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
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06510.
0361 -803X/79/1
Address
321-0087
reprint
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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,