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Pitfalls in the sonographic diagnosis of uterine fibroids

Article  in  American Journal of Roentgenology · November 1988

DOI: 10.2214/ajr.151.4.725 · Source: PubMed

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 725

Pictorial Essay

Pitfalls in the Sonographic Diagnosis of Uterine Fibroids

Oksana H. Baltarowich,1 Alfred B. Kurtz, Rebecca G. Pennell, Laurence Needleman, Maria M. Vilaro, and
Barry B. Goldberg

The sonographic diagnosis of uterine fibroids generally is and/or sonographic follow-up (five cases). The gross features of the
accepted as accurate. However, various sonographic features tumors included pedunculated (1 7), pedunculated and degenerated
of this common disorder may simulate a variety of pelvic (six), pedunculated and CalcifIed (two), degenerated intrauterine with
conditions. To date, only isolated examples of false-negative
or without hemorrhage (six), solid intrauterine calcified (seven), and
solid intrauterine noncalcified fibroids (six).
diagnoses of fibroids have been reported [1 -6]. We studied
a series of cases of fibroids in which mistaken sonographic
diagnoses of other pelvic disorders were made.
Results

Of the 44 patients, sonograms in 19 were interpreted as

Materials and Methods
showing an adnexal mass (1 8 solitary, one multiple) (Fig. 1).
During the past 5 years, 44 patients with proved fibroids were The sonographic findings in these patients included hyper-
reviewed in whom an unusual sonographic appearance caused diffi- echoic solid (Fig. 2) and complex masses (either predomi-
culty in establishing the correct diagnosis. Transabdominal sono- nantly cystic or predominantly solid). The initial diagnoses
grams were obtained in all patients with a variety of real-time (40 were based on a combination of clinical and sonographic
cases) and static (four cases) equipment. Three recent patients had
findings in these cases and included dermoid cyst (four) (Fig.
intravaginal sonograms also. Radiologists, radiology residents, and
ultrasound fellows with variable levels of experience interpreted the
3); endometrioma (three); ovarian malignancy (three) (Figs. 4
sonograms. and 5); cystadenoma (one); hemorrhagic ovarian cyst (one);
The patients were 22-57 years old (mean age, 32 years). Indica- and indefinite mass (seven). All 1 9 underwent surgery, and
tions for sonography included pelvic pain, bleeding, cramps, fever, fibroids were found.
weight loss, increasing abdominal girth, palpable mass, localization Five of the 44 patients were thought to have a bicornuate
of an intrauterine device, and discrepant pregnancy size and date. uterus on the basis of the sonograms (Fig. 6). In another
Three women had known endometriosis. Ten others were pregnant. seven, other conditions erroneously suspected included ret-
The initial interpretation of the sonograms failed to make the roverted uterus (two) (Fig. 7); pyometrium (two) (Figs. 8 and
diagnosis of fibroids in all cases. In 31 of the patients, the diagnosis
9); adenomyosis (one) (Fig. 1 0); and intrauterine device with
of a fibroid was not even mentioned in the differential diagnosis,
perforation (two) (Fig. 1 1). All were found to have fibroids,
whereas in the other 1 3, the possibility of a fibroid was included, but
which were proved surgically or by hysterosalpingography or
usually as the last possibility. Fibroids other than the ones described
in this report were detected on sonograms in 1 1 (25%) of the 44 repeat sonography (including intravaginal scans).
patients. Fibroids misdiagnosed as pregnancy-related conditions oc-
The final diagnoses in the 44 patients were based on pathologic curred in the remaining 1 3 cases (1 4 errors). The diagnoses
findings (35 cases), radiographic findings (four cases), and clinical included fetal heads in seven cases (three singleton, four twin)
Received February 22, 1988; accepted after revision May 20, 1988.
‘Jl authors: Department of Radiology, Division of Diagnostic (Jtrasound, Main Building, Seventh Floor, Tenth and Sansom Sts., Philadelphia, PA 19107. Address
reprint requests to 0. H. Baltarowich.
AJR 151:725-728, October 1988 0361-803x/88/1514-0725 C American Roentgen Ray Society
726 BALTAROWICH ET AL. AJA:151, October 1988

