Evaluation of Red Degeneration of Uterine Leiomyoma with Susceptibility-weighted MR Imaging

A giant degenerative uterine leiomyoma mimicking an ovarian neoplasm: Case report

Uterine leiomyoma, also referred to as fibroid or myoma, is a prevalent benign tumor that can present with a range of clinical manifestations. The symptoms, which vary based on the tumor's location, size, and number, include pain, constipation, urinary disturbances, and abnormal menstrual bleeding. Certain types of uterine leiomyomas, such as pedunculated subserosal myomas or large degenerating cystic myomas, may closely mimic ovarian tumors, leading to significant diagnostic and management challenges. In this report, we present the case of a 47-year-old woman who experienced severe dyspnea and abdominal distension. Comprehensive radiological evaluation revealed a massive lesion, with both solid and cystic components, occupying the entire abdominopelvic cavity. Histological analysis confirmed the diagnosis of cellular leiomyoma. This case underscores the importance of considering degenerative cystic myoma in the differential diagnosis of large, cystic intra-abdominal tumors of unknown origin, to avoid misdiagnosis and ensure appropriate management.

Low-Grade Endometrial Stromal Sarcoma: A Case Report of a Rare Uterine Malignancy Mimicking Degenerative Uterine Leiomyoma in a Nulliparous Woman

Background and Clinical Significance: Low-grade endometrial stromal sarcoma (LGESS) is a rare uterine malignancy that causes non-specific symptoms which presents more typically in younger women compared to other uterine sarcomas. Preoperative diagnosis of myometrial LGESS is challenging, as it is frequently mistaken for a benign uterine mass, such as a degenerating leiomyoma. Despite its rarity, the imaging findings of LGESS are highly variable, complicating the diagnostic process. Characteristic findings on magnetic resonance imaging T2-weighted imaging (T2WI)-including intra-tumoral low signal intensity (SI) bands (correlating with preserved myometrial bundles separated by tumor cells on histopathology), cystic/necrotic changes, and absence of a speckled appearance-have been significantly associated with LGESS. Additionally, apparent diffusion coefficient mapping can aid in the characterization of uterine masses. Case Presentation: We present a case of LGESS initially misdiagnosed as red degeneration of a uterine leiomyoma (RDL) due to a peripheral rim showing high SI on T1-weighted imaging and low SI on T2WI, which was interpreted as a thrombosed vessel. Histopathology demonstrated necrotic tissue outlined by normal uterine tissue, corresponding to the peripheral rim. We suggest that susceptibility-weighted imaging could have aided in distinguishing between the two conditions due to its high sensitivity to blood products. Moreover, diffusion-weighted imaging revealed restriction along T2 low SI bands, with no restrictions within the bands themselves, potentially indicating a viable tumor along preserved myometrium. Conclusions: These imaging features may provide valuable insights for diagnosing LGESS and differentiating it from RDL, supporting further research on LGESS imaging characteristics.

The value of susceptibility weighted imaging for immediate assessing the hyperacute outcome of MRgFUS ablation for uterine fibroids: a preliminary study

PURPOSE

To investigate the value of susceptibility weighted imaging (SWI) for assessing the hyperacute outcome of ablation of uterine fibroids immediately after magnetic resonance-guided focused ultrasound (MRgFUS) treatment.

METHODS

This retrospective imaging study included patients who underwent SWI and contrast-enhanced (CE) MR within 15 min of MRgFUS ablation for uterine fibroids. Two readers independently assessed the SWI features of ablative lesions and their association with the non-perfused volume (NPV) ratio. The intraclass correlation coefficient (ICC) and diagnostic value of SWI findings were calculated.

RESULTS

A total of 27 uterine fibroids from 21 participants (mean age 40.1 ± 7.2 years) were analyzed. 51.9% (14/27) leiomyomas had NPV ratio ≥90%. In post-ablation SWI images, the interobserver ICC for the relative signal intensity and hypointense peripheral rim were 0.613 and 0.843, respectively (both p < .001). There was a significant difference in the prevalence of hypointense peripheral rim in leiomyomas with NPV ratio ≥90% and < 90% (p < .01), while the prevalence of relative signal intensity showed no significant difference (p > .05). When using the complete hypointense peripheral rim as a diagnostic criterion to identify NPV ratio ≥ 90%, readers 1 and 2 showed diagnostic sensitivity, specificity, and accuracy of 85.7%, 76.9%, 81.5%, and 78.6%, 76.9%, 77.8%, respectively.

