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. Unusual-appearing uterine masses may best be treated surgically with myomectomy or hysterectomy rather than medically or with interventional radiology (i.e., uterine fibroid embolization). The diagnosis of a uterine fibroid with cystic degeneration was made. 5B —39-year-old woman with pelvic pain and presumed ordinary leiomyoma after receiving therapy with leuprolide acetate (Lupron, Abbvie). Maria Luisa C. Fogata MD. After surgery, mass was found to be atypical leiomyoma. 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 World Health Organization has recently (2014) updated its criteria for mesenchymal tumors of the female reproductive tract [8], and variants of benign smooth muscle tumors are diagnosed according to their unusual histologic features. Except for two, all were solid cystic masses whose solid part showed hypo- or isointensity on T1-weighted sequences, hyperintense signal intensity on T2-weighted scans, and heterogeneous enhancement. Results were read as fibroids, but at pathologic examination, large mass was found to be smooth muscle tumors of uncertain malignant potential (STUMP). The latter patient was found to have disease involving the cervical stump, the bladder dome, and a pelvic mass. Cellular leiomyomas in one series (n = 44) [36] had lower T2 signal intensity and were markedly enhanced compared with degenerated ordinary leiomyomas (Fig. Because leiomyomas may first be noted on CT scans, radiologists should become familiar with their characteristic appearance. She had uneventful post-operative recovery and was discharged on day 5. 9, No. [13] state, “The ideal criteria for follow-up remain elusive. 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. To our knowledge, there are no previous review articles in imaging journals addressing the many issues concerning leiomyoma variants. When fibroids bec… Imaging of leiomyomas and their variants allows classification by location in the uterus and pretreatment planning. 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. Unusual CT findings resembling malignant pelvic tumor: case report. Internal echo-poor foci suggest degeneration [25], and a hyperechoic echo pattern may suggest a lipoleiomyoma [26]. [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%). 4, 1 November 2009 | RadioGraphics, Vol. In addition, infarction, hemorrhage, hyalinization, and hydropic changes are also commonly present. Key teaching point, in this case, is that cystic degeneration of fibroids can look very large and alarming and raise the concern for a malignant mass. Also recently, the negative effect of leiomyoma morcellation devices on the survival of patients who are found to have malignant instead of benign uterine masses has received attention, not only in the medical literature but also in the lay press [6]. non-degenerated fibroids and calcification appear as low to intermediate. 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. Degenerating Cystic Uterine Fibroid Mimics an Ovarian Cyst in a Pregnant Patient. [7], who conducted a review of 1332 patients who underwent surgery for presumed leiomyoma and concluded that, “The incidence of sarcoma among patients having surgery for ‘rapidly growing' leiomyoma (0.27%) or among those who met published criteria for rapid growth (0%) does not substantiate the concept of increased risk of sarcoma in these women.” Thus, the diagnosis of a variant cannot be made with certainty until a pathologist thoroughly evaluates the surgically removed fibroid (see the Pathologic Features of Leiomyoma Variants section later in this article). stimulated by estrogens). Affiliations. B, Axial T1 fat-suppressed unenhanced scan is unremarkable. However, other investigators, such as Ip et al. 21, No. Although benign, they can be associated with significant morbidity and are the commonest indication for hysterectomy. In a series attempting to distinguish benign from malignant uterine tumors (n = 51) [39], there were five uterine STUMPs. Fig. 1B —38-year-old woman with symptomatic leiomyomas. The tumor is rich in vasculature of various calibers and types, including muscle-rich arteries, arterioles, and veins. A case of massive cystic degeneration in a uterine fibroid 21 cm × 16 cm × 12 cm. Jun 26, 2016. Fatty degeneration or lipoleiomyoma has signal intensity consistent with fat on MRI [32] (Fig. 6, International Journal of Surgery Case Reports, Vol. Often fibroids >5–8 cm in diameter degenerate. 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. Cystic degeneration of fibroids should be considered as one of the differential diagnosis for all women presenting with acute abdominal pain. A surgical approach is safe even though not well documented on acute presentations. 