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MR Imaging Findings of Adenomyosis: Correlation with Histopathologic Features and Diagnostic Pitfalls¹

¹ From the Department of Radiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan (K. Tamai, T.I., N.M.); the Departments of Nuclear Medicine and Diagnostic Imaging, Graduate School of Medicine, Kyoto University, Japan (K. Togashi, T.F.); and the Department of Radiology, Kyoto University Hospital, Japan (T.K.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received March 31, 2004; revision requested April 29 and received August 3; accepted August 5. All authors have no financial relationships to disclose. Address correspondence to K. Tamai, Departments of Nuclear Medicine and Diagnostic Imaging, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan (e-mail: tamai@kuhp.kyoto-u.ac.jp).

View larger version (181K): [in a new window]   Figure 1a.  Adenomyosis in a 48-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with homogeneous signal intensity. (b) Sagittal T2-weighted image shows an ill-defined myometrial lesion of low signal intensity in the anterior myometrium. Innumerable hyperintense foci (arrows) are embedded in the lesion.

View larger version (200K): [in a new window]   Figure 1b.  Adenomyosis in a 48-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with homogeneous signal intensity. (b) Sagittal T2-weighted image shows an ill-defined myometrial lesion of low signal intensity in the anterior myometrium. Innumerable hyperintense foci (arrows) are embedded in the lesion.

View larger version (190K): [in a new window]   Figure 2a.  Adenomyosis with hemorrhagic foci in a 52-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with multiple hyperintense foci in the anterior myometrium (arrows), which represent hemorrhage. (b) Sagittal T2-weighted image shows an ill-defined area of low signal intensity in the anterior myometrium. Hyperintense foci (arrows) are embedded in the lesion. (c) Photograph of the cut surface of the gross specimen shows multiple hemorrhagic cysts within a thickened myometrium. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows an island of ectopic endometrial tissue that contains blood (arrowheads).

View larger version (175K): [in a new window]   Figure 2b.  Adenomyosis with hemorrhagic foci in a 52-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with multiple hyperintense foci in the anterior myometrium (arrows), which represent hemorrhage. (b) Sagittal T2-weighted image shows an ill-defined area of low signal intensity in the anterior myometrium. Hyperintense foci (arrows) are embedded in the lesion. (c) Photograph of the cut surface of the gross specimen shows multiple hemorrhagic cysts within a thickened myometrium. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows an island of ectopic endometrial tissue that contains blood (arrowheads).

View larger version (120K): [in a new window]   Figure 2c.  Adenomyosis with hemorrhagic foci in a 52-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with multiple hyperintense foci in the anterior myometrium (arrows), which represent hemorrhage. (b) Sagittal T2-weighted image shows an ill-defined area of low signal intensity in the anterior myometrium. Hyperintense foci (arrows) are embedded in the lesion. (c) Photograph of the cut surface of the gross specimen shows multiple hemorrhagic cysts within a thickened myometrium. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows an island of ectopic endometrial tissue that contains blood (arrowheads).

View larger version (178K): [in a new window]   Figure 2d.  Adenomyosis with hemorrhagic foci in a 52-year-old woman. (a) Sagittal T1-weighted image shows an enlarged uterus with multiple hyperintense foci in the anterior myometrium (arrows), which represent hemorrhage. (b) Sagittal T2-weighted image shows an ill-defined area of low signal intensity in the anterior myometrium. Hyperintense foci (arrows) are embedded in the lesion. (c) Photograph of the cut surface of the gross specimen shows multiple hemorrhagic cysts within a thickened myometrium. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows an island of ectopic endometrial tissue that contains blood (arrowheads).

View larger version (173K): [in a new window]   Figure 3a.  Changing appearance of adenomyosis in a 47-year-old woman. (a) Sagittal T2-weighted image obtained on day 16 of the menstrual cycle shows a myometrial mass of high signal intensity protruding into the uterine cavity (arrows). (b) Sagittal T2-weighted image obtained 22 days later (on cycle day 10) shows the typical appearance of adenomyosis. Adenomyosis was confirmed at surgery.

