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UsualandUnusualImagingManifestationsonMRIofAdenomyosis 鄭州大學(xué)第一附屬醫(yī)院磁共振科何杰2013年4月17日 子宮腺肌癥常見(jiàn)和不常見(jiàn)的MRI表現(xiàn) Adenomyosisisacommonnonneoplasticgynecologicdiseasecharacterizedbythepresenceofectopicendometriumwithinthemyometrium Adenomyosistypicallyaffectsmultiparous premenopausalwomenover30yearsofageandmaycausedysmenorrhea menorrhagia andabnormalgenitalbleeding 子宮腺肌癥是一種常見(jiàn)的非腫瘤性婦科疾病 是發(fā)生在子宮肌層的子宮內(nèi)膜異位癥 其主要發(fā)生于超過(guò)30歲 絕經(jīng)前的經(jīng)產(chǎn)婦并且可能引起痛經(jīng) 月經(jīng)過(guò)多和不正常的陰道出血的癥狀 Magneticresonance MR imagingisanoninvasivemodalitywithhighsensitivityandspecificityfordiagnosisofadenomyosis Incasesofanenlargeduterusrevealedwithultrasonography MRimagingallowsdifferentiationofadenomyosisfromleiomyomaorotherpathologicconditionsowingtoitsexcellenttissuecontrastresolution 磁共振 MR 成像是一種非侵入性的檢查方式 其在診斷子宮腺肌癥上具有高的靈敏度和特異度 當(dāng)超聲檢查中發(fā)現(xiàn)子宮增大時(shí) 磁共振由于其出色的組織對(duì)比分辨率可以把子宮腺肌癥與子宮肌瘤或其他疾病鑒別出來(lái) Introduction OnT2 weightedimages typicaladenomyosisappearsasanill demarcatedlow signal intensitylesionwithuterineenlargement However variousphysiologicorpathologicstatesmayaffecttheMRimagingappearanceofadenomyosisandmayresultinatumorlikeappearance在T2WI上 子宮腺肌癥的典型表現(xiàn)為一個(gè)邊界不清的低信號(hào)強(qiáng)度病變伴隨著子宮增大 然而 多種生理和病理改變也許會(huì)影響子宮腺肌癥的MRI表現(xiàn)并且會(huì)導(dǎo)致其出現(xiàn)腫瘤樣的表現(xiàn)SpecifictopicsdiscussedareMRimagingmanifestationsoftypicaladenomyosis atypicalMRimagingmanifestationsofadenomyosis pitfallsindiagnosisofadenomyosis 討論的具體話題包括子宮腺肌癥的典型MRI表現(xiàn) 子宮腺肌癥的不典型MRI表現(xiàn) 子宮腺肌癥的診斷誤區(qū) Introduction MRImagingManifestationsofTypicalAdenomyosis 子宮腺肌癥的典型MRI表現(xiàn) TypicalAdenomyosis Atpathologicanalysis adenomyosisischaracterizedbythepresenceofectopicendometrialglandsandstromawithinthemyometriumwithhypertrophyandhyperplasiaofsmoothmuscleAdenomyosismayaffecttheuterinemyometriumdiffuselyandresultinadiffuselyenlargeduterus oritmaybelocalizedasanadenomyoma 病理分析 子宮腺肌癥的特征性表現(xiàn)是子宮肌層內(nèi)異位的子宮內(nèi)膜腺體和間質(zhì)的存在和平滑肌的肥大增生 子宮腺肌癥也許會(huì)彌漫性的影響子宮肌層并導(dǎo)致子宮彌漫性的增大 或者會(huì)作為腺肌瘤局限性的影響肌層 Acutsectionofadiffuselyadenomyoticuterusshowsthickenedmyometriumduetotheill definedadenomyosis thethickenedmyometriumiscomposedofhaphazardlydistributedhypertrophiedmusculartrabeculaesurroundingectopicendometrialtissue Fig1 Brownisholdhemorrhagicfocicorrespondingtohemolysedbloodandhemosiderinpigmentdepositsmaybecontainedwithintheareaofadenomyosis彌漫型腺肌型子宮的橫斷面顯示由于界限不清的子宮腺肌病導(dǎo)致肌層增厚 肥厚的肌層是由隨意分布的肥大性肌小梁及周圍的異位子宮內(nèi)膜組織所構(gòu)成 