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. 725 AJR 151:725-728, October 1988 0361-803x/88/1514-0725 C American Roentgen Ray Society 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 accepted as accurate. However, various sonographic features of this common disorder may simulate a variety of pelvic conditions. To date, only isolated examples of false-negative 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. Materials and Methods During the past 5 years, 44 patients with proved fibroids were reviewed in whom an unusual sonographic appearance caused diffi- culty in establishing the correct diagnosis. Transabdominal sono- grams were obtained in all patients with a variety of real-time (40 cases) and static (four cases) equipment. Three recent patients had intravaginal sonograms also. Radiologists, radiology residents, and ultrasound fellows with variable levels of experience interpreted the sonograms. The patients were 22-57 years old (mean age, 32 years). Indica- tions for sonography included pelvic pain, bleeding, cramps, fever, weight loss, increasing abdominal girth, palpable mass, localization of an intrauterine device, and discrepant pregnancy size and date. Three women had known endometriosis. Ten others were pregnant. The initial interpretation of the sonograms failed to make the diagnosis of fibroids in all cases. In 31 of the patients, the diagnosis of a fibroid was not even mentioned in the differential diagnosis, whereas in the other 13, the possibility of a fibroid was included, but 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 patients. The final diagnoses in the 44 patients were based on pathologic findings (35 cases), radiographic findings (four cases), and clinical and/or sonographic follow-up (five cases). The gross features of the tumors included pedunculated (1 7), pedunculated and degenerated (six), pedunculated and CalcifIed (two), degenerated intrauterine with or without hemorrhage (six), solid intrauterine calcified (seven), and solid intrauterine noncalcified fibroids (six). Results Of the 44 patients, sonograms in 19 were interpreted as showing an adnexal mass (1 8 solitary, one multiple) (Fig. 1). The sonographic findings in these patients included hyper- echoic solid (Fig. 2) and complex masses (either predomi- nantly cystic or predominantly solid). The initial diagnoses were based on a combination of clinical and sonographic findings in these cases and included dermoid cyst (four) (Fig. 3); endometrioma (three); ovarian malignancy (three) (Figs. 4 and 5); cystadenoma (one); hemorrhagic ovarian cyst (one); and indefinite mass (seven). All 19 underwent surgery, and fibroids were found. Five of the 44 patients were thought to have a bicornuate uterus on the basis of the sonograms (Fig. 6). In another seven, other conditions erroneously suspected included ret- roverted uterus (two) (Fig. 7); pyometrium (two) (Figs. 8 and 9); adenomyosis (one) (Fig. 1 0); and intrauterine device with perforation (two) (Fig. 1 1). All were found to have fibroids, which were proved surgically or by hysterosalpingography or repeat sonography (including intravaginal scans). Fibroids misdiagnosed as pregnancy-related conditions oc- curred in the remaining 1 3 cases (1 4 errors). The diagnoses included fetal heads in seven cases (three singleton, four twin) Downloaded from www.ajronline.org by 27.79.75.39 on 02/13/23 from IP address 27.79.75.39. Copyright ARRS. For personal use only; all rights reserved
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Pitfalls in the sonographic diagnosis of uterine fibroidsReceived 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.
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 accepted as accurate. However, various sonographic features of this common disorder may simulate a variety of pelvic conditions. To date, only isolated examples of false-negative
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.
Materials and Methods
During the past 5 years, 44 patients with proved fibroids were reviewed in whom an unusual sonographic appearance caused diffi- culty in establishing the correct diagnosis. Transabdominal sono- grams were obtained in all patients with a variety of real-time (40 cases) and static (four cases) equipment. Three recent patients had intravaginal sonograms also. Radiologists, radiology residents, and ultrasound fellows with variable levels of experience interpreted the sonograms.
The patients were 22-57 years old (mean age, 32 years). Indica- tions for sonography included pelvic pain, bleeding, cramps, fever, weight loss, increasing abdominal girth, palpable mass, localization of an intrauterine device, and discrepant pregnancy size and date. Three women had known endometriosis. Ten others were pregnant.
The initial interpretation of the sonograms failed to make the diagnosis of fibroids in all cases. In 31 of the patients, the diagnosis of a fibroid was not even mentioned in the differential diagnosis, whereas in the other 13, the possibility of a fibroid was included, but
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 patients.
