Abstract
Leiomyomas (LM) are easy to recognize on ultrasound (US) and magnetic resonance imaging (MRI), when they are typical. On the other hand, LM variants may differ in imaging findings. It is difficult to distinguish atypical LM from leiomyosarcoma (LMS). The presence of peritoneal implant/lymphadenopathy, having a signal equal to or higher than the myometrium in T2W images, having a signal equal to or higher than the endometrium in diffusion weighted imaging, and having a low signal in apparent diffusion coefficient map are among the MRI findings associated with LMS that have been reported to be at a high level of evidence. Adenomyoma may be confused with LM. Diagnosis can be made with US, but MRI is accepted as gold standard. A solid mass with ill-defined borders, internal vascularization, mild mass effect in an asymmetrically enlarged uterus may raise suspicion for adenomyoma; findings related with adenomyosis may accompany. Especially subserous LM can be confused with other adnexial lesions. If the ovary-related T2W black lesion is white on T1W images, it can be an endometrioma, or if it is black with mild contrast enhancement, it can be an ovarian fibroma. As a radiologist, in case of pelvic lesions, we must make sure the location of the lesion and then look for whole imaging findings.
Keywords: Leiomyomas, adenomyoma, leiomyosarcoma, FIGO
References
Kubik-Huch RA, Weston M, Nougaret S, Leonhardt H, Thomassin-Naggara I, et al. European Society of Urogenital Radiology (ESUR) Guidelines: MR imaging of leiomyomas.Eur Radiol. 2018; 28: 3125-37.
Nougaret S, Cunha TM, Benadla N, Neron M, Robbins JB. Benign uterine disease: the added role of imaging.Obstet Gynecol Clin North Am. 2021; 48: 193-214.
Hill S, Shetty MK. Abnormal uterine bleeding in reproductive age women: role of imaging in the diagnosis and management.Semin Ultrasound CT MR. 2023; 44: 511-8.
Bulun SE. Uterine fibroids.N Engl J Med. 2013; 369: 1344-55.
Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management.Fertil Steril. 1981; 36: 433-45.
Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions.Int J Gynaecol Obstet. 2018; 143: 393-408. Erratum in: Int J Gynaecol Obstet. 2019; 144: 237.
Gomez E, Nguyen MT, Fursevich D, Macura K, Gupta A. MRI-based pictorial review of the FIGO classification system for uterine fibroids.Abdom Radiol (NY). 2021; 46: 2146-55.
Bajaj S, Gopal N, Clingan MJ, Bhatt S. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas.Abdom Radiol (NY). 2022; 47: 341-51.
Di Spiezio Sardo A, Mazzon I, Bramante S, Bettocchi S, Bifulco G, Guida M, et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques.Hum Reprod Update. 2008; 14: 101-19.
Bura V, Pintican RM, David RE, Addley HC, Smith J, Jimenez-Linan M, et al. MRI findings in-between leiomyoma and leiomyosarcoma: a Rad-Path correlation of degenerated leiomyomas and variants.Br J Radiol. 2021; 94: 20210283.
Juhasz-Böss I, Gabriel L, Bohle RM, Horn LC, Solomayer EF, Breitbach GP. Uterine leiomyosarcoma.Oncol Res Treat. 2018; 41: 680-6.
Tu W, Yano M, Schieda N, Krishna S, Chen L, Gottumukkala RV, et al. Smooth muscle tumors of the uterus at MRI: focus on leiomyomas and FIGO classification.Radiographics. 2023; 43: e220161.
Wilde S, Scott-Barrett S. Radiological appearances of uterine fibroids.Indian J Radiol Imaging. 2009; 19: 222-31.
Pelage JP, Cazejust J, Pluot E, Le Dref O, Laurent A, Spies JB, et al. Uterine fibroid vascularization and clinical relevance to uterine fibroid embolization.Radiographics. 2005; 25 (Suppl 1): S99-117.
Abdel Wahab C, Jannot AS, Bonaffini PA, Bourillon C, Cornou C, Lefrère-Belda MA, et al. Diagnostic algorithm to differentiate benign atypical leiomyomas from malignant uterine sarcomas with diffusion-weighted MRI.Radiology. 2020; 297: 361-71. Erratum in: Radiology. 2020; 297: E347.
