Uterine leiomyomas: A diagnostic dilemma?

A pictorial
review of MRI appearances from typical to bizarre
Poster No.:

C-1222

Congress:

ECR 2010

Type:

Educational Exhibit

Topic:

Genitourinary

Authors:

K. H. Taylor, N. Napier, S. Gillespie, A. Grey, E. Murtagh; Belfast/

UK

Keywords:

Leiomyoma, MR Imaging, Leiomyosarcoma

DOI:

10.1594/ecr2010/C-1222

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Learning objectives
1.To visualise the wide spectrum of MRI appearances of uterine leiomyomas.
2. To understand the differential diagnosis of atypical appearances.

Background
Leiomyomas, often referred to as fibroids, are the most common gynaecological
neoplasm, occurring in 20%-30% of women and although often asymptomatic, they
can result in significant morbidity (1,2). They are benign tumours composed of smooth
muscle with varying amounts of fibrous connective tissue. They normally occur during
child bearing years being influenced by oestrogens and reduce in size following the
menopause. These tumours occur in different sites within the uterus and can be classified
as submucosal, intramural or subserosal (3). Tumour locations can appear unusual
and as they enlarge they may outgrow their blood supply, resulting in subsequent
degeneration that can produce a myriad of different imaging appearances.
Diagnosis of leiomyomas, for the majority of patients, is made with clinical and ultrasound
examination (4). Ultrasound remains the primary imaging modality for the vast majority of
routine clinical presentations and usually no further investigation is required. For patients
with symptoms, medical or surgical treatment may be indicated.
This subgroup of patients who require further medical or surgical treatment often require
more accurate evaluation of location, size and extent of disease. MRI offers a useful
adjunct in these patients as it is well recognised that it represents the most accurate
examination for the detection and characterisation of leiomyomas (4,5).

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The differential diagnosis of a leiomyoma includes an adenomyoma, a solid adnexal

mass, focal myometrial contraction, and a uterine leiomyosarcoma (6). MRI can provide
useful diagnostic clues in distinguishing between these entities, with improved detection
rates of adenomyosis (7). Unfortunately accurate diagnosis of sarcomatous change
is much more difficult as the wide spectrum of imaging findings associated with
degenerating leiomyomas can often overlap and a definitive diagnosis normally requires
histology. In this exhibit we present some of our experiences with MRI imaging of
leiomyomas. We provide examples of lesions with classical appearances along with some
of the more unusual cases that we have encountered.

Imaging findings OR Procedure details

The most accurate imaging modality for detecting and assessing leiomyomas is MRI
which provides accurate information on location and relationship with neighbouring
structures (4,5). Leiomyomas can be single or multiple and occur in different sites
within the uterus. They can be classified as submucosal, intramural or subserosal (3)
(Figure 1). The size of these lesions can vary enormously and they can enlarge to
occupy the entire pelvis. Classically leiomyomas on MRI are depicted as well defined
lesions of homogeneous hypointense to isointense signal intensity to myometrium
on T1. On T2 weighted sequences they are typically homogeneously hypointense
to myometrium. Degenerating leiomyomas have varying MRI signal intensity, often
appearing of inhomogeneous high signal intensity on T2 weighted sequences and lack
enhancement following administration of contrast on T1 weighted sequences (1,8). The
routine use of gadolinium has been shown not to contribute to either fibroid detection
or characterisation (9). Examples of the classical appearances and variable signal
characteristics seen in degenerating leiomyomas can be seen in the examples below.
Submucosal (Figure 2)
These arise from the myometrium immediately beneath the endometrium and are
visualised as solid masses that indent or distort the endometrium. They may even extend
into the uterine cavity and present as polypoid intracavitary masses. The differential
diagnosis for these lesions can include endometrial polyps, adenomyosis, endometrial
carcinomas and myometrial contractions (6).

