超音波教學 Section 2

陳志堯 Director

洪正修主任 趙灌中主任

September 15, 2006

Ultrasonic Characteristics & Differential Diagnosis on

Leiomyoma, Adenomyosis and Adenomyoma

Review of the Literature

What is Leiomyomata?The elephant in the room

Uterine leiomyomas are benign myometrial neoplasms enriched in extracellular matrix.

Uterine leiomyomas are the most

common gynecologic disease of the

corpus uteri and are readily detected

by trans-vaginal sonography.

They are the primary indication for hysterectomy, over

200000 cases annually in US. Science June, 2005

Tumors occur in 77% women and approximately 25% of Caucasians have clinical significant lesions.

In African-American women, clinical disease is more severe more and concordant with prevalence.

Science June, 2005

Risk Factors & Prevalence The prevalence of clinical significant fibroids peaks

in the perimenopausal years and declines after menopause.

Increased Risk: obesity & early menarche, race Decreased Risk: old age of the last child birth. (COX-2, PGE)

Science June, 2005

Genetics of Uterine Leiomyoma

• Approximately 40% display cytogenetic alternations, frequently involving chromosome 12, t(12;14). (HMGA2)

• Hereditary leiomyomatosis and RCC (HLRCC):

Fumarate hydratase gene (FH).

• Tuberous sclerosis complex gene (TSC); BHD.

• CYP19 & CYP17 (black African women).

• Deletions of 7q, 3q and 1p; rearrangements of 6p, 10q and 13q.

Science. June 2005; Obs & Gyn. April 2006

Genetic AlterFH

BHDTSC2

HMG2A

Autocrine: TGF.etc

Estrogen & Progesterone

Tumor Growth ECM

ObesityParityRace

Leiomyomata Leiomyosarcoma?

However, it appears that a subset of myomas with a deletion of a specific portion of chromosome 1 have both a specific cellular morphology and gene transcription profiles akin to those of leiomyosarcomas.

Christacos NC. Genes Chromosomes Cancer 2006;45:304–12.

Location of Leiomyoma

• Sub-serosa

• Intra-mural

• Sub-mucosal

• Cervical

• Broad Ligament

Subserosa

Intramural

Submucosa

Cervical

Broad Ligament

KC Wen. 2005

Misguided Mass Mimics Myoma

The Major impacts of Leiomyomata

Symptoms

Infertility a. Mechanical

b. Alter the biochemical nature of intrauterine fluid

C. Abnormal ultrastructure

Submucous and Outer Myometrium Leiomyomas are Two Distinct Clinical

Entities

Fertility Sterility 2003

Junctional Zone Myometrium

1. Expression levels of E and P receptors are significantly higher in submucous fibroids compared to subsersal leiomyomas.

2. Submucous leiomyomas have significantly less karyotype aberrations than outer myometrial leiomyomas.

3. Using color Doppler sonography, Tsuda identified a leiomyoma artery in 85% submucous leiomyoma, but only in 42% intramural leiomyoma.

4. Growth rate is less in submucous type.

What is Adenomyosis?What is Adednomyoma?

Adenmyosis is a common gynecological disorder that is characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia.

Bryann Bromley. J Ultrasound Med 19:529–534, 2000

Caroline Reinhold. Human Reprod Update 4:337-349, 1998

Prevalence: 5~70%

This broad range is due to the different criteria used for diagnosis, as well as the diligence with which adenomyosis is pursued on pathologic examination.

Kurman RJ. Pathology of the Female Genital Tract. 2nd Edition. New York, Springer-Verlag, 1984, p 297

• The frequency has been estimated between 20 and 40% of hysterectomy specimens.

Adenomyoma is the Nodular Form of

Adenomyosis

Sonographic Accuracy (84.3%)

General enlargement of uterine size

Global appearance (95%)

Mottled inhomogeneous myometrial texture (Sun-shine pattern) (100%)

Small cystic spaces within myometrium (82%)

Shaggy indistinct endometrial stripe (82%)

Bromley B. J Ultrasound Med. 2000

The Clinical Triads

Uterine enlargement

Dysmenorrhea

Menorrhagia

Small myometrial lucent areas

Shaggy endometrial stripe

ADENOMYOMA

The Final TalkAdenomyoma & Leiomyoma

How to Differentiate?

TVS is an effective, non-invasive, and relatively in-expensive procedure for the pre-operative differential diagnosis of adenomyoma versus leiomyoma.

Fedele L. Am J Obstet Gynecol, 1992

Botsis D. J Clinical Ultrasound, 1998

Huang RT.

Ultrasound OBS&GYN

1995

THANKS!