New cases of accessory and cavitated uterine masses (ACUM): a significant cause of severe dysmenorrhea and recurrent pelvic pain in young women

The Impact of Conservative Surgical Treatment of Adenomyosis on Fertility and Perinatal Outcomes

Adenomyosis is a benign condition commonly encountered in patients with infertility. While the definitive surgical management is hysterectomy, conservative surgical management is gaining attention in patients desiring future fertility. This review explores whether the surgical treatment of adenomyosis affects fertility outcomes for patients trying to conceive. The PubMed and Medline databases were searched using the keywords: "adenomyosis", "surgery", "radiofrequency", "infertility", "pregnancy", "sterility", "conception", "miscarriage", and "endometrial receptivity". Abstracts were screened, and relevant articles were selected for review. This review reveals that surgery appears to improve fertility outcomes with or without medical therapy; however, the risk of uterine rupture remains high and the best technique to reduce this risk is still not known. More studies are needed to formulate the best surgical approach for preserving fertility in treating adenomyosis and to establish standardized guidelines.

Cystic Adenomyoma in Pregnancy: A Case Report

Cystic adenomyomas (CA) are rare. They primarily affect adolescents and young women in their fertile years. Therefore, fertility and pregnancy outcome are of pivotal relevance in this patient collective. Apart from the guidelines of the European Society of Human Reproduction and Embryology (ESHRE) on the management of endometriosis in general, there are no specific treatment recommendations for CA and, as far as our research shows, no data illustrating the behavior of a CA over the course of pregnancy. Thus, we report the case of a 32-year-old 1-gravida, 1-para, preconceptionally diagnosed with a CA by ultrasound. After thoroughly discussing further treatment options, the decision was made to opt for a more conservative approach and not perform surgery before attempting a next pregnancy. The patient conceived spontaneously and sonographic monitoring of the CA throughout pregnancy showed complete regression of the cystic component during the second trimester. A healthy baby was delivered at term by an uncomplicated elective cesarean section. Following a review of the literature and taking into account the course of our case, we propose the feasibility of a conservative, non-surgical approach in women with a CA and the desire to conceive.

Endometriosis MR mimickers: T1-hyperintense lesions

Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.

Impact of an accessory cavitated uterine mass on fertility: case presentation and review of the literature

Objective

We report a case of an accessory cavitated uterine mass (ACUM) in a patient with infertility and chronic pelvic pain. In addition, we summarize the literature to better characterize ACUM diagnosis and management.

Design

A comprehensive literature search using the PubMed database was performed through April 2023. Historical ACUM diagnostic criteria were applied as inclusion criteria. Descriptive statistics and statistical evaluation were reported.

Results

A 31-year-old nulligravid woman presented with chronic pelvic pain, dysmenorrhea, primary infertility, and history of endometriosis. Three-dimensional ultrasonography identified an ACUM and laparoscopic excision provided complete resolution of symptoms. Subsequently, she conceived without assistance twice with uncomplicated vaginal deliveries. A total of 154 articles were identified, 34 papers met inclusion criteria and were individually reviewed, consisting of 70 reported cases. The most common presenting complaints were dysmenorrhea (81.4%), chronic pelvic/abdominal pain (54.1%), and refractory pain (34.3%). Diagnostic imaging included magnetic resonance imaging (62.9%) and transvaginal ultrasound (55.7%). Management included resection via laparoscopy (75.7%) or laparotomy (18.6%), or hysterectomy (5.7%). Of cases with reported outcomes, 90.7% had complete relief of symptoms after surgery.

Conclusion

ACUM often presents with dysmenorrhea, chronic pelvic pain, or abdominal pain and is identifiable on magnetic resonance imaging as a hyperenhancing mass. Three-dimensional transvaginal ultrasound can also accurately identify ACUM. A total of 90.7% of patients had complete relief of symptoms after intervention. It is important to identify ACUM early to relieve pain and reduce unnecessary interventions. Like our patient, other reports have demonstrated concomitant infertility and endometriosis. However, further investigation is needed to explore the association between infertility and ACUM.

Accessory and cavitated uterine masses: a case series and review of the literature

Objectives

The purpose of this study is to report nine patients of young women who underwent a surgical treatment of an accessory and cavitated uterine mass (ACUM) in our hospital between 2014 and 2022 and review all cases described in the literature.

Material and methods

The principal outcomes measured are the imaging techniques used to determine the diagnosis, the type of surgery used and the post-operative evolution of symptoms. We also report and analyse the 79 patients found in the literature since 1996 in addition to our 9 patients.

Results

Surgical excision is the only long-lasting treatment. Small invasive surgery with laparoscopic access is the gold standard and most widely used (83.0%). Some new therapeutic procedures have been recently described of which ethanol sclerotherapy seems very promising. Post-operatively, 54.5% of patients have a complete relief of symptoms. MRI is the best imaging technique to identify ACUM. Finally, we refine the description of this pathology and give a more precise definition of it.