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Intramural (Figure 3) (Figure 4)

This is the most common location for leiomyomas and they are seen as well defined,
rounded homogeneous myometrial masses. They often appear to have a pseudocapsule
which represents compressed normal myometrium. They can also have a hyperintense
rim on T2 which reflects oedema, dilated lymphatics and veins. The differential diagnosis
includes adenomyosis and malignant uterine neoplasms (6).
Subserosal (Figure 5) on page
These lesions can be sessile or pedunculated arising just deep to the serosa. The
myometrium does not surround the entire mass. On T2 sequences they appear as
homogeneous well defined low signal intensity masses protruding from the external
border of the uterus. The differential diagnosis includes ovarian neoplasms, broad
ligament leiomyomas and parasitic leiomyomas (6). The following case is a 68 year old
female who presented with lower abdominal pain. Transvaginal ultrasound showed a
mass and could not distinguish between an ovarian mass or a leiomyoma. An MRI was
performed which clarified that it was a leiomyoma (Figure 6).
Degenerating Leiomyoma (Figure 7)
The larger a leiomyoma grows the more likely it is to undergo some form of degeneration.
This is generally seen as heterogeneous signal intensity. The degree of heterogeneity
depends on the type and amount of degeneration. Types of degeneration include hyaline,
cystic, myxoid, calcific, haemorrhagic and oedematous change.
Degenerating leiomyomas have variable appearances on T2-weighted sequences.
Hyaline or calcific degeneration have low signal intensity on T2-weighted images.
Cystic degeneration is characterised by areas of high signal intensity on T2-weighted
images. Myxoid degeneration shows very high signal intensity on T2-weighted images.
Haemorrhagic degeneration demonstrates peripheral or diffuse high signal intensity on
T1-weighted images and variable signal intensity on T2-weighted images. High signal
intensity on T1-weighted images is likely secondary to the proteinaceous content of the
blood or the T1-shortening effects of met-haemoglobin. Oedematous change presents
as high signal intensity on T2 weighted sequences (1,5,8).
Imaging can not always reliably differentiate between types of degeneration and there
may be histopathological overlap within the same fibroid.
The following cases are some of the unusual presentations of leiomyomas that we
encountered;

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1. A 42 year old lady presented with a large right sided pelvic mass. The differential was
that of a leiomyoma or an ovarian mass. An MRI was performed for further clarification.
MRI demonstrated that there was a large, well encapsulated heterogeneous mass
in the right side of pelvis. It was predominantly T2 hyperintense although there was
considerable internal low signal matrix. Both ovaries were seen separately from the mass.
It had a very unusual appearance and histological examination showed it was a vascular
leiomyoma with areas of myxoid degeneration (Figure 8).
2. A 34 year old lady presented with secondary infertility and a large multicystic mass
in the right side of the pelvis. On ultrasound it was felt likely to represent an ovarian
mass. MRI demonstrated that there was a large heterogeneous multicystic mass arising
from the anterior aspect of the uterus. It was predominantly T2 hyperintense although
there was considerable internal low signal matrix. It was predominantly isointense to
myometrium on T1WI with some areas of T1 hypointensity. Both ovaries were seen
separately. Histological examination showed a degenerating leiomyoma with prominent
intercellular oedema (Figure 9).
3. A 47 year old female presented to urologists with mass extending from urethra.
MRI demonstrated a large polypoid lesion protruding through introitus. The lesion was
predominantly low signal intensity on T2WI with a high signal periphery. The uterus
and cervix were unremarkable. Histological examination showed this was a leiomyoma
(Figure 10).
4. A 43 year old female with a previous history of hysterectomy for dissecting leiomyoma.
MRI demonstrated three low signal masses within the pelvis with signal characteristics
of leiomyomatous tissue. The first lesion lies in the right ischio anal fossa and causes
displacement of the right levator sling (1). The second smallest lesion lies within
the left labum majorum, displacing labum minorum (2). The third lesion arises from
the rectovaginal septum and extends into the left ischio anal fossa (3). Histological
examination showed multiple leiomyomas (Figure 11).
5. A 32 year old female presented with bilateral adnexal masses. Sagittal and axial T2WI
demonstrates a large, predominantly T2 hypo intense mass arising from the right side of
the uterus (1). There was a further large, predominantly T2 hypointense mass with clefts
of T2 hyperintensity on the left side which might be arising from the broad ligament on the
left side (2). It was displacing the uterus to the right. Radiologically, they were consistent
with degenerating leiomyomas (Figure 12).
6. A 50 year old female presented with pelvic pain. Sagittal and axial T2WI demonstrated
a large mass arising from the lower uterine and proximal cervical segments consistent
with a leiomyoma (1). A smaller more fibrous subserosal leiomyoma was identified arising

