Epidemiology, Presentation, and Management of Retroperitoneal Leiomyomata: Systematic Literature Review and Case Report

Anesthetic management of a huge retroperitoneal leiomyoma: a case report

BACKGROUND

Retroperitoneal leiomyomas are rare, with just over 100 cases reported in the literature. Perioperative management of retroperitoneal leiomyomas can be challenging due to the large tumor size and the risk of hemorrhage.

CASE PRESENTATION

We report a case of a 40-year-old Han woman with a 40-cm retroperitoneal leiomyoma. General anesthesia was performed for the surgical resection. Key flow parameters like cardiac output and stroke volume variation, as shown by the Vigileo™-FloTrac™ system, enabled the anesthesiologist to implement goal-directed fluid optimization. Acute normovolemic hemodilution and cell salvage technique were used resulting in a successful en bloc tumor resection with a 6000-mL estimated blood loss. Although the patient experienced postoperative bowel obstruction, no other significant complications were observed.

CONCLUSION

Advanced hemodynamic monitoring and modern patient blood management strategies are particularly helpful for anesthetic management of huge retroperitoneal leiomyomas.

Current management of benign retroperitoneal tumors

Benign retroperitoneal tumors (BRT) represent a rare group of heterogeneous diseases. The literature lacks high-quality evidence about the optimal management of BRT, and most of the information available takes the form of case reports or case series. The aim of this review is to provide an overview of current management strategies for adult patients with BRT. A literature search using PubMed indexed articles was conducted and BRT were classified into five different biological subgroups: 1) lipomatous tumors, 2) smooth muscle tumors, 3) peripheral nerve sheath tumors, 4) myofibroblastic tumors, and 5) others. Tumors that are primarily pelvic in origin were excluded. Despite the significant heterogeneity of the disease, several generic considerations have emerged and can be applied to the management of BRT. Specifically, the risk of misdiagnosing a BRT with another pathology such as retroperitoneal sarcoma is notable. When encountered, suspected BRT should therefore be referred to a specialized sarcoma center. Multidisciplinary tumor boards, present at these centers, have a pivotal role in managing BRT. The decision of whether to offer surgery, nonsurgical treatment or a "watch-and-wait" approach should be made after multidisciplinary discussion, depending on tumor histology. Moving forward, collaborative research efforts dedicated to BRT remain crucial in gathering evidence and knowledge to further optimize patient care.

Extrauterine Retroperitoneal Leiomyomas: 3 Case Reports and Review of the Literature

Leiomyomas are benign mesenchymal tumors which originate from smooth muscle cells. Extrauterine leiomyomas are rare and they may arise where smooth muscle cells are found. Their diagnosis is challenging due to their heterogeneous ways of presentation. Histological analysis may reveal areas of sarcomatous differentiation; therefore, complete resection of the entire tumor is the only curative treatment. There is no adjuvant therapy proved to increase overall survival. It is essential to develop a standardized protocol, detailing how to follow up these patients since it is not reported in the literature to date; however, it is advisable to follow them because the local recurrence rate is high if small implants remain. In this review, we present 3 cases of extrauterine leiomyomas diagnosed and treated in our hospital. The management was different in each case, highlighting the heterogeneity of this condition. According to the literature, there are no solid guidelines on their management. We compare our experience with the data available to date in order to support the existing knowledge and provide our expertise for future studies.

Extrauterine leiomyomatosis, the great mimicker

OBJECTIVES

Describe the radiographic features of the different forms of extrauterine leiomyomatosis.

CONCLUSIONS

Leiomyomas with a rare growth pattern occur most often in women of reproductive age and with a history of hysterectomy. Extrauterine leiomyomas present a greater diagnostic challenge because they may mimic malignancies, and serious diagnostic errors may result.

Retroperitoneal leiomyoma located in the broad ligament: A case report

BACKGROUND

Retroperitoneal leiomyoma is a rare benign tumor. Retroperitoneal leiomyomas located in the latissimus uterine ligament are even rarer. Retroperitoneal leiomyomas have similar characteristics to uterine leiomyomas in terms of tissue, which results in confusion during diagnosis.

