Clinical update of smooth muscle tumors of the uterus

Large Submucosal Uterine Leiomyoma Prolapse Into the Vagina After Complicating a Pregnancy: A Case Report

Uterine leiomyomas are the most common pelvic neoplasm in females. They are non-cancerous monoclonal tumors that develop from the fibroblasts and smooth muscle cells of the myometrium. They can develop in females of reproductive age and post-menopausal as well. When symptomatic, they frequently manifest as abnormal uterine bleeding and/or pelvic pain or pressure. Reproductive effects are also possible in fibroids such as infertility and poor pregnancy outcomes. In this report, we present a case of a 39-year-old woman, G9P4A4, GA 16 weeks who came to the ER with an incomplete abortion at home after which she had large multiple uterine submucosal fibroids prolapsing into the vagina. On ultrasound, the placenta was still inside, and a large submucosal anterior uterine fibroid and a posterior uterine fibroid were found with sizes 10x10 cm and 2x3, respectively. Evacuation and curettage (E&C) could not be completed because fibroids were obstructing and limiting the access. The patient was managed medically and then discharged, after which she came back with prolapsing uterine fibroids and part of the placenta. In the end, she was managed by hysteroscopic myomectomy.

Lipoleiomyomas of the Uterine Cervix: A New Series including the First Recurrent Case and the First Systematic Literature Review

Uterine leiomyomas usually arise from the uterine body (95%), and rarely from the cervix (0.6%) or other urogenital sites. Lipoleiomyomas are benign, uncommon variants of leiomyomas (0.03-0.2%), histologically composed of smooth muscle cells and mature adipocytes; they usually occur in the uterine body and exceptionally in the cervix. We performed the first systematic literature review of cervical lipoleiomyomas (PRISMA guidelines), presenting five new cases. Including our series, thirty-one detailed cases were reported in the literature (mainly in Asia). The age range was 35-74 years, revealing a higher mean age than conventional cervical leiomyomas (46.5 vs. 39.4 years). Patients were usually multiparous (94%), typically complaining of vaginal bleeding (11/31, 36%), pelvic/abdominal pain (10/31, 32%), and/or urinary disturbances (6/31, 19%) 1 week to 10 months before presentation. Clinical examination revealed a pedunculated tumor (48%), or prolapse of ≥1 pelvic organs (16%). Twenty-four (77%) patients underwent total hysterectomy ± additional surgery; simple myomectomy/excision was performed in five (16%) cases. Only one (3%) of our cases recurred 2 years after partial excision; no evidence of disease was found 13 years after recurrence excision. Adipocytes occupied ≤50% of the tumor volume. Hyaline or myxoid changes and cartilaginous metaplasia were uncommon histological findings. Surgically challenging cases or pregnant patients may require expert gynecologists. Interventional radiology or conservative treatments were rarely proposed.

The assessment of the relationship between the vascularity of FIGO Type 4-7 leiomyomas and abnormal uterine bleeding

The current study aimed to analyse and compare the vascularity of FIGO Type 4-7 leiomyoma specimens obtained from women with or without abnormal uterine bleeding (AUB). The records of 31 women who underwent myomectomy for FIGO Type 4-7 leiomyomas in a university hospital setting were analysed. Group I (n = 16) was composed of women that were symptomatic for AUB and group II (n = 15) consisted of asymptomatic cases. The myomectomy material(s) of each case were processed with CD34 staining and evaluated by Image J^® software (Image J 1.52a, Wayne Rasband National Institutes of Health, Bethesda, MD). There was no statistically significant difference between the rates of vascular areas in the specimens of the two groups (p>.05). Although areas with large vessels were higher in group I compared to group II, the difference did not reach statistical significance (p>.05). AUB caused by FIGO Type 4-7 leiomyomas seems to be related to factors other than vascular density.Impact StatementWhat is already known on this subject? Uterine leiomyomas are the most common benign gynaecologic neoplasms with a prevalence of approximately 40% in women of reproductive age. They are most often asymptomatic but when symptomatic, abnormal uterine bleeding (AUB) is one of the most commonly observed symptoms. Although there are some hypothetical explanations, the exact pathogenesis underlying leiomyoma-associated AUB has not yet been elucidated. Almost a century ago, the vascular abnormalities of fibroids were hypothesised as one of the etiopathological factors correlated with clinical symptoms, such as AUB, and current data suggest that the vascular map of leiomyomas consists of an avascular core surrounded by a vascularised capsule. To our knowledge, there are no studies in the literature comparing the histopathological evaluation of the vascularity scores of FIGO Type 4-7 leiomyomas in symptomatic (with AUB) and asymptomatic (without AUB) women.What the results of this study add? The study revealed that there was no statistically significant difference between the vascularity scores of FIGO Type 4-7 leiomyomas excised from the symptomatic and asymptomatic women. Large vessel densities also did not statistically significantly differ between the two groups.What the implications are of these findings for clinical practice and/or further research? This study revealed that AUB caused by FIGO Type 4-7 leiomyomas was related to factors other than vascular density.

