Sonography of Uterine Myometrial Disorders - SD

Introduction

I am Dr. Al Taric from Jefferson Ultrasound Research and Education Institute at Thomas Jefferson University in Philadelphia.

And I'll be speaking about the sonography of uterine myometrial disorders.

The objectives of this talk are for you to be able to list the sonographic findings suggestive of adenomyosis to explain the common sonographic manifestations of uterine myta, and to describe mechanisms for uncommon sonographic presentations of uterine myta.

Anatomy of the Myometrium

First of all, let's start by reviewing the layers of the myometrium.

The highest echogenicity is that of the endometrium.

Right around it is a hypoechoic band, which is a thick band of compact hypoechoic inner myometrium.

So that's the first layer of my, it's not the basal layer of the endometrium.

It's the myometrial layer.

Then comes the thickest part of the myometrium, where the muscle is.

It's moderately echogenic, and where various circular and longitudinal muscle is located.

Then comes a fairly thin outer layer, which is pretty much isoechoic with the intermediate layer, maybe slightly less echogenic.

And you'll see vessels in between layer two and three.

And those vessels between layer two and three are the arcuate arteries and veins.

Basically there's really no visible vessels within the intermediate layer.

Vascular Structures in the Myometrium

Now, these arcuate vessels are located approximately five millimeters under the serosal surface of the uterus.

As we can see here, the vessels come in along the lateral aspects of the uterus, come around the periphery and send branches into the myometrium.

Now, these vessels can be very prominent in some patients, especially the veins.

They can be as prominent as in this patient.

But this is still normal in women of childbearing years.

These vessels are sometimes serpentine, very tortuous.

They're tubular fluid filled structures that go along the periphery of the intermediate layer.

Here's an example of a large vein coming across.

And we can doppler do a spectral tracing on it, proving that it is a venous structure.

Now, the arteries, I mentioned these because the arcuate arteries are also located in there, and eventually they may calcify in older patients, and then they become hyperechoic foci.

Some with shadowing, some don't really shadow 'cause they're very fine calcifications, and they really represent cystic medial necrosis, or this pathologically speaking monkey bird sclerosis.

So these dystrophic vascular calcifications represent the location of the arteries.

And when we see these, they're usually postmenopausal women, so it's not unusual to see it.

It is more common with diabetes and hypertension, although that's not to say that a patient who has these does have diabetes or hypertension.

So, just so that you are familiar with the distribution, five millimeters under the serosal surface, echogenic foci.

Now, sometimes the calcium is dense enough that it can cause acoustical shadowing, and that may actually cause so much attenuation shadowing that it may actually obscure the endometrial cavity line, and sometimes may even fool you and simulate a hydrometra.

This patient you can still barely make out this endometrial line, but in some patients, it looks like a hypoechoic center, and should not be mistaken for myometrium.

Artifacts and Technical Points

Another little technical point about the myometrium is that sometimes you'll see increased echogenicity within the myometrium, but you should make note, is it behind secretory endometrium.

So when the secretory phase is present, these little glands filled with mucus, there's increased water content that then increases sound transmission and may make this posterior myometrium look hyperechoic.

So that's just an artifact, and should not be taken for pathology.

Myometrial Ditzels

We have a little tiny so-called myometrial ditzels, the little tiny abnormalities in the myometrium, which really are clinically insignificant.

They're some of them have some pathologic significance, but you may see tiny punctate echo densities throughout the various layers of the myometrium.

Most of the time we don't even know exactly what they come from.

Sometimes we do think we know a specific cause for them, but here are some examples.

This is probably along the inner layer.

Here's a little clump of echogenic foci.

Here's a little tiny calcification with shadowing here.

Again, echogenic foci along the edge of the inner hypoechoic zone and around here.

Now, sometimes and this has been proven pathologically that this represents co placental site nodules, which are these little focal densities at the endometrial myometrial junction.

They probably represent the site of a prior pregnancy implantation.

When these were evaluated, the only thing they found in common was that the women had at least one pregnancy.

This, if you look under the microscope, it's a benign lesion of intermediate trophoblast.

Now, as soon as I say trophoblast, you're not supposed to think of potential for gestational trophoblastic disease or malignancy, or anything like that.

This is just how pathologists classify it.

There have been no reports of this degenerating microscopically.

They are well circumscribed nodules, and that's why we call them ditzels, because it's just a little collection of things.

Sometimes these little ditzels are actually small fibroids.

And these three examples here of old calcified involuted fibroids common in postmenopausal women, we can see scars.

The first three here are representatives of cesarean section scars.

That's in the lower uterine segment.

