Accuracy of magnetic resonance imaging in assessing types of degeneration in leiomyomas

Sheema Posh; Suhail Rafiq; Farzana Manzoor; Obaid Ashraf; Musaib Ahmad

doi:10.4103/jmgims.jmgims_40_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 25 | Issue : 2 | Page : 99-102

Accuracy of magnetic resonance imaging in assessing types of degeneration in leiomyomas

Sheema Posh¹, Suhail Rafiq², Farzana Manzoor³, Obaid Ashraf², Musaib Ahmad²
¹ Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir, India
² Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir, India
³ Department of Pathology, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission	20-Apr-2020
Date of Acceptance	11-Jun-2020
Date of Web Publication	15-Dec-2020

Correspondence Address:
Dr. Suhail Rafiq
Department of Radiodiagnosis and Imaging, GMC, Srinagar, Jammu and Kashmir
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmgims.jmgims_40_20

Abstract

Background: Leiomyomas are the most common benign uterine neoplasms arising from smooth muscle cells. Magnetic resonance (MR) imaging is the most accurate imaging technique for detecting and localizing leiomyomas. As leimyomas grow, they may outgrow their blood supply resulting in various types of degeneration such as myxoid, hyaline, cystic, red, and calcification. Degenerated leiomyomas have variable appearances on T2-weighted images and contrast-enhanced images. Materials and Methods: This was a retrospective hospital-based study done in Government Medical College, Srinagar, from January 2018 to December 2019. The study included 78 patients with more than 2 cm pathologically proven fibroids who underwent myomectomy or hysterectomy and preoperative MR imaging (MRI). We assessed the accuracy of MR for picking degeneration in fibroids. Aim and Objective: The aim and objective of this study is to determine the sensitivity, specificity, positive, and negative predictive value of MRI in assessing degeneration in uterine fibroids. Results: The sensitivity, specificity, positive and negative predictive values of MRI in assessing degeneration in uterine fibroids were 60%, 93.7%, 85.7%, and 78.9% respectively. Menorrhagia followed by dysmenorrhea was the most common presenting symptom. Conclusion: MRI has average sensitivity and very good specificity for picking fibroid degenerations. MRI has high accuracy for picking up myxoid, cystic, and red degeneration.

Keywords: Leiomyoma, magnetic resonance imaging, myxoid degeneration, red degeneration

How to cite this article:
Posh S, Rafiq S, Manzoor F, Ashraf O, Ahmad M. Accuracy of magnetic resonance imaging in assessing types of degeneration in leiomyomas. J Mahatma Gandhi Inst Med Sci 2020;25:99-102

How to cite this URL:
Posh S, Rafiq S, Manzoor F, Ashraf O, Ahmad M. Accuracy of magnetic resonance imaging in assessing types of degeneration in leiomyomas. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2023 Jun 4];25:99-102. Available from: https://www.jmgims.co.in/text.asp?2020/25/2/99/303419

Introduction

Uterine fibroids are a major cause of morbidity in women of reproductive age, with an incidence of 20-40% in women during their reproductive years.^[1],[2] Leiomyomas are the most common benign uterine neoplasms arising from smooth muscle cells with a large amount of extracellular matrix containing collagen, proteoglycan, and fibronectin.^[3],[4] Leiomyomas are classified as submucosal (projecting into the endometrial canal), intramural (within the substance of the myometrium), or subserosal (beneath the serosa) on the basis of location. Magnetic resonance (MR) imaging is the most accurate imaging technique for detecting and localizing leiomyomas. As leiomyomas grow, they may outgrow their blood supply resulting in various types of degeneration such as myxoid, hyaline, cystic, red, and calcification. Most of these histopathologic findings are unrelated to the clinical symptoms. In hyaline degeneration, there is the presence of proteinaceous tissue in the form of homogeneous eosinophilic bands or plaques in the extracellular space.^[5],[6] Myxoid degeneration is characterized by the presence of gelatinous intra-tumoral foci that contain hyaluronic acid-rich mucopolysaccharides.^[7] Red degeneration is a subtype of hemorrhagic infarction of leiomyomas that often occurs during pregnancy due to venous thrombosis within the periphery of the tumor or rupture of intratumoral arteries.^[8] Sarcomatous transformation of a preexisting leiomyoma is rare.^[7],[9]

Leiomyomas can present with symptoms such as menorrhagia, dysmenorrhea, pain, infertility, pressure, urinary urgency, or palpable abdominal/pelvic mass depending upon the size, location, and number of tumors.^[10] Non-degenerated uterine leiomyomas appear as well-circumscribed masses of homogeneously low-signal intensity on T2-weighted images (T2WIs) as compared to that of the outer myometrium. Degenerated leiomyomas have variable appearances on T2WIs and contrast-enhanced images.^[11]

Materials and Methods

This was a retrospective hospital-based study conducted in Government Medical College, Srinagar from January 2018 to December 2019. Seventy-eight patients with more than 2 cm pathologically proven fibroids after undergoing myomectomy or hysterectomy and preoperative MR imaging (MRI). We assessed the accuracy of MR for picking degeneration in fibroids. Out of 78 patients, only 30 patients had some sort of pathologically proven significant degeneration. MRI was done on 3.0 Tesla superconducting MR imager (Magnetom Avanto, Siemens Medical System) with a standard pelvic coil. Coronal T2WI and short T1-inversion recovery (STIR), sagittal T2WI and axial T2WI, T1WI, and STIR images were taken. Fat-suppressed T1W sequences before and after intravenous injection of gadolinium were also taken in some patients. We did not have the choice of adding post-contrast images in our study in all patients to increase sensitivity for picking up degeneration on MRI as study was retrospective in nature.

