Recurrent leiomyomatosis peritonealis disseminata after hysterectomy and bilateral salpingo-oophorectomy during combined hormone replacement therapy

Disseminated peritoneal leiomyomatosis after laparoscopic myomectomy - A case report

INTRODUCTION AND IMPORTANCE

Disseminated peritoneal leiomyomatosis (DPL) is a rare benign disease, characterized by intraperitoneal dissemination of smooth-muscle tumor masses.

CASE PRESENTATION

The patient, a 40-year-old, female - presented with complaints of periodic back pain. During the initial workup, a tumor mass was visualized in the pelvis on ultrasound. Further clinical workup included computer tomography (CT) scan and ultrasound-guided fine-needle biopsy. A tumor mass in the right adrenal gland was identified on CT. Pathological examination revealed no signs of malignancy. The multidisciplinary team decided on surgical treatment. Tumor masses were removed from the pelvic cavity, the anterior abdominal wall, and the projection of the right adrenal gland with preservation of the uterus and ovaries due to the patient's wishes. Pathological examination with immunohistochemistry of surgical specimen confirmed diagnosis of DPL.

CLINICAL DISCUSSION

Due to the rarity of DPL there are no standard guidelines for diagnostics and treatment. In many cases, on initial workup, DPL may look like a malignant tumor with intraperitoneal spread, which may lead to an inappropriate choice of treatment.

CONCLUSION

Differential diagnosis of DPL may be a challenge due to its appearance as a disseminated peritoneal malignancy on CT scans and at laparotomy. A multidisciplinary approach is key to choosing the right clinical course for such patients.

Combination therapy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent leiomyomatosis peritonealis disseminata with endometriosis: A case report

Background

Leiomyomatosis peritonealis disseminata (LPD) is a non-metastatic, homologous, multicentric benign disorder characterized by small leiomyomas scattered over the peritoneum and omentum. It is a rare and benign disease with invasive potential. LPD mainly attacks women of childbearing age but has also been reported in post-menopausal women, men, and young children. Non-specific clinical and imaging findings of LPD lead to difficult diagnoses and treatment.

Case presentation

This study reports the case of a patient with recurrent LPD with endometriosis after multiple myomectomies and hysterectomy, who presented recurrent abdominal pain with progressive exacerbation. Imaging examinations showed irregular shadows in the pelvic cavity and multiple nodular changes in the peritoneum, which were considered malignant lesions. A solid mass sized 10 cm × 9 cm × 10 cm in the inferior pelvis and nodules scattered over the surface of pelvic and abdominal organs and the peritoneum were detected during the surgery. The patient was treated with cytoreductive surgery (CRS), peritonectomy, ovarian ablation, and hyperthermic intraperitoneal chemotherapy (HIPEC). The surgery was challenging, and the intraoperative bleeding reached 900 ml. However, the patient recovered well and achieved a tumor-free survival of 13 months.

Conclusions

It was concluded that a combination of CRS, ovarectomy, and HIPEC might be one of the therapeutic strategies for recurrent LPD.

Primary and secondary tumors of the peritoneum: key imaging features and differential diagnosis with surgical and pathological correlation

Peritoneal malignancies represent a diagnostic challenge for abdominal radiologists, oncologists, surgeons and pathologists in multidisciplinary teams, who must address their differential diagnosis, staging and treatment. In this article, we explain the pathophysiology of these processes and lay out the role of different imaging techniques in their evaluation. Then, we review the clinical and epidemiological aspects, the main radiological features and the therapeutic approaches for each primary and secondary peritoneal neoplasm, with surgical and pathological correlation. We further describe other rare peritoneal tumors of uncertain origin and a variety of entities that may mimic peritoneal malignancy. Finally, we summarize the key imaging findings of each peritoneal neoplasm to facilitate an accurate differential diagnosis that may impact patient management.Clinical relevance statementImaging plays an essential role in the evaluation of peritoneal malignancies, assessing their extension, detecting unfavorable sites of involvement and facilitating an accurate differential diagnosis, helping to choose the best therapeutic approach.

