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