Uterine Leiomyomas: Histopathologic Features, MR Imaging Findings, Differential Diagnosis, and Treatment1
Eiko Murase, MD,
Evan S. Siegelman, MD,
Eric K. Outwater, MD,
Liza A. Perez-Jaffe, MD and
Richard W. Tureck, MD
1 From the Departments of Radiology (E.M., E.S.S.), Pathology (L.A.P.J.), and Obstetrics-Gynecology (R.W.T.), University of Pennsylvania Medical Center, First Floor Founders: MRI, 3400 Spruce St, Philadelphia, PA 19104; and the Department of Radiology, Thomas Jefferson University Hospital, Philadelphia (E.K.O.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received January 27, 1999; revision requested March 4 and received April 7; accepted April 12. Address reprint requests to E.S.S.
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Figure 1. Submucosal, intramural, and subserosal leiomyomas in a 43-year-old woman. Axial T2-weighted fast spin-echo (SE) MR image shows submucosal (large *), intramural (small *), intracavitary (straight arrow), and subserosal (curved arrow) leiomyomas. The latter manifested as a suspected adnexal mass at both rectal examination and an outside ultrasonographic (US) examination. MR imaging was requested to exclude an ovarian neoplasm. The left ovary was identified on other images (not shown).
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Figure 2a. Prolapsed pedunculated leiomyoma manifesting as a vaginal mass in a 57-year-old woman. Sagittal T2-weighted fast SE MR images show a mass of low to intermediate signal intensity (arrow in a) within a distended vaginal canal (arrows in b), which is continuous superiorly with the endometrial canal (* in a).
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Figure 2b. Prolapsed pedunculated leiomyoma manifesting as a vaginal mass in a 57-year-old woman. Sagittal T2-weighted fast SE MR images show a mass of low to intermediate signal intensity (arrow in a) within a distended vaginal canal (arrows in b), which is continuous superiorly with the endometrial canal (* in a).
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Figure 3a. Maturing hemorrhagic leiomyoma in a postpartum 34-year-old woman with lower abdominal discomfort and a palpable mass. (a, b) Sagittal (a) and axial (b) T2-weighted fast SE MR images show a normal uterus (arrow in a, straight arrow in b) and ovaries (curved arrows in b). There is a large, heterogeneous subserosal leiomyoma (*) that extends superiorly from the anterior body and fundus of the uterus. (c) Axial T1-weighted spoiled gradient-echo MR image obtained at the same level as b shows diffuse very high signal intensity within the mass (*); the very high signal intensity represents methemoglobin from subacute hemorrhage. (d) Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim (arrows). Both patterns of high signal intensity have been described in hemorrhagic degeneration of leiomyomas.
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Figure 3b. Maturing hemorrhagic leiomyoma in a postpartum 34-year-old woman with lower abdominal discomfort and a palpable mass. (a, b) Sagittal (a) and axial (b) T2-weighted fast SE MR images show a normal uterus (arrow in a, straight arrow in b) and ovaries (curved arrows in b). There is a large, heterogeneous subserosal leiomyoma (*) that extends superiorly from the anterior body and fundus of the uterus. (c) Axial T1-weighted spoiled gradient-echo MR image obtained at the same level as b shows diffuse very high signal intensity within the mass (*); the very high signal intensity represents methemoglobin from subacute hemorrhage. (d) Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim (arrows). Both patterns of high signal intensity have been described in hemorrhagic degeneration of leiomyomas.
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Figure 3c. Maturing hemorrhagic leiomyoma in a postpartum 34-year-old woman with lower abdominal discomfort and a palpable mass. (a, b) Sagittal (a) and axial (b) T2-weighted fast SE MR images show a normal uterus (arrow in a, straight arrow in b) and ovaries (curved arrows in b). There is a large, heterogeneous subserosal leiomyoma (*) that extends superiorly from the anterior body and fundus of the uterus. (c) Axial T1-weighted spoiled gradient-echo MR image obtained at the same level as b shows diffuse very high signal intensity within the mass (*); the very high signal intensity represents methemoglobin from subacute hemorrhage. (d) Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim (arrows). Both patterns of high signal intensity have been described in hemorrhagic degeneration of leiomyomas.
