Cystic adenomyosis with florid glandular differentiation mimicking ovarian malignancy.

We report a case of cystic adenomyosis, presenting as a huge exophytic cystic mass with florid glandular differentiation. MR findings of the mass mimicked ovarian carcinoma associated with endometriosis. The presence of signal voids bridging the uterus and tumour should suggest a mass of uterine origin. Hyperintense protuberance in a hypointense loculus on T(2) weighted images may suggest benign disease. However, surgical exploration and resection is still required to exclude an ovarian malignancy.

Value of magnetic resonance imaging in predicting efficacy of GnRH analogue treatment for uterine leiomyoma.

BACKGROUND: Estimating pharmacological efficacy is important when selecting conservative treatment of uterine leiomyoma. Hence, the ability of magnetic resonance (MR) imaging to predict gonadotrophin-releasing hormone (GnRH) analogue efficacy was investigated. METHODS: A total of 85 lesions was studied in 40 patients who were clinically diagnosed as having uterine leiomyoma and treated with GnRH analogue for 24 weeks. To evaluate changes in lesion size, T2-weighted and gadopentetate-dimeglumine (Gd-DTPA)-enhanced, T1-weighted MR images were obtained within 2 weeks before, and immediately after termination of, GnRH analogue treatment. RESULTS: An average 46.3% size reduction was observed in 45 lesions (52.9%); these were seen as low signal intensity on T2-weighted images and enhanced by Gd-DTPA. Also, an average 44.7% size reduction was observed in lesions enhanced by Gd-DTPA, irrespective of signal intensity findings on T2-weighted images. The average size reduction of unenhanced lesions was only 17.8%, and significantly different from enhanced lesions (P < 0.001). The prediction of efficacy was difficult in those lesions not enhanced. CONCLUSIONS: It is considered that evaluation of MR signal intensities, and the presence or absence of Gd-DTPA enhancement, would predict treatment efficacy before GnRH analogue administration.

Influence of radiographic technique and equipment on absorbed ovarian dose associated with uterine artery embolization.

PURPOSE: To evaluate the influence of pulsed fluoroscopy (PF), nonpulsed fluoroscopy (NPF), and various fluoroscopic techniques on the absorbed ovarian dose (AOD) associated with uterine artery embolization (UAE) of leiomyomata. MATERIAL AND METHODS: Ovarian location was estimated from preprocedural pelvic magnetic resonance images of 23 patients previously treated by means of UAE. The AOD was measured with thermoluminescent dosimeters (TLD) placed into an anthropomorphic phantom at the determined ovarian location. The following measurements from PF and NPF were obtained: 21.89 minutes of nonmagnified posterior-anterior fluoroscopy, 10 minutes of nonmagnified oblique fluoroscopy, 10 minutes of posterior-anterior magnified fluoroscopy, 10 minutes of combined oblique magnified fluoroscopy, and 47 simulated angiographic exposures. Numbers for nonmagnified posterior-anterior fluoroscopy time and exposure numbers were chosen from the average values from previous UAE procedures. AOD from pulsed and nonpulsed nonmagnified posterior-anterior fluoroscopy was compared to measurements from oblique magnified, posterior-anterior magnified, and oblique fluoroscopy. RESULTS: AOD from NPF was, on average, 1.7 times higher than from PF. When compared with nonmagnified posterior-anterior fluoroscopy, the AOD from oblique magnified fluoroscopy was 1.9 times greater; the AOD from nonmagnified oblique fluoroscopy was 1.1 times greater. The AOD from oblique magnified fluoroscopy was 1.5 times higher on the side closer to the x-ray tube than on the contralateral side. AOD from serial angiographic exposures contributed only less than 7% to the total AOD for the average UAE procedure. CONCLUSIONS: The AOD associated with UAE can best be reduced by limiting fluoroscopy time and the use of oblique or magnified fluoroscopy. Contribution of angiographic exposures to AOD is much less significant.

Symptomatic fibroleiomyomata: MR imaging of the uterus before and after uterine arterial embolization.