CONCLUSION

Identifying a complete hypointense peripheral rim on SWI may be a potential imaging marker for assessing the hyperacute outcome of uterine fibroids ablation by MRgFUS, specifically in determining whether the NPV ratio is ≥90%.

Acute abdomen by red degeneration of a parasitic leiomyoma: A case report and literature review

A 43-year-old woman, with a history of uterine fibroids and multiple myomectomy, presented with acute lower abdominal pain. Computed tomography revealed multiple tumors, including a high-density mass in the left lower abdomen indicative of a parasitic leiomyoma undergoing red degeneration. This uncommon condition is due to acute occlusion, often caused by peripheral venous thrombosis at the fibroid edge. The diagnosis was corroborated by distinctive findings on magnetic resonance imaging and computed tomography. Notably, high signal intensity on T1-weighted images (T1WI) suggested methemoglobin presence due to hemorrhagic infarction, whereas low signal intensity on T2-weighted images (T2WI) indicated deoxyhemoglobin. Symptom improvement followed treatment with analgesics. This case underscores the significance of considering parasitic myomas in the differential diagnosis of intraperitoneal tumors after myomectomy and proposes that vascular torsion from mechanical stress on the mobile mesentery may contribute to red degeneration in such tumors. In this report, we detail the imaging characteristics and clinical progression of red degeneration in a parasitic leiomyoma, emphasizing the importance of this diagnosis in patients with a history of uterine surgery.

Prognostic and reproductive outcomes in women who had uterine myomas removed during cesarean section and sutured using different techniques

BACKGROUND

In this study, the prognostic and reproductive outcomes of women who underwent excision of uterine myomas and were sutured using different techniques while undergoing a cesarean section were investigated.

METHODS

A total of 299 females who underwent cesarean section between January 2015 and June 2022 due to a scarred uterus were enrolled in this study. These participants were segregated into two categories: the experimental group (comprising 155 cases) in which uterine myoma (single lesion) was excised during the cesarean procedure, and the control group (consisting of 144 cases) in which only the cesarean section was conducted. A comparison between the two groups was carried out based on the following parameters: volume of intraoperative bleeding (mL), additional measures taken for intraoperative hemostasis (n, %), percentage (%) of patients experiencing postoperative fever, duration required for the passage of gas (hours [h]), length of hospital stay (days [d]), weight of newborns (kg) and their Apgar scores, and the reproductive outcomes of the experimental group assessed two years after the surgical procedure.

RESULTS

In the experimental group, the amount of bleeding during surgery, occurrence of postoperative fever among women, time taken for patients to resume passing gas, and length of hospital stay were 540.65 ± 269.12 mL, 9.03%, 15.99 ± 4.68 h, and 5.08 ± 1.18 days, respectively. In contrast, the control group had values of 409.03 ± 93.24 mL, 2.77%, 16.24 ± 4.92, and 4.47 ± 0.70 days, respectively (P < 0.05). No notable increase was observed in the need for additional intraoperative hemostasis measures, and there was no significant difference in the time it took for patients to pass gas after the surgery. All newborns had positive health status. In the experimental group, 25 patients underwent subsequent pregnancies, and 15 of them successfully reached full-term deliveries, all of which had positive outcomes.

CONCLUSION

Combining myomectomy with various suture methods during cesarean delivery did not cause excessive bleeding and resulted in healthy newborns. This approach offers the advantage of avoiding additional surgeries under anesthesia and can be considered a viable option. Subsequent pregnancies after myomectomy were considered high-risk.

Imaging findings of fibroid torsion in pregnancy: A case report

When our patient presented emergently to labor and delivery at 18 weeks pregnant with severe right abdominal pain, the common diagnoses (such as appendicitis, cholecystitis, etc.) were on the top of the differential. However, US and MRI revealed a rarer cause of her pain, a pedunculated fibroid. The most important question then became whether this fibroid had torsed, which would require surgical intervention to prevent life-threatening sequelae. Unfortunately, presurgical imaging diagnosis of fibroid torsion in pregnancy is difficult. We offer a description of our patient's imaging findings, which align with other radiologic descriptions of fibroid torsion in pregnancy in the literature, to contribute to the radiologist's diagnostic confidence in this patient population.

