Disseminated peritoneal leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenetic findings of uterine leiomyoma

Iatrogenic Parasitic Leiomyoma in the Lower Right Abdomen: A Rare Case in Plastic Surgery

A parasitic leiomyoma has no connection with the uterus itself and obtains its blood supply from the surrounding tissues. A parasitic leiomyoma that develops iatrogenically is called an iatrogenic parasitic leiomyoma. Clinical reports on parasitic leiomyoma are common in gynecology but not in plastic surgery. We report a rare case of an iatrogenic parasitic leiomyoma in a 46-year-old woman who was referred to our plastic surgery department. She presented with the main complaint of a subcutaneous mass in the lower right abdomen and had a history of laparoscopic myomectomy eight years ago. Magnetic resonance imaging showed two masses in the subcutaneous tissue of the lower right abdomen and the posterior rectus abdominis. The excision of these masses was performed through an abdominal wall incision. Histopathological examination revealed that the extracted mass was a leiomyoma. Plastic surgeons must keep in mind the appropriate management of rare cases of parasitic leiomyoma.

Leiomyoma-like Morphology in Metastatic Uterine Inflammatory Myofibroblastic Tumors

Uterine inflammatory myofibroblastic tumors (IMTs) are rare mesenchymal neoplasms that frequently harbor ALK gene rearrangements and have a low risk of metastasis. We reported 3 of these tumors mimicking the appearance of leiomyoma in their recurrence. These patients were 34, 43, and 45 years old. Two uterine tumors demonstrated classic morphology, with combined myxoid, compact fascicular, and hyalinized patterns and spindled cells with bipolar cytoplasmic processes, moderate atypia, and lymphoplasmacytic inflammatory infiltrates. The third had a "leiomyoma-like" appearance, with fascicles of plump spindled cells and a sparse lymphoplasmacytic infiltrate. ALK immunohistochemistry was positive in all the tumors, and all demonstrated ALK rearrangements using fluorescence in situ hybridization (n = 2) and/or RNA sequencing (n = 2). Two classic IMTs recurred at 3 and 50 months in the lung and abdomen, respectively, and recurrent tumors had a "leiomyoma-like" appearance, with 0 and 1 mitosis per 10 high-power fields, no inflammation in 1, and a sparse lymphocytic infiltrate in the other. ALK was positive in both tumors; 1 with available tissue showed an IGFBP5::ALK fusion using RNA sequencing. The third patient, who had a "leiomyoma-like" uterine tumor, experienced multiple recurrences, first in the abdomen at 100 months showing a similar appearance. Subsequent recurrence at 105 months showed transmural invasion of the sigmoid colon and a similar microscopic appearance but with the addition of infiltrative borders, moderate cellularity, mild-to-moderate atypia, and 10 mitoses per 10 high-power fields. Both recurrences were positive for ALK, and RNA sequencing revealed the same ACTG2::ALK fusion transcript identified in the primary tumor. The patient was treated with crizotinib, resulting in prolonged clinical remission, with no evidence of disease at 168 months from the initial surgery. Although "leiomyoma-like" uterine IMTs have been recently described, to our knowledge, this is the first report of recurrence of these tumors and the first report of a "leiomyoma-like" appearance in the recurrences of conventional uterine IMTs. A low threshold for performing ALK immunohistochemistry on recurrent uterine tumors can identify patients who may benefit from tyrosine kinase inhibitors.

