Abstract
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.
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Abbreviations
- ADC:
-
Apparent diffusion coefficient
- CT:
-
Computerized tomography
- DMPA:
-
Depot-medroxyprogesterone acetate
- DWI:
-
Diffusion-weighted imaging
- FIGO:
-
Fédération Internationale de Gynécologie et d’Obstétrique
- FDG:
-
18F-fluorodeoxyglucose
- GnRH:
-
Gonadotropin-releasing hormone
- HPF:
-
High-power fields
- IUD:
-
Intrauterine devices
- MRI:
-
Magnetic resonance imaging
- PET:
-
Positron emission tomography
- STUMP:
-
Smooth muscle tumor of uncertain malignant potential
- SUVmax:
-
Maximum standard uptake value
- UAE:
-
Uterine artery embolization
References
Bura, V., et al., MRI findings in-between leiomyoma and leiomyosarcoma: a Rad-Path correlation of degenerated leiomyomas and variants. Br J Radiol, 2021. 94(1125): p. 20210283.
Buttram, V.C., Jr. and R.C. Reiter, Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril, 1981. 36(4): p. 433–45.
Stewart, E.A., et al., Epidemiology of uterine fibroids: a systematic review. BJOG, 2017. 124(10): p. 1501-1512.
Cramer, S.F. and A. Patel, The frequency of uterine leiomyomas. Am J Clin Pathol, 1990. 94(4): p. 435-8.
Lepine, L.A., et al., Hysterectomy surveillance--United States, 1980-1993. MMWR CDC Surveill Summ, 1997. 46(4): p. 1-15.
Stewart, E.A., et al., The burden of uterine fibroids for African-American women: results of a national survey. J Womens Health (Larchmt), 2013. 22(10): p. 807-16.
Baird, D.D., et al., High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol, 2003. 188(1): p. 100-7.
Selo-Ojeme, D., et al., The incidence of uterine leiomyoma and other pelvic ultrasonographic findings in 2,034 consecutive women in a north London hospital. J Obstet Gynaecol, 2008. 28(4): p. 421-3.
Lumbiganon, P., et al., Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: a multicentre case--control study. Br J Obstet Gynaecol, 1996. 103(9): p. 909-14.
Sato, F., et al., Familial aggregation of uterine myomas in Japanese women. J Epidemiol, 2002. 12(3): p. 249-53.
Chiaffarino, F., et al., Use of oral contraceptives and uterine fibroids: results from a case-control study. Br J Obstet Gynaecol, 1999. 106(8): p. 857-60.
Munro, M.G., et al., FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011. 113(1): p. 3-13.
Puri, K., et al., Submucosal fibroids and the relation to heavy menstrual bleeding and anemia. Am J Obstet Gynecol, 2014. 210(1): p. 38 e1–7.
Pritts, E.A., W.H. Parker, and D.L. Olive, Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril, 2009. 91(4): p. 1215-23.
Lippman, S.A., et al., Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril, 2003. 80(6): p. 1488-94.
Tavernaraki, E., S. Athanasiou, and P. Ampatzis, Spontaneous Uterine Leiomyoma Torsion: A Challenging Differential Diagnosis for Radiologists. Eur J Case Rep Intern Med, 2020. 7(9): p. 001586.
Ueda, H., et al., Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics, 1999. 19 Spec No: p. S131–45.
Peddada, S.D., et al., Growth of uterine leiomyomata among premenopausal black and white women. Proc Natl Acad Sci U S A, 2008. 105(50): p. 19887-92.
Vitagliano, A., et al., Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature. Arch Gynecol Obstet, 2018. 297(4): p. 823-835.
Lete, I., et al., Parasitic leiomyomas: a systematic review. Eur J Obstet Gynecol Reprod Biol, 2016. 203: p. 250-9.
American College of, O. and B.-G. Gynecologists' Committee on Practice, Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228. Obstet Gynecol, 2021. 137(6): p. e100-e115.
Volkers, N.A., et al., Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J Obstet Gynecol, 2007. 196(6): p. 519 e1–11.
Wamsteker, K., M.H. Emanuel, and J.H. de Kruif, Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol, 1993. 82(5): p. 736-40.
Stewart, E.A., Clinical practice. Uterine fibroids. N Engl J Med, 2015. 372(17): p. 1646-55.
Woźniak, A. and S. Woźniak, Ultrasonography of uterine leiomyomas. Prz Menopauzalny, 2017. 16(4): p. 113-117.
Kubik-Huch, R.A., et al., European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas. Eur Radiol, 2018. 28(8): p. 3125-3137.
Wilde, S. and S. Scott-Barrett, Radiological appearances of uterine fibroids. Indian J Radiol Imaging, 2009. 19(3): p. 222-31.
