Kaori

Togashi,

Keiji

Yamashita,

Ikuo

Konishi,

#{149} Kazumasa

MD MD

MD

Nishimura,

#{149} Toshiya

Shibata,

#{149} Takahide

Mori,

Endometrial

made tense

ited

of endometrial

when

a cyst

on Ti-weighted

was

hypenintense

images

hypointense

sioms

(multiplicity)

the signal

was exhib-

on dithat signal

images.

regardless

intensity Surgery

of

on T2-weighted was

performed

in

293 patients, and confirmation was obtained in 354 lesions. MR imaging enabled accurate diagnosis of 77 of 86 endometrial cysts and exclusion of the diagnosis of endometrial cyst in 263 of 268 other gynecologic masses with or without internal hemorrhage. The overall diagnostic sensitivity, specificity, and accuracy were 90%, 98%, 96%, respectively. MR imaging seems to be an acceptable diagnostic test on which clinical decisions can be based

Index terms: Ovary, cysts, 852.1214 Radiology

in selecting

treatment.

Endometriosis, 852.3192 852.3117 #{149} Ovary, MR studies,

1991;

#{149} Junji

as

293

to hormonal

stimu-

hemorrhage and endometrial cysts (endometriomas) (2,3). When the suggestive clinical symptoms and pelvic signs of endometriosis are coupled with an enlarged ovary, the diagnosis of endometrial cyst is likely (2). However, carcinoma of the ovary can produce similar findings, and one cannot be certain that the adnexal masses are endometrial cysts rather than ovarian malignancies (2-4). While ultrasonography and computed tomography have played some role in the diagnosis of endometrial cyst, confident diffenemtiatiom of endometriab cysts from other admexal masses is difficult (5-9). In a previous report, we reviewed the appearance of endometrial cysts at magnetic resonance (MR) imaging and suggested the potential contribution of MR imaging in the diagnosis of this condition (10). However, 5everal reports have indicated that the MR imaging appearance of endometrial cyst is not definitive and can be seen with hemorrhagic masses as well, although MR imaging is probably more specific than other imaging techniques (11-15). The purpose of this

with internal to produce

study

was

to further

evaluate

the

potential of MR imaging in diagnosing endometrial cysts and in differentiating them from other gynecobogic

180:73-78

masses

with

(I. Konishi,

TM.),

Kyoto

University

School

of

Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto-shi, 606, Japan. Received May 30, 1990; revision requested July 17; revision received March 4, 1991; accepted March 11. Address reprint requests to K.T. C RSNA, 1991

MD MD

in a large

a clinically

series

MATERIALS A total

AND

adnexal

78 patients (with

more

than

patients

were

or without

6 months.

followed

up

medication)

There

were

for

no avail-

able data after the MR examination in three patients. Thus, 371 patients were available for inclusion in this study. MR imaging was performed with a 1.5-T superconducting magnet (Signa; GE Medical Systems, Milwaukee). Multisection spin-echo (SE) images with a short repeti-

lion time (TR) and short echo time (TE) (TR msec[FE msec = 500-600,20-25) and with a long TRITE (2,000/60-80) were acquired in the sagittat plane in all patients; axial images were obtained when needed.

The section 2.5-mm

thickness

intervals.

was 5 mm, with

Data

a 256 x 256 matrix,

were

collected

resulting

5- or with

in 0.6 x

0.6-mm formed

pixels. Signal averaging was pertwo or four times for Ti-weighted

images

and

two

times

for

T2-weighted

images.

MR images were read prospectively by one or two of the authors (K.T., K.N., I. Kimura), and official radiologic reports were tients

made with the knowledge that pahad a pelvic mass suggestive of an adnexat origin and with the knowledge of

brief clinical pitat

findings

order

We arrived trial

cyst

lowing

recorded

on the hos-

form.

at the diagnosis

when

the

criteria

lesion

of endome-

satisfied

developed

from

the fotpreviously

published data (10). We have attached importance to the presence of hyperintense signal (equal to or greater than the intensity

of fat)

on

“suggestive” cyst

that

Ti-weighted diagnosis

was

weighted

images

hyperintensity

images.

