A large pedunculated subserosal myoma with cystic and red degeneration: A case report with literature review.

A 30-year-old woman, with no significant medical history, married for 8 years and nulliparous, presented with primary infertility. Over the preceding 9 months, she had experienced a progressively increasing abdominal girth associated with abdominopelvic pain, as well as urinary and gastrointestinal disturbances, which prompted consultation with a gynecologist. On physical examination, the patient was hemodynamically stable, with preserved general condition and no signs of acute distress. Abdominal examination revealed marked distension and diffuse tenderness on palpation ( Fig. 1 ). The remainder of the clinical examination was unremarkable. Fig. 1 Clinical image of a large abdominopelvic distension. Fig 1: Clinical image of a large abdominopelvic distension. An abdominopelvic ultrasound was performed, revealing an anteverted and anteflexed uterus with asymmetric thickening of the myometrial walls, suggestive of adenomyosis. A large heterogeneous mass extending up to the epigastric region was visualized, with poorly defined borders and a mixed echotexture. The lesion displayed anechoic fluid components with septations ( Fig. 2 A and B), as well as solid areas showing color Doppler vascularity and anechoic cystic loculi ( Fig. 2 C). The ultrasound was inconclusive regarding the origin of the mass, warranting further evaluation by pelvic MRI. Fig. 2 Abdominopelvic ultrasound (A-C): Mass with ill-defined contours, mixed echostructure containing anechoic fluid and septa (A, B) and tissue structures with color Doppler showing anechoic cystic compartments (C). Fig 2: Abdominopelvic ultrasound (A-C): Mass with ill-defined contours, mixed echostructure containing anechoic fluid and septa (A, B) and tissue structures with color Doppler showing anechoic cystic compartments (C). Pelvic MRI demonstrated a large subperitoneal abdominopelvic mass, connected to the right uterine horn by a vascularized pedicle. A bicornuate uterus (highlighted in red lines) was also noted. The mass was well-demarcated with regular contours, predominantly cystic and multilocular, containing multiple septations. The cystic component exhibited high signal intensity on both T2- and T1-weighted sequences, with areas of hemorrhagic content (red stars). The solid component was hypointense on T1- and T2-weighted images, showed contrast enhancement following gadolinium administration, and displayed no diffusion restriction. The cystic areas did not enhance postcontrast ( Fig. 3 ). No ascites or abdominopelvic lymphadenopathy was identified, and the remaining abdominopelvic organs appeared normal. Fig. 3 Abdominopelvic MRI. T2 sequences (A), T1 (B), T1 with fat saturation (C), diffusion B1000 (D), ADC (E), and T1 postcontrast with fat saturation on axial slices (F). Voluminous abdominopelvic mass, subperitoneal, with identification of a connection to the right uterine horn, showing a bicornuate uterus (red lines), well-defined with regular contours, predominantly cystic, multiseptated, containing septa, with a predominantly hemorrhagic fluid portion showing high signal on T2 and T1 (red stars), and a tissue portion showing low signal on T1 and T2, enhanced after contrast injection, without restriction on the diffusion sequence, containing nonenhanced fluid compartments after Gadolinium injection (green stars). Fig 3: Abdominopelvic MRI. T2 sequences (A), T1 (B), T1 with fat saturation (C), diffusion B1000 (D), ADC (E), and T1 postcontrast with fat saturation on axial slices (F). Voluminous abdominopelvic mass, subperitoneal, with identification of a connection to the right uterine horn, showing a bicornuate uterus (red lines), well-defined with regular contours, predominantly cystic, multiseptated, containing septa, with a predominantly hemorrhagic fluid portion showing high signal on T2 and T1 (red stars), and a tissue portion showing low signal on T1 and T2, enhanced after contrast injection, without restriction on the diffusion sequence, containing nonenhanced fluid compartments after Gadolinium injection (green stars). The diagnosis of a giant pedunculated subserosal leiomyoma (FIGO type 7), with cystic and red degeneration, was established. Additional findings included a right ovarian endometrioma, focal adenomyosis, and a bicornuate uterus ( Fig. 4 ). Fig. 4 Abdominopelvic MRI. T2 sequences in coronal (A) and sagittal (B) planes: Bicornuate uterus with a right cavity containing microcystic formations at the junctional zone, showing low signal on T1, high signal on T2, nonenhanced after injection, associated with asymmetry in the size of the uterine walls, indicative of adenomyosis (red arrow). T1 sequence after fat signal saturation in axial slice (C), T2 sequence in axial slice (D): Well-defined ovoid formation with regular contours at the right ovary, showing high signal on T1, intermediate signal on T2, consistent with an endometrioma (green arrows). Fig 4: Abdominopelvic