Magnetic resonance imaging features of vaginal endometriosis

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(8):431 –435. w w w .ijc aserepo rtsandim ages.c o m M agnetic reso nance im aging featu res o f vaginal endo m etrio sis V aleria Fiaschetti, V alentina Cam a, L au ra Greco , M aria Fo rnari, Giu seppe So rrenti, Gio vanni Sim o netti AB STRACT Intro du ctio n: Deeply infiltrating endo m etrio sis (DIE)is defined by th e presence o f endo m etrial im plants penetrating u nder th e perito neal su rface o r u nder th e w all o f th e pelvic o rgans to a depth o f at least 5 m m . Th is case repo rt describes a case o f DIE invo lving vaginal w all, periu reth ral tissu e, to ru s u terinu s and sigm o id w all. Case Repo rt: A 4 6­year­o ld fem ale w as presented w ith pelvic pain and deep dyspareu nia w h ich started six years ago , after a spo ntaneo u s interru ptio n o f pregnancy and u terine cu rettage. Th e pelvic m agnetic reso nance im aging (M RI)sh o w ed m u ltiple DIE lesio ns lo calized in th e vaginal w all m ainly in th e lo w er th ird o f th e vagina, betw een th e anterio r vaginal w all and th e u reth ra, o n th e co nto u r o f th e u reth ra and betw een th e to ru s u terinu s and th e sigm o id w all. After M RI, laparo sco pic bio psies co nfirm ed th e DIE lesio ns. Co nclu sio n: Acco rding to th e im plantio n th eo ry, w e assu m e th at in o u r case th e vaginal endo m etrio sis w as th e resu lt o f im plantatio n o f endo m etrial glands into th e vaginal tearing du ring th e su rgical pro cedu re o f cu rettage. In th e cu rrent literatu re no au th o r h as so far described a diffu se invo lvem ento f th e vaginal w all in th e presence o f u terine cu rettage after interru ptio n o f pregnancy.In o u r case, th e anterio r (peri­u reth ral tissu e), m iddle (vaginal w all) and po sterio r (to ru s u terinu s and bo w el w all) co m partm ents are invo lved. W e can presu m e th atth e vaginal DIE is an early lesio n, w h ile th e o th ers lesio ns arise fro m vaginal w alls by a co ntigu o u s extensio n. O n M RI w ith endo vaginal gel th ese lesio ns w ere m o re evident rath er th an w ith o u t gel.M RI w ith gel allo w s u s to give essential preo perative m apping fo r th e su rgical rem o val o f th e DIE lesio ns. Keyw o rds: V aginal endo m etrio sis, Deeply infiltrating endo m etrio sis (DIE), Endo vaginal gel * * * * * * * * * Fiaschetti V , Cam a V , Greco L , Fo rnari M , So rrenti G, Sim o netti G. M agnetic reso nance im aging featu res o f vaginal endo m etrio sis. Internatio nal Jo u rnal o f Case Repo rts and Im ages 20 1 3;4 (8):4 31 –4 35. * * * * * * * * * do i:1 0 .534 8/ ijcri­20 1 3­0 8­34 9­CR­8 INTRO DUCTIO N Endo m etrio sis is a chro nic gyneco lo gic diso rder affecting w o m en in repro du ctive age; in the general po pu latio n the prevalence o f endo m etrio sis is 1 0 % [1 ].It is characterized by the presence o f fu nctio nal CASE REPORT OPEN ACCESS Valeria Fiaschetti1 , Valentina Cama2, Laura Greco2, Maria Fornari2, Giuseppe Sorrenti3, Giovanni Simonetti4 Affiliations: 1 Research, Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy. University Hospital Tor Vergata, Rome, Italy; 2Resident, Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy. University Hospital Tor Vergata, Rome, Italy; 3MD, Department of Gynecology and Obstetrics, University Hospital Tor Vergata, Rome, Italy; 4Professor, Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy. University Hospital Tor Vergata, Rome, Italy Corresponding Author: Valentina Cama, Viale Oxford 81 , Rome, Italy 001 33; Ph: +390620902400; Fax: +390620902404; Email: [email protected] Received: 22 November 201 2 Accepted: 1 2 January 201 3 Published: 01 August 201 3 Fiaschetti et al. 431 IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(8):431 –435. w w w .ijc aserepo rtsandim ages.c o m Fiaschetti et al. 432 endo m etrial glands and stro m a o u tside the u terine cavity.The m o stco m m o n lo calizatio ns o f endo m etrio sis are the o varies and the pelvic perito neu m , fo llo w ed by deep lesio ns o f the pelvic su bperito neal space.Deeply infiltrating endo m etrio sis (DIE) is a specific entity, histo lo gically defined by the presence o f endo m etrial im plants penetrating u nder the perito neal su rface o r u nder the w all o f the pelvic o rgans to a depth o f atleast 5 m m [2]. It invo lves m o re frequ ently fibro m u sco lar stru ctu res su ch as u tero sacral legam ents and recto vaginal septu m (RV S)(69.2% o f cases), rarely the vagina (1 4 .5% )[3].This case repo rt describes a case o f DIE invo lving vaginal w all, periu rethral tissu e and to ru s u terinu s w ith invo lvem ento f the sigm o id w all. CASE REPO RT W e repo rted a case o f a 4 6­year­o ld fem ale. H er clinical histo ry co nsisted o f exacerbated pelvic pain du ring her m enstru al cycle and deepdyspareu nia w hich started six years ago , after spo ntaneo u s interru ptio n o f pregnancy and u terine cu rettage. The clinical exam inatio n detected painfu l thickening o f the vagina bu t the u ltraso no graphy did no t repo rt abno rm al findings exceptfo r bilateral o varian cystis and m u ltiple sm all u terin fibro ids. V aginal bleeding w as o bserved after intro du ctio n o f the specu lu m . The patient w as referred by the Departm ent o f Gyneco lo gy and O bstetrics fo r clinical su spicio n o f DIE w hich w as based o n the detectio n o f painfu l thickening o f the vagina o n physical exam inatio n. W e perfo rm ed a pelvic m agnetic reso nance im aging (M RI) w ith a 1 .5 T scanner (Achieva, Philips m edical system s, B EST, Netherlands) u sing a pelvic phased­ array co il. W e u sed peristaltic inhibito rs (1 0 m g o f hyo scine­N­bu tylbro m ide, bu sco pan) dilu ted in 1 0 m L saline to redu ce gastro intestinal tractperistaltis. The im aging pro to co l inclu ded a T1 ­w eighted (W ) tu rbo spin­echo (TSE), a T2­W TSE, a T1 ­W TSE fat­ satu ratio n, perfo rm ed in the transverse plane (perpendicu lar to axis o f cervix).A T2­W TSE sequ ences and a T1 ­W TSE fat­satu ratio n w ere perfo rm ed o n sagittal plane. The transverse and sagittal T2­W TSE and the transverse and sagittal T1 ­W TSE fat­satu ratio n sequ ences w ere perfo rm ed befo re and after the intro du ctio n o f u ltraso no graphic gel (1 0 0 m L )into the vaginal canal. No intraveno u s co ntrast m ediu m w as adm inistered. The M RI sho w ed a hypo intense co ncentric thickening o f the vaginal w all o n T2­W sequ ences.The thickening w as m ainly evident in the lo w er third o f the vagina, w here it cau sed pseu do steno sis.O n the sagittal, T2­W sequ ence w ith endo vaginal gel this finding w as m o re evident than that w itho u t the u se o f the gel (Figu re 1 A–B ). O n T2­W sequ ence betw een anterio r vaginal w all and u rethra, abo ve the perineal bo dy, a hyperintense fo cu s w as revealed.Itw as m o re evidento n the sequ ence w ith gel (Figu re 1 B ). O n the T1 ­fat, satu ratio n sequ ence sho w ed a hyperintense signal indicating blo o dy co ntent. Urethral invo lvem ent w as su spected fo r hypo intense irregu lar spicu lated m ass­like thickening o n the co nto u r o f the u rethra invo lving the anterio r vaginal w all (Figu re 2).Thin hyperintense lines w ere revealed in the po sterio r vaginal w all, clearly visible in the T1 fat­satu ratio n sequ ence after the intro du ctio n o f gel into the vagina indicating blo o dy co ntent (Figu re 3). The T2­W sequ ence sho w ed thin hypo intense lines lo cated betw een the to ru s u terinu s and the sigm o id related to retractile adhesio ns (Figu re 4 ).After M RI, patientu nderw entto m u ltiple bio psies to o btain a definitive diagno se. H isto patho lo gy tests co nfirm ed islands o f endo m etrial tissu es and stro m a in the vaginal w all, periu rethral tissu e and to ru s u terinu s. Figu re 1 : (A, B ) Sagittal T2­w eighted sequ ences sho w s a diffu se thickening vaginal w all and a hyperintense o val lesio n lo calized betw een the anterio r vaginal w all and the u rethra, abo ve the perineal bo dy.