0:02

So our next topic is leiomyoma.

0:05

So these are generally called fibroids, and when

0:07

we say fibroids, we usually are referring to the

0:09

benign variant of these smooth muscle tumors.

0:12

But it's important to note that while

0:13

benign is by far the most common, there

0:16

is a spectrum that exists for these tumors

0:20

and that you have to keep that in mind.

0:22

Historically, we used to teach that

0:24

rapid growth was the sign that was most

0:26

reliable for evidence of malignancy

0:29

in these fibroids. However, that may

0:31

not be necessarily the most reliable

0:33

sign anymore, especially with the

0:36

advent of MRI and more recent studies

0:37

coming out talking about signs for that.

0:40

So most fibroids that we're going to see on

0:42

imaging are going to end up being benign.

0:44

We have different variants of them.

0:45

You have the classic non-degenerated appearance

0:48

of them, and then you have different degenerated

0:50

versions, and those can be cystic, they can

0:51

be hemorrhagic, fatty, hyaline, or myxoid.

0:55

Some of these you can tell on ultrasound,

0:57

but if you want to tell these apart,

0:58

MRI is most often going to be needed.

1:01

And remembering that this is a spectrum,

1:04

we'll go to the not benign category.

1:06

And that doesn't necessarily mean malignant,

1:07

just means not necessarily benign.

1:10

And these are going to be fibroids

1:11

that are more mitotically active.

1:13

They may have increased cellularity.

1:15

They may be atypical in pathology.

1:17

There is a variant called a stump,

1:19

which is a small muscle tumor of

1:20

uncertain malignant potential.

1:22

And then, of course, you do

1:23

have the malignant sarcomas.

1:26

On imaging, particularly on MRI, there are

1:29

some characteristic features that are going

1:30

to differentiate these, including the benign

1:32

versus the not benign and the malignant,

1:34

but there still may be some overlap and

1:36

ultimately may require pathologic diagnosis.

1:39

We are getting better at this, but

1:41

we're not going to talk too much about

1:42

differentiating these on MRI because

1:44

that's out of the scope of this talk.

1:45

However, it is important to note that of all

1:48

of the uterine malignancies, approximately 3

1:50

percent of them are going to be sarcomas, with

1:53

leiomyosarcomas being the most common subtype.

1:56

I'll also note that this doesn't cover parasitic

1:59

leiomyomas, leiomyomatosis, disseminated

2:01

peritoneal leiomatosis, etc., because these

2:04

are still histologically benign fibroids,

2:06

so they don't make the not benign list.

2:10

So let's talk about some of the

2:11

characteristic classic features of fibroids

2:14

that you'll see in ultrasound and MRI.

2:17

Generally, in ultrasound,

2:18

they'll be well-circumscribed.

2:19

They're often hypoechoic.

2:21

They may be a bit heterogeneous and

2:23

they can have some calcifications.

2:25

There can be shadowing because of these

2:27

calcifications, which can be quite coarse, or

2:30

you can have some shadowing at the margins of

2:32

the lesion that can cause some obscuration of

2:37

different soft tissues that may be behind there.

2:39

They often have increased vascularity

2:42

as well, although not necessarily.

2:45

So talking about MRI, and this is just the

2:46

classic appearance of a fibroid, they're

2:49

generally going to be T1 iso-intense

2:51

to the myometrium, and T2 hypo-intense,

2:55

and then in general they should enhance.

2:58

However, this chart here, which we won't

3:00

go over all of it, but you have here for

3:01

your reference, talks about the different

3:04

degenerating fibroid features that you can

3:06

see on MRI, and what they look like on the

3:08

T1 and T2 compared to the myometrium, and

3:11

what they look like on post-contrast imaging.

3:15

So, surgical planning, let's

3:17

talk about that for a moment.

3:19

In your reports, particularly on MRI,

3:21

but also on ultrasound when you can,

3:22

it's important to note the location

3:24

of where your fibroids are located.

3:27

And the reason that is is

3:28

because they can be causes for the

3:30

symptoms that patients are having.

3:32

So submucosal is one of the more common

3:34

causes of dysfunctional uterine bleeding.

3:37

Submucosal or intracavitary fibroids, meaning in

3:39

the endometrial canal, that's the least common,

3:42

but they are the most likely to be symptomatic.

3:45

Intramural fibroids, which are in

3:47

the myometrium itself, these are

3:48

the most common types of fibroids.

3:50

But they're usually asymptomatic but can

3:52

be a cause for infertility because they

3:54

can cause mass effect upon the endometrium,

3:57

they can cause growth problems, etc.

4:00

Pedunculated fibroids are another

4:01

variant and these are going to be

4:03

the most likely to torse and

4:04

cause an acute pain type of syndrome.

4:08

It's also important to note that you can have

4:09

different types such as cervical fibroids,

4:11

broad ligament fibroids, and all of these

4:13

are important to keep in mind if the surgeon

4:15

is planning potentially a myomectomy.

4:18

How are they going to approach

4:18

this patient and this surgery?

4:21

So again, remember, submucosal versus exophytic

4:23

or pedunculated, this is going to change the

4:26

technique, it's going to change the approach.

4:28

Vascularity is also important because

4:31

there is the non-invasive uterine artery

4:33

embolization that they can use for treatment,

4:35

but it's only going to work if that

4:36

fibroid has retained vascularity to it.

4:39

Fibroids in general, when they're

4:41

large, can outgrow their blood supply

4:43

and cause infarction, which is pain.

4:46

But that's also what uterine

4:47

artery embolization is going to do.

4:49

It's going to cause that infarction.

4:50

So that hopefully that fibroid will

4:52

shrink and decrease the symptoms

4:53

of the patient it's having.

4:55

It's also important to notice that you can

4:57

have increased numbers of calcifications

4:59

after a fibroid is necrosed or in the

5:01

postmenopausal patient for similar reasons.