CASE SUMMARY

A 47-year-old female with 3 years of pain in the right lower quadrant and discovery of a pelvic mass 13 d ago underwent open abdominal exploration. In the right broad ligament, a solid mass with well circumscribed boundaries, approximately 15 cm × 10 cm × 10 cm in size was bluntly peeled off. The pathological result was a spindle cell tumor, morphologically considered to originate from smooth muscle. Immunohistochemical results supported a deep soft tissue leiomyoma.

CONCLUSION

Retroperitoneal leiomyoma is a rare benign tumor, and surgical treatment can have a good therapeutic effect.

Retroperitoneal Hydropic Leiomyoma Mimicking an Ovarian Cyst

Leiomyoma is the most common benign neoplasm of the reproductive organs in women. Retroperitoneal hydropic leiomyoma is rare type of myoma. Herein, we present the case of a 46-year-old (gravida 0) woman with retroperitoneal hydropic leiomyoma that was preoperatively diagnosed as an ovarian cyst. Transvaginal sonography and abdominal computed tomography revealed a mass, measuring 8.1 × 3.8 cm, with solid and cystic components in the right pelvic cavity. The patient underwent laparoendoscopic single-site surgery for the tumor excision. During the surgery, a retroperitoneal cystic tumor was resected from the right retroperitoneal cavity. Histopathologic and microscopic examinations revealed a hydropic leiomyoma with infarction. This case is impressive because of the rare location and hydropic degeneration of the leiomyoma. Furthermore, it mimicked an ovarian cyst at its initial presentation making accurate diagnosis difficult. By warning of this case, surgeons can recognize the disease entities and provide the necessary treatment.

A RARE CASE OF A RETROPERITONEAL LEIOMYOMATOSIS

Leiomyomas are mostly located in the uterus.Retroperitoneal presentation of leiomyomas are rare and have a greater diagnostic challenge.Because retroperinoteal tumours are quite rare and mostly malignant. Therefore, differantial diagnosis is difficult.We report a rare case of retroperitoneal leiomyomatosis, in which there were concurrent leiomyomas in uterus, pelvic and paraaortic regions that are adjacent to pelvic and paraaortic vascular structures.The patient underwent type 1 hysterectomy and bilateral salpingo-oophorectomy and had a total excision of the myomas from adjacent structures. Histological examination of the surgical specimen revealed that leiomyoma. She has been disease -free for 24 months now.

Genetic heterogeneity in leiomyomas of deep soft tissue

Leiomyoma of deep soft tissue is a rare type of benign smooth muscle tumor that mostly occurs in the retroperitoneum or abdominal cavity of women, and about which very little genetic information exists. In the present study, eight leiomyomas of deep soft tissue were genetically analyzed. G-banding showed that three tumors carried rearrangements of the long arm of chromosome 12, three others had 8q rearrangements, the 7^th tumor had deletion of the long arm of chromosome 7, del(7)(q22), and the 8^th had aberrations of chromosome bands 3q21∼23 and 11q21∼22. The target genes of the 12q and 8q aberrations were HMGA2 and PLAG1, respectively. In the leiomyomas with 12q rearrangements, both HMGA2 and PLAG1 were expressed whereas in the tumors with 8q aberrations, only PLAG1 was expressed. In the cases without 12q or 8q aberrations, the expression of HMGA2 was very low and PLAG1 was expressed only in the case with del(7)(q22). All eight leiomyomas of deep soft tissue expressed MED12 but none of them had mutation in exon 2 of that gene. In two tumors with 12q rearrangements, RPSAP52 on 12q14.3 was fused with non-coding RNA (accession number XR_944195) from 14q32.2 or ZFP36L1 from14q24.1. In a tumor with inv(12), exon 3 of HMGA2 was fused to a sequence in intron 1 of the CRADD gene from 12q22. The present data together with those of our two previous studies in which the fusions KAT6B-KANSL1 and EWSR1-PBX3 were described in two retroperitoneal leiomyomas carrying a t(10;17)(q22;q21) and a t(9;22)(q33;q12) translocation, respectively, show that leiomyomas of deep soft tissue are genetically heterogenous but have marked similarities to uterine leiomyomas.