(A)Itis po o rly detectable w itho u tgel The vaginal pre­o rificial pseu do steno sis w as no t appreciable o n the im age w itho u t gel.(B ) The im age after gel allo w s to better evalu ate the thickening o f the vaginal w all, m ainly evident in the lo w er third w here it cau sed pseu do steno sis (arro w head)and the o val fo cu s (arro w ). Figu re 2: Axial T2­w eighted sequ ence sho w s an hypo intense irregu lar spicu lated m ass­like thickening o n the co nto u r o f the u rethra.Itinvo lves the anterio r vaginal w all (arro w ). IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(8):431 –435. w w w .ijc aserepo rtsandim ages.c o m Fiaschetti et al. 433 The excisio n o f all endo m etrio tic im plants is the treatm ent cho sen to co ntro l the sym pto m ato lo gy. Fo llo w ing the histo patho lo gical respo nse she to o k pre­ o perative ho rm o ne therapy to redu ce the size o f the lesio ns and decrease the risk o f po sto perative inco ntinence. DISCUSSIO N The patho genesis o f endo m etrio sis rem ains co ntro versial and is pro bably m u ltifacto rial.The m o st w idely accepted theo ry is the im plantio n theo ry (Sam pso n 1 927).Acco rding to this theo ry, the lesio ns are seco ndary to the im plantatio n and the pro liferatio n o f regu rgitated endo m etrial cells in an ecto pic po sitio n. Angio ­ and lym phatic theo ry, im pairm ent o f the im m u ne respo nse, heritable tendencies and secreted pro du cts o f endo m etrio tic lesio ns m ay co ntribu te to explain the patho genesis o f this diso rder [4 , 5]. In this case deepdyspareu nia and pelvic pain started im m ediately after spo ntaneo u s interru ptio n o f pregnancy and u terine cu rettage.Acco rding to the im plantio n theo ry w e assu m e that the vaginal endo m etrio sis w as the resu lt o f im plantatio n o f endo m etrial glandsinto vaginal tearing du ring su rgical pro cedu re o f cu rettage. In the cu rrent literatu re so m e au tho rs have described cases o f extraperito neal lo catio ns inclu ding vagina, RVS and m o stly o n episio to m y scars, after o bstetrical and su rgical trau m a, in particu lar after natu ral delivery [6].No au tho r has so far described diffu se invo lvem ento f vaginal w all in presence o f u terine cu rettage after pregnancy interru ptio n.O u r patient had a histo ry o f tw o cesarean sectio ns as w ell. Acco rding to a fu nctio nal and clinical classificatio n in o u r case the anterio r, m iddle and po sterio r co m partm ents are invo lved.In fact, the endo m etrio tic lesio ns affect periu rethral tissu e (anterio r co m partm ent), vagina (m iddle co m partm ent)and to ru s u terinu s and bo w el (po sterio r co m partm ent)[7].W e can presu m e that the vaginal DIE w as a previo u s lesio n, w hile the o thers lesio ns arise fro m vaginal w alls thro u gh a co ntigo u s extensio n.Iso lated u rethral invo lvem ent is po o rly described in literatu re. It is m o re frequ ently o bserved as an extensio n fro m the o thers o rgans su ch as the bladder [7]. In this case u ltraso no graphy w as the first diagno stic to o l u sed.It is reco m m ended fo r the stu dy o f the o vary and bladder bu tits sensitivity is lo w er than thato f M RI in identifying su bperito neal lesio ns extensio ns [8]. Ultraso no graphy repo rted the presence o f endo m etrio m