Two oncomiRs, miR-182-5p and miR-103a-3p, Involved in Intravenous Leiomyomatosis

Leiomyomas, also referred to as fibroids, belong to the most common type of benign tumors developing in the myometrium of the uterus. Intravenous leiomyomatosis (IVL) tends to be regarded as a rare type of uterine leiomyoma. IVL tumors are characterized by muscle cell masses developing within the uterine and extrauterine venous system. The underlying mechanism responsible for the proliferation of these lesions is still unknown. The aim of the study was to investigate the expression of the two epigenetic factors, oncomiRs miR-182-5p and miR-103a-3p, in intravenous leiomyomatosis. This study was divided into two stages: initially, miR-182-5p and miR-103a-3p expression was assessed in samples coming from intravenous leiomyomatosis localized in myometrium (group I, n = 6), intravenous leiomyomatosis beyond the uterus (group II; n = 5), and the control group, i.e., intramural leiomyomas (group III; n = 9). The expression level of miR-182-5p was significantly higher in samples coming from intravenous leiomyomatosis (group I and group II) as compared to the control group (p = 0.029 and p = 0.024, respectively). In the second part of the study, the expression levels of the studied oncomiRs were compared between seven samples delivered from one woman during a four-year observation. The long-term follow-up of one patient demonstrated significantly elevated levels of both studied oncomiRs in intravenous leiomyomatosis in comparison to intramural leiomyoma samples.

Disseminated peritoneal leiomyomatosis as an incidental finding: A case report

We present the case of a 23-year-old female with multiple diffuse and nodular masses of different sizes involving predominantly the posterior wall of the uterus, omentum, and peritoneum which were histopathologically confirmed to be disseminated peritoneal leiomyomatosis. Meticulous investigation and accurate diagnosis are of utmost importance for the establishment of the correct diagnosis. Additionally, proper management of the patient while considering choice of the patients including close follow-up of the patients is mandatory for the reason of ensuring early detection of recurrence.

Preclinical safety testing and initial experience of a morcellation bag with four sealable ports

Electromechanical morcellation-so called power morcellation-is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11-24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4-14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20-194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13-896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0-39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies.

Treatment of leiomyomatosis peritonealis disseminata with goserelin acetate: A case report and review of the literature

BACKGROUND

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition characterized by multiple pelvic and abdominal nodules, which are composed of smooth-muscle cells. To date, no more than 200 cases have been reported. The diagnosis of LPD is difficult and there are no guidelines on the treatment of LPD. Currently, surgical excision is the mainstay. However, hormone blockade therapy can be an alternative choice.

CASE SUMMARY

A 33-year-old female patient with abdominal discomfort and palpable abdominal masses was admitted to our hospital. She had undergone four surgeries related to uterine leiomyoma in the past 8 years. Computed tomography revealed multiple nodules scattered within the abdominal wall and peritoneal cavity. Her symptoms and the result of the core-needle biopsy were consistent with LPD. The patient refused surgery and was then treated with tamoxifen, ulipristal acetate (a selective progesterone receptor modulator), and goserelin acetate (a gonadotropin-releasing hormone agonist). Both tamoxifen and ulipristal acetate were not effective in controlling the disease progression. However, the patient achieved an excellent response when goserelin acetate was attempted with relieved syndromes and obvious shrinkage of nodules. The largest nodule showed a 25% decrease in the sum of the longest diameters from pretreatment to posttreatment. Up to now, 2 years have elapsed and the patient remains asymptomatic and there is no development of further nodules.

CONCLUSION

Goserelin acetate is effective for the management of LPD. The long-term use of goserelin acetate is thought to be safe and effective. Hormone blockade therapy can replace repeated surgical excision in recurrent patients.

Extrauterine adenomyoma located in the inguinal region: a case report of a 44-year-old woman

Adenomyomas are benign tumours made of smooth muscle cells, endometrial glands and stroma. An extrauterine location is extremely rare with an unknown pathogenesis. Preoperative diagnosis is challenging and pathologic examination is necessary to confirm the diagnosis. Here we present a case report of a 44-year-old woman with a painful non-reducible mass in the right inguinal region without fever or other alarming symptoms 2 months after a laparoscopic hysterectomy. She was treated with a surgical resection of the mass. Extrauterine adenomyoma is a very uncommon entity. Preoperative workup is challenging, as confirmation of the diagnosis can only be achieved by histopathological analysis following surgical excision.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

OBJECTIVE

This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas.

DATA SOURCES

Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020.

METHODS OF STUDY SELECTION

Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis.

TABULATION, INTEGRATION, AND RESULTS

The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen.

CONCLUSION

Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany

PURPOSE

During the last decade, electromechanical power morcellation (EMM) was more frequently used but it may be associated with the dissemination of occult malignancies. The aim of the present study was to determine the frequency of unexpected uterine malignancies after EMM.

