A, Axial T1-weighted image shows isolated large subserosal isointense well-circumscribed mass. The typical appearance of leiomyoma is easily recognized on ultrasound but degenerations, as in our case may cause confusion in diagnosis. 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. Because leiomyomas may first be noted on CT scans, radiologists should become familiar with their characteristic appearance. In other instances the women we see have numerous–up to 20–small. 205, No. One of the four patients with presumed stage I STUMP who was immediately surgically staged was found to have an omental implant. Their typical appearances at magnetic resonance (MR) imaging have been well established (,3,,4). 8), and on T2-weighted images, the sarcomas were intermediate to high signal intenstiy. 2, EMC - Radiologie et imagerie médicale - Génito-urinaire - Gynéco-obstétricale - Mammaire, Vol. Ultrasonography (USG) and CT showed a large mass abutting the uterus extending into the abdomen. Ultrasonography (USG) and CT showed a large mass abutting the uterus extending into the abdomen. Histologically, they exhibit hypercellularity, diffuse moderate-to-marked nuclear atypia, a high mitotic rate (≥ 10/hpf), and tumor cell necrosis. Corresponding Author. Uterine fibroids occur during the reproductive years. 7, Best Practice & Research Clinical Obstetrics & Gynaecology, Vol. Degenerating Cystic Uterine Fibroid Mimics an Ovarian Cyst in a Pregnant Patient. 3B —48-year-old woman referred for MRI for further evaluation of possible ovarian mass on ultrasound and pelvic examination. How to cite this article Jain N, Hakim M. Cystic Degeneration of Fibroid following Mifepristone. Linear signal void along posterior fundus represents prior myomectomy changes after removal of conventional fibroid. 6C —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. stimulated by estrogens). 6D —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. C, Axial T1-weighted fat-suppressed IV contrast-enhanced scan shows areas of nonenhancement that correspond to foci of hemorrhage, consistent with hemorrhagic necrosis, commonly seen in leiomyosarcomas. In our experience and on the basis of our review, the most suggestive features of leiomyosarcoma are foci of increased signal intensity on T1 that do not enhance hemorrhagic or proteinaceous (necrotic) fluid, moderate signal on T2-weighted scans (which enhances), and ill-defined margins. B, Axial T1 fat-suppressed unenhanced scan is unremarkable. 24, No. Cellular leiomyomas are more likely to be singular and larger than ordinary leiomyomas; there is also a higher likelihood that endometriosis or adenomyosis is absent, that the patient is symptomatic with menometrorrhagia, and that the indication for the imaging study is “enlarging leiomyoma” [11]. 10, 20 October 2013 | Head and Neck Pathology, Vol. Fortunately, most of these variants are rare and have a benign natural history, given currently there are no significant series to establish definitive clinical or imaging findings that can reliably distinguish among them. Fig. Zhang et al. 2, Surgical Pathology Clinics, Vol. A surgical approach is safe even though not well documented on acute presentations. Cystic degeneration may be considered an extreme sequela of edema and is observed in about 4% of leiomyomas (, 1). While fibroids are non-cancerous, they cause uncomfortable and often painful symptoms and can lead to infertility. If future MRI research cannot improve diagnostic imaging accuracy, perhaps there is a potential role for nuclear medicine imaging. Cystic degeneration is evidenced by internal areas of T2 hyperintensity (fluid signal) with a lack of contrast enhancement [30]. The histopathology result confirmed hyaline cystic degeneration of uterine fibroids. In contrast to coagulative tumor cell necrosis seen in malignant leiomyosarcomas, infarction necrosis observed in ordinary benign leiomyomas is typically zonal, with necrotic smooth muscle cells surrounded by rims of granulation to hyalinized fibrous tissue. Fever in addition to other symptoms. cystic degeneration: [ de-gen″ĕ-ra´shun ] deterioration; change from a higher to a lower form, especially change of tissue to a lower or less functionally active form. 7A —40-year-old woman who underwent MRI for pain and to evaluate uterine mass. This is due, at least in part, to the down‐regulation of local angiogenic factors alongside a significant reduction in fibroid vascularization 3, 4. At laparotomy a huge cyst of 41cm×38cm originating from the anterior uterine wall with multiple adhesions, cystic fluid measured about 8.2litres. study (CT or magnetic resonance imaging (MRI)) is mandatory to evaluate. [12] described 51 atypical leiomyomas of the uterus: one of 34 patients undergoing hysterectomy had recurrent disease in the retroperitoneum, two of 17 patients initially treated by myomectomy were found to have residual atypical leiomyoma in a subsequent hysterectomy, and a third patient underwent a second myomectomy for atypical leiomyoma (4/34; 12%). Uterine leiomyomas and leiomyosarcomas are at opposite ends of the pathologic spectrum of uterine smooth muscle tumors. