(Radiographics. 1999;19:S161-S170.)
© RSNA, 1999
Diffuse and Focal Adenomyosis: MR Imaging Findings1
Jae Young Byun, MD,
Sung Eun Kim, MD,
Byung Gil Choi, MD,
Gi Young Ko, MD,
Seung Eun Jung, MD and
Kyu Ho Choi, MD
1 From the Department of Radiology, Kangnam St Mary's Hospital, College of Medicine, Catholic University of Korea, 505 Banpo-dong, Seocho-ku, Seoul 137-040, Korea. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received January 28, 1999; revision requested April 16 and received May 10; accepted May 11. Address reprint requests to J.Y.B.
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Abstract
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Adenomyosis is a common gynecologic disorder that affects women during their menstrual life. Preoperative magnetic resonance (MR) images obtained in 45 patients with pathologically proved adenomyosis who underwent hysterectomy were retrospectively reviewed. Diffuse adenomyosis was seen in 30 cases (66.7%) and focal adenomyosis in 15 cases (33.3%). On T2-weighted MR images, diffuse adenomyosis usually manifested as diffuse thickening of the endometrial-myometrial junctional zone (7–37 mm; mean, 16 mm) with homogeneous low signal intensity. T2-weighted MR images were superior to contrast material–enhanced T1-weighted images in the evaluation of junctional zone thickening. High-signal-intensity foci were observed on T2-weighted images only in nine cases and on both T1- and T2-weighted images in three cases. Focal adenomyosis manifested on both T2-weighted and contrast-enhanced T1-weighted MR images as a localized, low-signal-intensity round or oval mass with a diameter of 2–7 cm (mean, 3.8 cm). All but one of the focal lesions had ill-defined margins. High-signal-intensity foci were noted in all cases of focal adenomyosis, either on T2-weighted images only (four cases) or on both T1- and T2-weighted images (11 cases). MR imaging is useful in diagnosing adenomyosis, differentiating adenomyosis from uterine myoma, and planning appropriate treatment.
Index Terms: Endometriosis, 854.3192 • Leiomyoma, 854.315 • Uterus, diseases, 854.3142, 854.317 • Uterus, MR, 854.121411, 854.12143
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INTRODUCTION
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Adenomyosis is a benign disease of the uterus characterized by ectopic endometrial glands and stroma within the myometrium. Adenomyosis is associated with myometrial hypertrophy (1) and may be either diffuse or focal. This common gynecologic disorder affects premenopausal women, especially those who are multiparous and over the age of 30 years (2). Clinical manifestations are similar to those of uterine fibroids and include dysmenorrhea and menorrhagia. The extent of disease roughly correlates with the severity of symptoms (3,4). The cause of adenomyosis remains poorly understood, although one report suggested a hereditary pathogenesis (5).
The clinical diagnosis of adenomyosis is difficult because of the nonspecific nature of signs and symptoms and the frequent coexistence of other pelvic diseases (2). Although adenomyosis and leiomyoma can have the same clinical signs and symptoms, their treatments can differ. Leiomyoma can be treated with myomectomy, whereas adenomyosis requires hysterectomy (6). In clinical settings in which uterine conservation is required or myomectomy is planned, exact preoperative diagnosis of uterine lesions is mandatory (7).
Magnetic resonance (MR) imaging is an excellent noninvasive means of directly evaluating the zonal architecture of the uterus (8,9) and has been shown to be reliable in detecting adenomyosis and differentiating it from leiomyoma (7,10). However, adenomyosis—especially in its focal form—may simulate a leiomyoma. To our knowledge, only a few articles have been written that discuss precise MR imaging evaluation of focal adenomyosis (6,7,10–12). In this article, we review and illustrate the spectrum of MR imaging findings in diffuse and focal adenomyosis.
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MATERIALS AND METHODS
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The medical records of all women who underwent hysterectomy at our institution between January 1 and December 31, 1997 were reviewed. During this 1-year period, adenomyosis was reported at histopathologic examination in 308 of 1,031 patients (29.8%). Of these 308 patients, 45 underwent preoperative MR imaging of the pelvis. The mean age of these 45 women was 44 years (range, 25–65 years). All but four patients were multiparous and had children.