Casillas, J., R.C. Joseph, and J.J. Guerra, Jr., CT appearance of uterine leiomyomas. Radiographics, 1990. 10(6): p. 999-1007.
Nishizawa, S., et al., Incidence and characteristics of uterine leiomyomas with FDG uptake. Ann Nucl Med, 2008. 22(9): p. 803-10.
Kitajima, K., et al., Standardized uptake values of uterine leiomyoma with 18F-FDG PET/CT: variation with age, size, degeneration, and contrast enhancement on MRI. Ann Nucl Med, 2008. 22(6): p. 505-12.
Tamai, K., et al., The utility of diffusion-weighted MR imaging for differentiating uterine sarcomas from benign leiomyomas. Eur Radiol, 2008. 18(4): p. 723-30.
Bolan, C. and M.P. Caserta, MR imaging of atypical fibroids. Abdom Radiol (NY), 2016. 41(12): p. 2332-2349.
Robboy, S.J., et al., Pathology and pathophysiology of uterine smooth-muscle tumors. Environ Health Perspect, 2000. 108 Suppl 5: p. 779-84.
Matsuura, K., et al., Utility of magnetic resonance imaging for differentiating malignant mesenchymal tumors of the uterus from T2-weighted hyperintense leiomyomas. Jpn J Radiol, 2021.
Yamashita, Y., et al., Hyperintense uterine leiomyoma at T2-weighted MR imaging: differentiation with dynamic enhanced MR imaging and clinical implications. Radiology, 1993. 189(3): p. 721-5.
Okizuka, H., et al., MR detection of degenerating uterine leiomyomas. J Comput Assist Tomogr, 1993. 17(5): p. 760-6.
Mittl, R.L., Jr., I.T. Yeh, and H.Y. Kressel, High-signal-intensity rim surrounding uterine leiomyomas on MR images: pathologic correlation. Radiology, 1991. 180(1): p. 81–3.
Shimada, K., et al., Differentiation between completely hyalinized uterine leiomyomas and ordinary leiomyomas: three-phase dynamic magnetic resonance imaging (MRI) vs. diffusion-weighted MRI with very small b-factors. J Magn Reson Imaging, 2004. 20(1): p. 97–104.
Clement, P.B., The pathology of uterine smooth muscle tumors and mixed endometrial stromal-smooth muscle tumors: a selective review with emphasis on recent advances. Int J Gynecol Pathol, 2000. 19(1): p. 39-55.
Isonishi, S., et al., Analysis of prognostic factors for patients with leiomyoma treated with uterine arterial embolization. Am J Obstet Gynecol, 2008. 198(3): p. 270.e1-6.
Harman, M., et al., Predictive value of magnetic resonance imaging signal and contrast-enhancement characteristics on post-embolization volume reduction of uterine fibroids. Acta Radiol, 2006. 47(4): p. 427-35.
Hamlin, D.J., et al., MR imaging of uterine leiomyomas and their complications. J Comput Assist Tomogr, 1985. 9(5): p. 902-7.
Cruz, M., et al., Myxoid leiomyoma of the uterus: CT and MRI features. Abdom Imaging, 2001. 26(1): p. 98-101.
Norris, H.J., G.D. Hilliard, and N.S. Irey, Hemorrhagic cellular leiomyomas ("apoplectic leiomyoma") of the uterus associated with pregnancy and oral contraceptives. Int J Gynecol Pathol, 1988. 7(3): p. 212-24.
Kawakami, S., et al., Red degeneration of uterine leiomyoma: MR appearance. J Comput Assist Tomogr, 1994. 18(6): p. 925-8.
Nakai, G., et al., Pathological findings of uterine tumors preoperatively diagnosed as red degeneration of leiomyoma by MRI. Abdom Radiol (NY), 2017. 42(7): p. 1825-1831.
Takeuchi, M., et al., Evaluation of Red Degeneration of Uterine Leiomyoma with Susceptibility-weighted MR Imaging. Magn Reson Med Sci, 2019. 18(2): p. 158-162.
Verma, S.K., et al., Spectrum of imaging findings on MRI and CT after uterine artery embolization. Abdom Imaging, 2010. 35(1): p. 118-28.
Zhang, Q., et al., Molecular analyses of 6 different types of uterine smooth muscle tumors: Emphasis in atypical leiomyoma. Cancer, 2014. 120(20): p. 3165-77.
Oliva, E., Practical issues in uterine pathology from banal to bewildering: the remarkable spectrum of smooth muscle neoplasia. Mod Pathol, 2016. 29 Suppl 1: p. S104-20.
Taran, F.A., et al., Understanding cellular leiomyomas: a case-control study. Am J Obstet Gynecol, 2010. 203(2): p. 109.e1-6.
