Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Imaging techniques for evaluation of uterine

myomas
Antonia Carla Testa, PhD a, Alessia Di Legge, MD a, *,
Matteo Bonatti, MD b, Riccardo Manfredi, PhD c,
Giovanni Scambia, PhD a
a
Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
b
Department of Radiology, Bolzano Central Hospital, Bolzano, Italy
c
Department of Radiology, University of Verona, Verona, Italy

Due to their high prevalence and related morbidity, uterine myomas

Keywords:
constitute a group of gynecological pathologies largely studied in all
uterine myomas
ultrasound clinical, diagnostic, and therapeutic aspects. They have been widely
magnetic resonance imaging evaluated with a large series of imaging techniques. In fact, ultra-
sound (also saline infusion sonohysterography) and magnetic
resonance imaging (MRI) are considered the optimal methods to
assess uterine fibroids in terms of number, volume, echostructure,
location, relation with endometrial cavity and uterine layers,
vascularization, and differential diagnosis with other benign (ade-
nomyosis) and malignant myometrial pathologies. Nevertheless,
further studies are required to fill some gaps such as the absence of a
common and sharable sonographic terminology and methodology
to scan the myometrium, as well as imaging parameters for differ-
entiation of typical myomas from smooth tumors of unknown ma-
lignant potential (STUMP) and leiomyosarcomas.
© 2016 Published by Elsevier Ltd.

Symptoms

Uterine myomas are benign tumors rarely associated with mortality but cause significant morbidity.
Due to their high prevalence, the incidence of leiomyoma-associated symptoms would be high, but in

* Corresponding author. Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy.
Tel.: þ39 0630156787; Fax: þ39 0630156332.
E-mail address: alessia.dilegge@virgilio.it (A. Di Legge, MD).

http://dx.doi.org/10.1016/j.bpobgyn.2015.11.014
1521-6934/© 2016 Published by Elsevier Ltd.
38 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

reality, the majority of fibroids (estimated to be >50%) are asymptomatic. When women with fibroids
present with symptoms, it is not always possible to be certain that the actual fibroids are causing the
symptoms. The multitude of symptoms can include abnormal uterine bleeding and anemia, feeling of
pelvic pressure or pain, urinary incontinence or retention, constipation, and reproductive dysfunction
(Table 1) [1].
Black women have a threefold higher incidence of fibroids than white women [2]. The prevalence of
clinically significant myoma peaks in the perimenopausal years and declines after menopause [3].
The presence and severity of symptoms have traditionally been thought to be largely dependent on
the size and location of the myomas (subserosal, intramural, or submucosal), although emerging ev-
idence suggests that molecular mechanisms play an important role in the negative effects of fibroids
[1].
The presenting symptoms are crucial for proposing the appropriate treatment. Management stra-
tegies are usually individualized based on the severity of symptoms, size and location of the fibroid,
patient's age, chronological proximity to menopause, and the patient's desire for future fertility [4].

Imaging techniques

Imaging techniques are crucial for the planning of medical or surgical treatment; the procedures
indicated in the work-up of uterine fibroids include ultrasound examination, saline infusion sonog-
raphy, and magnetic resonance imaging (MRI) [5]. The goals of imaging include localization, mea-
surement, characterization of fibroids, and differential diagnosis from other myometrial pathologies
such as adenomyosis, smooth tumors of unknown malignant potential (STUMP), and leiomyosarcomas.

Ultrasound and uterine myomas

Ultrasound is an easy, accessible, harmless, and inexpensive diagnostic procedure; it can indeed be
considered the first tool in the assessment of uterine myometrial pathology. Both transabdominal and

Table 1
Clinical presentation of uterine fibroids.

Asymptomatic

Abnormal uterine bleeding

Menorragia
Anemia
Pelvic pressure
Urinary frequency
Urinary incontinence
Difficulty with urination
Hydronephrosis
Constipation
Tenesmus
Pelvic mass
Pelvic pain
Infertility
Obstetric complications
Pregnancy related
Myoma growth
Red degeneration and pain
Spontaneous miscarriage
Malignancy
Rare association
Ascites
Polycythemia
Familiar syndromes, renal cell carcinoma
Benign metastasing
Adapted from Sabry and Al-Hendy 2012 (4)
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 39

