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Images in Women's Health

July 2004

Elizabeth Puscheck, MD, MS

Case

A 31-year-old G0 initially presented with menorrhagia. She had a hysteroscopy with dilation and curettage (D&C) approximately 2 months prior to this presentation. At that time, portions of a fibrovascular polyp were diagnosed on pathology. The operative report demonstrated that hysteroscopy was used for diagnostic evaluation only. The polyp was removed with polyp forceps and D&C; however, the patient's symptoms persisted. She presented for a second opinion with new complaints of pressure sensation, increased cramping, and persistent yellowish discharge. Pelvic examination demonstrated an anteverted, anteflexed mobile uterus which was normal in size. The cervix was closed and without lesion or visible polyp. No significant discharge was noted at the time of presentation.

Pelvic ultrasound with saline infusion sonohysterogram (SIS) was performed and revealed an intracavitary mass that measured 2.53 cm x 1.34 cm x 1.87 cm, and color flow Doppler demonstrated marked color flow (Figures 1 and 2). On SIS, the mass was noted to be hanging in the uterine cavity near the internal cervical os by a long stalk with a diameter of 1.59 cm (Figures 3 and 4). The stalk consisted mainly of two vessels as noted by color Doppler.

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Figure 1. This two dimensional transvaginal ultrasound reveals a mass that is most likely within the submucosa of the uterine myometrium. Figure 2. Power Doppler was used to evaluate this mass. The intrauterine mass appears very vascular.

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Figure 3. A saline infusion sonohysterogram confirms that the mass is submucosal and is attached to the anterior and fundal surface of the uterine wall. Figure 4. Power Doppler was used to assess this mass during the saline infusion sonohysterogram, and confirmed that the mass appears quite vascular.

Given the vascularity of the mass and diameter of the stalk, depot leuprolide acetate therapy was initiated for 3 months. Repeat ultrasound and SIS demonstrated an intrauterine mass measuring 1.9 cm x 1.5 cm with a stalk of 1.5 cm (Figure 5); the vascularity had decreased dramatically (Figure 6).

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Figure 5. Repeat saline infusion sonohysterogram reveals the persistence of this mass at roughly the same size, despite 3 months of depot leuprolide acetate therapy.

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Figure 6. The power Doppler during the repeat saline infusion sonohysterogram revealed a much less vascular mass.

Operative hysteroscopy was performed with removal of the mass and showed a gross picture (Figure 7). The mass was completely removed, and the pathology specimen was visualized both on low and high power; the pathology was clearly a leiomyoma (Figures 8 and 9).

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Figure 7. Hysteroscopic view of the intrauterine mass. It appears to be a leiomyoma.

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Figure 8. This pathology slide is a low power histologic section of the mass. The histologic diagnosis is submucous leiomyoma. The structures labeled are the submucous leiomyoma and myometrium. Figure 9. This pathology section shows a higher power histologic view of the submucous leiomyoma. The submucous leiomyoma and normal endometrium are labeled on this kodachrome.

The last ultrasounds taken after the surgery, while patient was still experiencing the effects of the pre-operative depot leuprolide acetate therapy, revealed the endometrial stripe at 2.1 mm; no mass was visualized (Figures 10 and 11).

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Figure 10. Transvaginal ultrasound of the longitudinal axis of the uterus reveals the absence of an intrauterine mass. Figure 11. Transvaginal ultrasound view of the transverse uterus after surgery. Again, there is no evidence of any residual mass.

Discussion

Differentiation between a polyp and a myoma is easily determined on pathology. In pathology, the polyp consists of a broad based, sessile mass or a protruding pedunculated mass from the endometrium; typically, three sides of the mass are lined with endometrium and a blood vessel feeding the protruding mass centrally. The endometrial stroma on a polyp is usually proliferative with varying portions out of synchrony with the endometrium. The blood vessels are located at the base of the polyp and usually are thick walled. Occasionally, abundant vessels may be present. There are three broad categories of polyps: hyperplastic, atrophic, and functional. Initially, one may have thought that this mass was a polyp given its initial vascular pattern.

Leiomyomas consist of "whorled, anastomosing fascicles of uniform, fusiform, smooth muscle cells"¹ and are more cellular than the surrounding myometrium. Degenerative changes may consist of hyaline fibrosis, edema, and hemorrhage. Vascular leiomyomas may have numerous large caliber, thick-walled vessels. It may be difficult to distinguish vascular myomas from hemangiomas.

On sonography, these uterine intracavitary masses may be a bit more deceptive. Transvaginal ultrasound allows for a closer look at the endometrium. Both endometrial polyps and submucous leiomyomas may appear hyperechoic within the endometrium. The submucous leiomyoma may vary in its appearance. It may be hyperechoic or hypoechoic. The typical leiomyoma may have shadowing below the mass, consistent with the tightly whorled smooth muscle mass that obscures the sound waves of ultrasound. The vascularity is typically low, although a hypervascular myoma may have multiple vessels. The vessels are usually found on the external surface of a myoma.

On SIS, the fluid used as contrast material separates the mass from the surrounding endometrium, so the mass is easily isolated with the fluid contrast. The mass can be more accurately measured. The attachment site can be localized. The width of the attachment site and the amount of myoma within the uterine cavity may help direct the surgical approach. Again, however, a polyp and a leiomyoma may be difficult to distinguish by this method alone.

Color Doppler or power Doppler during SIS may help in assessing the difference between a polyp and a leiomyoma. The polyp typically will have a single blood vessel to the central area of the polyp and will enter the polyp base, similar to the pathologic diagnosis. The leiomyoma may have little to no vascularity, or it may be highly vascular. In the latter case, the blood vessels are typically displaced to the outer surface as one observes in the operating room. It is the more vascular leiomyoma cases that respond well to medical treatment.

This particular case demonstrated the vascularity often associated with a hypervascularized leiomyoma. The vascular pedicle and the overall vascularity did respond well to gonadotropin-releasing hormone agonist therapy. The entire myoma was removed during the second procedure and the follow up ultrasound demonstrated that no residual myoma remained. The patient's symptoms resolved.

References

1. Kurman RJ and Mazur MT. Benign diseases of the endometrium. In: Kurman RJ, ed. Blaustein's Pathology of the Female Genital Tract. 3^rd ed. New York, NY: Springer Verlag; 1987:305-307.
2. Zaloudek C and Norris HJ. Mesenchymal tumors of the uterus. In: Kurman RJ, ed. Blaustein's Pathology of the Female Genital Tract. 3^rd ed. New York, NY: Springer Verlag; 1987:374-380.
3. Fleischer AC and Entman SS. Sonographic Evaluation of the Uterine Disorders. In: Fleischer AC, Manning FA, Jeanty P, and Romero R, eds. Sonography in Obstetrics & Gynecology (Principles and Practice). 6th ed. New York, NY: McGraw-Hill Companies, Inc; 2001:949-979.

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