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Diffusely Enlarged Uterus: Evaluation with MR Imaging¹

¹ From the Departments of Nuclear Medicine and Diagnostic Imaging (A.K., T.K., T.Y.), Diagnostic and Interventional Imageology (K.T., T.F.), and Obstetrics and Gynecology (S.F.), Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 19, 2003; revision requested March 20 and received May 5; accepted May 7. Address correspondence to A.K. (e-mail: akikido@kuhp.kyoto-u.ac.jp).

View larger version (175K): [in a new window]   Figure 1a.  Uterine changes during the menstrual cycle in a 31-year-old woman. (a) Sagittal T2-weighted image obtained during the periovulatory phase shows the anatomy of the three zones: endometrium, junctional zone (arrowheads), and outer myometrium. (b) Sagittal T2-weighted image obtained during the midsecretory phase shows increased thickness of the endometrium and myometrium. The signal intensity of the outer myometrium is increased. The thickness of the junctional zone (arrowheads) is significantly decreased. (c) Sagittal T2-weighted image obtained during the menstrual phase shows that the uterine corpus appears smaller than during the periovulatory and midsecretory phases. The zonal anatomy of the myometrium is ill defined and irregularly thick (). The low-signal-intensity band in the middle of the endometrium (arrowheads) represents menstrual blood.

View larger version (174K): [in a new window]   Figure 1b.  Uterine changes during the menstrual cycle in a 31-year-old woman. (a) Sagittal T2-weighted image obtained during the periovulatory phase shows the anatomy of the three zones: endometrium, junctional zone (arrowheads), and outer myometrium. (b) Sagittal T2-weighted image obtained during the midsecretory phase shows increased thickness of the endometrium and myometrium. The signal intensity of the outer myometrium is increased. The thickness of the junctional zone (arrowheads) is significantly decreased. (c) Sagittal T2-weighted image obtained during the menstrual phase shows that the uterine corpus appears smaller than during the periovulatory and midsecretory phases. The zonal anatomy of the myometrium is ill defined and irregularly thick (). The low-signal-intensity band in the middle of the endometrium (arrowheads) represents menstrual blood.

View larger version (170K): [in a new window]   Figure 1c.  Uterine changes during the menstrual cycle in a 31-year-old woman. (a) Sagittal T2-weighted image obtained during the periovulatory phase shows the anatomy of the three zones: endometrium, junctional zone (arrowheads), and outer myometrium. (b) Sagittal T2-weighted image obtained during the midsecretory phase shows increased thickness of the endometrium and myometrium. The signal intensity of the outer myometrium is increased. The thickness of the junctional zone (arrowheads) is significantly decreased. (c) Sagittal T2-weighted image obtained during the menstrual phase shows that the uterine corpus appears smaller than during the periovulatory and midsecretory phases. The zonal anatomy of the myometrium is ill defined and irregularly thick (). The low-signal-intensity band in the middle of the endometrium (arrowheads) represents menstrual blood.

View larger version (192K): [in a new window]   Figure 2.  Appearance of the uterus in a 30-year-old woman 5 days after normal vaginal delivery. Sagittal T2-weighted image shows an enlarged uterus with dilated vessels (arrows) in the myometrium. The junctional zone is not identifiable. The regions of the endometrial cavity with marked low signal intensity (arrowheads) represent blood products.

View larger version (162K): [in a new window]   Figure 3a.  Appearance of the uterus in a 26-year-old woman after cesarean section at 31 weeks gestation. MR imaging was performed 8 days later for evaluation of cervical cancer. (a) Sagittal T1-weighted image shows a high-signal-intensity lesion (arrowheads) at the site of uterine incision, a finding consistent with a hematoma. (b) Sagittal T2-weighted image shows a bandlike appearance of the uterine incision (arrow) and the hematoma (black arrowheads). There are multiple dilated veins (white arrowheads) in the posterior wall.