View larger version (186K): [in a new window]   Figure 3b.  Changing appearance of adenomyosis in a 47-year-old woman. (a) Sagittal T2-weighted image obtained on day 16 of the menstrual cycle shows a myometrial mass of high signal intensity protruding into the uterine cavity (arrows). (b) Sagittal T2-weighted image obtained 22 days later (on cycle day 10) shows the typical appearance of adenomyosis. Adenomyosis was confirmed at surgery.

View larger version (175K): [in a new window]   Figure 4a.  Pseudowidening of the endometrium in a 49-year-old woman. (a) Sagittal T2-weighted image shows an ill-defined area of high signal intensity along the posterior myometrium (arrows). The lesion simulates widening of the endometrium but actually represents benign, extensive invasion of ectopic endometrium into the myometrium. (b) Photograph of the histopathologic slide shows ectopic endometrial tissue extensively extending into the myometrium (arrows), an appearance that corresponds to the endometrial pseudowidening on the T2-weighted image. Arrowheads = eutopic endometrium.

View larger version (156K): [in a new window]   Figure 4b.  Pseudowidening of the endometrium in a 49-year-old woman. (a) Sagittal T2-weighted image shows an ill-defined area of high signal intensity along the posterior myometrium (arrows). The lesion simulates widening of the endometrium but actually represents benign, extensive invasion of ectopic endometrium into the myometrium. (b) Photograph of the histopathologic slide shows ectopic endometrial tissue extensively extending into the myometrium (arrows), an appearance that corresponds to the endometrial pseudowidening on the T2-weighted image. Arrowheads = eutopic endometrium.

View larger version (170K): [in a new window]   Figure 5.  Thickening of the junctional zone during the menstrual phase in a 31-year-old woman. Sagittal T2-weighted image obtained on cycle day 1 shows marked thickening of the junctional zone (arrows), which may closely simulate adenomyosis. The low-signal-intensity band in the endometrium (arrowheads) represents menstrual blood.

View larger version (152K): [in a new window]   Figure 6a.  Myometrial contraction in a healthy 30-year-old woman, who underwent MR imaging during a study that evaluated myometrial contractions during the menstrual phase. The half-Fourier acquisition single-shot turbo spin-echo sequence was used to obtain T2-weighted images. (a) Sagittal image obtained on cycle day 1 shows a focal area of low signal intensity in the anterior myometrium (arrows), a finding that closely simulates focal adenomyosis. (b) Sagittal image obtained on cycle day 3 shows a normal uterus with a thin and distinct junctional zone.

View larger version (155K): [in a new window]   Figure 6b.  Myometrial contraction in a healthy 30-year-old woman, who underwent MR imaging during a study that evaluated myometrial contractions during the menstrual phase. The half-Fourier acquisition single-shot turbo spin-echo sequence was used to obtain T2-weighted images. (a) Sagittal image obtained on cycle day 1 shows a focal area of low signal intensity in the anterior myometrium (arrows), a finding that closely simulates focal adenomyosis. (b) Sagittal image obtained on cycle day 3 shows a normal uterus with a thin and distinct junctional zone.

View larger version (190K): [in a new window]   Figure 7a.  Intramyometrial adenomyoma in a 21-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted images show an ill-defined, low-signal-intensity mass with an embedded hyperintense cyst in the posterior myometrium (arrows). (c) Sagittal T1-weighted image shows that the cyst within the mass (arrows) has high signal intensity, which represents hemorrhage. Myomectomy was performed, and adenomyosis was pathologically confirmed.

View larger version (192K): [in a new window]   Figure 7b.  Intramyometrial adenomyoma in a 21-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted images show an ill-defined, low-signal-intensity mass with an embedded hyperintense cyst in the posterior myometrium (arrows). (c) Sagittal T1-weighted image shows that the cyst within the mass (arrows) has high signal intensity, which represents hemorrhage. Myomectomy was performed, and adenomyosis was pathologically confirmed.

