Cunha, Teresa Margarida

Delgado, Lara

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Case 10940 A pitfall case of endometrial serous adenocarcinomaLara Delgado , Teresa Margarida Cunha  1 2 Genital (Female) Imaging Section: 2013, Jul. 10 Published: 78 year(s), femalePatient:Authors' Institution(1) Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal(2) Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, PortugalEmail: lara_sofia_81@hotmail.comClinical HistoryA 78 year-old-woman presented with a 6 month history of metrorrhagia and pelvic pain. The pastmedical history was unknown. The patient was referred for a pelvic ultrasound examination and,subsequently, a pelvic magnetic resonance imaging (MRI) was performed.Imaging FindingsA gynecological ultrasound (not showed) revealed two contiguous cystic lesions with 63 and 104mm, with scattered internal echos. A solid component was observed as a vegetation on the thelargest cyst. The uterus was not visualized.Subsequently, the patient was referred for an MRI which showed, above the vaginal cuff, a fluidfilled structure with folded configuration, with high signal intensity on T1 (Fig. 1) and on T2 (Fig.2) weighted images (WI); the signal intensity remained high on fat-suppressed T1WI, revealing itseither high protein or hemorrhagic content. Additionally scattered vegetations were seen with lowsignal intensity on T1WI, intermediate signal intensity on T2WI and presenting homogeneousenhancement after Gadolinium-DTPA administration on fat-suppressed T1WI (Fig. 3).Both ovaries were seen separate from the lesion without detectable abnormalities.DiscussionEndometrial carcinoma is the fourth most common female cancer and the most commonmalignancy of the female reproductive tract [1]. Most cases are diagnosed after menopause withhighest incidence around the seventh decade of life [2].About 80% of all endometrial carcinomas are adenocarcinomas of the endometriod type. Most ofthe endometriod carcinomas are well to moderately differentiated and arise on a background ofendometrial hyperplasia [2].Serous carcinoma is the most aggressive type of non-endometrioid endometrial carcinomas [2].In postmenopausal patients atrophy related to decrease in endocervical glands results in decreasedsecretion of mucus and represent a frequent cause of cervical stenosis, which when severe results inhydrometra, pyometra or hematometra [3].In this case report the patient presents with a 6 month history of metrorrhagia and pelvic pain, and isreferred for ultrasound examination and subsequently for MRI. In the presence of a pelvic dilated tubular fluid-filled (high protein or hemorrhagic content)structure with folded configuration, incomplete septations and scattered solid vegetation, a fallopiantube or an endometrial malignant tumor should be considered as differential diagnose.Tubal origin should be suspected in the presence of a dilated tubular adnexal structure with foldedconfiguration separated from the ovaries, with relatively thin walls and thin longitudinally orientedfolds along the interior of the tube [3]. The lesion was centrally located in the pelvis, just above thevaginal cuff between the bladder and the rectum. The inverted pear shape and the reduction in thediameter in the median zone (uterine isthmus) allow the identification of the uterus.The MRI revealed distention of the endometrial cavity and cervical canal with hematrometra andscattered foci of solid endometrial and cervical canal vegetations, without invasion of the outer halfof the myometrium.MRI is essential for the preoperative staging of endometrial cancer because it can accurately depictthe depth of myometrial invasion, which is the most important morphological prognostic factor andcorrelates with tumor grade, presence of lymph node metastases, and the overall patient survival[4]. Cervical and endometrial and biopsy were performed revealing a serous adenocarcinoma. Despite the aggressive behavior of the tumor, given the age of the patient three months later, totalhysterectomy, bilateral pelvic adnexectomy, partial omentectomy and paraaortic and pelviclymphadenectomy were performed. Histological evaluation revealed a multifocal endometrial tumorwith invasion of the inner half of the myometrium without lymph node involvement.Clinical history and good knowledge of anatomy are essential