View larger version (192K): [in a new window]   Figure 3b.  Appearance of the uterus in a 26-year-old woman after cesarean section at 31 weeks gestation. MR imaging was performed 8 days later for evaluation of cervical cancer. (a) Sagittal T1-weighted image shows a high-signal-intensity lesion (arrowheads) at the site of uterine incision, a finding consistent with a hematoma. (b) Sagittal T2-weighted image shows a bandlike appearance of the uterine incision (arrow) and the hematoma (black arrowheads). There are multiple dilated veins (white arrowheads) in the posterior wall.

View larger version (178K): [in a new window]   Figure 4.  Delayed uterine involution 10 days after vaginal delivery in a 33-year-old woman. Sagittal T2-weighted image shows that the uterus is still enlarged. The myometrium has high signal intensity with prominent vessels (arrowheads). Low-signal-intensity fluid is seen in the endometrial cavity (arrows), a finding indicative of blood products.

View larger version (172K): [in a new window]   Figure 5a.  Endometritis secondary to methicillin-resistant Staphylococcus aureus in a 31-year-old woman. Three weeks after cesarean section, the patient experienced septic shock. (a) Sagittal T2-weighted image shows the incision site for cesarean section in the anterior uterine wall (arrow). The uterus is enlarged with overall high signal intensity. The air (arrowhead) resulted from sanitization of the endometrial cavity. (b) Sagittal contrast material-enhanced T1-weighted image shows intense enhancement of the uterus with particularly prominent cervical enhancement (arrowheads). The cervix does not usually enhance so intensely unless it is significantly inflamed. The fluid seen in the endometrial cavity was found to be pus. (c) Sagittal T2-weighted image obtained 4 months after resolution of the endometritis shows decreased size of the uterus. The uterine position has changed from retroflexion to anteflexion. The zonal anatomy and the signal intensity of the myometrium have returned to normal. The diagnosis was confirmed with cultures of pus, which were positive for methicillin-resistant S aureus.

View larger version (165K): [in a new window]   Figure 5b.  Endometritis secondary to methicillin-resistant Staphylococcus aureus in a 31-year-old woman. Three weeks after cesarean section, the patient experienced septic shock. (a) Sagittal T2-weighted image shows the incision site for cesarean section in the anterior uterine wall (arrow). The uterus is enlarged with overall high signal intensity. The air (arrowhead) resulted from sanitization of the endometrial cavity. (b) Sagittal contrast material-enhanced T1-weighted image shows intense enhancement of the uterus with particularly prominent cervical enhancement (arrowheads). The cervix does not usually enhance so intensely unless it is significantly inflamed. The fluid seen in the endometrial cavity was found to be pus. (c) Sagittal T2-weighted image obtained 4 months after resolution of the endometritis shows decreased size of the uterus. The uterine position has changed from retroflexion to anteflexion. The zonal anatomy and the signal intensity of the myometrium have returned to normal. The diagnosis was confirmed with cultures of pus, which were positive for methicillin-resistant S aureus.

View larger version (182K): [in a new window]   Figure 5c.  Endometritis secondary to methicillin-resistant Staphylococcus aureus in a 31-year-old woman. Three weeks after cesarean section, the patient experienced septic shock. (a) Sagittal T2-weighted image shows the incision site for cesarean section in the anterior uterine wall (arrow). The uterus is enlarged with overall high signal intensity. The air (arrowhead) resulted from sanitization of the endometrial cavity. (b) Sagittal contrast material-enhanced T1-weighted image shows intense enhancement of the uterus with particularly prominent cervical enhancement (arrowheads). The cervix does not usually enhance so intensely unless it is significantly inflamed. The fluid seen in the endometrial cavity was found to be pus. (c) Sagittal T2-weighted image obtained 4 months after resolution of the endometritis shows decreased size of the uterus. The uterine position has changed from retroflexion to anteflexion. The zonal anatomy and the signal intensity of the myometrium have returned to normal. The diagnosis was confirmed with cultures of pus, which were positive for methicillin-resistant S aureus.