圖1 褐色的舊出血灶也許對(duì)應(yīng)著子宮腺肌癥區(qū)域內(nèi)的出血和含鐵血黃素沉積 TypicalAdenomyosis Fig 1A1B 1A 1B Figure1 Adenomyosisina47 year oldwoman 47歲女性 子宮腺肌癥患者 a Photographofthecutsurfaceofthegrossspecimenshowsdiffuselythickenedmyometrium b photomicrograph hematoxylin eosinstain showsectopicendometrialglandsandstroma arrow surroundedbyhypertrophiedsmoothmuscle a 大體標(biāo)本的切面照片顯示彌漫性增厚的子宮肌層b 顯微鏡下照片 HE染色 顯示異位的子宮內(nèi)膜腺體和間質(zhì)和周圍的肥厚的平滑肌 Typicaladenomyosisappearsasanill demarcatedlow signal intensityareaonT2 weightedimagesowingtoabundantsmoothmuscleproliferation Fig2 Becauseadenomyoticendometriumlookslikethebasalisendometrium whichseldomrespondstohormonalstimuli cyclicchangesincludingdegeneration bleeding andregenerationarelesscommoninadenomyosisthaninendometriosis 子宮腺肌癥的典型表現(xiàn)是在T2WI上有一界限不清的低信號(hào)區(qū)域 這是由于豐富的平滑肌細(xì)胞增殖 因?yàn)橄偌“Y子宮內(nèi)膜跟基底子宮內(nèi)膜一樣 很少對(duì)激素的刺激做出反應(yīng) 所以與其他子宮內(nèi)膜異位癥相比 包括變性 出血 再生這樣的周期性的變化較少出現(xiàn)在子宮腺肌癥中OnT2 weightedMRimages ectopicendometriumappearsassmallhigh signal intensityareaslikenormalendometrium Fig2 Smallcystsmayalsoappearashigh signal intensityspotsonT2 weightedimages Sometimes hemorrhagicfociappearas1 3mmhigh signal intensityfocionT1 weightedimagesowingtotheT1 shorteningeffectsofmethemoglobin Fig2 在T2WI圖像上 異位子宮內(nèi)膜表現(xiàn)為跟正常子宮內(nèi)膜一樣的小的片狀高信號(hào) 小的囊腫也可能在T2WI上表現(xiàn)為點(diǎn)狀高信號(hào) 有時(shí)候由于高鐵血紅蛋白T1縮短效應(yīng)的影響 出血灶在T1WI上表現(xiàn)為1 3mm的高信號(hào)病灶 TypicalAdenomyosis Susceptibility weightedimagingissensitiveforoldhemorrhagicfoci whichappearasspottysignalvoidsowingtotheT2 shorteningeffectsofhemosiderin Atdiffusion weightedimaging adenomyosishaslowtointermediatesignalintensity afindingconsistentwithitsbenign nonneoplasticnature Fig3 磁敏感加權(quán)成像對(duì)陳舊出血灶很敏感 由于含鐵血黃素T2縮短效應(yīng)的影像 表現(xiàn)點(diǎn)狀低信號(hào) 在彌散加權(quán)像上 子宮腺肌癥表現(xiàn)為低到中等信號(hào)強(qiáng)度 這種表現(xiàn)其實(shí)與它是良性 非腫瘤性病變這種性質(zhì)相一致However thereisnodirectcorrelationbetweensignalintensityatdiffusion weightedimagingandmalignancy mostmalignanttumorshaveveryhighsignalintensityatdiffusion weightedimaging afindingthatreflectsthelongT2relaxationtimeandrestricteddiffusionduetohighcellularity 然而 DWI上信號(hào)強(qiáng)度和惡性病變之間并沒(méi)有直接的相關(guān)性 大多數(shù)的惡性腫瘤在DWI上有非常高的信號(hào)強(qiáng)度 這反映了由于長(zhǎng)的T2弛豫時(shí)間和高的細(xì)胞密度導(dǎo)致的擴(kuò)散受限 TypicalAdenomyosis Figure2 Adenomyosisina46 year oldwoman 46歲女性 子宮腺肌癥患者 a SagittalT2 weightedfastspin echoMRimageshowsanenlargeduteruswithanill definedlow signal intensitylesion arrow intheposteriormyometrium Thelesioncontainsmultiplesmallhigh