transvaginal/transrectal (endocavitary) approach may be used, depending on the field of view desired.
Transabdominal imaging offers a wide field of view, increased depth of signal penetration, flexibility in
transducer movement, and the ability to examine other organs. Transabdominal ultrasound is more
effective than endocavitary ultrasound for the visualization of subserosal or parasitic myomas
extending into the abdominal cavity. It is also more effective in the presence of very large tumors.
Endocavitary ultrasound provides detailed images of the myoma as the probe is positioned close to
the tumor, indicating that high-frequency ultrasound can be used. Endocavitary ultrasound is reliable,
and a high level of interobserver agreement has been recorded for measurement of uterine size and
endometrial thickness [6]. Combined transabdominal ultrasound and endocavitary ultrasound is the
most widely used technique for detection, mapping, and characterization of myomas [7]. Fibroids
produce uterine enlargement, lobularity of the outline (if subserosal), and distortion of the endometrial
cavity (if submucosal). Intramural fibroids are most commonly found and may cause uterine
enlargement without contour changes.

Ultrasound and uterine myomas: imaging findings

Morphological appearance of typical myomas

At ultrasound examination, uterine fibroids appear as solid, well-defined, round lesions within the
myometrium or attached to it. In general, they have an inhomogeneous “stripy” or “fasciculate”
echostructure, characterized by radial shadowing (Fig. 1).
Echogenicity varies according to the different components in its context: muscle cells, fibrous
stroma, calcification, and lipomatous or hyaline degeneration. When fatty tissue is overrepresented,
myomas may appear hyperechoic (Fig. 2) [8]; calcification or hyperechoic capsule, caused by deposition
of calcium salts, is more frequent in postmenopausal women (Fig. 3). When an acute myoma necrosis
occurs, “complex heterogeneous internal structures” or “internal sonolucent areas” usually charac-
terize fibroids at ultrasound examination [9].

Diameters
Fibroid diameters are usually measured in three orthogonal planes.

Number
The higher the number of uterine fibroids, the greater the disruption of the uterine structure. In the
case of a low number of fibroids, it is recommended to describe each single lesion. On the contrary, in
the case of a very high number of myomas, it is important that the report describes the uterus as

Fig. 1. Transvaginal ultrasound image showing a fundic fibroid with an inhomogeneous echostructure characterized by radial
shadowing (arrows).
40 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

Fig. 2. Transvaginal ultrasound images showing a fundal fibroid that appears hyperechoic due to hyperrepresentation of fatty tissue.

“completely subverted,” thus conveying to the clinician the lack of a normal myometrium for a con-
servative surgery.

Location (relation with myometrium and endometrial cavity)

Uterine fibroids are usually located in the corpus uteri (95%) and rarely in the cervix (5%) [10].
According to their position and association with the uterine wall, fibroids are classified as intra-
mural, subserous, or submucous. Intramural fibroids develop within the myometrial wall and are more
commonly found (50%) [7]. Intramural myomas are usually well demarcated due to the compression of
the myometrium and subsequent formation of a pseudocapsule. When the growth of these masses
involves another uterine layer, fibroids may be classified as subserous or submucous myoma.
* Subserosal myomas: They are located beneath the peritoneal covering of the uterus. When they
extend into the peritoneal cavity, they may become sessile or pedunculated. Pedunculated myomas are
connected to the uterus via a stalk containing vessels. The pedicle of a subserous leiomyoma can be
very thin and frequently invisible at ultrasound examination.
When subserosal myomas extend into the peritoneal cavity, they may be described as parasitic or
broad ligament. Parasitic myoma is a rare type of pedunculated subserosal myoma that is partially or
completely separated from the uterus and receives an alternative blood supply from other sources such
as the omentum and mesenteric vessels [11].
Broad ligament fibroids originate from hormonally sensitive smooth muscle elements and extend
laterally from the uterus and are often confused with adnexal masses. In some cases, they can detach
from the uterus and become mobile within the peritoneal cavity [12].