a in the right adnexal, cyst in the left adnexal and m u ltiple no du les o f u terine fibro ids. The M RIsho w ed a hypo intense co ncentric thickening o f the vaginal w all o n T2­W im ages. The u se o f gel allo w ed u s to better evalu ate this finding.It w as m ainly evident in the lo w er third o f the vagina w here it cau sed pseu do ­steno sis (Figu re 1 B ).The pseu do steno sis w as no t appreciable o n the sequ ence w itho u tgel (Figu re 1 A). In ano ther recent repo rt, w e dem o nstrated that the u se o f intravaginal gel increases the sensitivity o f M RI w itho u t gel in detecting DIE lesio ns. Diagno stic difficu lties o f DIE are related to the inherentfeatu res o f endo m etrio tic lesio ns w hich can have an M RI signal intensity very sim ilar to tho se o f the su rro u nding fibro m u scu lar anato m ic stru ctu res. Also DIE invo lves m u ltiple clo sely related anato m ical stru ctu res and w ith o nly su btle signal alteratio ns. In this regard the advantage o f the gel is its hypersignal o n T2­W im age Figu re 3: Sagittal T1 ­w eighted sequ ence sho w s a thin hyperintense lines o f the po sterio r vaginal w all indicating plaqu es blo o dy co ntent (arro w ).This finding is visible o nly after vaginal distensio n. Figu re 4 : Axial T2­w eighted sequ ence sho w s the hypo intense lines lo cated betw een the to ru s u terinu s and the sigm o id related to retractile adhesio ns (arro w ). IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(8):431 –435. w w w .ijc aserepo rtsandim ages.c o m w hich co ntrasts the hypo signal o f the su rro u nding fibro m u sco lar anato m ical stru ctu res, therefo re facilitating the diagno sis [9]. So m e au tho rs claim thatthe presence o f sm all fo ci o f high signal w ithin o f fibro tic lesio ns can facilitate the diagno sis o f DIE.O u r case co ntradicts this assertio n.In fact, the endo m etrio tic blo o d lesio n lo calized betw een the anterio r vaginal w all and the u rethra, abo ve the perineal bo dy, w as po o rly detected in the sequ ence w itho u tgel (Figu re 1 A)rather than w ith gel (Figu re 1 B ). The intravaginal gel relaxing the vaginal w alls and the fo rnices allo w ed a better view o f the anterio r deeppelvic area and o f the retro cervical area, as co nfirm ed by literatu re [9]. The thin lines o f the po sterio r vaginal w all, hyperintense o n T1 ­W fat satu ratio n sequ ences, indicating blo o d plaqu es, w as detected o nly after vaginal distensio n (Figu re 3). An M RI w ith endo vaginal gel allo w s u s to give essential preo perative m apping fo r the su rgical rem o val o f the DIE lesio ns.Fu rtherm o re, this m etho d stands o u t becau se higher sensitivity co m pared to transvaginal u ltraso no graphy and M RI w itho u t gel, detecting m o re lesio ns [9]. A w ide excisio n o f all endo m etrio tic im plants rem ains the cho sen treatm ent and an accu rate preo perative assessm ent o f the extensio n o f the endo m etrio sis lesio ns is necessary fo r a su ccessfu l treatm entand to co ntro l the sym pto m ato lo gy. In deepextraperito neal area the radical excisio n o f endo m etrio sis lesio ns co u ld inclu de partial excisio n o f the sphincter, w hich that m ay co m pro m ise the u rinary co ntinence. In this case, ho rm o nal therapy w as u sed befo re o f the su rgical pro cedu re in o rder to decrease the risk o f po sto perative inco ntinence and to decrease the recu rrence rate.In acase serieso f six patientsL iang etal. o bserved recu rrence in patients treated w ith o nly su rgery, w hile no ne o f the patients treated w ith su rgical and m edical therapy had recu rrence o fendo m etrio sis[5]. Also the u se o f preo perative ho rm o nal therapy co u ld redu ce the size and facilitate the excisio n o f the lesio n redu cing dam age to su