Interactive Transcript
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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
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in these fibroids. However, that may
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not be necessarily the most reliable
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sign anymore, especially with the
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advent of MRI and more recent studies
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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
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of them, and then you have different degenerated
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versions, and those can be cystic, they can
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be hemorrhagic, fatty, hyaline, or myxoid.
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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.
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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,
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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.
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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
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that's out of the scope of this talk.
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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
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leiomyosarcomas being the most common subtype.
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I'll also note that this doesn't cover parasitic
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leiomyomas, leiomyomatosis, disseminated
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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
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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
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after a fibroid is necrosed or in the
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postmenopausal patient for similar reasons.
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