Caso cerrado resuelto: Leiomiomatosis intravascular
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La paciente es una mujer de 50 años que presenta disnea y una masa pélvica. La TC y RM muestran una masa uterina con realce heterogéneo y extensión intravascular a las venas pélvicas, vena cava inferior y aorta abdominal. El diagnóstico diferencial incluye leiomiosarcoma, leiomiatosis difusa, leiomiatosis diseminada y leiomiatosis intravascular. Esta última opción es la más probable dado el patrón de extensión vascular de la masa.
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Caso cerrado resuelto: Leiomiomatosis intravascular
- 1. Caso Cerrado 2 Octubre Roberto Correa
- 2. Historia clínica • Mujer de 50 años con disnea • Angio CT de tórax negativo para TEP
- 8. Hallazgos • Masa pélvica – Útero • Aumentado de tamaño con masa que realza de manera heterogénea en el TC CC. • RM T1+C: Masa uterina con realce ávido. • RM T2: Tumor hiperintenso en VCI. • Defecto de repleción de VCI • Dilatación de venas pélvicas
- 9. DIAGNÓSTICO DIFERENCIAL • Leiomiosarcoma. • Leiomiomatosis difusa. • Leiomiomatosis diseminada. • Leiomiomatosis benigna metastásica. • Carcinoma de células renales con invasión a VCI. • Trombosis venosa ovárica. • Leiomiomatosis intravascular.
- 10. LEIOMIOSARCOMA • Tumor raro • Mujeres 5ª década • Clínica • Masa • Tamaño • Metástasis • TC • Realce heterogéneo • Hemorragia • Necrosis
- 11. LEIOMIOSARCOMA • RM • T1 • T2 • T1+C • Puede confundirse con Leiomioma • Masa de crecimiento rápido
- 12. LEIOMIOSARCOMA
- 13. LEIOMIOSARCOMA
- 15. LEIOMIOMATOSIS DIFUSA • 40% mujeres > 35ª • Clínica • Masa • Tamaño • TC • Calcificaciones • Efecto masa • Masa homogénea • Degeneración
- 16. LEIOMIOMATOSIS DIFUSA • RM • T1 • T2 • Homogénea • Hipointensa • Bien definida • T1+C • Degeneración • Mixoide • Quística • Hialina • Hemorrágica
- 19. LEIOMIOMATOSIS DIFUSA • Puede confundirse con Leiomiosarcoma • Masa de crecimiento lento • No metástasis
- 20. LEIOMIOMATOSIS DISEMINADA • Nódulos de músculo liso • Implantan cavidad abdominal • Benignos • 100 casos reportados • Estrógeno dependientes • TC y RM • Músculo liso o miometrio
- 21. LEIOMIOMATOSIS DISEMINADA • No infiltran • No ascitis • Imitan carcinomatosis peritoneal
- 23. LEIOMIOMATOSIS BENIGNA METASTÁSICA • Leiomiomas benignos extrauterinos • 75 casos reportados • Asintomático • Pulmón • Hígado
- 24. LEIOMIOMATOSIS BENIGNA METASTÁSICA • Nódulos pulmonares incidentales • Antecedentes de leiomioma • Bien definidos, bilaterales • No calcifican • No adenopatías • No derrame pleural • No realzan significativamente • Clínica • Tos no productiva • Disnea • Dolor torácico T1+C: Múltiples nódulos que realzan.
- 25. CARCINOMA DE CÉLULAS RENALES CON INVACIÓN DE VCI
- 26. CARCINOMA DE CÉLULAS RENALES CON INVACIÓN DE VCI
- 27. CARCINOMA DE CÉLULAS RENALES CON INVACIÓN DE VCI
- 28. TROMBOSIS VENOSA OVÁRICA • Tromboflebitis ascendente • Postparto • Clínica • Vaso • Dilatado • Engrosado • Alteración de grasa adyacente • Defecto de llenado
- 31. LEIOMIOMATOSIS INTRAVASCULAR • Masa uterina • Realce heterogéneo • Crecimiento intravenoso • 200 casos reportados • 25 – 75 años • Clínica
- 33. LEIOMIOMATOSIS INTRAVASCULAR • Masas nodulares intravasculares • Extensión variable • TC • RM • T1+C • Realce heterogéneo y ávido. Útero con realce irregular Venas pélvicas dilatadas Tumor en vena ovárica derecha, VCI y AD.