METHODS

This retrospective study consisted of patients who were treated at three departments of Gynecology in Germany from 2008 to 2017. We identified women who underwent an operation with the use of EMM. Clinical records, risk factors, and the outcomes of the patients were reviewed.

RESULTS

We performed an analysis of 1683 patients who had undergone laparoscopic supracervical hysterectomy (LASH), total hysterectomy, or myomectomy (LM) (48.6%, 8.4%, and 43.0%, respectively). Unexpected malignancies were detected in 4 of 1683 patients (0.24%). In all cases, the malignancy proved to be a sarcoma and was detected after LASH. All patients with occult sarcomas were older than 45 years and the most common (75%) risk factor was the appearance of a solitary tumor. The patients underwent secondary laparotomy for complete oncological staging, and no histological dissemination of the sarcoma was registered. Two patients had a recurrence. At the final follow-up investigation all four patients were in good general health.

CONCLUSION

Occult malignancies are liable to spread after EMM, although the overall risk of being diagnosed with an occult malignancy and the risk of dissemination appear to be low. Once the preoperative diagnostic investigation has yielded no suspicious findings, laparoscopic morcellation may be considered a safe method, especially LM in patients of reproductive age.

A clinicopathological and molecular analysis in uterine leiomyomas and concurrent/metachronous peritoneal nodules: New insights into disseminated peritoneal leiomyomatosis

Disseminated peritoneal leiomyomatosis (DPL) is a rare, benign entity, but DPL following morcellation has become a major concern recently. This study aimed to investigate the molecular relationship between uterine leiomyoma and DPL. We analyzed the clinicopathological and molecular features of 8 DPL patients including 6 (#3-8) with and 2 (#1 and 2) without antecedent morcellation. Patients 1 and 2 were characterized by numerous, small peritoneal nodules whereas patients 4-8 harbored less but larger peritoneal nodules. Patient 3 had a peritoneal carcinomatosis-like dissemination, but she has been alive with disease for 68 months. Histological examination confirmed the diagnosis of leiomyomas in the uterus and extra-uterine sites. Immunohistochemistry demonstrated that both uterine and extra-uterine tumors were invariably positive for HMGA2 and MED12. MED12 mutation (c.130 G > A, p.G44S) was found in original uterine (n = 3) and peritoneal (n = 11) tumors from patients 3, 6, 7 and 8. Microsatellite instability at TPOX and D19S433 was observed in the uterine leiomyoma (patient 2) whereas LOH at CSF1PO was found in the peritoneal tumors (patient 1). D13S317 LOH was present in both uterine and peritoneal tumors detected (patient 8). However, D3S1358 LOH and D19S433 LOH was only found in the peritoneal tumors (patient 8) and recurrent tumors (patient 3), respectively. We suggested that DPLs following morcellation might be closely associated with original uterine leiomyomas. DPLs with and without prior morcellation may harbor different pathogenetic pathways. These findings are critical for the clinical intervention and prevention of DPL patients.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.

Leiomyomatosis Peritonealis Disseminata: A Clinical Analysis of 13 Cases and Literature Review

Objective. Leiomyomatosis peritonealis disseminata (LPD) is a rare benign disease that is characterized by numerous small muscle nodules disseminated in the abdominal and pelvic cavity. This study analyzed the clinical features, pathologic characteristics, and prognosis of LPD. Methods. We retrospectively analyzed the clinical data of 13 patients with pathologically diagnosed LPD in Shengjing Hospital of China Medical University from January 2001 to January 2018. Results. Overall, 13 cases were collected. The mean age of the 13 patients was 42.23 years (range = 26-51 years). In all 13 female patients, 11 had a surgical history related to uterine leiomyoma, and only 2 had no history of treatment. Most of them were asymptomatic. Thirteen patients underwent resections of the tumors by laparoscopy or laparotomy. Pathological reports of 13 cases indicated LPD. Twelve cases were followed up, and 1 case was lost to follow-up. The median follow-up time was 65.67 months, and 2 patients showed evidence of recurrence. Conclusions. LPD is a rare disease in women of reproductive age. LPD manifests atypical symptoms, which can be easily misdiagnosed and confirmed by the pathological diagnosis. Surgery is the main treatment. Although LPD is a benign disease, a few patients had a tendency for recurrence or malignancy. Therefore, strict follow-up is needed.

