Imaging of Giant Uterine Leiomyoma: A Diagnostic Dilemma

A 47-year-old woman presented to emergency complaining of diffuse abdominal pain and reporting a slight and progressive increase in weight and abdominal size in the last two years. Her sexual life was regular, with no pathological vaginal bleedings. Her medical and family history was unremarkable, and she had one full-term pregnancy 15 years earlier. Laboratory tests were normal. Physical examination demonstrated an enlarged and palpable abdominal-pelvic mass that appeared heterogeneous with solid and cystic areas at transabdominal ultrasound (US) and low intralesional vascularization at Color Doppler. On contrast-enhanced computed tomography (CE-CT) the lesion was well-circumscribed and multiloculated, extending from the pelvis up to the lower margin of the liver, with diameters of about 33 × 28 × 17cm. It appeared predominantly low-attenuated, with heterogeneous and late contrast enhancement. No intralesional calcifications were detected, and the aortoiliac vessels appeared not involved. The uterus was adherent to the mass, while the uterine cavity was completely attached to the abdominal wall. A small median hernia was also found, probably due to the increased intra-abdominal pressure (Fig. A-D). On magnetic resonance imaging (MRI) the mass showed heterogeneous high-signal intensity on T2-weighted images (T2-WI), more evident on the periphery, and low signal intensity on T1-weighted images (T1-WI). No lymphadenopathies were present. Some features were compatible with a markedly enlarged uterine leiomyoma, but the hypothesis of a malignant neoplasm could not be completely excluded (Fig. E). At laparotomy, an enlarged uterus replaced by a multiloculated and huge lesion was found, extended in the entire abdominal cavity. The uterus appeared stiff and poorly delimited from the sigmoid colon and the rectum, associated with thickening of parametrial tissues. An extra fascial hysterectomy was performed with a strong suspicion of malignancy, and the uterine mass was completely removed. Histopathologic examination revealed the final diagnosis of a giant cellular leiomyoma (Fig. E-F). Today, two years after surgery, the patient is in good health.