PURPOSE: To determine the magnetic resonance (MR) imaging features of uterine fibroleiomyomata after uterine arterial embolization (UAE) and identify pretreatment MR imaging features that may be predictive of successful UAE. MATERIALS AND METHODS: T1- and T2-weighted and dynamic gadolinium-enhanced T1-weighted images were obtained before and 3 months after UAE in 31 patients. Up to five fibroleiomyomata (total of 125) were evaluated for volume, location, signal intensity characteristics, and vascularity. Region-of-interest curves were used to assess the vascular enhancement pattern of each fibroleiomyoma and adjacent myometrium. Each patient completed a questionnaire on symptoms 3 months after UAE. RESULTS: UAE resulted in significant reductions in mean uterine volume (from 588.6 to 393.1 cm(3)) and mean fibroleiomyoma volume (from 69.4 to 41.4 cm(3)) (P <.005). After UAE, lesions showed signal intensity changes consistent with hemorrhagic infarction. The vascularity of fibroleiomyomata was decreased (P <.001), with no significant change in myometrial vascularity. Submucosal location was a strong positive predictor of fibroleiomyoma volume reduction (P < 001). When a reduction in vascularity was the measure of success, hypervascularity was a strong indicator of success (P <. 005). CONCLUSION: MR imaging is useful for quantitative assessment of signal intensity and morphologic changes before and after UAE. Pretreatment MR imaging findings may help predict the success of the procedure.

Tamoxifen-induced uterine abnormalities: the role of imaging.

Tamoxifen citrate is an orally administered, nonsteroidal antiestrogen agent that is widely used for the treatment of breast cancer and that has recently been found to prevent breast cancer in some high-risk populations. Tamoxifen may, however, cause adverse effects at the uterine level. In this article, the authors review (a) the histopathologic uterine changes associated with tamoxifen therapy, (b) the spectrum of uterine imaging findings in women treated with tamoxifen, and (c) the recommendations of the American College of Obstetrics and Gynecology for women treated with tamoxifen. An algorithm for imaging evaluation of the uterus in women treated with tamoxifen is presented.

Abnormal uterine cavity: differential diagnosis with MR imaging.

The objective of the study was to assess the usefulness of magnetic resonance (MR) imaging in distinguishing malignant from benign conditions in patients with an abnormal uterine cavity. Fifty-four patients that were suspected of having abnormal uterine cavities were retrospectively evaluated by using MR imaging. The diagnosis of an abnormal uterine cavity included a thickened endometrium, and/or a endometrial mass, and/or a submucosal mass. Threshold values to classify the uterine cavity as abnormal on sagittal T2-weighted images were >10 mm for premenopausal women and >5 mm for postmenopausal women. Malignancy was diagnosed when lesions invaded the myometrial/junctional zone, and/or lesion enhancement was lower than that of the adjacent myometrium. The results found that histology confirmed 18 malignant and 37 benign lesions. Twelve of 15 endometrial carcinomas and 3 malignant mixed mesodermal tumors (MMMT) were correctly characterized as malignant on enhanced T1-weighted images; whereas 6 of 15 endometrial carcinomas and 3 MMMT were correctly characterized on T2-weighted images. Thirty-four of 37 benign cases were correctly characterized as not malignant on enhanced T1-weighted images. One of 14 submucosal leiomyomas, one endometrial stromal metaplasia, and one of ten pathologically normal endometria were misdiagnosed on enhanced T1-weighted images but were correctly diagnosed on T2-weighted images. The overall sensitivity, specificity, and accuracy for distinguishing malignant from benign central uterine masses were 83%, 92%, and 89% for enhanced T1-weighted image, and 50%, 97%, and 82% for T2-weighted image, respectively. We came to the conclusion that in diagnosing patients with abnormal uterine cavity, MR imaging may help differentiate malignant from benign disorders.

Initial results from uterine fibroid embolization for symptomatic leiomyomata.

PURPOSE: To evaluate the safety and short-term efficacy of uterine fibroid embolization (UFE) in patients with symptomatic uterine fibroids. MATERIALS AND METHODS: Bilateral UFE was performed in 61 patients with symptomatic uterine leiomyomata during a 16-month period. Imaging was performed before the procedure and at 3 months and 1 year after the procedure. Questionnaires were obtained at regular intervals after the procedure to assess patient outcome. RESULTS: All procedures but one were technically successful. Mean clinical follow-up was 8.7 months. Minor complications occurred in five patients during the follow-up period. All were treated without permanent sequelae. Menstrual bleeding was improved in 89%, with 81% of patients moderately to markedly improved. Pelvic pain and pressure was improved in 96% of patients, with moderate to marked improvement in 79%. At initial imaging follow-up (mean, 4.4 months postprocedure), median uterine volume decreased 34% (P = .0001) and the median dominant fibroid volume decreased 50% (P = .0001). Imaging at 1 year (mean, 12.3 months) after the procedure showed continued reduction with a median uterine volume reduction of 48% (P = .0002) and median dominant fibroid volume decrease of 78% (P = .0002). CONCLUSION: In the authors' initial clinical experience, UFE appears effective in controlling symptoms and substantially reducing fibroid volume with few complications.

Inflammatory pseudotumor of the bladder: MR findings.