Often you can see a puckering of the anterior contour and associated with some type of triangular defect.

In this case, it's echogenic, in this case, possibly calcified.

And here is a small cystic changes.

So you'll see a variety of appearances.

Sometimes just a fluid-filled cavity.

One should pay attention to the thickness of the covering myometrium.

If you see that it's extremely thin, that would be worth reporting to the clinician.

And this is the site where ectopic pregnancies sometimes like to set up households, so that covering of myometrium, if it's extremely thin, that could be the site of a dehiscence.

Here is another myometrial scar.

This woman had a myomectomy, had a hysteroscopic removal of a fibroid, and an area, a small little scar calcified in her uterus.

Here's a sonohysterogram that shows us filling of a myomectomy defect, sort of almost a diverticulum that comes off of the endometrial cavity.

This has been described in the literature.

Here's another patient who had had a surgical myomectomy and developed a hematoma and eventually an area of scarring within the myometrium.

By the way, there have been reports of ectopic pregnancies establishing implantation in some of these sites as well.

We used to think that it was impossible to have a pregnancy within the myometrium, but now with all these surgical procedures, it is actually possible.

Preoperative Evaluation for Endometrial Ablation

Now, sometimes the clinician may ask us to evaluate the uterus prior to endometrial ablation.

What they're asking us to do is to comment on the myometrial thickness.

They would like to have or they need to have more than 10 millimeter thickness of myometrium.

So they're gonna ask us to measure the thinnest myometrium, because if the myometrium is too thin, they will not be able to do the procedure, because as they go into the endometrial cavity and wave around their instrument, which could be a number of different ways, it could be a laser beam.

They can use thermal destruction, electrical destruction, freezing microwaving of the endometrium.

So whatever they use that can actually penetrate heat or damage something beyond and cause further problem.

So they want to have a nice thick covering of myometrium.

So our job will be to measure the thinnest parts, not the thickest.

So here would be the thinnest, not this thick part.

Also make note of scars.

So if there's a c-section scar, they will not be able to do that because of penetrating damage.

Adenomyosis

Definition, Symptoms, and Prevalence

A major area of abnormality in the uterus is adenomyosis.

So I'd like to address this.

At this time, this is a common gynecologic disorder that affects premenopausal women.

Usually these women are over 30 years of age, they've had pregnancies.

Sometimes they're postmenopausal women, and the symptoms are variable, which include menorrhagia, dysmenorrhea, dyspareunia, pelvic tenderness, sometimes extremely serious to the point of being debilitating that during the menstrual cycle, the woman is incapacitated for a couple days and almost can't work.

So it is a serious condition for some, and the prevalence varies.

You can see find different series. Look at this range.

They range on surgical series from five to 70%, postmortem series 10 to 50%.

When you look at pathologic specimens, very often there'll be a line saying, adenomyosis present.

So it can be present in small amounts or larger amounts.

It's quite prevalent.

It's a difficult diagnosis for us to make.

It's an underdiagnosed condition in women.

We are more and more aware of this and looking for better ways of diagnosing this.

Years ago this was not even a sonographic diagnosis until we developed better equipment, higher frequency, higher resolution, transvaginal scanning.

We were able to start seeing things.

And you always have to remember that you see what you know.

So once we knew about it, we start looking for it.

It is operator dependent.

You have to do careful, meticulous scanning, and using higher resolution.

MRI has helped a lot in this diagnosis, and certainly is a way to correlate and also heightened awareness among patients, clinicians, and diagnostic imagers.

What is this adenomyosis?

Well, this is actually ectopic endometrial glands and stroma that has gone backward into the myometrium.

And as it has developed the focal site, it also has surrounding smooth muscle hyperplasia or hypertrophy around it.

So there's two things that go with it's glands and stroma, and it's in the myometrium.

So it's a focus of adenomyosis with adjacent smooth muscle hyperplasia, hypertrophy.

This can be in a diffuse form of foci scattered throughout the myometrium.

And it can also be a focal localized nodular aggregate that's called a focal adenoma sonographically.

We're gonna be looking for small echogenic foci islands collections of heterotopic endometrial gland and str surrounded by this smooth muscle hyperplasia.

And there are variable findings from solid to cystic areas, and we'll go through these.

Sonographic Findings

First of all, we may see asymmetrical wall thickening, and here we have a much thicker posterior wall than an anterior wall.

Also, notice that we have a fairly globular shaped uterus.

This is the corresponding MRI scan, which shows us this markedly thickened posterior wall, these small little fluid areas, areas of bleeding.

