495
김미성 외: 자궁내막종의 초음파 소견 외 자궁내막종에서 흔히 보일 수 있는 소견들을 알아보고 가 음성군과 가양성군을 분석함으로써 초음파 진단의 함정 및 감 별진단에 도움을 주는 소견을 알아 보았다. 대상과 방법 최근 4년 동안 자궁 부속기 종괴로 수술 전 골반 초음파 검 사를 시행하여 수술 전 초음파검사에서 자궁내막종으로 진단 되고 수술로 확진된(진양성군, 제1군) 85명 97예와, 초음파 검 사에서 자궁내막종으로 진단하였으나 술 후 다른 병명으로 확 인된(가양성군, 제2군) 10명 10예, 술 전 초음파상 다른 진단 이었으나 술 후 자궁내막종으로 진단된(가음성군, 제3군) 35 명 40예, 총 130명 환자의 147예 종괴를 대상으로 하였다. 초 음파검사에서 둘 이상의 감별 진단을 가진 경우는 우선 순위 의 감별 진단을 대상으로 하였다. 모든 환자는 초음파검사 시 행 4개월 이내에 종괴 제거술이나 일측 혹은 양측 난소 절제 술을 받았으며 평균 연령은 34세(19세-62세)였다. 사용된 초음파 기기는 ATL (Advanced Technology Laboratories, Bothell, WA) HDI 5000으로 3.5-5 MHz 볼록 형 탐촉자를 이용한 복식 초음파검사와 7-10 MHz 강 내 탐 촉자를 이용한 질식 초음파검사를 시행하였으며 32명의 환자 에서 복식 초음파검사만을, 68명에서는 질식 초음파검사만을, 그리고 30명에서는 질식 및 복식 초음파검사를 병행하였다. 초음파검사는 3명의 방사선과 전문의가 시행하였고 초음파 영상의 소견은 2명의 방사선과 의사의 합의 하에 후향적으로 분석하였다. 초음파검사에서 난소 종괴는 형태에 따라 단방형 Fig. 1. US classification according to morphology. Fig. 2. Endometrioma of the right ovary in a 30-year-old woman with typical features. Transvaignal ultrasonogram shows a thin-walled, unilocular cystic lesion with homogeneous fine low-level internal echoes. Fig. 3. Endometrioma in a 28-year-old woman. Transabdominal ultrasonogram shows a multiseptated cystic mass in the right ovary. Note variable internal echogenicity of different locules (arrows). 496
대한방사선의학회지 2003;49:495-501 (Fig. 1A, 2), 다발성 격벽형(Fig. 1B, 3), 다방형(Fig. 1C, 4), 고형 및 낭성형(Fig. 1D, 5), 혼합형(Fig. 1E, 6)으로 나누었 고 종괴 내부 에코는 균질한 미세 에코(Fig. 2, 7A), 무에코 (Fig. 7B), 미세 격벽성 에코(Fig. 7C), 복합 에코(Fig. 6, 7D) 로 나누었다. 그 외 종괴의 크기, 벽 두께와 함께 격벽, 벽 결 절, 벽에 국한된 고 에코성 병변, 고형성분 등의 유무를 분석 하였다. 벽에 국한된 고 에코 병변은 벽 결절과는 구별되는 것 으로, 벽 결절보다 더 에코가 높고 크기가 더 작은 경우로 정 의 하였다(7). 결 과 차지한 내부 에코는 균질한 미세에코(76예, 79%)였다(Table 2). 종괴의 크기는 10 cm 미만의 경우가 83예(86%)로 대부 분을 차지하였다. 종괴의 벽두께는 3 mm이하의 경우가 63예 (65%)였으며 종괴내에 격벽이 있는 경우는 31예였고, 벽 결 절의 경우는 11예(11%)가 관찰되었고, 벽에 국한된 고 에코 성 병변은16예(16%)였으며, 종괴 내 고형성분이 존재한 경우 는 8예(8%)였다(Table 3). 가양성군(group II)의 경우는 점액성 낭선종이 3예, 경계성 점액성 낭선종 암과 출혈성 낭종이 각각 2예였고 기능성 낭종, 자궁내막양성 난소암과 혈종이 각각 1예였다. 