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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.

Received July 14, 2005; accepted after revision October 21, 2005.

 
Address correspondence to D. T. Cohen.

Abstract

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
OBJECTIVE. This essay illustrates the salient features of variant smooth-muscle tumors on multiple imaging techniques with correlative pathology. We describe how recognition of these features allows the radiologist to distinguish a uterine leiomyoma variant from the classic fibroid or a leiomyosarcoma. Finally, we highlight the role of the radiologist in triaging these patients to surgical versus medical management and in surgical planning.

CONCLUSION. Parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma show key features on multiple imaging techniques that correlate with pathology findings. In the appropriate clinical setting, the radiologist should include these unusual lesions in the broader differential diagnosis of smooth-muscle tumors and, in certain cases, aid in surgical planning.

Keywords: CT • gynecologic imaging • leiomyoma • leiomyomatosis • MRI • oncologic imaging • sonography • uterine cancer • women's imaging

Introduction

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
The spectrum of smooth-muscle tumors arising from the uterus ranges from benign leiomyoma to malignant leiomyosarcoma but also includes a variety of lesions with growth patterns that extend outside the uterus, including parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma. These benign tumors resemble typical uterine leiomyomas at both gross and microscopic levels. However, the atypical location and aggressive growth of these variant tumors present a diagnostic dilemma and have led to controversy regarding their pathogenesis and actual "benignity."

Because these benign smooth-muscle tumors are rare, no series describing their imaging characteristics has been reported, to our knowledge. This essay illustrates the salient features of these tumors on multiple imaging techniques with correlative pathology. We describe how recognition of these features allows the radiologist to distinguish a uterine leiomyoma variant from the classic fibroid or a leiomyosarcoma. Finally, we highlight the role of the radiologist in triaging these patients to surgical versus medical management and in surgical planning.

Parasitic Leiomyoma

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
Parasitic leiomyomas present as peritoneal pelvic benign smooth-muscle masses separate from the uterus. A parasitic leiomyoma likely originates as a pedunculated subserosal leiomyoma that twists and torses from its uterine pedicle. Now, "free" in the peritoneal cavity, it survives by recruiting neovascularization from adjacent structures. The originating pedunculated fibroid likely develops premenopausally, whereas the parasitic leiomyoma may become clinically evident either before or after menopause.

On imaging, parasitic leiomyoma shows tissue characteristics similar to uterine leiomyoma. Because of their multiplanar capabilities, CT and MRI can show the location of the tumor relative to adjacent structures, which may be critical for surgical planning (Figs. 1A, 1B, and 1C). The differential diagnosis of parasitic leiomyoma varies with its location but can include ovarian stromal tumor, leiomyosarcoma, drop metastases, and lymphadenopathy. With behavior similar to uterine leiomyoma, parasitic leiomyoma may recur after resection or, conversely, may show hormone-responsive behavior, including size stability or even shrinkage with natural, surgical, or chemical menopause [1] (Fig. 2). Surgery is usually performed for symptomatic relief or to prevent impingement of vital structures.

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.

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

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.

If intravenous leiomyomatosis arises and remains solely in the uterus, a radiologic diagnosis is difficult because the tumor mimics a typical leiomyoma. If intrauterine intravenous leiomyomatosis is incidentally diagnosed on pathologic examination from a routine hysterectomy, one could consider interval surveillance examinations to assess for recurrence. However, given the benign indolent course of this disease, it is reasonable to defer imaging until there is a symptomatic indication.

Sonography may be sufficient for detecting atypical features of intravenous leiomyomatosis, such as extrauterine extension. The initial route outside the uterus for "intrauterine" intravenous leiomyomatosis may include the broad ligament veins (Figs. 4A, 4B, 4C, 4D, and 4E). The broader field of view of MRI and CT compared with sonography details additional anatomic relationships that are required for surgical planning.

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.

Disseminated Peritoneal Leiomyomatosis

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
Discrete nodules of benign smooth muscle scattered over the peritoneum characterize classic disseminated peritoneal leiomyomatosis. However, disseminated peritoneal leiomyomatosis presents a protean appearance, sometimes presenting as tiny peritoneal nodules mimicking peritoneal carcinomatosis or as bulky intra- or extraperitoneal masses resembling leiomyosarcoma [3, 4] (Figs. 5A, 5B, 5C, 5D, 6A, 6B, 6C, 6D, 6E, and 6F). Disseminated peritoneal leiomyomatosis is classically seen in premenopausal patients and is frequently seen in pregnant women. Disseminated peritoneal leiomyomatosis likely is the result of multifocal metaplasia of the peritoneum. However, some authors promote a disseminated origin from a single lesion [4].

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.

