CURRICULUM VITAE

Dr. dr. Lina Choridah, Sp.Rad (K)

RIWAYAT PENDIDIKAN :

❖ Doktor, Universitas Gadjah Mada, Lulus Tahun 2013

❖ Konsultan Radiologi, Universitas Gadjah Mada, Lulus Tahun 2012
❖ Spesialis Radiologi, Universitas Gadjah Mada, Lulus Tahun 2002
❖ Dokter Umum, Universitas Gadjah Mada, Lulus Tahun 1996

RIWAYAT PEKERJAAN :

❖ Wakil Dekan Bidang Penelitian dan Pengembangan, Fakultas Kedokteran,

❖ Kesehatan Masyarakat, dan Keperawatan, Universitas Gadjah Mada,
❖ Tahun 2021-2026
❖ Ketua Departemen Radiologi, Fakultas Kedokteran, Kesehatan Masyarakat, dan Keperawatan, Universitas Gadjah
Mada, Tahun 2016-2020

ORGANISASI PROFESI :

❖ PDSRI
❖ IWIS
❖ SBI
 THE ROLE OF MRI IN
ENDOMETRIOSIS DIAGNOSTIC
Lina Choridah
FKKMK UGM / RSUP Dr Sardjito
ENDOMETRIOSIS and ADENOMYOSIS
Chronic gynecological condition

• functional endometrial glands and stroma-like lesions

outside the uterus.

three main entities of pelvic endometriosis

• ovarian disease (endometriomas)

• superficial (peritoneal) disease
• deep infiltrating endometriosis (DIE), which is the most
complex and surgically challenging form.

Adenomiosis

• ectopic endometrial glands and stroma in the

myometrium
 • Young women (25-29 years)
• 5% in postmenopausal women.
• Potential risk factors : family history and
short menstrual cycles.
• women who underwent laparoscopy for
Epidemiology various reasons, the prevalence was as
follows :
• asymptomatic women (laparoscopy
for tubal ligation): 1-7%
• primary infertility: 17-50%
• pelvic pain: 5-21%
 • MRI is non-invasive, has no risk of
radiation, requires no anesthesia and is
less operator dependen

• MRI is well known to provide accurate

information about hemorrhage, fat, and
Advantage of collagen.
MRI
• It is able to identify different types of
tissue contained in pelvic masses,
distinguishing benign from malignant
ovarian tumors, with an overall accuracy
of 88% to 93%.
 ROLE OF MRI - ENDOMETRIOSIS
• Gold standard: Laparoscopy
• US is the first-line imaging modality for the assessment of pelvic
endometriosis
• Limitation of US: limited field of view and operator dependence.
• MRI is recognized as a valuable tool for diagnosis and presurgical planning.
• MRI has high sensitivity (90%) and specificity (91%) .
• Advantages
• more objective,
• the images can cover a large field-of-view with multiple directions
• Due to its excellent contrast resolution, detailed information about the locations and
histological characteristics of endometriosis.
MRI Protocols
Patient preparations
• 3–6 hours of fasting
• Bladder emptying one-hour before the examination
• Use of anti-peristaltic agent (unless contraindicated)
• (optional) vaginal/rectal opacification by gel

T2WI
• Axial, sagittal and oblique axial images (optional) 3D-T2WI

T1WI
• With and without fat saturation images
Location, Clinical Finding and DD of •
Endometriosis

6-9.2
MRI Finding of Endometrioma
• T1-high signal multiplicity
• Multiple high signal cysts on T1WI
• T2-Shading
• Marked T2
• shortening
• gradations on T2WI
• T2 dark spot sign
• Discrete well-defined markedly hypointense foci within the cyst on T2WI
MRI

• A homogenous
• B liquid-liquid level
• C liquid level
• D heterogenous
• E1 focal shading
• E2 multifocal shading
33 yo (Courtesy of Radiology Department FK-KMK UGM/RSUP Dr. Sardjito)
(Courtesy of Radiology Department FK-KMK UGM/RSUP Dr. Sardjito)

35 yo
Differential Diagnosis
Hemorrhagic
ovarian
cysts (HOCs)
Hemorrhagic ovarian cyst
Case contributed by Dr Ahmed Abdrabou
 DERMOID CYST
Complex cyst with
dense echogenic
nodule structure
with posterior
shadow, fluid-fluid
level appearance
with sebaceous/fat
Calcified structures
component
representing bone
or teeth and/or
multiple echogenic
lines representing
hair structures
within the cystmass
An echogenic
and posterior
shadow that
obscures the
posterior border of
the cyst is called a
"tip of iceberg".
 CT of Teratoma
(Courtesy of Radiology Department FK-KMK UGM/RSUP Dr. Sardjito)
 Mature cystic teratoma
Case contributed by Dr Prashant Mudgal
Ovarian dermoid
Case contributed by Dr Natalie Yan
SEROUS
CYSTADENOMA
Serous
cystadeno
carcinoma
MRI IMAGING OF OVARIAN TUMOR
 anterior cul-de-sac