Fig. 3. Ultrasound images showing two fibroids of the anterior wall (a, transabdominal examination) and the posterior wall (b,
transvaginal examination) with hyperechoic capsule due to calcium deposition.
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 41

The differential diagnosis for this type of fibroids includes masses of ovarian origin (both pri-
mary neoplasms and metastases), broad ligament cysts, and lymphadenopathy. Ultrasound ex-
amination may facilitate diagnosis of broad ligament leiomyomas because it allows clear visual
separation of the uterus and ovaries from the mass and mapping of the vascular supply of the
tumor.
* Submucosal myomas: They are located in close proximity to the endometrium. Submucosal my-
omas are estimated to represent 5e10% of all leiomyomas, although this may be an underestimated
proportion due to diagnostic difficulties. They tend to be the most bothersome clinically, causing
symptoms that may include menorrhagia and infertility due to distortion of the endometrium. Sub-
mucosal myomas that extend into the uterine cavity while being attached to the myometrium by a
pedicle are classified as pedunculated. A pedunculated submucosal myoma is at risk of torsion or
expulsion through the cervical os. Infection and necrosis are common in submucosal leiomyomas due
to inadequate blood supply. Myomas extending into the uterine cavity may be classified according to
the depth of protrusion.
The European Society of Hysteroscopy classifies submucosal myomas as follows:

type 0: fibroid polyp (the mass is located entirely within the uterine cavity);
type I: >50% contained within the uterine cavity or <50% contained within the myometrium;
type II: <50% contained within the uterine cavity or >50% contained within the myometrium [13].
Type III of submucosal myomas was included by Donnez et al. and corresponds to multiple (>2)
submucosal fibroids (myofibromatous uterus with submucosal fibroids and intramural fibroids)
[14].

Submucosal myomas can be easily studied by sonohysterography, a simple and well-tolerated

procedure with saline solution as the contrast medium. Results published in the literature show that
this procedure presents the same accuracy as hysteroscopy in terms of location, breadth of attachment,
and extent of protrusion into the uterine cavity of submucous myomas [7,15].
In the case of submucosal fibroids, minimal free myometrial margin, that is, the distance between
the outer margin of the fibroid and the uterus surface, has to be measured (Fig. 4). The myometrial free
margin has to be evaluated before performing hysteroscopic resection; in fact, some studies docu-
mented the possibility to remove submucosal myoma with a minimal free margin <5 mm, but the
recommended margin ranges between 5 and 10 mm [16,17].
Cervical fibroids may grow supravaginally or intravaginally; they are located very close to the
uterine artery and ureter. Sometimes, they can be confused with other cervical pathology such as

Fig. 4. Transvaginal ultrasound image showing a submucous myoma (G2) and the minimal free myometrial margin (stars).
42 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

cervical carcinoma (Figs. 5e6). In these cases, transvaginal ultrasound enables performing a guided
biopsy of the lesion, thus avoiding invasive surgery (Video 1).
Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.
bpobgyn.2015.11.014.

Vascularization
Color or power Doppler imaging shows myomas without rich vascularization; circumferential flow
around the lesion is often visible (perifibroid plexus), while central flow is not very well represented
(Fig. 7). Centripetal branches reach the center of the tumor via peripheral arteries. The peripheral
vascularity of fibroids is increased compared to that of normal myometrium and the center of the
tumor [18]. Doppler ultrasound may facilitate in distinguishing an endometrial polyp with a single
feeding vessel from an intracavitary submucosal fibroid tumor and adenomyosis, where vasculariza-
tion is characterized by diffusely spread vessels [19].
Doppler velocimetry usually attests a decreased resistance index in the perifibroid plexus in
comparison with the surrounding normal myometrium. Doppler findings and velocimetry indices have
been largely evaluated to predict proliferative status of the tumors and to differentiate benign from
malignant lesions [20], but inconclusive results have been obtained [18,21e24].
In the study of Testa et al., even if intratumoral resistance index values did not provide predictive
information of the proliferative status of the neoplasm, a significant negative correlation with the
myoma volume was found [25].

Variants of fibroids and other uterine smooth muscle tumors

Morphological appearance of atypical myomas

A typical leiomyoma is easily recognized by imaging. However, degenerative changes may cause a
leiomyoma to assume an atypical appearance that can cause diagnostic confusion. As leiomyomas
enlarge, they may outgrow their blood supply, thus resulting in various types of degeneration. These
include hyaline, myxoid, or cystic degeneration, dystrophic calcification, and red degeneration. Of
these, hyaline degeneration is most common, occurring in up to 60% of cases. Spontaneous degen-
eration may occur in pregnancy, and red degeneration is an initial manifestation [26]. No typical
aspects of infarcted lesions (red or hyaline degeneration) have been observed: fibroids are often

Fig. 5. Transvaginal ultrasound image showing a cervical myoma (arrow).

