BYBY

Mohammad A. EmamProf. of Obstetrics and Gynecology

Mansoura Faculty of MedicineMansoura integrated fertility center (MIFC)

Egypt

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

menopause

occur in women of reproductive age, often

Uterus Uterus deprived deprived from a baby from a baby consoles consoles itself with a itself with a fibroid.fibroid.

M.Emam

CausesCauses

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

fundus).

PathologyPathologyNIE:NIE: -Site - shape - size.

- Consistency - cut section - capsule - Number - varieties.

Varieties of leiomyoma

uterine •cervical.

•Corporeal

extrauterine•Round lig•brood lig

•Recto-vog. Sept•utero - sacral

Leiomyomotosis•tunica M

•extension from Myoma

Uterine leiomyoma

Corporeal •98%•multiple

Cervical •1-2%•solitary

M.Emam

M.Emam

Corporeal leiomyoma

submucus •24%•not capsulated

Subserous •18%

Interstitial •58%

M.Emam

M.Emam

M.Emam

Cervical leiomyoma

Supravaginal cervix true

(ant - post - central - combined) false

(intralig - retraperit- not capsulated)

Portio vaginalis •small •sessile•polypoid

CONSISTENCYCONSISTENCYFirmFirmHarder Harder (hyaline degeneration).(hyaline degeneration).Soft Soft (pregnancy-cystic degeneration).(pregnancy-cystic degeneration).

Stony hard (Calcification)Stony hard (Calcification)

Leiomyomata Uterus

CUT SECTIONCUT SECTIONWell demarcated Well demarcated

surrounding muscle.surrounding muscle.whorly (intermingling muscle whorly (intermingling muscle

fibers and fibrous tissue).fibers and fibrous tissue).Paler than surrounding (Ischaemia).Paler than surrounding (Ischaemia).

Leiomyoma:

Moham

Emam

Microscopic Microscopic ExaminationExamination

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 Changes occur with fibroidfibroid

GeneralGenital tract

Tumor itself

General changesGeneral changesErythrocytosis.Polycythaemia (erythropoitic).Carbohydrate metabolism

(hyperglycaemia).Anaemia (hge).

Genital tractGenital tractUterus (endomet.-cavity-myomet.-uterus

as a whole).Tubes inflammed (salpingitis)ovaries (tunica albuginea-endometriosis-

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

Tumour itselfTumour itselfAtrophy.Degeneration (hayline-red-cystic-fatty-

calcerous) Necrosis.Malignancy (growth after menopause-rapid

enlargement-recurrent fibroid polyp).Vascular (oedema-lymphangectasia)Infection.

DegenerationLeiomyomas 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%

DIAGNOSISDIAGNOSISHistoryExamination.Investigation.D.D.

SYMPTOMSSYMPTOMS Bleeding (menorrhagia-metrorrhagia). Pain uncomplicated (cong.

Dysmenorrhea – dull - colicky). Pain complicated deg.-malig.-

infection-torsion) infertility mass. Discharge. Pressure symptoms.

SignsSigns•Symmetrically enlarged uterus(submucosal fibroid).

•Asymmetrically enlarged uterus(subserous fibroid)

InvestigationsClinicalLaboratoryImaging techniquesInstrumentalMiscellaneous

Imaging TechniquesImaging Techniques (MR IMAGE)(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 TechniquesImaging Techniques (MR IMAGE) (MR IMAGE) contcont

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 TechniquesImaging Techniques (MR IMAGE)(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 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 DxDifferential 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 DxDifferential 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 DxDifferential DxFocal Myometrial Contraction

- appear as a myometrial mass of low

signal intensity on T2-weighted images

Differential DxDifferential 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 Treatment of LeiomyomaLeiomyoma

No treatmentConservativeRadiologicalSurgicalMyolysis.GNRHAUterine a

embolization.

Patient (age-parity-symptoms).

Fibroid (number-size-type)

Complications.

SURGICALSURGICALMyomectomy

Polypectomy.Hysterectomy.

(traditional- microsurgical).

M.Emam

Myomectomy Hysterectomy Patient

Age. Parity.

Fibroid

No

Type

Size Associated

<40 years anxious to have children solitary-few-welldefined subserous (pedunclated) small to moderate no

>40 years complete her family large subserous-submucous and complicated large +ve complications (pressure Symptoms)

OB& GYN, Mansoura Faculty of Medicine

Mansoura Integrated Fertility Center (MIFC) EGYPT

Telfax 0020502319922 & 0020502312299

Email. mae335@hotmail.com