A

made

when

was

entirely

hyperintense

exhibited

(equal of urine)

sisted of multiple cysts on Ti-weighted plicity”) regardless

METHODS

of 374 consecutive

patients;

clinically

the intensity

of patients

suspected

Imaging’

on

a Ti-

homogeneous

to or greater than on T2-weighted im-

ages. A definitive diagnosis was made when a cyst that was entirely hypenintense on Ti-weighted images exhibited hypointense signal (usually mixed with hypenintense areas) on T2-weighted images (“shading”) or when the lesion con-

mass. I From the Departments of Radiology and Nuclear Medicine (K.T., K.N., I. Kimura, Y.T., KY., T.S., Y.N., J.K.) and Gynecology and Obstetrics

Tsuda, Konishi,

MR

growth of endometrial tissue the uterus (1). The most fresite of ectopic endometrial imis the ovaries, where the le-

respond

lation enlarge

on T2-weighted images (shading) or when the lesion consisted of multiple hyperintense cysts on Ti-weighted images

#{149} Yoshiaki

with

is characterized

NDOMETRIOSIS

outside quent plants

on Ti-weighted

exhibited

Nakano,

the

hypenintensity

images. A definitive made when a cyst

MD MD

Kimura,

Diagnosis

E

hyperin-

images

homogeneous

T2-weighted agnosis was

cyst

that was

#{149} Issyu

#{149} Yoshihisa

MD

Cysts:

The value of 1.5-T magnetic resonance (MR) imaging in diagnosing endometrial cysts and differentiating them from other gynecologic masses was prospectively evaluated in 374 female patients with clinically suspected adnexal masses. A suggestive diagnosis

MD MD

(aged

on T2-weighted

entirely hyperintense images (“multiof the signal intensity

images.

9-85 years; mean, 40.8 years) with a clinically suspected adnexat mass underwent MR imaging. underwent

cal follow-up.

Nineteen multiple

Surgery

of these studies

was

patients

during

performed

clini-

in

Abbreviations: SE time, TR = repetition

=

spin time.

echo,

TE

=

echo

73

la.

lb.

Figures prominent

1, 2. (1) Endometrial hyperintense signal

greater in intensity because multiplicity to the uterus (U).

With

the cyst

intensity

on

from

predominantly

with

a faint

pletety extreme than

have

area

signal. hyperintense

images

the usual

the

variable

may

signal

be

less

bright

signal

shading.

seen

attached

“Multiplicity”

importance

tensity on Ti-weighted hibiting signal intensity hematomas (intermediate weighted images) and mas

(hyperintensity

area

of hypointensity

ages)

(i6-20)

metrial

cysts

orrhagic

to

a distinct

central

on Ti-weighted

and

not

were

adnexat

im-

considered

endo-

diagnosed

as hem-

specific

signal

intensity

to be endometriat associated with

were

were

considered

in the group

and

reports

and

compared

for

surgical the

lesions

that

the MR

Surgery patients.

revealed Sixty-one

bilateral

adnexal

masses

or two

sions in an ovary. Of the 293 64 had a total of 86 endometrial

74

#{149} Radiology

a total

le-

patients, cysts

of 268 gymecobogic

in intensity

endometnial

both

another

adnexal

correctly

cyst. mass.

cysts,

diagnosed

with

than

fat on

misdiagnosed

with

as cystic

MR

with

on Ti-weighted tensity noted

functional

results) these

cyst

were

pro-

(false-negative

(Figs 5, 6). Although mine lesions satisfied

two of the criteria

diagnosis

hyperintense

on

both

(entirely Ti-

T2-

images),

emdometniab cause the suspected

cyst was not made belesions were huge and we that septations were (Fig

diagnosis

5). These

two

of

lesions

as cystic neoplasms with protein-rich fluid or with internal hemorrhage. In another case, two juxtaposed cysts, which proved an