View larger version (178K): [in a new window]   Figure 7c.  Intramyometrial adenomyoma in a 21-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted images show an ill-defined, low-signal-intensity mass with an embedded hyperintense cyst in the posterior myometrium (arrows). (c) Sagittal T1-weighted image shows that the cyst within the mass (arrows) has high signal intensity, which represents hemorrhage. Myomectomy was performed, and adenomyosis was pathologically confirmed.

View larger version (163K): [in a new window]   Figure 8a.  Tamoxifen-induced adenomyoma in a 56-year-old woman. The patient underwent breast-conserving therapy for breast carcinoma 2 years earlier and was treated with tamoxifen. (a) Sagittal T2-weighted image shows a polypoid mass of heterogeneous high signal intensity in the endometrial cavity (arrows). (b) Sagittal contrast-enhanced T1-weighted image shows that the mass (arrows) enhances as well as the myometrium. (c) Photomicrograph (original magnification, x20; H-E stain) shows endometrial tissue surrounded by hyperplastic smooth muscle.

View larger version (176K): [in a new window]   Figure 8b.  Tamoxifen-induced adenomyoma in a 56-year-old woman. The patient underwent breast-conserving therapy for breast carcinoma 2 years earlier and was treated with tamoxifen. (a) Sagittal T2-weighted image shows a polypoid mass of heterogeneous high signal intensity in the endometrial cavity (arrows). (b) Sagittal contrast-enhanced T1-weighted image shows that the mass (arrows) enhances as well as the myometrium. (c) Photomicrograph (original magnification, x20; H-E stain) shows endometrial tissue surrounded by hyperplastic smooth muscle.

View larger version (205K): [in a new window]   Figure 8c.  Tamoxifen-induced adenomyoma in a 56-year-old woman. The patient underwent breast-conserving therapy for breast carcinoma 2 years earlier and was treated with tamoxifen. (a) Sagittal T2-weighted image shows a polypoid mass of heterogeneous high signal intensity in the endometrial cavity (arrows). (b) Sagittal contrast-enhanced T1-weighted image shows that the mass (arrows) enhances as well as the myometrium. (c) Photomicrograph (original magnification, x20; H-E stain) shows endometrial tissue surrounded by hyperplastic smooth muscle.

View larger version (177K): [in a new window]   Figure 9a.  Atypical polypoid adenomyoma in a 42-year-old woman. (a) Sagittal T1-weighted image shows a pedunculated polypoid mass projecting into the cervical canal (arrows). The mass has intermediate signal intensity and contains a large hyperintense cyst (arrowheads), which represents hemorrhage. (b) Sagittal T2-weighted image shows that the polypoid mass has slightly high signal intensity (arrows); the embedded cyst is hyperintense (arrowheads). (c) Photograph of the histopathologic slide shows the polypoid mass and the relatively large but deflated cyst (arrowheads), which correlates with the hemorrhagic cyst seen on the MR images.

View larger version (154K): [in a new window]   Figure 9b.  Atypical polypoid adenomyoma in a 42-year-old woman. (a) Sagittal T1-weighted image shows a pedunculated polypoid mass projecting into the cervical canal (arrows). The mass has intermediate signal intensity and contains a large hyperintense cyst (arrowheads), which represents hemorrhage. (b) Sagittal T2-weighted image shows that the polypoid mass has slightly high signal intensity (arrows); the embedded cyst is hyperintense (arrowheads). (c) Photograph of the histopathologic slide shows the polypoid mass and the relatively large but deflated cyst (arrowheads), which correlates with the hemorrhagic cyst seen on the MR images.

View larger version (126K): [in a new window]   Figure 9c.  Atypical polypoid adenomyoma in a 42-year-old woman. (a) Sagittal T1-weighted image shows a pedunculated polypoid mass projecting into the cervical canal (arrows). The mass has intermediate signal intensity and contains a large hyperintense cyst (arrowheads), which represents hemorrhage. (b) Sagittal T2-weighted image shows that the polypoid mass has slightly high signal intensity (arrows); the embedded cyst is hyperintense (arrowheads). (c) Photograph of the histopathologic slide shows the polypoid mass and the relatively large but deflated cyst (arrowheads), which correlates with the hemorrhagic cyst seen on the MR images.