View larger version (181K): [in a new window]   Figure 6a.  Retained placenta in a 37-year-old woman. (a) Sagittal T2-weighted image shows an enlarged uterus with a high-signal-intensity subendometrial layer. A protruding lesion with high signal intensity (arrow) is seen in the uterine cavity, which is filled with low-signal-intensity blood (arrowheads). (b) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the protruding lesion (arrow), which indicates a retained placenta. The nonenhancing area in the lesion corresponds to a clot. Arrowheads = blood in the uterine cavity. Dilation and curettage performed after MR imaging demonstrated the presence of retained placenta.

View larger version (182K): [in a new window]   Figure 6b.  Retained placenta in a 37-year-old woman. (a) Sagittal T2-weighted image shows an enlarged uterus with a high-signal-intensity subendometrial layer. A protruding lesion with high signal intensity (arrow) is seen in the uterine cavity, which is filled with low-signal-intensity blood (arrowheads). (b) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the protruding lesion (arrow), which indicates a retained placenta. The nonenhancing area in the lesion corresponds to a clot. Arrowheads = blood in the uterine cavity. Dilation and curettage performed after MR imaging demonstrated the presence of retained placenta.

View larger version (164K): [in a new window]   Figure 7a.  RPOC in a 29-year-old woman who experienced acute massive vaginal bleeding 6 weeks after artificial abortion, which was performed due to a fatal anomaly of the fetus. (a) Sagittal T1-weighted image shows a slightly enlarged uterus with multiple serpentine signal voids (arrowheads) in the anterior wall and high-signal-intensity fluid (arrows) in the endometrial cavity. The latter finding is consistent with blood products. (b) Sagittal T2-weighted image shows numerous signal voids with ill-defined borders (arrowheads) in the anterior uterine wall. (c) Sagittal contrast-enhanced T1-weighted image shows ill-defined areas of enhancement (arrowheads) in the anterior uterine wall. However, no enhancing tissue protruding into the uterine cavity is seen. The preliminary diagnosis was arteriovenous malformation (AVM) or placenta increta. Hysterectomy was performed due to continued bleeding and the patient’s refusal to undergo arterial embolization. Surgery revealed a mass in the anterior uterine wall, which was easily peeled away from the myometrium. Thus, the diagnosis of RPOC rather than placenta increta was established. This case illustrates the difficulty of differentiating RPOC from AVM or placenta increta with MR imaging.

View larger version (194K): [in a new window]   Figure 7b.  RPOC in a 29-year-old woman who experienced acute massive vaginal bleeding 6 weeks after artificial abortion, which was performed due to a fatal anomaly of the fetus. (a) Sagittal T1-weighted image shows a slightly enlarged uterus with multiple serpentine signal voids (arrowheads) in the anterior wall and high-signal-intensity fluid (arrows) in the endometrial cavity. The latter finding is consistent with blood products. (b) Sagittal T2-weighted image shows numerous signal voids with ill-defined borders (arrowheads) in the anterior uterine wall. (c) Sagittal contrast-enhanced T1-weighted image shows ill-defined areas of enhancement (arrowheads) in the anterior uterine wall. However, no enhancing tissue protruding into the uterine cavity is seen. The preliminary diagnosis was arteriovenous malformation (AVM) or placenta increta. Hysterectomy was performed due to continued bleeding and the patient’s refusal to undergo arterial embolization. Surgery revealed a mass in the anterior uterine wall, which was easily peeled away from the myometrium. Thus, the diagnosis of RPOC rather than placenta increta was established. This case illustrates the difficulty of differentiating RPOC from AVM or placenta increta with MR imaging.