signal intensityareas whichrepresentectopicendometrialtissueandsmallcysts 矢狀位T2加權(quán)快速自旋回波MR圖像顯示子宮增大 伴隨一個(gè)子宮肌層后壁內(nèi)界限不清的低信號(hào)強(qiáng)度的病變 箭頭處 病變包含多個(gè)小的高信號(hào)的區(qū)域 其代表了子宮內(nèi)膜異位組織和小囊腫 b SagittalT1 weightedspin echoMRimageshowshigh signal intensityspots arrow whichcorrespondtosomeofthesmallhigh signal intensityareasseenontheT2 weightedimage Thehigh signal intensityspotsrepresenthemorrhagewithintheectopicendometrialtissue 矢狀位T1加權(quán)自旋回波MR圖像顯示了點(diǎn)狀高信號(hào) 它們對(duì)應(yīng)了在T2WI上看到的一些小的高信號(hào)區(qū)域 這些點(diǎn)狀高信號(hào)代表了子宮內(nèi)膜組織內(nèi)的出血 Figure3 Adenomyosisina42 year oldwoman a Sagittaldiffusion weightedecho planarMRimage b 800sec mm2 showsanenlargeduteruswithanill definedlesionoflowtointermediatesignalintensity arrow intheposteriormyometrium b Correspondingapparentdiffusioncoefficient ADC mapshowsnoprominentdecreaseofADCvalueintheareaofadenomyosis arrow a 矢狀位擴(kuò)散加權(quán)回波平面MR圖像 b 800sec mm2 顯示增大的子宮伴隨后壁肌層內(nèi)界限不清的病變 呈低到中等信號(hào)強(qiáng)度 箭頭 b 相應(yīng)的ADC圖上在子宮腺肌癥的區(qū)域內(nèi)沒(méi)有顯示出明顯的ADC值的下降 Becauseadenomyosismayshowvariousdegreesofenhancementafteradministrationofcontrastmedium contrast enhancedstudydoesnotcontributetodiagnosticaccuracy Fig4 Dynamiccontrast enhancedimagingmayhavegreateraccuracythanT2 weightedimagingwhenadenomyosisandendometrialcancercoexist 16 因?yàn)樵谧⑸湓煊皠┖?子宮腺肌癥可能顯示為不同程度的強(qiáng)化 所以關(guān)于其對(duì)比增強(qiáng)的研究對(duì)診斷的準(zhǔn)確性沒(méi)有幫助 圖4 當(dāng)子宮腺肌癥和子宮內(nèi)膜癌同時(shí)存在時(shí)動(dòng)態(tài)對(duì)比增強(qiáng)圖像也許會(huì)比T2加權(quán)圖像更準(zhǔn)確However theheterogeneousenhancementofadenomyosismaycauseinaccuracywhenevaluatingthedepthofmyometrialinvasionbycoexistingendometrialcancer diffusion weightedimagingmaybehelpfulinaccuratelydeterminingthedepthofmyometrialinvasion 然而當(dāng)并發(fā)子宮內(nèi)膜癌時(shí) 子宮腺肌癥不均質(zhì)的強(qiáng)化可能會(huì)導(dǎo)致評(píng)估肌層浸潤(rùn)深度的不準(zhǔn)確 擴(kuò)散加權(quán)成像也許會(huì)幫助準(zhǔn)確的確定肌層浸潤(rùn)深度 TypicalAdenomyosis Diffusion weightedImagingDiffusion weightedimagingallowsvisualizationofthelocalmicrostructuralcharacteristicsofwaterdiffusion Thesignalintensityseenondiffusion weightedimagesisacombinationofthedegreeofwaterdiffusionandthesignalintensityoftheunderlyingT2 weightedimages 擴(kuò)散加權(quán)圖像能夠可視化水分子擴(kuò)散的微觀結(jié)構(gòu)特征 在DWI上看的信號(hào)強(qiáng)度是水分子擴(kuò)散程度和基礎(chǔ)T2加權(quán)圖像信號(hào)強(qiáng)度的結(jié)合 Inoncologicimaging variousmalignanttumorsmayshowhighsignalintensityatdiffusion weightedimagingduetotheirhighcellularityandlongT2relaxationtime在腫瘤成像上 由于高的細(xì)胞密度和長(zhǎng)的T2弛豫時(shí)間 