Cunha, TM

Leal, C

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Uterine Leiomyoma with Haemorrhagic Degeneration

Repositório do Centro Hospitalar de Lisboa Central, EPE

Case 7559 Uterine leiomyoma with haemorrhagic degenerationLeal CI, Cunha TM.Instituto Português de Oncologia Prof. Francisco Gentil, Lisboa. Hospital de São José, CentroHospitalar de Lisboa Central. Hospital de São José  Genital (Female) Imaging Section: 2009, Jun. 30 Published: 44 year(s), femalePatient:Clinical HistoryIn a reproductive-age patient with history of uterine leiomyoma and no pelvic acute symptoms, anMRI study revealed signs of haemorrhagic (red) degeneration.Imaging FindingsThe patient presented without acute symptoms, referred for an MRI study due to recent sizeincrease of a uterine leiomyoma previously documented by ultrasonography.DiscussionUterine leiomyoma is the most frequent solid benign uterine neoplasm, occurring in 20-30% ofwomen within the reproductive years and composed mainly of smooth muscle with varyingamounts of fibrous connective tissue elements.Their oestrogen-dependent nature is suggested by rapid development during pregnancy or oralcontraceptive use and regression after menopause. The enlargement of these lesions may lead tooutgrowth of their blood supply, resulting in various types of degeneration. The most common typeis hyaline degeneration developing in 60% of the cases. Cystic, myxoid and haemorrhagic (red)degeneration rarely occur. Most of these histopathologic findings are unrelated to the clinicalsymptoms.Haemorrhagic degeneration is a subtype of haemorrhagic infarction that results from obstruction ofvenous outflow (venous thrombosis) at the periphery of the uterine leiomyoma or rupture ofintratumoural arteries. They are usually related to rapid growth of leiomyoma during pregnancy orwith the use of oral contraceptives, what was not present in our case. It may present with systemicsymptoms, such as abdominal pain, low-grade fever and leukocytosis. Ultrasonography can often diagnose and locate leiomyomas, but MRI is the most accurate imagingtechnique for a precise characterization especially useful in symptomatic patients.Non-degenerated uterine leiomyomas are most commonly well-circumscribed homogeneousnodular lesions with signal intensity equal or slightly decreased comparatively to the myometriumon T1-weighted images and low signal intensity on T2-weighted images. They may be delineatedby a discrete low signal intensity margin and in about 50% of cases a high intensity rim surroundsthe lesion corresponding to dilated lymphatics, dilated veins or oedema.Haemorrhage in a leiomyoma may have variable MR appearances depending on the imagingsequence used and on the stage of evolution of the bleeding.T1-weighted images may show high signal diffusely distributed (early) or peripherally as a rim(late), persisting in the fat suppression sequence. Very high signal intensity on T1-weightedimaging represents intracellular methemoglobin from subacute haemorrhage and is accompanied bya signal intensity decrease on T2-weighted images. With maturation of the haemorrhage, the highsignal intensity on T1-weighted imaging becomes confined to a peripheral rim and a low signalintensity rim is seen on T2-weighted images. This peripheral rim corresponds to the obstructedveins at the periphery of the mass.MRI allows an accurate diagnosis and characterization of the prevalent uterine leiomyomas, namelyof its possible complications as rare hemorrhagic (red) degeneration enabling radiologicaldifferentiation from other clinical conditions that may need surgical intervention.Final DiagnosisUterine leiomyoma with hemorrhagic degeneration.FiguresFigure 1 No titleOn T1-weighted axial image a posterior uterine subserosal leiomyoma with heterogeneoushigh signal intensity is detected.Figure 2 No titleThe high signal intensity persists on the T1-weighted fat suppression sequence, notconsistent with adipose tissue. (axial plane, at the same level of figure 1)Figure 3 No titleAxial T2- weighted image shows decreased signal intensity indicating the presence of blood.Figure 4 No titleSagittal plane also showing decreased signal intensity on T2- weighted image. Note the smallposterior submucosal leiomyoma (arrow).MeSH [C13.371.270.875]Uterine NeoplasmsTumors or cancer of the UTERUS.References[1] Kawakami S, Togashi K, Konishi I, Kimura I, Fukuoka M, Mori T, et al. Red degeneration ofuterine leiomyoma: MR appearance. Journal of Computer Assisted Tomography 1994; 18(6):925-8.[2] Murase E, Siegelman ES, Outwaker EK, Perez-Jaffe LA, Tureck RW. Uterine leiomyomas:histopathologic features, MR imaging findings, differential diagnosis, and treatment. RadiographicsSep-Oct 1999; 19(5):1179-97.[3] Aggarwal BK, Panwar S, Rajan S, Aggarwal A, Ahlawat K. Varied appearances and signalcharacteristics of leiomyomas on MR imaging. Indian Journal of Radiology and Imaging 2005;15(2):271-276.[4] Jao M-S, Huang KG, Jung S-M, Hwang L-L. Postmenopausal uterine leiomyoma withhemorrhagic cystic degeneration mimicking ovarian malignancy. Taiwan J Obstet Gynecol Dec2007; 46(4):431-434.[5] LaCoursiere DY, Chin HG. Pedunculated atypical leiomyoma presenting as a hemoperitoneum.Journal of Gynecologic Surgery 2005; 21(1):21-24.CitationLeal CI, Cunha TM.Instituto Português de Oncologia Prof. Francisco Gentil, Lisboa. Hospital de São José, CentroHospitalar de Lisboa Central. (2009, Jun. 30)  Uterine leiomyoma with haemorrhagic degeneration {Online}URL: http://www.eurorad.org/case.php?id=7559

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Uterine Leiomyoma with Haemorrhagic Degeneration

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