View larger version (163K): [in a new window]   Figure 10a.  Subserosal adenomyotic cyst in a 46-year-old woman. (a) Sagittal T1-weighted image shows a cystic mass posterior to the uterus (U). The lesion consists of a hyperintense cyst, on top of which is curvilinear tissue of intermediate signal intensity (arrows). (b) Sagittal T2-weighted image shows that the curvilinear tissue is hypointense (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows the curvilinear tissue (arrows) enhancing as well as the myometrium. A pedicle containing enlarged vessels (arrowheads) connects the lesion to the uterus, indicating the uterine origin of the mass. Thus, the preoperative diagnosis was degenerated subserosal leiomyoma. (d) Photograph of the cut surface shows the hemorrhagic cystic mass and the curvilinear solid tissue (arrows). The initial pathologic diagnosis was leiomyoma because the lesion consisted of smooth muscle cells and hyaline degeneration. (e) Photomicrograph (original magnification, x40; H-E stain) shows endometrial tissue containing hemorrhage (arrow) and hemosiderin (arrowhead) lining the cyst wall.

View larger version (147K): [in a new window]   Figure 10b.  Subserosal adenomyotic cyst in a 46-year-old woman. (a) Sagittal T1-weighted image shows a cystic mass posterior to the uterus (U). The lesion consists of a hyperintense cyst, on top of which is curvilinear tissue of intermediate signal intensity (arrows). (b) Sagittal T2-weighted image shows that the curvilinear tissue is hypointense (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows the curvilinear tissue (arrows) enhancing as well as the myometrium. A pedicle containing enlarged vessels (arrowheads) connects the lesion to the uterus, indicating the uterine origin of the mass. Thus, the preoperative diagnosis was degenerated subserosal leiomyoma. (d) Photograph of the cut surface shows the hemorrhagic cystic mass and the curvilinear solid tissue (arrows). The initial pathologic diagnosis was leiomyoma because the lesion consisted of smooth muscle cells and hyaline degeneration. (e) Photomicrograph (original magnification, x40; H-E stain) shows endometrial tissue containing hemorrhage (arrow) and hemosiderin (arrowhead) lining the cyst wall.

View larger version (164K): [in a new window]   Figure 10c.  Subserosal adenomyotic cyst in a 46-year-old woman. (a) Sagittal T1-weighted image shows a cystic mass posterior to the uterus (U). The lesion consists of a hyperintense cyst, on top of which is curvilinear tissue of intermediate signal intensity (arrows). (b) Sagittal T2-weighted image shows that the curvilinear tissue is hypointense (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows the curvilinear tissue (arrows) enhancing as well as the myometrium. A pedicle containing enlarged vessels (arrowheads) connects the lesion to the uterus, indicating the uterine origin of the mass. Thus, the preoperative diagnosis was degenerated subserosal leiomyoma. (d) Photograph of the cut surface shows the hemorrhagic cystic mass and the curvilinear solid tissue (arrows). The initial pathologic diagnosis was leiomyoma because the lesion consisted of smooth muscle cells and hyaline degeneration. (e) Photomicrograph (original magnification, x40; H-E stain) shows endometrial tissue containing hemorrhage (arrow) and hemosiderin (arrowhead) lining the cyst wall.