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Figure 3d. Maturing hemorrhagic leiomyoma in a postpartum 34-year-old woman with lower abdominal discomfort and a palpable mass. (a, b) Sagittal (a) and axial (b) T2-weighted fast SE MR images show a normal uterus (arrow in a, straight arrow in b) and ovaries (curved arrows in b). There is a large, heterogeneous subserosal leiomyoma (*) that extends superiorly from the anterior body and fundus of the uterus. (c) Axial T1-weighted spoiled gradient-echo MR image obtained at the same level as b shows diffuse very high signal intensity within the mass (*); the very high signal intensity represents methemoglobin from subacute hemorrhage. (d) Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim (arrows). Both patterns of high signal intensity have been described in hemorrhagic degeneration of leiomyomas.
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Figure 4a. 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 (*).
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Figure 4b. 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 (*).
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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 (*).
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Figure 4d. 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 (*).
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Figure 5a. Multiple intramural and subserosal leiomyomas in a 31-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted fast SE MR images show a normal endometrial stripe (small black *) and junctional zone (straight arrow). Multiple relatively homogeneous leiomyomas of low to intermediate signal intensity are evident (white *), as are a normal-appearing left ovary (curved arrow in a) and physiologic cul-de-sac fluid (large black *). Two months after surgery, the patient returned for additional imaging because of pelvic pain. (c, d) Axial (c) and sagittal (d) T2-weighted fast SE MR images show that the leiomyomas have been removed. There is a large, unilocular fluid collection within the cul-de-sac that also abuts the left ovary (curved arrow in c) and displaces the uterus anteriorly (straight arrow). The fluid collection was confirmed to be a postprocedural peritoneal inclusion cyst.
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Figure 5b. Multiple intramural and subserosal leiomyomas in a 31-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted fast SE MR images show a normal endometrial stripe (small black *) and junctional zone (straight arrow). Multiple relatively homogeneous leiomyomas of low to intermediate signal intensity are evident (white *), as are a normal-appearing left ovary (curved arrow in a) and physiologic cul-de-sac fluid (large black *). Two months after surgery, the patient returned for additional imaging because of pelvic pain. (c, d) Axial (c) and sagittal (d) T2-weighted fast SE MR images show that the leiomyomas have been removed. There is a large, unilocular fluid collection within the cul-de-sac that also abuts the left ovary (curved arrow in c) and displaces the uterus anteriorly (straight arrow). The fluid collection was confirmed to be a postprocedural peritoneal inclusion cyst.
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Figure 5c. Multiple intramural and subserosal leiomyomas in a 31-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted fast SE MR images show a normal endometrial stripe (small black *) and junctional zone (straight arrow). Multiple relatively homogeneous leiomyomas of low to intermediate signal intensity are evident (white *), as are a normal-appearing left ovary (curved arrow in a) and physiologic cul-de-sac fluid (large black *). Two months after surgery, the patient returned for additional imaging because of pelvic pain. (c, d) Axial (c) and sagittal (d) T2-weighted fast SE MR images show that the leiomyomas have been removed. There is a large, unilocular fluid collection within the cul-de-sac that also abuts the left ovary (curved arrow in c) and displaces the uterus anteriorly (straight arrow). The fluid collection was confirmed to be a postprocedural peritoneal inclusion cyst.
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Figure 5d. Multiple intramural and subserosal leiomyomas in a 31-year-old woman. (a, b) Axial (a) and sagittal (b) T2-weighted fast SE MR images show a normal endometrial stripe (small black *) and junctional zone (straight arrow). Multiple relatively homogeneous leiomyomas of low to intermediate signal intensity are evident (white *), as are a normal-appearing left ovary (curved arrow in a) and physiologic cul-de-sac fluid (large black *). Two months after surgery, the patient returned for additional imaging because of pelvic pain. (c, d) Axial (c) and sagittal (d) T2-weighted fast SE MR images show that the leiomyomas have been removed. There is a large, unilocular fluid collection within the cul-de-sac that also abuts the left ovary (curved arrow in c) and displaces the uterus anteriorly (straight arrow). The fluid collection was confirmed to be a postprocedural peritoneal inclusion cyst.
