AJR 2002; 178:752-754
© American Roentgen Ray Society
MR Imaging of an Atypical Vaginal Leiomyoma
Ken Shimada1,2,
Isamu Ohashi2,
Hitoshi Shibuya2,
Fumiko Tanabe3 and
Takumi Akashi4
1
Department of Radiology, Toride Kyodo General Hospital, 2-1-1 Hongo,
Toride-shi, 302-0022 Ibaraki, Japan.
2
Department of Radiology, School of Medicine, Tokyo Medical and Dental
University, 1-5-45, Yushima, Bunkyo-ku, 113-0034 Tokyo, Japan.
3
Department of Obstetrics and Gynecology, School of Medicine, Tokyo Medical and
Dental University, 113-0034 Tokyo, Japan.
4
Department of Pathology, School of Medicine, Tokyo Medical and Dental
University, 113-0034 Tokyo, Japan.
Received April 26, 2001;
accepted after revision June 25, 2001.
Address correspondence to K. Shimada.
Introduction
Vaginal leiomyoma is a rare solid tumor with variable clinical
presentations [1,
2]. Since the first report by
Denys de Leyden in 1733, approximately 300 cases of vaginal leiomyoma have
been reported worldwide. Bennett and Ehrlich
[3] found only nine cases in
50,000 surgical specimens and only one case in 15,000 autopsies reviewed at
Johns Hopkins Hospital. Vaginal leiomyoma usually arises in the midline
anterior wall and, as usually seen with uterine leiomyomas, shows a slightly
lower signal intensity on MR images than normal myometrium.
We report a patient with a vaginal leiomyoma showing atypical anatomic
location and signal intensity on preoperative MR images.
Case Report
A 37-year-old woman was found to have uterine and vaginal tumors at a
screening physical examination program for uterine cancer. The patient was
referred to our hospital for further evaluation of the tumors. She had no
symptoms, such as pain, bladder outlet obstruction, constipation, or
difficulty with coitus.
MR imaging was performed using a 1.5-T superconductive system (Magnetom
Vision; Siemens, Erlangen, Germany) and a phased array surface multicoil.
Sagittal and axial T2-weighted (TR/TE, 4200/120) turbo spin-echo images were
obtained. Sagittal T1-weighted images and contrast-enhanced dynamic MR images
were also obtained using a multisection two-dimensional fast low-angle shot
sequence (150/4.1). Three-phase dynamic MR images (early, late, and delayed
phases) were obtained at 20, 60, and 180 sec after the start of rapid
injection (3 mL/sec) of 0.2 mmol/kg of body weight of gadodiamide hydrate
(Omniscan; Daiichi pharmaceutical, Tokyo, Japan) immediately followed by 20 mL
of saline. All MR images were obtained using a section thickness of 7 mm and a
20% intersection gap.
The MR images revealed a uterine tumor in the anterior wall of the uterine
body and a vaginal tumor in the posterior wall
(Fig. 1A). The uterine tumor,
5.2 cm in diameter, had a smooth contour and a homogeneous low intensity
signal on both T1- and T2- weighted images. Dynamic enhanced images showed
heterogeneous slight contrast enhancement. These MR findings were compatible
with those of typical leiomyomas. On the other hand, the vaginal tumor, 2.2 cm
in diameter, had a smooth contour and displayed a homogenous low signal
intensity on the T1-weighted images and a homogenous high signal intensity on
T2- weighted images. Dynamic enhanced images showed early homogenous marked
contrast enhancement and delayed staining (Figs.
1B,1C,1D,1E).
These MR findings were compatible with those of cellular-type leiomyoma.
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Fig. 1B. —37-year-old woman with vaginal leiomyoma. Dynamic enhanced MR
images obtained after rapid injection of gadodiamide hydrate (Omniscan;
Daiichi pharmaceutical, Tokyo, Japan) show marked contrast enhancement of
tumor (arrow). B = 0 sec, C = 20 sec, D = 60
sec, E = 180 sec.
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Fig. 1C. —37-year-old woman with vaginal leiomyoma. Dynamic enhanced MR
images obtained after rapid injection of gadodiamide hydrate (Omniscan;
Daiichi pharmaceutical, Tokyo, Japan) show marked contrast enhancement of
tumor (arrow). B = 0 sec, C = 20 sec, D = 60
sec, E = 180 sec.