DeMulder D, Ascher SM. Uterine leiomyosarcoma: can MRI differentiate leiomyosarcoma from benign leiomyoma before treatment?AJR Am J Roentgenol. 2018; 211: 1405-15.
Shimada K, Ohashi I, Kasahara I, Watanabe H, Ohta S, Miyasaka N, et al. Differentiation between completely hyalinized uterine leiomyomas and ordinary leiomyomas: three-phase dynamic magnetic resonance imaging (MRI) vs. diffusion-weighted MRI with very small b-factors.J Magn Reson Imaging. 2004; 20: 97-104.
Arleo EK, Schwartz PE, Hui P, McCarthy S. Review of leiomyoma variants.AJR Am J Roentgenol. 2015; 205:912-21.
Hindman N, Kang S, Fournier L, Lakhman Y, Nougaret S, Reinhold C, et al. MRI Evaluation of uterine masses for risk of leiomyosarcoma: a consensus statement.Radiology. 2023; 306: e211658.
Awiwi MO, Badawy M, Shaaban AM, Menias CO, Horowitz JM, Soliman M, et al. Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification.Abdom Radiol (NY). 2022; 47: 2468-85.
Rosa F, Martinetti C, Magnaldi S, Rizzo S, Manganaro L, Migone S, et al. Uterine mesenchymal tumors: development and preliminary results of a magnetic resonance imaging (MRI) diagnostic algorithm.Radiol Med. 2023; 128: 853-68.
Ricci S, Stone RL, Fader AN. Uterine leiomyosarcoma: epidemiology, contemporary treatment strategies and the impact of uterine morcellation.Gynecol Oncol. 2017; 145: 208-16.
Oliva E. Practical issues in uterine pathology from banal to bewildering: the remarkable spectrum of smooth muscle neoplasia.Mod Pathol. 2016; 29 (Suppl 1): S104-20.
Janicas C, Cunha TM. Adenomyosis at a glance: an integrated review of transvaginal ultrasound and MR imaging findings.Curr Probl Diagn Radiol. 2023; 52: 412-7.
Cohen I, Beyth Y, Shapira J, Tepper R, Fishman A, Cordoba M, et al. High frequency of adenomyosis in postmenopausal breast cancer patients treated with tamoxifen.Gynecol Obstet Invest. 1997; 44: 200-5.
Exacoustos C, Morosetti G, Conway F, Camilli S, Martire FG, Lazzeri L, et al. New sonographic classification of adenomyosis: do type and degree of adenomyosis correlate to severity of symptoms?J Minim Invasive Gynecol. 2020; 27: 1308-15.
Harmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, et al. Consensus on revised definitions of morphological uterus sonographic assessment (MUSA) features of adenomyosis: results of modified Delphi procedure.Ultrasound Obstet Gynecol. 2022; 60: 118-31.
Van den Bosch T, Dueholm M, Leone FP, Valentin L, Rasmussen CK, Votino A, et al D. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the morphological uterus sonographic assessment (MUSA) group.Ultrasound Obstet Gynecol. 2015; 46: 284-98.
Stamatopoulos CP, Mikos T, Grimbizis GF, Dimitriadis AS, Efstratiou I, Stamatopoulos P, et al. Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus.J Minim Invasive Gynecol. 2012; 19: 620-6.
Reinhold C, Atri M, Mehio A, Zakarian R, Aldis AE, Bret PM. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography.Radiology. 1995; 197: 609-14.
Dueholm M, Lundorf E, Hansen ES, Sørensen JS, Ledertoug S, Olesen F. Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis.Fertil Steril. 2001; 76: 588-94.
Novellas S, Chassang M, Delotte J, Toullalan O, Chevallier A, Bouaziz J, et al. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis.AJR Am J Roentgenol. 2011; 196: 1206-13.
Yajima R, Kido A, Kurata Y, Fujimoto K, Nakao KK, Kuwahara R, et al. Diffusion-weighted imaging of uterine adenomyosis: correlation with clinical backgrounds and comparison with malignant uterine tumors.J Obstet Gynaecol Res. 2021; 47: 949-60.
