MR Imaging of Malignancies Arising in Endometriomas and Extraovarian Endometriosis

Abstract

Cancers that arise in ovarian or extraovarian endometriosis are a distinct disease category with a histologic profile different from that of the more common epithelial ovarian cancers and with a better prognosis. Because the malignant transformation of endometriomas is rarely associated with lymphadenopathy or peritoneal carcinomatosis, a high index of suspicion on the part of the radiologist is necessary to establish a timely diagnosis of endometriosis-related ovarian cancers and allow appropriate oncologic management. Although imaging is not currently performed for surveillance of endometriosis, magnetic resonance (MR) imaging is often performed when surgical treatment is under consideration. An optimal MR imaging protocol for the detection of cancer arising in an endometrioma includes a review of subtraction images derived from unenhanced and contrast material-enhanced T1-weighted datasets. Subtraction images provide improved conspicuity of enhancing mural nodules--which are the most sensitive MR imaging sign of malignancy in ovarian endometriosis--against the background of the high-signal-intensity endometriotic cyst. Cancers arising in extraovarian endometriosis typically manifest as solid lesions with intermediate signal intensity on T1- and T2-weighted images, enhancement after the intravenous administration of a gadolinium-based contrast material, and restricted diffusion on diffusion-weighted images and apparent diffusion coefficient (ADC) maps. The signal intensity of myometrium, or, if the uterus is absent, that of the small bowel wall, is used as an internal reference standard for lesion signal intensity. Lesions are considered to have restricted diffusion if they show signal hyperintensity relative to the reference structure on diffusion-weighted images and hypointensity or isointensity relative to that structure on ADC maps. For definitive diagnosis, histopathologic analysis is required.

Management of pregnancy in woman with suspected malignant deep infiltrating endometriosis fistulised to the uterine cervix

“…On MRI, these cancers typically manifest as solid lesions with intermediate signal intensity on T1-weighted and T2-weighted images 4. These pelvic lesions characteristically enhance after the intravenous administration of gadolinium-based contrast material and demonstrate restricted diffusion on diffusion-weighted images and ADC maps 4 9 10. In our case, we suspected malignant transformation on the solid component of the mass with intermediate-signal intensity on T2-weighted images, type 2 enhancements and restricted ADC.…”

“…Approximately 1% of women with endometriosis develop an endometriosis-associated malignancy 8. Endometriosis-associated ovarian and extraovarian cancers represent a specific entity with distinct imaging features and management options described in the literature 4. On MRI, these cancers typically manifest as solid lesions with intermediate signal intensity on T1-weighted and T2-weighted images 4.…”

“…Endometriosis-associated ovarian and extraovarian cancers represent a specific entity with distinct imaging features and management options described in the literature 4. On MRI, these cancers typically manifest as solid lesions with intermediate signal intensity on T1-weighted and T2-weighted images 4. These pelvic lesions characteristically enhance after the intravenous administration of gadolinium-based contrast material and demonstrate restricted diffusion on diffusion-weighted images and ADC maps 4 9 10.…”

“…Association of malignant transformation of deep infiltrating endometriosis (DIE) with pregnancy is extremely rare and raises specific concerns about the progression of the lesion which could have lethal consequences, the impact on pregnancy outcome and the route of delivery 3 4. We report a case of a spontaneous pregnancy in a woman with DIE with suspicion of malignant transformation fistulised to the posterior uterine isthmus through to the cervical canal.…”

Friday 18th October 2013

“…Results: 22 patients with rectal cancer were treated on this protocol. Median age was 65 (36-75), median follow up was 6 months (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14). Patients were Stage II (54%), Stage III (32%) or IV (14%), with complete and partial pathological response seen in 18% and 50% respectively of patients who proceeded to surgery.…”