posterior cul-de-sac

pelvic sidewall

Deep pelvic gastrointestinal tract

endometriosis Urinary tract

MRI: variation of blood product
• Hemorhagic “powder burn”
• Bright on T1 fat sat
• Small and solid lesion
• hyperintense T1 and hypointense T2
• Adhesion and fibrosis
• Distortion of normal anatomy
• posterior displacement of the uterus, kissing ovaries sign,
• angulation of bowel loops
• elevation of the posterior vaginal fornix
• loculated fluid collections, hydrosalpinx
Irregular fibromuscular plaque (long arrow) involving the anterior rectal wall, and
endometrioma (short arrow). (B) Heterogeneous enhancement of mild rectal wall
lesion (long arrow).

Xue Tang et all, 2018

 (a) Heterogeneous
DIE endometriotic nodules
in bladder wall, anterior
rectal wall (white
arrow), vagina (black
arrow), and sigmoid
colon (*).
(b) Laparoscopic image
shows adhesion of the
retrocervical lesion
(arrow) to the rectum
(N).
(c) Images on vaginal
examination show
infiltration of
endometriosis into the
posterior fornix and
rectovaginal space
(arrows).
(A) T2 cross-sectional view showing endometrial cyst (star)
closed pouch of Douglas and asymmetrical fluid (arrow)
Xue Tang et all, 2018
ADENOMYOSIS

• Enlarged uterus with

globular, regular walls or
asymmetrical thickness
• Junctional zone >= 12 mm.
• Ill-defined hypointense
area with hyperintense
punctate myometrial
focus
Normal, diffuse and focal adenomiosis
MRI

T2 Sag T2 AX T1+C Fat Sat

T1WI-T2WIsagital
Malignant Transformation of Ovarian
Endometrioma

•Change towards malignancy (1%-2.5%)

•Endometrioid carcinoma (66.7%)
•Clear cell carcinoma (14.8%)

• mural nodule size> 3 cm, no shading on the T2W sequence, enlargement of the size of the lesion
•Disappearance of shading image on T2W
Dilution of blood products in endometriomas by non hemorrhagic fluids secreted by tumor components
.
• DIE and malignant
transformation of the
endometrial lesion in
the rectovaginal septum
• atypical epithelial cells in
glandular-tube-like,
stranding and papillary
arrangement

Xue Tang et all, 2018

 Endometrioid Carcinoma

MRI examination in a 48-year-old patient with endometrioid carcinoma (A) T1W sequence, multiple complex cystic masses with
a solid component in the central area (arrow) (B) T2W sequence shows signal intensity disappears in some cysts (dashed
arrow). Shows multifocal shading in complex cystic mass.
 Clear Cell
Carcinoma
•MRI examination in a 48-year-old patient with clear cell carcinoma originating from an endometrioma (A) T1W fat-suppressed
sequence axial section shows a mass with multiple septations in the left ovary with homogeneous hyperintense signal intensity and
hypointense mural nodule. (B) T1W sequence with visible contrast enhancement of the mural nodule. (C) The T2W sequence does not
show any shading in the endometrioma.
 Complication
Adhesion

Kissing ovaries kissing ovaries

Endometrioma Rupture

Transvaginal ultrasound
examination showed a cyst with
irregular walls and hypoechoic
internal echo on the right ovary
(B) and (C). MRI examination of
the pelvis showed hyperintense
signal intensity on the T1W
sequence and hypointense
signal intensity on the T2W
sequence with shading images.
The right ovary looks irregular.
Free fluid in the pelvic cavity
showing hyperintense signal
intensity on the T1W sequence
indicates hemoperitoneum. This
image shows bilateral
endometriomas with signs of
ruptured endometrioma11.
 • Despite all the advantages of MRI over all
other imaging modalities, it nonetheless has a
number of limitations, including:
• non-pigmented lesions will not be
hyperintense on T1, and thus harder to detect
• small foci may have variable signal intensity
• may appear similar to normal
Limitations of MRI endometrium: low T1, high T2
• hypointense on all sequences
• hyperintense on all sequences
• plaque-like implants are difficult to delineate
• adhesions cannot be directly identified,
usually relying on the distortion of normal
anatomy to imply their existence
CONCLUSION

Endometrial tissue grows

•Endometriosis
•Adenomyosis

Role Of MRI

•Diagnosis and presurgical planning, high sensitivity (90%) and specificity (91%) .
•More objective,.
•the images can cover a large field-of-view with multiple directions
•detailed information about the locations and histological characteristics of endometriosis.
THANK YOU