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  1. 1. <ul><li>BY </li></ul><ul><li>Mohammad A. Emam </li></ul><ul><li>Prof. of Obstetrics and Gynecology </li></ul><ul><li>Mansoura Faculty of Medicine </li></ul><ul><li>Mansoura integrated fertility center (MIFC) </li></ul><ul><li>Egypt </li></ul>Leiomyoma: An overview
  2. 2. Epidemiology <ul><li>The commonest of all pelvic T. (1/3). </li></ul><ul><li>20% of female > 30y do have fibroid. </li></ul><ul><li>Childbearing life. </li></ul><ul><li>often enlarge during pregnancy or </li></ul><ul><li>during oral contraceptive use, and regress after menopause </li></ul><ul><li>occur in women of reproductive age, often </li></ul>
  3. 3. <ul><li>Uterus deprived from a baby consoles itself with a fibroid. </li></ul>M.Emam
  4. 4. Causes <ul><li>Unknown. </li></ul><ul><li>Hyperestrogenemia. </li></ul><ul><li>Infertility ?! </li></ul><ul><li>Mechanical stress (lat wall + fundus). </li></ul>
  5. 5. Pathology <ul><li>NIE: </li></ul><ul><li>-Site - shape - size. </li></ul><ul><li> - Consistency - cut section </li></ul><ul><li>- capsule - Number </li></ul><ul><li>- varieties. </li></ul>
  6. 7. Varieties of leiomyoma <ul><li>uterine </li></ul><ul><li>cervical. </li></ul><ul><li>Corporeal </li></ul><ul><li>extrauterine </li></ul><ul><li>Round lig </li></ul><ul><li>brood lig </li></ul><ul><li>Recto-vog. Sept </li></ul><ul><li>utero - sacral </li></ul><ul><li>Leiomyomotosis </li></ul><ul><li>tunica M </li></ul><ul><li>extension from Myoma </li></ul>
  7. 8. Uterine leiomyoma <ul><li>Corporeal </li></ul><ul><li>98% </li></ul><ul><li>multiple </li></ul><ul><li>Cervical </li></ul><ul><li>1-2% </li></ul><ul><li>solitary </li></ul>
  8. 9. M.Emam
  9. 10. M.Emam
  10. 11. Corporeal leiomyoma <ul><li>submucus </li></ul><ul><li>24% </li></ul><ul><li>not capsulated </li></ul><ul><li>Subserous </li></ul><ul><li>18% </li></ul><ul><li>Interstitial </li></ul><ul><li>58% </li></ul>
  11. 12. M.Emam
  12. 13. M.Emam
  13. 14. M.Emam
  14. 15. Cervical leiomyoma Supravaginal cervix true (ant - post - central - combined) false (intralig - retraperit- not capsulated) <ul><li>Portio vaginalis </li></ul><ul><li>small </li></ul><ul><li>sessile </li></ul><ul><li>polypoid </li></ul>
  15. 16. CONSISTENCY <ul><li>Firm </li></ul><ul><li>Harder (hyaline degeneration). </li></ul><ul><li>Soft (pregnancy-cystic degeneration). </li></ul><ul><li>Stony hard (Calcification) </li></ul>
  16. 17. Leiomyomata Uterus
  17. 18. CUT SECTION <ul><li>Well demarcated surrounding muscle. </li></ul><ul><li>whorly (intermingling muscle fibers and fibrous tissue). </li></ul><ul><li>Paler than surrounding (Ischaemia). </li></ul>
  18. 19. Leiomyoma:
  19. 20. Moham Emam
  20. 21. Microscopic Examination <ul><li>Smooth muscle cells and fibrous tissue cells. </li></ul><ul><li>Few formed blood vessels. </li></ul>
  21. 23. CELLULAR LEIOMYOMAS <ul><li>Compact smooth muscle cells with little or no collagen, can have relatively higher signal intensity on T2. </li></ul>
  22. 24. Changes occur with fibroid <ul><li>General </li></ul><ul><li>Genital tract </li></ul><ul><li>Tumor itself </li></ul>
  23. 25. General changes <ul><li>Erythrocytosis. </li></ul><ul><li>Polycythaemia (erythropoitic). </li></ul><ul><li>Carbohydrate metabolism (hyperglycaemia). </li></ul><ul><li>Anaemia (hge). </li></ul>
  24. 26. Genital tract <ul><li>Uterus (endomet.-cavity-myomet.-uterus as a whole). </li></ul><ul><li>Tubes inflammed (salpingitis) </li></ul><ul><li>ovaries (tunica albuginea-endometriosis-cysts). </li></ul><ul><li>Blood vessels. </li></ul><ul><li>Endometriosis (30-40%). </li></ul>
