Diagnostic ultrasound ( PDFDrive )

CHAPTER 15 The Uterus 541
A
B
FIG. 15.12 Leiomyosarcoma. (A) Sagittal and (B) transverse TAS show a large heterogeneous uterine mass that is mostly solid but contains
cystic areas. It is dificult to distinguish this from a benign leiomyoma with cystic degeneration because the appearance of leiomyomas and leiomyosarcomas
overlap.
endometriosis may coexist; 22% to 49% of women with endometriosis
are reported to also have adenomyosis. 91
Adenomyosis most oten afects the myometrium difusely.
Occasionally it occurs in a focal form (sometimes called “focal
adenomyosis” when involving only part of the myometrium or
an “adenomyoma” when more distinct) 92 and rarely can take the
form of a cyst (“cystic adenomyoma”). 76 Ultrasound is an accurate
diagnostic test for adenomyosis, although about 9% of afected
patients have normal ultrasound indings. 93 Sonographic indings
that are suggestive of difuse adenomyosis include enlarged
globular shape of the uterus, heterogeneous myometrium, asymmetrical
thickening of the myometrium, indistinct interface
between the endometrium and myometrium, myometrial cysts,
and echogenic striations or nodules in the myometrium (Fig.
15.13, Video 15.4). 94-97 Heterogeneity of the myometrium has
been reported as the most common inding but has poor speciicity
96 ; this may be related to the subjective nature of determining
heterogeneity. hus it is important to look for other sonographic
features when one identiies a heterogeneous myometrium.
Echogenic linear striations, myometrial cysts, globular uterine
shape, and asymmetrical myometrial thickness have all been
reported to have high speciicity. 94,96,97 Although not generally
performed to diagnose adenomyosis, SHG may show communication
between the lesions of adenomyosis and the endometrial
cavity. 98 Rarely, adenomyosis can appear as an isolated cystic
mass, larger than the small myometrial cysts typically seen in
adenomyosis, and has been termed a juvenile cystic adenomyoma.
99 However, these isolated larger myometrial cysts may
instead represent a rare, recently proposed type of MDA, an
accessory and cavitated uterine mass (ACUM). Speciic criteria
to diagnose ACUM have been proposed. 100,101
Adenomyosis and leiomyomas oten coexist; 15% to 57% of
women with leiomyomas are reported to also have adenomyosis
in surgical series. 102 It can sometimes be diicult to distinguish
these two entities, or determine if both are present, by ultrasound.
Focal adenomyosis is usually the form most diicult to distinguish
from leiomyomas. Distinct borders are typical of leiomyomas,
whereas indistinct borders suggest adenomyosis. It has been
suggested that color or power Doppler may be helpful in making
the distinction, with adenomyosis tending to have more central
vascularity and leiomyomas tending to have mostly peripheral
vascularity. 92 However, the reliability of Doppler indings to make
this distinction has not been adequately evaluated. In patients
in whom one is uncertain whether the indings represent adenomyosis
or leiomyomas or both (when making this distinction is
important for clinical care), MRI is helpful.
Although adenomyosis is usually considered to occur mostly
in premenopausal women, it can be seen in postmenopausal
women. 103 Women with breast cancer who are treated with
tamoxifen have a higher incidence of adenomyosis. It may
be that the estrogen agonist efects of tamoxifen on endometrial
tissue cause adenomyosis or reactivate preexisting
adenomyosis. 90
Occasionally one may encounter one or a few small cysts at
the endometrial/myometrial border, in the absence of other
sonographic indings of adenomyosis. he signiicance of such
an isolated inding is not clear. As mentioned previously, the
histologic diagnosis of adenomyosis generally requires the presence
of endometrial glands or stroma to be located more than
2.5 or 3 mm away from the outer edge of the endometrium. 88,89
hus we would be reluctant to diagnose adenomyosis based solely
on one or a few small cysts at the endometrial/myometrial border,
in the absence of other sonographic features of adenomyosis.
ABNORMALITIES OF THE CERVIX
Ater a supracervical hysterectomy, one expects to see most or
all of the cervix remaining, and should not mistake the remaining
cervix for a mass (Fig. 15.14A). Occasionally one may observe
a cervical polyp on ultrasound (Fig. 15.14B), although many of