Disseminated peritoneal leiomyomatosis following laparoscopic myomectomy: a case report

Disseminated peritoneal leiomyomatosis (DPL) is a rare benign disease characterized by tumors derived from smooth muscles throughout the abdominal cavity. DPL has been reported following laparoscopic myomectomy or hysterectomy; however, few reports have described DPL after abdominal myomectomy or hysterectomy. In the present case, two intra-abdominal masses were incidentally discovered on imaging during a routine medical checkup of a 45-year-old woman who had undergone laparoscopic uterine myomectomy 10 years previously. The masses were later found to be near the ascending colon and between the liver and right kidney. A malignancy or stromal tumor was suspected, and the patient underwent exploratory surgery. Histopathologic examination revealed that the masses were leiomyomas. Considering the patient’s history of gynecologic surgery, we believe that this was a rare case of DPL following laparoscopic uterine myomectomy.

Simultaneously occurring disseminated peritoneal leiomyomatosis and multiple extrauterine adenomyomas following hysterectomy

Disseminated peritoneal leiomyomatosis (DPL), also known as leiomyomatosis peritonealis disseminata, is a rare condition characterized by multiple benign smooth muscle tumors proliferating along the peritoneal surfaces. In previous case reports, these tumors have been noted to involve the ovaries, round ligaments, bladder, bowel, peritoneum, and mesentery. To date, approximately 150 cases of DPL have been described in the literature. Extrauterine adenomyoma is an even rarer entity, involving benign tumors composed of smooth muscle tissue, endometrial glands, and endometrial stroma arising outside the uterus. Only 22 cases have previously been reported. We describe a woman presenting with both DPL and multiple extrauterine adenomyomas several years after undergoing laparoscopic morcellated hysterectomy.

Prevention and Management of Complications in Laparoscopic Myomectomy

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

Non-surgical intervention for retroperitoneal lymphogenic and pulmonary metastases of a benign leiomyoma: treatment with ulipristal acetate

This case report describes a very rare coexistence of retroperitoneal lymphogenic and pulmonary metastases of a benign leiomyoma: benign metastasising leiomyoma (BML). Despite surgical treatment growth of multiple nodules in the lungs, omentum, mesenterium and retroperitoneum was observed by CT scan. We started off-label ulipristal acetate treatment with impressive results. The lesions on the CT scan disappeared, and the patient was asymptomatic after treatment.

Multilocular cystic leiomyoma of the anterolateral abdominal wall: A case report and literature review

RATIONALE

Leiomyomas arising from the anterolateral abdominal wall are uncommon, and their pathogenesis remains unknown. We present the 15th case of such a tumor, having this unique tumor morphology, followed by a detailed discussion on disease pathogenesis.

PATIENT CONCERNS

A 48-year-old, asymptomatic perimenopausal, multiparous Japanese woman presented with a left-sided pelvic mass. She had no history of previous surgeries or uterine leiomyomas. Although a transabdominal ultrasonogram raised suspicions of an ovarian tumor, a transvaginal ultrasonogram confirmed normal ovaries. Radiological images showed a multilocular cystic mass with enhanced solid lesions connected to the uterus. Retrospective radiological evaluation showed that the mass was largely connected to the peritoneum of the anterolateral abdominal wall.

INTERVENTIONS

Intraoperatively, the mass appeared as a dome-like protrusion from the left lower quadrant of the abdominal wall, without connection to the uterus, ovaries, or the left round ligament. No other peritoneal masses were seen. The mass was easily enucleated from the abdominal wall. Pathology confirmed that the mass was a leiomyoma with hydropic and myxoid degeneration. No striated muscle tissues were noted between the tumor and resection margin, but a thin smooth muscle layer, positive for hormone receptors, was present at the periphery, suggesting the origin of the tumor.

LESSONS

Benign leiomyomas of the anterolateral abdominal wall likely originate from Müllerian-like smooth muscle remnants in this region. They should be considered in the differential diagnosis of solid and cystic masses and be distinguished from uterine and ovarian masses on imaging to avoid unnecessary organ resection.

Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery

PURPOSE

This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma.

METHOD

A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation.

RESULTS

Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids.

CONCLUSION

During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.

Disseminated Peritoneal Leiomyomatosis Status Post Laparoscopic Hysterectomy with Morcellation

Uterine leiomyomas (fibroids) are common benign neoplasms, which develop from the muscular tissue of the uterus with an estimated incidence of 20-40% in women of reproductive age. In the early nineties, power morcellators were introduced and became commonly used during hysterectomy for symptomatic fibroids. However, if all fragments are not removed, they may parasitize to other blood supply and present as abdominal or pelvic masses. Unfortunate cases have also been reported in which uterine sarcomas seeded throughout the abdomen and pelvis secondary to morcellation. The Food and Drug Administration (FDA) estimates that 1 in 350 women undergoing hysterectomy or myomectomy for fibroids is found to have an unsuspected uterine sarcoma. As a result, the FDA issued a press release in 2014 discouraging the use of power morcellators. Recently, the FDA approved a new containment device, the PneumoLiner, for use with certain power morcellation devices. However, it is unknown if this device will help to reduce the risk of seeding fibroids and unsuspected uterine malignancies. We present a case in which a patient who underwent morcellation therapy for symptomatic fibroids presented with recurrent abdominal and pelvic leiomyomas mimicking malignancy.

Parasitic leiomyomas: a systematic review

BACKGROUND

Parasitic leiomyomas were first described as early as 1909 but are a rare condition. In recent years, due to the rise of laparoscopic surgery and power morcellation, several cases of parasitic leiomyomas associated with this surgical procedure have been reported.

METHODS

A literature search was performed using PubMed, Embase and Google Scholar with the following combination of keywords: leiomyoma OR uterine neoplasms OR uterine myomectomy OR laparoscopy OR hysterectomy OR peritoneal neoplasms AND parasitic. Papers describing parasitic leiomyomas were included. The results of these studies are summarized herein.

RESULTS

We retrieved abstracts of 756 papers. Of these, 591 were excluded for not fulfilling the inclusion criteria and 54 were removed as duplicates; after full-text assessment, 8 were rejected for presenting cases of malignancy and finally 103 were included in our systematic review. From these, we present information about 274 patients with parasitic leiomyomas. The mean age of women was 40 years (range 18-79 years); and 154 (56%) had no history of uterine surgery, the others (120, 44%) having had a previous myomectomy or hysterectomy. Of the total, 106 (39%) women had a history of power morcellation. The most frequent clinical symptom was abdominal pain (49%) and the most frequent presentation was disseminated peritoneal leiomyomatosis.

CONCLUSIONS

While parasitic leiomyoma was first described a century ago, the recent introduction of laparoscopic power morcellation has increased the number of reported cases.

Intravenous leiomyomatosis: an unusual intermediate between benign and malignant uterine smooth muscle tumors

Intravenous leiomyomatosis is an unusual smooth muscle neoplasm with quasi-malignant intravascular growth but a histologically banal appearance. Herein, we report expression and molecular cytogenetic analyses of a series of 12 intravenous leiomyomatosis cases to better understand the pathogenesis of intravenous leiomyomatosis. All cases were analyzed for the expression of HMGA2, MDM2, and CDK4 proteins by immunohistochemistry based on our previous finding of der(14)t(12;14)(q14.3;q24) in intravenous leiomyomatosis. Seven of 12 (58%) intravenous leiomyomatosis cases expressed HMGA2, and none expressed MDM2 or CDK4. Colocalization of hybridization signals for probes from the HMGA2 locus (12q14.3) and from 14q24 by interphase fluorescence in situ hybridization (FISH) was detected in a mean of 89.2% of nuclei in HMGA2-positive cases by immunohistochemistry, but in only 12.4% of nuclei in negative cases, indicating an association of HMGA2 expression and this chromosomal rearrangement (P=8.24 × 10(-10)). Four HMGA2-positive cases had greater than two HMGA2 hybridization signals per cell. No cases showed loss of a hybridization signal by interphase FISH for the frequently deleted region of 7q22 in uterine leiomyomata. One intravenous leiomyomatosis case analyzed by array comparative genomic hybridization revealed complex copy number variations. Finally, expression profiling was performed on three intravenous leiomyomatosis cases. Interestingly, hierarchical cluster analysis of the expression profiles revealed segregation of the intravenous leiomyomatosis cases with leiomyosarcoma rather than with myometrium, uterine leiomyoma of the usual histological type, or plexiform leiomyoma. These findings suggest that intravenous leiomyomatosis cases share some molecular cytogenetic characteristics with uterine leiomyoma, and expression profiles similar to that of leiomyosarcoma cases, further supporting their intermediate, quasi-malignant behavior.