The final diagnoses in the 44 patients were based on pathologic findings (35 cases), radiographic findings (four cases), and clinical
and/or sonographic follow-up (five cases). The gross features of the tumors included pedunculated (1 7), pedunculated and degenerated (six), pedunculated and CalcifIed (two), degenerated intrauterine with or without hemorrhage (six), solid intrauterine calcified (seven), and solid intrauterine noncalcified fibroids (six).
Results
Of the 44 patients, sonograms in 19 were interpreted as showing an adnexal mass (1 8 solitary, one multiple) (Fig. 1). The sonographic findings in these patients included hyper- echoic solid (Fig. 2) and complex masses (either predomi- nantly cystic or predominantly solid). The initial diagnoses were based on a combination of clinical and sonographic findings in these cases and included dermoid cyst (four) (Fig. 3); endometrioma (three); ovarian malignancy (three) (Figs. 4 and 5); cystadenoma (one); hemorrhagic ovarian cyst (one); and indefinite mass (seven). All 1 9 underwent surgery, and fibroids were found.
Five of the 44 patients were thought to have a bicornuate uterus on the basis of the sonograms (Fig. 6). In another seven, other conditions erroneously suspected included ret- roverted uterus (two) (Fig. 7); pyometrium (two) (Figs. 8 and 9); adenomyosis (one) (Fig. 1 0); and intrauterine device with perforation (two) (Fig. 1 1). All were found to have fibroids, which were proved surgically or by hysterosalpingography or repeat sonography (including intravaginal scans).
Fibroids misdiagnosed as pregnancy-related conditions oc- curred in the remaining 1 3 cases (1 4 errors). The diagnoses included fetal heads in seven cases (three singleton, four twin)
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Fig. 1.-Parasagfttal pelvic sonogram in woman with pelvic pain shows three (1,2,3) pre- dominantly anechoic masses. Pedunculated fi- brolds were confirmed at surgery. U = uterus; B = bladder; H = head of patient.
Fig. 2.-Midline sagittal sonogram in 23-year- old woman shows large hyperechoic pedunculated fibroid (arrows) superior to fundus of uterus (U) mistakenly Interpreted as ovarian mass. B = blad- der H = head of patient.
Fig. 3.-Parasagittal sonogram shows multi- pIe internal hyperechoic reflectors due to calci- ficatlons in pedunculated fibrold (arrows) mis- takenly diagnosed as dermoid cyst of the ovary. 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.
726 BALTAROWICH ET AL. AJA:151, October 1988
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 14); two hydatidiform moles (Fig. 15); and two intrauterine gestational sacs, one of which was thought to be associated with a hydatidiform mole. Only fibroids with calcification or
necrosis were discovered. The correct diagnosis was estab- lished surgically; by repeat sonography; by correlation with the beta subunit of human chorionic gonadotropin; or in one case, at the time of vaginal delivery, when a singleton was born rather than the expected twins.
Discussion
Uterine fibroids have a variety of different sonographic appearances and presentations that sometimes create diffi- culty in establishing the correct diagnosis. Those that are pedunculated or exophytic, especially if they are on a narrow stalk, may simulate masses that are separate from the uterus. For this reason, fibroids were most often mistaken for an adnexal mass (Figs. 1 -5). A laterally bulging fibroid, creating a symmetric bibbed appearance to the uterus, may lead to misdiagnosis of a bicornuate uterus (Fig. 6). Pedunculated
fibroids may also lead to an erroneous diagnosis of ectopic pregnancy, especially of the interstitial type. Such an appear- ance is due to the marked uterine distortion caused by fibroids, which cause an eccentric location of the gestational
sac and apparent thinning of the myometrial echoes surround- ing it [7] (Figs. 1 3 and 14).
