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Uterine Smooth-Muscle Tumors with Unusual Growth Patterns: Imaging with Pathologic Correlation

¹ Department of Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA 02114.
² Mallinckrodt Institute of Radiology, 510 S. Kingshighway Blvd., Ninth Floor, St. Louis, MO 63110.
³ Department of Pathology, Massachusetts General Hospital, Boston, MA 02114.
⁴ Gillette Center for Gynecologic Oncology, Gynecologic Oncology, Massachusetts General Hospital, Boston, MA 02114.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Parasitic leiomyoma in 52-year-old woman with distant history of hysterectomy who presented with pelvic masses. Transverse transabdominal sonographic image of pelvis shows 5-cm right pelvic parasitic leiomyoma (arrows) indenting bladder (star). Heterogeneous echotexture of parasitic leiomyoma is similar to that of uterine fibroid.

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Parasitic leiomyoma in 52-year-old woman with distant history of hysterectomy who presented with pelvic masses. Sagittal fast spin-echo T2 MR image shows left pelvic parasitic leiomyoma (solid arrow) deforming bladder. Mass shows intermediate signal intensity that is slightly brighter than that of muscle. Internal swirling pattern is common for leiomyoma and is atypical for ovarian fibroma, which is usually homogeneously hypointense on T1 and T2 and without swirl pattern on contrast-enhanced or T2 images. Posterior aspect of mass abuts vagina (open arrow). Note close proximity of tumor to bladder wall (arrowheads). With this information, urologist was consulted preoperatively to repair cystostomy necessitated by tumor resection.

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Parasitic leiomyoma in 52-year-old woman with distant history of hysterectomy who presented with pelvic masses. Axial gradient-echo MR image obtained with fat saturation and gadolinium enhancement shows homogeneous hyperintense enhancement (star) after dynamic gadolinium injection that is similar to intrauterine fibroid. Rectum (arrow) is seen posteriorly.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Parasitic leiomyoma in 39-year-old woman with history of myomectomy who presented with pelvic masses. Coronal gradient-echo fat-suppressed gadolinium-enhanced T1-weighted MR image reveals multiple parasitic leiomyoma tumors. Note right adnexal tumor (asterisk), right pararectal tumor (star), and bilateral ischiorectal fossa tumors (arrowheads) in relation to uterine fundus (arrow). Tumors were stable on imaging over 9 months and clinically for years on medical management.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Intravenous leiomyomatosis in 43-year-old woman with history of hysterectomy at which intravenous leiomyomatosis was diagnosed histologically in uterus and who presented 1 year later with retroperitoneal mass. Axial fast spin-echo T2-weighted MR image shows bulky retroperitoneal tumor with solid and fluid components; arrows delineate tumor edge. T2 hyperintense components illustrate cystic areas (asterisks).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Intravenous leiomyomatosis in 43-year-old woman with history of hysterectomy at which intravenous leiomyomatosis was diagnosed histologically in uterus and who presented 1 year later with retroperitoneal mass. Obtained craniad to A, axial gradient-echo fat-suppressed T1-weighted image with dynamic gadolinium enhancement shows hypervascular tumor enhancement of solid components (black asterisk) and nonenhancement of cystic components (white asterisks) in this retroperitoneal intravenous leiomyomatosis tumor; solid arrows delineate tumor edge. Intravenous leiomyomatosis abuts and deforms "slitlike" T1 hyperintense inferior vena cava (arrowhead) adjacent to distal aorta (open arrow). Although intravascular component of tumor is not seen on imaging, excision required inferior vena cava venotomy and creation of neoileal ureter for resection.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Intravenous leiomyomatosis in 43-year-old woman with history of hysterectomy at which intravenous leiomyomatosis was diagnosed histologically in uterus and who presented 1 year later with retroperitoneal mass. Gross macroscopic image of firm, white intravenous leiomyomatosis shows swirling smooth muscle components and multifocal cystification; arrows denote cyst edge. This cyst is seen as T2 hyperintensity (A) and T1 hypointensity (B) on preoperative MRI. Metal stent (arrowhead) passes through ureter seen on opposite side of mass.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Intravenous leiomyomatosis in 47-year-old woman with intrauterine intravenous leiomyomatosis previously diagnosed histologically and who presented with palpable pelvic mass and abnormal vaginal bleeding. Coronal transvaginal sonographic image with color Doppler imaging shows increased vascularity (arrows) within mass.