가음성군(group III)의 술 전 초음파 진단은 낭선종이 15예로 가장 많았으며 진양성군(제1군)에서 가장 많은 비율을 차지한 종괴의 형태 는 단방형이었고(63예, 65%) 그 다음으로 많은 형태는 다발 성 격벽형(19예, 20%)이었으며(Table 1), 가장 많은 비율을 Fig. 6. Endometrioma of the right ovary in a 25-year-old woman. Transvaginal ultrasonogram demonstrates partly cystic and partly solid mass with internal septations and complex internal echo. Fig. 4. Endometrioma of the left ovary in a 43-year-old woman. Transvaginal ultrasonogram shows a lobulated mass. The echogenicities of each locules are different. Fig. 5. Endometrioma of the left ovary in a 22-year-old woman. Longitudinal transabdominal ultrasonogram shows diffuse fine internal echoes and solid component in posterior wall (arrows). Fig. 7. US classification according to internal echo. 497
Table 1. Results According to Sonographic Morphologic Classifications in Each Groups Group I Group II Group III Type of Morphology (n=97) (n=10) (n=40) Unilocular 63 (65) 5 (50) 16 (40) Multiseptated 19 (20) 2 (20) 12 (30) Multilobulated 2 (2) 1 (10) 2 (5) Table 3. Results According to Other Sonographic Findings in Solid & Cystic 4 (4) 2 (20) 04 (10) Each Groups Mixed 9 (9) 06 (15) Sonographic Findings Group I Group II Group III Numbers in parentheses are percentages. (n=97) (n=10) (n=40) Table 2. Results According to Sonographic Internal Echo in Each Groups Type of Internal Echo Group I Group II Group III (n=97) (n=10) (n=40) Homogeneous Fine 76 (79) 9 (90) 22 (55) Anechoic 10 (10) 1 (10) 005 (12.5) Fine Septation 2 (2) 05 (12.5) Complex 9 (9) 08 (20) Numbers in parentheses are percentages. Size(cm) 10 83 (86) 8 (80) 35 (87.5) >10 14 (14) 2 (20) 05 (12.5) Wall Thickness(mm) 3 63 (65) 7 (70) 35 (87.5) >3 34 (35) 3 (30) 05 (12.5) Septation 31 (32) 2 (20) 19 (48)0. Wall Nodularity 11 (11) 2 (20) 05 (12.5) Echogenic Wall Foci 16 (16) 3 (30) 1 (3)0. Solid Area 8 (8) 2 (20) 4 (10). Numbers in parentheses are percentages. Fig. 8. Hemorrhagic cyst of the right ovary in a 36-year-old woman. Longitudinal transvaginal ultrasonogram shows diffuse fine internal echo and thin internal septation (arrow). It was misdiagnosed as endometrioma by reviewer. 498 Fig. 9. Endometrioma of the right ovary in a 49-year-old woman. Transvaginal ultrasonogram shows large echogenic areas (asterisk) in a part of cystic mass. It was misdiagnosed as teratoma. Note the focal echogenic focus in the wall of the cyst (arrow).