If you look carefully, you probably will see that there are little collections in this wall to correlate with the MRI.

Another finding is heterogeneity.

The echo texture of the myometrium is no longer homogeneous, but becomes more coarse.

Here as we, here's another one that's globular.

Posterior wall is thick, but also notice this heterogeneity in the wall.

The endometrial myometrial border may become indistinct to the point where you don't know where to measure it.

Is this the endometrium, should you measure it here?

Should you measure it here? Where does it end exactly?

So when you have that problem, you should think of possibility of adenomyosis that can lead to this so-called pseudo widening, where the endometrium looks too thick, and it sometimes measured two to three centimeters, which and the patient has no bleeding.

Particularly, there's no evidence of a polyp.

And that happens because you have these confluent echogenic abnormal areas.

Sonohysterography becomes helpful in that case.

So when you think there's endometrial thickening, or you're not sure the sonohysterogram can help us.

So look at this uterus. Areas blend.

We can't tell exactly where the endometrium ends.

We put in a little bit of fluid, and we see that the endometrium is completely normal.

And this is then the area involved with adenomyosis.

Another finding is a very thin shadows emanating from nowhere in the myometrium, you trace the shadows back, and there's nothing there.

There's no calcification, there's no mass.

So these probably these are coming from these areas of smooth muscle hypertrophy or hyperplasia that are near these ectopic glands.

So these kind of shadows.

Now, these thin shadows have been described with fibroids.

So it's also possible you have to stand back and see, is this coming from a mass, a rounded area as it was in this large fibroid?

Or is this coming just from the wall with no evidence of a mass effect?

Okay. Another manifestation would be seeing sub endometrial echogenic linear structures emanating out from the endometrium into the myometrium here, for example.

So this is a track of adenomyosis going into the myometrium here.

Another representation.

This patient had a lot of pain, and here she actually had two small tracts that we could find.

Sometimes it's just rounded areas, these sort of hyperechoic echogenic type of nodules.

You can imagine that that's a pocket of blood or endometrium in the wall.

And multiple small hyperechoic kind of nodular distribution is another finding of adenomyosis.

And notice here, you're having difficulty delineating exactly where the endometrium is.

Another not that well described finding is seeing through transmission increased sound transmission.

There are areas of shadowing, but sometimes you'll see hyperechoic kind of these are actually reverberations, probably from a little cystic fluid area area of bleeding in the myometrium.

So that then leads us to sub endometrial cysts.

There can be actual cysts formed.

And some papers in the literature have described that these are not visible until menses commences.

And once the woman bleeds, then they turn cystic when fluid gets into them or blood.

So that's a clue. So those are sub endometrial.

And here are myometrial cysts.

Another finding adenomyosis is the most common cause of myometrial cysts.

Other findings in this patient that can posterior, in this case, anterior wall, sorry, this is a retroverted uterus.

So you have thickened wall, you have cystic changes.

You have thin pencil like shadows radiating, and a fairly globular appearance to this uterus.

A pitfall here could be at least for these myometrial cysts, could be a vessel.

So in this case, it looks like a cyst, but remember, everything has to be confirmed in a 90 degree projection.

And this is a patient I showed you earlier that has a huge arcuate vein underneath the outer layer.

Here's a sonohysterogram where we actually filled a small cavity at the beginning of the examination.

There was no cystic change here at all.

And as we introduced some fluid, eventually this area filled out.

So this is a filling of this.

So there are cracks so-called cracks in the myometrium, which were coined in an article that we had in 2009, showing that there are connections from the endometrium filling into these spaces.

Also, notice there are other changes of adenomyosis, thickened wall, shadowing from thin shadows emanating from the myometrium.

Focal Adenomyosis (Adenomyoma) vs. Fibroids

The focal form of adenomyosis is an adenomyoma, which is this nodular aggregate of abnormality of adenomyosis.

These ha should be differentiated from omas.

They have ill-defined borders.

They lack edge shadows because they're actually just abnormal tissue.

They can be elliptical.

They have very minimal mass effect.

They do not calcify, and they have vessels coursing through them that is in contrast to the myoma, which forms in the myometrium pushes the normal myometrium around it.

So, I've contrasted this for you here.

This is the features of adenomyomas, and here's a feature of omas.

So the adenomyoma has poorly defined margins because it just blends with the myometrium, whereas the fibroid is rounded and has borders.

The adenomyoma has mixed echogenicity, sometimes hard to even define it in the myometrium, whereas the oma can be hypoechoic to the myometrium, could be iso, could be hyperechoic.

The adenomyoma has cystic area, small cystic areas.