Current Treatment Options for Cervical Leiomyomas: A Systematic Review of Literature

Background and objectives: Cervical leiomyomas are a rare benign disease. Although they are mainly treated surgically, currently, there is not a standardized treatment for cervical leiomyomas. This study aims to summarize current literature evidence about treatment options for cervical leiomyomas. Materials and methods: A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, including observational prospective and retrospective studies, case series and case reports. We collected data regarding studies related to treatment options for cervical leiomyomas, evaluating the following aspects: study design, population, treatment type, rate of surgical complications, and fertility outcome. Results: According to literature research, 38 articles were included. Among 214 patients, the weighted average age was 39.4 years-old; 23 patients were pregnant. Most of the leiomyomas (78%) were extracervical; in 22% of cases (29 patients) were intracervical; 188 patients (88%) received surgical treatment, 6 (3%) received exclusive conservative management and 21 (10%) underwent interventional radiology treatment. One hundred twenty-seven patients (67.5%) underwent myomectomy, while 54 (28.7%) and 7 (3.7%) hysterectomy and trachelectomy, respectively. Cervical myomectomy was performed by open surgery in 21 out of 127 cases (16.5%), while in 92 (72.4%) and 6 (4.7%) patients the surgical approach was performed by traditional and robot-assisted laparoscopy, respectively. The total rate of surgical complications was 5.6%. Conclusion: Surgery is the primary therapeutic option for cervical leiomyomas with a low rate of surgical complications. Interventional radiology techniques have reported promising but still limited results.

Obstruction of the Hepatic Venous Flow Caused by Intravenous Leiomyomatosis

Budd–Chiari syndrome (BCS) is a rare intrahepatic vascular disease that is characterized by a hepatic venous outflow obstruction. Intravenous leiomyomatosis (ILs) is a rare complication of a myoma. Here, we report a case of BCS that was caused by intracaval ILs. A woman presented to the emergency department (ED) with abdominal distension that had gradually progressed over a period of 3 years. Bedside ultrasonography and contrast-enhanced computed tomography (CECT) showed a large ascites and pelvic mass. The mass continued to the inferior vena cava and the right atrium. The intracaval mass was obstructing the left and middle hepatic veins. We established a tentative diagnosis of BCS caused by intracaval ILs and attempted surgical resection. Complete resection of the intracaval mass failed because of adhesion; however, she was discharged from the hospital without any postoperative complications. After 3 months, a pelvic ultrasonography showed a recurrence of a 4 × 3 cm pelvic mass. The mass size increased to 6 cm after 30 months. ILs can cause secondary BCS and can lead to life-threatening conditions. Owing to its extreme rarity, early detection in the ED is challenging. Bedside ultrasonography and CECT can enable the early recognition of BCS by ILs.

Disseminated peritoneal leiomyomatosis: an unusual presentation of intra-abdominal lesion mimicking disseminated malignancy

Leiomyoma are commonly seen as benign smooth muscle tumors of the uterus. Smooth muscle tumors with unusual growth pattern are rare and include 3 primary neoplasms: intravenous leiomyomatosis (IVL), benign metastasizing leiomyoma (BML) and disseminated peritoneal leiomyomatosis (DPL). DPL is a rare benign disease, often giving the appearance of metastatic ovarian or peritoneal carcinoma. It is a disease that predominately affects women at their reproductive age. The risk of malignant transformation is 2–5%. There are no standard treatment guidelines for the management of the DPL. The unusual presentation of the disease delays the diagnosis or is often misdiagnosed and thus over treated, which may lead to increased morbidity and mortality. Therefore careful consideration and high index of suspicion is required for the proper management of such cases.

Aberrant uterine leiomyomas with extrauterine manifestation: intravenous leiomyomatosis and benign metastasizing leiomyomas

Objective

Intravenous leiomyomatosis (IVL) and benign metastasizing leiomyoma (BML) are uncommon variants of benign uterine leiomyomas with extrauterine manifestations. Categorizing the extent of disease allows clinicians to delineate the clinical spectrum and the level of sophistication for complete surgical resection.

Methods

Twelve patients with IVL and BML were reviewed. They were divided into early versus late stage disease groups, and initial manifestation, clinical characteristics, laboratory values, surgical pathology, and follow up data were summarized.