View larger version (185K): [in a new window]   Figure 7c.  RPOC in a 29-year-old woman who experienced acute massive vaginal bleeding 6 weeks after artificial abortion, which was performed due to a fatal anomaly of the fetus. (a) Sagittal T1-weighted image shows a slightly enlarged uterus with multiple serpentine signal voids (arrowheads) in the anterior wall and high-signal-intensity fluid (arrows) in the endometrial cavity. The latter finding is consistent with blood products. (b) Sagittal T2-weighted image shows numerous signal voids with ill-defined borders (arrowheads) in the anterior uterine wall. (c) Sagittal contrast-enhanced T1-weighted image shows ill-defined areas of enhancement (arrowheads) in the anterior uterine wall. However, no enhancing tissue protruding into the uterine cavity is seen. The preliminary diagnosis was arteriovenous malformation (AVM) or placenta increta. Hysterectomy was performed due to continued bleeding and the patient’s refusal to undergo arterial embolization. Surgery revealed a mass in the anterior uterine wall, which was easily peeled away from the myometrium. Thus, the diagnosis of RPOC rather than placenta increta was established. This case illustrates the difficulty of differentiating RPOC from AVM or placenta increta with MR imaging.

View larger version (177K): [in a new window]   Figure 8.  Uterine enlargement in a 22-year-old woman who had been taking estroprogesterone (oral contraceptive pills) for 3 months. Sagittal T2-weighted image shows a globular uterine corpus (arrowheads), a myometrium with increased signal intensity (higher than that of a normal uterus in a reproductive-age woman), and an atrophic endometrium.

View larger version (194K): [in a new window]   Figure 9.  Endometrial hyperplasia in a 43-year-old woman who had been taking tamoxifen for 8 years for treatment of breast cancer with multiple bone metastases. Sagittal T2-weighted image shows thickened endometrium (arrowheads) and myometrium. The endometrium is thickened in a heterogeneous manner, a finding consistent with endometrial hyperplasia. The thickened junctional zone in the posterior uterine wall () is indicative of adenomyosis. A leiomyoma (arrows) is present in the anterior uterine wall. Endometrial hyperplasia was demonstrated at histologic examination.

View larger version (192K): [in a new window]   Figure 10a.  Granulosa cell tumor in a 65-year-old woman with abnormal genital bleeding and an estradiol level of 36 pg/mL (normal level, <16 pg/mL). (a) Sagittal T2-weighted image shows that the uterus is slightly enlarged for the patient’s age with thickened endometrium (arrowheads). A subserosal leiomyoma (arrows) is present in the anterior wall. A large ovarian tumor with multiple cystic components is present anterior to the uterus. (b) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the endometrium (arrowheads), which is indicative of cystic hyperplasia. The ovarian wall and septa also demonstrate marked enhancement. The estradiol level returned to normal after surgery. Histologic examination demonstrated a granulosa cell tumor.

View larger version (180K): [in a new window]   Figure 10b.  Granulosa cell tumor in a 65-year-old woman with abnormal genital bleeding and an estradiol level of 36 pg/mL (normal level, <16 pg/mL). (a) Sagittal T2-weighted image shows that the uterus is slightly enlarged for the patient’s age with thickened endometrium (arrowheads). A subserosal leiomyoma (arrows) is present in the anterior wall. A large ovarian tumor with multiple cystic components is present anterior to the uterus. (b) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the endometrium (arrowheads), which is indicative of cystic hyperplasia. The ovarian wall and septa also demonstrate marked enhancement. The estradiol level returned to normal after surgery. Histologic examination demonstrated a granulosa cell tumor.

View larger version (190K): [in a new window]   Figure 11a.  Pelvic congestion syndrome in a 35-year-old woman (gravida 2, para 2) with chronic lower abdominal pain, hypermenorrhea, and abnormal genital bleeding. (a) Sagittal T2-weighted image shows thickened myometrium with numerous dilated signal voids (arrows). (b) Axial T2-weighted image shows multiple dilated veins (arrowheads) around the uterus. Abdominal CT demonstrated retrograde filling of the ovarian veins. Pelvic congestion syndrome was suspected on the basis of both the clinical presentation and the imaging findings. The symptoms and uterine size decreased after embolization of the ovarian veins.

