Role of 3D Coronal Ultrasound in Diagnosis of Accessory and Cavitated Uterine Mass: A rare Mullerian Anomaly

Abstract

Accessory and cavitated uterine mass is rare developmental Mullerian anomaly. There is a non-communicating uterus-like mass that occurs contiguously along wall of uterus often underdiagnosed and needs expertise to identify. To raise awareness, provide information about this pathology and emphasize role of coronal 3D ultrasound in its diagnosis. A 28-year-old married female presented with dysmenorrhea and chronic pelvic pain. On ultrasound, a homogeneously isoechoic mass was noted in right lateral wall of uterus with central echogenicity. On 3D reconstruction, the main uterine cavity was normal and both cornu were visualized without any recognized Mullerian anomaly. No communication with the main endometrial cavity seen. On laparoscopy, mass was located under right round ligament insertion. Sectioning revealed chocolate colored fluid. ACUM is non-communicating uterus-like mass. It resembles uterus both macroscopically and microscopically. It represents a cavitated mass lined by endometrial glands and stroma surrounded by irregular smooth muscle cells. Criterias for diagnosing ACUM are (1) accessory cavitated mass located under round ligament; (2) normal uterus, fallopian tubes, and ovaries (3) surgical case with excised mass and pathological examination; (4) accessory cavity lined by endometrium with glands and stroma; (5) chocolate-brown fluid contents. On ultrasound, they appear solid isoechoic masses with central cystic areas separate from ovaries. 3D reconstruction can be used to rule out Mullerian anomaly. ACUM is a rare surgically treatable cause of dysmenorrhea, often underdiagnosed due to lack of knowledge about entity. 3D ultrasound can be highly accurate in making the diagnosis.

Accessory cavitated uterine malformation: Enhancing awareness about this unexplored perpetrator of dysmenorrhea

“…Three-dimensional (3D) ultrasound may locate the interstitial portion of the ipsilateral fallopian tube. 6,14,47,50 • Examination with Doppler will reveal no discernible difference between the Doppler flow of the outer rim of the myometrial mantle and the surrounding myometrium. 14 • Doppler examination will reveal the cavity's contents to be avascular.…”

“…8,12,14,16,21,22,[47][48][49][50][51] The fluid-containing cavity and the myometrial mantle are the two defining characteristics of ultrasound. 6,12,14,[47][48][49] • The fluid in the accessory cavity was either echogenic (ground glass appearance) or hyperechoic. 3,4,9,14,22,49,50 However, this may be misdiagnosed, considering the prevalence of endometrioma among young women.…”

Accessory cavitated uterine malformation (ACUM): A hidden face of dysmenorrhea

“…Spherical-shaped cavitated lesion containing echogenic fluid surrounded by the myometrial mantle. 8,13,14,42,[44][45][46][47][48][49][50] 2. The myometrial mantle and the fluid-filled cavity are the defining features of ultrasound.…”

“…ACUM lesions are characteristically located in one of the lateral aspects of the anterior myometrium inferior to presumed insertion of the round ligament (3D ultrasound is helpful to locate the interstitial portion of the fallopian tube) and above the location of the uterine artery (on doppler). 45,49,51,53 6. On Doppler examination, the Doppler flow of the outer rim of the myometrial mantle will not be markedly different from that of the surrounding myometrium.…”

“…3D reconstruction can rule out Mullerian anomalies as this differential diagnosis should be considered in such cases. 45,45,49,50 Decidual changes observed in ectopic endometrial tissue within an adenomyotic area may be misdiagnosed as a focus of cornual ectopic pregnancy in such cases. Also, 3D images are helpful.…”