Management of a giant retroperitoneal leiomyoma: a case report

Background

Leiomyomas are benign tumors observed mainly in adult women. The retroperitoneum is a rare location for leiomyomas; almost 100 cases have been reported. Because retroperitoneal leiomyomas are paucisymptomatic and the tumor size at diagnosis is relatively large, surgical management is challenging. Regular follow-up is required because recurrence and malignant sarcomatous transformation have been described in a few cases.

Case presentation

We report a case of a 52-year-old North African woman with a 22-cm retroperitoneal leiomyoma. A preoperative embolization was performed 2 days before surgery. The clinical, therapeutic, and evolutive aspects of this rare entity are discussed.

Conclusions

Despite its benignity, retroperitoneal leiomyoma is a challenging diagnostic, therapeutic, and evolutive condition. Surgeons must consider mainly the tumor’s vascularization. Regular follow-up is mandatory because malignant transformation cannot be excluded.

Leiomyoma in the Retzius space

Parauterine location of leiomyomas is observed to be an extremely rare clinical condition. However, when benign or malignant primary tumours are detected in that area, they are often found in the Retzius space. There have been only six cases of leiomyomas in the Retzius space reported in the literature so far. The paper presents one such leiomyoma case located in the Retzius space. This extremely rare location of the tumour justifies its presentation. The medical records of the patient treated in the outpatient’s obstetrics and gynaecology (ob-gyn) clinic, her case history, and hospital records, supplemented by information obtained from the patient’s daughter, were analysed. The patient, a 50-year-old woman with type 2 diabetes, was referred to hospital for diagnosed secondary anaemia due to heavy menstruation for four months, which was associated with intramural leiomyoma in the anterior wall of the uterine body. Clinical examination found a large leiomyoma located in the anterior wall of the uterus. Laparotomy was performed: apart from and a leiomyoma in the uterine body it found a tumour, 140 × 100 mm in size, in the Retzius space. Total resection of the tumour was performed. Since the leiomyoma was located in the uterine wall, hysterectomy with bilateral excision of adnexa was also performed. The patient was discharged home in generally good condition on the sixth day following the operation. Concomitant occurrence of leiomyoma atypically located in the Retzius space and leiomyoma in the uterine body made perioperative diagnosis very difficult.

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.

Dyspareunia in a Teenager Reveals a Rare Occurrence: Retroperitoneal Cervical Leiomyoma of the Left Pararectal Space

BACKGROUND

Retroperitoneal uterine leiomyoma is a very rare occurrence and to discover it as a cause of female sexual dysfunction in a teen is unusual.

CASE

An 18-year-old black woman reported deep dyspareunia, resulting in severe distress. Gynecological and instrumental examinations showed a pelvic mass of 7 cm in diameter. The preoperative diagnosis was uterine fibroid, but the exact location of the leiomyoma was uncertain. Laparoscopic examination showed a pedunculated retroperitoneal cervical leiomyoma in the left pararectal space. After surgical excision of the mass, normal sexual activity was restored.

SUMMARY AND CONCLUSION

When a teen experiences pain with intercourse, pelvic masses should be part of differential diagnosis of dyspareunia.

