{"paper_id":"17934362-ee1d-4e30-b4b6-e02ca74ad79a","body_text":"Kumar et al. Egypt J Radiol Nucl Med          (2024) 55:229  \nhttps://doi.org/10.1186/s43055-024-01399-5\nCASE REPORT Open Access\n© The Author(s) 2024. Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.\nEgyptian Journal of Radiology\nand Nuclear Medicine\nAdenomyosis or endometrial carcinoma? \nRadiological pitfalls in postmenopausal \ndiagnosis: a case report\nNaina Kumar1*  , Abhimanyu Sharma2, Mishu Mangla1 and Annapurna Srirambhatla3 \nAbstract \nBackground Adenomyosis and endometrial carcinoma present distinct pathological conditions that pose consider-\nable diagnostic hurdles, especially in postmenopausal women, as they share common clinical manifestations. Further-\nmore, postmenopausal adenomyosis may exhibit radiological features resembling those of endometrial carcinoma, \npotentially leading to misdiagnosis and inappropriate management.\nCase presentation A 64-year-old para four and live four  (P4L4) postmenopausal woman, who had been postmeno-\npausal for 15 years, sought evaluation at the Gynecological Outpatient Department due to heavy postmenopausal \nbleeding lasting 30–45 days. Ultrasonography and MRI findings indicated a loss of the endo-myometrial junctional \nzone, delayed enhancement of the lesion, and suspected myometrial invasion, suggestive of endometrial malignancy, \nalongside a polypoidal lesion. Given the strong suspicion of endometrial carcinoma, the patient underwent hysteros-\ncopy-guided endometrial biopsy. However, histopathological analysis revealed disordered proliferative endometrium \nwith no evidence of malignancy. Considering the patient’s age, symptoms, and MRI findings, exploratory laparotomy \nwith total abdominal hysterectomy and bilateral salpingo-oophorectomy was planned. Subsequent histopathological \nexamination confirmed adenomyosis of the uterus, with the fallopian tubes and ovaries found to be healthy.\nConclusion The present case report underscores the radiological challenges encountered in distinguishing adeno-\nmyosis from endometrial carcinoma in postmenopausal women, emphasizing the importance of a multidisciplinary \napproach to enhance diagnostic accuracy and improve patient outcomes in this population.\nKeywords Adenomyosis, Endometrial carcinoma, Magnetic resonance imaging, Postmenopausal, Uterus\nBackground\nAdenomyosis is a common gynecological condition \nmarked by the presence of endometrial tissue abnormally \nlocated within the uterine myometrium [1]. It was first \ndescribed histopathologically by German pathologist \nCarl von Rokitansky in 1860 and was originally termed \n\"cystosarcoma adenoids uterinum\" [2]. The exact patho -\ngenesis of adenomyosis remains unclear, with several \ntheories proposing different origins. The most widely \naccepted theory suggests that adenomyosis arises from \na disrupted boundary between the deepest layer of the \nendometrium (endometrium basalis) and the underlying \nmyometrium. This disruption results in inappropriate \nendometrial proliferation into the myometrium, trig -\ngering small vessel angiogenesis and causing adjacent \nmyometrial smooth muscle hypertrophy and hyperpla -\nsia [3]. Another theory proposes an embryologic mecha -\nnism in which pluripotent Müllerian stem cells undergo \n*Correspondence:\nNaina Kumar\ndrnainakumar@gmail.com\n1 Department of Obstetrics and Gynecology, All India Institute of Medical \nSciences, Hyderabad Metropolitan Region, Bibinagar, Telangana 508126, \nIndia\n2 Department of Pathology, All India Institute of Medical Sciences, \nHyderabad Metropolitan Region, Bibinagar, Telangana 508126, India\n3 Department of Radiodiagnosis, All India Institute of Medical Sciences, \nHyderabad Metropolitan Region, Bibinagar, Telangana 508126, India\n\nPage 2 of 6Kumar et al. Egypt J Radiol Nucl Med          (2024) 55:229 \ninappropriate differentiation, resulting in the formation \nof ectopic endometrial tissue [1, 4].\nAdenomyosis is common in premenopausal, multipa -\nrous women in their thirties and forties, but it can also \noccur in postmenopausal women often with atypical fea -\ntures, though the exact prevalence in this group is not \nknown [1]. It is most frequently detected in patients aged \n40–50 years, with a prevalence rate of 57.6% [5].