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Images
in Women's Health
January 2003
Case
Jorge Londono, MD, RDMS; Elizabeth Puscheck,
MD
A 41-year-old G2 P2002 Hispanic woman was referred with a history
of abnormal uterine bleeding consisting of menorrhagia for 18 months.
Prior to the referral, she was treated with different regimens of
Depo-Provera (150 to 300 mg) each month on several occasions. She
partially responded to treatment with Depo-Provera 150 mg four times
per month and continuous oral contraceptives (Necon 1/35) for 4
months. In addition, she was diagnosed with mild anemia, which was
treated with oral iron therapy for the past 6 months. At the time
of the exam, she was having episodes of menorrhagia (once a month)
and continuous vaginal spotting.
Her past surgical history included a myomectomy 2 years prior,
and a left salpingoophorectomy 18 months prior due to a left ovarian
cyst. Her past obstetrics included two full-term cesarean deliveries.
Utrasound Findings
Her evaluation included the initial ultrasound (Figure 1). The
interpretation of this initial ultrasound is as follows: An enlarged
retroverted uterus measuring 6.5 x 6.3 x 7.5 cm with a 5-cm mass
consistent with a myoma. It was difficult to differentiate whether
this mass was intramural or submucosal. The endometrium was also
difficult to differentiate. There is a hyperechoic area, which is
posterior in location and may be confused with the endometrium.
The cervix measured 2.5 cm in length long (not shown) and the right
ovary was normal in appearance.
Next, a saline infusion sonohysterography (SIS) was performed.
The cervix was cleaned with betadine and then 10 cc of normal saline
was infused into the endometrial cavity through a Tampa catheter.
On initial evaluation, there is a retroverted uterus with a very
thin (less than 5 mm) scar from the cesarean delivery (Figure 2).
On the SIS, the image shown in Figure 3 was seen. It was clear
on the saline infusion sonohysterography that the mass was a submucosal
myoma and it was attached to the posterior wall of this retroverted
uterus. The endometrium was anterior to the myoma. The mass occupied
most of the posterior wall of the uterus. There was only about 0.8
cm from the posterior edge of the myoma to the serosal surface of
the uterine layer. The myoma was adherent to the anterior surface
at the white line (Figure 3).
Figure 4 has the green arrow pointing to the adhesion between
the leiomyoma and the anterior uterine endometrial surface. This
adhesion covers about half of the anterior endometrial cavity through
a thick, fixed synechiae (Figure 4.)
Figure 5 shows the fundal portion of the saline infusion sonohysterogram.
The endometrium is obviously very thin (approximately 1 mm) and
regular, consistent with an atrophic endometrium.
A Pipelle biopsy was done and the results were reported as atrophic
endometrium, negative for malignancy. Despite this finding, surgery
was recommended to treat her symptoms. She was no longer interested
in fertility and a hysterectomy was recommended. The patient was
taken to surgery and a total abdominal hysterectomy was performed.
Pathology report
Gross description: Within the uterine cavity was a 5-cm nodular
lesion with smooth yellow appearance. This lesion appears to arise
from below the endometrial surface and bulge out into endometrial
cavity. Endometrial lining ranges up to 3 mm.
Microscopic
Cystic endometrial atrophy. Polypoid mass compatible with endometrial
stromal sarcoma, low grade.
Later, a second-look laparotomy was performed and specimens for
cytology, peritoneal biopsies, and lymph nodes samples were sent
to pathology and were reported as negative for malignancy.
Figure 1 |
Figure 2
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Figure 3 |
Figure
4
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Figure
5 |
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Jorge Londono, MD, RDMS, is a resident at Hutzel
Hospital, Wayne State University School of Medicine, Detroit, Mich.
Elizabeth Puscheck, MD, MS, CCD is a reproductive endocrinologist
and infertility specialist who has developed expertise in gynecologic
ultrasound, bone densitometry, and medical education. She is currently
on faculty at Wayne State University Medical School, Detroit, Mich.
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