Benign Metastasizing Leiomyoma

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
Benign metastasizing leiomyoma classically has been described as incidental pulmonary nodules in women with a history of uterine leiomyomas [6]. Pathologically, these nodules are composed of benign smooth muscle similar to leiomyoma. Benign metastasizing leiomyoma can have a benign indolent clinical course with long-term stability. As with disseminated peritoneal leiomyomatosis, there is controversy in the medical literature regarding the pathogenesis of benign metastasizing leiomyoma. Does it represent multifocal metaplasia or, as the name suggests, is it a "metastatic" phenomenon secondary to vascular invasion within a uterine leiomyoma [7]?

Radiographically, benign metastasizing leiomyoma presents typically as solitary or multiple pulmonary nodules, and on CT these nodules enhance homogeneously (Figs. 7A, 7B, 7C, and 7D). Benign metastasizing leiomyoma can be seen as soft-tissue implants in the pleura (Fig. 8) and on solid abdominal viscera (Figs. 9A and 9B). Although the multiplicity of lesions raises the question of metastatic disease, in the clinical setting of a hormonally active woman with a history of uterine leiomyomas and no known primary malignancy, the radiologist can add benign metastasizing leiomyoma to the diagnostic considerations even before tissue sampling.

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.

Conclusion

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 
Parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma are rare histologically benign smooth-muscle tumors. Their variant nature stems from their location and unusual growth patterns either outside the uterus or within veins. They typically show indolent growth that is often hormonally responsive; frequently develop in premenopausal women; and often regress with medical hormonal blockade, oophorectomy, or natural menopause.

On imaging, these tumors mimic uterine fibroids, with well-defined margins and hypervascular smooth-muscle characteristics. However, the growth patterns of these leiomyoma variants can imitate those of more aggressive cancers: Disseminated peritoneal leiomyomatosis can resemble peritoneal carcinomatosis, parasitic leiomyoma or intravenous leiomyomatosis can resemble leiomyosarcoma, intravenous leiomyomatosis can resemble renal cell carcinoma in the setting of inferior vena cava involvement, and benign metastasizing leiomyoma can resemble pulmonary or hepatic metastatic disease. Thus, diagnosis requires a radiologist to be aware of these entities and to include them in the differential diagnosis in the appropriate clinical setting.

Because the imaging findings of parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma overlap with those of malignancy, these entities require direct pathologic sampling for diagnosis. Once a diagnosis is histologically confirmed, patients can be triaged to medical-hormonal management or can undergo surgical excision based on lesion location, degree of involvement of surrounding structures, and the severity of the patient's comorbid conditions. Multiplanar imaging depicts key anatomic points, such as ureter, bladder, or vessel involvement, that are crucial for surgical planning.

When presented with the radiologic appearance of "locally aggressive" or "metastatic" tumors with smooth-muscle characteristics in a woman with a history of fibroids, the radiologist should broaden the differential diagnosis to include variant uterine smooth-muscle tumors.

References

Top Abstract Introduction Parasitic Leiomyoma Intravenous Leiomyomatosis Disseminated Peritoneal... Benign Metastasizing Leiomyoma Conclusion References

 

1. Wilkinson N, Rollason TP. Recent advances in the pathology of smooth muscle tumors of the uterus. Histopathology2001; 39:331 -341[CrossRef][Medline]
2. Lam P, Lo K, Yu M, et al. IV leiomyomatosis: two cases with different routes of tumor extension. J Vasc Surg2004; 39:465 -469[CrossRef][Medline]
3. Fuller A Jr., Patterson D, Shimm D. Sarcomas of the female genital tract. In: Raaf J, ed. Soft tissue sarcomas: diagnosis and treatment. St. Louis, MO: Mosby, 1993:187 -200
4. Altinok G, Usubutun A, Kucukali T, et al. Disseminated peritoneal leiomyomatosis: a benign entity mimicking carcinomatosis. Arch Gynecol Obstet 2000;264:54 -55[CrossRef][Medline]
5. Naohiko U, Tetsuji T, Masato M. Positron emission tomography with ¹⁸F-FDG of uterine sarcoma: a comparison with magnetic resonance imaging and power Doppler imaging. Gynecol Oncol2001; 80:372 -377[CrossRef][Medline]
6. Abramson S, Gilkeson RC, Goldstein JD, Woodard PK, Eisenberg R, Abramson N. Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation. AJR2001; 176:1409 -1413[Abstract/Free Full Text]
7. Canzonieri V, D'Amore ES, Bartoloni G, Piazza M, Blandamura S, Carbone A. Leiomyomatosis with vascular invasion: a unified pathogenesis regarding leiomyoma with vascular microinvasion, benign metastasizing leiomyoma and intravenous leiomyomatosis. Virchos Arch1994; 425:541 -545

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cohen, D. T. Articles by Lee, S. I. Search for Related Content PubMed PubMed Citation Articles by Cohen, D. T. Articles by Lee, S. I. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?