子宫腺肌症常见和不常见的MRI表现-影像FTP

UsualandUnusualImagingManifestationsonMRIofAdenomyosis郑州大学第一附属医院磁共振科何杰2013年4月17日子宫腺肌症常见和不常见的MRI表现•Adenomyosisisacommonnonneoplasticgynecologicdiseasecharacterizedbythepresenceofectopicendometriumwithinthemyometrium.•Adenomyosistypicallyaffectsmultiparous,premenopausalwomenover30yearsofageandmaycausedysmenorrhea,menorrhagia,andabnormalgenitalbleeding.•子宫腺肌症是一种常见的非肿瘤性妇科疾病，是发生在子宫肌层的子宫内膜异位症。•其主要发生于超过30岁，绝经前的经产妇并且可能引起痛经，月经过多和不正常的阴道出血的症状。•Magneticresonance(MR)imagingisanoninvasivemodalitywithhighsensitivityandspecificityfordiagnosisofadenomyosis.Incasesofanenlargeduterusrevealedwithultrasonography,MRimagingallowsdifferentiationofadenomyosisfromleiomyomaorotherpathologicconditionsowingtoitsexcellenttissuecontrastresolution.•磁共振（MR）成像是一种非侵入性的检查方式，其在诊断子宫腺肌症上具有高的灵敏度和特异度。当超声检查中发现子宫增大时，磁共振由于其出色的组织对比分辨率可以把子宫腺肌症与子宫肌瘤或其他疾病鉴别出来。Introduction•OnT2-weightedimages,typicaladenomyosisappearsasanill-demarcatedlow-signal-intensitylesionwithuterineenlargement.However,variousphysiologicorpathologicstatesmayaffecttheMRimagingappearanceofadenomyosisandmayresultinatumorlikeappearance在T2WI上，子宫腺肌症的典型表现为一个边界不清的低信号强度病变伴随着子宫增大。然而，多种生理和病理改变也许会影响子宫腺肌症的MRI表现并且会导致其出现肿瘤样的表现•SpecifictopicsdiscussedareMRimagingmanifestationsoftypicaladenomyosis,atypicalMRimagingmanifestationsofadenomyosis,pitfallsindiagnosisofadenomyosis,讨论的具体话题包括子宫腺肌症的典型MRI表现，子宫腺肌症的不典型MRI表现，子宫腺肌症的诊断误区IntroductionMRImagingManifestationsofTypicalAdenomyosis子宫腺肌症的典型MRI表现TypicalAdenomyosis•Atpathologicanalysis,adenomyosisischaracterizedbythepresenceofectopicendometrialglandsandstromawithinthemyometriumwithhypertrophyandhyperplasiaofsmoothmuscle•Adenomyosismayaffecttheuterinemyometriumdiffuselyandresultinadiffuselyenlargeduterus,oritmaybelocalizedasanadenomyoma.•病理分析，子宫腺肌症的特征性表现是子宫肌层内异位的子宫内膜腺体和间质的存在和平滑肌的肥大增生。•子宫腺肌症也许会弥漫性的影响子宫肌层并导致子宫弥漫性的增大，或者会作为腺肌瘤局限性的影响肌层•Acutsectionofadiffuselyadenomyoticuterusshowsthickenedmyometriumduetotheill-definedadenomyosis;•thethickenedmyometriumiscomposedofhaphazardlydistributedhypertrophiedmusculartrabeculaesurroundingectopicendometrialtissue(Fig1).•Brownisholdhemorrhagicfocicorrespondingtohemolysedbloodandhemosiderinpigmentdepositsmaybecontainedwithintheareaofadenomyosis•弥漫型腺肌型子宫的横断面显示由于界限不清的子宫腺肌病导致肌层增厚。肥厚的肌层是由随意分布的肥大性肌小梁及周围的异位子宫内膜组织所构成（图1）。•褐色的旧出血灶也许对应着子宫腺肌症区域内的出血和含铁血黄素沉积TypicalAdenomyosisFig.1A1B1A1BFigure1.Adenomyosisina47-year-oldwoman.47岁女性，子宫腺肌症患者，(a)Photographofthecutsurfaceofthegrossspecimenshowsdiffuselythickenedmyometrium.