Parasitic and Pedunculated Leiomyomas: Ultrasonographic Features

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1 Parasitic and Pedunculated Leiomyomas: Ultrasonographic Features Hsu-Chong Yeh, MD, Michael Kaplan, MD, Liane Deligdisch, MD Leiomyomas are the most common benign uterine tumors. They may be intramural, subserosal, or submucosal in location. Subserosal leiomyomas may be beneath the uterine surface or exophytic or pedunculated. Submucosal leiomyomas may protrude into the uterine cavity and may also become pedunculated. If a pedunculated subserosal leiomyoma develops an extremely long, tenuous stalk, it is called a wandering or migrating leiomyoma. 1 Occasionally, such tumors become adherent to surrounding structures, such as the broad ligament or omentum, develop an auxiliary blood supply, and lose their original attachment to the uterus. They MR, Magnetic resonance REVITIONS Received May 11, 1999, from the Departments of Radiology (H.- C.Y., M.K.) and Pathology (L.D.), Mount Sinai Hospital and Mount Sinai School of Medicine of New York University, New York, New York. Revised manuscript accepted for publication ugust 9, ddress correspondence and reprint requests to Hsu-Chong Yeh, MD, Department of Radiology, ox 1234, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY are then called parasitic leiomyomas. 1,2 Rarely, a parasitic leiomyoma may become torsive and cause an acute abdomen. 3 Pedunculated leiomyomas of the uterus are not uncommon. However, parasitic leiomyomas of the uterus have been described only rarely in the ultrasonographic literature 3 5 and are seldom discussed in ultrasonography textbooks. We report two patients with parasitic leiomyomas, one of which underwent torsion. CSE 1 33 year old nulliparous woman was admitted because of mild lower abdominal pain for 5 days. The pain was aggravated by eating and associated with nausea and vomiting. Her last menstrual period was 8 days previously. Pelvic examination revealed a very tender firm mass that filled the pelvis and appeared to be distinct from the uterus. She had diffuse mild rebound tenderness. Laboratory tests were significant for a hemoglobin level of 8.1 g/dl and a white blood cell count of 15,800 cells/mm 3. Ultrasonography (Fig. 1) showed a small uterus, measuring 6 cm, with a 2 cm subserosal fibroid cm large mass was seen in the upper pelvis extended into the lower abdomen. The mass was slightly heterogeneous in echotexture, with poor through-transmission, similar to a fibroid. The mass was very tender when palpated. Since the mass was immediately beneath the anterior abdominal wall, its tenderness was readily demonstrable. No free fluid was found in the pelvis, but 1999 by the merican Institute of Ultrasound in Medicine J Ultrasound Med 18: , /99/$3.50

2 790 PRSITIC ND PEDUNCULTED LEIOMYOMS J Ultrasound Med 18: , 1999 C Figure 1 Case 1: Torsion of a parasitic leiomyoma., Longitudinal scan shows a small anterior leiomyoma (F) in an otherwise unremarkable uterus., Nine weeks later, when the patient was seen with acute abdominal pain, a large mass (M) is seen cephalad to the uterus. The uterus contains a small leiomyoma (F) as before. The bladder contains a Foley catheter (f). C, Longitudinal scan of lower abdomen shows a large mass (M) that is very tender and represents a twisted leiomyoma. D, Longitudinal scan of right kidney (between cursors) shows a small amount of ascites in the Morison pouch. D a small amount of ascites was seen in the Morison pouch. The right ovary was normal. The left ovary was slightly enlarged and contained two small cysts (or large follicles) of 1.1 and 1.5 cm. Ultrasonography suggested possible torsion of a pedunculated fibroid, with a thin pedicle (which was not visualized). n ultrasonogram done 9 weeks previously for right pelvic discomfort showed the same small subserosal fibroid and normal ovaries. t that time, the lower abdomen was not examined, and no mass was mentioned. Surgery revealed a 15 cm leiomyoma attached to the broad ligament that had twisted twice. Hemorrhagic infarction of the leiomyoma was found (Fig. 2). small amount of serosanguineous fluid was found in the peritoneal cavity. CSE 2 34 year old nulliparous woman was admitted because of a 2 month history of anorexia, constipation, progressive increase in abdominal size, and mild epigastric and right lower quadrant pain associated with nausea and vomiting. The pain worsened after eating. Physical examination revealed a large tender nonmobile mass in the right lower quadrant. lood chemistry and a hemogram were significant for elevation of the total bilirubin level to 1.5 mg/dl. Ultrasonography (Fig. 3) showed a large cm mass extending from the cul-de-sac to the upper abdomen, 9 cm cephalad to the umbilical level. The mass had a heterogeneous echotexture, and the uterus was markedly dis-

