Undergoing infertility evaluation and was found to have a large cervical cystic mass on outside ultrasound.
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A CT of the abdomen and pelvis with IV contrast showed a 5.5 x 4.5 x 5.5 cm cystic cervical mass and otherwise normal pelvis.
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A pelvic MRI with and without gadolinium was obtained and shows a septated cystic cervical mass with the same measurements. This mass occupies and expands the entire cervix, extending from the endocervix to the exocervix and contains multiple simple appearing cysts. This mass has low T1 signal and high T2 signal. There are no definite soft tissue nodules; however, the cyst wall and/or septations had prominent enhancement. Adenoma malignum was originally suggested at an outside institution, based on these imaging characteristics. The patient underwent a cone biopsy of the cervix which revealed cystic cervicitis with no evidence of adenoma malignum or adenocarcinoma.
This was presumed to represent a minimal deviation tumour (adenoma malignum) on the initial ultrasound. Subsequently, a CT and MRI were obtained to further evaluate the cervical mass, which also suggested a diagnosis of a possible adenoma malignum.
Multilocular cystic lesions of the cervix range from benign to malignant, while their imaging characteristics often overlap. Benign cystic cervical lesions include Nabothian cysts, tunnel cluster, endocervical hyperplasia, and cystic cervicitis while malignant lesions include adenoma malignum (minimal deviation tumor of the cervix) and adenoncarcinoma. There is a range of clinical and imaging findings that may help to differentiate these lesions. Imaging differentiation is mainly based on the percentage of solid component and depth of stromal invasion 1,4 . Benign lesions typically do not invade the deep cervical stroma, tend to be smaller in size, have well defined margins and do not contain solid component1,4 .Malignant lesions more often will demonstrate solid, enhancing components. Differentiation of the lesions, both radiographically and histologically, can be very difficult due to overlapping features.
We present a brief description of common cystic cervical lesions with their clinical presentation and imaging findings.
Benign cystic lesions of the cervix
Cystic cervicitis is one of the most common gynecological diseases which may be caused by a number of microorganisms, similar to those that cause vaginitis. Symptoms may include pelvic pressure, pain, or yellow, jelly-like vaginal discharge. However, if the inflammatory process is confined to the cervix, the patient may not have symptoms.
On imaging, cystic cervicitis usually appears as round, multi-cystic lesions, located centrally within the cervix. High T2 signal is typically seen within this lesion. Due to hemorrhage and infected material, the signal on pre contrast T1 weighted images may range from low to high 1, 6 .There are usually no solid enhancing components.
Nabothian cysts are non neoplastic lesions of the cervix that are usually found incidentally on imaging. They are most commonly asymptomatic, but may rarely present with vaginal discharge. They represent retention cysts of the cervix that occur as a result of chronic inflammation and healing2,6.
Nabothian cysts appear as single or multiple cervical cysts and range from a few millimeters to up to 4 cm or more in size. They are hyperintense on T2 weighted imaging and may have variable T1 signal, ranging from isointensity to hypointensity. Nabothian cysts typically have no solid enhancing components.1,5
A tunnel cluster is a type of Nabothian cyst with complex cystic dilatation of the endocervical glands. These lesions are typically seen in multigravida women. Like Nabothian cysts, tunnel cluster cysts are hyperintense on T 2 weighted images and have low signal on T1 weighted images and show no enhancement1.
Endocervical hyperplasia is a benign condition which results in thickening of the endocervical mucosa. There may or may not be cystic changes associated with it, and there may be a solid component. Endocervical hyperplasia is commonly seen in women who use oral progesterone agents or are in their reproductive years. Like the other benign cystic cervical lesions, these lesions usually display high T2 signal intensity, isointense on T1, and have no solid, enhancing components1.
Malignant cystic lesions
Only about 5-10% of all cervical cancers are adenocarcinomas or one of its subtypes1 . Some well-differentiated adenocarcinomas will contain tubular glands that can mimic other cystic lesions of the cervix.4 Adenocarcinomas are typically solid, cystic, or mixed solid and cystic masses with high T2 signal, located in the endocervical canal. The endocervical epithelium if commonly preserved1.
Adenoma malignum is also known as minimal deviation tumor of the cervix. It is a rare variant of mucinous adenocarcinoma of the cervix1,2. The prevalence of adenoma malignum is approximately 3% of all cervical adenocarcinomas1,2. The most common presenting symptom is watery discharge, although it may also be associated with menometrorrhagia, vaginal bleeding, and abdominal swelling. Adenoma malignum can be associated with Peutz-Jeghers syndrome, as well as mucinous tumors of the ovary. Due to its ability to spread throughout the peritoneal cavity and its poor response to chemotherapy and radiation therapy, adenoma malignum has a poor prognosis.
On imaging, adenoma malignum is characterized by multiple cystic lesions within the cervix with solid, enhancing components. These lesions are usually hyperintense on T2 weighted images, isointense on T1 weighted images, and have solid enhancing components on post contrast enhanced images.
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- 3. Park SB, Lee JH, Lee YH et-al. Adenoma malignum of the uterine cervix: imaging features with clinicopathologic correlation. Acta Radiol. 2013;54 (1): 113-20. doi:10.1258/ar.2012.120059 - Pubmed citation
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- 5. Graef M, Karam R, Juhan V, et al. High signals in the uterine cervix on T2-weighted MRI sequenes. Eur Radiol. 2003; 13: 118 - 126.