Most patients were referred for MR imaging on the basis of the following clinical findings: vaginal spotting (n = 12), premenstrual pelvic pain (n = 8), dysmenorrhea (n = 7), and other findings (n = 13). The remaining five patients were asymptomatic and underwent MR imaging due to suspicion for a uterine mass or myoma (n = 4) or incidental detection of cervical carcinoma at routine pelvic examination (n = 1). Hysterectomy was performed within 1 month of MR imaging.
MR imaging was performed with a 1.5-T superconducting imager (Signa Advantage; GE Medical Systems, Milwaukee, Wis; Magnetom Vision Plus; Siemens Medical Systems, Erlangen, Germany) with either a body coil (n = 29) or
a phased-array coil (n = 16). In all cases, T1-weighted images (repetition time msec/echo time msec = 350–650/17–30) were obtained. Conventional spin-echo T2-weighted images (1,800–2,700/60–100) were obtained in 11 cases and fast spin-echo T2-weighted images (2,700–4,600/75–132) in 34 cases. In 43 cases, repeat T1-weighted imaging was performed after infusion of gadopentetate dimeglumine at a rate of 0.1 mmol/kg. Imaging parameters were as follows: field of view, 24–26 cm; number of acquisitions, 2; matrix size, 256 x 128 or 256 x 192; section thickness, 5 mm; and intersection gap, 1.5–2.0 mm.
MR images were retrospectively reviewed by two experienced radiologists (J.Y.B., S.E.K.), and decisions were reached by consensus. The lesions were classified as either diffuse or focal. Diffuse adenomyosis was defined as diffuse ectopic growth of the endometrium into the myometrium with either diffuse or focal widening of the endometrial-myometrial junctional zone. Focal adenomyosis (adenomyoma) was defined as an actual circumscribed mass within the myometrium (6,11–13). In diffuse adenomyosis, images were evaluated for junctional zone thickness and areas of high signal intensity within the lesion. In focal adenomyosis, lesion size, shape, location, margin, pseudocapsule, and relation to the endometrium were evaluated.
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RESULTS
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Of the 45 patients who underwent both preoperative MR imaging and hysterectomy, 30 (66.7%) had diffuse adenomyosis and 15 (33.3%) had focal adenomyosis. In most cases, an enlarged uterus with a smooth external configuration was seen at MR imaging.
Diffuse Adenomyosis
Junctional Zone Thickness.—In 28 of the 30 cases of diffuse adenomyosis, the junctional zone was clearly visible due to thickening and measured 7–37 mm (mean, 16 mm). This thickening was either diffuse and even (n = 12) (Figs 1, 2) or diffuse and uneven (n = 16) (Fig 3). In 22 of 28 cases, junctional zone thickness exceeded 10 mm (Figs 1–3), and the diagnosis of adenomyosis was made with confidence at MR imaging. In six cases, the junctional zone measured 7–9 mm in thickness and the diagnosis was questionable. In the remaining two cases of diffuse adenomyosis, the junctional zone was not clearly visible: One patient had cervical carcinoma with hydrometra compressing the junctional zone (Fig 4), and the other was a postmenopausal woman with a small uterus.
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Figures 1, 2. (1) Mild diffuse adenomyosis in a 42-year-old woman. (a) Sagittal T1-weighted MR image shows a mildly enlarged anteverted uterus. The junctional zone is isointense relative to the myometrium. (b) Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis. (c) Sagittal contrast-enhanced fat-suppressed delayed T1-weighted MR image shows obliteration of the margin of the thickened junctional zone, a finding that is of no particular value in diagnosing adenomyosis. (2) Extensive involvement of diffuse adenomyosis in a 42-year-old woman. Sagittal T2-weighted MR image demonstrates diffuse areas of low signal intensity involving most of the uterus (straight arrows) and punctate high-signal-intensity foci (arrowhead). A few small nabothian cysts (curved arrows) are seen in the uterine cervix.