View larger version (129K): [in a new window]   Figure 10d.  Subserosal adenomyotic cyst in a 46-year-old woman. (a) Sagittal T1-weighted image shows a cystic mass posterior to the uterus (U). The lesion consists of a hyperintense cyst, on top of which is curvilinear tissue of intermediate signal intensity (arrows). (b) Sagittal T2-weighted image shows that the curvilinear tissue is hypointense (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows the curvilinear tissue (arrows) enhancing as well as the myometrium. A pedicle containing enlarged vessels (arrowheads) connects the lesion to the uterus, indicating the uterine origin of the mass. Thus, the preoperative diagnosis was degenerated subserosal leiomyoma. (d) Photograph of the cut surface shows the hemorrhagic cystic mass and the curvilinear solid tissue (arrows). The initial pathologic diagnosis was leiomyoma because the lesion consisted of smooth muscle cells and hyaline degeneration. (e) Photomicrograph (original magnification, x40; H-E stain) shows endometrial tissue containing hemorrhage (arrow) and hemosiderin (arrowhead) lining the cyst wall.

View larger version (151K): [in a new window]   Figure 10e.  Subserosal adenomyotic cyst in a 46-year-old woman. (a) Sagittal T1-weighted image shows a cystic mass posterior to the uterus (U). The lesion consists of a hyperintense cyst, on top of which is curvilinear tissue of intermediate signal intensity (arrows). (b) Sagittal T2-weighted image shows that the curvilinear tissue is hypointense (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows the curvilinear tissue (arrows) enhancing as well as the myometrium. A pedicle containing enlarged vessels (arrowheads) connects the lesion to the uterus, indicating the uterine origin of the mass. Thus, the preoperative diagnosis was degenerated subserosal leiomyoma. (d) Photograph of the cut surface shows the hemorrhagic cystic mass and the curvilinear solid tissue (arrows). The initial pathologic diagnosis was leiomyoma because the lesion consisted of smooth muscle cells and hyaline degeneration. (e) Photomicrograph (original magnification, x40; H-E stain) shows endometrial tissue containing hemorrhage (arrow) and hemosiderin (arrowhead) lining the cyst wall.

View larger version (133K): [in a new window]   Figure 11a.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (129K): [in a new window]   Figure 11b.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (143K): [in a new window]   Figure 11c.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (149K): [in a new window]   Figure 11d.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (145K): [in a new window]   Figure 11e.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (129K): [in a new window]   Figure 11f.  Submucosal adenomyotic cyst in a 37-year-old woman. (a) Sagittal T2-weighted image obtained 3 years earlier shows typical adenomyosis. (b) Sagittal T1-weighted image shows a polypoid mass in the endometrial cavity (arrows). The hyperintense area in the mass is hemorrhage. (c) Sagittal T2-weighted image shows the well-defined cystic mass (arrows). Its thick wall has inner low and outer high signal intensity (miniature uterus). The uterus is enlarged due to adenomyosis. (d) Sagittal contrast-enhanced T1-weighted image shows marked enhancement of the wall (arrows). (e) Photograph of the cut surface shows the uterus-like mass (arrows). (f) Photomicrograph (original magnification, x40; H-E stain) shows the cyst (*) surrounded by layers of endometrial tissue and smooth muscle.

View larger version (167K): [in a new window]   Figure 12a.  Decidual changes of adenomyosis in a 23-year-old woman with a hydatidiform mole. (a) Sagittal T2-weighted image shows an ill-defined lesion of heterogeneous high signal intensity in the posterior myometrium (arrows) in addition to a lesion in the uterine cavity (arrowheads). (b) Sagittal T2-weighted image obtained after suction and curettage shows that the lesion in the posterior myometrium is reduced in volume and signal intensity and now has the typical appearance of adenomyosis (arrows). The lesion in the uterine cavity was confirmed to be a hydatidiform mole. This case seems to represent decidual changes of adenomyosis because the serum level of human chorionic gonadotropin was highly elevated when the lesion demonstrated prominent high signal intensity in a.

View larger version (185K): [in a new window]   Figure 12b.  Decidual changes of adenomyosis in a 23-year-old woman with a hydatidiform mole. (a) Sagittal T2-weighted image shows an ill-defined lesion of heterogeneous high signal intensity in the posterior myometrium (arrows) in addition to a lesion in the uterine cavity (arrowheads). (b) Sagittal T2-weighted image obtained after suction and curettage shows that the lesion in the posterior myometrium is reduced in volume and signal intensity and now has the typical appearance of adenomyosis (arrows). The lesion in the uterine cavity was confirmed to be a hydatidiform mole. This case seems to represent decidual changes of adenomyosis because the serum level of human chorionic gonadotropin was highly elevated when the lesion demonstrated prominent high signal intensity in a.