各種惡性腫瘤在DWI上顯示為高信號(hào) ADCmeasurementyieldsquantitativeinformationabouttissuestructurethatisbasedonthemolecularmotionofwater MalignantlesionswithincreasedcellularityshowlowADCvalues whereasrelativelyhypocellularbenignlesionsandnormalstructurestendtoshowrelativelyhigherADCvalues ADC圖以水分子的運(yùn)動(dòng)為基礎(chǔ)來(lái)測(cè)量組織結(jié)構(gòu)的定量信息 高的細(xì)胞密度大的病變表現(xiàn)出低的ADC值 而相對(duì)低度增生的良性病變和正常組織顯示相對(duì)高的ADC值 TypicalAdenomyosis Figure4 Adenomyosisina47 year oldwoman 47歲女性 子宮腺肌癥患者 a SagittalT2 weightedfastspin echoMRimageshowsanenlargeduteruswithanill definedlow signal intensitylesion arrow intheposteriormyometrium Thelesioncontainsmultiplesmallhigh signal intensityareas b Unenhanced upperleft earlyarterialphase upperright latearterialphase lowerleft andvenousphase lowerright images obtainedwithadynamicgadolinium enhancedthree dimensionalfastspoiledgradient echosequencewithfatsuppression showheterogeneousandgradualenhancementofthelesion a 矢狀位T2加權(quán)快速自旋回波MR圖像顯示子宮增大伴隨子宮肌層后壁內(nèi)界限不清的低信號(hào)強(qiáng)度病變 病變內(nèi)包含多個(gè)小的高信號(hào)強(qiáng)度區(qū)域b 由一個(gè)壓脂動(dòng)態(tài)釓增強(qiáng)型三維快速小角度梯度回波序列獲得平掃 左上圖 動(dòng)脈早期相 右上圖 動(dòng)脈晚期相 左上圖 以及靜脈相 右下圖 病變表現(xiàn)為不均勻和漸進(jìn)性的強(qiáng)化 AtypicalMRImagingManifestationsofAdenomyosis 子宮腺肌癥的非典型MRI表現(xiàn) AtypicalAdenomyosis VariousphysiologicorpathologicstatesmayaffecttheMRimagingappearanceofadenomyosis amountoffunctionalendometrialtissue phaseofthemenstrualcycle endogenoushormonalabnormality andexogenoushormonalstimulation SecretorytransformationofadenomyoticendometriumincludingstromaldecidualizationmaycauseaheterogeneousincreaseinsignalintensityonT2 weightedimages 多種生理或病理狀態(tài)可能會(huì)影響子宮腺肌癥的MRI表現(xiàn) 功能性子宮內(nèi)膜組織的量 月經(jīng)周期的階段 內(nèi)源激素的異常 外源激素的刺激 腺肌癥子宮內(nèi)膜的分泌轉(zhuǎn)化包括間質(zhì)蛻膜化會(huì)導(dǎo)致T2WI上信號(hào)強(qiáng)度不均質(zhì)的提高Thisphenomenonmaybeencounteredduringgestationandexogenousprogestationaltherapyoreveninpatientswithoutspecifichormonalstimulation CongestionoredematouschangemayalsoincreasethesignalintensityofadenomyosisdiffuselyorfocallyonT2 weightedimages Fig5 這種現(xiàn)象可能發(fā)生于懷孕期間 外源性孕激素治療期間 或者甚至在沒(méi)有特定激素刺激的患者身上 充血或水腫的變化也可能會(huì)在T2WI上彌漫性增加子宮腺肌癥的信號(hào)強(qiáng)度或者局部信號(hào)強(qiáng)度 圖5 Insuchconditions MRimagingmanifestationsmayfluctuate andfollow upMRimagingmaybehelpfulfordiagnosis Gonadotropin releasinghormoneanalogisusedinthetreatmentofadenomyosis Afterhormonaltherapyormenopause anareaofadenomyosismayshrinkwithdecreasedsignalintensityonT2 weightedimages Fig6 在這種情況下 MRI表現(xiàn)會(huì)變化較大 再一次的復(fù)查對(duì)診斷有幫助 