Uterine leiomyoma

Uterine leiomyomas, also known as uterine fibroids, are benign tumors of myometrial origin and are the most common solid benign uterine neoplasms. Commonly an incidental finding on imaging, they rarely cause a diagnostic dilemma.

Epidemiology

They are clinically apparent in ~25% of women of reproductive age and over 70% of women by menopause ²¹. Fibroids are responsive to hormones (e.g. stimulated by estrogens). Being rare in prepubertal females, they commonly accelerate in growth during pregnancy and involute with menopause ¹.

Risk factors

• 2-3x increased incidence in Black women than in White women ^20,21
• increasing incidence with age: 10x more common in 41-60-year-olds than 21-30-year-olds, reaching a peak at 50-60 years ^20,21
• 3x increased incidence with a family history of uterine fibroids ²¹

Clinical presentation

They are often asymptomatic and discovered incidentally. Signs and symptoms associated with fibroids include:

• abnormal vaginal bleeding
• pain
• infertility
• palpable masses

Pathology

Leiomyomas are benign monoclonal tumors ¹⁶ predominantly composed of smooth muscle cells with variable amounts of fibrous connective tissue. They are commonly multiple (~85% ⁸), and range significantly in size.

Fibroids may have a number of locations within or external to the uterus:

• intrauterine
  • intramural leiomyoma: most common
  • subserosal leiomyoma
  • submucosal leiomyoma: least common (10-15%)
• extrauterine
  • broad ligament leiomyoma
  • cervical leiomyoma
  • parasitic leiomyoma ⁷
• diffuse uterine leiomyomatosis

Subserosal fibroids may be pedunculated and predominantly extra-uterine, simulating an adnexal mass. Any fibroid may undergo atrophy, internal hemorrhage, fibrosis, and calcification.

They can also undergo several types of degeneration:

• hyaline degeneration: focal or generalized hyalinisation: this is the most common type of degeneration (can occur in ~60% of cases) ⁶
• cystic degeneration: ~5%
• myxoid degeneration: generally considered uncommon although reported as high as 50% by some authors ¹⁴
• red (carneous) degeneration: due to hemorrhagic infarction, which can occur particularly during pregnancy, and may present with acute abdominal pain

Based on histology

• uterine lipoleiomyoma
• myxoid uterine leiomyoma

Radiographic features

Plain radiograph

Popcorn calcification within the pelvis may suggest the diagnosis.

Ultrasound

Ultrasound is used to diagnose the presence and monitor the growth of fibroids:

• uncomplicated leiomyomas are usually hypoechoic, but can be isoechoic, or even hyperechoic compared to normal myometrium
• calcification is seen as echogenic foci with shadowing
• cystic areas of necrosis or degeneration may be seen
• Venetian blind artefact may be seen but edge shadowing +/- dense posterior shadowing from calcification is also typically seen ¹⁷

CT

• fibroids are usually seen as soft tissue density lesions and may exhibit coarse peripheral or central calcification
• they may distort the usually smooth uterine contour
• enhancement pattern is variable

MRI

MRI is not generally required for diagnosis, except for complex or problem-solving cases. It is, however, the most accurate modality for detecting, localizing, and characterizing fibroids. Size, location, and signal intensity should be noted.

Signal characteristics are variable and include ^1-2:

• T1
  • non-degenerated fibroids and calcification appear as low to intermediate signal intensity compared with the normal myometrium
  • characteristic high signal intensity on T1 weighted images/an irregular, T1 hyperintense rim around a centrally located myoma suggests red degeneration, which is caused by venous thrombosis
• T2
  • non-degenerated fibroids and calcification appear as low signal intensity
  • as they are usually hypervascular, flow voids are often observed around them ¹⁰
  • fibroids that have undergone cystic degeneration/necrosis can have a variable appearance, usually appearing high signal on T2 sequences.
  • hyaline degeneration is demonstrated as low T2 signal intensity
  • cystic degeneration, which is an advanced stage of intratumoral edema, also shows high signal intensity on T2 weighted images and does not enhance ¹⁰
• T1 C+ (Gd)
  • variable enhancement is seen with contrast administration
  • the marked high signal intensity with gradual enhancement (albeit mild) suggests myxoid degeneration

MRI is of significant value in the symptomatic patient when surgery and uterine salvage therapy is considered. It is also of great value in differentiating a pedunculated fibroid from an adnexal mass ⁵.

Treatment and prognosis

There are various medical, surgical, and interventional treatment options:

• myomectomy
• focal endometrial curettage
• hormone administration
• hysterectomy
• uterine artery embolization (UAE)

Complications

• rarely invasion of adjacent venous channels leading to intravenous leiomyomatosis ¹⁵
• rarely (0.1-0.5%), they undergo malignant degeneration into leiomyosarcomas
• benign metastasizing leiomyoma - extremely rare³
• torsion of subserosal leiomyoma
• pyomyoma ¹⁹
• changes in pregnancy
  • about a 1/3^rd of fibroids may grow in pregnancy (especially in 1^st trimester ¹⁸)
  • pregnancy may cause fibroid growth by 30%

Differential diagnosis

General imaging differential considerations include:

• uterine leiomyosarcoma
  • malignant transformation into leiomyosarcoma is rare.
  • unfortunately, no imaging modality can reliably differentiate a benign leiomyoma from the rare leiomyosarcoma
• uterine smooth muscle tumors of uncertain malignant potential: rare
• uterine lipoleiomyoma: greater fat content (sometimes considered a variant of a leiomyoma)
• focal myometrial contraction (Braxton Hicks contraction): especially if seen during pregnancy
• focal adenomyosis: less well-defined; color Doppler demonstrates tortuous vessels through the abnormality; no calcifications ^4,17

In occasional situations, it may be difficult to differentiate between uterine leiomyomas and:

• ovarian or adnexal masses (especially if the leiomyoma is pedunculated)
• endometrial carcinoma