View larger version (140K): [in a new window]   Figure 13a.  Adenomyosis with leiomyomas in a 43-year-old woman. (a) Sagittal T2-weighted image shows typical adenomyosis in the anterior myometrium. Leiomyomas are demonstrated as well-circumscribed hypointense masses (arrows). (b) Photograph of the cut surface of the gross specimen shows several leiomyomas with well-defined borders (arrows) in the myometrium.

View larger version (99K): [in a new window]   Figure 13b.  Adenomyosis with leiomyomas in a 43-year-old woman. (a) Sagittal T2-weighted image shows typical adenomyosis in the anterior myometrium. Leiomyomas are demonstrated as well-circumscribed hypointense masses (arrows). (b) Photograph of the cut surface of the gross specimen shows several leiomyomas with well-defined borders (arrows) in the myometrium.

View larger version (168K): [in a new window]   Figure 14a.  Adenomatoid tumor of the uterus in a 42-year-old woman. (a) Axial T2-weighted image shows an ill-defined mass (arrowheads) that is slightly hypointense relative to the myometrium. The lesion is surrounded by cystic areas of high signal intensity (arrows), especially at the serosal aspect. (b) Photograph of the cut surface of the gross specimen shows an appearance that corresponds closely to that seen on the MR image. (c) Photomicrograph (original magnification, x40; H-E stain) shows the cystic spaces of dilated mesothelial tubules (*) within myometrial fibers.

View larger version (113K): [in a new window]   Figure 14b.  Adenomatoid tumor of the uterus in a 42-year-old woman. (a) Axial T2-weighted image shows an ill-defined mass (arrowheads) that is slightly hypointense relative to the myometrium. The lesion is surrounded by cystic areas of high signal intensity (arrows), especially at the serosal aspect. (b) Photograph of the cut surface of the gross specimen shows an appearance that corresponds closely to that seen on the MR image. (c) Photomicrograph (original magnification, x40; H-E stain) shows the cystic spaces of dilated mesothelial tubules (*) within myometrial fibers.

View larger version (119K): [in a new window]   Figure 14c.  Adenomatoid tumor of the uterus in a 42-year-old woman. (a) Axial T2-weighted image shows an ill-defined mass (arrowheads) that is slightly hypointense relative to the myometrium. The lesion is surrounded by cystic areas of high signal intensity (arrows), especially at the serosal aspect. (b) Photograph of the cut surface of the gross specimen shows an appearance that corresponds closely to that seen on the MR image. (c) Photomicrograph (original magnification, x40; H-E stain) shows the cystic spaces of dilated mesothelial tubules (*) within myometrial fibers.

View larger version (176K): [in a new window]   Figure 15a.  Low-grade endometrial stromal sarcoma in a 20-year-old woman. (a) Sagittal T2-weighted image shows a poorly defined mass in the myometrium. Numerous bands of low signal intensity are observed (arrowheads). The endometrial-myometrial border is obscured. (b) Photomicrograph (original magnification, x40; H-E stain) shows bundles of residual myometrial fibers (arrows) separated by cords of tumor cells. (c) Photomicrograph (original magnification, x200; H-E stain) shows tumor vessels closely resembling arterioles in the endometrial stroma (arrows).

View larger version (166K): [in a new window]   Figure 15b.  Low-grade endometrial stromal sarcoma in a 20-year-old woman. (a) Sagittal T2-weighted image shows a poorly defined mass in the myometrium. Numerous bands of low signal intensity are observed (arrowheads). The endometrial-myometrial border is obscured. (b) Photomicrograph (original magnification, x40; H-E stain) shows bundles of residual myometrial fibers (arrows) separated by cords of tumor cells. (c) Photomicrograph (original magnification, x200; H-E stain) shows tumor vessels closely resembling arterioles in the endometrial stroma (arrows).