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from the posterior wall of the uterus (2). The endometrial cavity was distended with blood
products, presumably secondary to the degree of cervical stenosis caused by the cervical
leiomyoma (Figure 13).
Diffuse Leiomyomatosis
A rare condition were multiple confluent leiomyomas displacing the normal myometrium.
(Figure 14).

Differential Diagnosis
Adenomyosis (Figure 15)
Differentiating between adenomyosis and submucusal or intramural leiomyomas is of
clinical significance. Leiomyomas can be treated medically or with myomectomy while
symptomatic adenomyosis can require a hysterectomy. Adenomyosis may be diffuse or
focal (adenomyoma). MR imaging does allow differentiation between focal adenomyosis
and leiomyoma (9). Focal adenomyosis in comparison with a leiomyoma appears more
ill-defined, elliptical in shape and is orientated along the endometrial axis. It is of low
signal intensity on T2 weighted sequences with punctate foci of high signal intensity on
T2 (6) (Figure 16).
Endometrial polyp/carcinoma
Differentiating between a submucosal leiomyoma and either an endometrial polyp or
carcinoma can be achieved by demonstrating the endometrial origin on T2 weighted MR
sequences of these endometrial pathologies (6).
Myometrial contraction
Uterine contractions can appear as a myometrial mass of low signal intensity on T2weighted images and may simulate leiomyomas or focal adenomyosis at MR imaging.
Because the contractions are transient, resolution of the mass at subsequent imaging
allows the diagnosis to be established (2,10).
Solid adnexal mass (Figure17)
Subserosal pedunculated leiomyomas can present as a diagnostic challenge, in trying
to differentiate them from other solid adnexal masses. Benign ovarian lesions can have
signal intensities that are similar to that of leiomyomas. Diagnostic clues indicating the
presence of a leiomyoma as opposed to an adnexal mass include continuity with the

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adjacent myometrium and ovaries, which appear normal. While the presence of a lesion
surrounded by ovarian stroma and follicles is more indicative of a primary ovarian lesion
(2,11).
Leiomyosarcoma (Figure 18)
Leiomyosarcomas are rare and represent malignant transformation of smooth muscle
cells either from the myometrium or from a leiomyoma. Accurate diagnosis of
leiomyosarcoma on MR imaging is difficult given that there is overlap in imaging
appearances with degenerating leiomyomas. Leiomyosarcomas are normally of
intermediate signal intensity on T2 weighted sequences with areas of high signal relating
to necrosis. The tumours are normally low to intermediate signal intensity on T1 weighted
sequences but areas of haemorrhage will demonstrate high signal. Best clues to the
presence of a leiomyosarcoma, as opposed to a degenerating leiomyoma include
poorly demarcated borders, rapid enlargement on interim imaging and the presence of
metastases (4,6). Definitive diagnosis normally requires histopathology.

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Conclusion
Leiomyomas although normally easy to diagnose on MRI can occasionally have
appearances that result in significant diagnostic dilemma. Leiomyomas are the most
common gynaecological tumours and are benign. It is important to be familiar with
the variety of MR imaging appearances to distinguish them from other pathologies.
The differential diagnosis can include adenomyoma, solid adnexal masses and uterine
leiomyosarcoma. Accurate evaluation and diagnosis on imaging can significantly impact
on management decisions.

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Personal Information
Dr Kristy Helen Taylor
Radiology Department
Belfast City Hospital
Belfast
Northern Ireland

References
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Leiomyomas: Histopathologic Features, MR Imaging Findings, Differential Diagnosis and
Treatment. Radiographics 1999;19:1179-97.

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