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Imaging appearance of pedunculated subserosal leiomyoma with red degeneration mimicking abdominal mass lesion


 Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India

Date of Submission06-Sep-2019
Date of Decision15-Dec-2019
Date of Acceptance12-Jan-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Reddy Ravikanth,
Department of Radiology, Holy Family Hospital, Thodupuzha - 685 605, Kerala
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_59_19



How to cite this URL:
Ravikanth R. Imaging appearance of pedunculated subserosal leiomyoma with red degeneration mimicking abdominal mass lesion. J Mar Med Soc [Epub ahead of print] [cited 2020 Nov 24]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=294886



Sir,

A 46-year-old woman presented with a sensation of fullness in the abdomen and a palpable mass in the lower abdomen and pelvis. She reported no changes in her menstrual cycle or bowel habits. Physical examination revealed a large palpable, relatively mobile, nontender mass in the lower abdomen. Laboratory test values were within normal limits. On magnetic resonance imaging (MRI), the lesion appeared heterogeneously hyperintense on T2-weighted images [Figure 1] measuring 9.5 cm × 15.1 cm × 12.5 cm (anteroposterior × mediolateral × craniocaudal) in the subserosal location attached to the anterior uterine wall through a broad stalk [Figure 2]. On MERGE, the lesion demonstrated multiple areas of blooming suggestive of hemorrhage [Figure 3]. The uterus was enlarged with a deformed uterine contour consistent with a pedunculated leiomyoma. Hysterectomy confirmed the diagnosis of a giant pedunculated subserosal leiomyoma with red degeneration.
Figure 1: Red degeneration with massive hemorrhagic infarction and necrosis (orange stars) of the entire leiomyoma, with a peripheral rim of low signal (blue stars) is demonstrated on this coronal T2-weighted magnetic resonance image

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Figure 2: Sagittal T1 + c magnetic resonance image demonstrating subserosal location of the leiomyoma (pink stars), and continuity with the uterus is demonstrated by a thick stalk (arrow). Note the mass effect exerted on the urinary bladder (green star)

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Figure 3: Axial MERGE magnetic resonance image demonstrating multiple areas of blooming (stars) consistent with hemorrhagic infarction of the leiomyoma known as red degeneration

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On MRI, the most common appearances are of well-circumscribed, rounded masses with lower signal intensity than myometrium on T2-weighted images and intermediate-signal intensity on T1-weighted images. Most fibroids enhance less than adjacent myometrium following contrast administration; however, a variety of degenerative processes can alter the characteristic appearances, making differential diagnosis more difficult. Cystic degeneration results in well-demarcated areas with fluid signal intensity, which do not enhance post-intravenous contrast medium. Myxoid degeneration may show very high signal intensity on T2-weighted images with minimal enhancement. Red degeneration involves massive hemorrhagic infarction and necrosis of the entire leiomyoma, with a peripheral rim of low signal on T2- and high signal on T1-weighted images, with no enhancement. Hyalinization is the most common type of degeneration, occurring in up to 60% of cases.[1] Rarely, uterine leiomyoma may undergo malignant degeneration to become a sarcoma.[2] The incidence of malignant degeneration is <1.0% and has been estimated to be as low as 0.2%.[3] Fat saturation T1-weighted images may be helpful in the cases of hemorrhage. Calcification usually results in areas of signal void on both T1- and T2-weighted images. Larger leiomyomas cause mass effect on neighboring organs such as the bladder or bowel loops. Pedunculated leiomyomas may cause sudden and severe pain. Torsion of the pedicle interrupts the blood flow to the leiomyoma, which can be extremely painful and is a surgical emergency. Uterine artery embolization has been developed as an alternative to myomectomy for women with symptomatic uterine leiomyomas, who desire to avoid surgery. This therapeutic modality results in a significant reduction in the dominant leiomyoma size, leading to a 77%–86% symptomatic relief for bleeding-related complaints within 3 months of the procedure.[4] However, leiomyoma size is only reduced by 40%–75%.[5] Detecting continuity of the mass lesion with the uterus by a stalk is the useful sign for the diagnosis of a pedunculated leiomyoma on cross-sectional imaging. Typical cases of leiomyoma are easy to diagnose on ultrasonography/cross-sectional imaging. However, uterine leiomyomas are commonly altered by degenerative changes, which can cause the misdiagnosis of tumors. In the current case, a submucosal, pedunculated leiomyoma with red degeneration mimicked an abdominal mass lesion and was treated with hysterectomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hacivelioglu S, Erkanli S. A large pedunculated leiomyoma with two-sided cystic degenerations mimicking a bilateral ovarian malignancy: A case report. Eur J Gynaecol Oncol 2014;35:192-4.  Back to cited text no. 1
    
2.
Yorita K, Tanaka Y, Hirano K, Kai Y, Arii K, Nakatani K, et al. A subserosal, pedunculated, multilocular uterine leiomyoma with ovarian tumor-like morphology and histological architecture of adenomatoid tumors: A case report and review of the literature. J Med Case Rep 2016;10:352.  Back to cited text no. 2
    
3.
Sharma P, Zaheer S, Yadav AK, Mandal AK. Massive broad ligament cellular leiomyoma with cystic change: A diagnostic dilemma. J Clin Diagn Res 2016;10:ED01-2.  Back to cited text no. 3
    
4.
Hacivelioglu S, Erkanli S. A large pedunculated leiomyoma with two-sided cystic degenerations mimicking a bilateral ovarian malignancy: A case report. Eur J Gynaecol Oncol 2014;35:192-4.  Back to cited text no. 4
    
5.
Karaman E, Çim N, Bulut G, Elçi G, Andıç E, Tekin M, et al. A case of giant uterine lipoleiomyoma simulating malignancy. Case Rep Obstet Gynecol 2015;2015:926961.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

 
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