11, Canadian Association of Radiologists Journal, Vol. A case of massive cystic degeneration in a uterine fibroid 21 cm × 16 cm × 12 cm mimicking malignant ovarian tumor. 3, Journal of Computer Assisted Tomography, Vol. 8, No. Degenerated leiomyomas have a variable appearance on T2WI. [11] reported the largest single-institution series of women who were treated for cellular leiomyomas, and only two of 99 patients (2%) had recurrent disease, one 43 months after an abdominal myomectomy and the other 120 months after a vaginal hysterectomy for multiple cellular leiomyomas (with benign metastasizing leiomyomas to the lungs). In non –pregnant it may appear so … 2A —53-year-old woman with indeterminate mass on ultrasound. A surgical approach is safe … Mass was predominantly cystic with septations. Bleeding during pregnancy, resulting from a type of degeneration called necrobiosis. [9] reviewed 127 patients representing the pathologic spectrum, from uterine leiomyomas to leiomyosarcomas, using World Health Organization and Stanford criteria. is a prerequisite for the development of targeted therapies against these lesions” (uterine leiomyomas). Fig. Dec 11, 2018. D, Representative histologic specimen of uterine STUMP shows marked cellularity and cytologic atypia (but mitotic count < 10/10 high-power fields). Int J Gynecol Endsc 2017;1(1):46-49. Ultrasonography (USG) and CT showed a large mass abutting the uterus extending into the abdomen. 6A —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. Imaging Features of Postoperative Complications After Spinal Surgery and Instrumentation, Review. Varras M 1, Antoniou S, Samara Ch, Frakala S, Angelidou-Manika Z, Paissios P. Author information. The process of fibroid degeneration may sometimes cause pain in the pelvic region. B, Oblique axial T2-weighted scan shows that mass arises from uterus and has peripheral high signal intensity with laminated low signal intensity. STUMP is diagnosed when atypical histologic features are found that range between leiomyoma and leiomyosarcoma [8]. A, Axial T1-weighted scan shows homogeneously low-signal intensity adnexal mass. 19, 2 December 2016 | Indian Journal of Gynecologic Oncology, Vol. PDF | Uterine fibroids, also known as leiomyomas, are the commonest uterine neoplasms. Atypical leiomyomas and STUMPs routinely express progestin receptors [20]; however, because of the low recurrence rates, there is no role established for adjuvant hormonal therapy. Though fibroid degeneration does decrease the size of fibroids, it cannot manage them long-term — a degenerated fibroid is likely to expand and degenerate again. Up to 75% of hysterectomy specimens harbor leiomyomas, with multiple leiomyomas seen in most cases. 6B —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. 8B —49-year-old woman with history of fibroids referred for MRI for before uterine fibroid embolization. An intramural fibroid is a noncancerous tumor that grows between the muscles of the uterus, typically discovered during a routing pelvic exam. Keywords: leiomyoma, leiomyoma variants, leiomyosarcoma, pelvic MRI, smooth muscle tumors of uncertain malignant potential. The two leiomyoma variants that require clinical and imaging surveillance after myomectomy are atypical leiomyoma and STUMP. MRI showed large multiseptated cystic mass 21 × 16 cm × 12 cm in the right. One case report [38] of an atypical leiomyoma arising from the vaginal fornix was well defined, moderately T2 intense, and homogeneously enhanced. Age and parity were significantly lower in patients with non-fibroid cysts. 5), as well as mitotically active leiomyomas, are very rare; hence, reports of their imaging appearance are scarce. For patients with STUMP who have undergone a morcellation myomectomy, prompt reexploration and staging to identify whether dissemination of abnormal smooth muscle cells occurred is indicated [16]. Ultrasonography (USG) and CT showed a large mass abutting the uterus extending into the abdomen. Typical appearance of fibroid uterus on CT. 6D —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. The preoperative diagnosis was accurate in 20/21 (95.2%) cases with a degenerated leiomyoma. cystic degeneration of the fibroid (arrows). 181, No. 4, American Journal of Roentgenology, Vol. 189, No. On ultrasound, the detection of hypervascularity in a large solitary uterine mass can identify suspicious masses, such as a leiomyosarcoma [27]. Large or small cystic spaces develop in the edematous, acellular center (, 1,, 5,, 6). Find out what symptoms intramural fibroids … 3C —48-year-old woman referred for MRI for further evaluation of possible ovarian mass on ultrasound and pelvic examination. 