The critical clinical questions to the radiologist in the setting of adnexal lesions are the site of origin, benign versus malignant features, and presence of infection or abscess. Pairing clinical presentation and imaging findings will direct appropriate management, whether it is reassurance, follow-up imaging, or surgery.

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Leiomyomas are the most common neoplasm found in the uterus and can present with a variety of symptoms or be entirely asymptomatic. Most often, the characteristic imaging appearance of leiomyoma does not pose a diagnostic dilemma. However, leiomyomas can demonstrate atypical imaging features that may be confusing. It is essential for the radiologist to be aware of both the typical and atypical findings to better assist the referring clinician with diagnosis and management decisions. Additionally, as uterine-sparing treatment alternatives with locoregional therapies become more popular, it is important to be aware of pre- and post-procedural imaging questions that may be encountered. Lastly, when atypical features are seen, it is important to understand the characteristics that may suggest a diagnosis of leiomyosarcoma. The goal of this study is to review imaging features of atypical leiomyoma with case-based examples.