endometrial

were

cystic

neoplasm

fluid

or internal

other

six lesions

to have

cyst

also with

and

a follic-

misdiagnosed

as

protein-rich

hemorrhage. were

internal

suspected

hemorrhage

of bevel effect”

of endometrial

made because intermediate on Ti-weighted nonmeoplastic

The

also

because

formation (21), but cyst

or the

was

not

the lesions exhibited to low signal intensity images (Fig 6). The nature of these six le-

sioms

was

suspected,

cause

five

lesions

however, consisted

beof multi-

small umibocular hematocrit effect. signal intensity

images

was

cyst

hyperim-

misdiagnosed

as other

adnexab

nine

false-negative

cases

were

of multiple cysts, their predominant signal intensity was intermediate to low on Ti-weighted images. Thirty-five endometrial cysts demonstrated both of the criteria for a definitive diagnosis-shading and multiplicity. cases

misdiagnosed

cyst,

and

masses (false-negative results). Two of these lesions had predominantly hypointense signal on both Ti- and T2weighted images. Shading was noticed in 55 endometrial cysts. (For the lesions consisting of multiple cysts, shading was considered to be present if one of those cysts demonstrated shading.) Multiplicity was noticed in 48 endometnial cysts. Although five of

the

weighted

present

the

and

The cyst shows image

similar to the intensity of fat, in 80 of the 86 emdometrial cysts. Six endometrial cysts exhibited predominantly bow signal intensity on Ti-weighted images, and these

tein-rich fluid or internal hemorrhage, five as cystic adnexal masses probably of monneoplastic mature with internal hemorrhage, and one as a hemorrhagic

Ti-weighted

The MR imaging diagnosis is definitive cysts (arrows) adhered to each other and

MR

imaging:

neoplasms

(b) SE 2,000/70.

the

77

imaging (true-positive results) (Figs 1-4). Ten diagnoses were suggestive (Fig 1) and 67 were definitive (Figs 2-4). Nine endometrial cysts were

were

(a) SE 600/20.

ple cysts and one showed a typical The predominant

an endometnial

86 endometriab

diagnosis

354 lesions in 293 patients had either

It is greater

than

had

of the presence the “hematocnit

RESULTS

239 had

and

to be

of endo-

had been clinically or radiologically pointed out. The surgeons knew imaging results before surgery.

and

cyst

ulan

metriat cysts. MR imaging records

were

implants incidentally other adnexat masses

not included

other

patients

for a suggestive

masses.

We also determined additional criteria to exclude neoplastic lesions. The diagnosis of endometnal cyst was not applied for huge lesions (eg, those protruding far above the promontorium) and for lesions with solid components or obvious septation. Tiny cysts that were hyperintense on both Ti- and T2-weighted images and located at the periphery of a mass of non-

is suggestive.

(2) Endometriat cyst in 31-year-old patient. The lesion consists of multiple hyperintense

three

to hyperin-

images, cysts extypical of acute intensity on Tisubacute hematowith

were

in

diagnosis

images.

Ten

were

2b.

MR imaging

T2-weighted

Of the

In cases with signal on

hyperintense

without

we

and

The

masses

to com-

means that the lesion consists of more than two hyperintense cysts adhering each other or neighboring structures. Since

Ti-

images,

hyperintense

hypointense shading,

lesions

can

T2-weighted

hypointense

Ti-weighted

both

patient.

than urine on the T2-weighted image. is seen. (a) SE 600/25. (b) SE 2,000170.

shading,

signal

2a.

in 46-year-old

cyst on

The

histologic

gymecobogic dometriab

were

as follows:

tumor tumor

of the

268

was

=

37),

malignant

epithelial

germ cell = 5), sarcoma (n = 3), metastasis (ii = ii), benign epithelial tumon (n = 44), benign germ cell tumor (ii = 80), gonadal stromal tumor (thecoma and fibroma) (ii = 5), nonmeoplastic cyst (n = 34), parovariam cyst (n = 8), tubal carcinoma (n = 5), pelvic inflammatory disease (n = 3), hydrosalpimx (n = 8), ectopic pregnancy (n = i), beiomyoma (n = i6), and miscellaneous (n = 8). Among these 268 lesions, the diagnosis of endometrial cyst

(n (n

diagnoses

masses other than encysts, seem in 239 patients,

correctly

malignant

excluded

with July

MR 1991

3a.

