Leiomyomas beyond the Uterus: Unusual Locations, Rare Manifestations

Extrauterine adenomyoma: A case report and systematic review of the literature

OBJECTIVE

To describe a case of extrauterine adenomyoma (EA) and review all the cases of EA in the literature.

METHODS

Pubmed/MEDLINE, Embase, and Google Scholar from 1807 to December 2022. All studies reporting the histologic diagnosis of an EA. We collected the following data: patient's age, size and location of adenomyoma, presence of endometriosis and adenomyosis, past gynecologic treatment, symptoms, diagnostic imaging, surgical intervention, alternative/adjuvant treatment, associated malignancy, and follow up.

RESULTS

Sixty-seven studies with 85 patients were included. Pain was the most frequent symptom (69.5%). Among diagnostic examinations, ultrasonography was used in 60 out of 81 reported cases, with several radiologic features described. EA was located inside the pelvis in 77.6% of patients. Adnexa were the most frequent site of the disease (24, 28.2%). History of endometriosis or adenomyosis was described in 35 patients (35, 41.2%). Uterine tissue morcellation was reported in 6 of the 85 patients (7.1%). Associated malignancy was detected in 9 out of 85 patients with available data (10.6%). There were two recurrences of disease.

CONCLUSION

Specific imaging features of EA are yet to be described in the literature. History of endometriosis and adenomyosis or uterine tissue morcellation may be suggestive of EA. Histologic examination can give a definitive diagnosis and exclude malignant transformation.

Primary Large Broad Ligament Fibroid: A Challenge in Surgical Practice

Primary broad ligament fibroids, whose surgical treatment is challenging, are extremely rare. Our case concerns the surgical treatment of a large broad ligament fibroid. A 48-year-old patient, asymptomatic and with a medical history of uterine leiomyomas, came to the gynecology outpatient clinic to undergo a routine gynecological examination. On bimanual pelvic examination, the presence of a painless palpable pelvic mass was found, without being able to clinically demarcate it. Computed tomography imaging confirmed the clinical suspicion of a pelvic mass. The pelvic mass was more consistent with the subserosal pedunculated fibroid of the uterine corpus, but the preoperative diagnosis of adnexal mass cannot be excluded. It was decided to surgical treatment of the patient with a total hysterectomy and bilateral salpingectomy-oophorectomy. Intraoperatively, the presence of a large intraligamental mass was detected. The uterus, cervix, and ovaries were normal but displaced by the tumor. After resection of the leiomyoma from the broad ligament, where it was not found to be connected to a vascular pedicle from the lateral wall of the uterine corpus or the cervix, total hysterectomy and bilateral salpingectomy-oophorectomy were performed, due to the necessary resection of the right fallopian tube and ovary and the extensive injuries in the area. The postoperative course was uneventful. In this paper, following the case presentation, a brief review of primary broad ligament fibroids is presented, emphasizing the significance of comprehensive preoperative planning in the challenging intraoperative management of these patients, who have an increased risk of intraoperative complications.

A contrast-enhanced CT-based radiomic nomogram for the differential diagnosis of intravenous leiomyomatosis and uterine leiomyoma

Objective

Uterine intravenous leiomyomatosis (IVL) is a rare and unique leiomyoma that is difficult to surgery due to its ability to extend into intra- and extra-uterine vasculature. And it is difficult to differentiate from uterine leiomyoma (LM) by conventional CT scanning, which results in a large number of missed diagnoses. This study aimed to evaluate the utility of a contrast-enhanced CT-based radiomic nomogram for preoperative differentiation of IVL and LM.

Methods

124 patients (37 IVL and 87 LM) were retrospectively enrolled in the study. Radiomic features were extracted from contrast-enhanced CT before surgery. Clinical, radiomic, and combined models were developed using LightGBM (Light Gradient Boosting Machine) algorithm to differentiate IVL and LM. The clinical and radiomic signatures were integrated into a nomogram. The diagnostic performance of the models was evaluated using the area under the curve (AUC) and decision curve analysis (DCA).