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Figure 6a. Cellular leiomyoma in a 28-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed, heterogeneous leiomyoma on the left side of the uterine body (arrow). (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows a uniform cellular neoplasm composed of whorls of smooth muscle cells with little intervening collagen.
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Figure 6b. Cellular leiomyoma in a 28-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed, heterogeneous leiomyoma on the left side of the uterine body (arrow). (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows a uniform cellular neoplasm composed of whorls of smooth muscle cells with little intervening collagen.
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Figures 7, 8. (7) Massive subserosal leiomyoma with cystic degeneration in a 46-year-old woman. Sagittal images (not shown) demonstrated continuity of the mass with the uterine fundus. Axial T2-weighted fast SE MR image (a) and corresponding contrast-enhanced fat-suppressed T1-weighted gradient-echo MR image (b) show a large, heterogeneous pelvic mass. Most of the mass is of low to intermediate signal intensity on the T2-weighted image (a), an appearance suggestive of a leiomyoma. Several small foci of very high signal intensity on the T2-weighted image (a) and no enhancement on the contrast-enhanced image (b) represent cystic degeneration (arrows). (8) Leiomyoma with myxoid degeneration in a 49-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed mass of the anterior uterus that has components of both low signal intensity (white *) and high signal intensity (black *) compared with that of the outer myometrium. (b) Contrast-enhanced fat-saturated T1-weighted gradient-echo MR image (repetition time msec/echo time msec = 500/3.3, 90° flip angle) obtained at the same level as a shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image (a) enhances. The enhancement indicates that this tissue does not represent intratumoral cysts or necrosis. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a myxoid leiomyoma in another patient shows loose, water-laden myxoid tissue (*), which contrasts with the denser smooth muscle bundles (arrow).
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Figures 7, 8. (7) Massive subserosal leiomyoma with cystic degeneration in a 46-year-old woman. Sagittal images (not shown) demonstrated continuity of the mass with the uterine fundus. Axial T2-weighted fast SE MR image (a) and corresponding contrast-enhanced fat-suppressed T1-weighted gradient-echo MR image (b) show a large, heterogeneous pelvic mass. Most of the mass is of low to intermediate signal intensity on the T2-weighted image (a), an appearance suggestive of a leiomyoma. Several small foci of very high signal intensity on the T2-weighted image (a) and no enhancement on the contrast-enhanced image (b) represent cystic degeneration (arrows). (8) Leiomyoma with myxoid degeneration in a 49-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed mass of the anterior uterus that has components of both low signal intensity (white *) and high signal intensity (black *) compared with that of the outer myometrium. (b) Contrast-enhanced fat-saturated T1-weighted gradient-echo MR image (repetition time msec/echo time msec = 500/3.3, 90° flip angle) obtained at the same level as a shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image (a) enhances. The enhancement indicates that this tissue does not represent intratumoral cysts or necrosis. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a myxoid leiomyoma in another patient shows loose, water-laden myxoid tissue (*), which contrasts with the denser smooth muscle bundles (arrow).
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Figures 7, 8. (7) Massive subserosal leiomyoma with cystic degeneration in a 46-year-old woman. Sagittal images (not shown) demonstrated continuity of the mass with the uterine fundus. Axial T2-weighted fast SE MR image (a) and corresponding contrast-enhanced fat-suppressed T1-weighted gradient-echo MR image (b) show a large, heterogeneous pelvic mass. Most of the mass is of low to intermediate signal intensity on the T2-weighted image (a), an appearance suggestive of a leiomyoma. Several small foci of very high signal intensity on the T2-weighted image (a) and no enhancement on the contrast-enhanced image (b) represent cystic degeneration (arrows). (8) Leiomyoma with myxoid degeneration in a 49-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed mass of the anterior uterus that has components of both low signal intensity (white *) and high signal intensity (black *) compared with that of the outer myometrium. (b) Contrast-enhanced fat-saturated T1-weighted gradient-echo MR image (repetition time msec/echo time msec = 500/3.3, 90° flip angle) obtained at the same level as a shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image (a) enhances. The enhancement indicates that this tissue does not represent intratumoral cysts or necrosis. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a myxoid leiomyoma in another patient shows loose, water-laden myxoid tissue (*), which contrasts with the denser smooth muscle bundles (arrow).