4a.

3b.

Figures 600/25.

3, 4. (3) Endometriat Q,) SE 2,000/70. One

cyst in 40-year-old of the cysts exhibits hyperintense cyst (arrowheads). (4) Endometrial and multiplicity. (a) SE 600/25. (b) SE 2,000/70.

weighted intense

images area,

(arrows).

as in the

case

However,

careful

of a large

5a.

observation

frequently

5b.

imaging in 263 (true-negative Among these 263 true-negative five unilocular cysts exhibited intensity

typical

of subacute

41-year-old

with

rhagic

adnexal

cysts

MR

were

imaging

masses

confirmed

results). cases, signal he-

as hemor-

(Fig 7). The to be hemor-

rhagic moid

functional cyst (n = 2), dercyst with internal hemorrhage (n = 1), chronic hematoma due to ectopic pregnancy (n = 1), and hemorrhagic necrosis of adnexal tumor ( n = 1). Five adnexal masses were misinterpretated as endometrial cysts at MR imaging (false-positive results) (Fig 8). The pathologic diagnosis for five filled

lesions were with chybous

mesentenic fluid, hemor-

rhagic corpus luteum oid cystadenofibroma

cyst, endometriarising within

Volume

1

180

#{149} Number

6a. patient.

The MR imaging

6b. diagnosis

was false-negative.

(a) SE 600/20.

(b) SE 2,000/70.

The le-

signal on both images. However, the diagnosis of endometriat cyst was not applied because of its huge (6) Endometrial cyst in 38-year-old patient. The MR imaging diagnosis was false-negative. (a) SE 600/25. multiple cysts with level formation (arrowheads in b). Nonneoplastic hemorrhagic mass was suspected, was not applied because of intermediate signal intensity on the Ti-weighted image.

matoma (hyperintensity with a distimct central area of hypointensity on Ti-weighted images) and were diagnosed

4b.

imaging diagnosis is definitive, as shading and multiplicity are noted. (a) SE the T2-weighted image, an inhomogeneous hypointense area is seen in a patient. The MR imaging diagnosis is definitive due to extreme shading shading may be of intermediate or even low signal intensity on T2reveals heterogeneity consisting of a hypointense area containing a hyper-

cyst.

Figures 5, 6. (5) Endometrial cyst in sion shows prominent hyperintense size and the suggestion of septation. (b) SE 2,000/60. The lesion consists of but the diagnosis of endometrial cyst

these cyst

patient. The MR faint shading. On cyst in 36-year-old Cysts with extensive

am endometrial

moma,

and

cyst,

dermoid

serous

cyst.

aging diagnosis for these suggestive of endometrial

cystade-

The

shading.

MR im-

lesions was cyst in

three

(mesenteric cyst, hemorrhagic luteum cyst, serous cystadenoma) (Fig 8) and definitive in two (endometrioid cystadenofibroma, denmoid cyst). The prominent hyperimtemsity on both Ti- and T2-weighted corpus

images

could

be easily

two of the three the reason for other suggestive emoma 3 cm in clear, as it was fluid (Fig 8). In two definitive

explained

in

suggestive cases, but hyperintensity in the case, a serous cystaddiameter, was not filled with clear yellow retrospect, one of the diagnoses was a cane-

less mistake involving images of poor quality; in this case a small denmoid cyst exhibiting chemical shift artifact was carelessly misinterpretated as an

endometrial

cyst

with

prominent

In the

other

false

definitive

case, endometrioid cystadenofibroma (no malignancy) was histologically diagnosed within an endometrial cyst 4 cm in diameter. The overall sensitivity, specificity, and accuracy of MR imaging in diagnosing

endometrial

cysts

and

separat-

ing them from other adnexal masses were 90%, 98%, and 96%, respectively. Among the 78 patients who were followed up clinically for more than 6 months with or without medication, the MR imaging diagnoses were endometrial cyst in 41 and other gynecobogic mass in 37. At the time of this report, none of the lesions presumed to be an endometrial cyst has demonstrated any signs of neoplasia such as tumor growth or positive tumor marker studies. Of the i9 patients who underwent multiple studies, mine were operated Radiology

#{149} 75

7a.

