Magnetic Resonance Imaging Spectrum of Uterine Pathologies: A Comprehensive Imaging Evaluation

Uterine pathologies are among the most frequently encountered gynaecological disorders in women and encompass a wide spectrum of conditions that can significantly impact reproductive health and quality of life. These conditions range from common benign lesions such as leiomyomas, adenomyosis, and endometrial polyps to malignant neoplasms including endometrial and cervical carcinomas, as well as congenital anomalies like Müllerian duct anomalies. Imaging plays a central role in the evaluation of these entities, guiding diagnosis, management, and surgical planning.

Ultrasonography (USG) is widely accepted as the initial imaging modality for suspected uterine pathology due to its accessibility, cost-effectiveness, and ease of use. Transvaginal and transabdominal sonography can effectively detect many uterine abnormalities such as leiomyomas and polyps, and provide useful information about lesion size, number, and location. However, USG may be limited in complex or indeterminate cases, particularly when lesions are deep-seated or when there is a need for detailed tissue characterization.¹

Magnetic resonance imaging (MRI) has emerged as a superior problem-solving tool in such scenarios, owing to its excellent soft tissue contrast resolution, multiplanar imaging capability, and ability to differentiate between tissue types without ionizing radiation. MRI is particularly valuable when sonographic findings are equivocal, in preoperative evaluation, and for detailed mapping of complex uterine lesions. It is also the preferred modality for characterization and staging of malignancies such as endometrial and cervical carcinoma, including evaluation of myometrial invasion, cervical stromal involvement, and lymph node assessment. ²

Among benign uterine lesions, leiomyomas (fibroids) are the most prevalent, often appearing as well-circumscribed masses with low signal intensity on T2-weighted MRI and varied appearances depending on degeneration, location, and size. MRI outperforms ultrasound in accurately determining the number, size, and exact location of fibroids, which is crucial for surgical planning. ³

Similarly, adenomyosis — characterized by the presence of ectopic endometrial glands and stroma within the myometrium — demonstrates distinctive MRI features such as thickening of the junctional zone, which aid in differentiation from other myometrial pathologies. ⁴

Endometrial polyps and hyperplasia also benefit from MRI assessment, where signal characteristics and enhancement patterns help differentiate them from malignant endometrial lesions. MRI evaluation of Müllerian duct anomalies is considered ideal due to its ability to delineate complex uterine anatomy and guide reproductive and surgical management.⁵

Overall, while ultrasound remains the first-line imaging approach for uterine pathologies, MRI significantly enhances diagnostic confidence, improves lesion characterization, and informs appropriate management strategies, especially in cases with inconclusive ultrasonographic findings or suspected malignancies.⁶

IMAGING FEATURES OF UTERINE PATHOLOGIES ON MRI

Magnetic resonance imaging plays a pivotal role in the characterization of uterine pathologies owing to its excellent soft tissue contrast and multiplanar capability.⁷

Leiomyomas typically appear as well-defined myometrial masses that are isointense on T1-weighted images and characteristically hypointense on T2-weighted images, reflecting their fibrous smooth muscle content.^8,9 Degenerative changes may result in heterogeneous signal intensity and variable post-contrast enhancement.⁹

Adenomyosis is best demonstrated on MRI as diffuse or focal thickening of the junctional zone exceeding 12 mm, with ill-defined low signal intensity on T2-weighted images and punctate hyperintense foci representing ectopic endometrial glands.^10,11

Endometrial polyps appear as focal endometrial masses with intermediate signal intensity on T1-weighted images and heterogeneous T2 signal, often showing early and persistent enhancement following contrast administration.¹²

In endometrial carcinoma, MRI typically demonstrates a mass of intermediate to high signal intensity on T2-weighted images replacing the normal endometrium, with restricted diffusion and reduced enhancement compared to the myometrium, aiding in assessment of myometrial invasion.¹³