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Figures 7, 8. (7) Massive subserosal leiomyoma with cystic degeneration in a 46-year-old woman. Sagittal images (not shown) demonstrated continuity of the mass with the uterine fundus. Axial T2-weighted fast SE MR image (a) and corresponding contrast-enhanced fat-suppressed T1-weighted gradient-echo MR image (b) show a large, heterogeneous pelvic mass. Most of the mass is of low to intermediate signal intensity on the T2-weighted image (a), an appearance suggestive of a leiomyoma. Several small foci of very high signal intensity on the T2-weighted image (a) and no enhancement on the contrast-enhanced image (b) represent cystic degeneration (arrows). (8) Leiomyoma with myxoid degeneration in a 49-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed mass of the anterior uterus that has components of both low signal intensity (white *) and high signal intensity (black *) compared with that of the outer myometrium. (b) Contrast-enhanced fat-saturated T1-weighted gradient-echo MR image (repetition time msec/echo time msec = 500/3.3, 90° flip angle) obtained at the same level as a shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image (a) enhances. The enhancement indicates that this tissue does not represent intratumoral cysts or necrosis. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a myxoid leiomyoma in another patient shows loose, water-laden myxoid tissue (*), which contrasts with the denser smooth muscle bundles (arrow).
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Figures 7, 8. (7) Massive subserosal leiomyoma with cystic degeneration in a 46-year-old woman. Sagittal images (not shown) demonstrated continuity of the mass with the uterine fundus. Axial T2-weighted fast SE MR image (a) and corresponding contrast-enhanced fat-suppressed T1-weighted gradient-echo MR image (b) show a large, heterogeneous pelvic mass. Most of the mass is of low to intermediate signal intensity on the T2-weighted image (a), an appearance suggestive of a leiomyoma. Several small foci of very high signal intensity on the T2-weighted image (a) and no enhancement on the contrast-enhanced image (b) represent cystic degeneration (arrows). (8) Leiomyoma with myxoid degeneration in a 49-year-old woman. (a) Axial T2-weighted fast SE MR image shows a well-circumscribed mass of the anterior uterus that has components of both low signal intensity (white *) and high signal intensity (black *) compared with that of the outer myometrium. (b) Contrast-enhanced fat-saturated T1-weighted gradient-echo MR image (repetition time msec/echo time msec = 500/3.3, 90° flip angle) obtained at the same level as a shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image (a) enhances. The enhancement indicates that this tissue does not represent intratumoral cysts or necrosis. (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a myxoid leiomyoma in another patient shows loose, water-laden myxoid tissue (*), which contrasts with the denser smooth muscle bundles (arrow).
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Figure 9a. Leiomyomas with coagulative necrosis in a 38-year-old woman. (a, b) Axial T2-weighted fast SE MR image (a) and T1-weighted SE MR image (b) show two intramural leiomyomas (straight arrows), which have lower signal intensity than the myometrium on the T2-weighted image (a) and higher signal intensity on the T1-weighted image (b). A small amount of liquefactive degeneration is present in the lateral aspect of the left-sided tumor (curved arrow). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the larger myoma shows a homogeneous matrix without recognizable cells, findings that correspond to coagulative necrosis.
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Figure 9b. Leiomyomas with coagulative necrosis in a 38-year-old woman. (a, b) Axial T2-weighted fast SE MR image (a) and T1-weighted SE MR image (b) show two intramural leiomyomas (straight arrows), which have lower signal intensity than the myometrium on the T2-weighted image (a) and higher signal intensity on the T1-weighted image (b). A small amount of liquefactive degeneration is present in the lateral aspect of the left-sided tumor (curved arrow). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the larger myoma shows a homogeneous matrix without recognizable cells, findings that correspond to coagulative necrosis.
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Figure 9c. Leiomyomas with coagulative necrosis in a 38-year-old woman. (a, b) Axial T2-weighted fast SE MR image (a) and T1-weighted SE MR image (b) show two intramural leiomyomas (straight arrows), which have lower signal intensity than the myometrium on the T2-weighted image (a) and higher signal intensity on the T1-weighted image (b). A small amount of liquefactive degeneration is present in the lateral aspect of the left-sided tumor (curved arrow). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the larger myoma shows a homogeneous matrix without recognizable cells, findings that correspond to coagulative necrosis.
