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1、Usual and Unusual Imaging Manifestations on MRI of Adenomyosis 2013 2013年年4 4月月1 17 7日日子宫腺肌症常见和不常见的MRI表现Adenomyosisisacommonnonneoplasticgynecologicdiseasecharacterizedbythepresenceofectopicendometriumwithinthemyometrium.Adenomyosistypicallyaffectsmultiparous,premenopausalwomenover30yearsofageandmay
2、causedysmenorrhea,menorrhagia,andabnormalgenitalbleeding.子子宫宫腺腺肌肌症症是是一一种种常常见见的的非非肿肿瘤瘤性性妇妇科科疾疾病病，是是发发生生在在子子宫宫肌肌层层的的子子宫宫内内膜膜异异位位症。症。其其主主要要发发生生于于超超过过3030岁岁，绝绝经经前前的的经经产产妇妇并并且且可可能能引引起起痛痛经经，月月经经过过多多和和不不正正常常的阴道出血的症状。的阴道出血的症状。Magneticresonance(MR)imagingisanoninvasivemodalitywithhighsensitivityandspecificit
3、yfordiagnosisofadenomyosis.Incasesofanenlargeduterusrevealedwithultrasonography,MRimagingallowsdifferentiationofadenomyosis from leiomyoma or other pathologic conditions owing to itsexcellenttissuecontrastresolution.磁磁共共振振（MRMR）成成像像是是一一种种非非侵侵入入性性的的检检查查方方式式，其其在在诊诊断断子子宫宫腺腺肌肌症症上上具具有有高高的的灵灵敏敏度度和和特特异异度度。
4、当当超超声声检检查查中中发发现现子子宫宫增增大大时时，磁磁共共振振由由于于其其出出色色的的组组织织对对比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。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。IntroductionOn T2-weighted images,typical adenomyosis appears as an ill-demarcated low-signal-intensity lesion with uterine enlargement.However,variousphysiologicorpathologicstatesmayaffecttheMRi
5、maging appearance of adenomyosis and may result in a tumorlikeappearance 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,pitfallsindiagnosisofadenomyos
6、is,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IntroductionMR Imaging Manifestations of Typical Adenomyosis子宫腺肌症的典型MRI表现 Typical AdenomyosisAtpathologicanalysis,adenomyosisischaracterizedbythepresenceofectopicendometrialglandsandstromawithinthemyometriumwithhypertrophyandhyperplasiaofsmoothmuscl
7、eAdenomyosismayaffecttheuterinemyometriumdiffuselyandresultinadiffuselyenlargeduterus,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-definedadeno
8、myosis;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
9、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 Typical AdenomyosisFig.1A 1B1A1BFigure 1.Adenomyosis in a 47-year-old woman.47岁女性，子宫腺肌症患者，(a)Photograph of the cut surface of the gross specimen shows diffusely thickened myometrium.(b)photomicrograph(hematoxylin-eosin stain)shows ectopi
10、c endometrial glands and stroma(arrow)surrounded by hypertrophied smooth muscle.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).Becauseadenomyoticendomet
11、riumlookslikethebasalisendometrium,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O