Cervical carcinoma appears as a lesion of intermediate to high T2 signal intensity disrupting the normal low-signal cervical stroma, and MRI is essential for accurate local staging and evaluation of parametrial invasion.¹⁴

MRI is also the imaging modality of choice for the evaluation of Müllerian duct anomalies, as it accurately delineates uterine morphology and endometrial cavity configuration.¹⁵

AIMS AND OBJECTIVES

1.      To assess the role of MRI in the evaluation of clinically suspected uterine pathologies.

2.      To categorize uterine lesions as benign or malignant based on MRI morphological features.

3.    To evaluate the role of MRI in lesion localization and assessment of disease extent.

This was a prospective, hospital-based observational study conducted in patients referred to the radiology department with clinically suspected uterine pathologies or uterine abnormalities detected on ultrasonography. A total of 45 patients were included in the study. MRI examinations were performed using a 1.5 Tesla Siemens Avanto scanner.

Figure 1. T2 weighted coronal image showing intramural fibroid on the right of endometrium in a 32-year-old woman.

Figure 2. T2 weighted sagittal image of a 65-year-old postmenopausal female showing intramural fibroid in posterior myometrium which is displacing the endometrium anteriorly

Figure 3. Sagittal MR T2WI of 55 years old woman showing subserosal fibroid arising from posterior myometrium of body of uterus.

Figure 4. Coronal MR T2WI of a 43-year-old woman showing submucosal fibroid within the endometrial cavity in body of uterus

Figure 5. T2 weighted sagittal image showing thickened junctional zone suggestive of Adenomyosis and intramural fibroid in anterior myometrium in 38 years old woman.

Figure 6. T2 weighted sagittal image of a 50-year-old postmenopausal female with globular uterus with thickened posterior myometrium suggestive of Adenomyosis and intramural fibroid

Figure 7. Sagittal MR T2WI showing thickened posterior myometrium with few T2 hyperintense cysts within it denoting ectopic endometrial glands. There is loss of endo-myometrial interface at places

Fig. 8A.                                                                             Fig. 8B.

Fig. 8C.                                                                           Fig. 8D.

Figure 8. Sagittal T2WI (8A) shows a hyperintense area in the endometrial canal showing heterogenous enhancement on post contrast scan (8B). The mass depicts restricted diffusion on DWI (8C) with corresponding low signal on ADC map (8D) - Biopsy was positive for Endometrial Adenocarcinoma.

Fig. 9A.                                                                             Fig. 9B

Fig.9C.                                                                             Fig.9D.

Figure 9. Sagittal T2WI (9A) shows an ill-defined hyperintense area in the cervical canal extending into body of uterus showing heterogenous enhancement on post contrast scan (9B). The mass depicts restricted diffusion on DWI (9C) & ADC (9D) - Biopsy was positive for Squamous cell carcinoma Cervix

Fig. 10A.                                                                            Fig. 10B.

Figure 10A & B. Coronal T2 weighted MR images show two uterine horns with two cervical canals, therefore the diagnosis of Bicornuate bicollis uterus was made.

Fig 11A and 11B

Figure 11A & B. Axial (Fig. 11A) and Coronal (Fig. 11B) images show separation of endometrial cavities in the fundal region with fundal dip < 1cm indicating Septate Uterus.

A total of 45 cases were studied. Among the 45 patients included in the study, benign uterine pathologies were identified in 31 patients (68%), malignant lesions in 10 patients (22%), and congenital anomalies in 4 patients (10%).

Of the malignant cases, cervical carcinoma was observed in 5 patients (50%), while endometrial carcinoma was identified in 5 patients (50%).

Among the benign uterine pathologies, leiomyomas (fibroids) constituted the majority, seen in 19 patients (61%). Adenomyosis was observed in 6 patients (19%), adenomyosis coexisting with fibroids in 3 patients (10%), and endometrial polyps in 3 patients (10%).