  25. 27. Tumour itself <ul><li>Atrophy. </li></ul><ul><li>Degeneration (hayline-red-cystic-fatty-calcerous) </li></ul><ul><li>Necrosis. </li></ul><ul><li>Malignancy (growth after menopause-rapid enlargement-recurrent fibroid polyp). </li></ul><ul><li>Vascular (oedema-lymphangectasia ) </li></ul><ul><li>Infection. </li></ul>
  26. 28. Degeneration <ul><li>Leiomyomas enlarge outgrow their blood supply various types of degeneration </li></ul><ul><ul><li>Hyaline degeneration :- the presence of homogeneous eosinophilic bands or plaques in the extracellular space. </li></ul></ul><ul><ul><li>Myxoid degeneration - presence of gelatinous intratumoral foci at gross examination that contain hyaluronic acid–rich mucopolysaccharides </li></ul></ul>
  27. 29. Degeneration cont <ul><ul><li>Red degeneration - during pregnancy, secondary to venous thrombosis within the periphery of the tumor or rupture of intratumoral arteries </li></ul></ul><ul><ul><li>Sarcomatous transformation -less than 3% </li></ul></ul>
  28. 30. DIAGNOSIS <ul><li>History </li></ul><ul><li>Examination. </li></ul><ul><li>Investigation. </li></ul><ul><li>D.D. </li></ul>
  29. 31. SYMPTOMS <ul><li>Bleeding (menorrhagia-metrorrhagia). </li></ul><ul><li>Pain uncomplicated (cong. Dysmenorrhea – dull - colicky). </li></ul><ul><li>Pain complicated deg.-malig.-infection-torsion) </li></ul><ul><li>infertility </li></ul><ul><li>mass. </li></ul><ul><li>Discharge. </li></ul><ul><li>Pressure symptoms. </li></ul>
  30. 32. Signs <ul><li>Symmetrically enlarged uterus(submucosal fibroid). </li></ul><ul><li>Asymmetrically enlarged uterus(subserous fibroid) </li></ul>
  31. 33. Investigations <ul><li>Clinical </li></ul><ul><li>Laboratory </li></ul><ul><li>Imaging techniques </li></ul><ul><li>Instrumental </li></ul><ul><li>Miscellaneous </li></ul>
  32. 34. Imaging Techniques (MR IMAGE) <ul><li>most accurate imaging technique for detection and localization of leiomyomas </li></ul><ul><li>myomatous uterus (>140 cm 3 ) is not consistently possible with US because of the limited field of view </li></ul><ul><li>uterine zonal anatomy enables accurate classification of individual masses as submucosal, intramural, or subserosal </li></ul>
  33. 35. Imaging Techniques (MR IMAGE) cont <ul><li>Nondegenerated uterine leiomyomas: </li></ul><ul><ul><li>- well-circumscribed masses of homogeneously decreased signal intensity compared with that of the outer myometrium on T2-weighted images </li></ul></ul><ul><ul><li>- whorls of uniform smooth muscle cells with various amounts of intervening collagen </li></ul></ul>
  34. 37. Imaging Techniques (MR IMAGE) <ul><li>Degenerated leiomyomas </li></ul><ul><ul><li>variable in T2 </li></ul></ul><ul><ul><li>hyaline and calcific degeneration (low) </li></ul></ul><ul><ul><li>cystic degeneration (high) </li></ul></ul><ul><ul><li>myxoid degeneration (very high, minimal enhance) </li></ul></ul><ul><ul><li>Necrotic leiomyomas without liquefaction </li></ul></ul><ul><ul><li>(variable in T1, low in T2) </li></ul></ul><ul><ul><li>Red degeneration </li></ul></ul><ul><ul><li>T1 : peripheral or diffuse high SI </li></ul></ul><ul><ul><li>T2 : variable SI with or without low SI rim on T2 </li></ul></ul>