A case of spontaneous parasitic myoma in a patient without a history of myomectomy treated laparoscopically

Parasitic myoma (PM) is a rare disease in which multiple leiomyomas are intraperitoneally formed. Recently, an increasing number of cases due to specimen morcellation during minimally invasive surgery has been reported. We present the first case of a PM identified intraoperatively during laparoscopic hysterectomy. A 40-year-old Japanese multiparous woman presented to our hospital with heavy menstrual bleeding. She had no history of previous surgery. Magnetic resonance imaging showed uterine myomas. As the patient did not wish for further pregnancy, she underwent oral gonadotropin-releasing hormone antagonist therapy followed by a total laparoscopic hysterectomy. Intraoperatively, we identified a thumb-sized tumor on the left side of the peritoneum. Histopathological examination showed evidence of benign leiomyoma.

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.

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.

Leiomyomatosis peritonealis dissemianata five years after laparoscopic uterine myomectomy: A case report

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose. In this report, we present a case of LPD arising 5 years after laparoscopic uterine myomectomy using a power morcellator.

Presentation of case

A 32-year-old woman was admitted to our hospital with complaints of vaginal bleeding and abdominal discomfort. Five years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. Pelvic ultrasonography and magnetic resonance imaging demonstrated multiple pelvic tumors closely attached to peritoneum with no indication of malignancy. An exploratory laparotomy revealed multiple sites of leiomyomatosis in the peritoneum, especially on the parietal peritoneum at the port site of the previous laparoscopic surgery. We surgically removed all visible tumors and performed a total hysterectomy. Histologic examination confirmed the diagnosis of LPD.

Discussion

The use of a power morcellator without in-bag containment system might have played a role in the pathogenesis of LPD in our case. Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

Conclusion

The physicians need to combine medical history, clinical findings, imaging techniques and histopathological examination to establish a correct diagnosis of LPD. The application of containment bags in the setting of power morcellation should be considered to reduce the risk of developing LPD. The optimal intervention strategy should be chosen according to the particular features of each patient.

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Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose.

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The physician should suspect LPD when the woman has a history of hysterectomy or myomectomy, particularly if a power morcellator was used.

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Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

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Tumor markers such as CEA, CA19-9 and CA-125 seem not to be useful for the differential diagnosis, since LPD are sometimes associated with elevated levels of these markers.

Disseminated peritoneal leiomyomatosis and malignant transformation: A case series in a single referral center

OBJECTIVE

The aim of this study was to describe one of the largest series of disseminated peritoneal leiomyomatosis (DPL) and its malignant counterpart, evaluating possible risk factors for both the benign and malignant condition, and highlighting any differences between them in terms of surgical and clinical management.

STUDY DESIGN

Clinical, surgical and histopathological characteristics of patients diagnosed with DPL (group 1) and malignant-DPL (group 2), between July 2010 and July 2020, were retrospectively retrieved.

RESULTS

A total of 14 benign and 5 malignant cases were selected. The duration of preoperative hormonal therapy was significantly longer in the benign condition while malignant DPL showed significantly larger lesions (median nodule size: 12 cm). However, surgical procedures and surgical outcomes did not differ among the two conditions, with highly complex surgery and relatively high post-operative complications in both groups.

CONCLUSION

Preoperative discrimination between benign and malignant DPL is challenging. Given the high surgical complexity required in both cases, addressing patients to referral cancer centers is strictly recommend, in order to offer them the best possible treatment and allowing a continuous and accurate collection of clinical information that might be crucial for further studies.

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.

Leiomyomatosis peritonealis disseminata: A case report and meticulous review of the literature

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Differential diagnosis of LPD from leiomyosarcoma or benign metastasizing leiomyoma remains difficult.

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Ample history of the patient, clinical evaluation, preoperative guided FNA and histopathologic analysis of the FNA tissue and of the tumor resection are essential for differential diagnosis.

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Prompt diagnosis of LPD is crucial because, although benign in nature, LPD may degenerate into malignancy.

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a peculiar benign clinical disorder characterized by proliferation of peritoneal and subperitoneal nodules. LPD is a difficultly diagnosed benign disease that rarely degenerates into malignancy.

Presentation of case

A 40-year-old Caucasian female with vaginal bleeding proceeded to our institution for elective excision of abdominal and pelvic masses which were firstly considered as leiomyosarcomas. The histologic diagnosis of the mass lesions revealed smooth muscle benign cells. This is the first case of LPD reported in Greece. A meticulous review of the literature was conducted as well.

