Uterine/Cervical Mass

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
      • Didelphys: Two separate uteri, each with its own cervix
      • Bicornuate: Concave or heart-shaped external fundal contour
      • Septate: Fundus mildly convex to mildly concave
  • 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
Aug 10, 2016 | Posted by in OBSTETRICS | Comments Off on Uterine/Cervical Mass

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