1. Woodward PJ, Sohaey R, Mezzetti TP Jr. Endometriosis: radiologic-pathologic correlation. Radiographics 2001;21:193-216 2. Umaria N, Olliff JF. Imaging features of pelvic endometriosis. Br J Radiol 2001;74:556-562 3. Missmer SA, Cramer DW. The epidemiology of endometriosis. Obstet Gynecol Clin North Am 2003;30:1-19 4. Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am 1997;24:235-258 499
5. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328: 1759-1769 6. Lu PY, Ory SJ. Endometriosis: current management. Mayo Clin Proc 1995;70:453-463 7. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas: diagnostic performance of US. Radiology 1999; 210:739-745 8. Volpi E, De Grandis T, Zuccaro G, La Vista A, Sismondi P. Role of transvaginal sonography in the detection of endometriomata. J Clin Ultrasound 1995;23:163-167 9. Guerriero S, Mais V, Ajossa S, Paoletti AM, Angiolucci M, Melis GB. Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma. Fertil Steril 1996;65:293-298 10. Alcazar JL, Laparte C, Jurado M, Lopez-Garcia G. The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil Steril 1997;67:487-491 11. Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB. The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril 1993;60:776-780 12. Fried AM, Rhodes RA, Morehouse IR. Endometrioma: analysis and sonographic classification of 51 documented cases. South Med J 1993;86:297-301 13.,,,.. 1997;16:355-361 14. Kupfer MC, Schwimer SR, Lebovic J. Transvaginal sonographic appearance of endometriomata: spectrum of findings. J Ultrasound Med 1992;11:129-133 15. Fleisher AC, Entman SS. Sonographic evaluation of pelvic masses with transabdominal and/or transvaginal sonography. In: Fleischer AC, ed. Sonography in obstetrics & gynecology: principles & practice. 5th ed. New York: Appleton & Lange, 1996;767-790 500
The Ultrasonographic Features of Endometriomas: Morphologic Analysis and Differential Diagnosis 1 Mi Sung Kim, M.D., Cheol Min Park, M.D. 2, Bo-hyun Kim, M.D. 3, Chan Sup Park, M.D., Soon Young Song, M.D., Eun Ja Lee, M.D., No Hyuck Park, M.D., Chan Kyo Kim, M.D. 3 1 Department of Diagnostic Radiology, College of Medicine, Kwandong University 2 Department of Diagnostic Radiology, College of Medicine, Korea Universty 3 Department of Radiology, College of Medicine, Sung Kyun Kwan University Purpose: To analyze the sonographic, morphologic, and internal echo patterns of endometriomas, and thus determine which ultrasonographic (US) findings assist diagnosis. Materials and Methods: One hundred and forty-seven eases of pathologically proven adnexal masses in 130 women were divided into three groups: group I, in which endometriomas were diagnosed at both preoperative US and surgery (true positive) (n=97); group II, in which endometriomas were misdiagnosed at preoperative US, and were confirmed after surgery to be other pathologic entities (false positive) (n=10); group III, in which other adnexal masses were misdiagnosed at preoperative US, but were proven after surgery to be endometriomas (false negative) (n=40). The US findings in these cases were retrospectively reviewed in terms of (a) morphologic type: unilocular, multiseptated, multilobulated, solid and cystic, or mixed; (b) internal echo pattern: homogeneous fine, anechoic, fine septation, or complex; (c) size; (d) wall thickness; (e) the presence or absence of septation; (f) wall nodularity; (g) echogenic wall foci; and (h) a solid area. Results: In group I, the most common morphological type was unilocular cyst (n=63; 65%). In lesions most commonly emitted homogeneous fine echoes (n=76; 78%). In this group, most masses (86%) were less than 10 cm in diameter and the wall thickness in 65% of cases was less than 3 mm. Additionally, internal septation, wall nodularity, focal echogenic wall foci, and a solid area were observed at US. Group II, cases were pathologically confirmed as mucinous cystadenoma (n=3), mucinous cystadenoma with borderline malignancy, hemorrhagic cyst, functional cyst, endometrioid carcinoma, and hematoma. In group III, cases were misdiagnosed as cystadenoma (n=15), hemorrhagic cyst, teratoma, ovarian cancer, functional cyst and ectopic pregnancy at preoperative US. There were no significant differences in size or wall thickness between groups II and III, and group I. At US, groups II and III also showed internal septation, wall nodularity, focal echogenic wall foci, and a solid area, all of which were also apparent in group I. Conclusion: The US findings of endometriomas vary: the most common is homogeneous fine internal echoes (79%), found in 85% of unilocular or multiseptated cysts. Their appearance may also be atypical, however: namely solid and cystic or mixed type, with diverse internal echogenicity, and such masses should be differentiated from other adnexal masses such as cystic neoplasm, teratoma, hemorrhagic cyst, functional cyst and ovarian cancer. Index words : Cyst Endometriosis Ovary Ovary, US Address reprint requests to : Mi Sung Kim, M.D., Department of Diagnostic Radiology, College of Medicine, Kwandong University, 697-24 Hwajung-dong, Dukyang-gu, Koyang, Kyunggi 412-270, Korea. Tel. 82-31-810-7164 Fax. 82-31-962-4902 E-mail: misung@kwandong.ac.kr 501