We report a case of inflammatory pseudotumor of the bladder in a 29-year-old woman with gross hematuria that was considered as embryonal rhabdomyosarcoma on biopsy specimens. MRI demonstrated a polypoid tumor covered by clot, which disrupted the low intensity of the bladder wall. The lesion exhibited an intermediate signal on T1-weighted images and prominent high intensity on T2-weighted images and was markedly enhanced. A pathologic study revealed a tumor of myxoid stroma invading into the deep muscular layer of the bladder wall.

CT and MR findings of splenic angiosarcoma.

A surgically confirmed primary splenic angiosarcoma is described. Although angiography showed most of the characteristic findings of the present patient, MR imaging provided a useful information as a supplemental tool. The tumor demonstrated low-signal intensity on both T1- and T2-weighted images, which might differ from hemangioma findings. Subacute hemorrhage within the tumor was revealed by MR imaging, suggesting the way in which the tumor grew during a short period of time. This finding was different from reported angiosarcoma MR findings of siderotic nodules within the tumor. After the administration of Gd-DTPA, MR images clearly demonstrated heterogeneous enhancement within the tumor, which corresponded to the pathologic findings of solid parenchyma with necrotic tissues.

A case of malignant mixed mesodermal tumor (MMMT) of the ovary: MR features before and after chemotherapy.

Malignant mixed mesodermal tumor (MMMT) of the ovary is rare. We describe the MR findings of this tumor before and after chemotherapy. Although MR findings were not specific to ovarian MMMT, MR images provided useful information about the effect of chemotherapy. Thus we could select appropriate therapy.

MR and CT cholangiography in evaluation of the biliary tract.

OBJECTIVE: To compare MR and CT cholangiography (MRC and CTC) in evaluating the anatomy of the extrahepatic biliary tract and the pathology related to the gallbladder. MATERIAL AND METHODS: Twenty-three patients underwent MRC and CTC with a biliary contrast medium for investigation of biliary disease. 3D displays of both were also obtained. Endoscopic retrograde cholangiography was performed in 17 patients, and the pathology of all 23 was evaluated. RESULTS: Overall, the image quality was higher with CTC than with MRC (4.7 vs 3.9, p < 0.05). The cystic duct was demonstrated better by CTC than MRC (p < 0.05). Multiplanar reformation (MPR) and source images provided additional information to that obtained from 3D MRC and CTC images. Gallstones were revealed in 6 patients by CTC and in 5 of these 6 by MRC. In 2 patients with cholecystitis, CTC demonstrated gallbladder wall thickening but MRC did not. In 3 patients with adenomyomatosis. MRC demonstrated Rokitansky-Aschoff sinuses (RAS) while CTC demonstrated focal gallbladder wall thickening in all 3 and RAS in 1 of them. CONCLUSION: Both MRC and CTC provided anatomical and pathological information about the biliary system. With both techniques, however, either MPR or source images proved necessary in addition for evaluating the biliary system anatomy and pathology. The gallbladder wall was depicted clearly in source CTC, but MRC is recommended for the evaluation of adenomyomatosis because it depicts RAS clearly.

Prognostic application of magnetic resonance imaging in patients with endometriomas treated with gonadotrophin-releasing hormone analogue.

We evaluated the usefulness of magnetic resonance imaging (MRI) for assessing the response of patients with endometriomas to medical therapy. MRI was performed before and after treatment in 20 consecutive patients with at least one endometrioma with a maximal diameter >10 mm diagnosed by laparoscopy who received 900 microg of buserelin acetate daily for 6 months. Patients were categorized as good responders (group I, n = 13) and poor responders (group II, n = 7) depending on the results of a third-look laparoscopy performed 6 months after treatment. We determined the ratio of the signal intensity (SI) of the endometrioma to the SI of the gluteus maximus muscle on T2-weighted images [T2SI/M (muscle) SI] and the volume of the endometrium. The volume decreased by >50% in 61.5% of the good-response group and 57.1% of the poor-response group. There was no significant difference between the two groups. The T2SI/MSI decreased in 12 of 13 patients in group I but in only one of seven patients in group II, a significant difference (P < 0.05) between the two groups. In the good-response group, there was a positive linear correlation between the decrease in the volume of the endometrioma and the decrease in the T2SI/MSI after treatment (r = 0. 561, P < 0.05). Therefore, the T2SI/MSI determined from MR images may be useful in assessing the therapeutic response of patients with endometriomas.

MRI in predicting the response of ovarian endometriomas to hormone therapy.