Conclusion

Through our literature review and the analysis of our cases, we want to underline an important diagnostic criterion of this pathology: the fallopian tube on the homolateral side of the ACUM never communicates with the latter. It is a capital element for differential diagnosis.

Imaging features of accessory cavitated uterine mass (ACUM): a peculiar yet correctable cause of dysmenorrhea

Accessory cavitated uterine mass (ACUM) is a rare form of developmental mullerian anomaly which causes chronic pelvic pain, dysmenorrhea and infertility in young females. It is a non-communicating, accessory cavity within an otherwise normal uterus, lined by functional endometrium and surrounded by myometrium-like smooth muscle cells which imparts it uterus-like appearance. USG and MRI are the imaging modalities which help in reaching the diagnosis. Knowledge of this entity and awareness of its imaging features can help diagnose this often underdiagnosed and surgically correctable cause of dysmenorrhea.

Robert's Uterus versus Juvenile Cystic Adenomyoma - Diagnostic and Therapeutic Challenges - Case Report and Review of Literature

This case report highlights the diagnostic dilemma and therapeutic challenges encountered while managing adolescent girls with progressive dysmenorrhoea and management of Robert's uterus. Two girls aged 20 years and 13 years presented with severe progressive dysmenorrhoea. In the first case, laparoscopy revealed juvenile cystic adenomyoma (JCA) of 3 cm × 3 cm on the left side anteroinferior to the round ligament. Laparoscopic resection of the lesion was done, and histopathology revealed features of adenomyosis. In the second case, there was a globular enlargement of the right half of the uterine body with round ligament and adnexa attached to the lesion (Robert's uterus). In view of severe symptoms, complete resection of the lesion and partial resection of hemi-uterus was done, followed by myometrial defect closure. Both cases were initially diagnosed as JCA, and the final diagnosis was made on laparoscopy. Both girls had complete symptomatic relief from the next menstrual cycle and have been under follow-up for 24 months and 18 months, respectively. Due to the rarity of conditions, Robert's uterus and JCA are usually misdiagnosed with each other or with other Mullerian anomalies such as a non-communicating unicornuate uterus. Radiologists and clinicians should be aware of these different pathologies causing similar symptoms. Understanding the pathology, early diagnosis, timely referral and correct surgical procedure are emphasised to improve reproductive outcomes.

Forty-two normomenstruating adolescents with Müllerian obstructive anomalies: Presentation, pitfalls in the dagnosis and surgical management

INTRODUCTION

We analyzed the frequency, presentation and pitfalls in the diagnosis and surgical management of a large group of normomenstruating adolescents with obstructive reproductive tract anomalies.

MATERIAL AND METHODS

Retrospective analysis of prospectively collected data. Of the 143 outpatients referred for severe dysmenorrhea and persistent pelvic pain, 42 (29.3%) young women with obstructive Müllerian anomalies and regular menstrual flow were identified. These patients were divided into four groups: (1) patients with duplicate uterine cavities, obstructed hemivagina and ipsilateral renal agenesis (n = 34); (2) patients with unicornuate uterus and noncommunicating cavitated rudimentary horn (n = 5); (3) patients with accessory cavitated uterine mass (n = 2); (4) patients with partially obstructed transverse vaginal septum (n = 1). All 42 patients were conservatively treated via laparoscopy and 35/42 patients had also vaginal surgery.

RESULTS

Of the four groups, patients in groups 2 and 3 (n = 7) were conservatively managed by laparoscopy alone; for patients in groups 1 and 4 (n = 35), laparoscopy and the vaginal approach were used. Patients of group 1 were treated by resecting the obstructed vaginal septum with drainage of retained collections. In patients in group 2, surgery consisted of the removal of the rudimentary horn. Patients of group 3 were treated by the removal of myometrial neoformations. In the patient in group 4, treatment consisted of removal of the septum. All surgical procedures were successful and no major complications were recorded. Follow-up reports highlighted the disappearance of obstruction and clear improvement in pain symptoms.

CONCLUSIONS

Unilateral obstructive anomalies of the female genital tract are difficult to identify. Early diagnosis allows the preservation of reproductive activity and avoids potential complications.

MRI and Adenomyosis: What Can Radiologists Evaluate?

Uterine adenomyosis is a common benign condition defined by the presence of heterotopic endometrial glands and stroma within the myometrium. Adenomyosis is often related to infertility and other adverse pregnancy outcomes. Modern imaging techniques allow the non-invasive diagnosis of adenomyosis and, in this framework, Magnetic Resonance Imaging (MRI) has assumed a central role due to its high diagnostic accuracy in the detection of adenomyosis. Currently, there is still a lack of international consensus on adenomyosis diagnostic criteria and classification, despite the fact that an agreed reporting system would promote treatment outcomes and research. This review aims to emphasize the important contribution of MRI to the diagnosis of adenomyosis and to highlight how, thanks to the great tissue differentiation provided by MRI, it is possible to identify the main direct (cystic component) and indirect (junctional zone features) signs of adenomyosis and to distinguish its various subtypes according to different MRI-based classifications. We also explored the main MRI criteria to identify the most common pitfalls and differential diagnoses of adenomyosis, whose features should be considered to avoid misdiagnosis.