Discussion

The differential diagnosis of LPD is difficult due to its clinical resemblance with peritoneal carcinomatosis or metastatic lesions and with benign metastasizing leiomyoma (BML) as well. Etiological factors, pathophysiology and clinical manifestations which lead to a safe diagnosis of LPD are adequately described.

Conclusion

Surgeons’ thorough knowledge concerning this rare clinical condition is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate treatment and the minimization of the probability of malignant transformation of LPD.

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.

Leiomyomatosis Peritonealis Disseminata (LPD) ten years after laparoscopic myomectomy associated with ascites and lymph nodes enlargement: a case report

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Leiomyomatosis peritonealis disseminata (LPD) is a rare pathology of unkown etiology.

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The relationship of LPD with myoma morcellation remains unclear.

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Ascites with lymph node enlargement can be present in LPD.

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Time of clinical presentation of LPD can be very long after laparoscopic myomectomy.

Introduction

We report a case of leiomyomatosis peritonealis disseminata (LPD) arising 10 years after a laparoscopic myomectomy that was associated with ascites and lymph nodes enlargement.

Presentation of case

The patient presented with small uterine fibroids with a dominant posterior intramural fibroid measuring 9 cm in diameter and normal Doppler. Laparotomy revealed a uterus enlarged with fibroids, which was densely adhering to the urinary bladder, greater omentum, and sigmoid colon. Multiple tumors of different size were found attached to the peritoneum, omentum and bowel. The histopathologic examination was consistent with leiomyomatosis peritonealis disseminata.

Discussion

Pieces of smooth muscle cell lost in the abdominal cavity during electrical morcellation after laparoscopic myomectomy may progress to leiomyomatosis peritonealis disseminata even after many years (ten in our case) and it can be associated with ascites and lymph nodes enlargement.

Conclusion

This is the first case reported in literature of leiomyomatosis peritonealis disseminata with these particular features (time of clinical presentation, ascites, lymph nodes enlargement).

Leiomyomatosis peritonealis disseminata: case report and review of the literature

Leiomyomatosis peritonealis disseminata (LPD) is typically a benign and rare disorder found in female patients, prior to menopause. It can be found in the subperitoneal or peritoneal spaces and is represented by multiple different sized myomatous nodules (smooth muscle tumors). Additionally, it has also been found in women after menopause as well as in men. Despite the fact that high levels of estrogen and progesterone play a significant role in this disorder, the mechanism behind LPD development and a definitive therapeutic concept has yet to be conceived. This disorder is mostly found incidentally during imaging or surgery as it is often an asymptomatic condition. The present case reports an incident of LPD, clinically similar to peritoneal metastases, in a patient with a past history of dermatofibrosarcoma of Darier and Ferrand.

Leiomyomatosis peritonealis disseminata associated with endometriosis: A case report and review of the literature

Leiomyomatosis peritonealis disseminata (LPD) is a specific type of leiomyomatosis with an unclear pathogenesis that is rarely diagnosed by clinical evaluation. To date, <200 cases have been reported. The majority of the patients have a medical history of laparoscopic myomectomy for uterine fibroids. The use of laparoscopic power morcellation may be a contributor to the development of LPD, therefore, the specific surgical approach used in laparoscopic myomectomy should be carefully considered, and protective measures should be taken to prevent myoma fragments spreading if laparoscopic power morcellation is used. The present study reviewed and analyzed the medical history, diagnostic process and treatment strategy of a case of LPD to improve our understanding of the disease. In this report, the case of a 34 year-old female who underwent laparoscopic myomectomy to remove a uterine fibroid is presented. During the surgery, a myoma was resected using morcellators. Three years after surgery, exploratory laparotomy was performed due to uterine fibroid recurrence. During surgery, myoma was identified at the uterine bladder peritoneal reflection, where several unequally sized leiomyoma tubercles were identified on the uterine surface. Subsequently, myomectomy was performed. Postoperative pathology diagnosed leiomyoma. Two years later, gynecological ultrasound revealed a mass in the abdomen. Exploratory laparotomy was subsequently performed. During surgery, compact myoma tubercle-like cysts were identified on the surface of the intestine and mesentery, and an endometriotic cyst was identified on the left ovary. As the myomas were too compact to remove completely, the majority of leiomyoma on the intestine and mesentery was resected. The endometriotic cyst on the left ovary was also resected. Considering the patient's medical history, observations during surgery and pathological results, the final diagnosis was LPD. Following surgery, the patient was treated with the gonadotropin-releasing hormone agonist, triptorelin acetate (3.5 mg, once every four weeks), for three months and followed-up every six months. In October 2014, a gynecological sonography examination revealed no abnormalities and at the time of writing, the patient remains alive and well.

