Mohammad A. Emam

BY

Mohammad A. Emam Prof. of Obstetrics and Gynecology Mansoura Faculty of Medicine Mansoura integrated fertility center (MIFC) Egypt

Epidemiology  The commonest of all pelvic T.

(1/3).  20% of female > 30y do have fibroid.  Childbearing life.  often enlarge during pregnancy or during oral contraceptive use, and regress after menopause

Uterus

deprived from a baby consoles itself with a fibroid.

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Causes Unknown. Hyperestrogenemia. Infertility

?! Mechanical stress (lat wall + fundus).

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

extrauterine

uterine

•cervical. •Corporeal

•Round lig •brood lig •Recto-vog. Sept •utero - sacral

Leiomyomotosis

•tunica M •extension from Myoma

Varieties of leiomyoma

Uterine leiomyoma

Cervical

•1-2% •solitary

Corporeal

•98% •multiple

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Corporeal leiomyoma

Interstitial

•58%

Subserous •18%

submucus

•24% •not capsulated

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Cervical leiomyoma

Portiovaginalis •small •sessile •polypoid

Supravaginal cervix true (ant - post - central - combined)

false

(intralig - retraperit- not capsulated)

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

Leiomyomata Uterus

CUT SECTION Well demarcated

surrounding muscle. whorly (intermingling muscle fibers and fibrous tissue).  Paler than surrounding (Ischaemia).

:Leiomyoma

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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 albugineaendometriosis-cysts).  Blood vessels.  Endometriosis (30-40%).

Tumour itself  Atrophy.  Degeneration (hayline-red-cystic-fattycalcerous)  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

Degenerationcont 



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 •Symmetrical ly enlarged uterus(subm ucosal fibroid). •Asymmetric ally enlarged uterus(subse

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)DD

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  Junctional

cont

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  Patient (age-parity Conservative symptoms).  Radiological  Fibroid (number-size Surgical type)  Myolysis.  Complications.  GNRHA  Uterine a embolization.

SURGICAL Myomectomy (traditionalmicrosurgical). Polypectomy. Hysterectomy.

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Myomectomy

Hysterectomy

Patient Age. • Parity. •

<40 years anxious to have children

>40 years complete her family

Fibroid No •

solitary-few-welldefined

large

•

Type

subserous (pedunclated)

•

Size

small to moderate

subserous-submucous and complicated large

Associated

no

+ve complications (pressure Symptoms)

OB& GYN, Mansoura Faculty of Medicine Mansoura Integrated Fertility Center (MIFC) EGYPT Telfax 0020502319922 & 0020502312299 Email. [email protected]