促性腺激素釋放激素類似物被用于治療子宮腺肌癥 激素治療后或在絕經(jīng)期時(shí) 子宮腺肌癥的面積可能會(huì)萎縮 并伴隨著T2WI上信號(hào)強(qiáng)度的降低 圖6 AtypicalAdenomyosis Figure5 Adenomyosiswithfocaledemaina54 year oldwoman a SagittalT2 weightedfastspin echoMRimageshowsanenlargeduteruswithanill definedlow signal intensitylesionintheposteriormyometrium Thelow signal intensitylesioncontainsafocalhigh signal intensitymasslikearea arrow b Ondiffusionweightedecho planarMRimage b 800sec mm2 thehigh signal intensitymasslikeareainasagittalshowsnoincreaseinsignalintensity arrow a 矢狀位T2加權(quán)快速自旋回波MR圖像顯示增大的子宮伴隨子宮后壁內(nèi)界限不清的低信號(hào)強(qiáng)度病變 這個(gè)低信號(hào)病變內(nèi)包含一個(gè)腫塊樣高信號(hào)強(qiáng)度區(qū)域 箭頭 b 在矢狀位擴(kuò)散加權(quán)平面回波MR圖像上 b 800sec mm2 這個(gè)高信號(hào)強(qiáng)度腫瘤樣區(qū)域沒(méi)有顯示信號(hào)強(qiáng)度的增高 箭頭 Figure5 c OnanimagefromMRspectroscopy thehigh signal intensitymasslikeareashowsalowcholinepeak Cho at3 2ppm Biopsyrevealedbenignadenomyotictissuewithstromaledema Thesignalintensityofthemasslikeareaisdecreasedonfollow upT2 weightedimagesobtained3monthslater c 在磁共振波譜上 這個(gè)高信號(hào)強(qiáng)度的腫塊樣區(qū)域在3 2ppm處顯示為低的膽堿峰 Cho 活檢發(fā)現(xiàn)良性子宮腺肌組織間質(zhì)水腫 這個(gè)腫塊樣區(qū)域的信號(hào)強(qiáng)度在3個(gè)月后的T2WI圖像上降低 MRspectroscopy Figure6 Adenomyosisina50 year oldwomanbeforeandafterhormonaltherapywithgonadotropinreleasinghormoneanalog 一個(gè)50歲女性 子宮腺肌癥患者 促性腺激素釋放激素類似物治療前后 a AxialT2 weightedfastspin echoMRimageshowsadenomyosisasanill definedheterogeneouslow signal intensitylesionwithlinearorreticularhigh signal intensityareasintheanteriormyometrium arrow b AxialT2 weightedfastspin echoMRimageobtainedafterhormonaltherapyshowsdecreasedvolumeandsignalintensityoftheareaofadenomyosis arrow a 在軸位T2加權(quán)快速自旋回波MR圖像上 子宮腺肌癥顯示為邊界不清的不均勻的低信號(hào)強(qiáng)度病變伴隨肌層前壁線狀或網(wǎng)狀高信號(hào)強(qiáng)度區(qū)域 箭頭 b 激素治療后 獲取的軸位T2加權(quán)快速自旋回波MR圖像顯示子宮腺肌癥區(qū)域的面積和信號(hào)強(qiáng)度都下降了 Insuchconditions MRimagingmanifestationsmayfluctuate andfollow upMRimagingmaybehelpfulfordiagnosis Gonadotropin releasinghormoneanalogisusedinthetreatmentofadenomyosis Afterhormonaltherapyormenopause anareaofadenomyosismayshrinkwithdecreasedsignalintensityonT2 weightedimages Fig6 在這種情況下 MRI表現(xiàn)會(huì)變化較大 再一次的復(fù)查對(duì)診斷有幫助 促性腺激素釋放激素類似物被用于治療子宮腺肌癥 激素治療后或絕經(jīng)期子宮腺肌癥的面積可能會(huì)萎縮 并伴隨著T2WI上信號(hào)強(qiáng)度的降低 Diffusion weightedimagingwithADCmeasurementmayprovideanotherclueforthediagnosis becausetheseconditions secretorytransformation decidualization congestionoredema usuallyincreasetheADCintissues ArelativelyhighADCinadenomyoticlesionswithhighsignalintensityonT2 