CT imaging of peritoneal carcinomatosis and its mimics

Invasive peritoneal disease includes more than just peritoneal carcinomatosis. Although this is the most common aetiology, especially when a primary is found, other conditions may be responsible for peritoneal invasion. A rigorous analysis of CT features taken together with the clinical and biological context usually allows the main differential diagnoses, which entail different types of management, to be drawn out. Pseudomyxoma peritonei, peritoneal lymphomatosis, tuberculosis, peritoneal mesothelioma, diffuse peritoneal leiomyomatosis, and benign splenosis are the main differential diagnoses.

Mutation status of the mediator complex subunit 12 (MED12) in uterine leiomyomas and concurrent/metachronous multifocal peritoneal smooth muscle nodules (leiomyomatosis peritonealis disseminata)

AIMS

The pathogenesis and classification of multicentric smooth muscle tumours with benign appearance and concurrent/metachronous uterine and peritoneal involvement is controversial and may on occasion be diagnostically challenging. Leiomyomatosis peritonealis disseminata (LPD) is a rare condition affecting women of reproductive age, characterised by the occurrence of multiple small peritoneal smooth muscle nodules with bland histology.

METHODS

We investigated a total of 12 uterine and seven concurrent/metachronous peritoneal smooth muscle nodules with benign appearance from two females for mutations in the mediator complex subunit 12 (MED12), which has recently been identified as the most frequent genetic aberration in uterine leiomyomas.

RESULTS

The first case harboured different MED12 mutations in the peritoneal nodules. Mutational status of peritoneal nodules was discordant with that of the uterine leiomyomas. The second case displayed the same MED12 mutation in all five peritoneal nodules, but this mutation was not detected in her current uterine leiomyomas.

CONCLUSIONS

Our results suggest that smooth muscle neoplasms with benign appearance of the primary and secondary müllerian system share a similar genetic background of MED12 mutation in combination with oestrogen dependency. Analysis of MED12 mutation status might be a valuable adjunct tool for the future classification of these sometimes diagnostically challenging multicentric tumours.

Two case reports of bowel leiomyomas and review of literature

We report two cases of two women underwent laparoscopic hysterectomy and myomectomy. During surgery, three myomas were identified as completely detached from the uterus, and attached to the bowel. Patients's history revealed a laparoscopic myomectomy. Our first hypothesis therefore was that these were lost myomas of the first surgery. However, only one leyomyoma was removed in both patients. Therefore, we can assume that these myomas were not certainly not lost-myomas and we may conclude that it could be either as residues of previous morcellation or they were pedunculated-myomas that have been spontaneously detached from the uterus and re-implanted onto the bowel.

Leiomyomatosis peritonealis disseminata in association with Currarino syndrome?

BACKGROUND

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease in which multiple smooth muscle or smooth muscle-like nodules develop subperitoneally in any part of the abdominal cavity. No reports of multiple congenital malformations associated with LPD have been found in the English literature.

CASE PRESENTATION

A 27 year-old patient referred to our gynaecology unit for pelvic pain, amenorrhoea, stress incontinence, chronic constipation and recurrent intestinal and urinary infections. Multiple congenital malformations had previously been diagnosed. Most of these had required surgical treatment in her early life: anorectal malformation with rectovestibular fistula, ectopic right ureteral orifice, megadolichoureter and hemisacrum. An ultrasound scan and computed tomography performed in our department showed an irregular, polylobate, complex 20 cm mass originating from the right pelvis that reached the right hypochondrium and the epigastrium. The patient underwent laparotomy. The three largest abdominal-pelvic masses and multiple independent nodules within the peritoneum were progressively removed. The histological diagnosis was of LPD.

CONCLUSION

The case we report is distinctive in that a rare acquired disease, LPD, coexists with multiple congenital malformations recalling a particular subgroup of caudal regression syndrome: the Currarino syndrome.