Imaging Manifestations of Accessory Cavitated Uterine Mass-A Rare Mullerian Anomaly

Context  Accessory cavitated uterine mass (ACUM) is an uncommon and under-recognized entity with distinct imaging characteristics and causing significant patient distress. Differentiating it from its other clinical and radiological differentials is therefore extremely important and prevents delay in surgical management which is the treatment of choice.

Aims  The aim of the study is to describe the MRI appearance of the surgically and pathologically proven ACUM cases from our institution in the last 2 years.

Settings and Design  This is a retrospective study in a tertiary care hospital in South India.

Methods and Material  We reviewed the clinical presentations and imaging findings of seven surgically proven cases of ACUM qualifying the proposed diagnostic criteria.

Results  All patients presented with chronic pelvic pain, dysmenorrhea, and prolonged post-menstrual pain. MRI in all seven cases showed an intramural, noncommunicating, and cavitating lesion near the uterine cornua with internal contents similar to that of endometrioma. Although the cavity was lined by endometrium in all the cases (proven in pathology), it was well appreciable on MRI in only five cases. The rest of the uterine myometrium and main endometrial cavity were normal with no features of adenomyosis.

Conclusion  MRI is a reliable diagnostic tool for accurate diagnosis of ACUM, and more importantly, in distinguishing it from other causes of chronic pelvic pain like adenomyosis and endometriosis and other imaging differentials like adenomyoma, noncommunicating uterine horn, and degenerating leiomyoma.

Diagnosis and laparoscopic excision of accessory cavitated uterine mass in a young woman: A case report

BACKGROUND

Accessory and cavitated uterine mass (ACUM) is an uncommon form of connate Müllerian anomaly seen in young and nulliparous women, which presents as chronic periodic pelvic pain and severe dysmenorrhea. The entity is often underdiagnosed due to a broad differential diagnosis, including rudimentary uterine horn, true cavitated adenomyosis and degenerating fibroids.

CASE SUMMARY

A 22-year-old woman who presented with severe dysmenorrhea and was initially misdiagnosed with cystic adenomyosis. Gynecological examination and ultrasonography were performed. The patient underwent laparoscopic excision of the mass and histopathological examination confirmed the diagnosis. Postoperatively, the patient did well, with no further dysmenorrhea.

CONCLUSION

ACUM is difficult to diagnose. A correct diagnosis can be made only after excision and histopathological evaluation. Surgical excision is necessary and can be carried out by laparoscopy.

Report of two cases of Accessory Cavitated Uterine Mass (ACUM): Diagnostic challenge for MRI

Cystic adenomyosis is an unusual form of adenomyosis, characterized by a well-circumscribed cavitated endometrial gland and stroma, ≥ 1 cm in diameter, located within the myometrium. Few cases have been reported in the gynecological literature, with confusing naming such as: juvenile cystic adenomyosis, cystic myometrial lesions, cystic adenomyoma or juvenile adenomyotic cysts. The current preferred terminology is accessory cavitated uterine mass /or malformation (ACUM). We report here the cases of two 17 and 18 -year-old nulliparous women, who complained of severe dysmenorrhea early after the onset of menarche, with none or partial efficiency of medical treatment. MRI findings, with a follow-up in one case and surgical treatment in both cases, are described with an emphasis on physiopathology. The typical MR appearance is a large well-circumscribed round mass within the external myometrium, composed by an inner cystic hemorrhagic layer surrounded by a thick fibrous crown. The first-line treatment is laparoscopic surgery with mass resection. This typical MRI pattern must be a part of the knowledge of the radiologists.

Unicornuate uterus with a functional non-communicating horn in adolescent

Common causes of pelvic pain are primary dysmenorrhoea, Müllerian duct anomalies, outflow obstruction, leiomyoma, endometriosis and adenomyosis. Unicornuate uterus with a rudimentary horn is a rare congenital malformation of the female genital tract, asymptomatic because of lack of functional endometrium. This study presents a rare case of a non-communicating functional rudimentary horn. A 16-year-old unmarried Yemeni female adolescent with a history of irregular painful menstrual period visited Obstetrics and Gynaecology outpatient clinic. Pelvic ultrasound was conducted showing an asymmetrical uterine configuration with the non-communicating rudimentary horn on the right side. Laparoscopic excision of the horn was planned for the patient. Non-communicating rudimentary horn with functional endometrium should be considered as a differential diagnosis in the female adolescent with obstructive uterine symptoms. Early diagnosis is crucial. Using the laparoscopic approach, an expert surgeon prefers definitive management to excise the rudimentary horn.

Imaging in gynecological disease (21): clinical and ultrasound characteristics of accessory cavitated uterine malformations

OBJECTIVE

To describe the clinical and ultrasound characteristics of accessory cavitated uterine malformations (ACUMs).