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Figure 10a. Intramural-submucosal leiomyoma with peritumoral high signal intensity in a 36-year-old woman. (a) Sagittal T2-weighted fast SE MR image shows a well-circumscribed mass of low signal intensity within the anterior uterine body that distorts the endometrial canal (*). The mass has a thin rim of high signal intensity (arrows). (b) Photomicrograph (original magnification, x20; hematoxylin-eosin stain) of the periphery of the myoma shows blood vessels (large *), lymphatic vessels (small *), and subjacent compact regions of smooth muscle.
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Figure 10b. Intramural-submucosal leiomyoma with peritumoral high signal intensity in a 36-year-old woman. (a) Sagittal T2-weighted fast SE MR image shows a well-circumscribed mass of low signal intensity within the anterior uterine body that distorts the endometrial canal (*). The mass has a thin rim of high signal intensity (arrows). (b) Photomicrograph (original magnification, x20; hematoxylin-eosin stain) of the periphery of the myoma shows blood vessels (large *), lymphatic vessels (small *), and subjacent compact regions of smooth muscle.
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Figure 11a. Focal adenomyosis mimicking a subserosal leiomyoma in a 42-year-old woman. (a, b) Axial (a) and coronal (b) T2-weighted fast SE MR images show a poorly marginated, heterogeneous mass (straight arrow) with punctate foci of high signal intensity (arrowhead) adjacent to the left side of the uterine body. There is mild thickening of the inner myometrium, a finding suggestive of adenomyosis. There is also a small, right-sided intramural mass, an appearance typical of a small leiomyoma (curved arrow in a). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the resected adnexal mass shows several islands of ectopic endometrial glands (*) surrounded by whorled hypertrophic smooth muscle.
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Figure 11b. Focal adenomyosis mimicking a subserosal leiomyoma in a 42-year-old woman. (a, b) Axial (a) and coronal (b) T2-weighted fast SE MR images show a poorly marginated, heterogeneous mass (straight arrow) with punctate foci of high signal intensity (arrowhead) adjacent to the left side of the uterine body. There is mild thickening of the inner myometrium, a finding suggestive of adenomyosis. There is also a small, right-sided intramural mass, an appearance typical of a small leiomyoma (curved arrow in a). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the resected adnexal mass shows several islands of ectopic endometrial glands (*) surrounded by whorled hypertrophic smooth muscle.
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Figure 11c. Focal adenomyosis mimicking a subserosal leiomyoma in a 42-year-old woman. (a, b) Axial (a) and coronal (b) T2-weighted fast SE MR images show a poorly marginated, heterogeneous mass (straight arrow) with punctate foci of high signal intensity (arrowhead) adjacent to the left side of the uterine body. There is mild thickening of the inner myometrium, a finding suggestive of adenomyosis. There is also a small, right-sided intramural mass, an appearance typical of a small leiomyoma (curved arrow in a). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the resected adnexal mass shows several islands of ectopic endometrial glands (*) surrounded by whorled hypertrophic smooth muscle.
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Figures 12, 13. (12) Left ovarian fibroma in a 41-year-old woman with pelvic pain and a palpable pelvic mass. Axial T2-weighted fast SE MR image shows a 5-cm-diameter adnexal mass with very low signal intensity (*) surrounded by attenuated ovarian stroma and follicles (arrows). The mass is separate from the uterus. Because MR imaging demonstrated that the mass was contained within the ovary, a diagnosis of leiomyoma of the broad ligament could be excluded. Histologic sections (not shown) revealed dense fibrous tissue admixed with foci of calcium. Ovarian fibromas contain focal or diffuse calcium in less than 10% of cases (43-45); along with fibrous tissue, calcium can result in low signal intensity on T2-weighted images. (13) Bilateral Brenner tumors and a left-sided serous cystadenoma with papillary projections in a 51-year-old woman. (a, b) Consecutive axial T2-weighted fast SE MR images (a obtained at a higher level than b) show bilateral adnexal masses (*) with lower signal intensity than an adjacent intramural-submucosal leiomyoma (curved arrow). There is an additional left adnexal mass with a thickened posterior wall and a small papillary projection along the anterior wall (straight arrow). The intraovarian location of this lesion and the difference in signal intensity between this lesion and the leiomyoma suggest a diagnosis of a fibrous adnexal neoplasm. Brenner tumors can be bilateral and are associated with other ovarian neoplasms in 30% of cases (42). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the solid left adnexal mass shows a focus of transitional cells (arrows) surrounded by reactive fibrous tissue. The nests of transitional cells are too small to be depicted as foci of intratumoral high signal intensity on T2-weighted images.