Typically fibroids do not, unless there's some degeneration vessels coarse through.

The adenoma vessels are displaced around a fibroid, which pushes them out to the periphery.

No shadowing except for these thin shadows once in a while, whereas you fibroids have much more shadowing.

The adenomyomas tender when you push with the uterus.

Fibroids tend not to be tender unless they've bled into themselves or become degenerated or become super infected.

Uterine Fibroids (Myomas)

Typical Features and Description

All right, so the now comes another very large area of myometrial sonography, and that is OMA fibroids, myomas, myta.

Those are the different words that we use, and we intermix them constantly.

I think everybody pretty much knows the typical sonographic features of a fibroid.

It's a round mass.

Heterogeneous, usually hypo relative to myometrium.

It tends to attenuate sound to the point of shadowing.

It deforms the contour of the uterus here, in this case, lumpy bumpy contour.

Often they calcify, and usually they are multiple, think of it as misery loves company.

Well, when we describe this, we should actually try to pay more attention to describing the location of these myomas.

It is very helpful for the clinician to know the precise location so that they can plan their surgery.

So we should be using more precise terminology.

We ha most fibroids start out intramural, of course.

And a fibroid can be completely intramural.

If the fibroid gets very large and abuts the mucosa and serosa, then it's a transmural fibroid with a small submucosal and subserosal component.

That's important for the clinician, because if you describe it that way, they know they're not gonna be able to get this out hysteroscopically nor laparoscopically.

They're probably going to have to do laparotomy to go in, remove it, and sew up the hole, or else there could be a uterine perforation if pregnancy forms, et cetera.

Or they may try other methods of treatment.

Classification and Location

Sub mucus myomas can be so much within covered by the mucosa that they could be completely intracavitary and polypoid, they look like a polyp, and they can be called pedunculated.

They can be on a stalk.

When you have pedunculated it, there has to be a stalk there.

So we would like to describe it.

We, in this case, we would like to, we should say that this is a fibroid, which is over 50% submucosal, and the rest of it is intramural when, and then if you tell the clinician there's a centimeter or 1.3 centimeter myometrial covering, then they know precisely they can go in hysteroscopically and take this out.

If you describe a fibroid such as this one that has less than 50% submucosal component, but only has a very thin couple millimeter covering of myometrium, they will think twice about removing this hysteroscopically, because the rate of perforation here would be quite high.

They may wanna use ultrasound during the procedure or may attempt something else.

Another therapy here are subserosal fibroids.

So here's a fibroid that is more than 50% subserosal, the physician, then the gynecologist will attempt this laparoscopically.

It will not do hysteroscopic removal, and we can have a subserosal fiber.

It's also, it's covered with serosa on a pedicle on a stalk.

So that's a pedunculated myoma.

We it's interesting that there can be cervical myomas.

There have been vaginal leiomyomas described tubal leiomyomas.

And that's actually not surprising because these originate from smooth muscle.

So wherever you have smooth muscle, that's where you can have a leiomyoma.

Let's look at some of these graphically.

So here we have a myoma that is predominantly intramural with a less than 50% submucosal component.

And I would tell the clinician how that there's a good centimeter of myoma on the around the periphery.

And they can then plan the resection.

Here is a fibroid that is more than 50% subserosal, and the distance, I could tell them the distance to the endometrial cavity, which is very reassuring.

They would go in this and do this fibroid laparoscopically.

Here's a myoma.

It's intramural with it just abuts the endometrium.

It really does not protrude into the cavity, and it has about a centimeter of myometrium covering it.

So this is an intramural leiomyoma.

Here is a transmural.

This is the a transabdominal scan showing this uterus with this large fibroid that extends from sero with a small submucosal component.

So this is a transmural, such a fibroid will not be removed laparoscopically nor hysteroscopically.

When there are multiple myomas and the uterus is enlarged, this may be a candidate for uterine artery embolization, or if the woman is trying to preserve her fertility.

So this may not be an operative approach at all.

Here's a sub mucus myoma or submucosal myoma sometimes called.

This is a myoma that is half or 50% submucosal and 50% intramural with a covering of myometrium.

This was a patient who had had three spontaneous abortions.

And once this was removed, she eventually became pregnant.

So this was removed hysteroscopically.

Now, sometimes you can't tell there's a fibroid here.

It's difficult to tell how much of it is really in the cavity.

Is it in the cavity at all, or is it just displacing the cavity?

And in that case, one wonders, is it maybe completely in the cavity?

The cavity comes here, and then it splits, and then the myomas in the cavity, or is it one of these that just pushes the endometrium and its intramural?