The variable patterns of echogenicity of fibroids also add to diagnostic confusion. Different forms of internal degenera- tion [8], hemorrhage, or proteolytic liquefaction [2] cause areas that are hypoechoic or anechoic. If extensive enough, they can mimic predominantly cystic (Fig. 1) [1 , 6] or multi- septated adnexal or ovarian masses [2, 6]. An area of cystic degeneration in an exophytic fibroid may be mistaken for an ectopic pregnancy. Cystic degeneration in a fibroid that is within the uterus may mimic an abnormal intrauterine gesta- tional sac, or, when it occurs in a centrally located submucosal fibroid, it may simulate an intrauterine fluid collection, such as hydrometrium or pyometrium (Figs. 8 and 9). A large, degen-
erated myoma filled with numerous small, anechoic areas may have the appearance of a hydatidiform mole (Fig. 15) [3, 4].
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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 with known endometrbosls shows enlarged uterus (straight arrows) with several small (1 cm) focal hypoechoic areas (curved arrows) scattered throughout myometrium considered to be adeno- myosis. Surgery was performed for a concomitant adnexal mass. Hysterectomy specimen revealed multiple small fibrolds. B = bladder H = head of patient.
Fig. 11.-In search for missing strIng from Intrauterine devlce(IUD), longitudinal pelvic son- ogram reveals confusing picture of metallic IUD (white arrow) curving sharply into very hypoech- ole posterior pelvic region (black arrows). Walled-off perforation by bUD was suspected. Surgery revealed multiple fibroids, the largest of which was located anteriorly (F) displacing uterus posteriorly and causing markedly retro- flexed canal. No perforation was found. The IUD was subsequently removed. (In another similar case, the IUD was removed under sonographic guidance.) Arrowheads outline uterine length. B = bladder H = head of patient.
Fig. 12.-Longitudinal statIc sonogram through uterus of pregnant woman shows normal fetal head (arrows) and a second calcIfied rim mistaken for demised twin (arrowheads). After labor resufted In delivery of a single healthy neonate and normal placenta, postpartum son- ogram revealed a calcified Intramural uterine fibrold (arrowheads). Such an error Is less likely wIth current real-time equipment and diligent search for Intracranial structures and remainIng fetal anatomy. B = bladder- H = head of patient.
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Fig. 14.-Transverse pelvic sonogram shows eccentrically located empty gestational sac (ar- rowheads) with abnormally echogenic rim and apparent thinning of surrounding posterolateral myometrial echoes (arrow) misinterpreted as in- terstitial ectopic pregnancy. Surgery revealed no evidence of ectopic pregnancy. Fibroids (F) caused distortion of uterine outline and endo- metrial canal in this case of a missed abortion. R = right side; B = bladder.
Fig. 15.-Midline sagittal sonogram in 22-year- old woman shows markedly enlarged uterus (ar- rows) with good sound transmission filled with variably echogenic tissue including numerous ane- choic areas. A hydatidiform mole was suspected, but beta subunit of human chorionic gonadotropin was negative and surgery revealed a large degen- crated fibroid. The distinction between a degen- crated fibroid and a hydatidiform mole may be more difficult when the fibroid is growing rapidly. (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.
728 BALTAROWICH ET AL. AJR:151, October 1988
Fig. 13.-Oblique longitudinal pelvic sono- gram shows bobulated uterus(U) with fibroids (F) and normal, lIve 8.5-week embryo in gestational sac (arrows) mistakenly judged to be in an so- topic location. With such close proximity to uter- ins fundus, a fatal Interstitial ectopic location was suspected. Surgical results yIelded no cvi- dance of ectopic pregnancy. The sac was inside a uterine canal markedly distorted owing to mul- tiple fibrolds. Pregnancy aborted spontaneously 3 weeks later.
Various calcification patterns of fibroids may contribute to unusual sonographic appearances. The hyperechoic present- ing rim of a calcified fibroid with its accompanying distal shadowing or the internal speckled pattern of bright reflectors may lead to misdiagnosis of an ovarian dermoid cyst (Fig. 3). When fibroids have a complete ringlike rim of calcification they may simulate a fetal head [5], which may be mistaken for a fetal demise or a twin (Fig. 12).
Because fibroids have so many sonographic appearances,
they can mimic numerous pelvic conditions. Awareness of these potential problems, especially in the presence of other fibroids, may be helpful in making the correct diagnosis. Proper identification of the uterus, close analysis of its echo
texture and cavity echoes [4], and attention to good sono- graphic technique will improve diagnostic accuracy and thereby improve patient care.
