity, no further abnormality It was felt that the marked overgrowth of muscle produced a bulging into the was noted. uterine cavity which simulated a submucous fibroid. We have since encountered this finding in another case confirmed by operation.

Conclusions 1. Hysterography is of great help in determining the presence oI’ intrauterine pathology. 2. Adenomyosis uteri can be occasionally diagnosed by hysterography, especially when the dye enters the endometrial pits which have invaded the nterinc musculature. 3. The above findings has been seen more frequent.]!- since the use of Skiodan acacia. 4. Hysterography has been very helpful in the institution of more specific t.herapy. 5. There have been no reactions or ill effects from the use of Skiodan acacia in t,hese cases.

Reference 1. Novak, E.: Gynecological Wilkins Company. 1075

PARK

AVENUE

and Obstetrical

Pathology,

Baltimore,

1940, The \Villiams

and