 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 43

Fig. 6. Transvaginal ultrasound image showing a cervical myoma with rich vascularization.

uniform, hypoechogenic, with a hyperechoic rim and acoustic shadows, without detectable flow
inside [27]. Only in the later phase of infarction, edema and necrosis may determine a mixed
echogenicity or hypoechoic cystic areas within fibroids (Fig. 8) easily recognizable by ultrasound
examination.
Cystic degeneration of uterine myomas, observed in about 4% of leiomyomas, may be considered as
an extreme sequela of edema. This may determine a “honeycomb pattern”; such ultrasound patterns
could be misleading especially when the “affected” myoma is submucous, mimicking an endometrial
pathology [28].

Differential diagnosis: STUMP

Uterine smooth muscle tumors have previously been included in benign leiomyomas and malignant
leiomyosarcomas. However, not all the uterine smooth muscle tumors are included in these two
classes; thus the current World Health Organization [29] classification indicates that uterine smooth
muscle tumors not diagnosed unequivocally as benign or malignant should be defined as STUMP. The
diagnosis of STUMP, firstly used by Kempson (1973) [30], is appropriate when a tumor shows any
unusual combination of the three Stanford criteria for the histologic diagnosis of leiomyosarcoma:

Fig. 7. Transvaginal ultrasound image showing a uterine myoma at color Doppler examination with normal vascularization (pe-
ripheral vessels) (a) and transabdominal ultrasound image showing a uterine myoma with rich vascularization (b).
44 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

Fig. 8. Transvaginal ultrasound image showing a myoma with inhomogeneous echostructure characterized by necrotic cystic areas
(stars) at gray scale (a) and color Doppler examination (b).

diffuse moderate to severe atypia, a mitotic count of at least 10 mitotic figures/10 high-power fields and
tumor cell necrosis. Cellularity, a subjective diagnosis, and tumor borders and their relation with the
surrounding myometrium represent additional but less weighted morphologic criteria in the diagnosis
of STUMP [31].
No specific ultrasound features have been described for STUMP. In the published manuscript,
STUMP do not constitute an entity on their own [22] but are usually absorbed in the group of typical
myomas or in the leiomyosarcomas group (Fig. 9).

Differential diagnosis: leiomyosarcomas

Leiomyosarcomas are rare tumors (1.3% of all uterine malignancies) that originate ex novo from the
uterus; the malignant degeneration of a typical leiomyoma is very rare (0.2%) [32e34]. Due to the rarity
of these neoformations and the absence of a common and shareable terminology for describing
myometrial pathology, no definite sonographic parameters at gray scale or at color Doppler ultrasound
examination have proven effective in differentiating “typical myoma” from “STUMP” and leiomyo-
sarcomas. In fact, even if several trials have attempted to detect the typical characteristics of malignant
lesions, a large series has not been studied.
In the study of Aviram R. et al., including 13 patients with uterine sarcomas (six leiomyosarcoma and
seven carcinosarcoma) and 98 with leiomyomas, sonographic differences at gray scale and at color
Doppler were detected between leiomyomas and carcinosarcomas but not between leiomyomas and
leiomyosarcomas. Resistance index was significantly different between leiomyomas (mean:

Fig. 9. Transabdominal ultrasound image showing a smooth tumor of unknown malignant potential (STUMP) at gray scale (a) and
color Doppler examination (b).
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 45

0.59 ± 0.01) and carcinosarcomas (mean: 0.41 ± 0.06; P < 0.001) but not between leiomyomas and
leiomyosarcomas (mean: 0.49 ± 0.18) [21].
Exacoustos C. et al. have reported the largest series of leiomyosarcomas, including only eight
leiomyosarcomas. The eight leiomyosarcomas reported in this series were larger in size (88% had a
diameter >8 cm) with inhomogeneous echostructure characterized by degenerative cystic areas (50%)
and rich central vascularization when compared with the 249 benign lesions in the study (21 cellular
leiomyomas, three STUMP, and 225 fibroids) [18].
In addition, Bonneau C. et al. analyzed ultrasound parameters essential for the differential diagnosis
between typical myomas (n ¼ 85) and malignant myometrial tumors (n ¼ 23, including three leio-
myosarcomas, one rhabdomyosarcoma, two low-grade endometrial stromal sarcomas, seven undif-
ferentiated endometrial sarcomas, four STUMP, and six carcinosarcomas). When compared with
benign lesions, the malignant lesions more frequently appeared as single masses, with a non-
myometrial origin and without acoustic shadowing [22].
Other trials attempted to differentiate benign from malignant lesions using Doppler findings such as
intratumoral resistance index and peak systolic velocity. No large series and no uniform data were
obtained in these cases as well [23,24].
A large multicenter series of benign and malignant myometrial tumors, analyzed by ultrasound
examination according to a predefined and standardized terminology, would be necessary for iden-
tifying parameters essential for differentiating myomas from leiomyosarcomas. Recently, a consensus
paper based on the opinion of a panel of clinicians (MUSA, Morphological Uterus Sonographic
Assessment) has been published, with the aim of formulating a common terminology to describe the
ultrasound features of the myometrial pathology [35].
At present, in our experience, the detection of a large uterine myometrial tumor with inhomo-
geneous compact echostructure (irregular anechoic areas due to necrosis and absence of “radial
stripy echogenicity”) and an irregular vascularization can be suggestive of malignant myometrial
lesions (Fig. 10). In any case, the ability of these parameters to discriminate between benign and
malignant myometrial tumors will need to be assessed, before an evidence-based statement could be
formulated.