8a.

7b.

Figures

8b.

(7) Corpus luteum hematoma in 38-year-old patient. The MR imaging diagnosis was hemorrhagic adnexal mass (true-negative result). (a) SE 600/25. (b) SE 2,000/70. The lesion exhibits hyperintensity with a distinct central area of hypointensity on the Ti-weighted image and homogeneous hyperintensity on the T2-weighted image, a finding that is opposite that of shading. (8) Serous cystadenoma ifiled with clear yellow fluid in 35-year-old patient. The suggestive MR imaging diagnosis was endometrial cyst (false-positive result). (a) SE 600/25. (b) SE 2,000/60. Unilocular cyst has prominent hyperintense signal on both Ti- and T2-weighted images (arrow). There was no clear explana-

tion

7, 8.

for the signal

intensity

of the contents.

a.

b.

Figure

9.

(arrows).

Endometrial (c) SE 2,000/70

cyst in 31-year-old image obtained

patient. 6 months

on. Twelve lesions in these mime patients were considered endometrial cysts at MR imaging, and all were surgicabby confirmed. At follow-up examinatiom of four lesions, the size of the lesion was obviously decreased and the changes in the signal intensity were observed. These four lesions exhibited obvious shading on T2weighted images, although no change was observed on Ti-weighted images (Fig 9).

Endometrial tion cysts that

cysts are unique have morphologic

characteristics

and

from those We designed 76

#{149} Radiology

reten-

different

of other adnexal masses. the MR imaging criteria

(b) SE 2,000/70. is smaller, and

The cyst extensive

shows shading

for diagnosis of endometnial cyst with emphasis on findings that seem to represent these features: hyperimtense signal on Ti-weighted images, shading on T2-weighted images, and

multiplicity of hypenintense Even when very small, cysts

show

perforation extruded in the

a strong

cysts. endometrial

tendency

cyst

wall,

and

blood

of the defect

then

repeated

rupture

with

accu-

subse-

quent sealing off, and the multicentric tendency of endometrial implants, will naturally result in the unique finding

of multiple

each

other

tunes

(multiplicity).

cysts

adhered

or to neighboring The

ten-

both

images

toward perforation also exthe size of the endometnab cyst, is described as rarely larger

than an orange Endometriab

which readily of endometnial

blood

signal on (arrows).

and

on grapefruit cysts usually contents,

or tarry make cysts

(3). have

thick

aged

choco-

blood,

the surgeon (2,3). This

its characteristic

may explain the signal actenistics of endometnial

think aged

viscosity intensity charcysts-hy-

penintensity on Ti-weighted and hypointense shading weighted images. A previous report on that analyzed the signal

to

strucstrong

dency plains which

characteristic

toward

(2,3). Organization blood seals over the

prominent hyperintense has abruptly developed

late-colored

mulates anew within the cavity until perforation again takes place (2,3). This

DISCUSSION

contents

C.

(a) SE 600/25. later. The cyst

images on T2endometriosis intensity

of

endometniab foci described frequent signal intensity

a second pattern, that

of hypoimtensity

Ti-

on

both

and

T2-

July

1991

weighted predominant weighted

images (ii). We found that signal intensity on Tiimages was hyperintensity

(80 of 86 lesions) sity on both Tiages is frequently

descriptions may well explain why shading can be characteristically seen in endometrial cysts. MR imaging is known to enable reliable distinction between hemorrhagic and nonhemorrhagic adnexal

and that hypointenand T2-weighted imobserved in small

boculi situated at the periphery of the predominant cysts (Fig 3). Because an endometrial cyst is a chronic retention cyst that undergoes cyclic bleeding for many years, its predominant content is aged blood. Fresh blood resulting from rebleeding will be mixed with preexisting aged blood and will thus lose its typical signal chanacteristics

of acute

hematoma.

