Figure 4c. Hyaline degeneration and ischemic necrosis in a surgically confirmed, chronically twisted subserosal leiomyoma in a 47-year-old woman with chronic pelvic pain. (a, b) Axial (a) and sagittal (b) T2-weighted fast SE MR images show an ovoid mass in the cul-de-sac (arrows) with heterogeneous predominantly low to intermediate signal intensity relative to that of the outer myometrium. No connection to the uterus was demonstrated. (c) Axial fat-saturated T1-weighted SE MR image shows high signal intensity within the cul-de-sac mass (*); the high signal intensity represents subacute to chronic hemorrhage. A hemorrhagic cyst or endometrioma is present in the left ovary (arrow). (d) Contrast material-enhanced axial fat-saturated T1-weighted SE MR image shows enhancement of the myometrium (straight arrow) and rectal wall (curved arrow) but no enhancement of the cul-de-sac mass (*).