Diagnostic usefulness of mri to evaluate endometrial pathologies

Magnetic Resonance Imaging

MRI is used to image the female pelvis when US and CT are inconclusive. MR is also the most accurate imaging
modality for characterizing congenital uterine anomalies and for staging most gynecologic malignancies. Cinematic
MRI can be useful for the evaluation of pelvic floor laxity. When performing MRI of the pelvis, it can be helpful to
have the patient fast or to administer glucagon to reduce artifact from bowel peristalsis. For evaluation of the
uterus, imaging planes should be chosen relative to the uterine axes rather than relative to the pelvis (
On T2-weighted MR images, the uterus can be divided into three distinct layers: the central high-signal-intensity
endometrium, the low-signal-intensity junctional zone, and the outer intermediate-signal-intensity myometrium
(Fig. 21-11). Thickness of the endometrium varies throughout the menstrual cycle in premenopausal women, with
a width of up to 14 mm considered normal during the secretory stage of the menstrual cycle. In postmenopausal
women, an endometrial thickness of 5 mm or less is considered normal.
The junctional zone, regarded as a distinct stratum by MRI, is actually the basal layer of the myometrium. This layer
is easy to identify on T2-weighted images because it appears as a smooth, dark band between the hyperintense
endometrium and the intermediate signal myometrium. The junctional zone should appear smooth, and a
thickness of less than 8 mm is considered normal. Zonal anatomy often becomes less distinct in postmenopausal
women
Uterine zonal anatomy cannot be distinguished on unenhanced T1-weighted images. After contrast administration,
the myometrium enhances briskly, whereas the endometrium undergoes more delayed progressive contrast
enhancement, eventually becoming isointense or hyperintense to myometrium. In postmenopausal women, a
zone of normal subendometrial enhancement on postcontrast T1-weighted images is often more helpful in
demarcating the transition from endometrium to myometrium than is the often inapparent junctional zone on T2-
weighted imagesThe zonal anatomy of the cervix is best appreciated on T2-weighted imaging sequences. From
central to peripheral, the three anatomic zones include the endocervix, the inner fibromuscular stroma (FMS), and
the outer FMS (Fig. 21-14). The endocervical mucosa, secretions, and plicae palmatae (mucosal folds) appear as
increased signal intensity centrally within the cervix on T2-weighted images. The inner FMS has low signal
intensity, likely the result of a densely packed zone of fibroblasts and smooth muscle cells. The outer FMS,
composed of more loosely packed tissue, is low-to-intermediate signal intensity on T2-weighted images.

Types of Endometrial Masses

The most common causes of abnormal thickening of the EMS include endometrial hyperplasia,
endometrial polyps, submucosal fibroids, and endometrial carcinoma.

ENDOMETRIAL HYPERPLASIA

Endometrial hyperplasia is excessive proliferation of the endometrial glands, focal or diffuse,

and is thought to result from unopposed estrogen stimulation. Such stimulation is commonly
seen in the setting of tamoxifen therapy in patients with breast carcinoma. Cellular atypia can be
present, in which case the risk for development of endometrial carcinoma is increased.
Hyperplasia usually appears as enlargement of the EMS on TVUS or MRI, a nonspecific finding.
In some cases, cystic dilatation of the endometrial glands results in anechoic spaces on TVUS
(Fig. 21-18). Cystic endometrial hyperplasia is particularly common with tamoxifen use. On
MRI, these cystic spaces appear as small foci of increased signal intensity on T2-weighted
images, which do not enhance after contrast administration.
Polyp;
Endometrial polyps can be considered as a more focal form of endometrial hyperplasia. Although they can be
multifocal, most are sessile or pedunculated solitary lesions
wide spectrum of uterine polyps including epithelial and mesenchymal
tumors and tumor-like lesions
Various epithelial and mesenchymal tumors and tumor-like lesions of the uterus may
appear as uterine polyps
The definition of Uterine Polyp:
Abnormal growth of benign or malignant tissue projecting from the inner lining of the
uterus to the cavity or cervical canal
Morphologic subtypes of the Uterine Polyps:
- Pedunculated: Attached to the surface by a narrow elongated pedicle (stalk).
- Sessile: Large flat base, No stalk
Endometrial polyp
- Polypoid focal endometrial hyperplasia
- Pedunculated or sessile
- Common endometrial tumor, 40-50 yrs. of age
- Typically asymptomatic, but may cause abnormal genital bleeding
- Occasionally carcinomas such as serous and clear cell carcinomas may occur
The MR signal characteristics of polyps are variable. Polyps are often hypointense relative to the adjacent
endometrium on T2-weighted images but can be isointense (Fig. 21-20). Both solid and cystic components are
often visible. Polyps demonstrate variable enhancement on postcontrast images, often enhancing more than
adjacent endometrium on early dynamic images but less than the endometrium on delayed images. Although only
occasionally visible on MRI, identification of a stalk strongly suggests the diagnosis. Whereas subtle discriminators
may allow differentiation of polyps from endometrial cancer in some cases (fibrous core, intratumoral cysts,
endometrial cysts, and lack of muscular invasion), overlap is present in the appearances of benign polyps and early
endometrial carcinoma.
MR manifestations:
- High on T2WI
High - intermediate on DWI w/ high ADC
- Central fibrous core (CFC): Low on T2WI
- CFC may show intense CE and be differentiated from intra-cavital clots.
- Intermediate - low choline peak on MRS

Endometrial cancer
- Most common malignancy in the female genital tract
- Abnormal genital bleeding
Focal /diffuse endometrial mass w/wo myometrial invasion
- May appear as polypoid mass, and may protrude through the ext. os into the vagina
(less common)
MR manifestations:
- Slight high on T2WI, High on DWI w/ low ADC
- Weak CE, well contrasted to myometrium
- High choline peak on MRS