Fig. 1.-Parasagfttal pelvic sonogram in Fig. 2.-Midline sagittal sonogram in 23-year- Fig. 3.-Parasagittal sonogram shows multi-
woman with pelvic pain shows three (1,2,3) pre- old woman shows large hyperechoic pedunculated pIe internal hyperechoic reflectors due to calci-
dominantly anechoic masses. Pedunculated fi- fibroid (arrows) superior to fundus of uterus (U) ficatlons in pedunculated fibrold (arrows) mis-
brolds were confirmed at surgery. U = uterus; B mistakenly Interpreted as ovarian mass. B = blad- takenly diagnosed as dermoid cyst of the ovary.
= bladder; H = head of patient. der H = head of patient. Plain-film radiographs may help suggest a fi-
broid when characteristic “popcorn” pattern of
calcification is present. B = bladder, H = head
of patient U = uterus.

Fig. 4.-Longitudinal sonogram

from xiphoid (X)to pubis (P) in 56-year-
old woman with increasing abdominal
girth and weight loss was misinter-
preted as showing a complex, predom-
inantiy solid malignant ovarian tumor.
Uterus was thought to be compressed
deep in the pelvis. A 7.7-kg (17-Ib) fi-
broid (arrows) was removed at surgery.
Fig. 5.-Sonogram in postmeno-
pausal woman shows small uterus (ar-
rows) displaced anteriorly by large hy-
poechoic pelvic mass(M)with interface
between ft and uterus. Central echo-
genie endometrial canal (arrowhead).
Ovarian carcinoma was suspected.
Surgical findings revealed a peduncu-
lated fibroid on a narrow stalk. B
bladder H = head of patient.

(Fig. 12); three interstitial ectopic pregnancies (Figs. 13 and fibroids may also lead to an erroneous diagnosis of ectopic
14); two hydatidiform moles (Fig. 15); and two intrauterine pregnancy, especially of the interstitial type. Such an appear-
gestational sacs, one of which was thought to be associated ance is due to the marked uterine distortion caused by
with a hydatidiform mole. Only fibroids with calcification or fibroids, which cause an eccentric location of the gestational
necrosis were discovered. The correct diagnosis was estab- sac and apparent thinning of the myometrial echoes surround-
lished surgically; by repeat sonography; by correlation with ing it [7] (Figs. 1 3 and 14).
the beta subunit of human chorionic gonadotropin; or in one The variable patterns of echogenicity of fibroids also add
case, at the time of vaginal delivery, when a singleton was to diagnostic confusion. Different forms of internal degenera-
born rather than the expected twins. tion [8], hemorrhage, or proteolytic liquefaction [2] cause
areas that are hypoechoic or anechoic. If extensive enough,
Discussion they can mimic predominantly cystic (Fig. 1) [1 6] or multi- ,

Uterine fibroids have a variety of different sonographic septated adnexal or ovarian masses [2, 6]. An area of cystic
appearances and presentations that sometimes create diffi- degeneration in an exophytic fibroid may be mistaken for an
culty in establishing the correct diagnosis. Those that are ectopic pregnancy. Cystic degeneration in a fibroid that is
pedunculated or exophytic, especially if they are on a narrow within the uterus may mimic an abnormal intrauterine gesta-
stalk, may simulate masses that are separate from the uterus. tional sac, or, when it occurs in a centrally located submucosal
For this reason, fibroids were most often mistaken for an fibroid, it may simulate an intrauterine fluid collection, such as
adnexal mass (Figs. 1 -5). A laterally bulging fibroid, creating hydrometrium or pyometrium (Figs. 8 and 9). A large, degen-
a symmetric bibbed appearance to the uterus, may lead to erated myoma filled with numerous small, anechoic areas may
misdiagnosis of a bicornuate uterus (Fig. 6). Pedunculated have the appearance of a hydatidiform mole (Fig. 15) [3, 4].
R:15i, October 1988 SONOGRAPHY OF UTERINE FIBROIDS 727

Fig. 6.-Transverse sonogram In young woman

with history of several first-trimester miscarrIages was
thought to have a bicornuate uterus. Uterus has a
symmetric bibbed appearance. Echoes from two ap-
parent canals (arrows) are seen, although entire right
side Is slightly more hypoechoic. Hysterosalpingog-
raphy revealed a normal central cavity and outlined a
mass consistent with a fibrold on the right side (A),
confirmed on a fellow-up sonogram. B = bladder.

