Adenomyosis or endometrial carcinoma? Radiological pitfalls in postmenopausal diagnosis: a case report

Background Adenomyosis and endometrial carcinoma present distinct pathological conditions that pose consider- able diagnostic hurdles, especially in postmenopausal women, as they share common clinical manifestations. Further- more, postmenopausal adenomyosis may exhibit radiological features resembling those of endometrial carcinoma, potentially leading to misdiagnosis and inappropriate management. Case presentation A 64-year-old para four and live four (P4L4) postmenopausal woman, who had been postmeno- pausal for 15 years, sought evaluation at the Gynecological Outpatient Department due to heavy postmenopausal bleeding lasting 30–45 days. Ultrasonography and MRI findings indicated a loss of the endo-myometrial junctional zone, delayed enhancement of the lesion, and suspected myometrial invasion, suggestive of endometrial malignancy, alongside a polypoidal lesion. Given the strong suspicion of endometrial carcinoma, the patient underwent hysteros- copy-guided endometrial biopsy. However, histopathological analysis revealed disordered proliferative endometrium with no evidence of malignancy. Considering the patient’s age, symptoms, and MRI findings, exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy was planned. Subsequent histopathological examination confirmed adenomyosis of the uterus, with the fallopian tubes and ovaries found to be healthy.

The present case report underscores the radiological challenges encountered in distinguishing adeno- myosis from endometrial carcinoma in postmenopausal women, emphasizing the importance of a multidisciplinary approach to enhance diagnostic accuracy and improve patient outcomes in this population.

Adenomyosis, Endometrial carcinoma, Magnetic resonance imaging, Postmenopausal, Uterus