rro u nding tissu e [1 0 ]. CO NCL USIO N In literatu re, m any au tho rs have described deeply infiltrating endo m etrio sis bu t no ne o f them has so far described diffu se invo lvem ento f the vaginal w all and o f the periu rethral tissu e w itho u t invo lvem ent o f the bladder yet. Fu rtherm o re, o u r stu dy is the first o ne to describe a case o f triple co nco m itant affected co m partm ents; periu rethral tissu e (anterio r co m partm ent), vagina (m iddle co m partm ent) and to ru s u terinu s and bo w el (po sterio r co m partm ent) in patient w ith deep extraperito neal endo m etrio sis. * * * * * * * * * Au th o r Co ntribu tio ns V aleria Fiaschetti – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished V alentina Cam a – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished L au ra Greco – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished M aria Fo rnari – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished Giu seppe So rrenti – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished Gio vanni Sim o netti – Co nceptio n and design, Acqu isitio n o f data, Analysis and interpretatio n o f data, Critical revisio n o f the article, Final appro val o f the versio n to be pu blished Gu aranto r The co rrespo nding au tho r is the gu aranto r o f su bm issio n. Co nflicto f Interest Au tho rs declare no co nflicto f interest. Co pyrigh t © V aleria Fiaschetti et al. 20 1 3; This article is distribu ted u nder the term s o f Creative Co m m o ns attribu tio n 3.0 L icense w hich perm its u nrestricted u se, distribu tio n and repro du ctio n in any m eans pro vided the o riginal au tho rs and o riginal pu blisher are pro perly credited. (Please see w w w .ijcaserepo rtsandim ages.co m / co pyright­po licy.phpfo r m o re info rm atio n.) REFERENCES 1 . V iganò P, Parazzini F, So m igliana E, V ercellini P. Endo m etrio sis: epidem io lo gy and aetio lo gical facto rs.B est Pract Res Clin O bstet Gynaeco l 20 0 4 Apr;1 8(2):1 77–20 0 . 2. Co rnillie Fj, O o sterlynck D, L au w eryns JM , Ko ninckx PR. Deeply infiltrating pelvic endo m etrio sis: histo lo gy and clinical significance. Fertil Steril 1 990 ;53(6):978–83. 3. Del Frate C, Giro m etti R, Pittino M , et al. Deep retro perito neal pelvic endo m etrio sis: M R im aging appearance w ith laparo sco pic co rrelatio n. Radio graphics.20 0 6 No v­Dec;26(6):1 70 5–1 8. 4 . Sim pso n JL , B ischo ff FZ.H eritability and m o lecu lar genetic stu dies o f endo m etrio sis.Ann N Y Acad Sci 20 0 2 M ar;955:239–51 . 5. Giu dice L C, Kao L C. Endo m etrio sis. L ancet 20 0 4 No v 1 3–1 9;364 (94 4 7):1 789–99. Fiaschetti et al. 434 IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 8, August 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(8):431 –435. w w w .ijc aserepo rtsandim ages.c o m 6. O do basic A, Pasic A, Iljazo vic­L atifagic E, et al. Perineal endo m etrio sis: a case repo rt and review o f the literatu re.Tech Co lo pro cto l 20 1 0 No v;1 4 Su ppl 1 :S25–7. 7. Co u tinho A Jr, B ittenco u rt L K, Pires CE, et al.M R im aging in deep pelvic endo m etrio sis: a picto rial essay.Radio graphics 20 1 1 M ar­Apr;31 (2):54 9–67. 8. B azo t M , Darai E, H o u rani R, et al. Deep pelvic endo m etrio sis: M R im aging fo r diagno sis and predictio n o f extensio n o f disease. Radio lo gy 20 0 4 ;232(2):379–89. 9. Fiaschetti V , Cru sco S, M eschini A, et al. Deeply infiltrating endo m etrio sis: Evalu atio n o f retro ­ cervical space o n M RI after vaginal o pacificatio n. Eu r JRadio l 20 1 2 No v;81 (1 1 ):3638–4 5. 1 0 . Chen N, Zhu L , L ang J, et al.The clinical featu res and m anagem ent o f perineal endo m etrio sis w ith anal sphincter invo lvem ent: a clinical analysis o f 31 cases.H u m Repro d 20 1 2 Ju n;27(6):1 624 –7. Fiaschetti et al. 435