Mohammad A. Emam

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Leiomyoma An overview

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

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Epidemiology

• The commonest of all pelvic T. (1/3).
• 20 of female gt 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

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

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Causes

• Unknown.
• Hyperestrogenemia.
• Infertility ?!
• Mechanical stress (lat wall fundus).

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Pathology

• NIE
• -Site - shape - size.
• - Consistency - cut section
• - capsule - Number
• - varieties.

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

• uterine
• cervical.
• Corporeal

• Leiomyomotosis
• tunica M
• extension from Myoma

Varieties of leiomyoma
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Uterine leiomyoma

• Cervical
• 1-2
• solitary

• Corporeal
• 98
• multiple

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Corporeal leiomyoma

• submucus
• 24
• not capsulated

• Subserous
• 18

• Interstitial
• 58

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Cervical leiomyoma

• Portiovaginalis
• small
• sessile
• polypoid

Supravaginal cervix true (ant - post - central
- combined) false (intralig - retraperit- not
capsulated)
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CONSISTENCY

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

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Leiomyomata Uterus
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CUT SECTION

• Well demarcated surrounding muscle.
• whorly (intermingling muscle fibers and fibrous
  tissue).
• Paler than surrounding (Ischaemia).

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Leiomyoma
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Microscopic Examination

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

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CELLULAR LEIOMYOMAS

• Compact smooth muscle cells with little or no
  collagen, can have relatively higher signal
  intensity on T2.

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Changes occur with fibroid

• General
• Genital tract
• Tumor itself

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General changes

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

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Genital tract

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

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Tumour itself

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

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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 acidrich mucopolysaccharides

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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

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DIAGNOSIS

• History
• Examination.
• Investigation.
• D.D.

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SYMPTOMS

• Bleeding (menorrhagia-metrorrhagia).
• Pain uncomplicated (cong.
  Dysmenorrhea dull - colicky).
• Pain complicated deg.-malig.-infection-tors
  ion)
• infertility
• mass.
• Discharge.
• Pressure symptoms.

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Signs

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

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Investigations

• Clinical
• Laboratory
• Imaging techniques
• Instrumental
• Miscellaneous

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Imaging Techniques (MR IMAGE)

• most accurate imaging technique for detection and
  localization of leiomyomas
• myomatous uterus (gt140 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

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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

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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

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DIFFERENTIAL Dx(DD)
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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

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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

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Uterus Adenomyosis
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Adenomyosis
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• 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.

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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

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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

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Differential Dx

• Focal Myometrial Contraction
• - appear as a myometrial mass of low signal
  intensity on T2-weighted images

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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

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Treatment of Leiomyoma

• No treatment
• Conservative
• Radiological
• Surgical
• Myolysis.
• GNRHA
• Uterine a embolization.

• Patient (age-parity-symptoms).
• Fibroid (number-size-type)
• Complications.

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SURGICAL

• Myomectomy
• Polypectomy.
• Hysterectomy.

• (traditional- microsurgical).

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Thank you
Prof. MOHAMMAD EMAM
OB GYN, Mansoura Faculty of Medicine Mansoura
Integrated Fertility Center (MIFC) EGYPT Telfax
0020502319922 0020502312299 Email.
mae335_at_hotmail.com