\nThe overlapping symptoms of adenomyosis and endo -\nmetrial carcinoma, particularly in postmenopausal \nwomen, can pose significant diagnostic and management \nchallenges. Symptoms like abnormal uterine bleeding \n(AUB), postmenopausal bleeding, dysmenorrhea, pelvic \npain, which are typically associated with adenomyosis, \ncan occur in endometrial carcinoma also, furthermore, in \npostmenopausal women, any abnormal bleeding should \nraise concerns and prompt detailed investigations [6, 7].\nIn addition to clinical symptoms, both adenomyo -\nsis and endometrial carcinoma can exhibit overlapping \nimaging characteristics, often leading to diagnostic ambi-\nguities that complicate clinical management. While aden-\nomyosis is a benign condition, endometrial carcinoma is \nmalignant requiring prompt and accurate diagnosis due \nto its potential for aggressive progression and significant \nimpact on patient prognosis [8, 9]. This underscores the \nimportance of precise diagnostic techniques to differenti-\nate between the two conditions and prevent mismanage -\nment. Histological diagnosis is crucial in distinguishing \nbenign adenomyosis from malignant endometrial carci -\nnoma. Furthermore, the presence of adenomyosis along -\nside other gynecological conditions such as endometrial \nhyperplasia, endometriosis, and leiomyomata can further \ncomplicate radiological interpretation.\nThe present case report underscores the difficulties and \npotential pitfalls in radiological diagnosis when differen -\ntiating between adenomyosis and endometrial carcinoma \nin postmenopausal women.\nCase presentation\nA 64-year-old para four and live four  (P4L4) postmeno -\npausal woman for 15  years presented to the Gyneco -\nlogical outpatient department with complaints of heavy \npostmenopausal bleeding per vaginum for 30–45  days. \nThere was no associated pain in the abdomen, white \ndischarge per vaginum, or postcoital bleed. She had \nno family or past history of any malignancy and had no \nother co-morbidities including hypertension, diabetes \nmellitus, or thyroid dysfunction. On general examina -\ntion, the patient appeared healthy with an average built. \nOn per abdominal examination, the abdomen was soft \nnon-tender to touch with no other organomegaly. On \nlocal examination, the labia majora and minora appeared \natrophic with sparse gray pubic hair. On per speculum \nexamination, the cervix was hypertrophied with no vis -\nible growth or lesion; vagina also appeared healthy. A \nPap smear was taken. On per vaginal examination, the \nuterus was bulky (6–8 weeks size), mobile with bilateral \nfornices free. Her routine investigations including com -\nplete blood counts, blood sugars, liver and renal func -\ntion tests, and viral markers for HIV, Hepatitis B, and \nC were negative and within normal limits. Pap smear \nreport revealed negative for intra-epithelial lesion or \nmalignancy. On transvaginal sonography (TVS) her \nuterus measured 7.8 × 4.3 × 4.7  cm with thickened, vas -\ncular endometrium of 18–19 mm. Bilateral ovaries were \natrophic. Based on these findings, the patient was advised \nmagnetic resonance imaging (MRI) of the abdomen and \npelvis to further rule out any endometrial malignancy. \nHer MRI report revealed thickened endometrium with \nareas of diffusion restriction (mean apparent diffusion \ncoefficient (ADC): 0.6 × 10.3   mm2/s). On dynamic con -\ntrast-enhanced MRI study, there was delayed enhance -\nment seen in the anterior and posterior endo-myometrial \njunction zone as well as the myometrium for a thickness \nof 9  mm anteriorly and 1.1  cm posteriorly. There was a \npolypoidal lesion with stalk seen arising from the pos -\nterior lower uterine cavity measuring 2.7  cm in longest \ndimension. Considering the loss of endo-myometrial \njunctional zone with delayed enhancement of the lesion \nand associated myometrial invasion, the final impression \nof endometrial malignancy along with a polypoidal lesion \nwas made (Figs. 1, 2).\nGiven the strong dilemma of endometrial malignancy, \nthe patient was taken up for hysteroscopic endometrial \nbiopsy and polypectomy. On hysteroscopy the endome -\ntrium appeared vascular and thickened with a polyp of \n2.5 cm seen in lower uterine cavity which was removed. \nHer histopathological report revealed disordered pro -\nliferative endometrium with a benign polyp. There was \nno evidence of malignancy or granuloma. Based on MRI \nfindings suggesting endometrial malignancy, symptoms \nand age of the patient, a decision of exploratory lapa -\nrotomy with total abdominal hysterectomy and bilateral \nsalpingo-oophorectomy was made.