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Figures 12, 13. (12) Left ovarian fibroma in a 41-year-old woman with pelvic pain and a palpable pelvic mass. Axial T2-weighted fast SE MR image shows a 5-cm-diameter adnexal mass with very low signal intensity (*) surrounded by attenuated ovarian stroma and follicles (arrows). The mass is separate from the uterus. Because MR imaging demonstrated that the mass was contained within the ovary, a diagnosis of leiomyoma of the broad ligament could be excluded. Histologic sections (not shown) revealed dense fibrous tissue admixed with foci of calcium. Ovarian fibromas contain focal or diffuse calcium in less than 10% of cases (43-45); along with fibrous tissue, calcium can result in low signal intensity on T2-weighted images. (13) Bilateral Brenner tumors and a left-sided serous cystadenoma with papillary projections in a 51-year-old woman. (a, b) Consecutive axial T2-weighted fast SE MR images (a obtained at a higher level than b) show bilateral adnexal masses (*) with lower signal intensity than an adjacent intramural-submucosal leiomyoma (curved arrow). There is an additional left adnexal mass with a thickened posterior wall and a small papillary projection along the anterior wall (straight arrow). The intraovarian location of this lesion and the difference in signal intensity between this lesion and the leiomyoma suggest a diagnosis of a fibrous adnexal neoplasm. Brenner tumors can be bilateral and are associated with other ovarian neoplasms in 30% of cases (42). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the solid left adnexal mass shows a focus of transitional cells (arrows) surrounded by reactive fibrous tissue. The nests of transitional cells are too small to be depicted as foci of intratumoral high signal intensity on T2-weighted images.
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Figures 12, 13. (12) Left ovarian fibroma in a 41-year-old woman with pelvic pain and a palpable pelvic mass. Axial T2-weighted fast SE MR image shows a 5-cm-diameter adnexal mass with very low signal intensity (*) surrounded by attenuated ovarian stroma and follicles (arrows). The mass is separate from the uterus. Because MR imaging demonstrated that the mass was contained within the ovary, a diagnosis of leiomyoma of the broad ligament could be excluded. Histologic sections (not shown) revealed dense fibrous tissue admixed with foci of calcium. Ovarian fibromas contain focal or diffuse calcium in less than 10% of cases (43-45); along with fibrous tissue, calcium can result in low signal intensity on T2-weighted images. (13) Bilateral Brenner tumors and a left-sided serous cystadenoma with papillary projections in a 51-year-old woman. (a, b) Consecutive axial T2-weighted fast SE MR images (a obtained at a higher level than b) show bilateral adnexal masses (*) with lower signal intensity than an adjacent intramural-submucosal leiomyoma (curved arrow). There is an additional left adnexal mass with a thickened posterior wall and a small papillary projection along the anterior wall (straight arrow). The intraovarian location of this lesion and the difference in signal intensity between this lesion and the leiomyoma suggest a diagnosis of a fibrous adnexal neoplasm. Brenner tumors can be bilateral and are associated with other ovarian neoplasms in 30% of cases (42). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the solid left adnexal mass shows a focus of transitional cells (arrows) surrounded by reactive fibrous tissue. The nests of transitional cells are too small to be depicted as foci of intratumoral high signal intensity on T2-weighted images.