3 J Ultrasound Med 18: , 1999 YEH ET L 791 placed anteriorly by the mass and markedly stretched and elongated. The uterus measured 23 cm in length. normal endometrium was clearly visualized. The ovaries were not visualized, possibly being obscured by the mass. The right renal collecting system was dilated. Our ultrasonographic impression was probable sarcoma. Surgery revealed a cm leiomyoma, separated from the uterus but attached to the left broad ligament. The uterus was normal in size, measuring 8 6 cm, and contained multiple small 8 mm leiomyomas. DISCUSSION Since pedunculated or parasitic leiomyomas are separate from the uterus, they are easily mistaken for adnexal tumors. 6 If a pelvic mass is seen separate from both ovaries and the uterus, an ultrasonographic diagnosis of pedunculated leiomyoma can be established if a pedicle is demonstrated between the leiomyoma and the uterus. When these two structures are adjacent to each other, the pedicle is usually not visualized, and whether one is present may be difficult to ascertain. If the two structures are deep in the pelvis, endovaginal ultrasonography should be performed. The transducer is placed between the two structures, and pressure is applied with the transducer to push the two structures apart. pedicle connecting the two structures often can be demonstrated clearly by this method (Fig. 4). If the two structures are high in the pelvis (e.g., a leiomyoma is adjacent to the fundus of an enlarged uterus), endovaginal scanning may not visualize the area well. In such instances, a transabdominal approach is necessary. The two structures can be pushed apart through the anterior abdominal wall with the transducer to demonstrate the pedicle (Fig. 5). Demonstration of vessels connecting the leimyoma to the uterus on color Doppler ultrasonography will further confirm the diagnosis of pedunculated leiomyoma. If a pedicle is not shown, a pedunculated leiomyoma still should be considered, since the pedicle may be too thin to see by ultrasonography. parasitic leiomyoma also should be included in the differential diagnosis. When scanning, a parasitic leiomyoma or a leiomyoma with a long thin pedicle may be easily movable and may migrate out of the true pelvis, especially with a distended bladder. Scanning only the true pelvis or only the retrovesical area may completely miss such a leiomyoma, even of a large size. Our first case is one such example. During the first examination, the tumor was completely missed by both the radiologist and the technician. highly Figure 2 Case 1: Hemorrhagic infarct of twisted leiomyoma. Low power view shows streaks of blood (H) between tissue planes. Necrotic changes of the tissue (T) are seen. mobile ovary or ovarian lesion also may be high in location. Therefore, when scanning for pelvic organs, it is preferable that the sonologist make a habit also of scanning the upper pelvis or lower abdomen as well as both iliac fossae. In our case of torsion of a parasitic leiomyoma, only two signs of torsion were seen: marked tenderness and ascites. lthough extensive hemorrhage was seen in the surgical specimen, no hematoma was discernible on ultrasonography because this was an interstitial hemorrhage, meaning that the blood infiltrated between the tissue planes within the leiomyoma and was not confined to one area, which might have been seen as a well defined hypoechoic hematoma. This is similar to a bruise on the skin, which ultrasonography shows as only a poorly defined area of increased echoes within swollen subcutaneous fat tissue. Some other signs also might become apparent if a previous ultrasonogram were available, including an increase in size of the tumor, a change in echopattern due to edema and interstitial hematoma, and decrease or absence of vascularity on color Doppler ultrasonography. lthough color Doppler ultrasonography was not available at the time of study, findings of absence of color flow signals on one examination does not always indicate a torsion, since leiomyomas frequently show absence of color flow signals. Thus, conversion of a leiomyoma with previously positive color flow signals to the absence of such flow would be more significant. On the other hand, presence of color flow signals may not exclude an intermittent torsion.

4 792 PRSITIC ND PEDUNCULTED LEIOMYOMS J Ultrasound Med 18: , 1999 In case 2, the leiomyoma was huge, but with a manual scanner 7 the entire mass was delineated in one view, and the overall dimensions of the mass were correctly measured. With real-time scanning, this has been impossible until recently, when the extended field of view 8 became available. MR image findings of an adnexal mass may suggest leiomyoma if it is predominantly of low signal intensity or isointense compared with myometrium on T1-weighted images and predominantly of low signal intensity on T2-weighted images. degenerative leiomyoma, however, may not have these features. 9 The uterus may not be a rigid structure and, in fact, can be highly pliable. In case 2, the uterus was stretched to 23 cm long, but after resection, it returned to a normal size of 8 cm. The diagnosis of parasitic fibroid in case 2 was not easy to make. Since the mass markedly displaced and stretched the uterus anteriorly, it appeared that the mass most likely arose from the pelvis, posterior to the uterus. The uterus appeared normal. The ovaries were not visualized, and the possibility of a solid ovarian tumor or retroperitoneal tumor could not be excluded. Figure 3 Case 2: giant leiomyoma of broad ligament., Manual longitudinal scan of pelvis and abdomen shows a large mass (M) in the pelvis, extending to the upper abdomen. The uterus (arrowheads) is markedly stretched and displaced anteriorly by the mass. U, Umbilicus; E, endometrium., Manual transverse scan 4 cm superior to the umbilicus shows the mass (M) in the abdomen extending to both sides. The uterus (arrowheads) is markedly displaced anteriorly. E, Endometrium. C, Longitudinal real-time scan of pelvis shows a large mass (M) markedly displacing the uterus (arrowheads) anteriorly. E, Endometrium. D, Transverse real-time scan of abdomen 4 cm superior to the umbilicus shows again a large mass (M) markedly displacing the uterus (arrowheads) anteriorly. E, Endometrium. C D