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Figures 1, 2. (1) Mild diffuse adenomyosis in a 42-year-old woman. (a) Sagittal T1-weighted MR image shows a mildly enlarged anteverted uterus. The junctional zone is isointense relative to the myometrium. (b) Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis. (c) Sagittal contrast-enhanced fat-suppressed delayed T1-weighted MR image shows obliteration of the margin of the thickened junctional zone, a finding that is of no particular value in diagnosing adenomyosis. (2) Extensive involvement of diffuse adenomyosis in a 42-year-old woman. Sagittal T2-weighted MR image demonstrates diffuse areas of low signal intensity involving most of the uterus (straight arrows) and punctate high-signal-intensity foci (arrowhead). A few small nabothian cysts (curved arrows) are seen in the uterine cervix.
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Figures 1, 2. (1) Mild diffuse adenomyosis in a 42-year-old woman. (a) Sagittal T1-weighted MR image shows a mildly enlarged anteverted uterus. The junctional zone is isointense relative to the myometrium. (b) Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis. (c) Sagittal contrast-enhanced fat-suppressed delayed T1-weighted MR image shows obliteration of the margin of the thickened junctional zone, a finding that is of no particular value in diagnosing adenomyosis. (2) Extensive involvement of diffuse adenomyosis in a 42-year-old woman. Sagittal T2-weighted MR image demonstrates diffuse areas of low signal intensity involving most of the uterus (straight arrows) and punctate high-signal-intensity foci (arrowhead). A few small nabothian cysts (curved arrows) are seen in the uterine cervix.
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Figures 1, 2. (1) Mild diffuse adenomyosis in a 42-year-old woman. (a) Sagittal T1-weighted MR image shows a mildly enlarged anteverted uterus. The junctional zone is isointense relative to the myometrium. (b) Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis. (c) Sagittal contrast-enhanced fat-suppressed delayed T1-weighted MR image shows obliteration of the margin of the thickened junctional zone, a finding that is of no particular value in diagnosing adenomyosis. (2) Extensive involvement of diffuse adenomyosis in a 42-year-old woman. Sagittal T2-weighted MR image demonstrates diffuse areas of low signal intensity involving most of the uterus (straight arrows) and punctate high-signal-intensity foci (arrowhead). A few small nabothian cysts (curved arrows) are seen in the uterine cervix.
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Figure 3a. Diffuse, uneven adenomyosis in a 42-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed delayed T1-weighted (b) MR images show diffuse, nonuniform thickening of the junctional zone subjacent to the endometrium (arrows), a finding that is diagnostic for adenomyosis. Note the presence of several high-signal-intensity foci (arrowheads in a) representing nonbleeding foci of endometrial tissue.
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Figure 3b. Diffuse, uneven adenomyosis in a 42-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed delayed T1-weighted (b) MR images show diffuse, nonuniform thickening of the junctional zone subjacent to the endometrium (arrows), a finding that is diagnostic for adenomyosis. Note the presence of several high-signal-intensity foci (arrowheads in a) representing nonbleeding foci of endometrial tissue.
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Figure 4a. Diffuse adenomyosis with cervical cancer and hydrometra in a 65-year-old woman. On sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) MR images, the junctional zone is not clearly visible because of compression of the junctional zone by hydrometra (H). The hydrometra is caused by a large obstructing mass in the uterine cervix (arrows).
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Figure 4b. Diffuse adenomyosis with cervical cancer and hydrometra in a 65-year-old woman. On sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) MR images, the junctional zone is not clearly visible because of compression of the junctional zone by hydrometra (H). The hydrometra is caused by a large obstructing mass in the uterine cervix (arrows).
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On T2-weighted MR images, diffuse adenomyosis usually manifested as diffuse thickening of the junctional zone with homogeneous low signal intensity (Figs 1–3). T2-weighted imaging provided significantly better lesion detection than unenhanced or contrast material–enhanced T1-weighted imaging (Fig 1). In one case, however, thickening of the junctional zone was more clearly seen on contrast-enhanced T1-weighted images than on T2-weighted images.
High-Signal-Intensity Foci within the Lesion.—In 12 cases, high-signal-intensity foci (usually a few millimeters in diameter) were clearly seen within the low-signal-intensity lesions (Figs 2, 3). High-signal-intensity foci were seen on T2-weighted images only in nine cases and on both T1- and T2-weighted images in three cases.