MRI. T2 sequences in coronal (A) and sagittal (B) planes: Bicornuate uterus with a right cavity containing microcystic formations at the junctional zone, showing low signal on T1, high signal on T2, nonenhanced after injection, associated with asymmetry in the size of the uterine walls, indicative of adenomyosis (red arrow). T1 sequence after fat signal saturation in axial slice (C), T2 sequence in axial slice (D): Well-defined ovoid formation with regular contours at the right ovary, showing high signal on T1, intermediate signal on T2, consistent with an endometrioma (green arrows). Laboratory workup was within normal limits, except for microcytic hypochromic anemia consistent with iron deficiency. Tumor markers, including CA-125, were negative, as was serum beta-hCG. After multidisciplinary discussion, a conservative surgical approach was chosen in light of the patient’s age and desire for future fertility. The patient underwent an exploratory laparotomy via a midline longitudinal incision. Intraoperatively, a large pedunculated mass arising from the right uterine horn was identified. Upon incision of the mass, approximately 2 liters of sero-hemorrhagic fluid were evacuated ( Fig. 5 ). Histopathological analysis confirmed the diagnosis of a leiomyoma with cystic and hemorrhagic degeneration ( Fig. 6 ). Fig. 5 Intraoperative images. The mass before and after evacuation of the large hemorrhagic cystic portion, which yielded approximately 2 liters of sero-hematic fluid (A-D), and the pedicle with the uterus (B). Fig 5: Fig. 6 (A and B): Microscopic images revealed a leiomyoma with cystic areas showing extensive degeneration, hemorrhages, and infarcts. Fig 6 Intraoperative images. The mass before and after evacuation of the large hemorrhagic cystic portion, which yielded approximately 2 liters of sero-hematic fluid (A-D), and the pedicle with the uterus (B). (A and B): Microscopic images revealed a leiomyoma with cystic areas showing extensive degeneration, hemorrhages, and infarcts. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. At follow-up visits, she remained in good general health with no reported complications.

Written informed consent for publication was obtained from patient.

The study of atypical degeneration in uterine fibroids, although rare, highlights the necessity of including it in the differential diagnosis of pelvic masses. Imaging, particularly MRI, plays a pivotal role in characterizing these lesions and guiding management. A multidisciplinary approach is essential to optimize diagnosis and determine the most appropriate therapeutic strategy, whether medical or surgical. This case underscores the importance of clinical and radiological expertise in evaluating complex pelvic masses, contributing to a deeper understanding of atypical variants of uterine fibroids and facilitating more tailored patient management.

The exact etiology remains unclear, but sex hormones, including estrogen and progesterone, play a crucial role in their development. This accounts for their appearance after menarche, growth during pregnancy, and regression after menopause. Recurrence can occur upon the initiation of hormonal therapy. Fibroids may undergo various types of degeneration, including hyaline, myxoid, calcified, cystic, or red (hemorrhagic infarction) degeneration, typically when the fibroid exceeds its blood supply [ 1 , 4 , 5 ]. The prevalence of fibroids ranges from 4.6% to 51%, depending on the population studied and diagnostic criteria, such as age and the presence of symptoms [ 1 , 4 ]. These hormone-dependent tumors tend to enlarge during pregnancy and regress after menopause [ 5 ]. Uterine fibroids can vary in size, from microscopic to giant, and are classified based on their location as submucosal, intramural, or subserosal. Pedunculated subserosal fibroids may mimic ovarian neoplasms [ 1 , 2 ]. Uterine fibroids, also known as leiomyomas, are the most common benign tumors of the uterus in women of reproductive age, affecting 20%-40% of women, with a higher prevalence among Black women [ [1] , [2] , [3] ]. These benign neoplasms consist of smooth muscle cells and varying amounts of fibrous connective tissue [ 1 ]. Degenerative changes in uterine fibroids are commonly observed, with approximately 65% of cases presenting such changes. These primarily include: Hyaline degeneration (63%), which begins in the stromal tissue, leading to the separation and eventual replacement of smooth muscle cells. This is the most frequent form of degeneration. Cystic degeneration (4%) occurs as a late-stage progression of hyalinization, resulting in liquefaction that creates cystic spaces filled with clear fluid or gelatinous material. This type of degeneration can mimic ovarian cancer, potentially leading to misdiagnosis [ 1 , 3 , [6] , [7] , [8] ]. Other forms include calcifications (8%), myxoid degeneration (19%), red degeneration (3%), and fatty degeneration (3%) [ 2 ]. Red degeneration, also referred to as carnous degeneration, is a severe