Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Leiomyoma TERMINOLOGY Abbreviations • Myoma Synonyms • Fibroid • Myoma • Uterine fibroma Definitions • Benign smooth muscle neoplasm of uterus IMAGING General Features • Best diagnostic clue ○ Circumscribed uterine wall mass • Location ○ Can develop anywhere within uterine smooth muscle – Submucosal: In close contact with endometrium – Intramural: Most common, entirely within myometrium – Subserosal: Bulges externally from uterine surface ○ Can also be exophytic/pedunculated, intracavitary, cervical, or within broad ligament • Size ○ Extremely variable, subcentimeter to > 10 cm • Morphology ○ Distortion of uterine contour and enlargement of uterus (subserosal or intramural) ○ Narrowing and distortion of endometrium (submucosal or intramural) ○ Mimics solid adnexal mass (pedunculated or broad ligament leiomyoma) Ultrasonographic Findings • Circumscribed mass, hypoechoic to myometrium ○ Poor posterior acoustic transmission ○ May demonstrate shadowing even without associated calcifications ○ Shadowing can limit utility of transvaginal ultrasound • Bulky uterine enlargement from large or multiple leiomyomas • Variable location: Submucosal, intramural, subserosal, intracavitary, pedunculated, cervical, or broad ligament ○ Submucosal: Mass effect on endometrium, may obstruct endometrial canal if intracavitary ○ Subserosal: Distorts uterine contour, especially if large ○ Pedunculated: At risk for torsion with vascular connection visible on color Doppler ○ Cervical: Unlike nabothian cyst, will have internal blood flow ○ Broad ligament: May be confused for solid ovarian mass, unless ovary identified separately • May appear heterogeneous if cystic degeneration or hemorrhage • Lipoleiomyoma: Variant of leiomyoma with variable amount of fat ○ May be hyperechoic due to significant fat component ○ May be confused for dermoid if exophytic/pedunculated • Peripheral vascularity on color Doppler ○ Submucosal fibroid tends to have multiple feeding vessels compared to single feeding vessel for endometrial polyp ○ Vascular stalk helps characterize pedunculated leiomyoma ○ Ischemia/degeneration: Decreased or absent color flow Saline Infusion Sonohysterography (SIS) • Helpful in characterizing submucosal fibroids ○ Leiomyomas more hypoechoic than endometrial polyps and associated with shadowing ○ Echogenic endometrial lining covers surface of leiomyoma ○ Multiple feeding vessels rather than linear stalk-like vascularity • Hysteroscopic resection if > 50% of myoma is intracavitary Angiographic Findings • Peripherally vascular masses, may have dual supply from both uterine arteries • May have additional vascular supply from ovarian arteries CT Findings • Enlarged uterus, may be lobular • Fibroid attenuation ○ Often similar attenuation to uterus on unenhanced scan ○ Variable enhancement after contrast ○ Heterogeneous if cystic degeneration, hemorrhage ○ May contain coarse, dense calcifications, especially in older women or after degeneration MR Findings • Low T1/T2 signal from smooth muscle proliferation • Variable enhancement on post-contrast imaging ○ Usually less than surrounding myometrium • High signal on T1WI if hemorrhage; high signal on T2WI if cystic degeneration • Expected appearance after uterine artery embolization: Decreased volume and enhancement Imaging Recommendations • Best imaging tool ○ Ultrasound initial study of choice – Transabdominal to evaluate for pedunculated or subserosal leiomyomas, which may be missed on transvaginal imaging alone – Transvaginal best to evaluate submucosal leiomyomas □ May be limited by extensive shadowing ○ Sonohysterography to evaluate submucosal leiomyomas ○ MR as supplement – Prior to uterine artery embolization: Evaluate for enhancement and map fibroids – Multiple or complex features, limited ultrasound • Protocol advice ○ Use both transabdominal and transvaginal ultrasound (TVUS) ○ Determine size, location, and effect of myomas on endometrium – At least largest 3 myomas should be measured as index lesions – Report size of submucosal interface; size of stalk if pedunculated Diagnoses: Female Pelvis 741

