Intraspinal Endometriosis Matthew Hermann M D Guarang Shah

Intraspinal Endometriosis Matthew Hermann, M. D. Guarang Shah, M. D. 3/23/2016 University of Michigan Department of Radiology

Disclosures None

History • 31 -year-old female with endometriosis status post multiple surgeries for endometriosis: – – – Total abdominal hysterectomy Salpingoorphrectomy Left nephrouretectomy for ileal stricture Partial cystectomy Sigmoidectomy Colostomy and ileostomy formation and takedown

History • Patient originally had a pelvic MRI for worsening sciatica and weakness which showed a large multilobulated mass with involvement of multiple sacral nerve roots. • Original pelvic MRI showing a large mass with sacral extension posteriorly, vaginal extension inferiorly, and anterior extension into a partially-resected bladder.

History • Patient was referred for a thoracic and lumbar MRI for further evaluation. • The following slides show the imaging findings.

T 1 Post contrast T 1

Images • Axial T 1 (left) and postcontrast axial T 1 (right) images of the sacrum show the previously-described pelvic mass with enhancement of multiple sacral nerve roots (arrows). • Also note the intradural and extradural enhancement of multiple masses from L 5 -S 4.

Images • Sagittal T 1 (left) and postcontrast axial T 1 (right) images of the lumbosacral spine showing an one of many enhancing extradural masses (arrows).

Images • Sagittal reformat T 1 and post contrast T 1 imaging of the thoracic spine shows an intramedullary enhancing mass within the dorsal cord of T 12 (arrows).

Follow up • Patient had pelvic and vaginal biopsies which showed endometrial tissue in the pelvis and findings in the vagina (arrows) concerning for transformation to clear cell carcinoma. Sagittal T 2 Coronal T 1 post contrast

Spinal Endometriosis • Rare, few case reports in the literature • Symptoms include catamenial lumbago and sciatica • Theories of intramedullary extension: – Perineural spread – Venous spread through Batson’s veins – Ectopic expression of Wnt-7 a signaling

Spinal Endometriosis • Imaging findings on MRI – Heterogeneous T 1 • Areas of low signal due to hemosiderin • Areas of high signal due to acute hemorrhage – Increased signal on T 2 – Enhancement on post contrast T 1 T 2 Post contrast

Future directions • Diffusion tensor imaging with tractography has been reported to be beneficial. • Findings: – Lower fractional anisotropy values – Disorganized appearance of the sacral nerve roots

Thank you

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