12、nT2-weightedMRimages,ectopicendometriumappearsassmallhigh-signal-intensityareaslikenormalendometrium(Fig2).Smallcystsmayalsoappearashigh-signal-intensityspotsonT2-weightedimages.Sometimes,hemorrhagicfociappearas13mmhigh-signal-intensityfocionT1-weightedimagesowingtotheT1-shorteningeffectsofmethemogl
13、obin(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 Typical AdenomyosisSusceptibility-weightedimagingissensitiveforoldhemorrhagicfoci,whichappearasspottysignalvoidsowingtotheT2*-shorteningeffectsofhemosiderin.Atdiffusion-weightedimaging,ad
14、enomyosishaslowtointermediatesignalintensity,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;mostmalig
15、nanttumorshaveveryhighsignalintensityatdiffusion-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。Typical AdenomyosisFigure2.Adenomyosisina46-year-oldwoman.46岁女性，子宫腺肌症
16、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
17、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，
18、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-planarMRimage(b=800sec/mm2)showsanenlargeduteruswithanill-definedlesionoflowtointermediatesignalintensity(arrow)intheposteriormyometrium.(b)Correspondingapparentdiffusioncoefficient(A
19、DC)mapshowsnoprominentdecreaseofADCvalueintheareaofadenomyosis(arrow).a.矢状位扩散加权回波平面MR图像(b=800sec/mm2)显示增大的子宫伴随后壁肌层内界限不清的病变，呈低到中等信号强度（箭头）。b.相应的ADC图上在子宫腺肌症的区域内没有显示出明显的ADC值的下降Becauseadenomyosismayshowvariousdegreesofenhancementafteradministrationofcontrastmedium,contrast-enhancedstudydoesnotcontributet
20、odiagnosticaccuracy(Fig4).Dynamiccontrast-enhancedimagingmayhavegreateraccuracythanT2-weightedimagingwhenadenomyosisandendometrialcancercoexist(16).因为在注射造影剂后，子宫腺肌症可能显示为不同程度的强化，所以关于其对比增强的研究对诊断的准确性没有帮助（图4）。当子宫腺肌症和子宫内膜癌同时存在时动态对比增强图像也许会比T2加权图像更准确However,theheterogeneousenhancementofadenomyosismaycausein
21、accuracywhenevaluatingthedepthofmyometrialinvasionbycoexistingendometrialcancer;diffusion-weightedimagingmaybehelpfulinaccuratelydeterminingthedepthofmyometrialinvasion.然而当并发子宫内膜癌时，子宫腺肌症不均质的强化可能会导致评估肌层浸润深度的不准确；扩散加权成像也许会帮助准确的确定肌层浸润深度 Typical AdenomyosisDiffusion-weighted ImagingDiffusion-weightedimag
22、ingallowsvisualizationofthelocalmicrostructuralcharacteristicsofwaterdiffusion.Thesignalintensityseenondiffusion-weightedimagesisacombinationofthedegreeofwaterdiffusionandthesignalintensityoftheunderlyingT2-weightedimages.扩散加权图像能够可视化水分子扩散的微观结构特征，在DWI上看的信号强度是水分子扩散程度和基础T2加权图像信号强度的结合。Inoncologicimaging
23、,variousmalignanttumorsmayshowhighsignalintensityatdiffusion-weightedimagingduetotheirhighcellularityandlongT2relaxationtime在肿瘤成像上，由于高的细胞密度和长的T2弛豫时间，各种恶性肿瘤在DWI上显示为高信号。ADCmeasurementyieldsquantitativeinformationabouttissuestructurethatisbasedonthemolecularmotionofwater.Malignantlesionswithincreasedce