Leiomyoma Diagnoses: Female Pelvis ○ Consider renal ultrasound to exclude hydronephrosis when uterus is large DIFFERENTIAL DIAGNOSIS Adenomyosis • Ectopic endometrial tissue; is similar in appearance to leiomyoma when mass-like • Often elliptical in shape; arises near endomyometrial junction if focal • More commonly associated with tender/painful uterus Focal Myometrial Contraction • Focal bulge of myometrium during pregnancy, resolves over time • Isoechoic to surrounding myometrium • Affects internal myometrial appearance more than external contour Leiomyosarcoma • Rapidly growing uterine mass, older or postmenopausal woman • Typically heterogeneous, with necrosis and hemorrhage, can be similar to leiomyoma • Rare tumor, not thought to arise from preexisting leiomyoma • Look for signs of tumor spread Uterine Duplication • Bicornuate uterus: 1 horn can mimic leiomyoma • Empty horn during pregnancy can also appear similar to leiomyoma • Can differentiate by central endometrial line, but noncavitary horns will lack endometrium PATHOLOGY Gross Pathologic & Surgical Features • Well-circumscribed, grayish-white mass with whorled cut surface • Red degeneration: Infarction and hemorrhage Microscopic Features • Whorled appearance of smooth muscle bundles with interspersed vascular connective tissue • May demonstrate areas of degeneration or calcification CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Symptoms primarily related to leiomyoma location, size, &/or growth – Submucosal: Dysfunctional uterine bleeding – Subserosal: Bulk symptoms, including urinary urgency &/or constipation – Pedunculated: Can have severe pain from torsion – Degeneration of leiomyoma can also cause pelvic pain – Cornual leiomyoma may cause tubal obstruction ○ Parasitic leiomyoma: Separate from uterine stalk and obtain vascular supply from adjacent pelvic structure (e.g., omentum) ○ Can undergo rapid growth during pregnancy – Low-lying leiomyomas can block birth canal (myoma previa), requiring cesarean section – May result in failure of implantation, loss of pregnancy, placental abruption Demographics • Age ○ Increase in size and frequency with age • Epidemiology ○ 25-30% incidence in United States ○ Higher incidence in African American women ○ 77% incidence in hysterectomy specimens Natural History & Prognosis • May grow during pregnancy • Involute after menopause and calcify Treatment • Hormonal therapy can be used for symptomatic relief • For bulk symptoms or bleeding, management includes uterine artery embolization, myomectomy, and hysterectomy ○ Similar rate of success and less morbidity associated with uterine artery embolization • If greater than 50% of submucosal leiomyoma is within endometrial cavity, will require hysteroscopy for removal DIAGNOSTIC CHECKLIST Consider • If borders are not well delineated, consider adenomyosis Image Interpretation Pearls • Circumscribed mass, hypoechoic to myometrium, with posterior acoustic shadowing • SIS to better characterize submucosal leiomyomas • MR prior to uterine artery embolization, and to evaluate multiple or complex leiomyomas • Consider malignant form if rapidly growing uterine mass in postmenopausal woman Reporting Tips • If multiple, report at least 3 largest index leiomyomas • Report size of submucosal component and size of stalk if pedunculated SELECTED REFERENCES 1. Van den Bosch T et al: Terms and definitions for describing myometrial pathology using ultrasonography. Ultrasound Obstet Gynecol. ePub, 2015 2. Akbulut M et al: Clinical and pathological features of lipoleiomyoma of the uterine corpus: a review of 76 cases. Balkan Med J. 31(3):224-9, 2014 3. Choi HJ et al: Is uterine artery embolization for patients with large myomas safe and effective? A retrospective comparative study in 323 patients. J Vasc Interv Radiol. 24(6):772-8, 2013 4. Islam MS et al: Uterine leiomyoma: available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab. 98(3):921-34, 2013 5. Ly A et al: Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases. Am J Surg Pathol. 37(5):643-9, 2013 6. Deshmukh SP et al: Role of MR imaging of uterine leiomyomas before and after embolization. Radiographics. 32(6):E251-81, 2012 7. Manyonda IT et al: Uterine Artery Embolization versus Myomectomy: Impact on Quality of Life-Results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. Cardiovasc Intervent Radiol. Epub ahead of print, 2011 8. Stamatopoulos CP et al: Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus. J Minim Invasive Gynecol. 19(5):620-6, 2012 742