METHODS

This was a single-center observational study of consecutive patients diagnosed with an ACUM, who had undergone an ultrasound examination by an experienced ultrasound examiner between January 2013 and May 2019, identified retrospectively from medical records. ACUM was diagnosed when a cavitated lesion with a myometrial mantle and echogenic contents was seen within the anterolateral wall of the myometrium beneath the insertion of the round ligament. In all women, presenting symptoms and clinical history were recorded along with detailed descriptions of the lesions and any concomitant pelvic abnormalities.

RESULTS

Twenty patients diagnosed with an ACUM were identified. Median age was 29.2 (interquartile range, 25.0-35.8) years. None of the women was premenarchal or postmenopausal. All of the women reported painful periods or pelvic pain and none of them reported subfertility. Twelve of the ACUMs were in the right anterolateral myometrium and eight were in the left anterolateral myometrium. Both a myometrial mantle and a fluid-filled cavity were considered to be defining features on ultrasound. The fluid contained within the cavity was either echogenic with a ground-glass appearance or hyperechoic. All of the lesions were spherical in shape. The Doppler flow seen in the outer rim was not markedly different from that of the surrounding myometrium, and the content of the cavity was avascular on Doppler examination. The mean outer cavity diameter of the ACUMs was 22.8 (95% CI, 20.9-24.8) mm and the mean internal cavity diameter was 14.1 (95% CI, 12.2-16.1) mm. Four women opted for transvaginal ultrasound-guided alcohol sclerotherapy. Surgical excision was carried out in eight cases, and the diagnosis was confirmed on histopathological examination in all of them.

CONCLUSIONS

ACUMs are a uterine abnormality with a distinct ultrasound appearance, which are associated with dysmenorrhea and chronic pelvic pain. Knowledge of their typical appearance on ultrasound could facilitate early detection and treatment. There are several treatment options for ACUM, ranging from simple analgesia to complete excision. Further prospective and longitudinal studies are required to study the prevalence and natural history of this condition. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

A Case Report of an Accessory and Cavitated Uterine Mass Treated with Total Laparoscopic Hysterectomy

Accessory and Cavitated Uterine Mass (ACUM) is a condition defined by the presence of a non-communicating uterine mass close to the insertion of the round ligament. ACUM is a rare Müllerian anomaly found in young women and is diagnosed by the presents of a central cavity in the uterus, lined by functional endometrium, and surrounded by a ring of smooth muscle. In most cases, surgical treatment is recommended due to severe dysmenorrhea. Herein, we present a case of a woman with severe dysmenorrhea since adolescence which was not relieved with any form of hormonal treatment. ACUM was suspected preoperatively based on MRI findings, and she was treated with total laparoscopic hysterectomy. A uterine mass was found at the insertion of the right round ligament during surgery. All her symptoms improved after resection.

Pelvic Pain and Adnexal Mass: Be Aware of Accessory and Cavitated Uterine Mass

Accessory and cavitated uterine mass (ACUM) is a rare form of Mullerian anomaly that usually presents in young females with chronic cyclic pelvic pain and/or dysmenorrhea. This clinical entity is often underdiagnosed as it may be mistaken for other differential diagnoses, such as pedunculated myoma or adnexal lesions. Imaging modalities, including ultrasonography and magnetic resonance imaging (MRI), accompanied with relevant and suspicious clinical findings are important tools in making acorrect diagnosis. To date, surgical excision of the mass remains the mainstay of treatment,which provides significant symptom relief. In this study, we present a female adolescent with chronic pelvic pain since menarche who underwent laparotomy with the presumed diagnosis of a left-sided ovarian mass. Retrospective evaluation of pelvic MR images demonstrated that the lesion was in fact an ACUM, which was further confirmed by histopathological examination.

Adenomyotic cyst mimicking a congenital Müllerian anomaly: Diagnosis and treatment with laparoscopy

A 28-year-old woman presented with a 1-year history of severe progressive dysmenorrhea following suction evacuation and tubal ligation. Sonography showed a bicornuate uterus with hematometra in the left horn. Hysteroscopy ruled out a diagnosis of a congenital Müllerian anomaly, as both ostia appeared normal. Under laparoscopy, a mass was seen on the left fundal region near the insertion of the round ligament, and needle aspiration of a chocolate-colored fluid confirmed the diagnosis of an adenomyotic cyst. The cyst was excised. The patient recovered well and has been symptom-free since surgery. Adenomyotic cyst is a rare entity in young women and must be differentiated from obstructive Müllerian anomaly. Laparoscopy is the preferred minimally invasive modality for managing this rare disorder.

The first ethanol sclerotherapy of an accessory cavitated uterine mass

Accessory cavitated uterine mass (ACUM) is a very rare, underdiagnosed pathology. It is treated with radical surgery, which results in uterine scarring. Here, we describe the first case of ethanol sclerotherapy of an ACUM, modeled on the treatment of recurring endometrioma. Ethanol sclerotherapy avoids uterine scarring and the secondary risk of uterine rupture and enables the rapid achievement of pregnancy.