REFERENCES
1 . Hassani N. ultrasonic appearance of pedunculated uterine fibroids and ovarian cysts. J Nat! Med Assoc 1974;66:432-435
2. Nocera RM, Fagan CJ, Hemadez JC. Cystic parametrial fibroids mimicking
ovarian cystadenoma. J Ultrasound Med 1984;3: 183-1 87 3. Rinehart JS, Hemandez E, Rosenshein NB, Sanders AC. Degeneratin9
leiomyomata uteri: an ultrasonic mimic of hydatidiform mole. J Reprod Med
1981;26(3): 142-144 4. And MH, McGahan JP, Oi R. Sonographic evaluation of hydatidiform mole
and its look-alikes. AiR 1983;140:307-31 1 5. Gross BH, Silver TM, Jaffe MH. Sonographic features of uterine Ieiomy-
omas: analysis of 41 proven cases. J Ultrasound Med 1983;2:401-406 6. Muram D, Gillieson M, Walters JH. Myomas of the uterus in pregnancy:
ultrasonographic follow-up. Am J Obstet Gynecol 1980;138: 16-19 7. Graham M, Cooperberg PL. Litrasound diagnosis of interstitial pregnancy:
findings and pitfalls. JCU 1979;7:433-437 8. Persaud V, Argcon PD. Uterine leiomyoma: incidence of degenerative
change and a correlation of associated symptoms. Obstet Gyneco! 1970;35(3):432-436
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‘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.
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 accepted as accurate. However, various sonographic features of this common disorder may simulate a variety of pelvic conditions. To date, only isolated examples of false-negative
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.
Materials and Methods
During the past 5 years, 44 patients with proved fibroids were reviewed in whom an unusual sonographic appearance caused diffi- culty in establishing the correct diagnosis. Transabdominal sono- grams were obtained in all patients with a variety of real-time (40 cases) and static (four cases) equipment. Three recent patients had intravaginal sonograms also. Radiologists, radiology residents, and ultrasound fellows with variable levels of experience interpreted the sonograms.
The patients were 22-57 years old (mean age, 32 years). Indica- tions for sonography included pelvic pain, bleeding, cramps, fever, weight loss, increasing abdominal girth, palpable mass, localization of an intrauterine device, and discrepant pregnancy size and date. Three women had known endometriosis. Ten others were pregnant.
The initial interpretation of the sonograms failed to make the diagnosis of fibroids in all cases. In 31 of the patients, the diagnosis of a fibroid was not even mentioned in the differential diagnosis, whereas in the other 13, the possibility of a fibroid was included, but
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 patients.
The final diagnoses in the 44 patients were based on pathologic findings (35 cases), radiographic findings (four cases), and clinical
and/or sonographic follow-up (five cases). The gross features of the tumors included pedunculated (1 7), pedunculated and degenerated (six), pedunculated and CalcifIed (two), degenerated intrauterine with or without hemorrhage (six), solid intrauterine calcified (seven), and solid intrauterine noncalcified fibroids (six).
Results
Of the 44 patients, sonograms in 19 were interpreted as showing an adnexal mass (1 8 solitary, one multiple) (Fig. 1). The sonographic findings in these patients included hyper- echoic solid (Fig. 2) and complex masses (either predomi- nantly cystic or predominantly solid). The initial diagnoses were based on a combination of clinical and sonographic findings in these cases and included dermoid cyst (four) (Fig. 3); endometrioma (three); ovarian malignancy (three) (Figs. 4 and 5); cystadenoma (one); hemorrhagic ovarian cyst (one); and indefinite mass (seven). All 1 9 underwent surgery, and fibroids were found.
Five of the 44 patients were thought to have a bicornuate uterus on the basis of the sonograms (Fig. 6). In another seven, other conditions erroneously suspected included ret- roverted uterus (two) (Fig. 7); pyometrium (two) (Figs. 8 and 9); adenomyosis (one) (Fig. 1 0); and intrauterine device with perforation (two) (Fig. 1 1). All were found to have fibroids, which were proved surgically or by hysterosalpingography or repeat sonography (including intravaginal scans).