Focal Adenomyosis
Signal Intensity, Size, Shape, and Location.—All 15 cases of focal adenomyosis manifested as a localized, low-signal-intensity mass within the myometrium on both T2-weighted (Fig 5) and contrast-enhanced T1-weighted MR images. On T1-weighted images, all but one of the masses were isointense relative to the surrounding myometrium; in one case, the mass had slightly higher signal intensity than the myometrium. The masses were 2–7 cm in diameter (mean, 3.8 cm). All focal lesions were round or oval. Ten lesions were located in the posterior wall, two in the anterior wall, and the remaining three in the fundus of the uterus.
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Figure 5a. Focal adenomyosis in a 35-year-old woman. Axial (a) and sagittal (b) T2-weighted MR images show an ill-defined, circumscribed area of low signal intensity within the myometrium (straight arrows) and punctate foci of high signal intensity (arrowheads in b). There are multiple small signal voids (curved arrows) representing intramuscular vessels, which may mimic leiomyoma. A small ovarian cyst (C in a) is noted incidentally.
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Figure 5b. Focal adenomyosis in a 35-year-old woman. Axial (a) and sagittal (b) T2-weighted MR images show an ill-defined, circumscribed area of low signal intensity within the myometrium (straight arrows) and punctate foci of high signal intensity (arrowheads in b). There are multiple small signal voids (curved arrows) representing intramuscular vessels, which may mimic leiomyoma. A small ovarian cyst (C in a) is noted incidentally.
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Margin, Pseudocapsule, and High-Signal-Intensity Foci.—In 14 cases (93%), focal adenomyosis had poorly defined margins that blended imperceptibly with the surrounding myometrium (Figs 5, 6). However, in one case the focal adenomyosis had a relatively well defined margin and mimicked leiomyoma (Fig 7). None of the lesions had a pseudocapsule. High-signal-intensity foci were seen within the focal masses in all 15 cases (100%): four on T2-weighted images only (Fig 5) and 11 on both T1- and T2-weighted images (Fig 6).
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Figure 6. Focal adenomyosis in a 31-year-old woman. Axial T2-weighted MR image demonstrates an ill-defined mass with low signal intensity within the myometrium of the uterine fundus (arrows). Multiple punctate foci of high signal intensity, which are thought to represent hemorrhagic endometrial nests, are scattered throughout the mass (arrowheads). These foci were also seen on T1-weighted images (not shown).
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Figure 7a. Focal adenomyosis in a 37-year-old woman. Axial (a) and sagittal (b) T2-weighted MR images demonstrate a well-defined, ovoid, low-signal-intensity mass within the myometrium mimicking leiomyoma (arrows).
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Figure 7b. Focal adenomyosis in a 37-year-old woman. Axial (a) and sagittal (b) T2-weighted MR images demonstrate a well-defined, ovoid, low-signal-intensity mass within the myometrium mimicking leiomyoma (arrows).
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Relation to Endometrium and Signal Voids.—Focal adenomyosis appeared to wrap around and mildly distort the endometrium in four cases (Fig 8) and compressed the endometrium in eight cases (Figs 9, 10). Three lesions were located away from the endometrium (Fig 9). Signal voids representing intramuscular vessels were seen in only two cases (Figs 5, 10).
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Figure 8. Focal adenomyosis in a 44-year-old woman. Sagittal T2-weighted MR image shows an ill-defined, low-signal-intensity mass within the myometrium (black arrows) that appears to wrap around the endometrium (white arrows). Multiple high-signal-intensity foci are also seen (arrowheads).
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Figure 9a. Focal adenomyosis associated with endometriosis in a 28-year-old woman. Axial T1-weighted (a) and T2- weighted (b) MR images demonstrate ill-defined focal adenomyosis (solid arrows in b) in the posterior uterine wall compressing the endometrial cavity (open arrows in b). The lesion is located away from the endometrium. There are small adnexal masses (E) with high signal intensity in a and characteristic shading in b representing endometriomas.
