子宮腺肌癥常見(jiàn)和不常見(jiàn)的MRI表現(xiàn)-影像FTP課件

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)UsualandUnusualImagingManiAdenomyosisisacommonnonneoplasticgynecologicdiseasecharacterizedbythepresenceofectopicendometriumwithinthemyometrium.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)。

IntroductionIntroductionOnT2-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)IntroductionOnT2-weightedimages,typicalMRImagingManifestationsofTypicalAdenomyosis子宮腺肌癥的典型MRI表現(xiàn)MRImagingManifestationsof

TypicalAdenomyosisAtpathologicanalysis,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TypicalAdenomyosisAtpathoAcutsectionofadiffuselyadenomyoticuterusshowsthickenedmyometriumduetotheill-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?chē)漠愇蛔訉m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

TypicalAdenomyosisAcutsectionofadiffuselyaFig.1A1B1A1BFigure1.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?chē)姆屎竦钠交?/p>

Fig.1A1B1A1BFigure1.AdenomTypicaladenomyosisappearsasanill-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

TypicalAdenomyosisTypicaladenomyosisappearsasSusceptibility-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。

TypicalAdenomyosisSusceptibility-weightedimaginFigure2.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Figure2.Adenomyosisina46-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Figure3.Adenomyosisina42-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

TypicalAdenomyosisBecauseadenomyosismayshowvDiffusion-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

TypicalAdenomyosisDiffusion-weightedImagingTFigure4.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。Figure4.Adenomyosisina47-AtypicalMRImagingManifestationsofAdenomyosis子宮腺肌癥的非典型MRI表現(xiàn)AtypicalMRImagingManifestatAtypicalAdenomyosis

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）。AtypicalAdenomyosis

VariousInsuchconditions,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(lèi)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

Insuchconditions,MRimagingFigure5.Adenomyosiswithfocaledemaina54-year-oldwoman.(a)SagittalT2-weightedfastspin-echoMRimageshowsanenlargeduteruswithanill-definedlow-signal-intensitylesionintheposteriormyometrium.Thelow-signal-intensitylesioncontainsafocalhigh-signal-intensitymasslikearea(arrow).(b)Ondiffusionweightedecho-planarMRimage(b=800sec/mm2),thehigh-signal-intensitymasslikeareainasagittal

showsnoincreaseinsignalintensity(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.AdenomyosiswithfocFigure5.（c

）

OnanimagefromMRspectroscopy,thehigh-signal-intensitymasslikeareashowsalowcholinepeak(Cho)at3.2ppm.Biopsy

revealedbenignadenomyotictissuewithstromaledema.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）?；顧z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。MRspectroscopyFigure5.（c）OnanimagefromFigure6.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(lèi)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Figure6.Adenomyosisina50-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(lèi)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

Insuchconditions,MRimagingPitfallsinDiagnosisofAdenomyosis子宮腺肌癥診斷中的陷阱PitfallsinDiagnosisofAdenoTheuterinebodymayshowphysiologicchangesduringthemenstrualcycle.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）PhysiologicChangesintheUterineBody

