British Journal of Radiology (2006) 79, e126-e128
© 2006 British Institute of Radiology
doi: 10.1259/bjr/54090919
MRI appearance of primary giant ovarian leiomyoma in a hysterectomised woman
T Tamada, MD, PhD
T Sone, MD, PhD
D Tanimoto, MD
H Higashi, MD
H Miyoshi, MD, PhD
N Egashira, MD
A Yamamoto, MD
and
S Imai, MD, PhD
Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan
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Abstract
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Primary leiomyoma is a rare, benign tumour of the ovary. We describe the MRI features of an ovarian leiomyoma identified in a 51-year-old woman after hysterectomy. The tumour appeared as a well-circumscribed low signal intensity mass on T1 weighted imaging, with mixed signal intensity on T2 weighted imaging. Areas of high signal intensity on T2 weighted imaging corresponded to degeneration of leiomyoma. Dynamic contrast-enhanced imaging revealed early enhancement of the lesion. MRI appearance was thus similar to that of uterine leiomyoma. This case suggests the potential usefulness of dynamic contrast-enhanced MRI for the diagnosis of ovarian leiomyoma.
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Introduction
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Primary ovarian leiomyoma is one of the rarest solid tumours of the ovary. Given the rarity of this lesion, ovarian leiomyoma can be confused with other spindle cell tumours such as fibroma and fibrothecoma, which display gross anatomical and histological similarities [1]. Findings on MRI in ovarian leiomyoma are also reportedly identical to those of ovarian fibroma and fibrothecoma [2, 3]. We present a case of ovarian leiomyoma in a woman who has undergone hysterectomy. To the best of our knowledge, this is the first report in the radiological literature of the appearance of ovarian leiomyoma using dynamic contrast-enhanced MRI.
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Case report
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A 51-year-old woman was admitted to our hospital for evaluation and treatment of a palpable abdominal mass. She had undergone hysterectomy for uterine leiomyomas 10 years previously. Physical examination revealed a large firm mass in the left lower abdomen. Laboratory data including various tumour markers were all within normal limits. Transabdominal ultrasound revealed a homogeneously hypoechoic mass. MRI was performed using a 1.5-T Signa Excite scanner (GE Medical Systems, Milwaukee, WI) and a phased-array torso coil. Sagittal and axial T1 weighted spin-echo imaging, and sagittal and axial T2 weighted fast spin-echo imaging were performed. Dynamic contrast-enhanced MRI was also performed using a fast spin-echo sequence. Multiphase dynamic MRI (five phases) was performed every 25 s from 25 s after the start of rapid injection (3 ml s–1) of 0.1 mmol kg–1 body weight of meglumine gadopentetate (Magnevist; Nihon Schering, Osaka, Japan) immediately followed by 20 ml of saline.
T1 weighted MRI revealed a sharply demarcated, snowman-shaped, low signal lesion with a maximum diameter of 15 cm (Figure 1
). On T2 weighted MRI, the mass appeared as a low signal lesion containing an area of high signal intensity in the caudal part of the mass (Figure 2). A dilated ovarian artery was identified supplying the cranial part of the mass. A normal right ovary containing several follicles was apparent. Dynamic contrast-enhanced MRI showed intense early enhancement and delayed washout in the cranial part (Figure 3), and weak enhancement in the caudal part of the mass.
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Figure 1. SagittalT1 weighted MRI shows a snowman-shaped, large, well-circumscribed mass displaying low signal intensity in the pelvis.
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Figure 2. SagittalT2 weighted MRI shows several high signal intensity foci in the caudal part of the mass, suggesting myxoid degeneration or oedema.
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Figure 3. AxialT1 weighted fast spin-echo imaging at (a) 0, (b) 25 s and (c) 125 s after contrast injection shows early enhancement and delayed washout in the cranial part of the mass.
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Bilateral adnexectomy was performed. The tumour displayed a smooth surface with a maximum diameter of 16 cm. Microscopic examination revealed that the mass predominantly comprised smooth muscle cells with no histological features of malignancy (Figure 4). Focal areas of hyaline and myxoid degeneration were apparent within the caudal part of the mass. Immunohistochemical staining of the tumour tissue yielded positive results for oestrogen and progesterone receptors. The final histological diagnosis was left ovarian leiomyoma.
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Figure 4. Histological section of the tumour with haematoxylin and eosin staining shows bundles of smooth muscle cells. Magnification,x200.
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Discussion
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Primary ovarian leiomyoma generally occurs in women aged between 20 years and 65 years old, and approximately 70 cases have been reported in the English-language medical literature to date [4–6]. Approximately 16% of cases occur after menopause [4–6]. Patient age is often similar to that for uterine leiomyoma, with which these lesions are frequently associated [5]. Tumours vary in size, with most displaying a diameter <3 cm [4–6]. Although most tumours are asymptomatic and found incidentally, some present with a palpable abdominal mass, ascites or hydronephrosis [7, 8]. Two cases of bilateral primary ovarian leiomyoma have been reported [1, 9].
Only a few cases of ovarian leiomyoma evaluated using MRI have been described [2, 3]. Generally, the mass displays low signal intensity on both T1 and T2 weighted imaging and is difficult to differentiate from ovarian tumours such as fibroma or fibrothecoma [2, 3]. As with uterine leiomyoma, some ovarian leiomyomas include areas of high signal intensity on T2 weighted imaging [2, 3, 10], corresponding to a combination of oedematous swelling of myoma cells from ischaemia, cystic changes and/or myxoid degeneration. However, this finding has been observed in ovarian fibroma and fibrothecoma [11, 12], and thus does not help in the process of differentiation.
On dynamic contrast-enhanced MRI or CT, ovarian fibroma and fibrothecoma have usually been reported as showing a pattern of delayed weak enhancement [13, 14]. In the present case, dynamic contrast-enhanced MRI demonstrated an area of intense early enhancement in the tumour. Undegenerated uterine leiomyomas commonly show a pattern of early enhancement on dynamic contrast-enhanced MRI [13, 15, 16]. The features of contrast enhancement in this case thus suggest a hypervascular nature that would be unusual in ovarian fibroma or fibrothecoma.
In the present case, the tumour appeared as a well-circumscribed low signal intensity mass on T1 weighted imaging, with mixed signal intensity on T2 weighted imaging. Areas of high signal intensity on T2 weighted imaging corresponded to degeneration of leiomyoma. Dynamic contrast-enhanced imaging revealed early enhancement of the lesion. MRI appearance thus resembled that of uterine leiomyoma. This case suggests the potential usefulness of dynamic contrast-enhanced MRI for the diagnosis of ovarian leiomyoma.
Received for publication May 9, 2005.
Revision received September 15, 2005.
Accepted for publication November 29, 2005.
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References
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Abstract
Introduction