Rebleeding

resulting in the formation of new peripheral small loculi may retain the appearance of acute hematoma, that is, hypotensity

on

both

Ti-

and

T2-

weighted images. The blood elements in chronic stage hematoma are well known to exhibit hyperintense signal on both Ti- and T2-weighted images (16-20). On the other hand, the viscosity of a fluid and the protein concentratiom are known to influence the signal intensity of fluid (22-24). We believe that high viscosity of the contents

of the

lesion,

known

to be char-

acteristic of endometrial cysts, contributes to the mechanism of shading, the finding of a hypointense area on T2-weighted images within a cyst that is hyperintense ages. It has

certain

been

protein

significant

protein

on Ti-weighted reported that

concentration,

“cross-linking”

molecules,

macroscopically sistency (22,23).

imat a

there

is

which

is observed in contime is

not as sensitive as is T2 relaxation time, and as a result, at a certain protein concentration, there is an abrupt drop in the signal intensity on T2weighted images (22,23). Indeed, we observed

the

abrupt

development

of

shading with the shrinkage of endometrial cysts, which is associated with a decrease in free water content and an increase in protein concentration. Although we are uncertain whether the shading may be attributable to an extremely high concentration of methemogbobin or a high protein concentration, we believe that the thick viscous content is necessary to produce shading in either explamation. Gynecobogic textbooks stress the characteristic viscosity of endometrial cysts (2,3). The blood in functional cysts is said to be much more apt to

form fluid

a clot than to remain as a thick as in endometnial cysts (2). In

cystadenomas,

the

blood

mixed

with

the original contents is usually not sufficient to alter the consistency of the original fluid content (2). These Volume

180

#{149} Number

i

(21).

However,

the

ability

of

MR imaging to allow one to distinguish endometrial cysts from other adnexal masses has not been fully determined. Most authors have stated that the MR appearance of endometrial cysts is not definitive and can be seen with hemorrhagic masses as well, although MR imaging is probably more specific than other imaging techniques (li-iS). However, we believe that the MR imaging findings of other adnexal masses with internal hemorrhage are substantially different from those of endometrial cyst. Gynecobogic textbooks state that a presumptive diagnosis of endometrial cyst

can

usually

be

made

macroscopi-

cally, even before microscopic examination, on the basis of the thick chocolate-colored content and morphologic characteristics (2,3). We believe that MR imaging can reflect these unique macroscopic features of endometrial cysts, although it cannot reflect microscopic characteristics of the lesions. The signal intensity of the blood mixed with the original fluid content of the adnexal mass will be less

among

as an increase Ti relaxation

masses

than

that

of blood

on

Ti-

weighted images, as the long Ti value of the original fluid content reduces the hyperintensity of the blood. Moreover, other adnexal masses will not exhibit cyclic bleeding for many years, and as a result, they will neithen contain thick, viscous aged blood nor show repeated rupture with subsequent sealing off. Thus, they will exhibit neither shading nor multiplicity. In addition, most sions with or without

neoplastic hemorrhage

be-

have the features that suggest their neoplastic nature: huge size, septation, or a solid component. In this study, we misdiagnosed only three small

neoplastic

lesions

(serous

cyst-

adenoma, endometrioid cystadenofibroma arising in an endometrial cyst, dermoid cyst) among 354 surgically confirmed lesions. No case of malignancy was misdiagnosed as an endometrial cyst. MR imaging had a sensitivity of 90%, a specificity of 98%, and an accuracy of 96% in diagnosing endometrial cysts and in separating them from other gynecobogic masses with or without internal hemorrhage. Given the 96% accuracy, MR imaging seems to be an acceptable diagnostic test on which clinical decisions can

be

based. Of course, MR imaging will not replace the baparoscopic examination for pelvic endometriosis (11,12). We completely agree with the authors of two previous reports describing the limitation of MR imaging arising from its back of sensitivity for detection of implants (10-12). However, baparoscopy will never permit direct inspection of the contents of a mass, and occasionally it fails to reveal even rebativeby large lesions in cases with dense adhesion. Thus, MR imaging seems