So a great way to look at this is to do a sonohysterogram, put a little bit of fluid in the cavity, and there you have fluid surrounding it.

This was one of these, a completely intra cavitary myoma.

Very useful information.

Another patient, this is a postmenopausal woman who had had some bleeding, and she has this myoma.

She had bigger fibroids during her life, but they were shrinking.

And here's the endometrial cavity.

So the question is, is this submucosal?

How much of it is submucosal?

How much of it is really intramural?

What can they do about this?

Sonohysterogram helps us fluid delineates the cavity, and the myoma is seen to be completely transmural and with no submucosal component.

So endometrium is cleared, and this patient's myoma is hopefully going to regress some more.

Another one here, what is the submucosal intramural component?

The sonohysterogram shows that about half of it is submucosal and the other half is intramural, and there is a good thick covering of myometrium.

So this could be removed hysteroscopically.

It is known that submucosal myomas do cause pregnancy problems.

There are histories of recurrent merit miscarriages, premature labor, abnormal presentations.

There are various complications of labor.

So these are very important for the clinician to know about.

Now, when the sub mucus myoma is on a stalk, that sets up a predisposition to a torsion of this myoma, and that can lead to a painful episode, necrosis, bleeding, et cetera.

And the rest of the story you can imagine from this wonderful drawing of Dr. Netter, they can also prolapse.

They prolapse out through the cervix.

And here's transvaginal representation.

Here's the cervix. Here's the anterior cervical wall.

This is the posterior cervical wall.

Internal os is about here, and the fibroid bulges out through the external os.

And color doppler adds a very important piece of information, that there's a thick vascular stalk feeding this fibroid.

We can alert the clinician then that there could be excessive bleeding during the surgical removal.

Now, you could say, well, why do you have to do transvaginal sonography if the clinician can see this from a pelvic exam?

Well, you certainly wanna know what else is going on in this patient.

And sometimes lately we find that our emergency rooms are just sending patients to us for whatever reason that they come without having a pelvic exam prior to the ultrasound.

So this can be completely unexpected, and that is one of the reasons why the cervix has to be looked at separately from the rest of the corpus, because you could easily miss this protrusion if you do not include the entire cervix in your transvaginal image.

The prolapsing sub mucus myoma can be especially the ones coming from the fundal part of the uterus, if they're fairly big and on a thick stalk, they can as they protrude, they can actually pull the soft uterus with it and cause an inversion.

And here it protrudes out the vaginal introitus.

And look what happens. I'll back that up again.

This is the serosal lining.

This is the endometrial lining.

So as it pulls out, this is the exposed endometrium, and the serosal surface is now in here.

So this can be quite a problem.

Can invert and pull a considerable amount of uterus with it.

Subserosal myomas tend to be removed laparoscopically, so we have to tell them the percentage, in this case, over 50% of this myoma is subserosal, in this case here, it protrudes from the entire lateral wall.

And one would have to think about this.

How much of the wall would be exposed if this was removed?

Perhaps this has to be converted into a laparotomy for surgical removal, when a subserosal myoma becomes very large, usually about over eight centimeters in size, then it's usually removed by laparotomy, subserosal myomas can be pedunculated.

Now this is if they are on a stalk.

So what is a pedicle? What exactly do we have to have?

That's difficult to define, and many gynecologists don't exactly know when to call it a pedunculated myoma.

But I have seen in the literature description that the diameter of the pedicle when it's less than 50% of the diameter of the myoma, then that's considered a stalk, a broad-based or thin stalk, whatever.

This patient who these patients with these pedunculated myomas are considered not good candidates for uterine artery embolizations because they then may necros and slough off the uterus and cause abdominal symptoms.

Now another problem with these is that if you do transvaginal sonography alone, you may only include the entire uterus, but cut off this large mast that's protruding from the fundus.

So that's a pitfall of transvaginal sonography, such as here, here we fit in the uterus, pretty much, not even the cervix, but there was a pedunculated myoma here attached.

It was completely cut off the image.

So if one has the transabdominal image first, it is very helpful then with your transvaginal exam.

Now, some of these pedicles, these stalks can be very thin thin and long years ago, and this is many years ago in the days of static scanning, and I often like to throw in a static scan just to remind us of the history of ultrasound, how far we've come with our technology.

But this woman had a mass that wandered around her abdomen and pelvis.

It was a solid mass that kept moving, moving around.

And one day she developed severe pain.

They opened her up.

It was a torsed pedunculated myoma on a very long stalk.

So one day it just twisted somehow on its pedicle and necros.

So this was kind of a wandering myoma, kind of similar to a wandering spleen, if you've ever heard of those.