Identification of Juvenile Cystic Adenomyoma Using High-Resolution Imaging

BACKGROUND

Juvenile cystic adenomyoma is a rare condition that is often misdiagnosed as a noncommunicating uterine horn or adnexal mass during adolescence.

CASES

We describe two patients who presented with dysmenorrhea unresponsive to standard management with oral contraceptives. Both patients were initially misdiagnosed as having endometriotic cysts. Juvenile cystic adenomyoma was suspected on standard pelvic ultrasound scan and subsequent high-resolution three-dimensional ultrasonography. The diagnosis was subsequently confirmed and the lesions successfully treated laparoscopically.

CONCLUSION

Gynecologists should be aware of the possibility of juvenile cystic adenomyoma in adolescents with dysmenorrhea refractory to medical management. Three-dimensional ultrasonography may provide the resolution necessary to distinguish this rare condition.

Decidualized juvenile cystic adenomyoma mimicking a cornual pregnancy

OBJECTIVE

To demonstrate the laparoscopic excision technique of a juvenile cystic adenomyoma and show how the decidualization of ectopic endometrial tissue can lead to the misdiagnosis of a focus of ectopic pregnancy.

DESIGN

Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3).

SETTING

Teaching and research hospital.

PATIENT(S)

A 27-year-old gravida 2 parity 1 patient with one previous caesarean delivery presented to the emergency department with symptoms of pelvic pain and delayed menses. Her beta-human chorionic gonadotropin level was 2,161 mIU/mL. On transvaginal ultrasonography the uterine cavity appeared empty without any signs of a gestational sac, and a 42×45 mm heterogeneous mass was observed on the right cornual area. An 18×21 mm cystic area was observed within the mass. A diagnosis of cornual pregnancy was made and two doses of systemic methotrexate treatment were administered. On the 12th day following medical treatment, the patient reported increasing abdominal pain and free fluid was observed in the pouch of Douglas on ultrasonography. The decision to perform laparoscopic cornual excision was made.

MAIN OUTCOMES AND MEASURE(S)

On laparoscopic exploration a tubal ectopic pregnancy was observed within the left fallopian tube. The presence of two simultaneous ectopic pregnancies, located in the left fallopian tube and the right cornual area, was suspected. However, upon careful inspection, the right fallopian tube appeared normal and the mass initially thought to be a right cornual pregnancy appeared more like a degenerated fibroid. A left salpingectomy was performed and the excision of the mass in the right cornual area was planned. An incision was made over the mass and the cystic inner area containing chocolate-brown colored fluid was drained. As there was no pseudo capsule surrounding the mass, the diagnosis of focal adenomyosis instead of degenerated fibroid was made. No endometriotic foci were observed within the pelvis. Different from the enucleation of a fibroid, the mass was dissected from the middle into two halves until healthy myometrium was reached on the floor of the mass. The two halves of the mass were resected totally by dissecting the adenomyotic tissue from the myometrium starting from the caudal end towards the cranial end. The first layer of the remaining myometrial defect was sutured extracorporeally with No.1 polyglactan sutures. The second and third layers were sutured intracorporeally with V-loc sutures. The resected left fallopian tube containing the ectopic pregnancy and the adenomyotic mass were externalized through a posterior colpotomy incision.

RESULT(S)

The patient was discharged 24 hours postoperatively without any complications. A diagnosis of juvenile cystic adenoma was made upon histopathological examination. The patient reported subsiding of her dysmenorrhea on the postoperative third month.

CONCLUSION(S)

Juvenile cystic adenomyosis (JCA), is a rare form of focal adenomyosis which is usually located in close proximity to the uterine insertion of the round ligament, contains a cystic inner area larger than 1 cm and is encountered before the age of 30 years. Some authors reported JCA to be an accessory and cavitated uterine mass (ACUM) anomaly developing as a result of gubernaculum dysfunction. The only difference between the two conditions is reported to be the presence of a denser area of adenomyosis surrounding the cystic area lined with endometrium in JCA than in ACUM. This case has shown that decidual changes observed in ectopic endometrial tissue within an adenomyotic area may be misdiagnosed as a focus of ectopic pregnancy. Atypical endometriomas demonstrating decidual changes may also be misdiagnosed as ovarian malignancies. In non-emergency situations, waiting for the decidualization effect of ectopic endometrium to subside can help in the definitive diagnosis of such cases. Our technique for JCA excision is different from enucleation of a fibroid and may aid in the total resection and dissection of the adenomyotic tissue from healthy myometrium.

Laparoscopic treatment of a large cystic adenomyosis of the uterus: A case report

•

Cystic adenomyosis is rarely reported in the medical literature.

•

It is easy for clinicians to misdiagnose or miss the diagnosis because of its low incidence, rare clinical and atypical clinical features.

