Rare association of diffuse adenomyosis with pedunculated subserosal leiomyoma on magnetic resonance imaging

Dear Editor, A 42-year-old perimenopausal, nulliparous woman of Indian ethnicity presented with complaints of pelvic pain, dysmenorrhea, and menorrhagia for the past 6 months. She provided a history for irregular menstrual cycles since the time of menarche which regularized after taking medication. The patient was referred for ultrasound of the abdomen and pelvis which revealed fatty hepatomegaly and bulky uterus with a differential diagnosis of pedunculated or broad ligament fibroid. Further, she was referred for magnetic resonance imaging (MRI) of the pelvis which demonstrated a bulky uterus measuring 8.2 cm × 4.9 cm × 6.5 cm with widening of the junctional zone measuring 14 mm in thickness. There was also evidence of a pedunculated subserosal fibroid measuring 5.2 cm × 4.4 cm with attachment to the uterine fundus by a broad stalk measuring 1.7 cm. On contrast MRI, there was intense homogeneous enhancement of the uterus and associated fibroid (Figures 1 and 2). Based on imaging findings, a diagnosis of diffuse adenomyosis with pedunculated subserosal leiomyoma was made, and the patient was referred to the gynecology department for further management where she underwent hysterectomy and histopathology of the resected specimen confirmed the same. The presence of ectopic endometrial tissue within the uterine myometrium is termed as “adenomyosis“ which may have focal or diffuse distribution and has strong association with hormone-dependent lesions, such as endometrial polyps, uterine fibroids, and pelvic endometriosis.[] Adenomyosis is commonly localized in the fundus and posterior wall of the uterus. The criterion for diagnosing adenomyosis on MRI includes widening of the junctional zone >12 mm and ratio of junctional zone to myometrial thickness >40%.[] On T2-weighted images that demonstrate the zonal anatomy, adenomyosis is seen as ill-defined focal/diffuse region of low-signal intensity and may have a striated appearance. Differential diagnosis includes transient uterine contractions that appear as hypointense bands adjacent to the junctional zone mimicking focal adenomyosis on T2-weighted MR images.[] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES - 1. Krentel H, Cezar C, Becker S, Di Spiezio Sardo A, Tanos V, Wallwiener M, et al. From clinical symptoms to MR imaging: Diagnostic steps in adenomyosis. Biomed Res Int, 2017; 2017: 1514029. - 2. Agostinho L, Cruz R, Osório F, Alves J, Setúbal A, Guerra A. MRI for adenomyosis: A pictorial review. Insights Imaging, 2017; 8: 549-56. - 3. Tamai K, Koyama T, Umeoka S, Saga T, Fujii S, Togashi K. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol, 2006; 20: 583-602.