PMC5894123_01
(A, B) Ultrasound images show multiple, well-defined, homogenous hypoechoic lesions in the pelvis and peritoneum.
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On ultrasound, multiple, well-defined, lobulated, solid, hypoechoic mass lesions were noted in the abdomen and pelvis (Figure 1A, 1B).
Color and spectral Doppler of one of the lesions shows a low-resistance arterial waveform.
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On a color Doppler study, few of these lesions showed significant internal vascularity with a low-resistance arterial waveform (Figure 2).
Axial plain CT image of the pelvis shows multiple, welldefined, isodense lesions as indicated by arrows.
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The patient was then evaluated by plain and contrast-enhanced computed tomography which revealed multiple lobulated, iso- to hypodense lesions in the peritoneum, bilateral adnexa, recto-uterine pouch, pre-vesical space and left rectus abdominis muscle (Figure 3).
Coronal, reformatted, postcontrast CT image shows heterogeneous enhancement of the above-seen lesions with central non-enhancing areas suggestive of necrosis.
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Most of these lesions showed moderate to intense enhancement on postcontrast images (Figure 4).
Axial T1W MR image of the pelvis shows multiple, welldefined, iso- to hypointense lesions as indicated by arrows.
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The same lesions appeared isointense to skeletal muscles on T1W images (Figure 5), isointense to moderately hyperintense on T2W images (Figure 6) and moderately hyperintense on short tau inversion recovery (STIR) images (Figure 7).
A xial T2W MR image at same level as in Figure 5 shows heterogeneous, predominantly hyperintense signal within the mass with cystic areas within. The lesion with the higher signal intensity is indicated by the arrow.
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The same lesions appeared isointense to skeletal muscles on T1W images (Figure 5), isointense to moderately hyperintense on T2W images (Figure 6) and moderately hyperintense on short tau inversion recovery (STIR) images (Figure 7).
Axial, STIR MR image at same level as in Figure 9 shows hyperintense signal of the same lesions.
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The same lesions appeared isointense to skeletal muscles on T1W images (Figure 5), isointense to moderately hyperintense on T2W images (Figure 6) and moderately hyperintense on short tau inversion recovery (STIR) images (Figure 7).
Axial, GRE MR image shows central areas of blooming within the masses as indicated by the arrows.
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Central areas of blooming were seen in few of these lesions on gradient echo (GRE) images, suggestive of hemorrhage (Figure 8).
Sagittal, oblique, postcontrast, fat-sat MR image shows intense enhancement of the lesions with central areas of non-enhancement suggestive of necrosis (arrows).
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T1W images, intense enhancement of these lesions was seen with few non-enhancing areas within due to necrosis (Figure 9). The patient underwent exploratory laparotomy with bilateral oophorectomy and most of the lesions were resected from the peritoneum and pelvis.
Gross surgical specimen of one of the lesions shows a pale, lobulated, solid mass.
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On gross appearance, the lesions appeared pale, lobulated and firm in consistency (Figure 10).
Low power microscopic histopathologic section of a lesion shows abundant spindle-shaped cells in bundles.
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On histopathological examination, the specimens consisted of spindle-shaped smooth muscle cells with intervening extracellular matrix and fibroblasts, consistent with leiomyoma (Figures 11, 12).
High power microscopic histopathologic section of the same slide shows spindle-shaped cells in bundles with few fibroblasts without cellular atypia or pleomorphism.
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On histopathological examination, the specimens consisted of spindle-shaped smooth muscle cells with intervening extracellular matrix and fibroblasts, consistent with leiomyoma (Figures 11, 12).
High power microscopic histopathologic section of another lesion shows cellular atypia with nuclear pleomorphism and increased mitotic figures (arrows).
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Two of the specimens showed cellular atypia, pleomorphism and increased mitotic activity suggestive of a malignant transformation (Figure 13).