Fig. 10. Transabdominal ultrasound images showing a leiomyosarcoma, 190 mm in size, at gray scale (a) and power Doppler ex-
amination (b).
46 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

Table 2
MRI appearance of uterine fibroids.

Fibroid Type Signal intensity on T1-weighted images Signal intensity on T2-weighted images Enhancement

Typical Isointense Hypointense Poor

Cellular Isointense Hyperintense Discrete
Hyaline Isointense Hypointense Poor
Calcified Iso-hypointense Markedly hypointense No
Cystic Iso-hypointense Markedly hyperintense No
Myxoid Iso-hypointense Markedly hyperintense Minimal
Necrotic Variable Hypointense No
Hemorrhagic Hyperintense Variable No

Differential diagnosis: adenomyosis

In addition to the vascular pattern (see “vascularization”), some sonographic parameters detectable
at gray scale examination are useful in differentiating myomas from adenomyosis. A uterus affected by
adenomyosis usually appears enlarged, globular, with regular external contour, while myomas cause
enlargement of the uterus but with an altered contour. At ultrasound examination, adenomyosis ap-
pears as an inhomogeneous tissue, with irregular and no defined border that causes asymmetric
thickening of the affected myometrium. The echostructure of adenomyosis is usually characterized by
vascular spaces and radial stripes that, moving the probe, may determine a visual effect called “rain in
the forest sign.” Conversely, myomas appear as solid well-defined lesions with a visible pseudocapsule
and shadowing.
Indeed, adenomyosis affecting the junctional zone pathology, causes its thickening [36] detectable
at 3D ultrasound examination on the coronal plane and determines an unclear demarcation of the
endometrium/myometrium margins [7,36].

MRI and uterine myomas

Due to its high tissue contrast resolution, multiplanarity, and reproducibility, MMRI represents
the most accurate imaging modality for the evaluation of uterine myomas. However, in

Fig. 11. a and b: Sagittal turbo spin-echo T2-weighted image (a) and contrast-enhanced fat-saturated turbo spin-echo T1-weighted
image; (b) showing the typical MRI features of uterine fibroids (arrows). Continuous arrows indicate two intramural fibroids and
dotted arrows two subserosal fibroids, whereas dashed arrows indicate a submucosal fibroid. All the lesions have round shape and
sharp margins and show homogeneous hypointensity on T2-weighted images and scarce to mild contrast enhancement.
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 47

comparison to ultrasound, MRI is time-consuming and expensive and is limited to selected cases.
Indications for MRI, when uterine fibroids are suspected, include suspicion of the anatomical (e.g.,
uterine vs. adnexal, intestinal, etc.) and histological origin of the mass (i.e., differential diagnosis of
adenomyosis and malignant mesenchymal tumors) [22,37,38]. Moreover, MRI is indicated as a
preoperative examination for uterine fibroid embolization and thermoablative procedures
[39e41].

MRI and uterine fibroids: Scanning protocol

Pelvic MRI examinations should be performed on 1.5-Tesla scanners or higher using phased-array
body coils after intramuscular administration of 20 mg of an antiperistaltic drug such as butylsco-
polamine bromide for reducing bowel motion artifacts. A standard MRI protocol for uterine fibroid
evaluation should always include large field-of-view T1-weighted images of the entire pelvis acquired
on the axial plane, T2-weighted images of the entire pelvis acquired according to the axial or coronal
plane, diffusion-weighted (suggested b-values of 0, 400, and 800 sec/mm [2]) images of the entire
pelvis acquired on the axial plane, and small field-of-view high-resolution T2-weighted images of the
uterus acquired on three orthogonal planes according to the longest axis of the endometrial cavity.