Now, the diagnosis of pedunculated myoma has to be made with caution, because this is a solid mass adjacent to the uterus, and it could be an ovarian tumor.

So it is crucial before we call a pedunculated myoma to find a separate ovary.

Once we do this, we can then study the relationship of this solid mass to the uterus.

One thing is to look for feeding vessels.

The vessels coming through the stalk.

These are can be confirmed with color here.

In this case, this was the uterus.

This is a pedunculated myoma.

There was a separate ovary, and now we confirm that the blood supply to this mass is coming from the uterus.

Masses are, if you don't know an origin of a mass, it's very helpful many times to find what vessel is feeding it.

And that helps you sometimes define the origin.

We know this from ct, for example, if there's a pelvic mass and we can trace the gonadal vessel, the ovarian vessels to that mass, then it's most likely of ovarian origin.

It's a fairly good assessment.

So in this case, we have vessels crossing through that vascular stalk, which then sets it up for possibility of a torsion.

So if a patient has a known myoma and then one day comes in with severe pain, certainly you have to think of torsion.

This lady came in with pain and didn't know she had one, but this is a solid mass, very solid, intimately related to the uterine wall.

Ovaries were separate.

There was no blood flow in this mass.

Very tender. Patient goes to surgery, and it is a torsed pedunculated myoma.

Another patient, large myoma, no internal flow.

Now it's extremely tender, has to go to surgery.

It's a torsed myoma.

Sometimes the subserosal myomas have such a broad connection to the surface of the uterus that we have to provide this information to the gynecologist so they can plan again, their surgery.

Now, look at this uterus. Here's the uterus.

The ovary was separate and arising from the entire anterior wall with large feeding vessels.

Confirmed here with Doppler feeding this huge mass, something like this cannot be removed from the entire wall with so many vessels to deal with.

Degenerative Changes

Now, fibroids can undergo some secondary changes, changes of degeneration, and there are various types of degeneration.

There's hyaline degeneration, calcific degeneration, cystic degeneration.

There's even fatty degeneration and rare, but it's possible sarcomas degeneration, which happens in less than 1% of myomas.

And there's so many myomas you can imagine that it's you might encounter one or two in your lifetime.

So that's degeneration.

They can necros outgrow their blood supply.

They can have internal hemorrhage.

They can become super infected.

So take the standard myoma and superimpose these changes.

Now, things start to get a little bit interesting.

Hyaline degeneration is the most common type of degeneration.

That's actually a pathologic kind of a diagnosis.

We can't really make that diagnosis from sonography.

It occurs typically at the center of the tumor because of the poor blood supply.

And the smooth muscle whorls are replaced by homogeneous hyaline material.

They stain that pink on their slides in pathology, and the tumor just becomes kind of soft, and patient can experience acute pain.

So it's not really a sonographic diagnosis, but I am showing you one that is here.

Pathologically proven tends to be a bit echogenic.

So sometimes they can be hyperechoic.

They can liquefy and develop cystic change on top of that.

And basically are removed only based on symptoms.

Now, calcific degeneration is the result of it's a late result of vascular impairment.

The fibroid becomes calcified and slowly involutes.

And here are some different patterns.

Here's kind of a peripheral calcification with a lot of attenuation.

Here's sort of a tip of the iceberg appearance, where you only see the top part with dense strong shadowing, very few reverberations.

And here speckled kind of a pattern.

The pattern of the so-called popcorn calcification, cystic degeneration obviously shows a cystic change.

Again, the result of outgrowing a blood supply.

And this can be a mimicker of a number of things.

In this case, there was a pregnancy, and we thought there was a twin pregnancy, but it turned out that this was a cystic degeneration in a myoma which fooled us.

There's fatty degeneration.

Fat is hyperechoic on sonography.

And here's a couple examples of a hyper coic change with cus with acoustical shadowing, at least in that case.

Now, there are a few types of fatty tumors in the uterus.

So I wanna just quickly talk about these for a second.

When you see a hyperechoic mass, and you can prove it on CT that it's fat, this could be fatty degeneration in a myoma.

It could be a so-called lipoleiomyoma with lipo and myo elements.

It could be an actual pure lipoma, could be a fibromyolipoma with fibrous myo and lipo elements, and myolipoma.

Any kind of combination that you can think of with the lipoma.

A lipoleiomyoma is a rare, benign tumor that contains fat.

It's usually asymptomatic. It's not a surgical lesion.

It does not degenerate into anything sarcomas.

It has mixtures of fat, smooth muscle, and fibrous tissue.