Gynaecological Causes of Acute Pelvic Pain: Common and Not-So-Common Imaging Findings

In female patients, acute pelvic pain can be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and degeneration or torsion of uterine leiomyomas. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients. Ultrasound (US) is usually the first-line diagnostic technique because of its sensitivity across most common aetiologies and its lack of radiation exposure. Computed tomography (CT) may be performed if ultrasound findings are equivocal or if a gynaecologic disease is not initially suspected. Magnetic resonance imaging (MRI) is an extremely useful second-line technique for further characterisation after US or CT. This pictorial review aims to review the spectrum of gynaecological entities that may manifest as acute pelvic pain in the emergency department and to describe the imaging findings of these gynaecological conditions obtained with different imaging techniques.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

Acute abdomen caused by spontaneous rupture of degenerative hysteromyoma during pregnancy: A case report

BACKGROUND

Hysteromyoma is not a rare tumor among pregnant women. During pregnancy, the symptoms caused by hysteromyoma can be improved through conservative treatment in most cases. However, in order to ensure the safety of mothers and children, surgeries are necessary in some special cases.

CASE SUMMARY

We report a case of pregnancy complicated with hysteromyoma red degeneration. The patient had peritonitis after sudden abdominal pain during the 20^th week of pregnancy. Laparoscopic exploration suggested rupture and bleeding of hysteromyoma, which were improved after drainage and an anti-inflammatory treatment. A cesarean section was performed after full term. This case shows the complications of rupture after red degeneration of hysteromyoma during pregnancy.

CONCLUSION

We should be alert to rupture of hysteromyoma during pregnancy, and active laparoscopic exploration is essential to improve the prognosis of such patients.

Computed tomography and magnetic resonance imaging findings of gynaecologic emergencies: A pictorial essay

Gynaecologic emergencies include diseases resulting from adnexal and uterine disorders. Some emergencies are life threatening; however, they often have non-specific symptoms and physical findings. Thus, imaging diagnosis is important for evaluating these conditions. The first-choice modality for obstetrics and gynaecology is ultrasonography; however, some cases require computed tomography (CT) and magnetic resonance imaging (MRI) for correct diagnosis. Treatment options for gynaecologic emergencies vary from conservative therapy to emergency surgery, thus a correct diagnosis is critical. The purpose of this article is to describe notable CT and MRI findings of gynaecologic emergencies, which will help emergency department physicians arrive at the correct diagnosis and thus facilitate optimal treatment for patients.

Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification

Uterine fibroids are the most common gynecologic neoplasm. Although non-degenerated fibroids are easily identifiable on imaging, degenerated fibroids, fibroid variants, and fibroids with unusual growth patterns can constitute a diagnostic dilemma. Identification of these abnormal morphologic features can alter the diagnosis of presumed uterine fibroids and hence change management plans. This article reviews the typical and atypical radiologic imaging features of uterine fibroids, with an emphasis on the pitfalls, mimics, and radiologically identifiable features that can alter clinical management plans.

Uterine leiomyomas revisited with review of literature

Uterine leiomyomas, more commonly known as fibroids, are the most common neoplasms of the uterus. These tumors have a profound effect on health care and cost worldwide. Depending on the race, uterine leiomyomas can be seen in 70-80% of all women. Although majority of the women with uterine leiomyomas remain asymptomatic, approximately 30% can present with symptoms. Diagnosing typical leiomyomas on imaging is straightforward. However, when large, located extrauterine and especially with degeneration, the diagnosis can be challenging on imaging. In this article, apart from reviewing the demographics and management of patients with leiomyomas, we describe in detail the imaging appearance of various atypical leiomyomas, uncommon locations outside the uterus and their important differential diagnosis that can have a profound effect on patient management.

Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check!

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET¹T²ER Check! to help identify key features more suggestive of a uterine sarcoma.

Myomectomy during cesarean section: A retrospective cohort study

OBJECTIVE

To evaluate the value of myomectomy during delivery by cesarean section (CS) in pregnant women with uterine fibroids.

METHODS

Retrospective cohort study of pregnant women diagnosed to have uterine fibroids during index pregnancy. Women who underwent myomectomy during CS (study group; n = 91) were compared with women in whom myomectomy was not performed during CS (control group; n = 87).

RESULTS

No significant difference between both groups in the amount of blood transfusion and postoperative hemoglobin level. The operative time was significantly higher in the myomectomy group than in the control group (80.22 ± 13.06 vs 56.67 ± 8.85 min; P <  0.001). Also, the postoperative hospital stay period was significantly higher in the myomectomy group (P <  0.001).

CONCLUSION

Myomectomy during CS can be performed safely without increase in the peripartum maternal morbidities. It only may prolong the operative time and postoperative hospital stay period but it may have many benefits including avoiding another operation to remove fibroids.

MRI of Acute Gynecologic Conditions

Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.