- 35. Historia clínica • Mujer de 50 años con disnea • Angio CT de tórax negativo para TEP
- 38. • LEIOMIOMATOSIS INTRAVASCULAR – LEIOMIOMATOSIS • (DEGENERACIÓN MIXOIDE, QUÍSTICA O HEMORRÁGICA)
Notas del editor
- Axial CECT shows a heterogeneous uterine mass (black arrow) with an anterior pelvic tumor implant (*).
- Axial T2WI MR shows a large heterogeneous mass (white open) in the uterus. Note that thinned but intact myometrium around the mass (white arrow) indicates that the mass is confined in the uterus.
- Sagittal T2WI MR shows a large heterogeneous mass (white open) with cystic and solid components replacing the entire uterus.
- Gross pathology shows heterogeneous, poorly-demarcated, myometrial mass (white arrow) with central necrosis (white curved) in a patient with uterine leiomyosarcoma.
- Coronal graphic shows a uterus with multiple intramural leiomyomas (white arrow).
- Axial T2WI MR shows a high SI cellular intramural leiomyoma (white open) approaching the endometrium. A low SI subserosal leiomyoma is also seen (white arrow).
- Axial T2WI MR shows an intramural leiomyoma surrounded by myometrium (black arrow). The leiomyoma has higher SI than myometrium consistent with cellular histology.
- Coronal gross pathology shows a hysterectomy specimen with multiple intramural leiomyomas (black open). (Courtesy B. Hamm, MD).
- Sagittal T2WI MR at 3.0T shows the same intramural leiomyoma (white arrow) as previous image. Note the improved spatial resolution associated with with a 3.0T system improves the conspicuity of smaller leiomyomas (white open).
- Axial CECT shows a round, solid, enhancing mass (white arrow) adjacent to the sigmoid colon (white open) in a 36 year old with abdominal pain. Reproduced with permission from AJR.
- Coronal CECT shows a heterogeneously enhancing left retroperitoneal mass (white arrow) which encases and displaces the left gonadal vein (white open). Reproduced with permission from AJR.
- Intra-operative photograph confirms the round mass (white arrow) seen on CT and also demonstrates radiologically occult, 4 mm peritoneal nodules (white open). Reproduced with permission from AJR.
- Axial T2WI MR shows a pelvic heterogeneous mass consistent with fibroids. Reprinted by permission of John Wiley & Sons, Inc. In: Abdominal-Pelvic MRI, Semelka RC (ed), Copyright 2002 by Wiley-Liss, Inc.
- Axial T1 C+ MR shows multiple enhancing nodules (white arrow) in a patient with BML. Reprinted by permission of John Wiley & Sons, Inc. In: Abdominal-Pelvic MRI, Semelka RC (ed), Copyright 2002 by Wiley-Liss, Inc.
- Axial CECT shows an enhancing filling defect (white curved) within the IVC and renal vein (not shown).
- CT shows a large renal mass invading the renal vein. The axial image shows a heterogeneous, vascular mass destroying much of the renal parenchyma at this level. The mass invades the left renal vein (curved arrow, #1, 2). An apparent filling defect within the IVC (open arrow, #1)
- Coronal reformations of CECT show a large mass (arrows, #1, 2) replacing all but the upper pole of the left kidney. Tumor extends into the left renal vein (curved arrow, #2) and into the IVC (open arrow, #2, 4).
- Axial CECT shows the classic appearance of POVT (black arrow) with a thick, enhancing vessel wall and low-density intraluminal clot. It is important to follow the course of this tubular structure to confirm it is the ovarian vein and evaluate for propagation of the clot into the IVC.
- Axial CECT shows an enlarged right ovarian vein with an avidly enhancing wall and low-attenuation intraluminal thrombus (white arrow).
- Coronal CT reconstruction in the same case shows the thrombus (white arrow) extending cephalad to the junction with the IVC. Treatment of ovarian vein thrombosis must include both antibiotics and heparin.
- Coronal reformatted CT shows enlarged, irregularly enhancing uterus (black curved), large enhancing pelvic veins, enhancing tumor in the right ovarian vein (white curved), subphrenic segment of the IVC (white arrow), and heart (white open).
- Coronal T1 C+ MR shows heterogeneously enhancing uterus (white open), enlarged pelvic veins, long and irregularly enhancing filling defects in the right ovarian vein (white curved) and subphrenic segment of the IVC (white arrow).