View larger version (191K): [in a new window]   Figure 11b.  Pelvic congestion syndrome in a 35-year-old woman (gravida 2, para 2) with chronic lower abdominal pain, hypermenorrhea, and abnormal genital bleeding. (a) Sagittal T2-weighted image shows thickened myometrium with numerous dilated signal voids (arrows). (b) Axial T2-weighted image shows multiple dilated veins (arrowheads) around the uterus. Abdominal CT demonstrated retrograde filling of the ovarian veins. Pelvic congestion syndrome was suspected on the basis of both the clinical presentation and the imaging findings. The symptoms and uterine size decreased after embolization of the ovarian veins.

View larger version (188K): [in a new window]   Figure 12.  Adenomyosis. Sagittal T2-weighted image shows indistinct zonal anatomy. Widening of the junctional zone is clearly seen in the region around the distorted endometrium (arrowheads). The myometrium has decreased signal intensity with tiny spots of high signal intensity (arrows).

View larger version (184K): [in a new window]   Figure 13.  Focal adenomyosis in a 49-year-old woman. Sagittal T2-weighted image shows a heterogeneous area of high signal intensity (arrowheads) within the myometrium that protrudes into the uterine cavity. The interface between the lesion and the myometrium is indistinct. Fine hyperintense striations (arrows) extend into the myometrium; this appearance is an extreme example of pseudowidening of the endometrium.

View larger version (186K): [in a new window]   Figure 14a.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. (a) Sagittal T2-weighted image shows a mass (M) in the submucosal area of the posterior region. The mass is hyperintense relative to the myometrium. (b) Sagittal T2-weighted image obtained 1 cm lateral to a shows that the margins of the mass (M) are indistinct at its periphery. Arrows = endometrium. Histologic examination of the surgical specimen revealed endometrioid adenocarcinoma arising from adenomyosis.

View larger version (179K): [in a new window]   Figure 14b.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. (a) Sagittal T2-weighted image shows a mass (M) in the submucosal area of the posterior region. The mass is hyperintense relative to the myometrium. (b) Sagittal T2-weighted image obtained 1 cm lateral to a shows that the margins of the mass (M) are indistinct at its periphery. Arrows = endometrium. Histologic examination of the surgical specimen revealed endometrioid adenocarcinoma arising from adenomyosis.

View larger version (175K): [in a new window]   Figure 15.  Multiple leiomyomas in a 44-year-old woman. Sagittal T2-weighted image shows a diffusely enlarged uterus with multiple leiomyomas. Each leiomyoma has clear margins and distinct low signal intensity.

View larger version (187K): [in a new window]   Figure 16.  Diffuse leiomyomatosis in a 31-year-old woman. Sagittal T2-weighted image shows a prominently enlarged uterus with innumerable leiomyomas that appear to blend with one another. The endometrium (arrows) is markedly elongated and distorted by multiple submucosal nodules.

View larger version (184K): [in a new window]   Figure 17a.  Leiomyosarcoma in a 44-year-old woman. (a) Sagittal T2-weighted image shows a tumor (M) with slightly high signal intensity and irregular margins. The tumor protrudes from the posterior myometrium into the endometrial cavity (arrows). Small leiomyomas (m) with clear margins are present in the anterior wall. (b) Sagittal T2-weighted image, obtained 3 months later after the patient experienced rapidly progressing abdominal fullness, shows an irregularly shaped uterus that has clearly increased in size. The tumor occupies the endometrial cavity (arrows). The nodules (m) in the anterior wall also demonstrate remarkable increase in size.

View larger version (147K): [in a new window]   Figure 17b.  Leiomyosarcoma in a 44-year-old woman. (a) Sagittal T2-weighted image shows a tumor (M) with slightly high signal intensity and irregular margins. The tumor protrudes from the posterior myometrium into the endometrial cavity (arrows). Small leiomyomas (m) with clear margins are present in the anterior wall. (b) Sagittal T2-weighted image, obtained 3 months later after the patient experienced rapidly progressing abdominal fullness, shows an irregularly shaped uterus that has clearly increased in size. The tumor occupies the endometrial cavity (arrows). The nodules (m) in the anterior wall also demonstrate remarkable increase in size.