OBJECTIVE: Our goal was to investigate the usefulness of MRI in predicting the response of endometriomas to hormone therapy. MATERIALS AND METHODS: MRI and laparoscopy at the onset of treatment and follow-up MRI after 6 months of hormone therapy were performed in 21 patients with 49 endometriomas. T1- and T2-weighted images were obtained with a 1.5 T apparatus using a body coil. The lesions were divided into a responder group and a nonresponder group according to whether the lesion size decreased by > or = 50% or not. RESULTS: With MRI, shading was seen in 25 of 27 lesions (93%) from the nonresponder group, but in only 6 of 22 (27%) from the responder group. Low SI rim was seen in 59% of the responders and 89% of the nonresponders. Multiplicity in 68% of the responders and in 85% of the nonresponders and irregularity in 41% of the responders and in 78% of the nonresponders were shown. Multiple logistic analysis revealed shading was the most important factor in prediction of the response to hormone therapy. CONCLUSION: Shading was an important sign in evaluating the response of endometriomas to hormone therapy. MRI may assist in selecting the appropriate therapy for endometriomas.

Studies on the detection of small endometrial implants by magnetic resonance imaging using a fat saturation technique.

To assess the usefulness of fat-saturated magnetic resonance (MR) imaging in detecting small endometrial implants, 258 pigmented lesions of endometriosis from 80 consecutive patients with histopathologically diagnosed pelvic endometriosis were compared using fat-saturated and conventional MR imaging. MR imaging was performed with a 1.5-tesla superconducting magnet with spin echo T1-, T2-, and fat-saturated T1-weighted images. Both conventional MR images and fat-saturated MR images permitted identification of almost all endometriomas > 10 mm in diameter. With conventional MR imaging, 29 endometrial implants measuring < 10 mm in diameter were detected. One hundred and seven lesions were detected by fat-saturated MR imaging. However, conventional MR images demonstrated only 4 lesions among these 111 small endometrial implants that measured < 5 mm in diameter. The addition of fat-saturated MR imaging increased the detection rate to 55 of 111 lesions. Fat-saturated MR imaging can, therefore, be useful in detecting small endometrial implants.

Ovarian cystic teratomas: value of chemical fat saturation magnetic resonance imaging.

Chemical fat saturation (FS) magnetic resonance imaging (MRI) for the characterization of ovarian cystic teratoma was evaluated in 19 patients with 22 lesions. The tumour was evaluated for signal intensity, location and size; the presence of chemical shift artefact, debris and fat-fluid level. Ovarian cystic teratoma was diagnosed prospectively if the mass contained fat and/or more than one type of internal pattern on (1) SE T1-, T2-, (2) SE T1-, T2-, FS T1-weighted images. A correct diagnosis was reached in 17 of 22 tumours on conventional T1- and T2-weighted images, and in 21 of 22 tumours when fat-saturation images were added. When fat-saturation images were added, four of five tumours misdiagnosed on conventional images were then correctly diagnosed. These tumours contained only small amounts of fat. Fat-saturation images could detect smaller amounts of fat than conventional images. However, one tumour did not show decreased intensity on fat saturation images, and was not diagnosed even when fat-saturation images were added. Fat saturation images have been shown to be of value in diagnosing cystic teratomas.

Pelvic endometriosis: detection and diagnosis with chemical shift MR imaging.

Fat-saturation magnetic resonance (MR) imaging for detection and characterization of pelvic endometriosis was prospectively investigated in 35 women with a clinical diagnosis of the disease. Large endometrioma was diagnosed when the lesion was larger than 1 cm in diameter and hyperintense on T1- and T2-weighted images. Small endometrioma was diagnosed when a well-demarcated hyperintense lesion less than 1 cm in diameter was seen on T1-weighted or fat-saturated T1-weighted images. Surgery performed after MR imaging revealed a normal pelvis in six patients, endometriosis in 26 (33 large and 19 small endometriomas), and other cystic lesions in three. Conventional T1- and T2-weighted imaging accurately demonstrated 27 of 33 large endometriomas and two of 19 small endometriomas. Fat-saturation T1-weighted imaging in combination with conventional technique accurately demonstrated 30 of 33 large and nine of 19 small endometriomas. Diagnostic accuracy was improved with addition of fat-saturated images, so their use together with conventional images is recommended in assessment of endometriosis.

Case report: MR imaging of a carcinoid tumour of the liver.

A surgically confirmed solitary primary liver carcinoid tumour is described. MR imaging demonstrated a low signal intensity mass on T1-weighted images, a low signal intensity mass with small area of higher intensity on fat saturation T1-weighted images, and heterogeneous high signal intensity mass on T2-weighted images. The fibrous capsule and septa were demonstrated as low signal intensity bands on both proton- and T2-weighted images.