hemorrhagic infarction resulting from peripheral venous obstruction, frequently associated with pregnancy or the use of oral contraceptives. Macroscopically, it appears as a red and hemorrhagic mass. Spontaneous intraleiomyomatoid hemorrhages have been rarely documented [ [4] , [5] , [6] , [7] ]. We present a rare case of a large uterine fibroid exhibiting both cystic and red degeneration, which mimics ovarian malignancy. These variations in presentation highlight the necessity for meticulous diagnostic evaluation to prevent clinical misdiagnosis [ 3 , 5 ]. Uterine fibroids are seldom diagnosed prior to puberty and generally regress after menopause [ 4 ]. Most cases are asymptomatic and are identified incidentally during routine physical exams or pelvic imaging studies, such as ultrasound, CT, or MRI [ 4 , 5 ]. When symptomatic, approximately 20%-50% of fibroids present with symptoms that are influenced by their location, size, and any degenerative changes. Common manifestations include metrorrhagia, menorrhagia, pelvic pain, pelvic pressure, signs of compression on adjacent organs, and occasionally, an abdominal mass perceived by the patient [ 2 , 4 ]. Certain specific complications may arise, such as hemorrhagic episodes leading to microcytic hypochromic anemia, particularly in the context of submucosal fibroids. Additionally, pelvic pain may result from aseptic necrosis secondary to fibroid ischemia, often accompanied by low-grade fever (38°C-39°C) and dark-colored (blackish) metrorrhagia [ 4 ]. More rarely, mechanical complications related to mass effect can cause urinary or gastrointestinal disturbances. Obstetric complications, such as recurrent spontaneous miscarriages, may also occur, especially in cases involving submucosal fibroids [ 3 , 4 ]. Malignant transformation of fibroids remains extremely rare and has not been conclusively demonstrated to date [ 4 ]. Giant uterine fibroids, although uncommon, can lead to emergency situations due to massive genital hemorrhage or compression of abdominal organs or the diaphragm. These complications may account for the digestive and urinary disturbances observed in our case [ 3 ]. Ultrasound is the first-line imaging modality for diagnosing uterine fibroids and their associated complications. Fibroids typically appear as well-circumscribed, hypoechoic masses arising from the myometrium. However, when degenerative changes are present, they may exhibit cystic areas or complex echotexture, complicating the diagnosis particularly in cases of a polymyomatous uterus or when associated conditions such as adenomyosis coexist [ 1 , 4 , 5 ]. When transabdominal or transvaginal ultrasound is limited such as in virginal patients or in cases involving voluminous fibroids, as observed in our patient,MRI is the preferred modality. MRI enables precise mapping of fibroids, allowing for accurate assessment of their number, size, and degree of degeneration. It remains the most reliable technique for characterizing degenerative changes and differentiating benign uterine lesions from malignant ones [ 1 , 5 ]. In the early stages of venous infarction, MRI may show high signal intensity on T1-weighted images due to methemoglobin formation delineating the leiomyoma borders, and low signal intensity on T2-weighted images related to deoxygenated hemoglobin. T1 hyperintensity typically becomes evident several days after infarction, whereas the T2 hypointensity is observable within approximately 12 hours. As the infarction evolves, the central portion of the fibroid often becomes progressively hyperintense on T1, with variable signal behavior on T2 sequences. Overall, a persistent absence of contrast enhancement is characteristic throughout the leiomyoma [ 6 , 7 ]. Susceptibility-weighted sequences (SWS) may further assist in identifying leiomyomas with red degeneration by revealing a distinctive peripheral hypointense [ 6 ]. However, MRI is less suitable for acute or emergency settings due to its limited accessibility and longer acquisition times [ 5 ]. Uterine fibroids with cystic and hemorrhagic degeneration may exhibit heterogeneous ultrasound features, often appearing as complex cystic masses with thin septations and solid components, which can mimic malignant ovarian tumors. Demonstrating continuity between the mass and the uterine wall serves as a key diagnostic criterion but may be challenging in the context of large fibroids. The addition of color Doppler imaging provides further diagnostic value, especially for assessing the vascularity of the lesion [ 1 ]. Although computed tomography (CT) is not routinely used for diagnosing uterine fibroids, it may incidentally detect them during imaging performed for other clinical indications. CT proves useful in staging when malignancy, particularly ovarian cancer, is suspected, or when evaluating large fibroids with mixed or atypical degenerative changes [ 2 , 3 , 5 ]. On noncontrast CT, red degeneration typically manifests as areas of increased attenuation. Perilesional fat