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弥漫性子宫内膜息肉一例

2020-07-24 宋彦芳 尚华 马毓梅 临床放射学杂志

患者女,23岁。已婚。3天前体检发现宫腔内病变后入院。患者平素月经欠规律,2~7/27~30天,量中,色暗红,无血块。妇科检查:子宫体前位,大小如孕4个月,质中,活动欠佳,表面光滑,无压痛,双附件区未

患者女,23岁。已婚。3天前体检发现宫腔内病变后入院。患者平素月经欠规律,2~7/27~30天,量中,色暗红,无血块。妇科检查:子宫体前位,大小如孕4个月,质中,活动欠佳,表面光滑,无压痛,双附件区未及明显异常。

实验室检查:人绒毛膜促性腺激素(HCG)19.8mIU/ml(正常0~20mIU/ml),CA125128.30U/ml(正常0~35U/ml)。1.5TMR检查:T2WI示宫腔内充满“蜂窝”样高信号小囊泡,其间伴多发条状低信号分隔及迂曲流空信号,子宫结合带未见显示,病变与肌层分界不清,局部似伸入肌层(图1、2);T1WI上“蜂窝”样小囊泡呈低信号,条状分隔呈等信号,亦可见流空信号(图3、4);动态增强扫描囊泡未见强化,分隔呈轻中度强化(图5)。MRI诊断:考虑妊娠相关滋养细胞肿瘤。


图1、2T2WI(图1:矢状位,图2:轴位)。宫腔内多发小囊泡样高信号(红箭),其间夹杂条状稍低信号(绿箭),及线样流空信号(黄箭);图3、4T1WI(图3:矢状位,图4:轴位)。囊泡结构呈低信号,囊泡间分隔呈等信号;图5动态增强扫描囊泡未见强化,分隔呈轻度强化

宫腔镜检查及刮宫术示:颈管未见异常,未见宫腔正常形态,宫腔内见“蜂窝”状结构及多个小空洞,可见粗大血管,各空洞间似有纤维组织相连,双侧输卵管开口未见。探宫腔深约10 cm,刮出组织约15g。病理诊断:子宫内膜息肉伴部分腺体单纯性增生(图6)。


图6 镜下示肿瘤由扩张的子宫内膜腺体、纤维化的内膜间质及厚壁血管构成(HE×40)

讨论

子宫内膜息肉(endometrial polyp,EP)由增生囊变的内膜腺体、增生纤维化的内膜间质和厚壁血管组成,是常见的子宫内膜良性病变,径线多小于2 cm,与肌层分界清晰,不引起临床症状,大于4 cm的EP少见,多发生于服用他莫昔芬的妇女,与肌层分界不清的EP则未见报道。本例EP的MRI表现与宫腔镜及显微镜下所见相吻合:多发小囊泡样长T1、长T2无强化信号提示“蜂窝”状结构及小空洞,由扩张囊变的内膜腺体组成;囊泡间条状、分支状的等T1、稍短T2轻中度强化信号提示空洞间的纤维组织,由增生并纤维化的内膜间质组成;囊泡间的流空信号提示粗大的血管。

众多学者认为代表内膜间质的核状或条状短T2信号和代表增生腺体的囊泡样长T2信号是EP最具特征的MRI表现,两者含量及其比例不定,本例的“蜂窝”样长T2信号及其间夹杂的短T2信号符合EP的特征,但是其最特殊之处在于病变与肌层分界不清,局部似伸入子宫肌层,此特点易于与恶性病变混淆,推测其原因是:EP内的血管来自肌层内的子宫动脉分支,子宫内膜腺体和间质通过来自肌层血管的联系到达了肌层,造成本例子宫肌层内亦出现囊泡样结构的表现。与肌层边界不清的弥漫性EPMRI表现主要应与妊娠相关滋养细胞疾病(gestational trophoblastic diseases,GTD)相鉴别。

患者月经不规律,不能排除有妊娠的可能,虽然低水平的HCG不支持常见GTD,但是GTD中的一种特殊类型——胎盘部位滋养细胞肿瘤(PSTT)不会引起HCG的升高。GTD由高度水肿的胎盘绒毛组成,呈多发薄壁水泡样结构,非侵袭性GTD局限于宫腔内,不侵犯肌层;侵袭性GTD依靠侵袭宿主血管获取营养,宫腔及肌层内均出现多发囊泡及明显强化的实体结构,病变和周围正常组织内常有明显的出血和坏死。多发囊泡样结构类似GTD,但常见GTD的囊泡数量更多、体积更大,并且本例不伴出血和坏死,强化程度亦不符合GTD明显不均匀强化的特征。

总之,弥漫性EP少见,但其仍具有EP较特征性的结构,即扩张囊变的内膜腺体和纤维化的内膜间质,当MRI显示病变内囊泡样长T2信号和条带状短T2信号时,不论其与肌层分界清晰与否,均应考虑到EP的可能。

原始出处:

宋彦芳,尚华,马毓梅.弥漫性子宫内膜息肉一例[J].临床放射学杂志,2019(03):446-447.

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    2022-08-12 慧子

    这个人跟我一样,只不过我40了,不孕没孩子

    0

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    2020-07-24 1240394fm61暂无昵称

    清宫清出组织15g,4个月大的子宫,后续治疗?

    0

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    2020-07-24 1240394fm61暂无昵称

    ʕ•̫͡•ོʔ•̫͡•ཻʕ•̫͡•ʔ•͓͡•ʔ

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