View larger version (186K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Intravenous leiomyomatosis in 47-year-old woman with intrauterine intravenous leiomyomatosis previously diagnosed histologically and who presented with palpable pelvic mass and abnormal vaginal bleeding. Axial fast spin-echo T2-weighted (B) and axial gradient-echo T1-weighted with fat saturation and gadolinium enhancement (C) MR images show heterogeneous leiomyomatous uterus (leiomyoma edge, open arrows, B; endometrial canal, arrowhead, B). Our standard pelvic MR protocol includes up to 10 mL (0.1 mmol/kg) of IV gadolinium chelate with power injection at 4 mL/s and dynamic imaging at 20, 70, and 180 seconds. Intravenous leiomyomatosis (solid arrows, B) and other smooth-muscle tumors enhance similarly to nonnecrotic leiomyoma or myometrium (asterisk, C). Extrauterine extension of intravenous leiomyomatosis into broad ligament (solid arrows, C) resulted in triage of patient to open laparotomy over vaginal or laparoscopic resection.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Intravenous leiomyomatosis in 47-year-old woman with intrauterine intravenous leiomyomatosis previously diagnosed histologically and who presented with palpable pelvic mass and abnormal vaginal bleeding. Axial fast spin-echo T2-weighted (B) and axial gradient-echo T1-weighted with fat saturation and gadolinium enhancement (C) MR images show heterogeneous leiomyomatous uterus (leiomyoma edge, open arrows, B; endometrial canal, arrowhead, B). Our standard pelvic MR protocol includes up to 10 mL (0.1 mmol/kg) of IV gadolinium chelate with power injection at 4 mL/s and dynamic imaging at 20, 70, and 180 seconds. Intravenous leiomyomatosis (solid arrows, B) and other smooth-muscle tumors enhance similarly to nonnecrotic leiomyoma or myometrium (asterisk, C). Extrauterine extension of intravenous leiomyomatosis into broad ligament (solid arrows, C) resulted in triage of patient to open laparotomy over vaginal or laparoscopic resection.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Intravenous leiomyomatosis in 47-year-old woman with intrauterine intravenous leiomyomatosis previously diagnosed histologically who presented with palpable pelvic mass and abnormal vaginal bleeding. Gross macroscopic image shows white-tan lobulated mass (stars) fills and distends right broad ligament vein; thin red wall of vein is denoted by arrowheads.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —Intravenous leiomyomatosis in 47-year-old woman with intrauterine intravenous leiomyomatosis previously diagnosed histologically who presented with palpable pelvic mass and abnormal vaginal bleeding. H and E histologic image shows parauterine broad ligament vein lined by endothelium (arrowheads) is distended by benign smooth-muscle proliferation (asterisk) of intravenous leiomyomatosis.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Disseminated peritoneal leiomyomatosis in 36-year-old woman who presented with abdominal pain and intraperitoneal soft-tissue nodules. IV contrast-enhanced axial CT image shows round, solid, enhancing mass (arrowheads) adjacent to sigmoid colon (arrow).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Disseminated peritoneal leiomyomatosis in 36-year-old woman who presented with abdominal pain and intraperitoneal soft-tissue nodules. Axial image from 18F-FDG PET/CT examination shows 6- and 12-mm disseminated peritoneal leiomyomatosis nodules (arrows) without increased metabolic 18F-FDG uptake. Increased 18F-FDG uptake (red) is seen on this fusion image; for example, loop of small bowel shows physiologic intestinal uptake (arrowhead). Lack of 18F-FDG avidity makes malignancy, such as leiomyosarcoma, less likely. However, malignancy can be definitively excluded only with histologic sampling.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Disseminated peritoneal leiomyomatosis in 36-year-old woman who presented with abdominal pain and intraperitoneal soft-tissue nodules. Intraoperative photograph obtained during laparotomy shows round mass (arrowheads), as seen on CT (A), and 4-mm radiologically occult small nodules on peritoneal lining (arrows).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —Disseminated peritoneal leiomyomatosis in 36-year-old woman who presented with abdominal pain and intraperitoneal soft-tissue nodules. Gross macroscopic image shows smooth-muscle character (asterisks) of firm white intraperitoneal mass, which abuts sigmoid colon, with its wall (arrowheads) and lumen (arrow) noted.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. Transverse transvaginal sonographic image of pelvis shows heterogeneous leiomyomatous uterus (arrows) and left hydrosalpinx (star) caused by left pelvic and retroperitoneal mass (not shown).