\nThe intraoperative findings included: an enlarged \nuterus (6–8  weeks) with intact serosal surface, bilateral \natrophic but healthy ovaries and fallopian tubes (Fig.  3). \nThere were no deposits seen over serosal surface of \nuterus, ovaries/ fallopian tubes, peritoneum or omen -\ntum. Peritoneal washings with 100  mL normal saline \nwas taken for cytological examination which revealed no \nmalignant cells. There was no gross pelvic or para-aortic \nlymphadenopathy observed.\nOn the cut section, the uterus measured \n12.5 × 9.5  × 5  cm, and endocervical canal measured \n2 cm. Endometrial thickness was 8 mm and myometrial \n\nPage 3 of 6\nKumar et al. Egypt J Radiol Nucl Med          (2024) 55:229 \n \nthickness 2  cm with no myometrial invasion seen. On \nmicroscopic examination, cervix had features of chronic \ncervicitis, endo-myometrium had adenomyosis with \nbilateral tubes and ovaries unremarkable (Fig.  4a–d). \nHence, on gross and microscopic examination, the final \nimpression of adenomyosis was made. The patient tol -\nerated the surgery well and was discharged under sat -\nisfactory condition after suture removal on eighth \npost-operative day.\nDiscussion\nDiscerning between adenomyosis and endometrial car -\ncinoma in postmenopausal women poses a challenge \nowing to shared clinical symptoms and radiological fea -\ntures. However, accurate differentiation is imperative for \neffective disease management, given that adenomyosis \nis benign, while endometrial carcinoma is malignant, \nnecessitating prompt diagnosis and treatment. Radio -\nlogical manifestations of adenomyosis encompass myo -\nmetrial cysts, hyperechoic islands, and hyperechoic \nsub-endometrial lines or buds, alongside asymmetrical \nmyometrial thickening, fan-shaped shadowing, irregular \njunctional zone, and interrupted junctional zone [10].\nHowever, these characteristics may occasionally over -\nlap with findings observed in endometrial carcinoma, \nunderscoring the need for a thorough assessment to \naccurately differentiate between the two conditions. \nSeveral studies have compared the radiological features \nof adenomyosis that mimic endometrial carcinoma. In \nadenomyosis, ectopic endometrial glands can present \nas echogenic nodules and striations extending from the \nendometrium into the myometrium, resembling features \ncommonly associated with endometrial carcinoma [11]. \nAdditionally, adenomyosis might exhibit hyperintense \nlinear striations on T2-weighted MRI images, potentially \nmisleadingly suggesting endometrial enlargement with \nmyometrial invasion and leading to a misdiagnosis of \nendometrial carcinoma [12]. Specific sonographic crite -\nria characteristic of adenomyosis, such as sub-endome -\ntrial echogenic linear striations, may also be erroneously \ninterpreted as indicators of endometrial carcinoma, con -\ntributing to potential misinterpretations [13]. Moreover, \nFig. 1 Magnetic resonance imaging—T1 weighted fat saturation image post-contrast and subtracted contrast image showing enhancement \nof endometrium in the posterior wall of fundus (white arrows). Underlying myometrium shows decreased enhancement compared to rest \nof myometrium simulating invasion (black arrow)\nFig. 2 Diffusion-weighted imaging, b value 1000 and apparent diffusion coefficient (ADC) map shows restricted diffusion in the endometrium \nwith low ADC values\n\nPage 4 of 6Kumar et al. Egypt J Radiol Nucl Med          (2024) 55:229 \nCut open section of uterus showing \nnormal endometrial cavity\nBilateral fallopian tubes and \novaries\nHealthy appearing endocervical \ncanal and cervix\nFig. 3 Gross cut-open section of the uterus with bilateral fallopian tubes and ovaries\nFig. 4 a Low power view showing atrophic endometrium (Hematoxylin and Eosin, 40× magnification). b Low power view showing endometrial \nglands and stroma lying away from endometrial cavity amidst myometrium (Hematoxylin and Eosin, 40× magnification). c Shows entrapped \nendometrial glands along with stroma amidst myometrium (Hematoxylin and Eosin, 100× magnification). d Higher magnification shows \nendometrial glands and stroma amidst smooth muscle bundles (Hematoxylin and Eosin, 400× magnification)\n\nPage 5 of 6\nKumar et al. Egypt J Radiol Nucl Med          (2024) 55:229 \n \nthe recognized phenomenon of malignant transforma -\ntion of adenomyosis into endometrial carcinoma further \ncomplicates radiological assessments [14].