Adenomyosis: usual and unusual imaging manifestations, pitfalls, and problem-solving MR imaging techniques

Adenomyosis is a common nonneoplastic gynecologic disease characterized by the presence of ectopic endometrium within the myometrium. On T2-weighted magnetic resonance (MR) images, typical adenomyosis appears as an ill-demarcated low-signal-intensity lesion with uterine enlargement. However, various physiologic or pathologic states such as amount of functional endometrial tissue, phase of the menstrual cycle, endogenous hormonal abnormality, and exogenous hormonal stimulation may affect the MR imaging appearance of adenomyosis and may result in a tumorlike appearance. Problem-solving MR imaging techniques used in diagnosis of adenomyosis include diffusion-weighted imaging, susceptibility-weighted imaging, hydrogen 1 MR spectroscopy, cine MR imaging, and high-resolution MR imaging at 3 T. Adenomyotic lesions that show high signal intensity relative to the outer myometrium on T2-weighted images mimic malignancies such as leiomyosarcoma and endometrial stromal sarcoma. In these cases, a relatively high apparent diffusion coefficient at diffusion-weighted imaging and a low choline peak at MR spectroscopy are suggestive of a benign lesion. Small hemorrhagic foci suggestive of an adenomyotic lesion are well demonstrated as signal voids at susceptibility-weighted imaging. Cine MR imaging is useful in differentiating transient myometrial contraction from focal adenomyosis. High-resolution MR imaging at 3 T demonstrates anatomically detailed structures and may improve diagnostic accuracy in differentiating adenomyosis from its mimics, such as low-grade endometrial stromal sarcoma.