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Figure 9b. Focal adenomyosis associated with endometriosis in a 28-year-old woman. Axial T1-weighted (a) and T2- weighted (b) MR images demonstrate ill-defined focal adenomyosis (solid arrows in b) in the posterior uterine wall compressing the endometrial cavity (open arrows in b). The lesion is located away from the endometrium. There are small adnexal masses (E) with high signal intensity in a and characteristic shading in b representing endometriomas.
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Figure 10a. Focal adenomyosis associated with endometriosis and signal voids in a 50-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) MR images demonstrate ill-defined focal adenomyosis (straight solid arrows) and high-signal-intensity foci (arrowheads in a) within the anterior myometrium with compression of the endometrial cavity (curved arrows). There are multiple small signal voids (open arrows) representing intramuscular vessels, which may mimic leiomyoma. An ovoid mass with a signal intensity that is characteristic of endometrioma (E) is located superior to the uterine fundus.
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Figure 10b. Focal adenomyosis associated with endometriosis and signal voids in a 50-year-old woman. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted (b) MR images demonstrate ill-defined focal adenomyosis (straight solid arrows) and high-signal-intensity foci (arrowheads in a) within the anterior myometrium with compression of the endometrial cavity (curved arrows). There are multiple small signal voids (open arrows) representing intramuscular vessels, which may mimic leiomyoma. An ovoid mass with a signal intensity that is characteristic of endometrioma (E) is located superior to the uterine fundus.
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Associated Diseases
Various associated diseases proved to be concurrent gynecologic abnormalities and were not seen with increased frequency in patients with adenomyosis. These diseases included cervical cancer (n = 14), uterine myoma (n = 9) (Fig 11), endometriosis (n = 3) (Figs 9, 10), endometrial polyp (n = 1), and adenomatoid tumor in the uterine corpus (n = 1).
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Figure 11. Focal adenomyosis associated with leiomyoma in a 47-year-old woman. Sagittal T2-weighted MR image shows ill-defined focal adenomyosis (solid arrows) with high-signal-intensity foci (arrowheads) in the anterior uterine wall coexisting with a small, well-circumscribed, low-signal-intensity leiomyoma (open arrows).
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DISCUSSION
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Adenomyosis is a relatively common gynecologic disease characterized by benign invasion of the myometrium by the endometrium (endometrial islands) and diffuse hypertrophy of the musculature (13). At pathologic analysis, endometrial glands lying deeper than one-fourth of the thickness of the junctional zone usually indicate adenomyosis (14). Endometrial glands in adenomyosis are basal; they are also resistant to hormonal stimulation and do not undergo the full cyclic changes of the normal, functional endometrium. In contrast, in endometriosis the glands undergo the same cyclic changes as the normal endometrium (6). The cause of adenomyosis is unknown. Various pathogenic mechanisms have been proposed, including uterine trauma in childbirth, chronic endometritis, and hyperestrogenemia, but none of these has proved causative (15).
The prevalence of adenomyosis in unselected hysterectomy patients has been reported to range from 8.8% to 31% (4,16). Clinical manifestations of adenomyosis vary and are nonspecific (2). The diagnosis of adenomyosis is made clinically only by excluding other causes and has required surgical exploration for verification (6). The definitive treatment for adenomyosis is hysterectomy, but conservative hormonal therapy may be instituted instead (7). A growing interest in the nonsurgical diagnosis of adenomyosis is driven by concerns about inappropriate hysterectomy, the introduction of less invasive alternatives to surgery, and the development of imaging techniques that can allow reliable diagnosis of this disorder (12). The importance of accurately diagnosing adenomyosis preoperatively has been stressed in several previous articles (6,7,10,17–19).
Published reports advocate the use of MR imaging and transvaginal ultrasound (US) in the noninvasive diagnosis of adenomyosis (12,20). Mark et al (6) and Togashi et al (7,10) established the feasibility of MR imaging for demonstrating pathologically proved adenomyosis. MR imaging may be more sensitive (88%–93%) and specific (66%–91%) than transvaginal US in the diagnosis of adenomyosis, presumably due to its superior spatial and contrast resolution (17,18). The large field of view in MR imaging allows for a more complete pelvic survey. Moreover, as conservative therapy for adenomyosis continues to be investigated, MR imaging may provide an accurate, noninvasive means of monitoring response to treatment (17).