Fibroids misdiagnosed as pregnancy-related conditions oc- curred in the remaining 1 3 cases (1 4 errors). The diagnoses included fetal heads in seven cases (three singleton, four twin)
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9. 75
.3 9.
C op
yr ig
ht A
R R
S. F
or p
er so
se o
nl y;
a ll
ri gh
ts r
es er
ve d
Fig. 1.-Parasagfttal pelvic sonogram in woman with pelvic pain shows three (1,2,3) pre- dominantly anechoic masses. Pedunculated fi- brolds were confirmed at surgery. U = uterus; B = bladder; H = head of patient.
Fig. 2.-Midline sagittal sonogram in 23-year- old woman shows large hyperechoic pedunculated fibroid (arrows) superior to fundus of uterus (U) mistakenly Interpreted as ovarian mass. B = blad- der H = head of patient.
Fig. 3.-Parasagittal sonogram shows multi- pIe internal hyperechoic reflectors due to calci- ficatlons in pedunculated fibrold (arrows) mis- takenly diagnosed as dermoid cyst of the ovary. 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.
726 BALTAROWICH ET AL. AJA:151, October 1988
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 14); two hydatidiform moles (Fig. 15); and two intrauterine gestational sacs, one of which was thought to be associated with a hydatidiform mole. Only fibroids with calcification or
necrosis were discovered. The correct diagnosis was estab- lished surgically; by repeat sonography; by correlation with the beta subunit of human chorionic gonadotropin; or in one case, at the time of vaginal delivery, when a singleton was born rather than the expected twins.
Discussion
Uterine fibroids have a variety of different sonographic appearances and presentations that sometimes create diffi- culty in establishing the correct diagnosis. Those that are pedunculated or exophytic, especially if they are on a narrow stalk, may simulate masses that are separate from the uterus. For this reason, fibroids were most often mistaken for an adnexal mass (Figs. 1 -5). A laterally bulging fibroid, creating a symmetric bibbed appearance to the uterus, may lead to misdiagnosis of a bicornuate uterus (Fig. 6). Pedunculated
fibroids may also lead to an erroneous diagnosis of ectopic pregnancy, especially of the interstitial type. Such an appear- ance is due to the marked uterine distortion caused by fibroids, which cause an eccentric location of the gestational
sac and apparent thinning of the myometrial echoes surround- ing it [7] (Figs. 1 3 and 14).
The variable patterns of echogenicity of fibroids also add to diagnostic confusion. Different forms of internal degenera- tion [8], hemorrhage, or proteolytic liquefaction [2] cause areas that are hypoechoic or anechoic. If extensive enough, they can mimic predominantly cystic (Fig. 1) [1 , 6] or multi- septated adnexal or ovarian masses [2, 6]. An area of cystic degeneration in an exophytic fibroid may be mistaken for an ectopic pregnancy. Cystic degeneration in a fibroid that is within the uterus may mimic an abnormal intrauterine gesta- tional sac, or, when it occurs in a centrally located submucosal fibroid, it may simulate an intrauterine fluid collection, such as hydrometrium or pyometrium (Figs. 8 and 9). A large, degen-
erated myoma filled with numerous small, anechoic areas may have the appearance of a hydatidiform mole (Fig. 15) [3, 4].
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9. 75
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yr ig
ht A
R R
S. F
or p
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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 with known endometrbosls shows enlarged uterus (straight arrows) with several small (1 cm) focal hypoechoic areas (curved arrows) scattered throughout myometrium considered to be adeno- myosis. Surgery was performed for a concomitant adnexal mass. Hysterectomy specimen revealed multiple small fibrolds. B = bladder H = head of patient.
Fig. 11.-In search for missing strIng from Intrauterine devlce(IUD), longitudinal pelvic son- ogram reveals confusing picture of metallic IUD (white arrow) curving sharply into very hypoech- ole posterior pelvic region (black arrows). Walled-off perforation by bUD was suspected. Surgery revealed multiple fibroids, the largest of which was located anteriorly (F) displacing uterus posteriorly and causing markedly retro- flexed canal. No perforation was found. The IUD was subsequently removed. (In another similar case, the IUD was removed under sonographic guidance.) Arrowheads outline uterine length. B = bladder H = head of patient.
