Gray

Scale

Ultrasonography

in the Diagnosis

of Endometriosis

and

Adenomyosis

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JAMES

W. WALSH,”2

KENNETH

J. W. TAYLOR,’

Ultrasound findings in 25 patients with surgically proven endometriosis are presented. Of the 31 lesions characterized at ultrasound examination, 17 were described as cystic, four as polycystic, five as mixed, and four as solid. Nine patients had a diagnostic pattern of sonolucent zones within the uterus representing blood lakes (adenomyosis) associated with cxtrauterine masses. In the remaining 16 patients, ultrasound alone could not differentiate endometriosis from diseases such as tubovarian abscess, ruptured ectopic pregnancy, ovarian cyst(s), or tumor. Clinical history contributed to proper diagnosis in these patients.

AND

About

15%

active 20%

pattern.

All

cystic

ultrasound

findings

in

25

surgically

proven

cases

patient, adhered Three

Over a 2 year suspected pelvic Surgery confirmed

surgery

consisting

and

was

of

centrally

ovarian

endometriosis

Methods five

of the endometrioma

having

with

with

lining

the

two

3).

small

the patient

focal

clusters wall

patients

with

ovaries

bilateral

with

focal

uterus

was

clusters

of

incorporated

echogenic

into

the

debris

mass

Classic ultrasound patients. In four

mass

was

dium

gray-toned

round

patient

criteria of these

with

fine,

echoes

a 9 x

suggested patients the

Nine

were of dis-

The sound

the

masses patterns:

were

characterized

cystic,

polycystic,

homogeneous, uniformly

12 cm

light

filling

the

endometrioma

to me-

lesion.

extended

different and

In

In

13

cases

the

masses

were

located

in

fine,

speckled

5). The

,

myometrium

the

the 25 patients, 31 lesions were classified. In 13 patients, 17 cystic lesions with an average size of 4-8 cm were noted. In 10 of these lesions, the inner wall of the cyst was irregular and shaggy. In seven cysts, the mass had a smooth, well defined inner wall. Fifteen cysts were acoustically sonolucent and two had internal septation.

to

have

was

echo

honeycomb

due

to

these

uterus

remained

132:87-90, January 1979 1979 American Roentgen Ray Society

changes

of

was chardisrupting the

uterus

appearance

of

blood-containing

in situ.

When pian

sound bined

the

external

tubes,

endometriosis involves the ovary, fallothe pelvic peritoneum, gray scale ultrapromote the correct diagnosis when coma characteristic clinical history or physical and

may with

examination.

When

ultrasonography

shows

enomyosis

(internal

endometriosis)

combined

of the

four

osis can

described

endometriosis

patterns,

87

uterine

ad-

with

any

endometri-

be diagnosed.

Received June 2, 1978; accepted after revision September 29, 1978. , Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut requests to K. J. W. Taylor. 2 Present address: Department of Diagnostic Radiology, Medical College of Virginia, Richmond, Virginia 23298.

©

of blood.

It was most or cul-de-sac

pattern

focal

patho-

Discussion

adnexae and in four cases, the cul-de-sac (fig. 1). In one patient, a cystic endometrioma was present in an enlarged left ovary and a right ovarian endometrioma was located in the cul-de-sac (fig. 2). The uterus closely

AJR

uterine

location. adnexal

In from

cavities (adenomyosis). This was only confirmed by pathologic examination in four of nine patients; in the others

ultrasolid.

noted

a subserosal with cystic

On ultrasonogram, this abnormality by 5-7 mm irregular cystic spaces

1 2, and

the

mixed,

were

those in associated

normal

(figs. by four

patients

masses. acterized

Results

in all

solid lesions in 4-7 cm adnexal

including commonly

Ultrasonograms and organ site

not

when reviewing the ultrasonograms. In the cul-de-sac was filled with confluent

2.25 or 3.5 MHz, depending upon the patient’s was routinely scanned using the full bladder transverse and sagittal sections. with pathologic morphology

of pro-

could

the left true pelvis to the umbilicus (fig. 6). The logic specimen in each patient was an endometrioma the ovary filled with characteristic, brown altered

multiple correlated ease.

the

and

formed in 21 patients and hysterectomy in four. One patient was 60 years old and the others ranged from 22 to 46. Ultrasound examinations were performed with commercially available gray scale equipment at a transducer frequency of

size. The pelvis technique with

uterus

In one cyst

the

small

In each

chocolate

cases

pattern.

cystic In

to five

(fig.