3A —48-year-old woman referred for MRI for further evaluation of possible ovarian mass on ultrasound and pelvic examination. Benign uterine leiomyomas (fibroids) are the most common pelvic. On ultrasound, the classic appearance of an ordinary (nondegenerated) leiomyoma is a round or oval circumscribed hypoechoic solid mass, often with associated posterior shadowing due to calcifications or interface of the margins of the leiomyoma with the normal myometrium. Occasionally, cells have further chromatin condensation and fragmentation, resembling atypical mitotic figures. Taran et al. Parasitic leiomyomas are attached to the pelvic peritoneum and are presumed to originate from a pedunculated subserosal leiomyoma that became vascularized by the adjacent peritoneum, losing its attachment to the uterus and its blood supply, but are also histologically benign. 2C —53-year-old woman with indeterminate mass on ultrasound. 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]. A, Axial T2-weighted image shows several well-circumscribed hypointense submucosal intramural and subserosal leiomyomas. When there is chemical change of the tissue itself, it is true degeneration; when the change consists in the deposit of abnormal matter in the tissues, it is infiltration. D, Axial T1-weighted fat-suppressed subtraction image after IV contrast administration shows minimal enhancement of nonfat component. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma can undergo. Uterine STUMPs have been only sporadically described in the imaging literature given their rareness. Out of these, hyaline degeneration is common occurring in about 60% of cases whereas cystic degeneration is rare in about 4%. One patient with STUMP was found to have implants on the rectosigmoid colon when undergoing surgical reexploration 102 days after a power morcellation procedure. 6C —45-year-old woman who underwent MRI to evaluate size of uterine fibroids. If a leiomyoma undergoes myxoid degeneration, then hypocellularity and a myxoid matrix without nuclear atypia or other features of malignancy is seen. Cystic degeneration of uterine leiomyoma is a rare condition that may sometimes present with clinical and imaging findings giving impression of other diagnosis like ovarian mass or … Maria Luisa C. Fogata MD. If a leiomyoma undergoes fatty degeneration, pathologically the lipoleiomyoma has an integral component of mature adipose tissue. Myxoid degeneration is very rare but has been reported to show marked hyperintensity but with an unusual enhancement pattern (Fig. Myxoid degeneration is a rare type of leiomyoma degeneration. Your doctor may feel moderate and large uterine fibroids during a routine. Fig. A history of tamoxifen use for more than five yea… There was no sign of appendicitis. Precise knowledge of the histopathologic backgrounds of degeneration and the clinical course helps u… Fig. describe the CT findings of uterine leio- myomas and their secondary changes, including cystic degeneration, calcification, infection, necrosis, fatty degeneration . STUMPs also have the malignant potential to develop a low-grade leiomyosarcoma (not the high grade). 4A —45-year-old woman with symptomatic fibroids who underwent MRI for preoperative planning. On the basis of these findings, subserosal myoma or an intra-ligamentary fibroid with. Fig. Methods: The incidence, clinical presentation and accuracy in preoperative diagnosis of cystic uterine tumors were studied in a university hospital population over a 6-year period. 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 … 29, No. Case reports [43, 44] have also reported these findings on conventional sequences. Of these, 8 corresponded to the diagnosis of a non-fibroid uterine cystic enlargement, and 21 to that of a fibroid with cystic degeneration. Ultrasound diagnosis was ovarian cyst. 6, Journal of Computer Assisted Tomography, Vol. Leiomyosarcomas, on gross pathologic analysis, typically are large solitary masses with a diameter greater than 10 cm and are not well circumscribed (i.e., with infiltrating margins) [8]. Fig. Journal of Evolution of Medical and Dental Sciences, Vol. This variant, Ly et al of enhancement consistent with myxoid leiomyoma nuclear medicine imaging case: a,. Oblique Sagittal IV contrast-enhanced scan, mass enhances less than myometrium and appears well.... Because it is not a reliable predictor of leiomyosarcoma according to Parker et al study... Stump tumors in patients with mitotically active leiomyomas, leiomyoma variants are neither well studied nor understood an. Various forms of degeneration that can occur in pregnancy and non-pregnant state in the imaging literature their. Of mature adipose tissue both mitotically active leiomyomas, are one of the rarer types of leiomyomas shows mass... 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