24、llularityshowlowADCvalues,whereasrelativelyhypocellularbenignlesionsandnormalstructurestendtoshowrelativelyhigherADCvalues.ADC图以水分子的运动为基础来测量组织结构的定量信息。高的细胞密度大的病变表现出低的ADC值，而相对低度增生的良性病变和正常组织显示相对高的ADC值 Typical AdenomyosisFigure4.Adenomyosisina47-year-oldwoman.47岁女性，子宫腺肌症患者(a)SagittalT2-weightedfastspin-
25、echoMRimageshowsanenlargeduteruswithanill-definedlow-signal-intensitylesion(arrow)intheposteriormyometrium.Thelesioncontainsmultiplesmallhigh-signal-intensityareas.(b)Unenhanced(upperleft),earlyarterialphase(upperright),latearterialphase(lowerleft),andvenousphase(lowerright)images,obtainedwithadynam
26、icgadolinium-enhancedthree-dimensionalfastspoiledgradient-echosequencewithfatsuppression,showheterogeneousandgradualenhancementofthelesion.a.矢状位T2加权快速自旋回波MR图像显示子宫增大伴随子宫肌层后壁内界限不清的低信号强度病变。病变内包含多个小的高信号强度区域b.由一个压脂动态钆增强型三维快速小角度梯度回波序列获得平扫（左上图），动脉早期相（右上图），动脉晚期相（左上图），以及静脉相（右下图），病变表现为不均匀和渐进性的强化。Atypical MR I
27、maging Manifestations of Adenomyosis子宫腺肌症的非典型MRI表现Atypical Adenomyosis VariousphysiologicorpathologicstatesmayaffecttheMRimagingappearanceofadenomyosis:amountoffunctionalendometrialtissue,phaseofthemenstrualcycle,endogenoushormonalabnormality,andexogenoushormonalstimulation.Secretorytransformationof
28、adenomyoticendometriumincludingstromaldecidualizationmaycauseaheterogeneousincreaseinsignalintensityonT2-weightedimages.多种生理或病理状态可能会影响子宫腺肌症的MRI表现：功能性子宫内膜组织的量，月经周期的阶段，内源激素的异常，外源激素的刺激。腺肌症子宫内膜的分泌转化包括间质蜕膜化会导致T2WI上信号强度不均质的提高Thisphenomenonmaybeencounteredduringgestationandexogenousprogestationaltherapyore
29、veninpatientswithoutspecifichormonalstimulation.CongestionoredematouschangemayalsoincreasethesignalintensityofadenomyosisdiffuselyorfocallyonT2-weightedimages(Fig5).这种现象可能发生于怀孕期间，外源性孕激素治疗期间，或者甚至在没有特定激素刺激的患者身上。充血或水肿的变化也可能会在T2WI上弥漫性增加子宫腺肌症的信号强度或者局部信号强度（图5）。Insuchconditions,MRimagingmanifestationsmayfl
30、uctuate,andfollow-upMRimagingmaybehelpfulfordiagnosis.Gonadotropin-releasinghormoneanalogisusedinthetreatmentofadenomyosis.Afterhormonaltherapyormenopause,anareaofadenomyosismayshrinkwithdecreasedsignalintensityonT2-weightedimages(Fig6)在这种情况下，MRI表现会变化较大，再一次的复查对诊断有帮助。促性腺激素释放激素类似物被用于治疗子宫腺肌症。激素治疗后或在绝经期
31、时，子宫腺肌症的面积可能会萎缩，并伴随着T2WI上信号强度的降低(图6)。Atypical Adenomyosis Figure 5.Adenomyosis with focal edema in a 54-year-old woman.(a)Sagittal T2-weighted fast spin-echo MR image shows an enlarged uterus with an ill-defined low-signal-intensity lesion in the posterior myometrium.The low-signal-intensity lesion
32、contains a focal high-signal-intensity masslike area(arrow).(b)On diffusion weighted echo-planar MR image(b=800 sec/mm2),the high-signal-intensity masslike area in a sagittal shows no increase in signal intensity(arrow).a.矢状位T2加权快速自旋回波MR图像显示增大的子宫伴随子宫后壁内界限不清的低信号强度病变。这个低信号病变内包含一个肿块样高信号强度区域（箭头）b.在矢状位扩散