Iatrogenic parasitic leiomyoma and leiomyomatosis peritonealis disseminata following uterine morcellation

AIM

To assess the impact of morcellation on the spread of uterine leiomyoma.

METHODS

Cases of parasitic leiomyoma involving prior laparoscopy were collected between 2012 and 2015 in a tertiary women's hospital in China. Their clinicopathological features and the associated reports were reviewed.

RESULTS

All six patients with parasitic leiomyoma had laparoscopic myomectomy or hysterectomy with power morcellation 39-132 months previously. Patient 1 had widely disseminated tumors in the peritoneum and pelvis, in keeping with leiomyomatosis peritonealis disseminata (LPD). She received debulking of peritoneal tumors and lived with disease for 22 months. The implanting sites of the other parasitic tumors (patients 2-6) included the mesentery (n = 2), intestine (n = 1), pelvic parietal (n = 1), bladder (n = 1), and musculus rectus abdominis (n = 1). The diameter varied from 1 cm to 6 cm. The patients underwent abdominal subtotal hysterectomy, cervicectomy or tumor debulking and the postoperative course was unremarkable for a period of 2-32 months. Pathologically, these disseminated or parasitic leiomyomas did not show any evidence of malignancy. There were no morphological or immunohistochemical differences between the original tumor and the following seeding tumors. On literature review, 11 iatrogenic LPD have been reported after laparoscopic surgery for uterine leiomyoma. These cases may provide an alternative pathogenic mechanism for a distinct variant of LPD.

CONCLUSIONS

Laparoscopic hysterectomy with tumor morcellation may increase the chance of tumor implantation and dissemination. Both clinicians and pathologists should be alert to this rare complication.

Parasitic myoma after laparoscopic surgery: a mini-review

The aim of this review is to summarize the cases of parasitic myomas after laparoscopic surgery. A literature search was performed using the PubMed database for the period of January 1997 to December 2014. We used the following keywords: "laparoscopic hysterectomy," "laparoscopic myomectomy," "morcellation," "parasitic fibroids," "parasitic myomas," and "leiomyomatosis." A total of 29 articles meeting the selection criteria were included in our review, describing 53 patients who underwent surgery for parasitic myomas. Parasitic myoma is a rare condition resulting from the small fibroid fragments left after morcellation and can be either asymptomatic or symptomatic. Although it is rare, patients should be informed about the risk of this condition after laparoscopic surgery. It is important for surgeons to look for small fibroid fragments during and after morcellation and make an effort to remove every piece of tissue.

Clonally related uterine leiomyomas are common and display branched tumor evolution

Uterine leiomyomas are extremely frequent benign smooth muscle tumors often presenting as multiple concurrent lesions and causing symptoms such as abnormal menstrual bleeding, abdominal pain and infertility. While most leiomyomas are believed to arise independently, a few studies have encountered separate lesions harboring identical genetic changes, suggesting a common clonal origin. To investigate the frequency of clonally related leiomyomas, genome-wide tools need to be utilized, and thus little is known about this phenomenon. Using MED12 sequencing and SNP arrays, we searched for clonally related uterine leiomyomas in a set of 103 tumors from 14 consecutive patients who entered hysterectomy owing to symptomatic lesions. Whole-genome sequencing was also utilized to study the genomic architecture of clonally related tumors. This revealed four patients to have two or more tumors that were clonally related, all of which lacked MED12 mutations. Furthermore, some tumors were composed of genetically distinct subclones, indicating a nonlinear, branched model of tumor evolution. DEPDC5 was discovered as a novel tumor suppressor gene playing a role in the progression of uterine leiomyomas. Perhaps counterintuitively—considering Knudson's two-hit hypothesis—a large shared deletion was followed by different truncating DEPDC5 mutations in four clonally related leiomyomas. This study provides insight into the intratumor heterogeneity of these tumors and suggests that a shared clonal origin is a common feature of leiomyomas that do not carry an MED12 mutation. These observations also offer one explanation to the common occurrence of multiple concurrent lesions.