View larger version (160K): [in a new window]   Figure 18a.  Malignant lymphoma in a 48-year-old woman with multiple swollen lymph nodes in the paraaortic and supraclavicular regions. (a) Sagittal T1-weighted image shows extensive uniform enlargement of the uterus (arrowheads), which has homogeneous low signal intensity. (b) Sagittal T2-weighted image shows diffuse symmetrical enlargement of the uterus, especially of the cervix (arrows). The lack of signal in the cervical stroma is obvious. The myometrium also lacks its zonal appearance and has low signal intensity with an irregular contour. The cause of this signal intensity is unknown. (c) Sagittal contrast-enhanced T1-weighted image shows heterogeneous enhancement of the uterus. The diagnosis of malignant lymphoma was established by means of biopsy of a lymph node. The uterine lesion significantly decreased in size with chemotherapy and was considered to represent uterine involvement by lymphoma.

View larger version (167K): [in a new window]   Figure 18b.  Malignant lymphoma in a 48-year-old woman with multiple swollen lymph nodes in the paraaortic and supraclavicular regions. (a) Sagittal T1-weighted image shows extensive uniform enlargement of the uterus (arrowheads), which has homogeneous low signal intensity. (b) Sagittal T2-weighted image shows diffuse symmetrical enlargement of the uterus, especially of the cervix (arrows). The lack of signal in the cervical stroma is obvious. The myometrium also lacks its zonal appearance and has low signal intensity with an irregular contour. The cause of this signal intensity is unknown. (c) Sagittal contrast-enhanced T1-weighted image shows heterogeneous enhancement of the uterus. The diagnosis of malignant lymphoma was established by means of biopsy of a lymph node. The uterine lesion significantly decreased in size with chemotherapy and was considered to represent uterine involvement by lymphoma.

View larger version (152K): [in a new window]   Figure 18c.  Malignant lymphoma in a 48-year-old woman with multiple swollen lymph nodes in the paraaortic and supraclavicular regions. (a) Sagittal T1-weighted image shows extensive uniform enlargement of the uterus (arrowheads), which has homogeneous low signal intensity. (b) Sagittal T2-weighted image shows diffuse symmetrical enlargement of the uterus, especially of the cervix (arrows). The lack of signal in the cervical stroma is obvious. The myometrium also lacks its zonal appearance and has low signal intensity with an irregular contour. The cause of this signal intensity is unknown. (c) Sagittal contrast-enhanced T1-weighted image shows heterogeneous enhancement of the uterus. The diagnosis of malignant lymphoma was established by means of biopsy of a lymph node. The uterine lesion significantly decreased in size with chemotherapy and was considered to represent uterine involvement by lymphoma.

View larger version (177K): [in a new window]   Figure 19.  Low-grade endometrial stromal sarcoma in a 21-year-old woman. Sagittal T2-weighted image shows a huge tumor that replaces the endometrial cavity (arrowheads) and infiltrates the myometrium. Bands of low signal intensity (arrows) are seen in the infiltrated myometrium; these bands corresponded to preserved bundles of myometrium at histologic examination.

View larger version (187K): [in a new window]   Figure 20.  Uterine metastatic disease in a 51-year-old woman with abnormal genital bleeding who had undergone mastectomy for breast cancer. Sagittal T2-weighted image shows a diffusely thickened myometrium with low signal intensity (arrows) and a small amount of low-signal-intensity blood (arrowheads) in the uterine cavity. There is a leiomyoma (m) in the posterior wall. Cytologic analysis of endometrial tissue demonstrated metastatic adenocarcinoma from the breast tumor.

View larger version (165K): [in a new window]   Figure 21.  Uterine enlargement in a 41-year-old woman with an IUD that was placed 6 years earlier. Sagittal half-Fourier single-shot turbo spin-echo image shows a globular uterus. The IUD (arrow) is seen as a band of low signal intensity in the endometrium.