•

In case of large cystic adenomyoma, the surgeon can diagnose and treate the patient with laparoscopic.

Introduction

We describe a patient with a large cystic adenomyosis of the uterus who was treated by a laparoscopic approach.

Case presentation

A 38-year-old woman presented with dysmenorrhoea for 4 months. A 104 mm × 55 mm × 60 mm cystic mass was detected on the right side of the posterior wall of the uterus by ultrasound. Laparoscopy was performed, during which a bumpy mass was discovered protruding from the surface of the uterine myometrium. Both ovaries were normal. When the wall of the cystic mass was opened, chocolate-colored fluid was visible. The cyst was completely removed, and postoperative histopathology confirmed a cystic adenomyosis. One month later, the uterus was found to be normal on ultrasound.

Discussion

Endometriosis is a common disease in women and is divided into ovarian endometrioid cysts, superficial endometriosis, deep infiltrating endometriosis and other special types according to pathological characteristics. As a special type of endometriosis, the incidence of cystic adenomyosis is low, and its specific incidence is unknown. Cystic adenomyosis is clinically characterized by the appearance of one or more cystic cavities between the walls of the uterine muscles.

Conclusion

Laparoscopic surgery is an effective method for the diagnosis and treatment of large cystic masses in the uterine myometrium.

Diagnosis and laparoscopic excision of accessory cavitated uterine mass in young women: Two case reports

Introduction

An accessory cavitated uterine mass (ACUM) is a rare congenital Mullerian anomaly where an accessory cavity with normal endometrial lining lies within a normally functioning uterus. It is common among young and nulliparous women presenting with severe dysmenorrhea and infertility.

Presentation of the Cases

We present two cases of ACUM. The first case was a 22-year-old woman who presented with severe dysmenorrhea and was initially misdiagnosed with non-communicating rudimentary horn The second case was a 36-year-old woman who presented with primary infertility and dysmenorrhea. Gynecological examination and ultrasound scanning were done for both patients. Subsequently, laparoscopic excision of the ACUM was performed on both patients. Histopathological examination confirmed the diagnosis. Postoperatively, both patients did well, with no further dysmenorrhea. The second patient conceived spontaneously at the first attempt and at the time of writing was 33 weeks pregnant without any maternal or fetal problems.

Conclusion

The diagnosis of ACUM is often confused with non-communicating rudimentary uterine horn, true cavitated adenomyosis and degenerating fibroids. It is important to understand and distinguish ACUM. A thorough history, detailed gynecological examination and correct radiological modalities are critical to a proper diagnosis so that the correct surgery can be performed, especially when fertility is desired.

•

Accessory cavitated uterine mass is rare congenital Mullerian anomaly.

•

It happens among young, nulliparous women presenting with dysmenorrhea and infertility.

•

It is a diagnostic challenge and often confused with other differential diagnosis.

•

A thorough history, detailed and proper examination and imaging are mandatory.

•

Laparoscopic excision is crucial to relieve symptoms and improve reproduction.

Juvenile cystic adenomyosis: A case report and review of the literature

This report describes a case of a uterine cystic myometrial lesion in a 16-year-old adolescent girl presenting with pelvic pain and severe progressively worsening dysmenorrhoea. Patient's symptoms, ultrasound and MRI were suggestive of juvenile cystic adenomyosis (JCA). Medical treatment and alcohol sclerotherapy had a moderate and transient effect. The symptoms rapidly recurred, and the lesion was successfully excised via laparoscopic surgery. The treatment of JCA depends on patient's age, the symptoms' severity and the cyst location. Although rare, juvenile cystic adenomyosis should be considered in young women with severe dysmenorrhoea.

Accessory cavitated uterine mass: MRI features and surgical correlations of a rare but under-recognised entity

OBJECTIVES

To describe MRI features of accessory cavitated uterine mass (ACUM) with surgical correlations.

METHODS

Eleven young women with an ACUM at pathology underwent preoperative pelvic MRI. Two experienced radiologists retrospectively analysed MR images in consensus to determine the lesion location within the uterus, its size, morphology (shape and boundaries), and structure reporting the signal and enhancement of its different parts compared to myometrium. The presence of an associated urogenital malformation or other gynaecological anomaly was reported. MRI features were correlated with surgical findings.

RESULTS

All 11 lesions were well correlated with surgical findings, lateralised (seven were left-sided), and located under the horn and the round ligament insertion. Nine were located within the external myometrium, bulging into the broad ligament. Two were extrauterine, entirely located within the broad ligament. On MRI, the mean size was 28 mm (range 17-60 mm). Nine lesions were round-shaped, two were oval; all had regular boundaries. At surgery, the ACUM were not encapsulated but were possible to enucleate. On MRI, all lesions were well defined and showed a central haemorrhagic cavity surrounded by a regular ring (mean thickness, 5 mm) which had the same signal compared to the junctional zone. ACUM was isolated in all women, without urogenital malformation, adenomyosis or deep endometriosis.