Takeuchi, M., K. Matsuzaki, and H. Nishitani, Hyperintense uterine myometrial masses on T2-weighted magnetic resonance imaging: differentiation with diffusion-weighted magnetic resonance imaging. J Comput Assist Tomogr, 2009. 33(6): p. 834-7.
Batur, A., et al., Uterin Lipoleiomyoma: MR Findings. Pol J Radiol, 2015. 80: p. 433-4.
Kitajima, K., et al., MRI findings of uterine lipoleiomyoma correlated with pathologic findings. AJR Am J Roentgenol, 2007. 189(2): p. W100-4.
Huo, L., et al., Oncologic and Reproductive Outcomes of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Single Center Retrospective Study of 67 Cases. Front Oncol, 2020. 10: p. 647.
Bacanakgil, B.H., et al., Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: Clinicopathologic-Sonographic Characteristics, Follow-Up and Recurrence. World J Oncol, 2017. 8(3): p. 76-80.
Yordanov, A.D., et al., Uterine smooth muscle tumours of uncertain malignant potential: single-centre experience and review of the literature. Prz Menopauzalny, 2020. 19(1): p. 30-34.
Tanaka, Y.O., et al., Smooth muscle tumors of uncertain malignant potential and leiomyosarcomas of the uterus: MR findings. J Magn Reson Imaging, 2004. 20(6): p. 998-1007.
Cornfeld, D., et al., MRI appearance of mesenchymal tumors of the uterus. Eur J Radiol, 2010. 74(1): p. 241-9.
Koh, J., et al., Uterine artery embolization (UAE) for diffuse leiomyomatosis of the uterus: clinical and imaging results. Eur J Radiol, 2012. 81(10): p. 2726-9.
Tiltman, A.J., Leiomyomas of the uterine cervix: a study of frequency. Int J Gynecol Pathol, 1998. 17(3): p. 231-4.
Sikora-Szczęśniak, D.L., Leiomyoma and leiomyoma cellulare of the fallopian tube: review of the literature and case reports. Prz Menopauzalny, 2016. 15(3): p. 143-147.
Yang, C.C., et al., Primary leiomyoma of the fallopian tube: preoperative ultrasound findings. J Chin Med Assoc, 2007. 70(2): p. 80-3.
Sun, D., et al., Fallopian tube lipoleiomyoma with degeneration: a case report and literature review. Int J Clin Exp Pathol, 2020. 13(8): p. 2163-2168.
Jha, S., et al., Huge broad ligament leiomyoma with cystic degeneration: A diagnostic and surgical challenge. J Obstet Gynaecol Res, 2020. 46(5): p. 791-794.
Yajima, R., et al., Diagnostic performance of preoperative MR imaging findings for differentiation of uterine leiomyoma with intraligamentous growth from subserosal leiomyoma. Abdom Radiol (NY), 2021. 46(8): p. 4036-4045.
Mallick, D., et al., Leiomyoma of broad ligament mimicking ovarian malignancy- report of a unique case. Kathmandu Univ Med J (KUMJ), 2014. 12(47): p. 219-21.
Bansal, P. and D. Garg, A case of massive broad ligament leiomyoma imitating an ovarian tumour. J Clin Diagn Res, 2014. 8(3): p. 136-7.
Naz Masood, S., Y. Masood, and J. Mathrani, Diagnostic dilemma in Broad Ligament Leiomyoma with Cystic Degeneration. Pak J Med Sci, 2014. 30(2): p. 452–4.
Najjar, M. and M. Mandel, Round Ligament Leiomyoma Presenting as an Incarcerated Inguinal Hernia: Case Report and Review of the Literature. Case Rep Surg, 2016. 2016: p. 9380212.
Efthimiadis, C., et al., Leiomyoma of round ligament mimicking an incarcerated inguinal hernia-report of a rare case. J Surg Case Rep, 2017. 2017(11): p. rjx237.
Kypriotis, K., et al., Leiomyoma originating from left round ligament presents as symptomatic inguinal hernia. Clin Case Rep, 2021. 9(7): p. e04445.
Yano, M., et al., Uterine intravenous leiomyomatosis with an isolated large metastasis to the right atrium: a case report. Diagn Pathol, 2020. 15(1): p. 4.
Yu, X., et al., Clinicopathologic features and clinical outcomes of intravenous leiomyomatosis of the uterus: A case series. Medicine (Baltimore), 2021. 100(1): p. e24228.
Mathey, M.P., C. Duc, and D. Huber, Intravenous leiomyomatosis: Case series and review of the literature. Int J Surg Case Rep, 2021. 85: p. 106257.
