Case 10442 Endometrial carcinoma vs endometrial polyp: MR imaging findings Athina C. Tsili1, Anna Batistatou2, Maria I. Argyropoulou1 (1) Department of Clinical Radiology (2) Department of Pathology University Hospital of Ioannina, Leoforos S. Niarchou, 45500; Pl. Pargis 2, 45332 Ioannina, Greece; Email:
[email protected] University Hospital of Ioannina Section: Genital (Female) Imaging Published: 2013, Jan. 7 Patient: 76 year(s), female
Clinical History A 76-year-old woman was referred to the Gynaecology clinic for abnormal uterine bleeding. Endometrial biopsy revealed papillary serous endometrial adenocarcinoma of moderate differentiation. MR imaging of the pelvis followed.
Imaging Findings MR imaging showed a heterogeneous mass, causing distension of the endometrial cavity (Fig. 1-3). The lesion was barely visible on T1-weighted images (Fig. 1c), heterogeneous on T2-weighted images, partly of intermediate signal intensity (Fig. 1b). The same component showed poor enhancement when compared to the normally enhancing myometrium (Fig. 2) and restricted diffusion (Fig. 3). Imaging findings were strongly suggestive of endometrial carcinoma. The junctional zone was intact. Neither cervical invasion, nor pelvic lymphadenopathy was revealed. Part of the endometrial mass was also depicted heterogeneous, with an area of very low signal intensity on T2-weighted images and small, well-defined intratumoral cysts (Fig. 1b). This
component showed strong, heterogeneous enhancement on late post-contrast T1-weighted images (Fig. 2). Imaging findings were suggestive of the coexistence of an endometrial polyp. The high ADC values of this part (Fig. 3) confirmed the diagnosis of benignity. Histology following radical hysterectomy reported papillary serous endometrial adenocarcinoma (stage IA), coexisting with endometrial polyp.
Discussion Background Endometrial carcinoma represents the most common gynaecologic malignancy in many developed countries [1-3]. Most endometrial carcinomas are diagnosed at an early stage due to post-menopausal bleeding. Surgical treatment options depend on the local extent of the disease. MR imaging is recommended as the staging examination of choice in women with newly diagnosed endometrial carcinoma [1-3]. Endometrial polyps are common, with an incidence of 10-24%, usually seen at the age of 40-50 years and rarely after menopause [4-6]. They represent localized hyperplastic overgrowths of endometrial glands and stroma around a thick-walled vascular core, forming a sessile or pedunculated projection from the surface of the endometrium. Focal or diffuse dense fibrous tissue and sometimes smooth muscle are seen in the polyps. Cystic glandular hyperplasia often coexists [4]. Endometrial polyps are almost always benign. Less than 1% is associated with malignancy and the risk increases with advancing age [4-6]. Imaging Perspective On MR imaging endometrial polyps are usually of intermediate signal intensity on T1-weighted images, with heterogeneous high signal intensity on T2-weighted images. Differentiation from endometrial carcinoma may be possible based on morphologic features. A central fibrous core, of low signal intensity on T2-weighted images and intralesional cysts that are small, smooth-walled sharply-defined hyperintense structures on T2-weighted images may strongly suggest the diagnosis of endometrial polyp. These findings were met in this case. After gadolinium administration, intense enhancement of the fibrous core may be seen [4-6]. However, biopsy in these patients is not obviated, partly due to the presence of microscopic carcinomas and the coexistence of polyps and carcinomas. Endometrial carcinoma is usually detected with signal intensity similar to that of normal myometrium on T2-weighted images, enhancing less than myometrium on post-contrast T1-weighted images, as in this patient. Myometrial invasion and presence of necrosis proved of high predictive value for the diagnosis of malignancy [4]. Diffusion-weighted (DW) sequences are planned to identify alterations in thermally induced random (Brownian) motion of water molecules within tissues [7-11]. A variety of endometrial lesions were differentiated by Fujii et al based on DW imaging characteristics. Malignancies such as endometrial carcinoma and carcinosarcoma had lower ADC values than benign lesions including submucosal leiomyomas and endometrial polyps in this study [7]. In this patient, DW imaging characteristics increased the diagnostic confidence in differentiating between endometrial carcinoma and endometrial polyp. However, overlap between benign and malignant endometrial lesions may occur (e.g, celluar leiomyomas, necrotic or haemorrhagic tumours, low grade endometrial carcinomas).
Final Diagnosis Endometrial carcinoma coexisting with endometrial polyp.