CONCLUSIONS

On MRI, ACUM was an isolated round accessory cavitated functional non-communicating horn-like aspect in an otherwise normal uterus. MRI may facilitate timely diagnosis and appropriate curative fertility-sparing laparoscopic resection.

KEY POINTS

• ACUM is rare, with delayed diagnosis in young women with severe dysmenorrhoea. Pelvic MRI facilitates timely diagnosis and appropriate curative fertility-sparing laparoscopic resection. • Quasi-systematically located under the uterine round ligament insertion, ACUM may be intramyometrial and/or in the broad ligament. • On MRI ACUM resemble a non-communicating functional accessory horn within a normal uterus; the mass, most often round-shaped, had a central haemorrhagic cavity surrounded by a regular ring which had the same low signal compared to the uterine junctional zone.

MRI for adenomyosis: a pictorial review

Adenomyosis is defined as the presence of ectopic endometrial glands and stroma within the myometrium. It is a disease of the inner myometrium and results from infiltration of the basal endometrium into the underlying myometrium. Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) are the main radiologic tools for this condition. A thickness of the junctional zone of at least 12 mm is the most frequent MRI criterion in establishing the presence of adenomyosis. Adenomyosis can appear as a diffuse or focal form. Adenomyosis is often associated with hormone-dependent lesions such as leiomyoma, deep pelvic endometriosis and endometrial hyperplasia/polyps. Herein, we illustrate the MRI findings of adenomyosis and associated conditions, focusing on their imaging pitfalls.

TEACHING POINTS

• Adenomyosis is defined as the presence of ectopic endometrium within the myometrium. • MRI is an accurate tool for the diagnosis of adenomyosis and associated conditions. • Adenomyosis can be diffuse or focal. • The most established MRI finding is thickening of junctional zone exceeding 12 mm. • High-signal intensity myometrial foci on T2- or T1-weighted images are also characteristic.

Juvenile Cystic Adenomyoma Mimicking a Uterine Anomaly: a Report of Two Cases

Juvenile cystic adenomyoma is a rare form of adenomyosis and described as a new type of mullerian anomaly in literature. We are presenting two cases of juvenile cystic adenomyoma which were misdiagnosed preoperatively as unicornuate uterus with haematometra in a non-communicating rudimentary horn. The mainstay of treatment is complete resection of lesion.

Diagnostic imaging and cataloguing of female genital malformations

Abstract

To help physicians and radiologists in the diagnosis of female genito-urinary malformations, especially of complex cases, the embryology of the female genital tract, the basis for Müllerian development anomalies, the current classifications for such anomalies and the comparison for inclusion and cataloguing of female genital malformations are briefly reviewed. The use of the embryological system to catalogue female genito-urinary malformations may ultimately be more useful in correlations with clinical presentations and in helping with the appropriate diagnosis and treatment. Diagnostic imaging of the different genito-urinary anomalies are exposed, placing particular emphasis on the anomalies within group II of the embryological and clinical classification (distal mesonephric anomalies), all of them associated with unilateral renal agenesis or dysplasia. Similarly, emphasis is placed on cases of cervico-vaginal agenesis, cavitated noncommunicated uterine horns, and cloacal and urogenital sinus anomalies and malformative combinations, all of them complex malformations. Diagnostic imaging for all these anomalies is essential. The best imaging tools and when to evaluate for other anomalies are also analysed in this review.

Teaching points

• The appropriate cataloguing of female genital malformations is controversial.

• An embryological classification system suggests the best diagnosis and appropriate management.

• The anomalies most frequently diagnosed incorrectly are the distal mesonephric anomalies (DMAs).

• DMAs are associated with unilateral renal agenesis or renal dysplasia with ectopic ureter.

• We analyse other complex malformations. Diagnostic imaging for these anomalies is essential.

Uterine Cystic Adenomyosis: A Disease of Younger Women

PURPOSE OF REVIEW

We adopted a life-cycle approach to further our understanding of the natural history of the cystic forms of uterine adenomyosis first described by Cullen in 1908.

SEARCH STRATEGY

Scopus and PubMed were searched for all terms referring to cystic variant of adenomyosis or adenomyoma. References found in major publications were also included in the review.

MAIN FINDINGS

With the introduction of non-invasive imaging techniques, a number of cases of cystic variants of adenomyosis have been reported. Progressive, severe, medication-resistant dysmenorrhea is the main clinical feature but delay in diagnosis remains problematic. The life-cycle approach demonstrates that cystic adenomyosis is more relevant to adolescent and young adulthood. Congenital müllerian and wolffian cysts and the uterus-like masses are more frequent in women >30 years of age. The latter is frequently located outside the uterus and may represent a form of endometriosis rather than adenomyosis. Differential diagnosis includes ovarian cysts and congenital uterine anomalies. Menstruation suppression with continuous oral contraceptive pill with ultrasonographic monitoring of cyst regression may prove successful in the young woman, but surgical excision using minimally invasive endoscopy is highly effective. The various terms used in literature to describe these lesions cause considerable confusion. Here we propose a classification into 3 subtypes and standardized reporting criteria to enable comparison.

