Out of these, hyaline degeneration is common occurring in about 60% of cases whereas cystic degeneration is rare in about 4%. Atypical leiomyomas (Fig. However, overwhelmingly, the leiomyoma variants behave in a clinically benign fashion and require no adjuvant therapy [8]. The other was found to have a pelvic mass 20 months after a supracervical hysterectomy. A pelvic mass was felt, and computed tomography demonstrated a 13-cm hypodense multilocular cystic mass … Ultrasonography (USG) and CT showed a large mass abutting the uterus extending into the abdomen. Results were read as fibroids, but at pathologic examination, large mass was found to be smooth muscle tumors of uncertain malignant potential (STUMP). 4C —45-year-old woman with symptomatic fibroids who underwent MRI for preoperative planning. 8B —49-year-old woman with history of fibroids referred for MRI for before uterine fibroid embolization. However, the cystic areas do not enhance well and can be distinguished from other types of leiomyomas. An intramural fibroid is a noncancerous tumor that grows between the muscles of the uterus, typically discovered during a routing pelvic exam. 8), and on T2-weighted images, the sarcomas were intermediate to high signal intenstiy. 3A —48-year-old woman referred for MRI for further evaluation of possible ovarian mass on ultrasound and pelvic examination. MRI showed large multiseptated cystic mass 21 × 16 cm × 12 cm in the right. Uterine leiomyomas, commonly known as fibroids, are one of the most common pelvic tumors found in women. [10] reported an isolated case of a mitotically active leiomyoma in a 68-year-old woman treated with a hysterectomy that recurred 7 months later as a leiomyosarcoma, the authors noted no prior published reports of this phenomenon among the 89 previously reported cases of mitotically active uterine leiomyoma. D, Representative histologic specimen of uterine STUMP shows marked cellularity and cytologic atypia (but mitotic count < 10/10 high-power fields). Subserosal are in the outer wall of. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma can undergo. B, Axial T1 fat-suppressed unenhanced scan is unremarkable. 8, No. There are no clinical findings that reliably differentiate ordinary leiomyomas from leiomyoma variants and leiomyosarcomas. Case reports [43, 44] have also reported these findings on conventional sequences. The public has recently become aware of dissemination of leiomyosarcoma associated with the use of power morcellators to remove fibroids [6, 15, 16]. Fibroids are uncommon before the onset of puberty and regress after menopause. is a prerequisite for the development of targeted therapies against these lesions” (uterine leiomyomas). On MRI, moderate T2 signal intensity is the only finding that may be suggestive of one of the variants; although ordinary leiomyomas can have homogeneous moderate T2 signal intensity, this is quite infrequent. Varras M 1, Antoniou S, Samara Ch, Frakala S, Angelidou-Manika Z, Paissios P. Author information. Despite this, because of their rarity, there are no well-defined clinical guidelines for the clinician to follow. Maria Luisa C. Fogata MD. To our knowledge, there are no previous review articles in imaging journals addressing the many issues concerning leiomyoma variants. Fig. Dec 11, 2018. CONCLUSION. Transabdominal biopsy confirmed benign, degenerating fibroid. Typical appearance of fibroid uterus on CT. The purpose of this article is to review the clinical, imaging, and pathologic features of leiomyoma variants. The patient underwent a laparotomy. As fibroids enlarge, they outgrow their blood supply which may evoke cascade of inflammatory reactions and ischaemic changes leading to various types of degenerations. Fig. An intermediate T2 signal and a high b value (1000 s/m2) signal were found in STUMPs and malignant tumors significantly more often than in benign tumors. Hemorrhagic (carneous) degeneration typically shows high signal intensity on T1-weighted scans and moderate to high signal intensity on T2-weighted scans; there can also be a hyperintense rim on T1-weighted scans and a very hypointense rim on T2-weighted scans [ 31 ]. Although CT is not a recommended imaging modality for the evaluation of leiomyomas, they are frequently incidentally seen, usually appearing as a variably enhancing mass, sometimes with dystrophic calcifications [24]. The typical appearance of leiomyoma is easily recognized on ultrasound but degenerations, as in our case may cause confusion in diagnosis. 3) because of the intense enhancement of the stroma with no enhancement of the intervening mucinous lakes [34]. B, Axial nonfat-suppressed T1-weighted image shows T1 hyperintensity anteriorly within mass, compatible with fat. In a study attempting to differentiate uterine leiomyosarcomas (n = 10) from degenerated leiomyomas (n = 32) [42], the combined use of dynamic MRI and serum lactate dehydrogenase (isotypes) yielded a high accuracy. 8A —49-year-old woman with history of fibroids referred for MRI for before uterine fibroid embolization. B, Axial T1-weighted fat-suppressed unenhanced scan is unremarkable. Ordinary leiomyomas can degenerate in many ways (Table 2). They appear hypocellular with a myxoid matrix 6. 