Adenomyosis is a common gynecological condition marked by the presence of endometrial tissue abnormally located within the uterine myometrium [1]. It was first described histopathologically by German pathologist Carl von Rokitansky in 1860 and was originally termed "cystosarcoma adenoids uterinum" [2]. The exact patho - genesis of adenomyosis remains unclear, with several theories proposing different origins. The most widely accepted theory suggests that adenomyosis arises from a disrupted boundary between the deepest layer of the endometrium (endometrium basalis) and the underlying myometrium. This disruption results in inappropriate endometrial proliferation into the myometrium, trig - gering small vessel angiogenesis and causing adjacent myometrial smooth muscle hypertrophy and hyperpla - sia [3]. Another theory proposes an embryologic mecha - nism in which pluripotent Müllerian stem cells undergo *Correspondence: Naina Kumar [email protected] 1 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Hyderabad Metropolitan Region, Bibinagar, Telangana 508126, India 2 Department of Pathology, All India Institute of Medical Sciences, Hyderabad Metropolitan Region, Bibinagar, Telangana 508126, India 3 Department of Radiodiagnosis, All India Institute of Medical Sciences, Hyderabad Metropolitan Region, Bibinagar, Telangana 508126, India Page 2 of 6Kumar et al. Egypt J Radiol Nucl Med (2024) 55:229 inappropriate differentiation, resulting in the formation of ectopic endometrial tissue [1, 4]. Adenomyosis is common in premenopausal, multipa - rous women in their thirties and forties, but it can also occur in postmenopausal women often with atypical fea - tures, though the exact prevalence in this group is not known [1]. It is most frequently detected in patients aged 40–50 years, with a prevalence rate of 57.6% [5]. The overlapping symptoms of adenomyosis and endo - metrial carcinoma, particularly in postmenopausal women, can pose significant diagnostic and management challenges. Symptoms like abnormal uterine bleeding (AUB), postmenopausal bleeding, dysmenorrhea, pelvic pain, which are typically associated with adenomyosis, can occur in endometrial carcinoma also, furthermore, in postmenopausal women, any abnormal bleeding should raise concerns and prompt detailed investigations [6, 7]. In addition to clinical symptoms, both adenomyo - sis and endometrial carcinoma can exhibit overlapping imaging characteristics, often leading to diagnostic ambi- guities that complicate clinical management. While aden- omyosis is a benign condition, endometrial carcinoma is malignant requiring prompt and accurate diagnosis due to its potential for aggressive progression and significant impact on patient prognosis [8, 9]. This underscores the importance of precise diagnostic techniques to differenti- ate between the two conditions and prevent mismanage - ment. Histological diagnosis is crucial in distinguishing benign adenomyosis from malignant endometrial carci - noma. Furthermore, the presence of adenomyosis along - side other gynecological conditions such as endometrial hyperplasia, endometriosis, and leiomyomata can further complicate radiological interpretation. The present case report underscores the difficulties and potential pitfalls in radiological diagnosis when differen - tiating between adenomyosis and endometrial carcinoma in postmenopausal women. Case presentation A 64-year-old para four and live four (P4L4) postmeno - pausal woman for 15  years presented to the Gyneco - logical outpatient department with complaints of heavy postmenopausal bleeding per vaginum for 30–45  days. There was no associated pain in the abdomen, white discharge per vaginum, or postcoital bleed. She had no family or past history of any malignancy and had no other co-morbidities including hypertension, diabetes mellitus, or thyroid dysfunction. On general examina - tion, the patient appeared healthy with an average built. On per abdominal examination, the abdomen was soft non-tender to touch with no other organomegaly. On local examination, the labia majora and minora appeared atrophic with sparse gray pubic hair. On per speculum examination, the cervix was hypertrophied with no vis - ible growth or lesion; vagina also appeared healthy. A Pap smear was taken. On per vaginal examination, the uterus was bulky (6–8 weeks size), mobile with bilateral fornices free. Her routine investigations including com - plete blood counts, blood sugars, liver and renal func - tion tests, and viral markers for HIV, Hepatitis B, and C were negative and within normal limits. Pap smear report revealed negative for intra-epithelial lesion or malignancy. On transvaginal sonography (TVS) her uterus measured 7.8 × 4.3 × 4.7  cm with thickened, vas - cular endometrium of 18–19 mm. Bilateral ovaries were atrophic. Based on these findings, the patient was advised magnetic resonance imaging (MRI) of the abdomen and pelvis to further rule out any endometrial malignancy. Her MRI report revealed thickened endometrium with areas of diffusion restriction (mean apparent diffusion coefficient (ADC): 0.6 × 10.3  mm2/s). On dynamic con - trast-enhanced MRI study, there was delayed enhance - ment seen in the anterior and posterior endo-myometrial junction zone as well as the myometrium for a thickness of 9  mm anteriorly and 1.1  cm posteriorly. There was a polypoidal lesion with stalk seen arising from the pos - terior lower uterine cavity measuring 2.7  cm in longest dimension. Considering the loss of endo-myometrial junctional zone with delayed enhancement of the lesion and associated myometrial invasion, the final impression of endometrial malignancy along with a polypoidal lesion was made (Figs. 1, 2). Given the strong dilemma of endometrial malignancy, the patient was taken up for hysteroscopic endometrial biopsy and polypectomy. On hysteroscopy the endome - trium appeared vascular and thickened with a polyp of 2.5 cm seen in lower uterine cavity which was removed. Her histopathological report revealed disordered pro - liferative endometrium with a benign polyp. There was no evidence of malignancy or granuloma. Based on MRI findings suggesting endometrial malignancy, symptoms and age of the patient, a decision of exploratory lapa - rotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy was made. The intraoperative findings included: an enlarged uterus (6–8  weeks) with intact serosal surface, bilateral atrophic but healthy ovaries and fallopian tubes (Fig.  3). There were no deposits seen over serosal surface of uterus, ovaries/ fallopian tubes, peritoneum or omen - tum. Peritoneal washings with 100  mL normal saline was taken for cytological examination which revealed no malignant cells. There was no gross pelvic or para-aortic lymphadenopathy observed. On the cut section, the uterus measured 12.5 × 9.5 × 5  cm, and endocervical canal measured 2 cm. Endometrial thickness was 8 mm and myometrial Page 3 of 6 Kumar et al. Egypt J Radiol Nucl Med (2024) 55:229 thickness 2  cm with no myometrial invasion seen. On microscopic examination, cervix had features of chronic cervicitis, endo-myometrium had adenomyosis with bilateral tubes and ovaries unremarkable (Fig.  4a–d). Hence, on gross and microscopic examination, the final impression of adenomyosis was made. The patient tol - erated the surgery well and was discharged under sat - isfactory condition after suture removal on eighth post-operative day.

