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Leiomyoma: An overview

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.

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Leiomyoma: An overview

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  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 pregnancyor during oral contraceptive use, and regress after menopause • occurin 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.

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

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

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

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

  9. Leiomyomata Uterus

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

  11. CELLULAR LEIOMYOMAS • Compact smooth muscle cells with little or no collagen, canhave relatively higher signal intensity on T2.

  12. Changes occur with fibroid General Genital tract Tumor itself

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

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

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

  16. Degeneration • Leiomyomas enlarge outgrow their blood supply various types of degeneration • Hyaline degeneration :- thepresence of homogeneous eosinophilic bands or plaques in theextracellular space. • Myxoid degeneration - presence ofgelatinous intratumoral foci at gross examination that containhyaluronic acid–rich mucopolysaccharides

  17. Degeneration cont • Red degeneration - during pregnancy, secondary to venous thrombosis within the periphery ofthe tumor or rupture of intratumoral arteries • Sarcomatoustransformation -less than 3%

  18. DIAGNOSIS • History • Examination. • Investigation. • D.D.

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

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

  21. Investigations • Clinical • Laboratory • Imaging techniques • Instrumental • Miscellaneous

  22. Imaging Techniques(MR IMAGE) • most accurate imagingtechnique for detection and localization of leiomyomas • myomatous uterus (>140 cm3) is not consistentlypossible with US because of the limited field of view • uterine zonal anatomy enables accurate classification ofindividual masses as submucosal, intramural, or subserosal

  23. Imaging Techniques(MR IMAGE) cont • Nondegenerated uterine leiomyomas: • - well-circumscribed masses of homogeneously decreasedsignal intensity compared with that of the outer myometriumon T2-weighted images • - whorlsof uniform smooth muscle cells with various amounts of interveningcollagen

  24. 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

  25. DIFFERENTIAL Dx • ADEMOMYOSIS • - presence of ectopic endometrial glands and stroma withinthe myometrium, which are associated with reactive hypertrophyof the surrounding myometrial smooth muscle • - most commonly a diffuse abnormality butmay also occur as a focal mass, which is known as an adenomyoma • - diffuse form of adenomyosis appears as athickened junctional zone (inner myometrium) on T2-weightedimages

  26. DIFFERENTIAL Dx • ADEMOMYOSIS cont • Junctional zone 12 mm thick or thicker is highly predictiveof adenomyosis • Small foci of high signal intensity on T2-weightedimages represent the endometrial glands

  27. Uterus Adenomyosis:

  28. Adenomyosis:

  29. Distinction between adenomyosis and leiomyomas is of clinicalimportance because, unlike leiomyomas, which may be treatedwith myomectomy, adenomyosis can be extirpated only with hysterectomy • Adenomyosis appears asan ill-defined, poorly marginated area of low signal intensitywithin the myometrium on T2.

  30. Differential Dx • Solid Adnexal Mass • - If MR imaging can demonstrate continuityof an adnexal mass with the adjacent myometrium, then a diagnosisof leiomyoma can be established. • - Ovarian fibromas and Brenner tumorsare benign ovarian neoplasms that have a large fibrous componentand can have signal intensity similar to that of a pedunculatedleiomyoma

  31. Differential Dx • Solid Adnexal Masscont • fibromas and Brenner tumors surroundedby ovarian stroma and follicles, thus establishing the ovarianorigin of the mass and excluding a diagnosis of leiomyoma • - important in pregnant patients because a confidentdiagnosis of a uterine leiomyoma may eliminate the need forsurgery during pregnancy

  32. Differential Dx • Focal Myometrial Contraction • - appear as a myometrial mass of lowsignal intensity on T2-weighted images

  33. Differential Dx • Uterine Leiomyosarcoma • - may arise in a previously existing benign leiomyoma(sarcomatous transformation) or independently from the smoothmuscle cells of the myometrium • - Although it has been suggestedthat an irregular margin of a uterine leiomyoma at MR imagingis suggestive of sarcomatous transformation , thespecificity of this finding has not been established • - A diagnosis of leiomyosarcoma isestablished histologically by noting the presence of infiltrativemargins, nuclear atypia, and increased mitotic figures

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

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

  36. uterine artery imbolization

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