Leiomyoma: An overview

Epidemiology The commonest of all pelvic T. (1/3). 20-50% of female > 30y do have fibroid. Childbearing life. often enlarge during pregnancy or during oral contraceptive use, and regress after menopause occur in women of reproductive age, often

Causes Unknown. Hyperestrogenemia. Infertility ?! Mechanical stress (lat wall + fundus).

Pathology NIE: -Site - shape - size. - Consistency - cut section - capsule - Number - varieties.

Varieties of leiomyoma extrauterine Round lig brood lig Recto-vog. Sept utero - sacral uterine cervical. Corporeal Leiomyomotosis tunica M extension from Myoma Varieties of leiomyoma

Uterine leiomyoma Cervical 1-2% solitary Corporeal 98% multiple

Corporeal leiomyoma Subserous 18% submucus 24% not capsulated Intramural 58%

CONSISTENCY Firm Harder (hyaline degeneration). Soft (pregnancy-cystic degeneration). Stony hard (Calcification)

Leiomyomata Uterus

Microscopic Examination Smooth muscle cells and fibrous tissue cells. Few formed blood vessels.

CELLULAR LEIOMYOMAS Compact smooth muscle cells with little or no collagen, can have relatively higher signal intensity on T2.

Changes occur with fibroid General Genital tract Tumor itself

General changes Erythrocytosis. Polycythaemia (erythropoitic). Carbohydrate metabolism (hyperglycaemia). Anaemia (hge).

Genital tract Uterus (endomet.-cavity-myomet.-uterus as a whole). Tubes inflammed (salpingitis) ovaries (tunica albuginea-endometriosis-cysts). Blood vessels. Endometriosis (30-40%).

Tumour itself Atrophy. Degeneration (hayline-red-cystic-fatty-calcerous) Necrosis. Malignancy (growth after menopause-rapid enlargement-recurrent fibroid polyp). Vascular (oedema-lymphangectasia) Infection.

Degeneration Leiomyomas enlarge outgrow their blood supply various types of degeneration Hyaline degeneration :- the presence of homogeneous eosinophilic bands or plaques in the extracellular space. Myxoid degeneration - presence of gelatinous intratumoral foci at gross examination that contain hyaluronic acid–rich mucopolysaccharides

Degeneration cont Red degeneration - during pregnancy, secondary to venous thrombosis within the periphery of the tumor or rupture of intratumoral arteries Sarcomatous transformation -less than 3%

DIAGNOSIS History Examination. Investigation. D.D.

SYMPTOMS Bleeding (menorrhagia-metrorrhagia). Pain uncomplicated (cong. Dysmenorrhea – dull - colicky). Pain complicated deg.-malig.-infection-torsion) infertility mass. Discharge. Pressure symptoms.

Signs Symmetrically enlarged uterus(submucosal fibroid). Asymmetrically enlarged uterus(subserous fibroid)

Investigations Clinical Laboratory Imaging techniques Instrumental Miscellaneous

Imaging Techniques (MR IMAGE) most accurate imaging technique for detection and localization of leiomyomas myomatous uterus (>140 cm3) is not consistently possible with US because of the limited field of view uterine zonal anatomy enables accurate classification of individual masses as submucosal, intramural, or subserosal

Imaging Techniques (MR IMAGE) cont Nondegenerated uterine leiomyomas: - well-circumscribed masses of homogeneously decreased signal intensity compared with that of the outer myometrium on T2-weighted images - whorls of uniform smooth muscle cells with various amounts of intervening collagen

Imaging Techniques (MR IMAGE) Degenerated leiomyomas variable in T2 hyaline and calcific degeneration (low) cystic degeneration (high) myxoid degeneration (very high, minimal enhance) Necrotic leiomyomas without liquefaction (variable in T1, low in T2) Red degeneration T1 : peripheral or diffuse high SI T2 : variable SI with or without low SI rim on T2

DIFFERENTIAL Dx ADEMOMYOSIS - presence of ectopic endometrial glands and stroma within the myometrium, which are associated with reactive hypertrophy of the surrounding myometrial smooth muscle - most commonly a diffuse abnormality but may also occur as a focal mass, which is known as an adenomyoma - diffuse form of adenomyosis appears as a thickened junctional zone (inner myometrium) on T2-weighted images

DIFFERENTIAL Dx ADEMOMYOSIS cont Junctional zone 12 mm thick or thicker is highly predictive of adenomyosis Small foci of high signal intensity on T2-weighted images represent the endometrial glands

Uterus Adenomyosis:

Adenomyosis:

Distinction between adenomyosis and leiomyomas is of clinical importance because, unlike leiomyomas, which may be treated with myomectomy, adenomyosis can be extirpated only with hysterectomy Adenomyosis appears as an ill-defined, poorly marginated area of low signal intensity within the myometrium on T2.

Differential Dx Solid Adnexal Mass - If MR imaging can demonstrate continuity of an adnexal mass with the adjacent myometrium, then a diagnosis of leiomyoma can be established. - Ovarian fibromas and Brenner tumors are benign ovarian neoplasms that have a large fibrous component and can have signal intensity similar to that of a pedunculated leiomyoma

Differential Dx Solid Adnexal Mass cont fibromas and Brenner tumors surrounded by ovarian stroma and follicles, thus establishing the ovarian origin of the mass and excluding a diagnosis of leiomyoma - important in pregnant patients because a confident diagnosis of a uterine leiomyoma may eliminate the need for surgery during pregnancy

Differential Dx Focal Myometrial Contraction - appear as a myometrial mass of low signal intensity on T2-weighted images

Differential Dx Uterine Leiomyosarcoma - may arise in a previously existing benign leiomyoma (sarcomatous transformation) or independently from the smooth muscle cells of the myometrium - Although it has been suggested that an irregular margin of a uterine leiomyoma at MR imaging is suggestive of sarcomatous transformation , the specificity of this finding has not been established - A diagnosis of leiomyosarcoma is established histologically by noting the presence of infiltrative margins, nuclear atypia, and increased mitotic figures

Treatment of Leiomyoma No treatment Conservative Radiological Surgical Myolysis. GNRHA Uterine a embolization. Patient (age-parity-symptoms). Fibroid (number-size-type) Complications.

Myomectomy Polypectomy. Hysterectomy. SURGICAL Myomectomy Polypectomy. Hysterectomy. (traditional- microsurgical).

uterine artery imbolization