David Sutton Radiology Textbook Reading, Radiology Resident of Gajah Mada University

1. TEXTBOOK READING OF SUTTON
Textbook of Radiology and Imaging
7th Edition, Volume 2, page 1095-1097
CHAPTER 34:
GYNECOLOGICAL IMAGING
Presented by: Yessi Oktiari
Consultant: dr. Yana Supriatna, Ph.D, Sp.Rad(K)RI

2. CHAPTER 34: GYNECOLOGICAL IMAGING
 Ultrasound
 Plain Film Radiology
 Contrast Studies
 Computed Tomography
 Interventional Radiology
 Magnetic Resonance Imaging
 Uterus, Cervix and Vagina
 Congenital Uterine Abnormalities
 Uterine Tumours
 Cervical Carcinoma
 Ovaries

3. UTERUS ANATOMY
Source: Atlas of Human Anatomy 6th Ed
Source: Diagnostic Imaging 7th Ed

4. LEIOMYOMA (UTERINE FIBROID)
 Most common solid uterine
tumour
 Composed of smooth muscle,
varying amount of fibrous tissue
 Single or multiple
 Estrogen dependent
Location
 Submucosal
 Intramural
 Subserosal Source: mayoclinic.org

5. LEIOMYOMA
MRI
 Accurate assesment of the site,
number, size as small as 3 mm
diameter
 IV gadolinium-chelate does not
improve the detection

6. LEIOMYOMA
Non degenerating
T1: uniform signal intensity
T2: low signal intensity
Degenerating
T1: intermediate-high signal
intensity
T2: high signal intensity
Source: Diagnostic Imaging 7th Ed
Sagittal T2-weighted MRI demonstrating
several uterine fibroids (white arrows), which
are of low signal intensity. The endometrial
cavity is normal (black arrow).
B, bladder; C, cervix

7. LEIOMYOMA
USG
• Useful in demonstrating
subserosal and submucosal lesion
on pedicle
• Precludes the use of uterine
artery ablation
MRI
• Limited in the presence of
retroverted displaced uterus
• Difficult in discriminating a uterine
& adnexal mass
• False negative up to 20%

8. ADENOMYOSIS
http://www.emedicinehealth.com/adenomyosis-health/article_em.htm
The presence of endometrial
glandular cells and cells of the
chorion more than 2.5 mm from
the endometrium-myometrium
interface
Risk factor:
1. Prior endouterine surgery
2. Multiparity
3. Women between 40-50
tahun
Signs and symptoms:
1. Menorrhagia
2. Dysmenorrhea
3. Recent onset of menstrual
cramping that is gradually
getting worse
MRI Characteristics of the Uterine Junctional Zone: From Normal to the Diagnosis of Adenomyosis, Novellas et al., 2011

9. ADENOMYOSIS
 Can’t be distinguished from leiomyomas on clinical findings or by
ultrasound
 Similar pelvic pain & menorraghia with uterine enlargement
 Different treatment
 Adenomyosis vs leiomyoma on MRI
MRI findings Adenomyoma Leiomyoma
1. Diffuse or focal thickening
of junctional zone
Yes No
2. Ill-defined margin Yes No
3. Signal intensity Low Low but often high
4. Periphery large vessels No Yes

10. JUNCTIONAL ZONE
 MRI is the first imaging technique to reveal this structure
 Innermost layer of myometrium
 A distinct low signal on T2-weighted sequences separating the
endometrium in high signal intensity from the outer
myometrium in intermediate signal
 Looser extracellular matrix, lower water content
 The upper limit of normal for the junctional zone thickness: up
to 5–8 mm (midsagital image through the long axis of uterus)
MRI Characteristics of the Uterine Junctional Zone: From Normal to the Diagnosis of Adenomyosis, Novellas et al., 2011

11. JUNCTIONAL ZONE
MRI Characteristics of the Uterine Junctional Zone: From Normal to the Diagnosis of Adenomyosis, Novellas et al., 2011

12. ADENOMYOSIS ON MRI
Direct sign Indirect sign
1. Microcysts
2. Adenomyoma
Thickness of the junctional zone exceeding
12 mm
Diagnostic accuracy 85% and spesificity of
96%
Advantages Limitation
• Less interoperator variability
• More specific diagnosis
• Only 50% cases detecting mycrocysts
• From 20% to 30% of patients will not have
a measurable junctional zone during their
reproductive cycle, 50% in postmenopausal
women
MRI Characteristics of the Uterine Junctional Zone: From Normal to the Diagnosis of Adenomyosis, Novellas et al., 2011
Sensitivity: 70% to 86% and a specificity of 86–93%
These numbers are similar to ultrasound

13. ADENOMYOSIS
Source: Diagnostic Imaging 7th Ed

14. RESUME
 Uterus anatomy
 Leiomyoma
 Pathology
 MRI
 Adenomyoma
 Definition
 Junctional Zone
 MRI

15. QUIZ
What is the most likely diagnosis
on the following MRI:
a. Endometriomas
b. Adenomyosis
c. Leiomyosarcoma
d. Uterine fibroids
e. Cervical carcinoma

16. TERIMA KASIH
MOHON ASUPAN