Aim

The aim of our study was to determine the sensitivity, specificity, positive and negative predictive value of MRI in assessing degeneration in uterine fibroids.

Inclusion criteria

Women in the age group of 20–70 years
All patients with histopathologically proven fibroids with size >2 cm
All patients with MRI findings available.

Exclusion criteria

Patients with previous operative history related to uterus.

Statistical analysis

The data were analyzed using SPPS v 20.0 software (SPSS South Asia (P) Ltd, Bangalore, India). Categorical values were presented with absolute and relative frequencies (%) and continuous values with mean. Sensitivity, specificity, positive, and negative predictive values were calculated.

Results

Patients ranged in the age from 20 to 70 years, with a mean age of 42 years and a median age of 40 years. Out of 78 patients, 54 underwent myomectomy and 24 underwent hysterectomy. About 29 (37.1%) had menorrhagia as their presenting symptom followed by dysmenorrhea in 22 (28.2%) patients [Table 1]. Thirteen (16.6%) patients had pelvic pain, 12 (15.5%) had palpable mass, 10 (12.8%) had irregular bleeding, 7 (8.9%) had infertility, 5 (6.4%) had postmenopausal bleeding, 4 (5.1%) had urinary urgency, and 3 (3.8%) patients had constipation due to pressure on the urinary bladder and rectum.

Table 1: Symptomatology of uterine leiomyomas

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Out of 78 pathologically proven fibroids with size more than 2 cm, 30 (38.4%) had pathologically proven significant degeneration. MRI was able to pick 18 pathologically proven degenerations. In three patients, MRI depicted degeneration; however, no significant degeneration was found on the pathological basis or MRI predicted wrong type of degeneration. About twelve patients had pathologically proven significant degeneration that was not picked on MRI. Degeneration, especially in the form of calcification and hyalinization, was missed by MRI. Forty-five patients had no evidence of degeneration on MRI with pathology revealing the same. The sensitivity, specificity, positive, and negative predictive values of MRI in assessing degeneration in uterine fibroids were 60%, 93.7%, 85.7%, and 78.9% respectively [Diagram 1].

Out of 18 degenerations picked by MRI, seven patients had myxoid [Figure 1] degeneration, 2 had red degeneration [Figure 2], four had cystic degeneration [Figure 3], three had calcification, and two had hyaline degeneration. Out of 12 fibroids with pathologically significant degeneration which MRI did not pick up, seven had hyaline degeneration, four had calcific degeneration, and one had sarcomatous degeneration.

Figure 1: Sagittal T2, Postcontrast T1 magnetic resonance images revealing submucosal fibroid with multiple T2 hyperintense areas which do not enhance on postcontrast images. Photomicrograph (×20) of hematoxylin- and eosin-stained of same fibroid obtained postoperatively revealing areas of loose, water-laden myxoid tissue along with denser smooth muscle bundles myxoid degeneration

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Figure 2: Axial T1, Fat saturates T1 magnetic resonance images revealing subserosal fibroid with multiple T1 hyperintense areas which do not suppress on fat saturated images. Photomicrograph (×20) of Hematoxylin and eosin stained of same fibroid obtained post operatively revealing cluster of red blood cells along with smooth muscle cells in red degeneration

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Figure 3: Axial T2, Postcontrast T1 magnetic resonance images revealing large subserosal fibroid with large T2 hyperintense areas with thin hypointense septa. Cystic areas do not enhance on postcontrast images while thin septa do enhance. Photomicrograph (×20) of Hematoxylin and eosin stained of same fibroid obtained postoperatively revealing extensive cystic spaces along with smooth muscle cells in cystic degeneration

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Discussion

The most common clinical presentation in our study was menorrhagia (37.1%) followed by dysmenorrhea (28.2%). This is in accordance to a study done by Moghadam et al.^[12] Our study is one of the first studies to assess the accuracy of MRI in picking leiomyoma degenerations. About 11 out of 12 degenerations not picked by MRI were hyaline and calcific degenerations. Leiomyomas with hyaline or calcific degeneration have low-signal intensity on T2WIs simulating standard leiomyomas^[13] making them difficult to pick up on MRI especially without contrast. Contrast should be added to routine MRI of fibroid. Fibroids with hyaline degeneration enhance less than normal fibroids increasing the diagnostic possibility of picking up hyaline degeneration on postcontrast images. MRI was also not able to pick one case of sarcomatous degeneration in fibroid because there is no reliable feature for picking sarcomatous degeneration in leiomyomas except for the presence of bulky lymphadenopathy and adjacent organ infiltration. Rapid growth of a leiomyoma is not a reliable indication of sarcomatous degeneration.^[14]

Degenerations that were picked with high accuracy included myxoid, cystic and red degeneration. Leiomyomas with cystic degeneration are hyperintense on T2WIs with non-enhancing cystic areas on postcontrast T1 images. Leiomyomas with myxoid degeneration show very high-signal intensity on T2WIs due to the presence of gelatinous intratumoral foci and enhance minimally on contrast-enhanced images. Red degeneration occurs due to venous thrombosis within the periphery of the tumor or rupture of intratumoral arteries. Leiomyomas with red degeneration show the areas of high-signal intensity on T1-weighted images likely secondary to the proteinaceous content of the blood or the T1-shortening effects of methaemoglobin.^[15] Fat-saturated sequence should be added to rule out lipomatous degeneration in fibroids in patients with suspected red degeneration.

Conclusion

MRI has average sensitivity and very good specificity for picking fibroid degenerations. MRI has high accuracy for picking myxoid, cystic, and red degeneration. Post-contrast imaging may be helpful in increasing the accuracy of MRI in picking type of fibroid degeneration.

Acknowledgments

We would like to thank the Department of Pathology and Gynecology and Obstetrics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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