Uterine/Cervical Mass
Paula J. Woodward, MD
DIFFERENTIAL DIAGNOSIS
Common
Focal Myometrial Contraction
Leiomyoma
Placental Abruption, Mimic
Uterine Duplication
Adenomyosis
Less Common
Chorioangioma, Mimic
Rare but Important
Gestational Trophoblastic Neoplasia
Invasive Mole
Choriocarcinoma
Cervical Cancer
Uterine Sarcoma
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Is the finding constant?
Myometrial contractions are transient and change over course of the exam
Hematomas evolve over days to weeks
Fibroids may grow or degenerate
Is it truly within the myometrial wall?
Retroplacental hemorrhage between wall and placenta
Chorioangioma originates from the placenta
Helpful Clues for Common Diagnoses
Focal Myometrial Contraction
Transient myometrial thickening, which changes during course of examination
May appear mass-like with elliptical shape and no defined borders
Inner myometrium affected more than outer
Iso- to hyperechoic compared to myometrium
Leiomyoma
Involves myometrium or cervix
Submucosal, intramural, subserosal, pedunculated
Generally round, well-defined, hypoechoic mass
May grow or degenerate during pregnancy
Degenerated fibroids more heterogeneous and variable in appearance
Hyperechoic with hemorrhage
Cystic often with thick, irregular septations
Calcified with dense shadowing
Color Doppler
Hypovascular compared to surrounding myometrium
May see uterine vessels splayed around mass
Increased complications if placental implantation is on fibroid
Abruption
Spontaneous abortion
Preterm labor
Intrauterine growth restriction
Postpartum hemorrhage
Cervical or lower uterine segment fibroids may obstruct delivery
Placental Abruption, Mimic
Echogenicity varies according to age
Acutely more echogenic and may be similar to placenta
Becomes more hypoechoic and heterogeneous over time
Most are marginal abruptions
Begin at placental edge and dissect under chorionic membrane
Have a crescentic or lentiform configuration and usually not confused with a mass
Retroplacental abruption appears more “mass-like”
Hematoma contained between placenta and uterus
May give erroneous appearance of either an enlarged placenta or a retroplacental fibroid
Uterine Duplication
Second horn in a duplicated uterine anomaly may give appearance of uterine mass
Always look for echogenic endometrium within center of the “mass”
3 types of Müllerian duct anomalies (didelphys, bicornuate, septate) have two endometrial cavities, which may be confused with a uterine mass
Key to diagnosis is visualization of external uterine contour
Adenomyosis
Uterine enlargement without well-defined mass
Usually seen in multiparous women
Very heterogeneous appearing with fine, linear areas of attenuation throughout the thickened wall (“rain shower” appearance)
Endometrium may be obscured
Myometrial cysts (2-6 mm) in 50%, highly specific for diagnosis
May be focal (adenomyoma)
May potentially be confused with fibroid
Adenomyoma has an elliptical shape rather than round
Poor definition of borders
Color Doppler shows speckled pattern of increased vascularity, without peripheral draping vessels seen in leiomyomas
Helpful Clues for Less Common Diagnoses
Chorioangioma, Mimic
Benign, vascular placental tumor
Large ones may abut adjacent uterine wall causing confusion with a uterine mass
Most common on fetal side of placenta, near cord insertion
Helpful Clues for Rare Diagnoses
Invasive Mole
Echogenic cystic mass invading myometrium
Markedly vascular on Doppler images
↑ Human chorionic gonadotropin (hCG) levels
12-15% of complete hydatidiform moles progress to invasive mole
Choriocarcinoma
Suspect choriocarcinoma if ↑ hCG after any type gestational trophoblastic neoplasia (hydatidiform or invasive mole) or any pregnancy (ectopic, abortion or normal)
Uterine findings quite variable ranging from normal to infiltrating heterogeneous mass
Enlarged cystic ovaries (theca lutein cysts)
Lung, brain, liver metastases common
Cervical Cancer
Arises from squamocolumnar junction with 80-90% being squamous cell
Adenocarcinoma and small cell are majority of remainder (both have worse prognosis)
Most tumors exophytic in younger woman
Cervical cancer appears as a hypoechoic mass on ultrasound but can be easily missed, especially in the early stages
MR best imaging for staging
Uterine Sarcoma
Uncommon in women < 40 years old
Multiple histologic types including leiomyosarcoma, adenosarcoma, malignant mixed mesodermal modality tumor
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