A Novel Molecular Cytogenetic Finding of Leiomyomatosis Peritonealis Disseminata

BACKGROUND

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease characterised by the subperitoneal proliferation of smooth muscle cells that form benign nodules. A few studies have aimed to reveal the pathogenesis of LPD without reaching a clear explanation.

METHODS

Karyotype analysis and array-comparative genomic hybridization (aCGH) of a human LPD case were performed to evaluate the role of chromosomal abnormalities in LPD pathogenesis.

RESULTS

The LPD nodules showed a 45, XX, del(7p), t(11; 17) (q23;q25),-22 de novo karyotype, and the aCGH analysis confirmed these deletions at 7p22.3-p12.1 (1,862,362-52,766,911 bp) and 22q11.23-q13.33 (21,973,915-49,265,116 bp) with lengths of 50.9 Mb and 27.3 Mb, respectively.

CONCLUSION

In this study, we described two large novel aberrations - deletions in chromosome 7 and 22 - that might play an important role in LPD disease. These findings might contribute to new insights to unravel the pathogenesis of LPD and develop further clinical treatments. © 2015 S. Karger AG, Basel.

Options on fibroid morcellation: a literature review

In laparoscopy, specimens have to be removed from the abdominal cavity. If the trocar opening or the vaginal outlet is insufficient to pass the specimen, the specimen needs to be reduced. The power morcellator is an instrument with a fast rotating cylindrical knife which aims to divide the tissue into smaller pieces or fragments. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of these power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. This project was initiated by the executive board of the European Society of Gynaecological Endoscopy. A steering committee on fibroid morcellation was installed and experienced ESGE members requested to chair an action group to address distinct clinical questions. Clinical questions were formulated with regards to the sarcoma risk in presumed uterine fibroids, diagnosis of sarcoma, complications of morcellation and future research. A literature review on the different subjects was conducted, systematic if appropriate and feasible. It was concluded that the true prevalence of uterine sarcoma in presumed fibroids is not known given the wide range of prevalences (0.45–0.014 %) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics such as ‘lacunes’ suggesting necrosis and increased central vascularisation of the tumour are associated with a higher risk of uterine sarcoma, although the risks remain low. There is not enough evidence to estimate this risk in individual patients. Complications of morcellation are rare. Reported are direct morcellation injuries to vessels and bowel, the development of so-called parasitic fibroids requiring reintervention and the spread of sarcoma cells in the abdominal cavity, which may possibly or even likely upstaging the disease. Momentarily in-bag morcellation is investigated as it may possibly prevent morcellation complications. Because of lack of evidence, this literature review cannot give strong recommendations but offers only options which are condensed in a flow chart. Prospective data collection may clarify the issue on sarcoma risk in presumed fibroids and technology to extract tissue laparoscopically from the abdominal cavity should be perfected.

Cost-effectiveness of endometrial evaluation prior to morcellation in surgical procedures for prolapse

OBJECTIVE

The objective of the study was to compare the cost-effectiveness of 3 screening options for endometrial cancer in asymptomatic, postmenopausal women prior to undergoing morcellation in minimally invasive supracervical hysterectomy and minimally invasive sacral colpopexy for the treatment of pelvic organ prolapse.

STUDY DESIGN

A decision tree model was constructed to compare no screening, endometrial biopsy, and transvaginal ultrasound for asymptomatic, postmenopausal women prior to surgery. Effectiveness was measured by life-years. The incremental cost-effectiveness ratio, defined as the difference in cost between 2 screening options divided by the difference in life-years between the 2 options, was calculated in 2012 US dollars for endometrial biopsy and transvaginal ultrasound, in comparison with no screening.