Results

Patients were mostly pre- or peri-menopausal and parous. Patients with late stage disease were more likely to present with cardiac symptoms or abnormal findings on chest X-ray, whereas those with early stage disease presented with classical leiomyoma symptoms including heavy menstrual bleeding, increased myoma size, or lower abdominal discomfort. Tumor marker levels were within normal ranges. A trend of higher neutrophil to leukocyte ratio was observed in the late versus the early stage group (10.4 vs. 1.51, P=0.07); the platelet leukocyte ratio was statistically higher in patients with late stage IVL (0.23 vs. 0.13, P=0.04). The overall recurrence rate was 25%. No recurrence was observed in stage I or stage III IVL groups, while 50% of the stage II IVL group showed recurrence in the pelvic cavity.

Conclusion

IVL and BML are benign myoma variants with paradoxically metastatic clinical presentation. Careful inquiry of systemic symptoms, the presence of underlying systemic inflammation, and a high index of suspicion are required for preoperative diagnosis. Furthermore, a multidisciplinary approach is necessary to improve outcomes of surgical resection.

ERα inhibited myocardin-induced differentiation in uterine fibroids

Uterine fibroids, also known as uterine leiomyomas, are a benign tumor of the human uterus and the commonest estrogen-dependent benign tumor found in women. Myocardin is an important transcriptional regulator in smooth and cardiac muscle development. The role of myocardin and its relationship with ERα in uterine fibroids have barely been addressed. We noticed that the expression of myocardin was markedly reduced in human uterine fibroid tissue compared with corresponding normal or adjacent myometrium tissue. Here we reported that myocardin induced the transcription and expression of differentiation markers SM22α and alpha smooth muscle actin (α-SMA) in rat primary uterine smooth muscle cells (USMCs) and this effect was inhibited by ERα. Notably, we showed that, ERα induced expression of proliferation markers PCNA and ki-67 in rat primary USMCs. We also found ERα interacted with myocardin and formed complex to bind to CArG box and inhibit the SM22α promoter activity. Furthermore, ERα inhibited the transcription and expression of myocardin, and reduced the levels of transcription and expression of downstream target SM22α, a SMC differentiation marker. Our data thus provided important and novel insights into how ERα and myocardin interact to control the cell differentiation and proliferation of USMCs. Thus, it may provide potential therapeutic target for uterine fibroids.

Treatment of Intravenous Leiomyomatosis with Cardiac Extension following Incomplete Resection

Aim. Intravenous leiomyomatosis (IVL) with cardiac extension (CE) is a rare variant of benign uterine leiomyoma. Incomplete resection has a recurrence rate of over 30%. Different hormonal treatments have been described following incomplete resection; however no standard therapy currently exists. We review the literature for medical treatments options following incomplete resection of IVL with CE. Methods. Electronic databases were searched for all studies reporting IVL with CE. These studies were then searched for reports of patients with inoperable or incomplete resection and any further medical treatments. Our database was searched for patients with medical therapy following incomplete resection of IVL with CE and their results were included. Results. All studies were either case reports or case series. Five literature reviews confirm that surgery is the only treatment to achieve cure. The uses of progesterone, estrogen modulation, gonadotropin-releasing hormone antagonism, and aromatase inhibition have been described following incomplete resection. Currently no studies have reviewed the outcomes of these treatments. Conclusions. Complete surgical resection is the only means of cure for IVL with CE, while multiple hormonal therapies have been used with varying results following incomplete resection. Aromatase inhibitors are the only reported treatment to prevent tumor progression or recurrence in patients with incompletely resected IVL with CE.

Cellular leiomyoma with necrosis and mucinous degeneration presenting as pseudo-Meigs' syndrome with elevated CA125

Pseudo-Meigs' syndrome is a syndrome rarely caused by leiomyomas. Elevated CA125 usually suggests malignancy of the ovary. No reported case of pseudo-Meigs' syndrome presenting with necrosis and mucinous degeneration of uterine cellular leiomyomas (CLs) and an elevated CA125 level was found upon a PubMed search. A 37-year-old woman presenting with massive ascites, bilateral pleural effusions and a pelvic mass measuring 20 x 18 x 10 cm is described. The pre-operative serum CA125 was 920.4 U/ml. After total abdominal hysterectomy and partial omentumectomy, the final pathologic diagnosis was CL with focal hemorrhage, necrosis and mucinous degeneration. The ascites and pleural effusion disappeared, and the CA125 level returned to normal in one month. Benign leiomyoma accompanied by pseudo-Meigs' syndrome and elevated serum CA125 can mimic a pelvic malignancy.

A retrospective analysis of the clinicopathologic characteristics of uterine cellular leiomyomas in China

OBJECTIVE

To investigate the clinicopathologic features of uterine cellular leiomyomas (CLs) by comparing them with those of uterine leiomyosarcomas (LMSs).

