fibroids
DESCRIPTION
TRANSCRIPT
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BYBY
Mohammad A. EmamProf. of Obstetrics and Gynecology
Mansoura Faculty of MedicineMansoura integrated fertility center (MIFC)
Egypt
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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
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Uterus Uterus deprived deprived from a baby from a baby consoles consoles itself with a itself with a fibroid.fibroid.
M.Emam
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CausesCauses
Unknown.Hyperestrogenemia.Infertility ?!Mechanical stress (lat wall +
fundus).
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PathologyPathologyNIE:NIE: -Site - shape - size.
- Consistency - cut section - capsule - Number - varieties.
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Varieties of leiomyoma
uterine •cervical.
•Corporeal
extrauterine•Round lig•brood lig
•Recto-vog. Sept•utero - sacral
Leiomyomotosis•tunica M
•extension from Myoma
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Uterine leiomyoma
Corporeal •98%•multiple
Cervical •1-2%•solitary
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M.Emam
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M.Emam
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Corporeal leiomyoma
submucus •24%•not capsulated
Subserous •18%
Interstitial •58%
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M.Emam
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M.Emam
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M.Emam
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Cervical leiomyoma
Supravaginal cervix true
(ant - post - central - combined) false
(intralig - retraperit- not capsulated)
Portio vaginalis •small •sessile•polypoid
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CONSISTENCYCONSISTENCYFirmFirmHarder Harder (hyaline degeneration).(hyaline degeneration).Soft Soft (pregnancy-cystic degeneration).(pregnancy-cystic degeneration).
Stony hard (Calcification)Stony hard (Calcification)
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Leiomyomata Uterus
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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).
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Leiomyoma:
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Moham
Emam
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Microscopic Microscopic ExaminationExamination
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 Changes occur with fibroidfibroid
GeneralGenital tract
Tumor itself
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General changesGeneral changesErythrocytosis.Polycythaemia (erythropoitic).Carbohydrate metabolism
(hyperglycaemia).Anaemia (hge).
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Genital tractGenital tractUterus (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 itselfTumour itselfAtrophy.Degeneration (hayline-red-cystic-fatty-
calcerous) Necrosis.Malignancy (growth after menopause-rapid
enlargement-recurrent fibroid polyp).Vascular (oedema-lymphangectasia)Infection.
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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
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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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DIAGNOSISDIAGNOSISHistoryExamination.Investigation.D.D.
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SYMPTOMSSYMPTOMS Bleeding (menorrhagia-metrorrhagia). Pain uncomplicated (cong.
Dysmenorrhea – dull - colicky). Pain complicated deg.-malig.-
infection-torsion) infertility mass. Discharge. Pressure symptoms.
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SignsSigns•Symmetrically enlarged uterus(submucosal fibroid).
•Asymmetrically enlarged uterus(subserous fibroid)
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InvestigationsClinicalLaboratoryImaging techniquesInstrumentalMiscellaneous
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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
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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
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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
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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 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
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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
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Differential DxDifferential DxFocal Myometrial Contraction
- appear as a myometrial mass of low
signal intensity on T2-weighted images
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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
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Treatment of Treatment of LeiomyomaLeiomyoma
No treatmentConservativeRadiologicalSurgicalMyolysis.GNRHAUterine a
embolization.
Patient (age-parity-symptoms).
Fibroid (number-size-type)
Complications.
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SURGICALSURGICALMyomectomy
Polypectomy.Hysterectomy.
(traditional- microsurgical).
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M.Emam
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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)
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OB& GYN, Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center (MIFC) EGYPT
Telfax 0020502319922 & 0020502312299
Email. [email protected]