Differential Diagnosis List Endometrial carcinoma, Endometrial polyp, Endometrial hyperplasia, Submucosal leiomyoma, Uterine sarcoma
Figures Figure 1 MR examination.
Sagittal T2-weighted image shows a heterogeneous mass within the expanded endometrial cavity, predominantly with signal intensity similar to that of normal myometrium. Note that the junctional zone is intact. © Tsili A, Department of Clinical Radiology, University Hospital of Ioannina, Greece.
Area of Interest: Genital / Reproductive system female; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Neoplasia;
Transverse T2-weighted image depicts partly the lesion isointense to normal myometrium (arrow) and partly with presence of small, smooth-walled, well-defined high-signal intensity intratumoral cysts and a low-signal intensity fibrous core (arrowhead). © Tsili A, Department of Clinical Radiology, University Hospital of Ioannina, Greece.
Area of Interest: Genital / Reproductive system female; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Neoplasia;
Transverse T1-weighted image shows no obvious lesion. © Tsili A, Department of Clinical Radiology, University Hospital of Ioannina, Greece.
Area of Interest: Genital / Reproductive system female; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Neoplasia; Figure 2 MR examination, post-contrast image.
Transverse post-contrast fat-suppressed T1-weighted image shows part of the lesion enhancing less than normal myometrium (arrow, corresponding to endometrial carcinoma) and part enhancing strongly and heterogeneously (long arrow, corresponding to endometrial polyp). © Tsili A, Department of Clinical Radiology, University Hospital of Ioannina, Greece.
Area of Interest: Genital / Reproductive system female; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Neoplasia; Figure 3 MR examination, ADC map.
Transverse ADC map (b700 s/mm2) shows hypointensity of endometrial carcinoma (ADC value: 0.69 mm2/s, arrow) and hyperintensity of endometrial polyp (ADC value: 1.77 mm2/s, asterisk). © Tsili A, Department of Clinical Radiology, University Hospital of Ioannina, Greece
Area of Interest: Genital / Reproductive system female; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Comparative studies; Special Focus: Neoplasia;
MeSH Endometrial Neoplasms [C13.371.852.762.200] Tumors or cancer of ENDOMETRIUM, the mucous lining of the UTERUS. These neoplasms can be benign or malignant. Their classification and grading are based on the various cell types and the percent of undifferentiated cells. Endometrial Hyperplasia [C13.371.852.228] Benign proliferation of the ENDOMETRIUM in the UTERUS. Endometrial hyperplasia is classified by its cytology and glandular tissue. There are simple, complex (adenomatous without atypia), and atypical hyperplasia representing also the ascending risk of becoming malignant. Diagnosis, Differential [E01.171] Determination of which one of two or more diseases or conditions a patient is suffering from by systematically comparing and contrasting results of diagnostic measures. Magnetic Resonance Imaging [E01.370.350.500] Non-invasive method of demonstrating internal anatomy based on the principle that atomic nuclei in a strong magnetic field absorb pulses of radiofrequency energy and emit them as radiowaves which can be reconstructed into computerized images. The concept includes proton spin tomographic techniques.
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[8] Namimoto T, Awai K, Nakaura T, Yanaga Y, Hirai T, Yamashita Y (2009) Role of diffusion-weighted imaging in the diagnosis of gynecologic diseases Eur Radiol 19:745-760. [9] Fujii S, Matsusue E, Kigawa J, et al (2008) Diagnostic accuracy of the apparent diffusion coefficient in differentiating benign from malignant uterine endometrial cavity lesions: initial results Eur Radiol 18:384-389. [10] Wang J, Yu T, Bai R, et al (2010) The value of the apparent diffusion coefficient in differentiating stage IA endometrial carcinoma from normal endometrium and benign diseases of the endometrium: initial study at 3-T magnetic resonance scanner J Comput Assist Tomogr 34:332-337. [11] Tamai K, Koyama T, Saga T, et al (2008) The utility of diffusion-weighted MR imaging for differentiating uterine sarcomas from benign leiomyomas Eur Radiol 18:723-30.
Citation Athina C. Tsili1, Anna Batistatou2, Maria I. Argyropoulou1 (1) Department of Clinical Radiology (2) Department of Pathology University Hospital of Ioannina, Leoforos S. Niarchou, 45500; Pl. Pargis 2, 45332 Ioannina, Greece; Email:
[email protected] (2013, Jan. 7) Endometrial carcinoma vs endometrial polyp: MR imaging findings {Online} URL: http://www.eurorad.org/case.php?id=10442