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma can undergo. Cystic degeneration—Cystic degeneration occurs in approximately 4% of leiomyomas and may be the result of liquefaction after extreme hyaline degeneration . 26, No. [13] state, “The ideal criteria for follow-up remain elusive. In terms of treatment, if a clinician is informed that a fibroid or uterine mass looks unusual on imaging studies, then this can influence how the tumor is treated. When fibroids bec… 2B —53-year-old woman with indeterminate mass on ultrasound. This article reviews current approaches to the management of uterine fibroids, soft-tissue detail when compared with computed tomography (CT), and has a useful. Rates of symptomatic women (60 vs. 55.6%) were similar in both groups. Internal echo-poor foci suggest degeneration [25], and a hyperechoic echo pattern may suggest a lipoleiomyoma [26]. For patients who have only undergone a myomectomy and found to have an atypical leiomyoma and wish to retain their uterus, annual pelvic ultrasound or, preferably, MRI should be incorporated into surveillance of the uterus. The purpose of this review is thus to summarize the relevant clinical, imaging, and pathologic findings of leiomyoma variants. There was no sign of appendicitis. Find out what symptoms intramural fibroids … 5C —39-year-old woman with pelvic pain and presumed ordinary leiomyoma after receiving therapy with leuprolide acetate (Lupron, Abbvie). There are no clinical findings that reliably differentiate ordinary leiomyomas from leiomyoma variants and leiomyosarcomas. The typical appearance of a … 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. STUMPs also have the malignant potential to develop a low-grade leiomyosarcoma (not the high grade). The presence of a T2-hyperintense rim indicates a pseudocapsule of edema secondary to some degree of venous or lymphatic obstruction [29]. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Degenerated Leiomyoma 20: Red (hemorrhagic) degeneration of UF is characterised by variable signal. Much remains to be learned clinically, particularly regarding those histologic entities that lie between, called leiomyoma variants. 4, Korean Journal of Radiology, Vol. Epidemiology This type of degeneration is thought to represent ~4% of all types of degeneration. Fig. No matter how severe the pain is, it is not life threatening. is a prerequisite for the development of targeted therapies against these lesions” (uterine leiomyomas). MRI showed large multiseptated cystic mass 21 × 16 cm × 12 cm in the right. Specifically, a rapidly growing uterine mass is not a reliable predictor of leiomyosarcoma according to Parker et al. 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 ]. 1, No. Degeneration, involving cell death, occurs inside the fibroid, and calcification, where calcium is deposited in the fibroid tissue, may be seen on an ultrasound scan. Maria Luisa C. Fogata MD. Hyaline (60%),; Cystic (4%),; Red (3%), Myxoid (1-3%); Calcified (4%); Sarcomatous degeneration (0.1-0.8%).1Hyaline cystic degenerations are rare as only case reports were found in the literature.1The … To our knowledge, there are no previous review articles in imaging journals addressing the many issues concerning leiomyoma variants. A CT scan of the abdomen and pelvis performed to exclude a surgical cause showed a 7.3×10.0×12.0 cm mass arising from the posterior wall of the uterus with irregular margin inferiorly representing a fibroid with degeneration, infarction or, less likely, malignant changes and surrounding mesenteric inflammation . If the address matches an existing account you will receive an email with instructions to reset your password. Background/aims: The differential diagnosis of cystic uterine tumors includes fibroids showing cystic degeneration, cystic adenomyomas, congenital cysts, and developmental anomalies. However, frequently these tumors are not accompanied by symptoms, and they are found incidentally during computed tomographic (CT) examinations performed for other indications. Case reports [43, 44] have also reported these findings on conventional sequences. Histologically, leiomyomas are composed of fascicles of elongated smooth muscle cells with eosinophilic cytoplasm and a centrally located cigar-shaped nucleus. Ultrasound diagnosis was ovarian cyst. Once the degeneration is complete, any pain or fever usually goes away. The latter patient was found to have disease involving the cervical stump, the bladder dome, and a pelvic mass. Generally, the ultrasonic appearance of uterine fibroids is typical, and diagnosis is uncomplicated. The National Comprehensive Cancer Network Clinical Practice Guidelines for posttreatment surveillance of leiomyosarcomas include physical examination every 3–4 months for 2 years as well as imaging of the chest, abdomen, and pelvis every 3–4 months for 2–3 years, then every 6–12 months for the next 2 years. CT is not the primary modality in the diagnosis of fibroid It is unclear whether uterine fibroid embolization treats a STUMP or atypical myoma, but if the fibroid could be a leiomyosarcoma, then uterine fibroid embolization will not be effective and it will continue to grow [21]. These atypical smooth muscle cells have abundant eosinophilic cytoplasm, irregular nuclear shapes, and multinucleation. 