weightedimagesmayallowdifferentiationfrommalignantlesions whichhavealowADCduetotheirhighcellularity Fig5 15 彌散加權(quán)成像圖像上ADC值的測(cè)量可能提供診斷的另一條線索 因?yàn)樵谶@些情況下 分泌轉(zhuǎn)化 蛻膜變 充血或水腫 通常會(huì)增加組織的ADC值 子宮腺肌癥病灶的一個(gè)相對(duì)高的ADC值和高的T2信號(hào)強(qiáng)度可以將其從惡性病變中鑒別出來(lái) 因?yàn)閻盒圆∽冇捎谄涓叩募?xì)胞密度導(dǎo)致低的ADC值MRspectroscopymayalsoprovideaclueforthediagnosis becausethesebenignadenomyoticconditionsdonotshowhighmetabolicactivity Arelativelylowcholinepeakinadenomyoticlesionsmayallowdifferentiationfrommalignanttumors whichshowahighcholinepeakduetotheirhighmetabolicactivity Fig5 磁共振質(zhì)子波譜也可以提供診斷線索 因?yàn)檫@些良性的腺肌并沒(méi)有表現(xiàn)為高的代謝活動(dòng) 子宮腺肌癥病變的一個(gè)相對(duì)低的膽堿峰有助于將其與惡性腫瘤鑒別開(kāi) 因?yàn)閻盒阅[瘤由于其高的代謝活動(dòng)顯示為高的膽堿峰 AtypicalAdenomyosis PitfallsinDiagnosisofAdenomyosis 子宮腺肌癥診斷中的陷阱 Theuterinebodymayshowphysiologicchangesduringthemenstrualcycle Thelow signal intensityjunctionalzoneandadenomyosisarewellvisualizedduetoincreasedsignalintensityofthemyometriuminthesecretoryphase lutealphase 子宮體在月經(jīng)周期中表現(xiàn)了生理性的變化 由于在分泌期 黃體期 時(shí)子宮肌層信號(hào)變高 導(dǎo)致能清楚的看到低信號(hào)的結(jié)合帶和子宮腺肌癥Decreasedsignalintensityofthemyometriuminthemenstrual earlyproliferativephase follicularphase maycausewideningofthejunctionalzone whichmimicsdiffuseadenomyosis Therefore MRimagingfortheevaluationofauterinemyometriallesionshouldbeperformedinthelateproliferative secretoryphase Fig7 肌層在月經(jīng)早期增殖期 卵泡期 信號(hào)強(qiáng)度的下降會(huì)引起結(jié)合帶的增寬 使其像彌漫性子宮腺肌癥 因此MRI對(duì)子宮肌層的評(píng)價(jià)應(yīng)該在增生晚期 分泌期進(jìn)行 圖7 PhysiologicChangesintheUterineBodyduringtheMenstrualCycle在月經(jīng)周期中子宮體的生理變化 Figure7 Subserosaladenomyosis likelesion invasivesolidendometriosis ina33 year oldwomanduringdifferentphasesofthemenstrualcycle a SagittalT2 weightedfastspin echoMRimageobtainedintheearlyproliferativephaseshowsdecreasedsignalintensityofthemyometrium Theboundarybetweenthemyometriumandasubserosaladenomyosis likelesion arrow isobscure b SagittalT2 weightedfastspin echoMRimageobtainedinthelatesecretoryphaseshowsincreasedsignalintensityofthemyometrium Thelow signal intensityjunctionalzoneandthesubserosaladenomyosis likelesion arrow areclearlyvisualized 33歲女性 漿膜下的子宮腺肌樣病變 在月經(jīng)周期的不同階段a 在增殖早期時(shí)相獲取的矢狀位T2加權(quán)快速自旋回波MR圖像顯示肌層信號(hào)強(qiáng)度的下降 肌層和漿膜下子宮腺肌樣病變之間的界限是模糊的b 在分泌晚期階段獲得的矢狀位T2加權(quán)快速自旋回波MR圖像顯示肌層信號(hào)強(qiáng)度增高 低信號(hào)強(qiáng)度的結(jié)合帶和漿膜下腺肌樣病變清晰可見(jiàn) Variousbenignconditionsandmalignanttumorsmaymimicadenomyosis physiologicmyometrialcontraction myometrialinvolvementbypelvicendometriosis low gradeendometrialstromasarcoma LG ESS