Clinical History
A 47-year-old female patient presented with chronic menorrhagia and metorrhagia, causing iron deficiency anaemia.
Imaging Findings
Pre-embolisation MRI (Fig. 1, 2, 3) shows ill-defined heterogeneous signal intensity of the uterine fundus, with indistinct adjacent junctional zone (JZ). JZ thickness at some other portions exceeds 12 mm, in addition to multiple hyperintense stria and tiny foci seen within the myometrium, on both T2 and T1-weighted images (WI). No significant post-contrast enhancement is noted, nor enlarged pelvic lymph nodes. These findings are in keeping with adenomyosis. There is also a well-defined T2 hypointense focal lesion at the anterior myometrium, isointense on T1-WI both pre and post-contrast, in keeping with leiomyoma.
Pre and post-embolisation angiographic images (Fig. 4) show adequate embolisation.
Three months post-embolisation MRI (Fig. 5, 6, 7) shows decreased size of the above mentioned lesions, decreased signal intensity, as well as decreased post-contrast enhancement. Also, the multiple tiny bright foci and stria seen on pre-operative MRI are no longer visible postoperatively. Collectively, these postoperative changes denote reduced vascular supply to the lesions.
Discussion
Adenomyosis is a relatively common gynaecological condition during reproductive age. If it is symptomatic, it usually presents with menorrhagia, metrorrhagia, dysmenorrhoea or mass effect [1]. MRI is the most accurate radiological modality for its diagnosis, with typical imaging features as described above. These features correspond to the presence of ectopic endometrial tissue within myometrium: thickened JZ (more than or equal to 12 mm), ill-defined rounded/oval area of heterogeneous signal intensity (representing adenomyoma), myometrial hyperintense foci and stria on T2-WI (representing cystic glandular changes), also some tiny hyperintense foci can be seen on T1-WI (representing haemorrhagic foci). Adenomyosis is commonly associated with uterine leiomyomas [2].
The usual definitive therapy is hysterectomy. Our patient wanted to avoid hysterectomy, although she was not seeking fertility. After informed consent, she chose to undergo uterine arteries embolisation procedure under local groin anaesthesia. Using 4 French Cobra catheter, permanent embolisation microparticles measuring 500-700 micron were selectively injected into both uterine arteries, until uterine branches pruning and contrast stasis were achieved. Transient severe pelvic pain is expected after such a procedure, thus patient-controlled opioid analgesia is routinely prescribed. No peri-operative complications were encountered, nevertheless, potential complications include: post-embolisation syndrome, infections (e.g. endometritis), arterial puncture site complications, iodinated contrast-induced nephropathy, and iodinated contrast anaphylaxis.
Three months post-embolisation, the patient reported marked improvement of her menorrhagia and metrorrhagia, denoting clinical success. Three-month post-operative MRI revealed decreased size of the fundal adenomyoma and anterior wall leiomyoma, decreased signal intensity, as well as decreased post-contrast enhancement. Also, the multiple tiny bright foci and stria seen on pre-operative MRI were no longer visible post-operative. Collectively, these post-operative changes imply reduced vascular supply to the lesions.
Diagnostic radiologists and gynaecologists at the front-line of adenomyosis diagnosis should be aware of uterine arteries embolisation as a valuable minimally-invasive treatment option for adenomyosis patients, especially those who wish to preserve fertility or keep their uterus. Statistically significant clinical improvement can reach up to 95% of patients [3]. Enhancing hypervascular lesions showed the best response to embolisation [4].
Differential Diagnosis List
Improved uterine adenomyosis and leiomyoma, after transcatheter uterine arteries embolisation
Leiomyosarcoma
Endometrial carcinoma
Final Diagnosis
Improved uterine adenomyosis and leiomyoma, after transcatheter uterine arteries embolisation
