1. Leiomyoma:
An overview

2. 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

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

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

6. 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

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

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

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

13. Leiomyomata Uterus

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

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

16. Changes occur with fibroid
General
Genital tract
Tumor itself

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

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

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

20. 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

21. 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%

22. DIAGNOSIS
History
Examination.
Investigation.
D.D.

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

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

25. Investigations Clinical Laboratory Imaging techniques Instrumental
Miscellaneous

26. 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

27. 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

29. 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

31. 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

32. 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

33. Uterus Adenomyosis:

34. Adenomyosis:

35. 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.

36. 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

37. 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

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

40. 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

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

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

45. uterine artery imbolization