(b)photomicrograph(hematoxylin-eosinstain)showsectopicendometrialglandsandstroma(arrow)surroundedbyhypertrophiedsmoothmuscle.a.大体标本的切面照片显示弥漫性增厚的子宫肌层b.显微镜下照片（HE染色）显示异位的子宫内膜腺体和间质和周围的肥厚的平滑肌•Typicaladenomyosisappearsasanill-demarcatedlow-signal-intensityareaonT2-weightedimagesowingtoabundantsmoothmuscleproliferation(Fig2).•Becauseadenomyoticendometriumlookslikethebasalisendometrium,whichseldomrespondstohormonalstimuli,cyclicchangesincludingdegeneration,bleeding,andregenerationarelesscommoninadenomyosisthaninendometriosis.•子宫腺肌症的典型表现是在T2WI上有一界限不清的低信号区域，这是由于丰富的平滑肌细胞增殖。•因为腺肌症子宫内膜跟基底子宫内膜一样，很少对激素的刺激做出反应，所以与其他子宫内膜异位症相比，包括变性，出血，再生这样的周期性的变化较少出现在子宫腺肌症中•OnT2-weightedMRimages,ectopicendometriumappearsassmallhigh-signal-intensityareaslikenormalendometrium(Fig2).Smallcystsmayalsoappearashigh-signal-intensityspotsonT2-weightedimages.•Sometimes,hemorrhagicfociappearas1–3mmhigh-signal-intensityfocionT1-weightedimagesowingtotheT1-shorteningeffectsofmethemoglobin(Fig2)•在T2WI图像上，异位子宫内膜表现为跟正常子宫内膜一样的小的片状高信号，小的囊肿也可能在T2WI上表现为点状高信号。有时候由于高铁血红蛋白T1缩短效应的影响，出血灶在T1WI上表现为1-3mm的高信号病灶TypicalAdenomyosis•Susceptibility-weightedimagingissensitiveforoldhemorrhagicfoci,whichappearasspottysignalvoidsowingtotheT2*-shorteningeffectsofhemosiderin.•Atdiffusion-weightedimaging,adenomyosishaslowtointermediatesignalintensity,afindingconsistentwithitsbenign,nonneoplasticnature(Fig3)•磁敏感加权成像对陈旧出血灶很敏感，由于含铁血黄素T2缩短效应的影像，表现点状低信号。•在弥散加权像上，子宫腺肌症表现为低到中等信号强度，这种表现其实与它是良性，非肿瘤性病变这种性质相一致•However,thereisnodirectcorrelationbetweensignalintensityatdiffusion-weightedimagingandmalignancy;mostmalignanttumorshaveveryhighsignalintensityatdiffusion-weightedimaging,afindingthatreflectsthelongT2relaxationtimeandrestricteddiffusionduetohighcellularity.•然而，DWI上信号强度和恶性病变之间并没有直接的相关性；大多数的恶性肿瘤在DWI上有非常高的信号强度，这反映了由于长的T2弛豫时间和高的细胞密度导致的扩散受限。TypicalAdenomyosisFigure2.Adenomyosisina46-year-oldwoman.46岁女性，子宫腺肌症患者(a)SagittalT2-weightedfastspin-echoMRimageshowsanenlargeduteruswithanill-definedlow-signal-intensitylesion(arrow)intheposteriormyometrium.Thelesioncontainsmultiplesmallhigh-signal-intensityareas,whichrepresentectopicendometrialtissueandsmallcysts.矢状位T2加权快速自旋回波MR图像显示子宫增大，伴随一个子宫肌层后壁内界限不清的低信号强度的病变（箭头处），病变包含多个小的高信号的区域，其代表了子宫内膜异位组织和小囊肿(b)SagittalT1-weightedspin-echoMRimageshowshigh-signal-intensityspots(arrow),whichcorrespondtosomeofthesmallhigh-signal-intensityareasseenontheT2-weightedimage.Thehigh-signal-intensityspotsrepresenthemorrhagewithintheectopicendometrialtissue.矢状位T1加权自旋回波MR图像显示了点状高信号，它们对应了在T2WI上看到的一些小的高信号区域。这些点状高信号代表了子宫内膜组织内的出血Figure3.Adenomyosisina42-year-oldwoman.(a)Sagittaldiffusion-weightedecho-pl