to offer

additional

information

in evaluating adnexal masses suggestive of endometrial cysts. Patients with endometriosis usually present with one of three complaints: pelvic pain, adnexal mass, or infertility (2,4). Since endometriosis is a benign process that becomes quiescent with pregnancy or menopause, consideration of the natural history and severity of the disease, as well as age and reproductive status, is necessary when deciding on treatment. There are many treatment options such as observation, hormonal therapy, and conservative or radical surgery. The ultimate goal of treatment in all the protean manifestations of emdometriosis

is relief

surgery patients

of symptoms.

However,

has usually been indicated with adnexal masses, even

asymptomatic

patients.

This

in

is partly

because hormonal therapy will not cause an established endometrial cyst to regress but mainly because one cannot be certain that the adnexal masses

are

rather

than

(2,4).

With

indeed

endometriosis

an ovarian its high

malignancy

accuracy

in distin-

guishing endometrial cysts from other adnexal masses, MR imaging may neduce the need for diagnostic surgery. This will be particularly useful not only in asymptomatic patients but also in young women or women approaching menopause, in whom temporization cam be used in anticipation of spontaneous improvement with menopause or pregnancy. At the least, MR imaging will aid in selecting one of the many treatment options, from simple observation to immediate diagnostic surgery, including the choice to set back the surgery after some dissolution of adhesions with hormonal manipulation. U References 1. Sampson JA. Perforating hemorrhagic (chocolate) cyst of the ovary. Arch Surg 1921; 3:245-323. 2.

3.

Williams TJ. Endometriosis. In: Mattingly RF, Thompson JD, eds. Te Linde’s operative gynecology. 6th ed. Philadelphia: Lippincott, 1985; 257-286. Novak ER, WoodruffJD. Pelvic endo-

Radiology

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4.

5.

metriosis. In: Novak ER, WoodruffJD, eds. Novak’s gynecologic and obstetric pathology with clinical and endocrine relations. 8th ed. Philadelphia: Saunders, 1979; 561584. Barbieri RL, Hornstein MD. Medical therapy for endometriosis. In: Wilson EA, ed. Endometriosis. New York: Liss, 1987; iii140. Fleischer AC, James AE Jr. Millis JB,Julian C. Differential diagnosis of pelvic masses

by gray scale sonography. 6.

469-476. Walsh JW, Taylor KJW, Schwartz PE, Rosenfield

10.

11.

12.

13.

AJR 1978; 131: Wasson AT.

JFM, Gray-scale

14.

8.

9.

15.

puted

17.

of endornetriosis.

Gomori

diology

Assist Tornogr 1983; 7:257-264. RW, Walsh JW. CT in gynecologic pelvic diseases. Semin Ultrasound CT MR 1988; 9:122-142. Cornput Sawer

#{149} Radiology

Mitchell

Zimmerman hematomas:

18.

78

1986; 158:639-646. Mitchell DG, Mintz

masses:

MC,

Spritzer

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DG.

Magnetic

ing of the adnexa. MR 1988; 9:143-157.

16.

aging

CE, et al.

Semin

JM, Grossman

20.

21.

22.

Ultrasound

CT

ing.

1985; 157:87-93.

obstructed

observation

Dillon

24.

Hayman

JM, Grossman RI, Hackney DB, HI, Zimmerman RA, Bilaniuk LT. Variable appearance of subacute intracranial hematomas on high-field spin-echo

B, Marom sinonasal

Z.

secre-

on Ti and T2 shorten1989;

172:515-520.

WP, Som PM, Fullerton

GD. pointense MR signal in chronically sated sinonasal secretions. Radiology

Hyinspis1990;

174:73-78. LA, Taber

fect of clot formation

Gomori Goldberg

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July 1991

Endometrial cysts: diagnosis with MR imaging.

The value of 1.5-T magnetic resonance (MR) imaging in diagnosing endometrial cysts and differentiating them from other gynecologic masses was prospect...
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