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Figures 12, 13. (12) Left ovarian fibroma in a 41-year-old woman with pelvic pain and a palpable pelvic mass. Axial T2-weighted fast SE MR image shows a 5-cm-diameter adnexal mass with very low signal intensity (*) surrounded by attenuated ovarian stroma and follicles (arrows). The mass is separate from the uterus. Because MR imaging demonstrated that the mass was contained within the ovary, a diagnosis of leiomyoma of the broad ligament could be excluded. Histologic sections (not shown) revealed dense fibrous tissue admixed with foci of calcium. Ovarian fibromas contain focal or diffuse calcium in less than 10% of cases (43-45); along with fibrous tissue, calcium can result in low signal intensity on T2-weighted images. (13) Bilateral Brenner tumors and a left-sided serous cystadenoma with papillary projections in a 51-year-old woman. (a, b) Consecutive axial T2-weighted fast SE MR images (a obtained at a higher level than b) show bilateral adnexal masses (*) with lower signal intensity than an adjacent intramural-submucosal leiomyoma (curved arrow). There is an additional left adnexal mass with a thickened posterior wall and a small papillary projection along the anterior wall (straight arrow). The intraovarian location of this lesion and the difference in signal intensity between this lesion and the leiomyoma suggest a diagnosis of a fibrous adnexal neoplasm. Brenner tumors can be bilateral and are associated with other ovarian neoplasms in 30% of cases (42). (c) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) of the solid left adnexal mass shows a focus of transitional cells (arrows) surrounded by reactive fibrous tissue. The nests of transitional cells are too small to be depicted as foci of intratumoral high signal intensity on T2-weighted images.
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Figure 14a. Focal myometrial contraction mimicking an intramural leiomyoma in a 38-year-old pregnant woman. (a) Sagittal T2-weighted fast SE MR image shows a well-circumscribed mass of low signal intensity within the anterior uterine wall (*). (b) Axial T2-weighted fast SE MR image obtained 20 minutes later shows almost complete resolution of the mass (*), thus allowing exclusion of a diagnosis of leiomyoma. An embryo is shown in the sagittal plane (arrow).
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Figure 14b. Focal myometrial contraction mimicking an intramural leiomyoma in a 38-year-old pregnant woman. (a) Sagittal T2-weighted fast SE MR image shows a well-circumscribed mass of low signal intensity within the anterior uterine wall (*). (b) Axial T2-weighted fast SE MR image obtained 20 minutes later shows almost complete resolution of the mass (*), thus allowing exclusion of a diagnosis of leiomyoma. An embryo is shown in the sagittal plane (arrow).
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Figure 15a. Metastatic uterine leiomyosarcoma in a 43-year-old woman. (a) Sagittal T2-weighted fast SE MR image shows a poorly marginated mass of the posterior uterine body (arrows). The region of low signal intensity in the anterior part of the mass (*) represents high-volume flow within a draining vein. (b) Contrast-enhanced axial T1-weighted spoiled gradient-echo MR image shows bilateral pulmonary nodules (arrows). The lungs and liver are the most common sites of metastatic spread of uterine leiomyosarcoma (6,49). (c) Photograph of the cut specimen shows good MR imaging-histopathologic correlation of the infiltrating sarcoma (arrows). * = draining vein.
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Figure 15b. Metastatic uterine leiomyosarcoma in a 43-year-old woman. (a) Sagittal T2-weighted fast SE MR image shows a poorly marginated mass of the posterior uterine body (arrows). The region of low signal intensity in the anterior part of the mass (*) represents high-volume flow within a draining vein. (b) Contrast-enhanced axial T1-weighted spoiled gradient-echo MR image shows bilateral pulmonary nodules (arrows). The lungs and liver are the most common sites of metastatic spread of uterine leiomyosarcoma (6,49). (c) Photograph of the cut specimen shows good MR imaging-histopathologic correlation of the infiltrating sarcoma (arrows). * = draining vein.
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Figure 15c. Metastatic uterine leiomyosarcoma in a 43-year-old woman. (a) Sagittal T2-weighted fast SE MR image shows a poorly marginated mass of the posterior uterine body (arrows). The region of low signal intensity in the anterior part of the mass (*) represents high-volume flow within a draining vein. (b) Contrast-enhanced axial T1-weighted spoiled gradient-echo MR image shows bilateral pulmonary nodules (arrows). The lungs and liver are the most common sites of metastatic spread of uterine leiomyosarcoma (6,49). (c) Photograph of the cut specimen shows good MR imaging-histopathologic correlation of the infiltrating sarcoma (arrows). * = draining vein.
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Copyright © 1999 by the Radiological Society of North America.