Leiomyoma<br />

TERMINOLOGY<br />

Abbreviations<br />

• Myoma<br />

Synonyms<br />

• Fibroid<br />

• Myoma<br />

• Uterine fibroma<br />

Definitions<br />

• Benign smooth muscle neoplasm of uterus<br />

IMAGING<br />

General Features<br />

• Best diagnostic clue<br />

○ Circumscribed uterine wall mass<br />

• Location<br />

○ Can develop anywhere within uterine smooth muscle<br />

– Submucosal: In close contact with endometrium<br />

– Intramural: Most common, entirely within<br />

myometrium<br />

– Subserosal: Bulges externally from uterine surface<br />

○ Can also be exophytic/pedunculated, intracavitary,<br />

cervical, or within broad ligament<br />

• Size<br />

○ Extremely variable, subcentimeter to > 10 cm<br />

• Morphology<br />

○ Distortion of uterine contour <strong>and</strong> enlargement of uterus<br />

(subserosal or intramural)<br />

○ Narrowing <strong>and</strong> distortion of endometrium (submucosal<br />

or intramural)<br />

○ Mimics solid adnexal mass (pedunculated or broad<br />

ligament leiomyoma)<br />

Ultrasonographic Findings<br />

• Circumscribed mass, hypoechoic to myometrium<br />

○ Poor posterior acoustic transmission<br />

○ May demonstrate shadowing even without associated<br />

calcifications<br />

○ Shadowing can limit utility of transvaginal ultrasound<br />

• Bulky uterine enlargement from large or multiple<br />

leiomyomas<br />

• Variable location: Submucosal, intramural, subserosal,<br />

intracavitary, pedunculated, cervical, or broad ligament<br />

○ Submucosal: Mass effect on endometrium, may obstruct<br />

endometrial canal if intracavitary<br />

○ Subserosal: Distorts uterine contour, especially if large<br />

○ Pedunculated: At risk for torsion with vascular<br />

connection visible on color Doppler<br />

○ Cervical: Unlike nabothian cyst, will have internal blood<br />

flow<br />

○ Broad ligament: May be confused for solid ovarian mass,<br />

unless ovary identified separately<br />

• May appear heterogeneous if cystic degeneration or<br />

hemorrhage<br />

• Lipoleiomyoma: Variant of leiomyoma with variable<br />

amount of fat<br />

○ May be hyperechoic due to significant fat component<br />

○ May be confused for dermoid if exophytic/pedunculated<br />

• Peripheral vascularity on color Doppler<br />

○ Submucosal fibroid tends to have multiple feeding<br />

vessels compared to single feeding vessel for<br />

endometrial polyp<br />

○ Vascular stalk helps characterize pedunculated<br />

leiomyoma<br />

○ Ischemia/degeneration: Decreased or absent color flow<br />

Saline Infusion Sonohysterography (SIS)<br />

• Helpful in characterizing submucosal fibroids<br />

○ Leiomyomas more hypoechoic than endometrial polyps<br />

<strong>and</strong> associated with shadowing<br />

○ Echogenic endometrial lining covers surface of<br />

leiomyoma<br />

○ Multiple feeding vessels rather than linear stalk-like<br />

vascularity<br />

• Hysteroscopic resection if > 50% of myoma is intracavitary<br />

Angiographic Findings<br />

• Peripherally vascular masses, may have dual supply from<br />

both uterine arteries<br />

• May have additional vascular supply from ovarian arteries<br />

CT Findings<br />

• Enlarged uterus, may be lobular<br />

• Fibroid attenuation<br />

○ Often similar attenuation to uterus on unenhanced scan<br />

○ Variable enhancement after contrast<br />

○ Heterogeneous if cystic degeneration, hemorrhage<br />

○ May contain coarse, dense calcifications, especially in<br />

older women or after degeneration<br />

MR Findings<br />

• Low T1/T2 signal from smooth muscle proliferation<br />

• Variable enhancement on post-contrast imaging<br />

○ Usually less than surrounding myometrium<br />

• High signal on T1WI if hemorrhage; high signal on T2WI if<br />

cystic degeneration<br />

• Expected appearance after uterine artery embolization:<br />

Decreased volume <strong>and</strong> enhancement<br />

Imaging Recommendations<br />

• Best imaging tool<br />

○ <strong>Ultrasound</strong> initial study of choice<br />

– Transabdominal to evaluate for pedunculated or<br />

subserosal leiomyomas, which may be missed on<br />

transvaginal imaging alone<br />

– Transvaginal best to evaluate submucosal leiomyomas<br />

□ May be limited by extensive shadowing<br />

○ Sonohysterography to evaluate submucosal leiomyomas<br />

○ MR as supplement<br />

– Prior to uterine artery embolization: Evaluate for<br />

enhancement <strong>and</strong> map fibroids<br />

– Multiple or complex features, limited ultrasound<br />

• Protocol advice<br />

○ Use both transabdominal <strong>and</strong> transvaginal ultrasound<br />

(TVUS)<br />

○ Determine size, location, <strong>and</strong> effect of myomas on<br />

endometrium<br />

– At least largest 3 myomas should be measured as<br />

index lesions<br />

– Report size of submucosal interface; size of stalk if<br />

pedunculated<br />

Diagnoses: Female <strong>Pelvis</strong><br />

741

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