CONCLUSIONS

Endometrial lined myometrial cysts are almost specific to adolescent and young women. We propose a new classification system.

Laparoscopic treatment of a large uterine cystic adenomyosis in a young patient

We describe a rare case of a young woman with a large cystic adenomyotic lesion that was treated laparoscopically. The patient presented with severe dysmenorrhoea refractory to common analgaesics. She was initially diagnosed with right-sided ovarian endometrioma. MRI revealed a cystic lesion of 4 cm attached to the right uterine wall. Under laparoscopic vision, the uterine lesion was identified on the right portion of the uterine fundus close to the round ligament. Monopolar diathermy was used to dissect the lesion. When the incision reached the cystic cavity, dark-brown content flowed from the cyst. After resection was complete, the surgical wound was closed with two-layer interrupted sutures. The patient made a good recovery and was discharged the following day. Since patients with cystic adenomyosis are young, a minimally invasive procedure such as laparoscopic excision is considered optimal. The exact topography of the lesion is crucial in determining the site of the incision.

Accessory Cavitated Uterine Mass: A Rare Cause of Severe Dysmenorrhea in Young Women

We present 3 case reports of a rare Müllerian anomaly called accessory and cavitated uterine mass (ACUM), which is found in young women >30 years of age. They presented with severe dysmenorrhea refractory to medical treatment. The patients were 17, 19, and 25 years old. The patients had the classic Müllerian anomalies. The hysteroscopic examination was normal in all 3 cases, and laparoscopic examination showed a 3- to 4-cm ill-defined mass on the right half of the uterus, without any communication to the uterine cavity. The chocolate-colored material was drained in all of the cases, during excision of the mass. The myometrial defect was sutured laparoscopically. On histological examination, the mass was found to be a cystic cavity, lined by endometrial glands and stroma, which confirmed the diagnosis of ACUM.

Twin pregnancy in an accessory cavitated non-communicating uterus

•

Obtaining a detailed medical history is important, and we should not depend on examination tools when dealing with patients.

•

Unexplained findings should raise suspicions regarding other possible diagnoses, and the same non-conclusive procedures should not be repeated.

•

Following this advice can prevent unnecessary operative procedures and the complication of perforation of the uterus.

Background

A uterine malformation is a type of female genital malformation resulting from abnormal development of the Mullerian duct(s) during embryogenesis. The type and degree of uterine malformation depends on the level at which the fusion process of the two Mullerian ducts stops; thus, there is a wide variety of malformations. A newly described deformity called accessory cavitated uterine mass (ACUM) has been increasingly reported.

The case

We report this deformity (in a 20-year-old married woman) which appears to be an additional incompletely developed, cavitated and presumably non-communicating uterus in addition to a normally shaped and developed uterus. The former uterus became impregnated with twins that died in a missed abortion at 13 weeks of gestation. Before discovering the presence of the deformity, three attempts were made to evacuate the dead fetuses by cervical dilatation and curettage of the normal empty uterus. These attempts resulted in perforation of its fundus, a laparotomy was performed to repair the uterus. During the laparotomy, the pregnant accessory uterus was discovered and was excised with the dead twins.

Discussion

The lack of good medical history was a cause of the mismanagement of this patient. Most probably, the origin of ACUM is a growth from the right Mullerian duct. The ovum has entered the ACUM through the rudimentary tube and has been fertilized by a sperm travelled either through the normal vaginal and uterine cavities or through the lymphatics.

Conclusions

(1) A detailed case history is important. (2) An ACUM can be impregnated.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system

STUDY QUESTION

How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies?

SUMMARY ANSWER

The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system.

WHAT IS KNOWN ALREADY

Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment.

STUDY DESIGN, SIZE AND DURATION

The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies.

MAIN RESULTS AND THE ROLE OF CHANCE

The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system.

LIMITATIONS, REASONS FOR CAUTION

The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare.

WIDER IMPLICATIONS OF THE FINDINGS

The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research.

STUDY FUNDING/COMPETING INTERESTS

None.

Imaging diagnosis of accessory and cavitated uterine mass, a rare mullerian anomaly

Accessory and Cavitated Uterine Mass (ACUM) is a rare form of developmental Mullerian anomaly seen in young females, which presents as chronic recurrent pelvic pain and severe dysmenorrhea. It is an accessory cavity lying within an otherwise normal uterus. It is lined by functional endometrium and surrounded by myometrium-like smooth muscle cells; hence, it bears striking macroscopic and microscopic resemblance to the uterus. Hysterosalpingography (HSG), Ultrasonography (USG), and Magnetic Resonance Imaging (MRI) form the mainstay of diagnostic imaging. The entity is often under diagnosed; therefore, a high index of suspicion combined with HSG and MRI imaging can help in making an accurate diagnosis.