In two

outer

a polycystic

three

multiple

at surgery,

of the

patients.

one

was per-

had

4).

part

septations

mass. a mixed

(fig.

masses

5). The

as

cells.

tissue

jecting

(fig.

ovary

echogenic

cystic

by

predominantly

be distinguished both patients

period, 325 consecutive female patients with masses were referred for ultrasound study. endometriosis in 25 patients. Conservative

of resection

excised

formed

ovary

by endometrial to the adnexal patients had

mass

ultrasound pattern is described.

an enlarged separated

the lined

three Subjects

had

cavities

cysts

of all women develop endometriosis during menstrual life [1], and it is discovered in of gynecologic laparotomies [2]. Gray scale

endometriosis are reported, and one specific for diagnosing endometriosis

T. ROSENFIELD1

adhered to the cystic mass and cyst wall in eight patients. Four patients were classified

irregular

their about

ARTHUR

06510.

0361 -803X/79/1

Address

321-0087

reprint

$0.00

88

ET

AL.

AJR:132,

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WALSH

Fig. through

January

-A, Transverse true pelvis revealing

1

bibbed

cystic

mass

1979

section

3 cm

(E) behind

uterus

(U) in pouch of Douglas. Sonolucent areas (arrows) in uterus represent adenomyosis. B = bladder. B, Midline

sagittal

section

through

bladder

demonstrating

adenomyosis

in

endometrioma

uterus

(U);

(B)

(arrows) (E)

lo-

cated in cul-de-sac.

Fig.

2.-Bilateral

endometriomas.

A, Transverse section through bladder (B) 6 cm above symphysis pubis showing cystic masses (E) in left adnexa and cul-de-sac. Irregular cystic spaces in uterus (arrows) represent adenomyosis. B, Sagittal section through bladder (B) 1 cm left of midline demonstrating cystic spaces from adenomyosis throughout uterus (arrows). Right

ovarian

cated in pouch

chocolate

cyst

(E)

lo-

of Douglas.

Fig. 3.-Multiple endometrial cysts. A, Transverse section through bladder (B) 2 cm above symphysis pubis revealing 5 cm mass (arrows) left of uterus (U). Multiple chocolate cysts found in left ovary at surgery. B, Longitudinal section through bladder (B) 3 cm left of midline showing multiple oblong cysts in left ovary (arrows) separated by septations.

Uterine endometrium

adenomyosis into

the

is characterized myometrium,

and

by ingrowths

of

are caused

the

of

ucts

presence

glandular and stromal tissue among the uterine muscle fibers [3]. Cystic blood-containing spaces in the uterus

[2].

by dilated Pathologically,

or diffuse, and usually wall. On ultrasonography,

glands

filled

adenomyosis

involves these

with

menstrual may

be

the posterior dilated glands

prodlocalized

uterine appear

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AJR:132, January

4.-A,

Fig. through right

Transverse

bladder

plex cystic

ULTRASOUND

1979

(B) and

ENDOMETRIOSIS

AND

ADENOMYOSIS

89

section

revealing

mass (black arrows)

adnexa

OF

cul-de-sac

cornfilling behind

uterus

(U). Solid tissue (white arrow) lines posterior wall. B, Sagittal section through true pelvis revealing cystic mass

(black

Fig.

verse cm

solid

5.-Frozen

section

above

behind

arrows)

(B) with central (white arrow).

pelvis.

through

symphysis

bladder

component

A,

bladder pubis

Trans-

(B) 4

revealing

confluent cystic mass (black arrows) filling pelvic floor and pouch of Douglas. Multiple sonolucent spaces in

uterus (white arrows) represent adanomyosis. B, Longitudinal section through bladder (B) 1 cm left of midline revealing irregular in pouch of Douglas.

spaces (arrows) in uterine

cystic mass (E) Confluent cystic

due to adenomyosis

fundus.

as irregular cystic spaces through the myometrium [4]. The incidence of this ultrasound pattern was 36% in these patients. This coincidence of adenomyosis with endometriosis is higher than is reported in pathologic literature. Typically, adenomyosis is described as distinct from endometriosis, although associated with it in 13% [5]. It is said to occur in older women who have had more children. However, it is also described as the “hidden” disease

removed incidence because

and,

as

in this

series,

the

uterus

is not

always

to allow pathologic examination. The higher found in this series may be real, although of the small subject population further study is

needed.