[Atypical localization of myomas during surgery: report of two cases including one in an emergency context]

Les fibromyomes sont des tumeurs bénignes de localisation utérine courante. Elles sont fréquentes chez la femme noire, le diagnostique est échographique et anatomo-histologique. La localisation extra utérine est rare et de physio-pathogénie mal connue. Cette localisation pose des problèmes de diagnostique. Nous rapportons deux cas cliniques de fibromes localisés sur le segment sigmoïdien de l'intestin et sur la paroi interne du muscle transverse de l'abdomen d'une part chez une patiente âgée de 41 ans et d'autre part en région épigastrique, chez une patiente de 47 ans. Toutes les patientes ont été opérées respectivement l'une de myomes utérins pour infertilité et l'autre de laparotomie en urgence pour syndrome sub-occlusif au cinquante huitième jour post hystérectomie. Ces observations doivent inciter les cliniciens ou les radiologistes à réaliser un bilan étendu à la recherche de localisation extra-utérine avant une myomectomie ou hystérectomie car un myome peut en cacher un autre en dehors de l'utérus.

[Retroperitoneal leiomyoma: report of 2 cases]

Les tumeurs bénignes du muscle lisse sont fréquentes dans le tractus gastro-intestinal et génito-urinaire, et rares au niveau rétro péritonéal. Leur prévalence parmi les tumeurs rétropéritonéales primitives a été estimée entre de 0,5 à 1,2%. Une situation qui conduit à des erreurs de diagnostic. On rapporte dans cet article deux cas de léiomyome rétropéritonéal (LRP) retrouvés chez des femmes âgées entre 47et 54 ans. L'imagerie a mis en évidence une masse rétro-péritonéale, ce qui a motivé une exérèse totale de la tumeur. L'examen anatomopathologique de la pièce opératoire a posé le diagnostic de léiomyome rétro-péritonéal. L’évolution sans récidive était bonne.

Fusion of the genes EWSR1 and PBX3 in retroperitoneal leiomyoma with t(9;22)(q33;q12)

Retroperitoneal leiomyoma is a rare benign smooth muscle tumor almost exclusively found in women and with histopathological features similar to uterine leiomyomas. The pathogenesis of retroperitoneal leiomyoma is unclear and next to nothing is known about the cytogenetics and molecular genetics of the tumor. We present here a retroperitoneal leiomyoma with a t(9;22)(q33;q12) as the sole karyotypic aberration. The translocation resulted in an EWSR1-PBX3 fusion gene in which exon 9 of EWSR1 (nucleotide 1320 accession number NM_013986 version 3) was in-frame fused to exon 5 of PBX3 (nucleotide 824 accession number NM_006195 version 5). The EWSR1-PBX3 fusion transcript codes for a 529 amino acids long chimeric EWSR1-PBX3 protein which contains the N-terminal transactivation part of EWSR1 and the homeodomain of PBX3. The present study, together with our previous finding of a retroperitoneal leiomyoma with t(10;17)(q22;q21) as the sole karyotypic aberration and a KAT6B-KANSL1 fusion gene, indicates that retroperitoneal leiomyomas may be characterized by fusion genes coding for chimeric proteins. However, cytogenetic and molecular heterogeneity exists in these tumors and it is too early to tell how many and which different pathways lead to retroperitoneal leiomyomagenesis.

Novel KAT6B-KANSL1 fusion gene identified by RNA sequencing in retroperitoneal leiomyoma with t(10;17)(q22;q21)

Retroperitoneal leiomyoma is a rare type of benign smooth muscle tumor almost exclusively found in women and with histopathological features similar to uterine leiomyomas. The pathogenesis of retroperitoneal leiomyoma is unclear and next to nothing is known about the cytogenetics and molecular genetics of the tumor. Here we present the first cytogenetically analyzed retroperitoneal leiomyoma. It had a t(10;17)(q22;q21) as the sole chromosomal abnormality. Using RNA-Sequencing and the ‘grep’ command to search the fastq files of the sequence data we found that the translocation resulted in fusion of the genes KAT6B (10q22) with KANSL1 (17q21). RT-PCR together with direct (Sanger) sequencing verified the presence of a KAT6B-KANSL1 fusion transcript. No reciprocal KANSL1-KAT6B transcript was amplified suggesting that it was either absent or unexpressed. The KAT6B-KANSL1 fusion transcript consists of exons 1 to 3 of KAT6B and exons 11 to 15 of KANSL1, is 3667 bp long, has a 1398 bp long open reading frame, and codes for a 466 amino acid residue protein. The corresponding KAT6B-KANSL1 protein contains the NEMM domain (including the linker histone H1/H5, domain H15) of KAT6B and the PEHE domain of KANSL1. The function of the fusion protein might be regulation of transcription with an affinity for chromatin (linker histone H1/H5) and interaction with the HAT domain of KAT8 (PEHE domain). The tumor expressed HMGA2 and HMGA1 even though 12q14-15 and 6p looked normal by G-banding analysis. The tumor also expressed MED12 in the absence of exon 2 mutations. Overall, the data show that the examined retroperitoneal leiomyoma resembles a subset of uterine leiomyomas in terms of histology and genetics.