Fig. 12. aed: Axial fat-saturated turbo spin-echo T2-weighted image (a), axial fat-saturated T1-weighted image (b), sagittal turbo
spin-echo T2-weighted image (c), and sagittal contrast-enhanced fat-saturated turbo spin-echo T1-weighted image (d).
48 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

Moreover, post-contrast fat-saturated T1-weighted images should be acquired after endovenous

administration of 0.1 mmol/Kg gadolinium chelate, in accordance with the same planes used for the
high-resolution T2-weighted images.

MRI and uterine fibroids: Imaging findings

MRI findings of uterine fibroids are reported in Table 2. Uterine fibroids appear as well-delimited
round masses located within the myometrium (intramural fibroids) protruding toward the endome-
trial cavity (submucosal fibroids) or distorting the outer uterine contour (subserosal fibroids). Fibroids
may also occur less frequently in the cervix uteri. Signal intensity of uterine fibroids varies according to
their histological composition. Typical non-degenerated uterine fibroids are prevalently composed of
connective tissue alternated with whorls of uniform smooth muscle cells, appear hypointense on T2-
weighted images, compared to the adjacent myometrium (isointense on T1-weighted images), and
show poor contrast enhancement (Fig. 11 a and b). Conversely, cellular fibroids are prevalently
composed of compact smooth muscle cells alternated with scant connective tissue and show relatively
higher signal intensity on T2-weighted images associated with more evident contrast enhancement
[42]. Fibroids generally lack sufficient blood supply upon enlargement and undergo degeneration with
subsequent changes in their histological and MRI features. Hyaline degeneration, the most common
form of degeneration, does not significantly alter the above-described MRI features (Fig. 11 a and b),
whereas calcification results in a more marked hypointensity on T2-weighted images associated with
no contrast enhancement. In the case of cystic degeneration, fibroids become markedly hyperintense
on T2-weighted images and hypointense on T1-weighted ones and show no contrast enhancement,
whereas myxoid degeneration manifests with a significant increase in signal intensity on T2-weighted
images associated with minimal contrast enhancement. Necrotic fibroids that have not liquefied show
variable signal intensity on T1-weighted images and hypointensity on T2-weighted images, and
hemorrhagic fibroids (red degeneration) show high signal intensity on T1-weighted images with
variable signal intensity on T2-weighted images (Fig. 12 a and d). A hyperintense rim on T2-weighted
images, representing dilated lymphatic vessels and veins, may surround fibroids, but it is not patho-
gnomonic [37]. Uterine fibroids may show variable signal intensities on high-b-value diffusion-
weighted images (DWIs), but in the majority of cases, they appear iso- or hypointense in compari-
son with the endometrium; moreover, no significant hypointensity on apparent diffusion coefficient
(ADC) maps should be appreciated.

Fig. 13. Sagittal turbo spin-echo T2-weighted image showing a typical intramural fibroid (star) and a large ovarian fibroid (arrow).
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 49

MRI and uterine fibroids: Anatomical relationships

In the large majority of cases, transvaginal ultrasound, eventually combined with transabdominal
scans, clearly depicts the uterine origin of fibroids; nevertheless, doubts may arise in the case of
subserosal lesions (especially pedunculated), which may mimic other pelvic and, in particular,
adnexal masses. MRI represents an extremely accurate tool for determining the anatomical origin of
a pelvic mass, and high-resolution T2-weighted images acquired orthogonal to the longest axis of
the endometrium are particularly useful for this purpose. Indeed, the demonstration of continuity of
the pelvic mass with the adjacent myometrium facilitates in assessing its uterine origin, whereas the
presence of a cleavage plane between the mass and the adjacent myometrium helps exclude its
uterine origin with certainty (Figs. 12c and 13). Moreover, the visualization of normal ovaries
separated from the mass definitely excludes its ovarian origin. MRI may also show the feeding
vessels extending from the uterus to an exophytic fibroma similar to the hypointense tubular
structures on T2-weighted images or the enhancing tubular structures on post-contrast T1-weighted
ones [43].