Fig. 7.-Sonogram in 36-year-old woman with vag-

Inal bleeding was initially misdiagnosed as showing a
retroverted/retrofiexed uterus. Hypoechogenicity of
uterine body and fundus was attributed to deep boa-
tion of fundus In pelvis. Reexamination wIth patient’s
urinary bladder (B) less full shows absence of normal
canal and presence of fibrold (arrows). V = vagina; H
= head of patient.

Fig. 8.-Sagittal sonogram in postmenopausal

woman with fever and pelvic tenderness shows can-
tral fluid collection (C) within uterus (arrows) misdi-
agnosed as pyometrium. Surgery revealed a centrally
located degenerated fibrold (C). B = bladder H =
head of patient.

Fig. 9.-Transverse sonogram of pelvis shows

uterus to be enlarged (arrows) and contain central
fluid with excellent sound through-transmission (1),
misdiagnosed as pyometrium. A large degenerated
fibroid was removed at surgery. A = right side.

Fig. 10.-MldIlno sagfttal sonogram In woman Fig. 11.-In search for missing strIng from Fig. 12.-Longitudinal statIc sonogram
with known endometrbosls shows enlarged uterus Intrauterine devlce(IUD), longitudinal pelvic son- through uterus of pregnant woman shows normal
(straight arrows) with several small (1 cm) focal ogram reveals confusing picture of metallic IUD fetal head (arrows) and a second calcIfied rim
hypoechoic areas (curved arrows) scattered (white arrow) curving sharply into very hypoech- mistaken for demised twin (arrowheads). After
throughout myometrium considered to be adeno- ole posterior pelvic region (black arrows). labor resufted In delivery of a single healthy
myosis. Surgery was performed for a concomitant Walled-off perforation by bUD was suspected. neonate and normal placenta, postpartum son-
adnexal mass. Hysterectomy specimen revealed Surgery revealed multiple fibroids, the largest of ogram revealed a calcified Intramural uterine
multiple small fibrolds. B = bladder H = head of which was located anteriorly (F) displacing fibrold (arrowheads). Such an error Is less likely
patient. uterus posteriorly and causing markedly retro- wIth current real-time equipment and diligent
flexed canal. No perforation was found. The IUD search for Intracranial structures and remainIng
was subsequently removed. (In another similar fetal anatomy. B = bladder- H = head of patient.
case, the IUD was removed under sonographic
guidance.) Arrowheads outline uterine length. B
= bladder H = head of patient.
 728 BALTAROWICH ET AL. AJR:151, October 1988

Fig. 13.-Oblique longitudinal pelvic sono- Fig. 14.-Transverse pelvic sonogram shows Fig. 15.-Midline sagittal sonogram in 22-year-
gram shows bobulated uterus(U) with fibroids (F) eccentrically located empty gestational sac (ar- old woman shows markedly enlarged uterus (ar-
and normal, lIve 8.5-week embryo in gestational rowheads) with abnormally echogenic rim and rows) with good sound transmission filled with
sac (arrows) mistakenly judged to be in an so- apparent thinning of surrounding posterolateral variably echogenic tissue including numerous ane-
topic location. With such close proximity to uter- myometrial echoes (arrow) misinterpreted as in- choic areas. A hydatidiform mole was suspected,
ins fundus, a fatal Interstitial ectopic location terstitial ectopic pregnancy. Surgery revealed no but beta subunit of human chorionic gonadotropin
was suspected. Surgical results yIelded no cvi- evidence of ectopic pregnancy. Fibroids (F) was negative and surgery revealed a large degen-
dance of ectopic pregnancy. The sac was inside caused distortion of uterine outline and endo- crated fibroid. The distinction between a degen-
a uterine canal markedly distorted owing to mul- metrial canal in this case of a missed abortion. crated fibroid and a hydatidiform mole may be
tiple fibrolds. Pregnancy aborted spontaneously R = right side; B = bladder. more difficult when the fibroid is growing rapidly.
3 weeks later. (Another similar case had the appearance of a
coexisting gestational sac, attributed to a degen-
crating fibroid at surgery.) B = bIadder- H = head
of patient.

Various calcification patterns of fibroids may contribute to REFERENCES

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