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Fibroids – Introduction

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0:02

So our next topic is leiomyoma.

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So these are generally called fibroids, and when

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we say fibroids, we usually are referring to the

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benign variant of these smooth muscle tumors.

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But it's important to note that while

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benign is by far the most common, there

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is a spectrum that exists for these tumors

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and that you have to keep that in mind.

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Historically, we used to teach that

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rapid growth was the sign that was most

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reliable for evidence of malignancy

0:29

in these fibroids. However, that may

0:31

not be necessarily the most reliable

0:33

sign anymore, especially with the

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advent of MRI and more recent studies

0:37

coming out talking about signs for that.

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So most fibroids that we're going to see on

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imaging are going to end up being benign.

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We have different variants of them.

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You have the classic non-degenerated appearance

0:48

of them, and then you have different degenerated

0:50

versions, and those can be cystic, they can

0:51

be hemorrhagic, fatty, hyaline, or myxoid.

0:55

Some of these you can tell on ultrasound,

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but if you want to tell these apart,

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MRI is most often going to be needed.

1:01

And remembering that this is a spectrum,

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we'll go to the not benign category.

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And that doesn't necessarily mean malignant,

1:07

just means not necessarily benign.

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And these are going to be fibroids

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that are more mitotically active.

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They may have increased cellularity.

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They may be atypical in pathology.

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There is a variant called a stump,

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which is a small muscle tumor of

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uncertain malignant potential.

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And then, of course, you do

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have the malignant sarcomas.

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On imaging, particularly on MRI, there are

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some characteristic features that are going

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to differentiate these, including the benign

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versus the not benign and the malignant,

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but there still may be some overlap and

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ultimately may require pathologic diagnosis.

1:39

We are getting better at this, but

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we're not going to talk too much about

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differentiating these on MRI because

1:44

that's out of the scope of this talk.

1:45

However, it is important to note that of all

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of the uterine malignancies, approximately 3

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percent of them are going to be sarcomas, with

1:53

leiomyosarcomas being the most common subtype.

1:56

I'll also note that this doesn't cover parasitic

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leiomyomas, leiomyomatosis, disseminated

2:01

peritoneal leiomatosis, etc., because these

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are still histologically benign fibroids,

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so they don't make the not benign list.

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So let's talk about some of the

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characteristic classic features of fibroids

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that you'll see in ultrasound and MRI.

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Generally, in ultrasound,

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they'll be well-circumscribed.

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They're often hypoechoic.

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They may be a bit heterogeneous and

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they can have some calcifications.

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There can be shadowing because of these

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calcifications, which can be quite coarse, or

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you can have some shadowing at the margins of

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the lesion that can cause some obscuration of

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different soft tissues that may be behind there.

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They often have increased vascularity

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as well, although not necessarily.

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So talking about MRI, and this is just the

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classic appearance of a fibroid, they're

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generally going to be T1 iso-intense

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to the myometrium, and T2 hypo-intense,

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and then in general they should enhance.

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However, this chart here, which we won't

3:00

go over all of it, but you have here for

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your reference, talks about the different

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degenerating fibroid features that you can

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see on MRI, and what they look like on the

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T1 and T2 compared to the myometrium, and

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what they look like on post-contrast imaging.

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So, surgical planning, let's

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talk about that for a moment.

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In your reports, particularly on MRI,

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but also on ultrasound when you can,

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it's important to note the location

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of where your fibroids are located.

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And the reason that is is

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because they can be causes for the

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symptoms that patients are having.

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So submucosal is one of the more common

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causes of dysfunctional uterine bleeding.

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Submucosal or intracavitary fibroids, meaning in

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the endometrial canal, that's the least common,

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but they are the most likely to be symptomatic.

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Intramural fibroids, which are in

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the myometrium itself, these are

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the most common types of fibroids.

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But they're usually asymptomatic but can

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be a cause for infertility because they

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can cause mass effect upon the endometrium,

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they can cause growth problems, etc.

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Pedunculated fibroids are another

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variant and these are going to be

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the most likely to torse and

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cause an acute pain type of syndrome.

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It's also important to note that you can have

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different types such as cervical fibroids,

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broad ligament fibroids, and all of these

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are important to keep in mind if the surgeon

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is planning potentially a myomectomy.

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How are they going to approach

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this patient and this surgery?

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So again, remember, submucosal versus exophytic

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or pedunculated, this is going to change the

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technique, it's going to change the approach.

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Vascularity is also important because

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there is the non-invasive uterine artery

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embolization that they can use for treatment,

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but it's only going to work if that

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fibroid has retained vascularity to it.

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Fibroids in general, when they're

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large, can outgrow their blood supply

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and cause infarction, which is pain.

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But that's also what uterine

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artery embolization is going to do.

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It's going to cause that infarction.

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So that hopefully that fibroid will

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shrink and decrease the symptoms

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of the patient it's having.

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It's also important to notice that you can

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have increased numbers of calcifications

4:59

after a fibroid is necrosed or in the

5:01

postmenopausal patient for similar reasons.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Vascular

Uterus

Ultrasound

Neoplastic

MRI

Idiopathic

Gynecologic (GYN)

CT

Body

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