Mohammad a. Emam

8/14/2019 Mohammad a. Emam

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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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UterusUterusdepriveddeprived

from a babyfrom a babyconsolesconsoles

itself with aitself with afibroid.fibroid.M.Ema

m


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PathologyPathology

NIE:NIE: -Site - shape - size.

- Consistency - cut section

- capsule - Number - varieties.


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Uterine leiomyoma

Corporeal 98% multiple

Cervical 1-2%

solitary


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Corporeal leiomyoma

submucus 24% not capsulated

Subserous 18%

Interstitial 58%


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M.Ema

m


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Cervical leiomyoma

Supravaginal cervixtrue

(ant - post - central - combined)

false(intralig - retraperit- not capsulated

Portiovaginalis smallsessile

polypoid


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CONSISTENCYCONSISTENCYFirmFirm

Harder Harder (hyaline degeneration).(hyaline degeneration).SoftSoft (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 demarcatedWell demarcated

surrounding muscle.surrounding muscle.whorly (intermingling musclewhorly (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 cellsand fibrous tissue cells.

Few formed bloodvessels.


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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 withChanges occur with

fibroid fibroid

General

Genital tract Tumor itself


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General changesGeneral changes

Erythrocytosis.

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


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Genital tract Genital tract Uterus (endomet.-cavity-myomet.-uterusas a whole).

Tubes inflammed (salpingitis)ovaries (tunica albuginea-endometriosis-cysts).Blood vessels.Endometriosis (30-40%).


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Tumour itself Tumour itself Atrophy.Degeneration (hayline-red-cystic-fatty-calcerous)

Necrosis.Malignancy (growth after menopause-rapienlargement-recurrent fibroid polyp).

Vascular (oedema-lymphangectasia )Infection.


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DegenerationLeiomyomas enlargeoutgrow their blood supply

various types of degeneration

Hyaline degeneration :- the presence of homogeneous eosinophilic bands or plaquesin the extracellular space.Myxoid degeneration - presence of gelatinousintratumoral foci at gross examination thatcontain hyaluronic acidrichmucopolysaccharides


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Degeneration contRed degeneration - during pregnancy,secondary to venous thrombosis within theperiphery of the tumor or rupture of intratumoral arteriesSarcomatous transformation -less than 3%


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DIAGNOSIS DIAGNOSIS History

Examination.Investigation.

D.D.


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SYMPTOMS SYMPTOMS Bleeding (menorrhagia-metrorrhagia).Pain uncomplicated (cong.Dysmenorrhea dull - colicky).Pain complicated deg.-malig.-

infection-torsion)infertilitymass.Discharge.Pressure symptoms.


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SignsSigns Symmetrically enlarged

uterus(submucosalfibroid).

Asymmetrically enlarged

uterus(subse


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InvestigationsClinicalLaboratoryImaging techniquesInstrumentalMiscellaneous

h


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Imaging TechniquesImaging Techniques ))MR IMAGE))MR IMAGE

most accurate imaging technique for detectionand localization of leiomyomasmyomatous uterus (>140 cm 3) is not consistently

possible with US because of the limited field of viewuterine zonal anatomy enables accurateclassification of individual masses assubmucosal, intramural, or subserosal

h


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Imaging TechniquesImaging Techniques )MR IMAGE)MR IMAGE contcont

Nondegenerated uterine leiomyomas:

- well-circumscribed masses of homogeneously decreased signal intensitycompared with that of the outer myometrium

on T2-weighted images

- whorls of uniform smooth muscle cells withvarious amounts of intervening collagen


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I i T h i


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Imaging TechniquesImaging Techniques ))MR IMAGE))MR IMAGE

Degenerated leiomyomas variable in T2hyaline and calcific degeneration (low)

cystic degeneration (high)myxoid degeneration (very high, minimalenhance)Necrotic leiomyomas without liquefaction

(variable in T1, low in T2)Red degeneration

T1 : peripheral or diffuse high SIT2 : variable SI with or without low SI rim on T2


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DIFFERENTIAL DxADEMOMYOSIS

- presence of ectopic endometrial glands andstroma within the myometrium, which areassociated with reactive hypertrophy of thesurrounding myometrial smooth muscle- most commonly a diffuse abnormality but may

also occur as a focal mass, which is known as anadenomyoma

- diffuse form of adenomyosis appears as a

thickened junctional zone (inner myometrium) onT2-weighted images


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DIFFERENTIAL DxADEMOMYOSIS cont

Junctional zone 12 mm thick or thicker is highly predictive of adenomyosisSmall foci of high signal intensity onT2-weighted images represent theendometrial glands


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:Adenomyosis


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Distinction between adenomyosis and leiomyomas is of

clinical

importance because, unlike leiomyomas, which may betreated with myomectomy, adenomyosis can be extirpated onlywith hysterectomy Adenomyosis appears as an ill-defined, poorly marginatedarea of low signal intensity within the myometrium on T2.


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Differential DxDifferential DxSolid Adnexal Mass

- If MR imaging can demonstrate continuity of an adnexal mass with the adjacentmyometrium, then a diagnosis of leiomyomacan be established.

- Ovarian fibromas and Brenner tumors are

benign ovarian neoplasms that have a large

fibrous component

and can have signalintensity similar to that of a pedunculated leiomyoma


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Differential DxDifferential Dx Solid Adnexal Mass cont

- fibromas and Brenner tumorssurrounded by ovarian stroma and

follicles, thus establishing the ovarian

origin of the mass and excluding adiagnosis of leiomyoma

- - important in pregnant patients

because a confident

diagnosis of auterine leiomyoma may eliminate theneed 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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Treatment of Treatment of

LeiomyomaLeiomyomaNo treatment

ConservativeRadiologicalSurgical

Myolysis.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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Myomectomy HysterectomyPatient

Age. Parity.

Fibroid No

Type

Size

Associated

40 yearscomplete her family

large

subserous-submucous andcomplicatedlarge

+ve complications(pressure Symptoms)


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OB& GYN, Mansoura Faculty of Medicine

Mansoura Integrated Fertility Center (MIFC)EGYPT

Telfax 0020502319922 & 0020502312299

Mohammad a. Emam

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