stranding seen on CT may indicate associated edema and inflammatory changes secondary to infarction [ 7 ]. In our case, the combination of ultrasound and MRI facilitated the characterization of a large leiomyoma with cystic and hemorrhagic degeneration—an uncommon presentation among those described in the literature [ 1 ]. Uterine leiomyomas are believed to result from various chromosomal abnormalities. Each fibroid is monoclonal in origin, arising from a single smooth muscle cell harboring a specific cytogenetic alteration. The size and growth potential of the fibroid are thought to correlate with the extent and nature of these chromosomal changes [ 8 ]. The main differential diagnosis for a large pelvic mass with solid and cystic components and irregular septations is ovarian malignancy [ 2 ]. However, the demonstration of continuity between the mass and the uterine wall or the visualization of normal ovaries on imaging can assist in ruling out this diagnosis. The absence of ascites and normal serum tumor markers, such as CA-125, further supports the diagnosis of a uterine fibroid rather than an adnexal malignancy [ 2 ]. To date, fewer than 20 cases of pedunculated subserosal fibroids with degenerative changes mimicking ovarian tumors have been reported in the literature [ 2 ]. Abdoul-Samadou Aboubakari et al. [ 3 ] documented a case of a giant uterine fibroid with cystic degeneration simulating an ovarian neoplasm. Jao MS et al. [ 1 ] described a large fibroid with cystic and red degeneration associated with an elevated CA-125 level, in contrast to our case, which involved a giant fibroid with mixed cystic and hemorrhagic degeneration and no increase in CA-125. The management of symptomatic uterine leiomyomas typically begins with pharmacologic therapy aimed at mitigating clinical manifestations, most notably menorrhagia.However, medical therapy does not eradicate fibroids, and surgical intervention often becomes necessary in cases of therapeutic failure or the development of complications. Consequently, leiomyomas represent the leading indication for hysterectomy among premenopausal women [ 4 , 8 ]. Medical treatment is primarily focused on controlling abnormal uterine bleeding. Progestins and levonorgestrel-releasing intrauterine systems (LNG-IUS) are effective in reducing menorrhagia by modulating endometrial proliferation. In the context of acute uterine bleeding, therapeutic options include tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), and high-dose estrogen therapy. Gonadotropin-releasing hormone (GnRH) agonists can be administered for a short duration (typically 2-3 months) to induce a hypoestrogenic state, leading to temporary reduction in fibroid volume, diminished bleeding, and correction of iron-deficiency anemia prior to surgical management [ 4 , 8 ]. The definitive management of symptomatic uterine leiomyomas is surgical, with the choice between myomectomy and hysterectomy guided primarily by the patient’s reproductive goals. Myomectomy is the procedure of choice for women desiring fertility preservation and is typically performed via laparotomy when dealing with multiple (≥3) or large fibroids (>9 cm). In women with no future fertility plans, hysterectomy is recommended and may be total or subtotal depending on clinical indications [ 4 , 5 ]. For giant fibroids, laparotomy remains the standard approach, offering optimal exposure and facilitating complete resection, as was necessary in our reported case. Uterine artery embolization represents a minimally invasive therapeutic option for controlling hemorrhage while preserving fertility. It is particularly indicated for submucosal or pedunculated subserosal fibroids and may be performed preoperatively to reduce intraoperative and postoperative blood loss [ 4 , 5 ]. In our case, laparotomy was chosen based on the patient's history of uterine fibroids, the considerable size of the pelvic mass, and the absence of malignant features such as ascites, lymphadenopathy, or metastases. Surgical exploration enabled confirmation of the diagnosis and effective management of the lesion.

Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age. They are frequently asymptomatic but can occasionally lead to complications such as abnormal uterine bleeding, pelvic pain, or mass effect due to compression of adjacent organs [ [1] , [2] , [3] ]. Degenerative changes—particularly cystic and hemorrhagic (also referred to as red degeneration) are relatively rare and may simulate adnexal or ovarian neoplasms, thereby complicating the differential diagnosis [ 4 , 5 ]. While transvaginal ultrasonography remains the first-line imaging modality, magnetic resonance imaging (MRI) offers superior soft tissue contrast and is particularly valuable for characterizing atypical or complex lesions [ 6 , 7 ]. We report a case of a pedunculated subserosal leiomyoma with mixed cystic and hemorrhagic degeneration mimicking an ovarian mass, highlighting the crucial role of imaging in establishing an accurate diagnosis.