33、加权平面回波MR图像上(b=800 sec/mm2)，这个高信号强度肿瘤样区域没有显示信号强度的增高（箭头）Figure 5.（c）On an image from MR spectroscopy,the high-signal-intensity masslike area shows a low choline peak(Cho)at 3.2 ppm.Biopsyrevealed benign adenomyotic tissue with stromal edema.The signal intensity of the masslike area is decreased on fol
34、low-up T2-weighted images obtained 3 months later.c.在磁共振波谱上，这个高信号强度的肿块样区域在3.2ppm处显示为低的胆碱峰（Cho）。活检发现良性子宫腺肌组织间质水肿，这个肿块样区域的信号强度在3个月后的T2WI图像上降低。MR spectroscopyFigure 6.Adenomyosis in a 50-year-old woman before and after hormonal therapy with gonadotropinre leasing hormone analog.一个50岁女性，子宫腺肌症患者，促性腺激素释放激
35、素类似物治疗前后(a)Axial T2-weighted fast spin-echo MR image shows adenomyosis as an ill-defined heterogeneous low-signal-intensity lesion with linear or reticular high-signal-intensity areas in the anterior myometrium(arrow).(b)Axial T2-weighted fast spin-echo MR image obtained after hormonal therapy shows
36、 decreased volume and signal intensity of the area of adenomyosis(arrow).a.在轴位T2加权快速自旋回波MR图像上，子宫腺肌症显示为边界不清的不均匀的低信号强度病变伴随肌层前壁线状或网状高信号强度区域（箭头）b.激素治疗后，获取的轴位T2加权快速自旋回波MR图像显示子宫腺肌症区域的面积和信号强度都下降了Insuchconditions,MRimagingmanifestationsmayfluctuate,andfollow-upMRimagingmaybehelpfulfordiagnosis.Gonadotropin-
37、releasinghormoneanalogisusedinthetreatmentofadenomyosis.Afterhormonaltherapyormenopause,anareaofadenomyosismayshrinkwithdecreasedsignalintensityonT2-weightedimages(Fig6)在这种情况下，MRI表现会变化较大，再一次的复查对诊断有帮助。促性腺激素释放激素类似物被用于治疗子宫腺肌症。激素治疗后或绝经期子宫腺肌症的面积可能会萎缩，并伴随着T2WI上信号强度的降低。Diffusion-weightedimagingwithADCmeasu
38、rementmayprovideanotherclueforthediagnosis,becausetheseconditions(secretorytransformation,decidualization,congestionoredema)usuallyincreasetheADCintissues.ArelativelyhighADCinadenomyoticlesionswithhighsignalintensityonT2-weightedimagesmayallowdifferentiationfrommalignantlesions,whichhavealowADCdueto
39、theirhighcellularity(Fig5)(15).弥散加权成像图像上ADC值的测量可能提供诊断的另一条线索，因为在这些情况下（分泌转化，蜕膜变，充血或水肿）通常会增加组织的ADC值。子宫腺肌症病灶的一个相对高的ADC值和高的T2信号强度可以将其从恶性病变中鉴别出来，因为恶性病变由于其高的细胞密度导致低的ADC值MRspectroscopymayalsoprovideaclueforthediagnosis,becausethesebenignadenomyoticconditionsdonotshowhighmetabolicactivity.Arelativelylowcholi
40、nepeakinadenomyoticlesionsmayallowdifferentiationfrommalignanttumors,whichshowahighcholinepeakduetotheirhighmetabolicactivity(Fig5)磁共振质子波谱也可以提供诊断线索，因为这些良性的腺肌并没有表现为高的代谢活动。子宫腺肌症病变的一个相对低的胆碱峰有助于将其与恶性肿瘤鉴别开，因为恶性肿瘤由于其高的代谢活动显示为高的胆碱峰。Atypical Adenomyosis Pitfalls in Diagnosis of Adenomyosis子宫腺肌症诊断中的陷阱子宫腺肌症诊断
41、中的陷阱Theuterinebodymayshowphysiologicchangesduringthemenstrualcycle.Thelow-signal-intensityjunctionalzoneandadenomyosisarewellvisualizedduetoincreasedsignalintensityofthemyometriuminthesecretoryphase(lutealphase).子宫体在月经周期中表现了生理性的变化。由于在分泌期（黄体期）时子宫肌层信号变高，导致能清楚的看到低信号的结合带和子宫腺肌症Decreasedsignalintensityoft