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Fig. 1D. —37-year-old woman with vaginal leiomyoma. Dynamic enhanced MR
images obtained after rapid injection of gadodiamide hydrate (Omniscan;
Daiichi pharmaceutical, Tokyo, Japan) show marked contrast enhancement of
tumor (arrow). B = 0 sec, C = 20 sec, D = 60
sec, E = 180 sec.
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Fig. 1E. —37-year-old woman with vaginal leiomyoma. Dynamic enhanced MR
images obtained after rapid injection of gadodiamide hydrate (Omniscan;
Daiichi pharmaceutical, Tokyo, Japan) show marked contrast enhancement of
tumor (arrow). B = 0 sec, C = 20 sec, D = 60
sec, E = 180 sec.
|
|
The patient subsequently underwent an exploratory laparotomy and
myomectomy. Enucleation of the vaginal tumor using a transvaginal approach was
also performed. Postoperative examination revealed a well-circumscribed mass.
Histopathologic examination revealed an ordinary leiomyoma composed of
spindle-shaped cells. No prominent increase in cellularity was visible, but
many capillary-sized vessels were present
(Fig. 1F). The uterine tumor
was a pathologically normal ordinary leiomyoma.
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Fig. 1F. —37-year-old woman with vaginal leiomyoma. Photomicrograph of
histopathologic specimen shows tumor composed of spindle-shaped cells. No
prominent increase in cellularity is visible, but many capillary-sized vessels
are present. (H and E, x267)
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Discussion
According to previous reports, vaginal leiomyomas usually arise in the
midline anterior wall and vary between 1 and 5 cm. Vaginal leiomyomas can
cause urinary tract symptoms, such as frequency, urgency, dysuria, urinary
retention, and bladder neck obstruction
[1,
2]. Although the mass may occur
anywhere along the vaginal tube
[2], to our knowledge, all
previously reported vaginal leiomyomas have been located on the anterior wall.
In our patient, the vaginal leiomyoma was found on the posterior wall.
Consequently, she did not have any urinary tract symptoms. Furthermore, she
did not have a defecation disorder or difficulty with coitus, probably as a
result of the small size of the tumor. To our knowledge, ours is the first
report of a vaginal leiomyoma arising from the posterior wall.
The value of MR imaging in characterizing pelvic neoplasms has already been
established. However, the imaging features of this rare tumor have not been
previously described, except for the report by Ruggieri et al.
[1]. In their case report, the
tumor showed a low intensity signal on both T1- and T2-weighted images, as
seen in typical uterine leiomyomas, and was histopathologically shown to be an
ordinary-type leiomyoma. Yamashita et al.
[4] reported that hyperintense
uterine leiomyomas on T2-weighted images showing marked contrast enhancement
on early dynamic images corresponded well with the cellular histologic
sub-type of leiomyomas. The MR findings in our patient were not similar to
those of Ruggieri et al. but were similar to those of the cellular-type
leiomyomas described by Yamashita et al. Nevertheless, the histopathologic
examination of the vaginal tumor in our patient revealed an ordinary-type
leiomyoma [1,
4]. The cause of the
inconsistency between the MR findings and the histologic subtype found in our
patient is unclear. Some authors have reported MR findings for vascular
leiomyomas occurring in an extremity
[5,
6]. These lesions originate in
the tunica media of the vein and contain many vessels in the tumor. Vascular
leiomyomas show hyperintensity on T2-weighted images and marked contrast
enhancement, as seen in our patient
[5,
6]. We suggest that the
abundance of vessels in the vaginal leiomyoma in our patient may have caused
hyperintensity on T2-weighted images and showed marked contrast enhancement on
the early dynamic image, even though the number of intratumoral vessels was
not as great as that found in vascular leiomyomas. Various tumors showing high
signal intensity on T2-weighted images can occur in the vaginal wall,
including cystic tumor (cystocele, urethrocele, Skene's duct abscess,
Gartner's duct cyst, urethral diverticula, vaginal cyst, and Bartholin's gland
cyst) and solid tumors (carcinoma, invasive cervical carcinoma, and
rhabdomyosarcoma) [1].
Leiomyoma is easily diagnosed when it shows low signal intensity on both T1-
and T2-weighted images. Like uterine leiomyomas, however, vaginal leiomyomas
can show various signal intensities on MR images, depending on the
histopathologic changes that have occurred in the lesion.
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Introduction
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