It's highly echogenic. It attenuates sound.

It kind of reminds you of what a dermoid looks like.

Also reminds you of what an AML looks like in the kidney angiomyolipoma, because that has fat in, so there's fat with attenuation, and you can confirm this with CT or mr.

And it's a benign condition. Does not need to be removed.

The only thing is you have to be sure that that's actually in the uterus and not, for example, an adnexal mass such as a dermoid.

Here are a couple more examples.

Hyperechoic mass with areas of sound attenuation.

Here's another one, homogeneous hyperechoic with sound attenuation.

Hyperechoic mass.

Here's a more complicated, one more mixed kind of a pattern.

Probably has more mitus and fibers kind of elements inside.

Leiomyosarcoma

The worst tumor that can occur in the myometrium is the leiomyosarcoma.

It's very rare. It may arise de novo, or it can arise in a preexisting myoma.

It's indistinguishable from a leiomyoma.

So the only thing that we have to go on is that there's symptoms, there's pain, there's bleeding, and there's rapid growth of a mass in the uterus.

And changes in a postmenopausal woman, postmenopausal women tend to shrink their leiomyomas.

And if it's a postmenopausal woman and the myoma is getting larger, or the myoma is degenerating, then one has to consider the presence of a leiomyosarcoma.

They can be they're locally invasive, and of course, they metastasize.

This is a leiomyosarcoma that occurred in a 22-year-old woman.

She was nulliparous, and went to see the doctor.

Her uterus was enlarged and was told she has a fibroid.

She was not followed, and the fibroid kept growing and growing, and eventually she came back.

Diagnosis was made of a leiomyosarcoma.

This is more typical of the presentation.

A 68-year-old post-menopausal woman with a kind of a mixed pattern of a fibroid that was enlarging close follow up is very important in these patients.

Another example here.

This was a 60 some year old woman with bleeding, and a very heterogeneous kind of mass cystic and solid elements in the myometrium invading now the endometrium.

And this was a leiomyosarcoma.

This is in the differential.

Endometrial sarcoma can look very much like a leiomyosarcoma.

This is an unusual situation.

The tumor begins in the endometrium.

And this pathology in this patient revealed a high grade sarcoma originating in the endometrium, and it invaded completely through the wall of the myometrium.

So this was very difficult. At first.

We thought this was going to be a leiomyosarcoma because the bulk of it looked like it was in the wall.

So that's kind of a in the back of your mind, an unusual tumor to differentiate or at least not be surprised at.

The final impression of the pathologist now more of these changes.

We talked about these up here, ending with sarcomas degener.

Infection, Necrosis, and Hemorrhage

Now let's talk about necrosis, hemorrhage, infection.

A fibroid can become super infected.

In that case, it's called a pyomyoma.

You may see, of course, the patient will have a fever and there'll be tenderness, but you may see bright reflectors that shadow that look like gas and gas is gas.

You can confirm this with a CT scan showing these gas bubbles.

The way the bacteria get in is usually through a submucosal myoma that's prone to infection.

This if not treated, can lead to sepsis and can become a extremely difficult situation to treat.

And this has to be differentiated from necrosis.

Now necrosis, I've seen cases where the myoma outgrew its blood supply and actually had air or gas in it, some release, maybe some type of nitrogen gas, whatever, but there was no pain.

I'm sorry, there was no fever.

There was pain, but there was no fever.

And this sometimes occurs with pregnancy.

When a fibroid begins to grow, and may have a very similar appearance on ultrasound.

Now take the solitary myoma, mix up some secondary changes and make it pedunculated.

Now you have a setup for some very atypical sonographic appearances, and that's why fibroids have been called the pelvic mimicker, because they can mimic normal or abnormal pelvic conditions in up to 5% of cases.

So let's look at some of these atypical presentations that we should be aware of.

Atypical Presentations and Mimickers

They can mimic an ovarian mass.

Now here we have a pedunculated myoma with cystic changes, and it looks like an adnexal mass with linear septations and fluid and some solid elements.

So it's crucial in this case to find a separate ovary.

Here are some more atypical myomas mimicking adnexal masses.

Here's an ovarian quote mass with the septation.

It's just a pedunculated myoma.

Here is a undulated myoma.

Another one that had mostly cystic degeneration here, looked like a perhaps a dermoid because it had some calcification.

Here was one that was thought to be a large lymph node lateral to the uterus.

All of these or pedunculated myomas, they can even mimic an endometrioma.

This was a pedunculated myoma.

It had a vessels feeding it, but it was so homogeneous that it looked like an endometrioma here.

This was a huge mass extending up to the xiphoid.