Results

Clinical factors, such as symptoms, menopausal status, age, and selected imaging features, were found to have significant correlations with the differential diagnosis of IVL and LM. A total of 108 radiomic features were extracted from contrast-enhanced CT images and selected for analysis. 29 radiomics features were selected to establish the Rad-score. A clinical model was developed to discriminate IVL and LM (AUC=0.826). Radiomic models were used to effectively differentiate IVL and LM (AUC=0.980). This radiological nomogram combined the Rad-score with independent clinical factors showed better differentiation efficiency than the clinical model (AUC=0.985, p=0.046).

Conclusion

This study provides evidence for the utility of a radiomic nomogram integrating clinical and radiomic signatures for differentiating IVL and LM with improved diagnostic accuracy. The nomogram may be useful in clinical decision-making and provide recommendations for clinical treatment.

A Case Report of Vulvar Leiomyoma: A Rare Pathological Entity

Smooth muscle tumors, known as leiomyomas, are benign and can grow anywhere in the body, but the uterine myometrium is the most common site. Vulvar leiomyomas are uncommon and rare. We report a case of a 25-year-old female P (para) 1 L (live) 1 with a previous normal vaginal delivery, who presented two painless swelling of in vulva for one year. The urethral meatus deviated to the left side. After surgical excision, a histopathological examination was performed that confirmed leiomyoma. The patient was discharged after an uneventful postoperative period. A vulvar leiomyoma tumor is often mistaken for a Bartholin cyst, and it is challenging to distinguish between benign and malignant types of vulvar leiomyomas, making diagnosis extremely challenging.

Unusual Vulvar, Perineal, and Uterine Leiomyomas: A Case Report

Vulvar leiomyomas are extremely rare smooth muscle tumors that are easily mistaken for other lesions, as the differential diagnosis must consider a wide spectrum of benign and malignant lesions. We present the case of a 52-year-old woman with a three-year history of progressive abdominal distension and pain and an enlarging vulvar mass distorting the labia majora and causing gait disturbance. Imaging confirmed an enormous pelvic mass originating in the uterus, compatible with a leiomyoma/sarcoma, and large perineal and vulvar masses with similar characteristics. Histopathology after surgical removal revealed benign abdominal, vulvar, and perineal leiomyomas. This case highlights the rarity and diagnostic challenges of extra-uterine leiomyomas, particularly those in the vulvar region.

Extremely Rare CT and MRI Findings of Peritoneal Leiomyoma Mimicking Hepatic Mass: A Case Report

Leiomyoma is a common benign tumor from smooth muscle cells, mostly in the uterus. Peritoneal leiomyomas (PLs) are extremely rare and mostly reported as disseminated peritoneal leiomyomatosis. However, to the best of out knowledge, radiologic findings of isolated PL are not reported in English literature. Herein, we introduce the radiologic findings of PL mimicking hepatic mass in a 34-year-old female. CT showed a mass with curvilinear heterogeneous enhancement at the liver's peripheral area. On MRI, the mass showed gradual and heterogeneous enhancement on gadoxetic acid-enhanced MRI and diffusion restriction. The radiologic diagnosis was a benign hepatic tumor, such as degenerated hemangioma, adenoma, and inflammatory myofibroblastic tumor; however, the mass was diagnosed as PL pathologically.

Vaginal Leiomyomas - Safe Steps for Laparoscopic removal: feasibility from 3 case reports

BACKGROUND

Leiomyomas are a common pathology in reproductive-aged women. However, they rarely originate from extrauterine sites. Vaginal leiomyomas constitute a challenging diagnosis, regarding their surgical treatment. Despite the well- established advantages of laparoscopic myomectomy, the efficacy and feasibility of a total laparoscopic approach for such cases has not been yet investigated.

OBJECTIVES

To describe step-by-step the laparoscopic technique for vaginal leiomyoma removal (narrated video presentation) and demonstrate the outcomes of a small series managed at our institution.