The tables illustrate the nature and distribution of uterine pathologies, categorizing lesions into benign, malignant, and congenital anomalies, along with their respective frequencies as observed on MRI.

Table 1 shows distribution of patients based on the nature of pathology.

Table 2 shows distribution of patients based on the malignant diseases.

Table 3 shows distribution of patients based on the benign diseases.

The present study classified uterine pathologies into benign, malignant, and congenital anomalies. MRI accurately delineated the number, size, and location of lesions and demonstrated high sensitivity and specificity in their diagnosis and localization. These findings underscore the importance of comprehensive knowledge of MRI appearances of uterine pathologies among radiologists to facilitate accurate diagnosis and guide appropriate clinical management.

1. Dueñas-González A, Zuna R, Lau S, et al. Role of magnetic resonance imaging in the evaluation of gynecologic disease. In: Hricak H, Lim TK, editors. Imaging of the Female Pelvis: A Multidisciplinary Approach. Springer; 2017. p. 45-60. doi:10.1007/978-3-319-75019-4_3.
2. Gupta P, Rustogi R, Singh AK, et al. Magnetic resonance imaging in the evaluation of endometrial and cervical carcinoma. Medical Journal of Diagnostic and Interventional Imaging. 2016;1(1):19-27.
3. Moyle P, Twomey M, Gruber GP. MR imaging of leiomyomas and other benign uterine conditions. Applied Radiology. 2018;47(2):24-38.
4. Champaneria R, Lalji S, Shah L, et al. Diagnostic accuracy of MRI in adenomyosis: a systematic review and meta-analysis. J Magn Reson Imaging. 2018;48(5):1315-1325.
5. Troiano RN, McCarthy SM. Müllerian duct anomalies: imaging and clinical issues. Radiology. 2004;233(1):19-34.
6. Dueñas-González A, Zuna R, Lau S, et al. Imaging evaluation of uterine pathology: role of ultrasound and MRI. In: Hricak H, Lim TK, editors. Imaging of the Female Pelvis: A Multidisciplinary Approach. Springer; 2017. p. 45-60. doi:10.1007/978-3-319-75019-4_3.
7. Hricak H, Gatsonis C, Chi DS, et al. Role of imaging in pretreatment evaluation of endometrial cancer: results of the ACRIN 6651–GOG 183 intergroup study. Radiology. 2007;245(2):431–439.
8. Arleo EK, Schwartz PE, Hui P, McCarthy S. Review of leiomyoma variants and their imaging characteristics. AJR Am J Roentgenol. 2015;205(6):1201–1212.
9. Nougaret S, Reinhold C, Alsharif SS, et al. Endometrial cancer: combined MR volumetry and diffusion-weighted imaging for assessment of myometrial and lymphovascular invasion. Radiology. 2015;276(3):797–808.
10. Champaneria R, Abedin P, Daniels J, et al. Diagnostic accuracy of MRI in adenomyosis: a systematic review and meta-analysis. J Magn Reson Imaging. 2010;31(4):1036–1042.
11. Agostinho L, Cruz R, Osório F, Alves J, Setúbal A. MRI for adenomyosis: a pictorial review. Insights Imaging. 2017;8(6):549–556.
12. Takeuchi M, Matsuzaki K, Nishitani H. Magnetic resonance manifestations of endometrial polyp, hyperplasia, and carcinoma. Eur Radiol. 2006;16(9):1987–1997.
13. Sala E, Rockall AG, Freeman SJ, Mitchell DG, Reinhold C. The role of dynamic contrast-enhanced and diffusion-weighted MRI in the female pelvis. Radiology. 2013;266(3):677–690.
14. Bhosale PR, Iyer RB, Devine CE. MRI of cervical cancer: staging and follow-up. AJR Am J Roentgenol. 2010;194(2):394–404.
15. Troiano RN, McCarthy SM. Müllerian duct anomalies: imaging and clinical issues. Radiology. 2004;233(1):19–34.