duringtheMenstrualCycle

在月經(jīng)周期中子宮體的生理變化TheuterinebodymayshowphysFigure7.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)Figure7.SubserosaladenomyosVariousbenignconditionsandmalignanttumorsmaymimicadenomyosis:physiologicmyometrialcontraction,myometrialinvolvementbypelvicendometriosis,low-gradeendometrialstromasarcoma(LG-ESS),andmyometrialmetastases多種良性改變和惡性腫瘤類(lèi)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(lèi)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(lèi)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(lèi)似于子宮腺肌癥的良性和惡性病變VariousbenignconditionsandFigure8.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(lèi)似于子宮腺肌癥。其在接下來(lái)的T2WI上消失了。PitfallsinDiagnosisFigure8.PitfallsinDiagnosiFigure9.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(lèi)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Figure9.TransientmyometrialSusceptibility-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PitfallsinDiagnosisSusceptibility-weightedimaginFigure10.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.Adenomyosisina46Figure10(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.PitfallsinDiagnosisFigure10PitfallsinDiagnosis.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.Figure11.PitfallsinDiagnoSomeprimaryorsecondarymalignanttumorsmayappearasill-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(lèi)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-weightedimagesareacharacteristicMRimagingfinding.However,intramyometrialtumormaysimulateadenomyosis,andpreoperativediagnosisisoccasionallydifficult.LG-ESS的肌層浸潤(rùn)的程度是很深的，MRI上特征性的影像表現(xiàn)是T2WI上低信號(hào)強(qiáng)度的肌束內(nèi)有高信號(hào)強(qiáng)度的腫瘤。然而肌層內(nèi)的腫瘤類(lèi)似于子宮腺肌癥，術(shù)前診斷有時(shí)候是很困難的PitfallsinDiagnosisSomeprimaryorsecondarymaliHigh-resolutionT2-weightedimagingat3TishelpfulfordiagnosisofLG-ESSbydemonstratingpreservedfinemuscularfiberswithinthetumoraswormlikelow-signal-intensitystructures(Fig13).3T高分辨T2加權(quán)成像對(duì)診斷LG-ESS是有幫助的，其表現(xiàn)是腫瘤內(nèi)的細(xì)肌纖維呈現(xiàn)為蠕蟲(chóng)狀的低信號(hào)。HighsignalintensitywithdecreasedADCatdiffusionweightedimagingandahighcholinepeakatMRspectroscopyareothercluesfordiagnosisofthisraremalignanttumor(Fig13).擴(kuò)散加權(quán)成像上的高信號(hào)強(qiáng)度伴隨ADC值的下降，MR波譜上高的膽堿峰是診斷這種罕見(jiàn)惡性腫瘤的別的線索Diffusionweightedimagingisalsousefulinevaluatingtumorextensionalongthevessels,whichisanothercharacteristicofLG-ESSDWI也是一種有用的評(píng)估腫瘤沿著血管方向浸潤(rùn)的方法，這是LG-ESS的另一個(gè)特點(diǎn)PitfallsinDiagnosisHigh-resolutionT2-weightedimFigure13.LG-ESSina37-year-oldwoman.一個(gè)37歲的女性，LG-ESS患者(a)Sagittalhigh-resolutionT2-weightedfastspin-echoMRimageobtainedat3Tshowsalargeendometrial-myometrialmass.Characteristicwormlikelow-signal-intensitymusclefibers(arrows)areclearlyseen.(b)ImagefromMRspectroscopyshowsahighcholinepeak(Cho)at3.2ppm,whichreflectshighcellularproliferatingactivity,andahighcreatinepeak(Cre)at3ppm,whichispossiblyduetoresidual

myometriuma.3T矢狀位高分辨T2加權(quán)快速自旋回波MR圖像顯示一個(gè)大的子宮內(nèi)膜肌層腫塊。非常有特點(diǎn)的蠕蟲(chóng)樣低信號(hào)強(qiáng)度肌肉纖維（箭頭）清晰可見(jiàn)b.磁共振波譜顯示在3.2mm處有一高的膽堿峰，其反映了高的細(xì)胞增殖。3mm處高的肌酸峰，這可能是殘留的肌層造成的Figure13.LG-ESSina37-year

Conclusion1.Magneticresonance(MR)imagingisanoninvasivemodalitywithhighsensitivityandspecificityfordiagnosisofadenomyosis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2.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)3.WemustbecarefulofPitfallsinDiagnosisofAdenomyosisandDWI,SWI,MRScanhelpustodiagnoseadenomyosisConclusThanksforyourattention!Thanksforyourattention!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)UsualandUnusualImagingManiAdenomyosisisacommonnonneoplasticgynecologicdiseasecharacterizedbythepresenceofectopicendometriumwithinthemyometrium.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)。

IntroductionIntroductionOnT2-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)IntroductionOnT2-weightedimages,typicalMRImagingManifestationsofTypicalAdenomyosis子宮腺肌癥的典型MRI表現(xiàn)MRImagingManifestationsof

TypicalAdenomyosisAtpathologicanalysis,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TypicalAdenomyosisAtpathoAcutsectionofadiffuselyadenomyoticuterusshowsthickenedmyometriumduetotheill-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?chē)漠愇蛔訉m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

TypicalAdenomyosisAcutsectionofadiffuselyaFig.1A1B1A1BFigure1.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?chē)姆屎竦钠交?/p>

Fig.1A1B1A1BFigure1.AdenomTypicaladenomyosisappearsasanill-demarcatedlow-signal-intensityarea