View larger version (163K): [in a new window]   Figure 15c.  Low-grade endometrial stromal sarcoma in a 20-year-old woman. (a) Sagittal T2-weighted image shows a poorly defined mass in the myometrium. Numerous bands of low signal intensity are observed (arrowheads). The endometrial-myometrial border is obscured. (b) Photomicrograph (original magnification, x40; H-E stain) shows bundles of residual myometrial fibers (arrows) separated by cords of tumor cells. (c) Photomicrograph (original magnification, x200; H-E stain) shows tumor vessels closely resembling arterioles in the endometrial stroma (arrows).

View larger version (186K): [in a new window]   Figure 16a.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. Hysteroscopy showed a submucosal mass, but preoperative histologic evaluation showed no malignancy. (a) Sagittal T1-weighted image shows a slightly enlarged uterus for the patient’s age (arrows). (b) Sagittal T2-weighted image shows a well-demarcated mass of high signal intensity in the myometrium (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows weak enhancement (arrows). (d) Photograph of the cut surface shows the mass (arrows), which resembles a leiomyoma. (e) Photomicrograph (original magnification, x40; H-E stain) shows moderately differentiated endometrioid carcinoma (*) separated from the endometrium and surrounded by adenomyosis, which was not seen on the MR images.

View larger version (203K): [in a new window]   Figure 16b.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. Hysteroscopy showed a submucosal mass, but preoperative histologic evaluation showed no malignancy. (a) Sagittal T1-weighted image shows a slightly enlarged uterus for the patient’s age (arrows). (b) Sagittal T2-weighted image shows a well-demarcated mass of high signal intensity in the myometrium (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows weak enhancement (arrows). (d) Photograph of the cut surface shows the mass (arrows), which resembles a leiomyoma. (e) Photomicrograph (original magnification, x40; H-E stain) shows moderately differentiated endometrioid carcinoma (*) separated from the endometrium and surrounded by adenomyosis, which was not seen on the MR images.

View larger version (186K): [in a new window]   Figure 16c.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. Hysteroscopy showed a submucosal mass, but preoperative histologic evaluation showed no malignancy. (a) Sagittal T1-weighted image shows a slightly enlarged uterus for the patient’s age (arrows). (b) Sagittal T2-weighted image shows a well-demarcated mass of high signal intensity in the myometrium (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows weak enhancement (arrows). (d) Photograph of the cut surface shows the mass (arrows), which resembles a leiomyoma. (e) Photomicrograph (original magnification, x40; H-E stain) shows moderately differentiated endometrioid carcinoma (*) separated from the endometrium and surrounded by adenomyosis, which was not seen on the MR images.

View larger version (122K): [in a new window]   Figure 16d.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. Hysteroscopy showed a submucosal mass, but preoperative histologic evaluation showed no malignancy. (a) Sagittal T1-weighted image shows a slightly enlarged uterus for the patient’s age (arrows). (b) Sagittal T2-weighted image shows a well-demarcated mass of high signal intensity in the myometrium (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows weak enhancement (arrows). (d) Photograph of the cut surface shows the mass (arrows), which resembles a leiomyoma. (e) Photomicrograph (original magnification, x40; H-E stain) shows moderately differentiated endometrioid carcinoma (*) separated from the endometrium and surrounded by adenomyosis, which was not seen on the MR images.

View larger version (182K): [in a new window]   Figure 16e.  Adenocarcinoma arising from adenomyosis in a 71-year-old woman. Hysteroscopy showed a submucosal mass, but preoperative histologic evaluation showed no malignancy. (a) Sagittal T1-weighted image shows a slightly enlarged uterus for the patient’s age (arrows). (b) Sagittal T2-weighted image shows a well-demarcated mass of high signal intensity in the myometrium (arrows). (c) Sagittal contrast-enhanced T1-weighted image shows weak enhancement (arrows). (d) Photograph of the cut surface shows the mass (arrows), which resembles a leiomyoma. (e) Photomicrograph (original magnification, x40; H-E stain) shows moderately differentiated endometrioid carcinoma (*) separated from the endometrium and surrounded by adenomyosis, which was not seen on the MR images.

