IMAGES IN REPRODUCTIVE MEDICINE

Massive cystic degeneration of a pedunculated

leiomyoma
Christina E. Dancz, M.D., and Heather R. Macdonald, M.D.
Department of Obstetrics and Gynecology, Los Angeles County–University of Southern California Medical Center, Women’s and
Children’s Hospital, Los Angeles, California

A 51-year-old woman presented with a large abdominopelvic mass suspicious on preoperative imaging for ovarian
malignancy. At laparotomy, a large cystic mass was found originating from the uterus and adherent to the proximal
ileum. Pathologic evaluation confirmed the diagnosis of cystic leiomyoma. (Fertil Steril 2008;90:1180–1. 2008
by American Society for Reproductive Medicine.)

A 51-year-old gravida 5, para 1 woman presented with in-
creasing abdominal girth and severe anemia. Her tumor
markers were normal. Pelvic ultrasound revealed a >30-
cm mass with multiple septations and internal debris (Fig.
1, left). A CT scan showed a 32-cm cystic mass with areas
of soft tissue component (Fig. 1, right). A magnetic reso-
nance image (MRI) showed a large cystic mass, and normal
ovaries were not identified. Preoperative diagnosis was ovar-
ian neoplasm, suspicious for malignancy. At laparotomy,
normal ovaries were identified and a 40-cm mass was at-
tached by a 1-cm stalk to the posterior uterine fundus, deriv-
ing its blood supply from the proximal ileum (Fig. 2). The
mass was drained of 7 liters of old blood. Pathologic evalu-
ation confirmed the diagnosis of cystic leiomyoma (Fig. 3).
Cystic degeneration may occur in up to 4% of leiomyomata
(1). Several case reports have shown that these masses may

FIGURE 1
Abdominal ultrasound showing large cystic mass with internal debris and multiple septations (left); CT showing
large cystic mass occupying entire abdominal cavity (right).

Dancz. Leiomyoma with cystic degeneration. Fertil Steril 2008.

Received October 31, 2007; revised and accepted December 13, 2007.
The authors have no potential conflicts of interest to report.
Reprint requests: Christina Dancz, M.D., Department of Obstetrics and
Gynecology, Los Angeles County–University of Southern California
Medical Center, Women’s and Children’s Hospital, Los Angeles, CA
90033-0800 (FAX: 323-226-2989; E-mail: dancz@usc.edu).

1180 Fertility and Sterility Vol. 90, No. 4, October 2008 0015-0282/08/$34.00
Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2007.12.046
 FIGURE 2
Cystic leiomyoma at the time of laparotomy; arrows
point to omentum and ileum densely adherent to the
superior/cranial aspect of the mass. Inset included
for scale.
Dancz. Leiomyoma with cystic degeneration. Fertil Steril 2008.
masquerade as ovarian neoplasms (2, 3). Ultrasound and
MRI are accurate in diagnosis of uncomplicated leiomyo-
mata, although they have a lower sensitivity for cystic sub-
types (1, 4) as these tumors have a variable appearance. The
diagnosis of leiomyoma on an MRI can readily be made by
demonstrating that the mass is continuous with the adjacent
myometrium (5); however, in the case of pedunculated or
parasitic leiomyomata, this may not be possible. This case
represents an unusual case of massive cystic degeneration
of a pedunculated leiomyoma masquerading as an adenexal
mass.
Fertility and Sterility
FIGURE 3
Histopathologic specimen showing smooth muscle
cells separated by fibrous connective tissue (A), an
area of hemorrhagic infarct (B), and cystic
degeneration (C).
Dancz. Leiomyoma with cystic degeneration. Fertil Steril 2008.
REFERENCES
1. Mayer D, Shipilov V. Ultrasonography and magnetic resonance imaging
of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667–725.
2. Yarwood R, Arroyo E. Cystic degeneration of a uterine leiomyoma
masquerading as a postmenopausal ovarian cyst. A case report. J Reprod
Med 1999;44:649–52.
3. Kulshrestha R, Lakhe M, Rani S. Massive cystic degeneration of a uterine
leiomyoma presenting as an ovarian cyst: a case report. Indian J Pathol
Microbiol 2003;46:86–8.
4. Schwartz L, Zawin M, Carcangiu M, Lange R, McCarthy S. Does pelvic
magnetic resonance imaging differntiate among the histologic subtypes of
uterine leiomyomata? Fertil Steril 1998;70:580–7.
5. Murase E, Siegelman E, Outwater E, Perez-Jaffe L, Tureck R. Uterine
leiomyomas: histopathologic feastures, MR imaging findings, differential
diagnosis, and treatment. Radiographics 1999;19:1179–97.
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