andmyometrialmetastases多種良性改變和惡性腫瘤類似于子宮腺肌癥 生理肌層收縮 肌層受累的盆腔子宮內(nèi)膜異位癥 低度惡性子宮內(nèi)膜間質(zhì)肉瘤 LG ESS 和肌層轉(zhuǎn)移Transientmyometrialcontractionasaphysiologicphenomenonmaymimicadenomyosis thisappearancemaydisappearonsubsequentimagesoratcineMRimaging whereasfocaladenomyosispersistsonsubsequentimagesoratcineMRimaging Fig8 Inthepregnantuterus myometriumadjacenttotheimplantsitemayshowlowsignalintensity whichreflectsbloodsupplyingacontraction thisfindingmimicsphysiologiccontractionorfocaladenomyosis Fig9 作為一種生理現(xiàn)象的瞬態(tài)肌層收縮類似于子宮腺肌癥 這種外觀可能會(huì)消失在隨后的圖像或電影MRI圖像 而局灶性子宮腺肌病持續(xù)的存在于隨后的圖像或電影MR成像 在懷孕的子宮 子宮肌層植入的地方表現(xiàn)為低信號(hào) 這反映了血液供給的收縮 這個(gè)表現(xiàn)類似于生理性收縮或局灶性腺肌病 Contractionsinthepregnantuterusarecommonlyseenandusuallydonotpresentadiagnosticdilemma however radiologistswhoarenotfamiliarwithMRimagingofpregnantwomenmaymisdiagnosethecontraction孕婦子宮的收縮很常見(jiàn) 通常不存在診斷的難題 然而 不熟悉懷孕女性MR成像的放射學(xué)醫(yī)生可能會(huì)將子宮收縮誤診 BenignandMalignantMimicsofAdenomyosis類似于子宮腺肌癥的良性和惡性病變 Figure8 Physiologictransientmyometrialcontractionina32 year oldwoman 發(fā)生在一個(gè)32歲女性的生理性瞬間肌層收縮SagittalT2 weightedfastspin echoMRimageshowsfocallow signal intensitybulgingofthemyometrium arrow afindingthatmimicsadenomyosis ThisfindingdisappearedonsubsequentT2 weightedimages 矢狀位T2加權(quán)快速自旋回波MR圖像顯示為子宮肌層局灶性低信號(hào)強(qiáng)度的膨脹 箭頭 這個(gè)表現(xiàn)類似于子宮腺肌癥 其在接下來(lái)的T2WI上消失了 PitfallsinDiagnosis Figure9 Transientmyometrialcontractionduringpregnancyina31 year oldwoman 一個(gè)31歲女性懷孕期間的瞬間肌層收縮 a AxialT2 weightedfastspin echoMRimageshowsalocalizedareaoflowsignalintensity arrow intheuterus afindingthatmimicsadenomyosis BecausearapidT2 weightedsequence eg half Fourieracquisitionsingle shotturbospin echoorsingle shotfastspin echo wasnotused depictionoftheembryo fetusispoor b Axialsusceptibility weightedgradient echoMRimageshowsabsenceofsignalvoids arrow withinthelow signal intensityarea However absenceofsignalvoidsatsusceptibility weightedimagingshouldnotbeconsideredtoexcludeadenomyosis Toestablishthediagnosisofacontraction itwouldbecriticaltoshowthelow signal intensityareaonsubsequentT2 weightedimages a 軸位T2加權(quán)快速自旋回波MR圖像顯示子宮內(nèi)一個(gè)局部低信號(hào) 類似于子宮腺肌癥 因?yàn)榭焖賂2加權(quán)序列沒(méi)有使用 導(dǎo)致顯示胎兒顯示較差b 軸位SWI圖顯示低信號(hào)區(qū)域內(nèi)沒(méi)有點(diǎn)狀低信號(hào) 然而在SWI圖上缺乏點(diǎn)狀低信號(hào)并不能排除子宮腺肌癥 為了確定生理收縮的診斷 在隨后的T2加權(quán)圖像上顯示低信號(hào)強(qiáng)度的區(qū)域至關(guān)重要 Susceptibility weightedimagingcanshowsmallhemorrhagicfociinadenomyosisasspottysignalvoidsandmaybehelpfulindifferentiatingadenomyosisfromfocalcontraction Fig10 