METHODS

A case-control study comparing 78 cases of CL with 10 cases of LMS was conducted. The patients' records were reviewed to abstract information on tumors features and treatment, immunohistochemical findings, and disease prognosis.

RESULTS

The mean age at diagnosis was 45.3 ± 8.41 years in the CL group. The main clinical CL manifestations were menstrual abnormalities (56.4%), abdominal pain or distension (14.1%), and pelvic pressure (8.9%). Abdominal pain or distension was significantly more common in the LMS than in the CL group (P<0.05). Generally, CL tumors were smaller in diameter than LMS tumors (P<0.05). Moreover, lower levels of Ki-67 and PCNA expression were measured in CL than in LMS tumors (P<0.05). There were no cases of malignant transformation or metastasis in 41 patients with CL who adhered to long-tern follow-up.

CONCLUSION

No symptoms were found to be specifically associated with CL, and management of CL does not need to differ from that of ordinary leiomyoma. In contrast to malignant disease, CL has a favorable long-term prognosis. However, given its "borderline" pathologic nature, patients with CL require clinical surveillance.

Successful pregnancy outcome after laparoscopic-assisted excision of a bizarre leiomyoma: a case report

Introduction

Bizarre leiomyoma is a rare leiomyoma variant that requires a precise histopathological evaluation. Especially when diagnosed in a younger woman, this tumor leads to challenging treatment issues involving fertility preservation. Owing to the low incidence of bizarre leiomyoma, there is insufficient evidence to support myomectomy alone as an appropriate management option. Also, the impact of bizarre leiomyoma on fertility is not well known.

Case presentation

A 30-year-old Japanese woman who had never given birth was referred to us because of a uterine tumor with an unusual diagnostic image and was treated by a gasless laparoscopic-assisted excision with a wound retractor. Owing to an unclear margin between her uterine tumor and myometrium, a concomitant excision of adjacent myometrial tissue was required to achieve the maximum resection of her tumor. The histopathological diagnosis was bizarre leiomyoma. Seven months later, she conceived spontaneously and her pregnancy course was uneventful. At 37 weeks of gestation, an elective cesarean section was performed. Although a slight omental adhesion was noted at the postexcisional scar, her uterine wall structure was well preserved and a recurrence of bizarre leiomyoma was not noted.

Conclusions

A laparoscopic-assisted excision of bizarre leiomyoma is a feasible and minimally invasive conservative measure for a woman who wishes to preserve fertility.

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy for cervical myoma

OBJECTIVE

To report our initial experience with temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy (LAVH) for cervical myoma.

STUDY DESIGN

Thirteen patients with cervical myoma were treated by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries from September 2008 to October 2010. Preoperative evaluation of cervical myoma was made by ultrasonography, magnetic resonance imaging and three-dimensional computerized tomographic angiography, and curative management was made by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries.

RESULTS

Nine patients with extracervical myoma and 4 patients with intracervical myoma were successfully managed by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries. For extracervical myomas, the median extirpated uterine weight was 591 g (range 360-1010 g). Median duration required for placement of balloon occlusion catheter was 60 min (range 47-69 min). Median surgical duration was 98.5 min (range 77-149 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 66 min (range 42-98 min). The median estimated blood loss was 355 mL (range 50-1950 mL). For intracervical myomas, the median extirpated uterine weight was 513 g (range 302-710 g). Median duration required for placement of balloon occlusion catheter was 63 min (range 42-76 min). Median surgical duration was 96.5 min (range 92-100 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 49 min (range 44-60 min). The median estimated blood loss was 210 mL (range 150-650 mL). Transfusion of preoperatively donated autologous blood negated the need for bank blood. There were no major interventional radiological and surgical complications in the present case series.

CONCLUSIONS

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries is a feasible minimally invasive alternative to control hemorrhage during LAVH for cervical myoma.

Uterine smooth-muscle tumors with unusual growth patterns

Uterine smooth-muscle tumors with unusual growth patterns include a variety of neoplastic lesions characterized histologically by their similarity to adult smooth muscle tissue. The 3 primary neoplasms are intravenous leiomyomatosis, benign metastasizing leiomyoma, and leiomyomatosis peritonealis disseminata. We present a review of the recent literature along with the clinical and pathologic features of 5 illustrative cases from Mayo Clinic Arizona, Scottsdale.

Laparoscopic management of large myomas

The objective of this article is to review the different techniques that have been adopted for removal of large myomas laparoscopically. We have also quoted literature about the impact of myomas on Pregnancy and obstetrical outcome and the effect of laparoscopic myomectomy on the same. Technical modifications to remove large myomas have been described along with methods to reduce intraoperative bleeding. This comprehensive review describes all possibilities of laparoscopic myomectomy irrespective of size, site and number.