5 J Ultrasound Med 18: , 1999 YEH ET L 793 Figure 4 pedunculated fibroid demonstrated on endovaginal scanning., Transverse transabdominal image shows a large mass (M) that appears separate from both the right ovary (O) and the uterus (U)., Endovaginal scanning shows the mass (M) and uterus (U) together with a wide connection (between arrowheads). C, Pressure was applied with transducer during endovaginal scanning to separate the mass (M) from the uterus (U). Now a pedicle (P) connecting the two is seen. The mass is therefore a pedunculated leiomyoma. Solitary tumors of the broad ligament are rare. The most frequent solid tumor of the broad ligament is leiomyoma. The differential diagnosis for an adnexal mass that is separate from the ovaries includes (1) inflammatory lesions of the fallopian tube, such as gonococcal or chlamydial salpingitis or granulomatous salpingitis (mycobacterial, fungal, parasitic, sarcoidosis, Crohn disease, etc.), 10 (2) a malignant tumor (e.g., adenocarcinoma or tubal gestational choriocarcinoma), 10 (3) tumors of the broad ligament such as papillary cystadenoma (wolffian duct origin), müllerian carcinoma, teratoma, 10 leiomyosarcoma, 11 and malignant fibrous histiocytoma, 12 (4) parasitic infections such as dra- Figure 5 pedunculated fibroid demonstrated on transabdominal scanning., Sagittal image of pelvis shows a large mass (M) superior to the uterus (U)., pplying pressure with the transducer between the mass (M) and the uterus (U), the mass moves superiorly, and a pedicle (P) is now evident, bridging the mass to the uterus. Therefore, the mass is a pedunculated leiomyoma and not an exophytic leiomyoma. C

6 794 PRSITIC ND PEDUNCULTED LEIOMYOMS J Ultrasound Med 18: , 1999 cunculosis (guinea worm), 13 which have also been called parasitic leiomyomas but in fact represent parasites in fibrous tissue, 13 (5) endometriosis, and (6) ectopic pregancy. When the mass has relatively poor through-transmission, a pedunculated or parasitic leiomyoma is highly suggested. In summary, diagnosis of a parasitic leiomyoma should be considered if a mass with poor throughtransmission, which is separate from the uterus and both ovaries, is seen in the pelvis and a pedicle is not visible connecting the uterus and the mass. When the mass is very large, occupying the entire pelvis, the diagnosis becomes more difficult. If the mass is very tender, torsion or acute hemorrhage may be suspected. Interstitial hemorrhage in the tumor may be very difficult to discern on ultrasonography unless previous images are available for comparison. REFERENCES 1. Robbins SL, Cotran RS, Kumar V: Pathologic asis of Disease. 3rd Ed. Philadelphia, W Saunders, 1984, p Ritchie C: oyd s Textbook of Pathology. 9th Ed. Vol. 11. Philadelphia, Lea & Febiger, 1990, p rody S, rookly NY: Parasitic fibroid. m J Obstet Gynecol, 65:1354, rieger GM, MacGibbon L, Peat P: Torsion of a parasitic fibroid. ust N Z J Obstet Gynaecol 35:224, Gowri V, Sudheendra, Oumachigui, et al: Giant broad ligament leiomyoma. Int J Gynecol Obstet 37:207, altarowich OH, Kurtz, Pernell RG, et al: Pitfalls in the sonographic diagnosis of uterine fibroids. JR 151:725, Yeh HC: Manual scanner vs real-time scanner. J Clinical Ultrasound 9:33, Weng L, Tirumalai P, Lowery CM, et al: US extendedfield-of-view imaging technology. Radiology 203:877, Weinreb JC, arkoff ND, Megibow, et al: The value of MR imaging in distinguishing leiomyomas from other solid pelvic masses when sonography is indeterminate. JR 154:295, Thor D, Young RH, Clement P: Pathology of the fallopian tube, broad ligament, peritoneum and pelvic soft tissues. Hum Pathol 22:856, Cheng WF, Lin HH, Chen CK, et al: Leiomyosarcoma of the broad ligament: case report and literature review. Gynecol Oncol 56:85, Mai YL, Lin YH, Chen RJ, et al: Malignant fibrous histiocytoma of broad ligament. Gynecol Oncol 54:362, llaire D, Majmudar : Dracunculosis of the broad ligament, a case of a parasitic leiomyoma. m J Surg Pathol 17:937, 1993

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