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. IV and oral contrast-enhanced axial CT image (B) and coronal reformation image (C) show left retroperitoneal mass (solid arrows). Tumor shows intense enhancement typical of leiomyoma. Central low attenuation (asterisk, B) may indicate central degeneration or ischemia. Tumor encases and displaces dilated left gonadal vein (open arrow) laterally from aorta (arrowhead).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. IV and oral contrast-enhanced axial CT image (B) and coronal reformation image (C) show left retroperitoneal mass (solid arrows). Tumor shows intense enhancement typical of leiomyoma. Central low attenuation (asterisk, B) may indicate central degeneration or ischemia. Tumor encases and displaces dilated left gonadal vein (open arrow) laterally from aorta (arrowhead).

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. Coronal fast spin-echo T2-weighted MR image reveals that both left pelvic and retroperitoneal masses (open and solid arrows, respectively) show intermediate gray signal intensity that is slightly brighter than that of muscle. Uterine myometrium shows multiple small T2 hypointense intramural leiomyomas (solid arrowhead) and mild distortion of endometrial stripe (open arrowhead).

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6E —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. Gross macroscopic image shows that two well-defined medium-sized 10- and 8-mm nodules (arrows) that were not detected on imaging are present in mesentery (asterisk) of bowel. Note smooth-bowel wall serosa (arrowhead).

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6F —Disseminated peritoneal leiomyomatosis in 48-year-old woman with history of myomectomy who presented 1 year later with intra- and retroperitoneal soft-tissue masses. H and E histologic image shows fascicles of benign smooth muscle forming mass (asterisk) in lymph node. Note residual lymph node (arrow) with blue lymphocytes.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Benign metastasizing leiomyoma in 54-year-old woman who underwent hysterectomy 14 years earlier and was found to have incidental pulmonary nodules that had been stable for more than 10 years. Several nodules were resected soon after their initial incidental discovery for histologic diagnosis. Frontal radiograph with digital magnification view shows multiple 14- and 8-mm pulmonary nodules (arrowheads) of benign metastasizing leiomyoma.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Benign metastasizing leiomyoma in 54-year-old woman who underwent hysterectomy 14 years earlier and was found to have incidental pulmonary nodules that had been stable for more than 10 years. Several nodules were resected soon after their initial incidental discovery for histologic diagnosis. IV contrast-enhanced axial CT image in lung windows shows numerous randomly distributed, smooth, rounded nodules (arrows) that are characteristic of benign metastasizing leiomyoma.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Benign metastasizing leiomyoma in 54-year-old woman who underwent hysterectomy 14 years earlier and was found to have incidental pulmonary nodules that had been stable for more than 10 years. Several nodules were resected soon after their initial incidental discovery for histologic diagnosis. Gross macroscopic image shows that whitish-gray well-defined mass (arrows) is present in lung parenchyma (asterisks).

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —Benign metastasizing leiomyoma in 54-year-old woman who underwent hysterectomy 14 years earlier and was found to have incidental pulmonary nodules that had been stable for more than 10 years. Several nodules were resected soon after their initial incidental discovery for histologic diagnosis. H and E histologic image shows bland smooth-muscle cells are arranged in fascicles (arrows) and entrap alveolar epithelium (arrowheads) at periphery.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —Benign metastasizing leiomyoma in 48-year-old woman who was found to have pleural masses with benign smooth-muscle histology on biopsy. Left hemithorax pleural masses (arrows) seen on IV contrast-enhanced axial CT image were classified as benign metastasizing leiomyoma after hysterectomy, which revealed multiple intramural leiomyomas.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Benign metastasizing leiomyoma in 34-year-old woman with pathologically proven pulmonary benign metastasizing leiomyoma nodules found to have liver and adrenal nodules that remained slowly growing on imaging over 5-year period. Axial arterial phase IV contrast-enhanced CT (A) and T1-weighted gadolinium-enhanced MR (B) images show hypervascular enhancing 1.5-cm mass in segment VI of right lobe of liver (circle) and 2.5-cm enhancing right adrenal mass (solid arrow). Note appearance of inferior vena cava (open arrow) and aorta (asterisk) during arterial phase.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Benign metastasizing leiomyoma in 34-year-old woman with pathologically proven pulmonary benign metastasizing leiomyoma nodules found to have liver and adrenal nodules that remained slowly growing on imaging over 5-year period. Axial arterial phase IV contrast-enhanced CT (A) and T1-weighted gadolinium-enhanced MR (B) images show hypervascular enhancing 1.5-cm mass in segment VI of right lobe of liver (circle) and 2.5-cm enhancing right adrenal mass (solid arrow). Note appearance of inferior vena cava (open arrow) and aorta (asterisk) during arterial phase.

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