Retroperitoneal leiomyoma of the uterus mimicking sarcoma in perimenopausal woman: case report

Leiomyomas are very common benign tumors in the uterus and it is rare condition to present the retroperitoneal leiomyoma. The author reported a 48-year-old female patient who presented right pelvic mass with urinary incontinence and lower abdominal discomfort. Based on the preoperative imaging, provisional diagnosis was mesenchymal sarcoma. In the intraoperative findings, huge mass abutting to the uterus was observed in retroperitoneal space beneath the right broad ligament. After the exposure the retroperitoneal space, we encountered the well-demarcated tumor measuring 8 × 6 cm in diameter and this tumor attached the right surface of the uterus with fibrotic tissue. Pathologic findings demonstrated retroperitoneal uterine leiomyoma.

[Retroperitoneal leiomyoma: a case report]

Retroperitoneal leiomyoma is a rare benign tumor of the retroperitoneum. We report a clinical case of a 43-year-old patient, who suffered from back pain and weight loss. Imaging revealed a retroperitoneal mass, then the patient had a total excision of the tumor. Histological examination of the surgical specimen concluded to retroperitoneal leiomyoma. The evolution was good without recurrence after 12 months.

Giant cystic leiomyoma of the uterus occupying the retroperitoneal space

A 31-year-old nulliparous woman visited our hospital complaining of abdominal distension. Abdominal ultrasonography and computed tomography revealed a 40 × 40 × 30-cm, multilocular cystic mass extending from the upper abdomen to the pelvis. Magnetic resonance imaging (MRI) revealed a cystic tumor that was hypointense on T1-weighted images and was heterogeneously hyperintense on T2-weighted images. The final diagnosis was an 8 kg leiomyoma with cystic degeneration. Uterine leiomyomas are common benign tumors in females of reproductive age. However, subserosal leiomyomas with complete cystic degeneration of the retroperitoneal space are rare, and they are difficult to accurately diagnosis without pathological examination.

A rare case of retroperitoneal leiomyoma

Introduction. Leiomyoma uteri is one of the most common benign conditions for which women undergo hysterectomy every year. Fibroids found retroperitoneally are a rare entity, especially, primary retroperitoneal fibroid. Case Presentation. We report a case of 42-year-old para 1 who presented to our hospital with recurring retention of urine, lower abdominal and pelvic pain, and dyspareunia . Provisional diagnosis on the basis of examination and imaging was large subserosal fibroid with mild right-sided hydroureteronephrosis, due to pressure effect of the fibroid. Abdominal hysterectomy was done for the patient, and intraoperatively, a bulky uterus was found with multiple small fibroids on anterior and posterior walls, and a large fibroid approx. 10 × 8 cm was found arising from the posterior surface at the level of internal os retroperitoneally, which was confirmed by histopathology as leiomyoma. Conclusion. Retroperitoneal fibroids are rare neoplasms and treatment is surgical removal. Preoperative imaging can only give provisional diagnosis and can be misguiding. Final diagnosis of retroperitoneal fibroid can be made only intraoperatively.