View larger version (175K): [in a new window]   Figure 17a.  Adenocarcinoma arising within adenomyosis in a 46-year-old woman. (a) Sagittal T2-weighted image shows diffuse thickening of the junctional zone, which is indicative of adenomyosis. The endometrium has heterogeneous signal intensity. (b) Sagittal contrast-enhanced fat-suppressed T1-weighted image shows a normal appearance except for an ill-defined border between the endometrium and myometrium. (c) Photomicrograph (original magnification, x40; H-E stain) shows adenocarcinoma within the adenomyosis; the adenocarcinoma was not identifiable on the MR images. The tumor cells diffusely involve the ectopic endometrial tissue within the myometrium (*), whereas the endometrium () is relatively intact with only minimal lesions at the bottom of the endometrial layer (arrows).

View larger version (166K): [in a new window]   Figure 17b.  Adenocarcinoma arising within adenomyosis in a 46-year-old woman. (a) Sagittal T2-weighted image shows diffuse thickening of the junctional zone, which is indicative of adenomyosis. The endometrium has heterogeneous signal intensity. (b) Sagittal contrast-enhanced fat-suppressed T1-weighted image shows a normal appearance except for an ill-defined border between the endometrium and myometrium. (c) Photomicrograph (original magnification, x40; H-E stain) shows adenocarcinoma within the adenomyosis; the adenocarcinoma was not identifiable on the MR images. The tumor cells diffusely involve the ectopic endometrial tissue within the myometrium (*), whereas the endometrium () is relatively intact with only minimal lesions at the bottom of the endometrial layer (arrows).

View larger version (157K): [in a new window]   Figure 17c.  Adenocarcinoma arising within adenomyosis in a 46-year-old woman. (a) Sagittal T2-weighted image shows diffuse thickening of the junctional zone, which is indicative of adenomyosis. The endometrium has heterogeneous signal intensity. (b) Sagittal contrast-enhanced fat-suppressed T1-weighted image shows a normal appearance except for an ill-defined border between the endometrium and myometrium. (c) Photomicrograph (original magnification, x40; H-E stain) shows adenocarcinoma within the adenomyosis; the adenocarcinoma was not identifiable on the MR images. The tumor cells diffusely involve the ectopic endometrial tissue within the myometrium (*), whereas the endometrium () is relatively intact with only minimal lesions at the bottom of the endometrial layer (arrows).

View larger version (137K): [in a new window]   Figure 18a.  Endometrial adenocarcinoma extending into adenomyosis in a 48-year-old woman. (a) Axial T2-weighted image shows linear striations extending from the posterior endometrium (arrowheads), a finding that may suggest myometrial invasion by carcinoma. (b) Photomicrograph (original magnification, x40; H-E stain) shows endometrial carcinoma extending into a tongue of adenomyosis, thus producing the linear striations or pseudowidening of the endometrium seen on the MR image. The tumor cells (*) are completely within the adenomyosis and surrounded by the endometrial tissue, an appearance that implies absence of true myometrial invasion.

View larger version (174K): [in a new window]   Figure 18b.  Endometrial adenocarcinoma extending into adenomyosis in a 48-year-old woman. (a) Axial T2-weighted image shows linear striations extending from the posterior endometrium (arrowheads), a finding that may suggest myometrial invasion by carcinoma. (b) Photomicrograph (original magnification, x40; H-E stain) shows endometrial carcinoma extending into a tongue of adenomyosis, thus producing the linear striations or pseudowidening of the endometrium seen on the MR image. The tumor cells (*) are completely within the adenomyosis and surrounded by the endometrial tissue, an appearance that implies absence of true myometrial invasion.