Ontheotherhand absenceofsignalvoidsatsusceptibility weightedimagingshouldnotbeconsideredtoexcludeadenomyosis 磁敏感圖能顯示子宮腺肌癥中的小的出血灶 表現(xiàn)為點(diǎn)狀低信號(hào) 可以幫助鑒別子宮腺肌癥和局灶性收縮 另一方面 磁敏感圖上點(diǎn)狀低信號(hào)的不存在不應(yīng)該認(rèn)為可以排除子宮腺肌癥Adenomyosisisduetobenigninvasionofthemyometriumbyectopicendometriumandisadifferententityfromendometriosis However someadenomyosis likelesionsmaybesituatedinthesubserosalregionapartfromthejunctionalzone Figs7 11 Theselesionsmaybeduetomyometrialinvolvementbypelvicendometriosis patientstendtoexperienceseveremenstrualpainduetoadhesions子宮腺肌癥是子宮內(nèi)膜異位癥中子宮肌層的良性浸潤(rùn) 是一種不同于子宮內(nèi)膜異位癥的實(shí)體腫瘤 然而 一些腺肌樣病變有的除了位于結(jié)合帶也會(huì)位于漿膜區(qū)這些病變可能是由于盆腔子宮內(nèi)膜異位癥侵入到肌層 由于粘連的原因 患者會(huì)感到嚴(yán)重的經(jīng)期疼痛 PitfallsinDiagnosis Figure10 Adenomyosisina46 year oldwoman a AxialT2 weightedfastspin echoMRimageshowsadiffuselyenlargeduteruswithlowsignalintensity b Axialfat saturatedT1 weightedspin echoMRimageshowsabsenceofhigh signal intensityhemorrhagicfociwithintheuterus 46歲的女性 子宮腺肌癥患者a 軸位T2加權(quán)快速自旋回波MR圖像顯示一個(gè)彌漫擴(kuò)大的子宮伴隨信號(hào)強(qiáng)度減低b 軸位脂肪抑制T1加權(quán)自旋回波MR圖像顯示子宮內(nèi)沒(méi)有高信號(hào)的出血灶 Figure10 c Axialsusceptibility weightedgradientechoMRimageshowsmultiplespottysignalvoids arrows whichareduetohemosiderindepositsandreflectoldhemorrhagicfocic 軸位SWI圖像顯示多個(gè)大小不等的低信號(hào) 這是由于含鐵血黃素沉積和反應(yīng)了陳舊出血灶 PitfallsinDiagnosis Figure11 Subserosaladenomyosis likelesionina41 year oldwoman 一個(gè)41歲的女性 漿膜下子宮腺肌樣病變的患者SagittalT2 weightedfastspin echoMRimageshowsalow signal intensityadenomyosislikelesion arrow situatedinthesubserosalregionapartfromthejunctionalzone Thelesionmaybeduetomyometrialinvolvementbypelvicendometriosis Theuterusisdeformedduetoadhesions EM endometrioma 矢狀位T2加權(quán)快速自選回波MR像顯示除了結(jié)合帶還有位于漿膜下的低信號(hào)強(qiáng)度腺肌樣病變 這個(gè)病變可能是由于盆腔子宮內(nèi)膜異位癥侵入到肌層 子宮由于粘連而變形 PitfallsinDiagnosis Someprimaryorsecondarymalignanttumorsmayappearasill demarcatedmyometrialmasseswithuterineenlargement findingsthatmimicadenomyosis LG ESSisararemalignantmesenchymaltumoraffectingyoungwomenandusuallyoccursintheendometriumwithextensivemyometrialinvasion LG ESSmayoccasionallybesituatedalmostwithinthemyometrium 有些原發(fā)性或繼發(fā)性的惡性腫瘤可能會(huì)出現(xiàn)邊界不清的肌層內(nèi)腫塊伴隨子宮增大 表現(xiàn)類似于子宮腺肌癥 LG ESSS是一種罕見(jiàn)的發(fā)生于年輕女性的惡性間質(zhì)瘤 通常發(fā)生于子宮內(nèi)膜并伴隨著廣泛的肌層浸潤(rùn)MyometrialinvasionbyLG ESSisveryinfiltrative andpreservedlow signal intensitymusclebundleswithinthehigh signal intensitytumoronT2 weightedimagesareacharacte

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