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. Using apparent diffusion coefficient values, a value less than 1.1 put the lesion in a high-risk group; an apparent diffusion coefficient value of 1.1 or higher categorized the lesion as low risk, but apparent diffusion coefficient values for cellular leiomyomas overlapped. Radiologist suggested that leiomyoma could be smooth muscle tumor of uncertain malignant potential, so patient underwent myomectomy. On gross pathologic analysis, uterine leiomyomas are circumscribed with a solid rubbery firm texture and bulging cut surface [46]; they are generally white, but if degeneration is present, the color (red, brown, or yellow) and texture (edematous, fleshy, or obviously necrotic) may be different. Many myomectomies are performed in women who wish to preserve fertility or do not want to undergo a hysterectomy; in such cases, it would seem prudent to avoid morcellation procedures to remove an unusual-appearing fibroid if preoperative imaging studies raise the possibility of a leiomyoma variant. Fig. 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). They appear hypocellular with a myxoid matrix 6. Fig. Fig. An icon used to represent a menu that can be toggled by interacting with this icon. The following histologic findings are frequently entertained as STUMP: a smooth muscle tumor with an uncertain type of necrosis, the presence of focal or diffuse cytologic atypia but the mitotic count is less than 10/10 hpf, the presence of coagulative tumor necrosis but mitosis is less than 10/10 hpf, and cellular tumors with more than 15 mitoses/10 hpf. Fig. 3) because of the intense enhancement of the stroma with no enhancement of the intervening mucinous lakes [34]. On ultrasound, the detection of hypervascularity in a large solitary uterine mass can identify suspicious masses, such as a leiomyosarcoma [27]. C, Axial T1-weighted fat-suppressed IV contrast-enhanced scan shows heterogeneous enhancement. cystic. Because of moderate signal intensity on T2-weighted scans, mass was thought to be smooth muscle tumor of uncertain malignant potential, but at pathologic analysis, it was determined to be cellular myoma. CONCLUSION. Transabdominal biopsy confirmed benign, degenerating fibroid. 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. Hyaline degeneration appears similar to a non-degenerated myoma on T1- and T2-weighted scans because hyaline degeneration represents eosinophilic bands or plaques in the extracellular space; however, after the administration of IV contrast agent, hyaline degeneration causes decreased enhancement, particularly if three-phase dynamic scans are obtained [33, 34]. The purpose of this article is to review the clinical, imaging, and pathologic features of leiomyoma variants. For example, in one of the largest series on this variant, Ly et al. Ultrasound is the first-line imaging modality because it is a cost-effective portable real-time examination that provides good anatomic detail without radiation. the degeneration – hyaline, cystic, myxoid, red degeneration and dystrophic. In a series attempting to distinguish benign from malignant uterine tumors (n = 51) [39], there were five uterine STUMPs. Fig. Often fibroids >5–8 cm in diameter degenerate. Transabdominal biopsy confirmed benign, degenerating fibroid. The 43 years, patient presented with lump abdomen with heavy periods and anemia. non-degenerated fibroids and calcification appear as low to intermediate. Because of moderate signal intensity on T2-weighted scans, mass was thought to be smooth muscle tumor of uncertain malignant potential, but at pathologic analysis, it was determined to be cellular myoma. Patient underwent … Affiliations. OBJECTIVE. A case of massive cystic degeneration in a uterine fibroid 21 cm × 16 cm × 12 cm. Ultrasonography and CT revealed a large solid mass with cystic areas extending into both uterine adnexa. 5A —39-year-old woman with pelvic pain and presumed ordinary leiomyoma after receiving therapy with leuprolide acetate (Lupron, Abbvie). cystic degeneration of the fibroid (arrows). Cystic degeneration of fibroids should be considered as one of the differential diagnosis for all women presenting with acute abdominal pain. 1C —38-year-old woman with symptomatic leiomyomas. 8C —49-year-old woman with history of fibroids referred for MRI for before uterine fibroid embolization. 21, No. 7, No. After surgery, mass was found to be atypical leiomyoma. Journal of Evolution of Medical and Dental Sciences, Vol. 7B —40-year-old woman who underwent MRI for pain and to evaluate uterine mass. 2, No. 3C —48-year-old woman referred for MRI for further evaluation of possible ovarian mass on ultrasound and pelvic examination. 1. 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