RESULTS

Using an endometrial cancer prevalence of 0.6% and a 40% risk of upstaging after morcellation, the expected per-patient cost was $8800, $9023, and $9112 over 5 years for no screening, endometrial biopsy, and transvaginal ultrasound, respectively. The expected life-years saved compared with no screening were 0.00108 for endometrial biopsy and 0.00105 for transvaginal ultrasound, ie, 0.39 and 0.38 days, respectively. The estimated incremental cost-effectiveness ratio was $207,348 for endometrial biopsy and $298,038 for transvaginal ultrasound compared with no screening. A sensitivity analysis showed that the prevalence of endometrial cancer and the risk of endometrial cancer upstaging after morcellation had the greatest impact on the cost-effectiveness of screening.

CONCLUSION

For asymptomatic, postmenopausal women, preoperative endometrial evaluation via endometrial biopsy or transvaginal ultrasound helps improve the preoperative detection of endometrial cancer, but universal screening is not cost effective.

Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms

Background

Power morcellation has become a common technique for the minimally invasive resection of uterine leiomyomas. This technique is associated with dissemination of cellular material throughout the peritoneum. When morcellated uterine tumors are unexpectedly found to be leiomyosarcomas or tumors with atypical features (atypical leiomyoma, smooth muscle tumor of uncertain malignant potential), there may be significant clinical consequences. This study was undertaken to determine the frequency and clinical consequence of intraperitoneal dissemination of these neoplasms.

Methodology/Principal Findings

From 2005–2010, 1091 instances of uterine morcellation were identified at BWH. Unexpected diagnoses of leiomyoma variants or atypical and malignant smooth muscle tumors occurred in 1.2% of cases using power morcellation for uterine masses clinically presumed to be “fibroids” over this period, including one endometrial stromal sarcoma (ESS), one cellular leiomyoma (CL), six atypical leiomyomas (AL), three smooth muscle tumor of uncertain malignant potential (STUMPs), and one leiomyosarcoma (LMS). The rate of unexpected sarcoma after the laparoscopic morcellation procedure was 0.09%, 9-fold higher than the rate currently quoted to patients during pre-procedure briefing, and this rate may increase over time as diagnostically challenging or under-sampled tumors manifest their biological potential. Furthermore, when examining follow-up laparoscopies, both from in-house and consultation cases, disseminated disease occurred in 64.3% of all tumors (zero of one ESS, one of one CL, zero of one AL, four of four STUMPs, and four of seven LMS). Only disseminated leiomyosarcoma, however, was associated with mortality. Procedures are proposed for pathologic evaluation of morcellation specimens and associated follow-up specimens.

Conclusions/Significance

While additional study is warranted, these data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated increase in mortality much higher than appreciated currently.

A genome-wide association study identifies a genetic variant in the SIAH2 locus associated with hormonal receptor-positive breast cancer in Japanese

In Japan, breast cancer is the most common cancer among women and the second leading cause of cancer death among women worldwide. To identify genetic variants associated with the disease susceptibility, we performed a genome-wide association study (GWAS) using a total of 1086 Japanese female patients with hormonal receptor-positive (HRP) breast cancer and 1816 female controls. We selected 33 single-nucleotide polymorphisms (SNPs) with suggestive associations in GWAS (P-value of <1 × 10(-4)) as well as 4 SNPs that were previously implicated their association with breast cancer for further replication by an independent set of 1653 cases and 2797 controls. We identified significant association of the disease with a SNP rs6788895 (P(combined) of 9.43 × 10(-8) with odds ratio (OR) of 1.22) in the SIAH2 (intron of seven in absentia homolog 2) gene on chromosome 3q25.1 where the involvement in estrogen-dependent diseases was suggested. In addition, rs3750817 in intron 2 of the fibroblast growth factor receptor 2 gene, which was reported to be associated with breast cancer susceptibility, was significantly replicated with P(combined) of 8.47 × 10(-8) with OR=1.22. Our results suggest a novel susceptibility locus on chromosome 3q25.1 for a HRP breast cancer.