Wang, H., et al., Contrast-enhanced CT findings of intravenous leiomyomatosis. Clin Radiol, 2018. 73(5): p. 503.e1-503.e6.
Sousa, F.A.E., J. Ferreira, and T.M. Cunha, MR Imaging of uterine sarcomas: a comprehensive review with radiologic-pathologic correlation. Abdom Radiol (NY), 2021. 46(12): p. 5687-5706.
Wu, C.Q., et al., Occult Leiomyosarcomas in a Canadian Province: A Retrospective Cohort Study. J Obstet Gynaecol Can, 2019. 41(1): p. 46-51.
Lakhman, Y., et al., Differentiation of Uterine Leiomyosarcoma from Atypical Leiomyoma: Diagnostic Accuracy of Qualitative MR Imaging Features and Feasibility of Texture Analysis. Eur Radiol, 2017. 27(7): p. 2903-2915.
Sahin, H., et al., Diagnostic interpretation of non-contrast qualitative MR imaging features for characterisation of uterine leiomyosarcoma. Br J Radiol, 2021. 94(1125): p. 20210115.
Abdel Wahab, C., et al., Diagnostic Algorithm to Differentiate Benign Atypical Leiomyomas from Malignant Uterine Sarcomas with Diffusion-weighted MRI. Radiology, 2020. 297(2): p. 361-371.
Jagannathan, J.P., et al., Differentiating leiomyosarcoma from leiomyoma: in support of an MR imaging predictive scoring system. Abdom Radiol (NY), 2021. 46(10): p. 4927-4935.
Lin, G., et al., Comparison of the diagnostic accuracy of contrast-enhanced MRI and diffusion-weighted MRI in the differentiation between uterine leiomyosarcoma / smooth muscle tumor with uncertain malignant potential and benign leiomyoma. J Magn Reson Imaging, 2016. 43(2): p. 333-42.
Kusunoki, S., et al., Efficacy of PET/CT to exclude leiomyoma in patients with lesions suspicious for uterine sarcoma on MRI. Taiwan J Obstet Gynecol, 2017. 56(4): p. 508-513.
Tellum, T., et al., Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker. Eur Radiol, 2019. 29(12): p. 6971-6981.
de Bruijn, A.M., et al., Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol, 2017. 28(12): p. 1629-1642.e1.
Zaki, M.N., et al., Late presentation of extrauterine adenomyomas after laparoscopic morcellation at hysterectomy: a case report. BMC Womens Health, 2021. 21(1): p. 269.
Agostinho, L., et al., MRI for adenomyosis: a pictorial review. Insights Imaging, 2017. 8(6): p. 549-556.
Liu, L., et al., Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for Adenomyosis: Systematic Review and Meta-Analysis and Review of Sonographic Diagnostic Criteria. J Ultrasound Med, 2021. 40(11): p. 2289-2306.
Yajima, R., et al., Diffusion-weighted imaging of uterine adenomyosis: Correlation with clinical backgrounds and comparison with malignant uterine tumors. J Obstet Gynaecol Res, 2021. 47(3): p. 949-960.
Thomassin-Naggara, I., et al., Value of dynamic enhanced magnetic resonance imaging for distinguishing between ovarian fibroma and subserous uterine leiomyoma. J Comput Assist Tomogr, 2007. 31(2): p. 236-42.
Omary, R.A., et al., The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids. J Vasc Interv Radiol, 2002. 13(11): p. 1149-53.
Kohi, M.P. and J.B. Spies, Updates on Uterine Artery Embolization. Semin Intervent Radiol, 2018. 35(1): p. 48-55.
Siddiqui, N., et al., Uterine artery embolization: pre- and post-procedural evaluation using magnetic resonance imaging. Abdom Imaging, 2013. 38(5): p. 1161-77.
Marret, H., et al., Predictive factors for fibroids recurrence after uterine artery embolisation. Bjog, 2005. 112(4): p. 461-5.
Mori, K., et al., Assessment of uterine and ovarian arteries before uterine artery embolization: advantages conferred by unenhanced MR angiography. Radiology, 2010. 255(2): p. 467-75.
Naguib, N.N., et al., Uterine artery embolization: optimization with preprocedural prediction of the best tube angle obliquity by using 3D-reconstructed contrast-enhanced MR angiography. Radiology, 2009. 251(3): p. 788-95.
Kirby, J.M., et al., Utility of MRI before and after uterine fibroid embolization: why to do it and what to look for. Cardiovasc Intervent Radiol, 2011. 34(4): p. 705-16.
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Awiwi, M.O., Badawy, M., Shaaban, A.M. et al. Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification. Abdom Radiol 47, 2468–2485 (2022). https://doi.org/10.1007/s00261-022-03545-x
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DOI: https://doi.org/10.1007/s00261-022-03545-x