42、hemyometriuminthemenstrualearlyproliferativephase(follicularphase)maycausewideningofthejunctionalzone,whichmimicsdiffuseadenomyosis.Therefore,MRimagingfortheevaluationofauterinemyometriallesionshouldbeperformedinthelateproliferativesecretoryphase(Fig7)肌层在月经早期增殖期（卵泡期）信号强度的下降会引起结合带的增宽，使其像弥漫性子宫腺肌症。因此MR
43、I对子宫肌层的评价应该在增生晚期-分泌期进行（图7）Physiologic Changes in the Uterine Body during the Menstrual Cycle 在月经周期中子宫体的生理变化Figure7.Subserosaladenomyosis-likelesion(invasivesolidendometriosis)ina33-year-oldwomanduringdifferentphasesofthemenstrualcycle.(a)SagittalT2-weightedfastspin-echoMRimageobtainedintheearlyproli
44、ferativephaseshowsdecreasedsignalintensityofthemyometrium.Theboundarybetweenthemyometriumandasubserosaladenomyosis-likelesion(arrow)isobscure.(b)SagittalT2-weightedfastspin-echoMRimageobtainedinthelatesecretoryphaseshowsincreasedsignalintensityofthemyometrium.Thelow-signal-intensityjunctionalzoneand
45、thesubserosaladenomyosis-likelesion(arrow)areclearlyvisualized.33岁女性，浆膜下的子宫腺肌样病变，在月经周期的不同阶段a.在增殖早期时相获取的矢状位T2加权快速自旋回波MR图像显示肌层信号强度的下降。肌层和浆膜下子宫腺肌样病变之间的界限是模糊的b.在分泌晚期阶段获得的矢状位T2加权快速自旋回波MR图像显示肌层信号强度增高。低信号强度的结合带和浆膜下腺肌样病变清晰可见Variousbenignconditionsandmalignanttumorsmaymimicadenomyosis:physiologicmyometrialco
46、ntraction,myometrialinvolvementbypelvicendometriosis,low-gradeendometrialstromasarcoma(LG-ESS),andmyometrialmetastases多种良性改变和恶性肿瘤类似于子宫腺肌症：生理肌层收缩，肌层受累的盆腔子宫内膜异位症，低度恶性子宫内膜间质肉瘤（LG-ESS），和肌层转移Transientmyometrialcontractionasaphysiologicphenomenonmaymimicadenomyosis;thisappearancemaydisappearonsubsequentim
47、agesoratcineMRimaging,whereasfocaladenomyosispersistsonsubsequentimagesoratcineMRimaging(Fig8)Inthepregnantuterus,myometriumadjacenttotheimplantsitemayshowlowsignalintensity,whichreflectsbloodsupplyingacontraction;thisfindingmimicsphysiologiccontractionorfocaladenomyosis(Fig9).作为一种生理现象的瞬态肌层收缩类似于子宫腺肌
48、症，这种外观可能会消失在随后的图像或电影MRI图像，而局灶性子宫腺肌病持续的存在于随后的图像或电影MR成像。在怀孕的子宫，子宫肌层植入的地方表现为低信号，这反映了血液供给的收缩；这个表现类似于生理性收缩或局灶性腺肌病。Contractionsinthepregnantuterusarecommonlyseenandusuallydonotpresentadiagnosticdilemma;however,radiologistswhoarenotfamiliarwithMRimagingofpregnantwomenmaymisdiagnosethecontraction 孕妇子宫的收缩很常见
49、，通常不存在诊断的难题，然而，不熟悉怀孕女性MR成像的放射学医生可能会将子宫收缩误诊Benign and Malignant Mimics of Adenomyosis 类似于子宫腺肌症的良性和恶性病变Figure 8.Physiologic transient myometrial contraction in a 32-year-old woman.发生在一个32岁女性的生理性瞬间肌层收缩Sagittal T2-weighted fast spin-echo MR image shows focal low-signal-intensity bulging of the myometriu
50、m(arrow),a finding that mimics adenomyosis.This finding disappeared on subsequent T2-weighted images.矢状位T2加权快速自旋回波MR图像显示为子宫肌层局灶性低信号强度的膨胀（箭头），这个表现类似于子宫腺肌症。其在接下来的T2WI上消失了。Pitfalls in Diagnosis Figure 9.Transient myometrial contraction during pregnancy in a 31-year-old woman.一个31岁女性怀孕期间的瞬间肌层收缩(a)Axial