CASE 18712 Published on 30.09.2024

Teaching Case

Section

Genital (female) imaging

Case Type

Clinical Case

Authors

Maria Leonor Vilela¹, Filipa Bento¹, Danilo Alves¹, Tiago Oliveira¹, Paulo Donato^1,2

¹ Medical Imaging Service, Unidade Local de Saúde (ULS) de Coimbra, Coimbra, Portugal

² Faculty of Medicine of the University of Coimbra, Coimbra, Portugal

Patient

57 years, female

Categories

Area of Interest Genital / Reproductive system female ; Imaging Technique MR ;

Procedure Diagnostic procedure ; Special Focus Congenital ;

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Clinical History

A 57-year-old postmenopausal woman underwent a routine transvaginal ultrasound that detected a unilocular solid lesion in the right ovary, with intense peripheral colour-Doppler signal and a central hypoechoic area, with 31 x 28 x 25 mm (T x AP x L). The patient was asymptomatic. A magnetic resonance imaging (MRI) was requested for further characterisation of the lesion.

Differential Diagnosis List

Uterine malformation

Ovarian cancer

Imaging Findings

Pelvic MRI revealed a left hemi-uterus and a right rudimentary cavity (Figures 1 and 2). The rudimentary cavity is filled with T1-hyperintense content, indicating blood (Figure 3). The cervix and the vagina are normal (Figure 4).

The ovaries are small and have no follicles, in keeping with the postmenopausal state. There is an epithelial inclusion cyst in each ovary (Figures 5 and 6).

Discussion

Congenital malformations of the female reproductive tract are a broad spectrum of anomalies resulting from the maldevelopment of the Müllerian ducts [1,2]. These malformations are common, with a prevalence of 4%–7% [1,3], and may be associated with infertility, recurrent miscarriage and other obstetric complications. Thus, effective diagnosis is essential.

Anomalies vary according to the phase of the embryological maldevelopment [1]. First, the pair of Müllerian ducts is formed. Then occurs the fusion of both ducts, which originates the Fallopian tubes, the uterus, the cervix and the upper two-thirds of the vagina. The last step is the reabsorption of the septum.

Hemi-uterus with a rudimentary cavity occurs due to a formation defect, specifically when only one of the Müllerian ducts is completely formed and the contralateral duct is only partially developed [1,3].

Pelvic MRI has emerged as a powerful diagnostic technique for these malformations due to its high resolution in assessing soft tissue and uterine anatomy, without ionising radiation.

There are many classification systems for these anomalies, such as the ESHRE/ESGE and the ASRM, that facilitate the interpretation of the radiologist’s report and the communication among peers [1,2]. In our case, the classification of the uterine malformation would be U4aC0V0, according to the ESHRE/ESGE consensus, and left unicornuate with right distal uterine remnant with functional endometrium, according to the ASRM.

Written informed patient consent for publication has been obtained.

References

[1] Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De Angelis C, Gergolet M, Li TC, Tanos V, Brölmann H, Gianaroli L, Campo R (2013) The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod 28(8):2032-44. doi: 10.1093/humrep/det098. (PMID: 23771171)

[2] Pfeifer SM, Attaran M, Goldstein J, Lindheim SR, Petrozza JC, Rackow BW, Siegelman E, Troiano R, Winter T, Zuckerman A, Ramaiah SD (2021) ASRM müllerian anomalies classification 2021. Fertil Steril 116(5):1238-52. doi: 10.1016/j.fertnstert.2021.09.025. Erratum in: Fertil Steril 119(6):1088. doi: 10.1016/j.fertnstert.2023.04.001. (PMID: 34756327)

[3] Saravelos SH, Cocksedge KA, Li TC (2008) Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal. Hum Reprod Update 14(5):415-29. doi: 10.1093/humupd/dmn018. (PMID: 18539641)

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