Adenomyosis is often seen as either diffuse or focal widening of the junctional zone along with a low-signal-intensity myometrial mass with indistinct margins on T2-weighted images (6,7,10,12) (Table). T2-weighted imaging is superior to contrast-enhanced T1-weighted imaging in diagnosing adenomyosis. MR imaging findings in adenomyosis correlate closely with gross pathologic changes. At gross examination, adenomyosis is characterized by smooth muscle hypertrophy surrounding a focus of basal endometrium that is less vascular than the smooth muscle of the myometrium (6). The histopathologic explanation for the low signal intensity of the mass on T2-weighted images is not clear. This low signal intensity might be attributable to reduced vascularity and lack of edema in the hypertrophic smooth muscle (6), or the entire lesion might be understood as clusters of miniature low-signal-intensity bands surrounding numerous tiny foci of endometrial tissue (7). The thickness of the normal junctional zone changes during the menstrual cycle (21), whereas the thickness of diffuse adenomyosis remains unchanged (14).
Some investigators recommended that a cutoff value for junctional zone thickness be used to differentiate patients with adenomyosis from those without adenomyosis. A junctional zone thickness greater than 5 mm was believed to be diagnostic for adenomyosis, whereas a thickness of 3–5 mm was considered indeterminate (6,17). Reinhold et al (18) recently reported that use of a junctional zone thickness greater than 12 mm should further optimize the diagnostic accuracy of MR imaging. In our study, when junctional zone thickness was greater than 10 mm, an MR imaging diagnosis of adenomyosis was made with confidence. However, false-negative diagnoses can occur with MR imaging when the junctional zone is not clearly visible (as in two cases in our study).
In contrast to adenomyosis, leiomyomas appeared as sharply defined masses of variable signal intensity within the myometrium. When a leiomyoma has homogeneous low signal intensity on T2-weighted images and the margins are indistinct, the two conditions may appear similar (6,12). Conversely, if focal adenomyosis has a relatively well-defined margin, it may mimic leiomyoma (as in one case in our study). Dilated veins are often demonstrated in leiomyoma, but they may not be seen in adenomyosis (10): As mentioned earlier, signal voids representing dilated intramuscular vessels were seen in only two cases in our study. In addition, adenomyosis appears to wrap around the endometrium and cause relatively mild distortion of its shape, whereas leiomyomas demonstrate greater mass effect and distortion of the endometrium (12).
In patients with adenomyosis, high-signal-intensity foci are commonly seen within the low-signal-intensity lesions on T2-weighted images, whereas they are rarely seen in patients without adenomyosis (18). These foci represent either endometrial tissue, endometrial cysts, or hemorrhagic foci (18). At histologic analysis, high-signal-intensity foci on T2-weighted images correspond to heterotopic endometrial tissue. Foci that have low signal intensity on T1-weighted images correspond to nonbleeding endometrial tissue, whereas foci with high signal intensity on both T1- and T2-weighted images correspond to hemorrhage within endometrial islands (17) (Table). Identification of punctate high-signal-intensity foci adds specificity to the diagnosis of adenomyosis (12). In our study, these foci were seen in 40% of cases of diffuse adenomyosis and in 100% of cases of focal adenomyosis.
Between 60% and 80% of adenomyotic uteri are accompanied by additional pelvic disease. The most frequent finding is leiomyoma, which is present in 35%–55% of affected patients (16). Leiomyoma was present in nine (20%) of 45 cases in our study. The reported prevalence of adenomyosis and its coincidence with endometriosis varies widely. The coincidence of the two pathologic conditions has been reported as ranging from 36% to 40% (12,20). In our study, such coincidence was seen in three cases (7%).
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CONCLUSIONS
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Junctional zone thickening, a low-signal-intensity myometrial mass with ill-defined margins, and high-signal-intensity foci within the lesion are characteristic MR imaging findings in adenomyosis. MR imaging is highly accurate in diagnosing adenomyosis and in differentiating adenomyosis from uterine leiomyoma. It is also useful in planning appropriate treatment when uterine conservation is desired.
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Abstract
INTRODUCTION