Fig. 12.-Longitudinal statIc sonogram through uterus of pregnant woman shows normal fetal head (arrows) and a second calcIfied rim mistaken for demised twin (arrowheads). After labor resufted In delivery of a single healthy neonate and normal placenta, postpartum son- ogram revealed a calcified Intramural uterine fibrold (arrowheads). Such an error Is less likely wIth current real-time equipment and diligent search for Intracranial structures and remainIng fetal anatomy. B = bladder- H = head of patient.
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Fig. 14.-Transverse pelvic sonogram shows eccentrically located empty gestational sac (ar- rowheads) with abnormally echogenic rim and apparent thinning of surrounding posterolateral myometrial echoes (arrow) misinterpreted as in- terstitial ectopic pregnancy. Surgery revealed no evidence of ectopic pregnancy. Fibroids (F) caused distortion of uterine outline and endo- metrial canal in this case of a missed abortion. R = right side; B = bladder.
Fig. 15.-Midline sagittal sonogram in 22-year- old woman shows markedly enlarged uterus (ar- rows) with good sound transmission filled with variably echogenic tissue including numerous ane- choic areas. A hydatidiform mole was suspected, but beta subunit of human chorionic gonadotropin was negative and surgery revealed a large degen- crated fibroid. The distinction between a degen- crated fibroid and a hydatidiform mole may be more difficult when the fibroid is growing rapidly. (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.
728 BALTAROWICH ET AL. AJR:151, October 1988
Fig. 13.-Oblique longitudinal pelvic sono- gram shows bobulated uterus(U) with fibroids (F) and normal, lIve 8.5-week embryo in gestational sac (arrows) mistakenly judged to be in an so- topic location. With such close proximity to uter- ins fundus, a fatal Interstitial ectopic location was suspected. Surgical results yIelded no cvi- dance of ectopic pregnancy. The sac was inside a uterine canal markedly distorted owing to mul- tiple fibrolds. Pregnancy aborted spontaneously 3 weeks later.
Various calcification patterns of fibroids may contribute to unusual sonographic appearances. The hyperechoic present- ing rim of a calcified fibroid with its accompanying distal shadowing or the internal speckled pattern of bright reflectors may lead to misdiagnosis of an ovarian dermoid cyst (Fig. 3). When fibroids have a complete ringlike rim of calcification they may simulate a fetal head [5], which may be mistaken for a fetal demise or a twin (Fig. 12).
Because fibroids have so many sonographic appearances,
they can mimic numerous pelvic conditions. Awareness of these potential problems, especially in the presence of other fibroids, may be helpful in making the correct diagnosis. Proper identification of the uterus, close analysis of its echo
texture and cavity echoes [4], and attention to good sono- graphic technique will improve diagnostic accuracy and thereby improve patient care.
REFERENCES
1 . Hassani N. ultrasonic appearance of pedunculated uterine fibroids and ovarian cysts. J Nat! Med Assoc 1974;66:432-435
2. Nocera RM, Fagan CJ, Hemadez JC. Cystic parametrial fibroids mimicking
ovarian cystadenoma. J Ultrasound Med 1984;3: 183-1 87 3. Rinehart JS, Hemandez E, Rosenshein NB, Sanders AC. Degeneratin9
leiomyomata uteri: an ultrasonic mimic of hydatidiform mole. J Reprod Med
1981;26(3): 142-144 4. And MH, McGahan JP, Oi R. Sonographic evaluation of hydatidiform mole
and its look-alikes. AiR 1983;140:307-31 1 5. Gross BH, Silver TM, Jaffe MH. Sonographic features of uterine Ieiomy-
omas: analysis of 41 proven cases. J Ultrasound Med 1983;2:401-406 6. Muram D, Gillieson M, Walters JH. Myomas of the uterus in pregnancy:
ultrasonographic follow-up. Am J Obstet Gynecol 1980;138: 16-19 7. Graham M, Cooperberg PL. Litrasound diagnosis of interstitial pregnancy:
findings and pitfalls. JCU 1979;7:433-437 8. Persaud V, Argcon PD. Uterine leiomyoma: incidence of degenerative
change and a correlation of associated symptoms. Obstet Gyneco! 1970;35(3):432-436
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