PATIENTS

Three patients diagnosed with symptomatic vaginal leiomyomas that presented to our laparoscopic department. Patients aged 29, 35 and 47 years with BMI 20.6 kg/m2, 19.5kg/m2 and 30.1 kg/m2, respectively.

RESULTS

Total laparoscopic excision of the vaginal leiomyomas was successful in all three cases without conversion to laparotomy. The technique is demonstrated in a step-by-step video narration. There were no major complications. Average operative time was 146.25 min (range 90- 190 min) and intraoperative blood loss was 120 ml (range 20-300ml). Fertility was preserved in all patients.

CONCLUSION

Laparoscopy is a feasible technique to approach vaginal masses. Further studies are needed to assess safety and efficacy of the laparoscopic technique in such cases.

Smooth Muscle Tumors of the Uterus at MRI: Focus on Leiomyomas and FIGO Classification

Leiomyomas are smooth muscle tumors of the uterus and are the most common uterine neoplasm. Although leiomyomas are usually asymptomatic, they can manifest with symptoms such as pain or uterine bleeding. Leiomyomas are classified on the basis of their anatomic location and morphology. Localization of leiomyomas relative to the endometrium, myometrium, and uterine serosa with use of the International Federation of Gynecology and Obstetrics (FIGO) classification system is helpful for guiding management in symptomatic patients. The FIGO system is a practical and universally accepted approach for classifying leiomyomas to guide radiologists and clinicians in deciding management. The MRI appearance of conventional leiomyomas is related to their tissue contents of smooth muscle and fibrous tissue and is well established. The MRI features of some leiomyoma subtypes and forms of degeneration also have been described. Other smooth muscle tumors of the uterus recognized in the 2020 World Health Organization classification system include intravenous leiomyomatosis, smooth muscle tumors of uncertain malignant potential, and metastasizing leiomyoma. At the far end of the spectrum are leiomyosarcomas, which are frankly malignant and therefore must be managed accordingly. Although MRI features that suggest a diagnosis of leiomyosarcoma have been proposed, these features overlap with those of some leiomyoma subtypes and degeneration. ^© RSNA, 2023 See the invited commentary by Fennessy and Gargiulo in this issue. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Incidental Finding of a Lipoleiomyoma During Robotic Inguinal Hernia Repair: A Case Report

Lipoleiomyomas are rare, fatty variants of leiomyomas (commonly referred to as fibroid), which are frequently found in the uterine corpus and cervix. Here, we present a case of a robotic inguinal hernia repair with resection of an incidental lipoleiomyoma. A 74-year-old woman presented to the office with complaints of pain and a palpable mass in the right inguinal region. Physical examination revealed tender, moderate-to-large bilateral inguinal hernias. Robotic bilateral inguinal hernia repair with mesh was performed. Intraoperatively, a mass measuring 4 × 3 cm was noted near the round ligament of the uterus. The mass was encapsulated without invading any surrounding structures. The mass was resected and sent to the histopathology department. The pathological evaluation identified a leiomyoma filled with mature adipocytes, compatible with the diagnosis of an extrauterine lipoleiomyoma. Lipoleiomyoma incidentally found in the inguinal canal is extremely rare. The medical literature regarding this incidental finding is limited. Resection of the mass was easily performed using the same robotic instruments as used for the inguinal hernia repair.

Conservative Management and Ultrasound Follow-Up of Parasitic Myoma: Our Experience and Literature Review

A uterine fibroid is a benign smooth muscle neoplasm of the uterus. Parasitic fibroids (PMs) are a type of myoma that do not have any direct attachment to the uterus. PMs can arise from the implantation of tissue fragments generated during the morcellation process in previous laparoscopic myomectomies or hysterectomies. Transvaginal ultrasound (TV-US) may be helpful in the diagnosis of these benign tumors. Almost all the case reports in the literature suggest surgical management of parasitic fibroids. Conversely, we report an ultrasound-guided histological diagnosis and a non-surgical treatment of a parasitic myoma that arose twenty years after a total laparotomic hysterectomy and bilateral adnexectomy in a patient with multiple comorbidities, in order to offer a follow-up alternative to the management of this rare pathology. Our experience reveals that a non-surgical conservative approach can be considered as an alternative therapeutic option for the management of rare cases such as PMs in highly selected patients.