And everybody thought it was gonna be a large ovarian solid mass.

Turned out to be a large pedunculated myoma.

Here is a solid mass in the cul-de-sac.

Thought it was gonna be a fibroma.

And it was a pedunculated myoma.

They can mimic dermoids.

These are the fatty containing lesions with sound attenuation, especially when it's pedunculated off in the adnexa.

In this case, it was clearly in the wall, and there was endometrium.

So the sonohysterogram helped us see that it was a myometrial mass, not an adnexal mass.

Here's myoma with tip of the iceberg, mimicking a dermoid.

Here's another one, sound attenuation, mimicking a dermoid.

Here's a myoma mimicking adenomyosis.

Looks like a bulgy thick heterogeneous uterus.

And it was filled with these little small myomas.

This one had uterine enlargement.

It was thought to be a sarcoma, and turned out to be just atypical myoma.

With some bleeding, they can mimic uterine anomalies here.

Seems like a bi lobed uterus. Here's an endometrium.

Something in here looked like an endometrium.

Surgery showed.

This was just a pedunculated myoma.

Another one where it was thought to be a bicornuate uterus.

One of these, and I can't even remember which one was the myoma can mimic pregnancy, large uterus with a big fibroid and a cystic space.

Wanted, wanna do a pregnancy test? Here's that case.

I showed you a little embryo here.

We thought there was a twin. No, this one stayed the same.

Was was a degenerated myoma.

And this pregnancy continued to grow.

Here's another one that looked like a little gestational sack.

They can mimic ectopic pregnancies.

Now, here are two different cases, both of which mimicked ectopics.

In the adnexa, there was a mass with the hyperechoic rim, and something that possibly looked like an embryo inside, except that the vascular pedicle sign showed up here that we have the pet the vascular pedicle feeding the mass instead of a sort of ring of fire around the mass.

And this the pregnancy test was negative.

This was a myoma partially pedunculated.

Now, here was another case completely separate individual having a very similar appearance.

The pregnancy test is negative.

This was not a cornual ectopic which it simulated, but it was just a degenerated myoma.

They can mimic fetal heads.

This is always fun when you find a fetus inside the uterus, and then you see something that looks like a calcified head, and you study it, and it's actually within the myometrium, and there's no body to go with it.

There's no spine here in this patient. It bulges out.

These are calcified myomas and not some weird type of demise.

The fetus.

Uterine Arteriovenous Malformations

A couple other things at the end here.

Uterine arteriovenous malformation that occurs in the myometrium.

This is a rare vascular lesion.

It's a vascular plexus of arteries and veins with some arteriovenous shunting.

There's no intervening capillary network.

So the blood goes directly from an artery into a vein.

This can happen after some type of trauma surgery, after a pregnancy, after an abortion, DNC.

So most of them are acquired.

A few of them could be congenital.

These patients have abnormal heavy bleeding to the point where about 30% of them require transfusions.

Now, you have to make the diagnosis cautiously, because if you make this diagnosis, DNC is not indicated because that in itself could cause massive hemorrhage.

So surgery would not be the approach.

It's a conservative management of this, and nowadays can be even embolized in interventional radiology.

So what could we see with ultrasound?

Well, the findings are not always specific.

Usually you'll see some kind of inhomogeneity in the uterus.

Sometimes you may recognize tortuous tubular serpiginous kind of structures.

Turn on the color doppler, and you see lighting up in a very hypervascular area in the uterus.

And you take a tracing with spectral doppler.

And that shows us high velocity but very low resistance wave form.

So you have this venous flow continuous, and you have these little superimposed arterial peaks.

The color is intense.

There's a mosaic pattern with aliasing.

And one should attempt to take a peak systolic velocity.

Now, this can mimic retained products of conception.

It can mimic abnormal placentation.

And gestational trophoblastic disease is in the differential these patients.

So of course, a beta would be indicated a beta HCG level.

Now what about differentiating it from a retained product of conception?

Now, that's difficult.

There is some information in the literature that tells us that if you do a peak systolic velocity on these vessels, and if it's low, less than 40 centimeters per second, then these are reportedly not requiring any kind of therapy.

This is these pon regress spontaneously.

But if you get very high velocity flow, then these are the real arterial venous malformations that may require treatment, especially if they're bleeding.

Conclusion

So I hope that I've given you a spectrum of various myometrial disorders, especially focusing on adenomyosis and unusual manifestations of uterine fibroids.

Hopefully this will improve your diagnostic accuracy and lead to the correct diagnosis and subsequently the proper management of your patient.

Thank you for your attention.