MyPACS.net: Radiology Teaching Files > Case 5422138

Never visited UTERINE LEIOMYOMAS - INTRACAVITARY, SUBMUCOSAL, INTRAMURAL
Contributed by: Radiology Residency Program Faculty & Staff, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals, Ohio, USA.
Patient: 42 year old female
History:

42 year old female with left adnexal pain.

7/20/2006: Transvaginal pelvic ultrasound
7/20/2006: Contrast Enhanced CT Abdomen/Pelvis
7/27/2006: MRI Pelvis

Images:[small]larger

Fig. 1: Transvaginal Pelvic Ultrasound

Fig. 2: CE-CT Pelvis

Fig. 3: T2WI MR
Findings:

Fig. 1: Transvaginal ultrasound
Left coronal and sagittal images: Centrally in the expected location of the endometrial cavity is a 2.5 cm mass.   Differential diagnosis would inclued an intracavitary fibroid or endometrial mass.
Right coronal and sagittal images: Posteriorly there is a 3.7 cm heterogenoeous mixed echogenicity mass, likely a fibroid.  A smaller 1.0 cm intramural mass can also be seen.

Fig. 2: CE-CT Pelvis
Lobular masses within the endometrial cavity are isoattenuating to uterine myometrium.
A small amount of free pelvic fluid is also present.

Fig. 3: T2WI MR
Sagittal T2WI:  Multiple well circumscribed homogeneous hypointense masses are seen within the uterus: Two small lesions intramural in location at the anterior uterine body; a 1.8 cm intracavitary lesion contiguous with the mid uterine body; and a 3.3 cm submucosal lesion at the posterior fundus.  Nabothian cysts are also present.
Axial Oblique and Coronal Oblique T2WI: The intracavitary and submucosal masses are demonstrated.  There is slight inhomegeneity of the larger submucosal lesion, probably secondary to degeneration. A small amount of free pelvic fluid is seen (Axial Oblique T2WI).

Diagnosis: Uterine Leiomyomas - Intracavitary, Submucosal, Intramural
Discussion:

Uterine Leiomyoma

- syn: fibroid
- benign neoplasms derived from the smooth muscle myoma cells of the uterine myometrium
- the most common uterine neoplasm
- present in greater than 20% of women older than age 30 years

Categorized by location:
- subserosal: lesions centered external to the uterus; these can mimic adexal lesions on sonography and physical examination
- intramural: majority of fibroids
- submucosal: leiomyomas with some component extending into the endometrial canal, even if covered by a layer of endometrium
- intracavitary: submucosal fibroids almost entirely located with the endometrial canal

MR findings:
- characteristic low SI on T2-WI
- well circumscribed with well-defined margins
- ~ 1/3 are surrrounded by a high SI rim on T2-WI that correlates with peritumoral lymphatics, veins, and edema

Various types of degeneration:
Hyaline:
- most common

Hemorrhagic:
- uncommon; associated with leiomyomas during pregnancy
- "red degeneration" with peripheral or central high SI on T1-WI secondary to methemoglobin
- minimal contrast enhancement

Cystic:
- 5% of fibroids
- very high SI on T2-WI
- do not enhance after contrast

Fatty:
- rare: 0.5% of cases
- degeneration into a lipoleiomyoma
- hypothesized as metamorphosis of smooth muscle cells into adipocytes
- can be detected and characterized using fat suppresion techniques

Calcific:
- more accurately detected by radiography and CT

Malignant:
- rare
- difficult to accurately diagnose on MR in the absence of metastatic disease

References:

Brant, WE and Helms, CA. Fundamentals of Diagnostic Radiology. 3rd edition. Lippincott Williams & Wilkins, 2006.

Siegelman, ES., Body MRI. Elsevier, 2005.

Submitted by:

Aakash D. Singh, M.D. – PGY-V Radiology Resident

Mark R. DeGalan, M.D., Ph.D. - Radiologist
Mercy Medical Center

Comments:
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Additional Details:

Case Number: 5422138Last Updated: 2011-08-15
Anatomy: Genitourinary (GU)   Pathology: Benign Mass, Cyst
Modality: CT, MR, USAccess Level: Readable by all users
Keywords: uterine leiomyoma, fibroidsACR: 851.315

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