Download - Mohammad a. Emam
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BYBY
Mohammad A. EmamProf. of Obstetrics and Gynecology
Mansoura Faculty of MedicineMansoura integrated fertility center (MIFC)
Egypt
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UterusUterusdepriveddeprived
from a babyfrom a babyconsolesconsoles
itself with aitself with afibroid.fibroid.M.Ema
m
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PathologyPathology
NIE:NIE: -Site - shape - size.
- Consistency - cut section
- capsule - Number - varieties.
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Uterine leiomyoma
Corporeal 98% multiple
Cervical 1-2%
solitary
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Corporeal leiomyoma
submucus 24% not capsulated
Subserous 18%
Interstitial 58%
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M.Ema
m
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Cervical leiomyoma
Supravaginal cervixtrue
(ant - post - central - combined)
false(intralig - retraperit- not capsulated
Portiovaginalis smallsessile
polypoid
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CONSISTENCYCONSISTENCYFirmFirm
Harder Harder (hyaline degeneration).(hyaline degeneration).SoftSoft (pregnancy-cystic degeneration).(pregnancy-cystic degeneration).
Stony hard (Calcification)Stony hard (Calcification)
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Leiomyomata Uterus
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CUT SECTIONCUT SECTIONWell demarcatedWell demarcated
surrounding muscle.surrounding muscle.whorly (intermingling musclewhorly (intermingling muscle
fibers and fibrous tissue).fibers and fibrous tissue).Paler than surrounding (Ischaemia).Paler than surrounding (Ischaemia).
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:Leiomyoma
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Moham
Emam
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Microscopic Microscopic ExaminationExamination
Smooth muscle cellsand fibrous tissue cells.
Few formed bloodvessels.
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CELLULAR LEIOMYOMAS
Compact smooth muscle cells with little or no collagen, can
have relatively higher signal intensity on T2.
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Changes occur withChanges occur with
fibroid fibroid
General
Genital tract Tumor itself
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General changesGeneral changes
Erythrocytosis.
Polycythaemia (erythropoitic)Carbohydrate metabolism(hyperglycaemia).Anaemia (hge).
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Genital tract Genital tract Uterus (endomet.-cavity-myomet.-uterusas a whole).
Tubes inflammed (salpingitis)ovaries (tunica albuginea-endometriosis-cysts).Blood vessels.Endometriosis (30-40%).
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Tumour itself Tumour itself Atrophy.Degeneration (hayline-red-cystic-fatty-calcerous)
Necrosis.Malignancy (growth after menopause-rapienlargement-recurrent fibroid polyp).
Vascular (oedema-lymphangectasia )Infection.
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DegenerationLeiomyomas enlargeoutgrow their blood supply
various types of degeneration
Hyaline degeneration :- the presence of homogeneous eosinophilic bands or plaquesin the extracellular space.Myxoid degeneration - presence of gelatinousintratumoral foci at gross examination thatcontain hyaluronic acidrichmucopolysaccharides
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Degeneration contRed degeneration - during pregnancy,secondary to venous thrombosis within theperiphery of the tumor or rupture of intratumoral arteriesSarcomatous transformation -less than 3%
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DIAGNOSIS DIAGNOSIS History
Examination.Investigation.
D.D.
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SYMPTOMS SYMPTOMS Bleeding (menorrhagia-metrorrhagia).Pain uncomplicated (cong.Dysmenorrhea dull - colicky).Pain complicated deg.-malig.-
infection-torsion)infertilitymass.Discharge.Pressure symptoms.
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SignsSigns Symmetrically enlarged
uterus(submucosalfibroid).
Asymmetrically enlarged
uterus(subse
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InvestigationsClinicalLaboratoryImaging techniquesInstrumentalMiscellaneous
h
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Imaging TechniquesImaging Techniques ))MR IMAGE))MR IMAGE
most accurate imaging technique for detectionand localization of leiomyomasmyomatous uterus (>140 cm 3) is not consistently
possible with US because of the limited field of viewuterine zonal anatomy enables accurateclassification of individual masses assubmucosal, intramural, or subserosal
h
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Imaging TechniquesImaging Techniques )MR IMAGE)MR IMAGE contcont
Nondegenerated uterine leiomyomas:
- well-circumscribed masses of homogeneously decreased signal intensitycompared with that of the outer myometrium
on T2-weighted images
- whorls of uniform smooth muscle cells withvarious amounts of intervening collagen
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I i T h i
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Imaging TechniquesImaging Techniques ))MR IMAGE))MR IMAGE
Degenerated leiomyomas variable in T2hyaline and calcific degeneration (low)
cystic degeneration (high)myxoid degeneration (very high, minimalenhance)Necrotic leiomyomas without liquefaction
(variable in T1, low in T2)Red degeneration
T1 : peripheral or diffuse high SIT2 : variable SI with or without low SI rim on T2
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DIFFERENTIAL DxADEMOMYOSIS
- presence of ectopic endometrial glands andstroma within the myometrium, which areassociated with reactive hypertrophy of thesurrounding myometrial smooth muscle- most commonly a diffuse abnormality but may
also occur as a focal mass, which is known as anadenomyoma
- diffuse form of adenomyosis appears as a
thickened junctional zone (inner myometrium) onT2-weighted images
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DIFFERENTIAL DxADEMOMYOSIS cont
Junctional zone 12 mm thick or thicker is highly predictive of adenomyosisSmall foci of high signal intensity onT2-weighted images represent theendometrial glands
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:Adenomyosis
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Distinction between adenomyosis and leiomyomas is of
clinical
importance because, unlike leiomyomas, which may betreated with myomectomy, adenomyosis can be extirpated onlywith hysterectomy Adenomyosis appears as an ill-defined, poorly marginatedarea of low signal intensity within the myometrium on T2.
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Differential DxDifferential DxSolid Adnexal Mass
- If MR imaging can demonstrate continuity of an adnexal mass with the adjacentmyometrium, then a diagnosis of leiomyomacan be established.
- Ovarian fibromas and Brenner tumors are
benign ovarian neoplasms that have a large
fibrous component
and can have signalintensity similar to that of a pedunculated leiomyoma
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Differential DxDifferential Dx Solid Adnexal Mass cont
- fibromas and Brenner tumorssurrounded by ovarian stroma and
follicles, thus establishing the ovarian
origin of the mass and excluding adiagnosis of leiomyoma
- - important in pregnant patients
because a confident
diagnosis of auterine leiomyoma may eliminate theneed for surgery during pregnancy
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Differential DxDifferential DxFocal Myometrial Contraction
- appear as a myometrial mass of low
signal intensity on T2-weighted images
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Treatment of Treatment of
LeiomyomaLeiomyomaNo treatment
ConservativeRadiologicalSurgical
Myolysis.GNRHAUterine a
embolization.
Patient (age-parity-
symptoms).Fibroid (number-size-type)
Complications.
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SURGICALSURGICALMyomectomy
Polypectomy.
Hysterectomy.
(traditional-microsurgical ).
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Myomectomy HysterectomyPatient
Age. Parity.
Fibroid No
Type
Size
Associated
40 yearscomplete her family
large
subserous-submucous andcomplicatedlarge
+ve complications(pressure Symptoms)
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OB& GYN, Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center (MIFC)EGYPT
Telfax 0020502319922 & 0020502312299