for correct interpretation of images.Final DiagnosisSerous adenocarcinoma of the endometrium.Differential Diagnosis ListEndometrial Carcinoma, Primary Fallopian Tube CarcinomaFiguresFigure 1 Figure 1 Pelvic MRT1-weighted image on axial plane shows a high signal intensity fluid filled structure withfolded configuration and with scaterred low signal vegetations (arrows). © Ramalho M, Department of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Tissue characterisation; Figure 2 Figure 2 Pelvic MRT2-weighted image on sagittal plane shows a high signal intensity fluid filled structure withfolded configuration and a incomplete septation (arrow). © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Tissue characterisation; T2-WI on sagittal plane shows above the vaginal cuff between the bladder and the rectum acentrally located high signal intensity fluid filled structure with folded configuration withscatterred intermediate signal intensity vegetations (arrow) © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Tissue characterisation; T2-weighted image on axial plane shows a high signal intensity fluid filled structure withfolded configuration and with scaterred intermediate signal vegetations. © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; T2-weighted image on axial plane shows a cystic lesion, with intermediate signal intensityvegetations. © Ramalho M, Departement of Radiology, Hospital Garcia de Horta Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; T2-weighted image on coronal plane shows a cystic lesion, with intermediate signal intensityvegetations. © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 3 Figure 3 Pelvic MRFat-suppressed T1WI after gadolinium administration on sagittal plane shows the high signalintensity of the fluid filled structure showing either high protein or hemorrhagic contend andthe solid vegetations (arrow) © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Tissue characterisation; Fat-suppressed T1WI after gadolinium administration on axial plane shows the enhancementof the solid vegetations. © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Fat-suppressed T1WI after gadolinium administration on axial plane shows the enhancementof the solid vegetations. © Ramalho M, Departement of Radiology, Hospital Garcia de Horta, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; MeSH [A05.360.319.679.490]EndometriumThe mucous membrane lining of the uterine cavity that is hormonally responsive during theMENSTRUAL CYCLE and PREGNANCY. The endometrium undergoes cyclic changes thatcharacterize MENSTRUATION. After successful FERTILIZATION, it serves to sustain thedeveloping EMBRYO. [A05.360.319.114.373]Fallopian TubesA pair of highly specialized muscular canals extending from the UTERUS to its correspondingOVARY. They provide the means for OVUM collection, and the site for the final maturation ofgametes and FERTILIZATION. The fallopian tube consists of an interstitium, an isthmus, anampulla, an infundibulum, and fimbriae. Its wall consists of three histologic layers: serous,muscular, and an internal mucosal layer lined with both ciliated and secretory cells. [C13.371.270.875.750]Endometrial NeoplasmsTumors or cancer of ENDOMETRIUM, the mucous lining of the UTERUS. These neoplasms canbe benign or malignant. Their classification and grading are based on the various cell types and thepercent of undifferentiated cells.References[1] Sala E, Walkely S, Senior E, Lomas D (2007) MRI of Malignant Neoplasms of the UterineCorpus and Cervix AJR Jun;188(6):1577-8[2] Hamm B, Forstner R, Baert A, Knauth M, Sartor K (2007) MR and CT of the Female PelvisSpringer-Verlag Berlin Heidelberg (101-102)[3] Hricak H, Akin O, Sala E, Ascher S, Levine Deborah, Reinhold C (2007) Diagnostic imagingGynecology (3-2;8-6)[4] Beddy P, O'Neil A, Yamamoto A, Addley H, Reinhold C, Sala E (2012) Figo Staging Systemfor Endometrial Cancer: Added Benefits of MR Imaging Radiographics Jan-Feb;32(1):241-54CitationLara Delgado , Teresa Margarida Cunha  (2013, Jul. 10) 1 2 A pitfall case of endometrial serous adenocarcinoma {Online}URL: http://www.eurorad.org/case.php?id=10940

A pitfall case of endometrial serous adenocarcinoma

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A pitfall case of endometrial serous adenocarcinoma

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