Degenerated huge retroperitoneal leiomyoma presenting with sonographic features mimicking a large uterine leiomyoma in an infertile woman with a history of myomectomy: a case report

Introduction

Retroperitoneal leiomyomata are rare. They are either mistaken preoperatively for malignant retroperitoneal tumors or dealt with as cases of subserous leiomyomata that turn out intraoperatively to be huge retroperitoneal masses of unknown nature.

Case presentation

We report the case of a 46-year-old nulligravid female patient of Middle Eastern ethnicity who presented to our university hospital with lower abdominal as well as pelvic pain along with a bloated sensation. She also reported noticing an unusual increase in her abdominal girth. These symptoms developed over the previous two months. Preoperative investigation by means of an ultrasound suggested a degenerated subserous huge uterine leiomyoma. An abdominal hysterectomy was planned. Intraoperatively, a normal sized uterus was found, the surface of which was studded with multiple variable sized pedunculated subserous leiomyomata. Another huge retroperitoneal soft to firm mass was found extending from her left pelvic wall to the level of her spleen, with no connections to her uterus. The mass was excised and a histopathological examination revealed a degenerated leiomyoma.

Conclusion

Some unusually located extra-uterine leiomyomata have been reported; retroperitoneal leiomyoma being among them. The origin of such tumors is still obscure; a parasitic origin as well as Müllerian cell rests or smooth muscle cells in the retroperitoneal vessels wall have been suggested. An 'iatrogenic' origin for such growths is also a possible theory. The origin of uncommonly located leiomyomata is an unexplored issue that merits more investigation.

Pelvic retroperitoneal leiomyoma

Primary retroperitoneal leiomyomas are a rare and unusual differential diagnosis in the acute abdomen. A 26-year-old woman presented with chronic constipation and acute abdominal pain. The diagnostic workup included contrast computer tomography, transabdominal ultrasonography, and colonoscopy that revealed an 8-cm homogeneous pelvic tumor with rectal compression. Retroperitoneal leiomyoma was suspected on imaging studies and finally confirmed after tumor excision and immunohistochemical staining.

Sleep and fatigue symptoms in women before and 6 weeks after hysterectomy

OBJECTIVE

To compare sleep and fatigue experiences of women before hysterectomy and at 3 and 6 weeks after surgery, to compare symptoms by type of surgical procedure, and to examine the biopsychosocial contextual factors related to symptoms.

DESIGN

A descriptive repeated measures study assessed sleep and fatigue using questionnaires and objective wrist actigraphy monitoring for sleep.

SETTING

Data were collected in women's homes at least 2 days before surgery, and at 3 and 6 weeks postoperatively.

PARTICIPANTS

A convenience sample of 25 women scheduled for hysterectomy.

RESULTS

There was significantly higher self-reported sleep disturbance 3 weeks after surgery compared with baseline. Women who had vaginal hysterectomy continued to experience sleep disturbance and fatigue 6 weeks after surgery, while those who had abdominal hysterectomy reported better sleep and less fatigue at 6 weeks compared with baseline. The number of awakenings recorded with actigraphy increased postoperatively for both groups, and younger women experienced more wake time during the night than older women. Level of education was positively related to preoperative fatigue severity.

CONCLUSIONS

Findings suggested poor sleep and fatigue during the postoperative period should be evaluated in light of women's ages, level of education, and type of surgical procedure.

Retroperitoneal leiomyomata as a cause of bilateral hydronephrosis and lumbosciatic pain

Leiomyomas can occasionally be found in the pelvic and/or abdominal parietal retroperitoneum. This rare entity is known as retroperitoneal leiomyomata. We report the case of a 46-year-old female with bilateral hydronephrosis and chronic sciatic pain caused by invasive retroperitoneal leiomyoma 3 years after hysterectomy, and a successful outcome after treatment with surgery followed by aromatase inhibitors to control pelvic residual disease. Aromatase inhibitors could be a satisfactory treatment option after surgery to control retroperitoneal leiomyoma residual disease.