Unusual Presentation of Uterine Fibroids

Case History: A 40-year-old female referred for evaluation of lower abdominal pain and polymenorrhea for six months.

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Figure 1. T2W axial pelvis: Enlarged uterus with a large intracavitary fibroid and a small sub serosal fibroid at 3:00 position.

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Figure 2. T2W mid-sagittal pelvis shows a large intracavitary fibroid (within yellow stars )

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Figure 3. T2W parasagittal pelvis shows a small subserosal fibroid (within red stars )

Patient underwent ultrasonography which showed two fibroids, one of which was very large and the other small. She was later referred for MRI scan which showed enlarged uterus measuring 11 cm x 9 cm x 9 cm.There was a large sub -mucosal fibroid measuring 9.6 cm x 7.9 cm x 7.6 cm. ( Fig 1 ) attached to the right side with a short peduncle. The small sub serosal fibroid, measuring 2.9 cm x 2.7 cm x 3.3 cm, was sessile( Fig.3 ) and seen arising from left lateral wall. There was marked internal degeneration of the large fibroid.( Fig.2 )

In transverse section both the fibroids gave the appearance of a signet ring. The concentrically enlarged uterus together with degenerated sub-mucosal fibroid appears as ring shape and the calcified small fibroid appears as the signet.

Discussion: Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. Growth and location are the main factors that determine if a fibroid leads to symptoms and problems. Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesion in this location may lead to bleeding and infertility. A pedunculated lesion within the cavity is termed an intracavitary fibroid and can be passed through the cervix. Subserosal fibroids are located underneath the mucosal (peritoneal) surface of the uterus and can become very large. They can also grow out in a papillary manner to become pedunculated fibroids.

Ultrasonography, CT and MRI can be used to diagnose uterine fibroids. Magnetic Resonance guided Focused Ultrasound, is a non-invasive intervention (requiring no incision) that uses high intensity focused ultrasound waves to destroy tissue in combination with magnetic resonance imaging (MRI), which guides and monitors the treatment.

References:
1.Brian D. Sydow, and Evan S. Seigelman,Uterine MRI: A review of technique and diagnosis,Applied Radiology; 37; 10; October 2008
2. Wilde S, Scott-Barrett S. Radiological appearances of uterine fibroids. Indian J Radiol Imaging 2009;19:222-31

G. Balachandran, MD, DNB,DMRD,
Associate Professor of Radiology,
Sri Manakula Vinayakar Medical College and Hospital
Pondicherry, S. India