  36. 40. DIFFERENTIAL Dx <ul><li>ADEMOMYOSIS </li></ul><ul><ul><li>- presence of ectopic endometrial glands and stroma within the myometrium, which are associated with reactive hypertrophy of the surrounding myometrial smooth muscle </li></ul></ul><ul><ul><li>- most commonly a diffuse abnormality but may also occur as a focal mass, which is known as an adenomyoma </li></ul></ul><ul><ul><li>- diffuse form of adenomyosis appears as a thickened junctional zone (inner myometrium) on T2-weighted images </li></ul></ul>
  37. 41. DIFFERENTIAL Dx <ul><li>ADEMOMYOSIS cont </li></ul><ul><ul><li>Junctional zone 12 mm thick or thicker is highly predictive of adenomyosis </li></ul></ul><ul><ul><li>Small foci of high signal intensity on T2-weighted images represent the endometrial glands </li></ul></ul>
  38. 42. Uterus Adenomyosis:
  39. 43. Adenomyosis:
  40. 44. <ul><li>Distinction between adenomyosis and leiomyomas is of clinical importance because, unlike leiomyomas, which may be treated with myomectomy, adenomyosis can be extirpated only with hysterectomy </li></ul><ul><li>Adenomyosis appears as an ill-defined, poorly marginated area of low signal intensity within the myometrium on T2. </li></ul>
  41. 45. Differential Dx <ul><li>Solid Adnexal Mass </li></ul><ul><ul><li>- If MR imaging can demonstrate continuity of an adnexal mass with the adjacent myometrium, then a diagnosis of leiomyoma can be established. </li></ul></ul><ul><ul><li>- Ovarian fibromas and Brenner tumors are benign ovarian neoplasms that have a large fibrous component and can have signal intensity similar to that of a pedunculated leiomyoma </li></ul></ul>
  42. 46. Differential Dx <ul><li>Solid Adnexal Mass cont </li></ul><ul><ul><li>fibromas and Brenner tumors surrounded by ovarian stroma and follicles, thus establishing the ovarian origin of the mass and excluding a diagnosis of leiomyoma </li></ul></ul><ul><ul><li>- important in pregnant patients because a confident diagnosis of a uterine leiomyoma may eliminate the need for surgery during pregnancy </li></ul></ul>
  43. 48. Differential Dx <ul><li>Focal Myometrial Contraction </li></ul><ul><ul><li>- appear as a myometrial mass of low signal intensity on T2-weighted images </li></ul></ul>
  44. 49. Differential Dx <ul><li>Uterine Leiomyosarcoma </li></ul><ul><ul><li>- may arise in a previously existing benign leiomyoma (sarcomatous transformation) or independently from the smooth muscle cells of the myometrium </li></ul></ul><ul><ul><li>- Although it has been suggested that an irregular margin of a uterine leiomyoma at MR imaging is suggestive of sarcomatous transformation , the specificity of this finding has not been established </li></ul></ul><ul><ul><li>- A diagnosis of leiomyosarcoma is established histologically by noting the presence of infiltrative margins, nuclear atypia, and increased mitotic figures </li></ul></ul>
  45. 51. Treatment of Leiomyoma <ul><li>No treatment </li></ul><ul><li>Conservative </li></ul><ul><li>Radiological </li></ul><ul><li>Surgical </li></ul><ul><li>Myolysis. </li></ul><ul><li>GNRHA </li></ul><ul><li>Uterine a embolization. </li></ul><ul><li>Patient (age-parity-symptoms). </li></ul><ul><li>Fibroid (number-size-type) </li></ul><ul><li>Complications. </li></ul>
  46. 52. SURGICAL <ul><li>Myomectomy </li></ul><ul><li>Polypectomy. </li></ul><ul><li>Hysterectomy. </li></ul><ul><li>(traditional- microsurgical ). </li></ul>
  47. 53. M.Emam
  48. 56. OB& GYN, Mansoura Faculty of Medicine Mansoura Integrated Fertility Center (MIFC) EGYPT Telfax 0020502319922 & 0020502312299 Email. Prof. MOHAMMAD EMAM Thank you