Fig. 14. aed: axial fat-saturated turbo spin-echo T2-weighted image (a), sagittal turbo spin-echo T2-weighted image (b), axial
b ¼ 600 s/mm2 diffusion-weighted image (c), and axial apparent diffusion coefficient (ADC) map (d) showing a uterine
leiomyosarcoma
50 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53

MRI may also be useful for studying large fibromatous uteri, whose evaluation might be difficult by
ultrasound; in these cases, MRI clearly depicts the number of fibroids, highlighting fibroids as small as
5 mm, and their distribution and relationship with the adjacent structures.

MRI and uterine fibroids: Differential diagnosis

The increase in the use of conservative approaches for uterine fibroid management has highlighted
the importance of an accurate differential diagnosis of fibroids from malignant or STUMP; MRI may be
useful for this purpose. The absence of a clear myometrial origin, lack of a normal endometrial stripe,
intermediate signal intensity on T2-weighted images, T2-weighted signal heterogeneity, signs of
intratumoral hemorrhage, heterogeneous contrast enhancement, hyperintensity on high-b-value
DWIs, and low ADC values are associated with malignancy (Fig. 14 aed), whereas contradictory results
are reported in literature about the significance of poorly defined margins of lesions [22,44,45].
Nonetheless, a lot of overlap exists between benign and malignant lesions if these parameters are
individually evaluated; therefore, different diagnostic flowcharts have been proposed. The flowchart
proposed by Sato [46] claims that hypointense lesions on high-b-value DWIs should always be
considered as fibroids; however, in the case of iso- or hyperintense lesions on high-b-value DWIs,
which also show high and/or heterogeneous signal intensity on T2-weighted images, mean ADC
values should be measured and lesions with mean ADC values <1.1  103 mm2/s should be
considered as malignant, until differently proven (Fig. 14aed). This approach warrants 100% sensi-
tivity and 94% specificity (94.6% accuracy) in identifying malignant lesions; other authors reported
similar results [45,47]. Conversely, perfusion MRI has not demonstrated any practical utility for this
purpose [44].
Given the different treatments required, uterine fibroids must also be accurately differentiated from
adenomyosis. Typically both fibroids and adenomyosis appear as hypointense lesions on T2-weighted
images, but adenomyosis usually shows poorly defined margins and irregular shape (Fig. 15). However,
uterine fibroids show well-defined margins and round shape; moreover, focal spots of hyperintensity
on T2-weighted images, with some of them associated with a corresponding hyperintensity on T1-
weighted ones, are usually significant in adenomyosis [48]. Diffusion-weighted imaging may further
help in distinguishing these entities, thanks to the higher and more homogeneous ADC values of
adenomyosis in comparison with those of the fibroids [49]. In any case, it should be considered that
adenomyosis and fibroids often coexist in the same patients.

Fig. 15. Coronal turbo spin-echo T2-weighted image showing the typical features of focal adenomyosis.
 A.C. Testa, PhD et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 34 (2016) 37e53 51

Practice points

1. Ultrasound can be used as the first imaging technique in evaluating uterine fibromatosis.
2. Ultrasound is able to provide an accurate assessment of tumor diameter, echostructure, and
location and its association with myometrium and endometrium.
3. Ultrasound enables differentiation of myomas from other uterine pathologies (i.e., adeno-
myosis or endometrial polyps).
4. Ultrasound allows identification of the atypical appearance of fibroids that can be suggestive
of atypical myoma/STUMP or leiomyosarcoma. However, at present, it is not possible to
accurately discriminate between benign and malignant myometrial tumors based on any
ultrasound parameter.
5. Indications for MRI include suspicion of the anatomical (e.g., uterine vs. adnexal, intestinal,
etc.) and histological origin of the mass (i.e. differential diagnosis of adenomyosis and
malignant mesenchymal tumors).
6. Diagnostic flowcharts including MRI parameters (DWI and ADC) have been suggested for
distinguishing between benign and malignant myometrial tumors

Research agenda

e To evaluate myometrial pathology using MUSA (Morphological Uterus Sonographic

Assessment) consensus.
e To conduct multicenter prospective trials on myometrial pathology in order to identify pa-
rameters able to predict the benignity or malignity of a myometrial neoformation.

Conflicts of interest

The authors whose names are listed immediately below certify that they have NO affiliations with
or involvement in any organization or entity with any financial interest (such as honoraria; educational
grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership,
or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial
interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the sub-
ject matter or materials discussed in this manuscript.

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