\nBottom of form\nMisdiagnosis of adenomyosis or endometrial carcinoma \ncan have significant clinical repercussions. Incorrect or \ndelayed diagnosis of endometrial carcinoma may result \nin adverse patient outcomes, including delayed treatment \nand a worsened prognosis. On the other hand, unneces -\nsary interventions for presumed adenomyosis can lead to \npatient anxiety, escalated healthcare expenses, and avoid-\nable risks linked to invasive procedures.\nTo address these challenges effectively, an interdisci -\nplinary approach involving collaboration among radi -\nologists, gynecologists, and pathologists is essential. \nThis ensures a thorough evaluation and interpretation of \nimaging findings within the context of clinical presenta -\ntion and histopathological assessment. Advanced imag -\ning techniques, such as MRI with diffusion-weighted \nimaging or dynamic contrast enhancement, along with \nTVS, play a pivotal role in enhancing the accuracy of \nradiological diagnosis, especially in postmenopausal \nwomen [15]. However, the definitive diagnosis is typically \nestablished through histopathological examination of the \nspecimen. Histopathological analysis, including endome -\ntrial sampling or biopsy, may be necessary to confirm the \npresence of endometrial carcinoma, particularly in cases \nwhere imaging results are inconclusive [16]. Additionally, \nthe use of immunohistochemical markers, such as estro -\ngen and progesterone receptors, can provide valuable \ninsights into the pathogenesis of adenomyosis, especially \nwhen concurrent endometrial pathology is present [17].\nConclusion\nThe resemblance in symptoms between adenomyosis \nand endometrial carcinoma in postmenopausal women \nemphasizes the necessity of a comprehensive diagnos -\ntic assessment to effectively differentiate between these \nconditions. Clinicians must maintain a heightened level \nof suspicion for endometrial malignancies in women dis -\nplaying symptoms suggestive of both adenomyosis and \nendometrial carcinoma, ensuring prompt and suitable \nmanagement. A multidisciplinary approach that inte -\ngrates clinical, radiological, and histopathological evalu -\nations is essential to improve the precision of radiological \ndiagnosis. By leveraging advanced imaging technolo -\ngies, histopathological analyses, and clinical correlations, \nhealthcare providers can optimize the diagnostic pro -\ncess and ensure timely and appropriate management \nfor patients grappling with these intricate gynecological \nconditions.\nAbbreviations\nAUB  Abnormal uterine bleeding\nADC  Apparent diffusion coefficient\nHIV  Human immunodeficiency virus\nMRI  Magnetic resonance imaging\nTVS  Transvaginal sonography\nAcknowledgements\nI thank Mrs. Amrita Kumar, Dr. Namit Singh, Adhvan Singh, Nutty Singh, and \nLexi Singh for their constant support and motivation.\nAuthor contributions\nN. Kumar contributed to conceptualization, literature search, data collection, \nformal analysis, writing original drafts, writing review and editing, final review, \nand approval of the manuscript. A. Sharma contributed to literature search, \ndata collection, formal analysis, writing and editing, final review, and approval \nof the manuscript. M. Mangla contributed to literature search, data collection, \nformal analysis, writing and editing, final review, and approval of the manu-\nscript. A. Srirambhatla contributed to data collection, formal analysis, writing \nand editing, final review, and approval of the manuscript.\nFunding\nNone.\nAvailability of data and materials\nNot Applicable.\nDeclarations\nEthics approval and consent to participate\nThe case report was conducted after informed written consent from the \npatient.\nConsent for publication\nThe case report was conducted after informed written consent from the \npatient regarding the publication of data.\nCompeting interests\nAuthors have no conflicts of interest to disclose.\nReceived: 22 June 2024   Accepted: 20 November 2024\nReferences\n 1. Gunther R, Adenomyosis WC (2024) In: StatPearls. Treasure Island (FL): \nStatPearls Publishing\n 2. 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