We observed endometrial lesions with a cystic, mixed, or solid pattern similar to those previously reported [6]. in addition, four patients had a unilateral enlarged polycystic ovary. An ovary with multiple benign follicular or inclusion cysts may mimic this pattern of endometriosis. This ultrasonic appearance was similar to bilateral polycystic ovaries we observed in the Stein-Leventhal syndrome. The solid echo pattern noted in five chocolate cysts

was presumably osition. Although ian

tumors,

geneous, transmission.

been highly The

due to organized blood difficult to distinguish

these

endometriomas

low-level

echo

had

pattern

In ourexperience,

and from a uniform,

with ovarian

was

adherent,

border

through

neoplasms

forming,

depovarhomo-

good

inhomogeneous, mixed with cystic echogenic, and sound attenuating. uterus

fibrin solid

have

elements, or incorpo-

rated into the adnexal or cul-de-sac endometriosis deposits in 13 of 25 patients. Cyclic hemorrhage into the lesions probably resulted in a fibrotic reaction and cicatrization between pelvic organs. Primary differential diagnoses are tuboovarian abscess and ruptured ectopic pregnancy. Cystic collections of purulent material or blood (endometriosis or ruptured ectopic pregnancy) may have identical ultrasonic appearances. Evaluation of the uterine echo pattern can be the key to correct diagnosis. In patients with tuboovarian abscess, the uterus should have a normal echo pattern; fever and an exquisitely tender pelvic examination are adjunct clinical data. In patients with ectopic pregnancy, the uterus may contain clusters of high amplitude echoes

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90

WALSH

ET AL.

AJR:132,

January

1979

may contain small cystic lakes of blood due to adenomyosis. A history of dysmenorrhea, menorrhagia, chronic pelvic or sacral pain, or dyspareunia also contributes to proper diagnosis. Gray scale ultrasound is a valuable tool in the evaluation of patients with endometriosis. Specific diagnosis is possible when adenomyosis is present or a typical clinical history is obtained. REFERENCES 1.

Jenkinson

EL,

Brown

WH:

JAMA

Endometriosis.

122:349-

354, 1943 2. Browne JCM:

Postgraduate Obstetrics and Gynecology. Butterworths, 1973 3. Dewhurst CJ: Integrated Obstetrics and Gynaecology for Postgraduates. Oxford , Blackwell Scientific Publications, London,

1976 Fig. bladder

from with

6.-Left ovarian endometrioma. (B) 6 cm left of midline revealing

4 cm above homogeneous

symphysis

pubis

Longitudinal section through 9 x 12 cm mass (E) extending

(SP) to umbilicus

(U). Mass filled

4, Taylor 5.

echoes.

due to increased vascularity of the myometrium or to a decidual reaction [7]. A positive urine chorionic gonadotropin or beta subunit blood result is important clinical information. In patients with endometriosis, the uterus

KJW: Atlas

burgh,

Churchill

Benson

AC,

Sneeden

symptomatology. 6.

SandIer

MA,

endometriosis. 7.

Maklad

diagnosis 1978

NF,

of Grey Livingstone,

Scale 1978

VD:

Adenomyosis:

Am J Obstet Karo

JJ:

The

Radiology Wright

of ectopic

CH:

Ultrasonography.

Gynecol

spectrum Grey

pregnancy.

scale

a reappraisal

76 : 1044-1061

of ultrasonic

1 27 : 229-231

Edin-

,

of ,

1958

findings

in

1978

ultrasonography

Radiology

in

the

126 : 221 -225,

Gray scale ultrasonography in the diagnosis of endometriosis and adenomyosis.

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