1B —38-year-old woman with symptomatic leiomyomas. A, Coronal T2-weighted scan shows moderate-signal mass, which was also moderate signal on T1-weighted scan (not shown). Fibroid degeneration takes place when the fibroid has been increasing in size over a number of years, and its blood supply is no longer adequate to support the center of the tumor. For example, in one of the largest series on this variant, Ly et al. 5C —39-year-old woman with pelvic pain and presumed ordinary leiomyoma after receiving therapy with leuprolide acetate (Lupron, Abbvie). Ultrasonography and CT revealed a large solid mass with cystic areas extending into both uterine adnexa. This picture was classic for cystic degeneration of a fibroid and I was able to remove just the fibroid and preserve her uterus, per her wishes. Other studies also support that both mitotically active and cellular leiomyomas rarely recur. Being rare in prepubertal females, they commonly accelerate in growth during pregnancy and involute with menopause 1. The 43 years, patient presented with lump abdomen with heavy periods and anemia. 3, Journal of Minimally Invasive Gynecology, Vol. Hemorrhagic (carneous) degeneration typically shows high signal intensity on T1-weighted scans and moderate to high signal intensity on T2-weighted scans; there can also be a hyperintense rim on T1-weighted scans and a very hypointense rim on T2-weighted scans [31]. Ultrasound and CT -Scan suggested “Ovarian Malignancy”!! Uterine leiomyomas, commonly known as fibroids, are one of the most. Precise knowledge of the histopathologic backgrounds of degeneration and the clinical course helps u… B A C vol25_no5_jum_online.q 4/14/06 10:26 AM Page 673. characteristic of a rim of myometrium usually seen in a cystic fibroid.5 The cesarean delivery surgical report stated that the 18-cm pedunculat-ed cystic mass arose from the posterior surface of the body of the uterus and extended inferiorly in the cul-de-sac. Fig. 14, No. The diagnosis of a uterine fibroid with cystic degeneration was made. Patients with mitotically active leiomyomas and cellular leiomyomas are usually cured with surgery, and no additional postoperative surveillance is routinely necessary. However, leiomyomas vary widely in appearance and may be confused with other gynecologic malignancies. 4, American Journal of Roentgenology, Vol. 11, Canadian Association of Radiologists Journal, Vol. Uterine fibroid vascular supply from … Results were read as fibroids, but at pathologic examination, large mass was found to be smooth muscle tumors of uncertain malignant potential (STUMP). One of the four patients with presumed stage I STUMP who was immediately surgically staged was found to have an omental implant. Fibroid degeneration can bring pain or fever, there is also a good chance that you may experience severe pain that is comparable to uterine cramps but which is a bit more severe. C, Typical histologic specimen of ordinary leiomyoma shows fascicles or bundles of elongated spindle cells with eosinophilic cytoplasm and centrally located cigar-shaped nucleus with interstitial and rich vasculature. [11] reported the largest single-institution series of women who were treated for cellular leiomyomas, and only two of 99 patients (2%) had recurrent disease, one 43 months after an abdominal myomectomy and the other 120 months after a vaginal hysterectomy for multiple cellular leiomyomas (with benign metastasizing leiomyomas to the lungs). Once the degeneration is complete, any pain or fever usually goes away. uterine leiomyomas) that have undergone myxoid degeneration are filled with a gelatinous material and can be difficult to differentiate from cystic degeneration; however, they typically appear as more complex cystic masses. Key teaching point, in this case, is that cystic degeneration of fibroids can look very large and alarming and raise the concern for a malignant mass. However, in another study of mesenchymal tumors of the uterus (n = 26) [40], the two uterine STUMPs exhibited homogeneous enhancement (Figs. However, despite the rarity of the latter, both the clinician and radiologist caring for a woman with presumed benign myomas sometimes share the underlying worry that they could be dealing with a leiomyosarcoma. D, Axial T1-weighted fat-suppressed subtraction image after IV contrast administration shows minimal enhancement of nonfat component. Subserous fibroids—these fibroids grow predominantly outside the uterus and bulge. CT is not the primary modality in the diagnosis of fibroid The nuclei are hyperchromatic, often with intranuclear inclusions. This is concerning for clinicians and radiologists alike, who both struggle with the same question: when should I refer a patient for MRI? A subsequent CT scan (B) reveals an incidental calcified. However, because leiomyoma variants have lower recurrence rates and malignant potential, future guidelines for posttreatment surveillance might be less rigorous, weighing the possible benefits of CT surveillance against the risk of radiation exposure. Uterine STUMPs have been only sporadically described in the imaging literature given their rareness. Leiomyomas with unusual growth patterns, such as parasitic leiomyoma, IV leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma, are histologic benign myomas that are thus not categorized as variants (Table 1). If the tumor is troubling you, or if it is growing rapidly, or the radiologist has other concerns, you should consider having it removed or you may be given other options such as embolization. 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