Discerning between adenomyosis and endometrial car - cinoma in postmenopausal women poses a challenge owing to shared clinical symptoms and radiological fea - tures. However, accurate differentiation is imperative for effective disease management, given that adenomyosis is benign, while endometrial carcinoma is malignant, necessitating prompt diagnosis and treatment. Radio - logical manifestations of adenomyosis encompass myo - metrial cysts, hyperechoic islands, and hyperechoic sub-endometrial lines or buds, alongside asymmetrical myometrial thickening, fan-shaped shadowing, irregular junctional zone, and interrupted junctional zone [10]. However, these characteristics may occasionally over - lap with findings observed in endometrial carcinoma, underscoring the need for a thorough assessment to accurately differentiate between the two conditions. Several studies have compared the radiological features of adenomyosis that mimic endometrial carcinoma. In adenomyosis, ectopic endometrial glands can present as echogenic nodules and striations extending from the endometrium into the myometrium, resembling features commonly associated with endometrial carcinoma [11]. Additionally, adenomyosis might exhibit hyperintense linear striations on T2-weighted MRI images, potentially misleadingly suggesting endometrial enlargement with myometrial invasion and leading to a misdiagnosis of endometrial carcinoma [12]. Specific sonographic crite - ria characteristic of adenomyosis, such as sub-endome - trial echogenic linear striations, may also be erroneously interpreted as indicators of endometrial carcinoma, con - tributing to potential misinterpretations [13]. Moreover, Fig. 1 Magnetic resonance imaging—T1 weighted fat saturation image post-contrast and subtracted contrast image showing enhancement of endometrium in the posterior wall of fundus (white arrows). Underlying myometrium shows decreased enhancement compared to rest of myometrium simulating invasion (black arrow) Fig. 2 Diffusion-weighted imaging, b value 1000 and apparent diffusion coefficient (ADC) map shows restricted diffusion in the endometrium with low ADC values Page 4 of 6Kumar et al. Egypt J Radiol Nucl Med (2024) 55:229 Cut open section of uterus showing normal endometrial cavity Bilateral fallopian tubes and ovaries Healthy appearing endocervical canal and cervix Fig. 3 Gross cut-open section of the uterus with bilateral fallopian tubes and ovaries Fig. 4 a Low power view showing atrophic endometrium (Hematoxylin and Eosin, 40× magnification). b Low power view showing endometrial glands and stroma lying away from endometrial cavity amidst myometrium (Hematoxylin and Eosin, 40× magnification). c Shows entrapped endometrial glands along with stroma amidst myometrium (Hematoxylin and Eosin, 100× magnification). d Higher magnification shows endometrial glands and stroma amidst smooth muscle bundles (Hematoxylin and Eosin, 400× magnification) Page 5 of 6 Kumar et al. Egypt J Radiol Nucl Med (2024) 55:229 the recognized phenomenon of malignant transforma - tion of adenomyosis into endometrial carcinoma further complicates radiological assessments [14]. Bottom of form Misdiagnosis of adenomyosis or endometrial carcinoma can have significant clinical repercussions. Incorrect or delayed diagnosis of endometrial carcinoma may result in adverse patient outcomes, including delayed treatment and a worsened prognosis. On the other hand, unneces - sary interventions for presumed adenomyosis can lead to patient anxiety, escalated healthcare expenses, and avoid- able risks linked to invasive procedures. To address these challenges effectively, an interdisci - plinary approach involving collaboration among radi - ologists, gynecologists, and pathologists is essential. This ensures a thorough evaluation and interpretation of imaging findings within the context of clinical presenta - tion and histopathological assessment. Advanced imag - ing techniques, such as MRI with diffusion-weighted imaging or dynamic contrast enhancement, along with TVS, play a pivotal role in enhancing the accuracy of radiological diagnosis, especially in postmenopausal women [15]. However, the definitive diagnosis is typically established through histopathological examination of the specimen. Histopathological analysis, including endome - trial sampling or biopsy, may be necessary to confirm the presence of endometrial carcinoma, particularly in cases where imaging results are inconclusive [16]. Additionally, the use of immunohistochemical markers, such as estro - gen and progesterone receptors, can provide valuable insights into the pathogenesis of adenomyosis, especially when concurrent endometrial pathology is present [17].

The resemblance in symptoms between adenomyosis and endometrial carcinoma in postmenopausal women emphasizes the necessity of a comprehensive diagnos - tic assessment to effectively differentiate between these conditions. Clinicians must maintain a heightened level of suspicion for endometrial malignancies in women dis - playing symptoms suggestive of both adenomyosis and endometrial carcinoma, ensuring prompt and suitable management. A multidisciplinary approach that inte - grates clinical, radiological, and histopathological evalu - ations is essential to improve the precision of radiological diagnosis. By leveraging advanced imaging technolo - gies, histopathological analyses, and clinical correlations, healthcare providers can optimize the diagnostic pro - cess and ensure timely and appropriate management for patients grappling with these intricate gynecological conditions. Abbreviations AUB Abnormal uterine bleeding ADC Apparent diffusion coefficient HIV Human immunodeficiency virus MRI Magnetic resonance imaging TVS Transvaginal sonography

I thank Mrs. Amrita Kumar, Dr. Namit Singh, Adhvan Singh, Nutty Singh, and Lexi Singh for their constant support and motivation. Author contributions N. Kumar contributed to conceptualization, literature search, data collection, formal analysis, writing original drafts, writing review and editing, final review, and approval of the manuscript. A. Sharma contributed to literature search, data collection, formal analysis, writing and editing, final review, and approval of the manuscript. M. Mangla contributed to literature search, data collection, formal analysis, writing and editing, final review, and approval of the manu- script. A. Srirambhatla contributed to data collection, formal analysis, writing and editing, final review, and approval of the manuscript. Funding None. Availability of data and materials Not Applicable. Declarations Ethics approval and consent to participate The case report was conducted after informed written consent from the patient. Consent for publication The case report was conducted after informed written consent from the patient regarding the publication of data. Competing interests Authors have no conflicts of interest to disclose. Received: 22 June 2024 Accepted: 20 November 2024

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