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.

Minimally Invasive Image-Guided Transgluteal Approach for Resection of a Sciatic Nerve Tumor: A Technical Note

There are a variety of surgical approaches to lesions around the sciatic notch. Historically, peripheral nerve surgeons prefer an infragluteal approach involving a large incision with reflection of the gluteus maximus to better visualize the operative field. This approach was imperative when lesion localization was imprecise. Comparatively, orthopedic surgeons prefer a muscle-splitting, transgluteal approach to operate on the static structures of the posterior hip. The transgluteal approach is significantly less morbid, allowing for same-day discharge and less extensive rehab given preservation of the gluteal muscle. In this article we describe the use of dynamic ultrasound imaging to localize and aid in the resection of three unique tumors around the sciatic notch using a minimally invasive, tissue-sparing, transgluteal technique. We offer a comprehensive description of the benefits, anatomic considerations, and nuances of using a transgluteal approach for the resection of lesions at the sciatic notch.

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.

Unusual case of a leiomyoma in the space of Retzius mimicking broad ligament fibroid

This case report will discuss an interesting case of a patient who presented with pain in the lower abdomen of 2-month duration. Clinical examination and imaging findings were suggestive of a broad ligament fibroid. However, intraoperatively, the mass was found to be present in the space of Retzius, which is an extremely rare location for such a pathology. The access to the tumour was very challenging. Successful surgical excision was done with the help of a multidisciplinary team involving a gynaecologist, a urologist and an anaesthetist. Histopathology reported it to be benign leiomyoma. Postoperatively, the patient made an uneventful recovery.

Vulvar leiomyoma in an adolescent girl: a case report and review of the literature

BACKGROUND

Vulvar leiomyoma is a rare soft tissue tumor, with only around 300 cases described in the literature. Owing to its low incidence of just 0.03% of all gynecological tumors, it often poses a great diagnostic challenge, especially in teenagers. We report this rare occurrence of vulvar leiomyoma in a teenage girl who was primarily left untreated due to cultural taboos and fear of loss of virginity. The main aim in presenting such rare case studies is to raise awareness and expand the diagnostic horizon of the surgeon for appropriate management.

CASE PRESENTATION

We describe a case of a 15-year-old North Indian, sexually inactive unmarried girl, who presented with a history of painless swelling in the left labia majora for the last 1 year, which gradually increased in size. There was no associated pain or any other difficulty. Local examination revealed a 14 × 10 cm solid, unilateral nonpedunculated mass on the left labia majora with superficial vascularity. Differential diagnoses of sarcoma, lipoma, Bartholin cyst, and fibroid were kept in mind. Ultrasonography revealed a solid mass with superficial vascularity with normal internal genitalia. The mass was enucleated with an intact capsule under anesthesia. Histopathology confirmed it to be benign vulvar leiomyoma. The patient was discharged after 3 days in a satisfactory condition.

CONCLUSION

Leiomyoma of the vulva is an exceptionally rare tumor and is seldom seen in teenagers. It is often misinterpreted as a Bartholin cyst and should be kept as one of the differential diagnosis in teenage girls presenting with unilateral vulvar swelling. Vulvar leiomyoma can be completely cured by surgical removal if diagnosed timely without compromising virginity, so should never be missed in adolescents.

Clinical features and prognostic factors analysis of intravenous leiomyomatosis

Background

The treatment and prognostic factors of intravenous leiomyomatosis (IVL) remain lacking systematic evidence.

Methods

A retrospective study was conducted on IVL patients from the Qilu Hospital of Shandong University, and IVL cases were published in PubMed, MEDLINE, Embase and Cochrane Library databases. Descriptive statistics were used for the basic characteristics of patients. The Cox proportional hazards regression analysis was used to assess the high-risk factors related to the progression-free survival (PFS). The comparison of survival curves was performed by Kaplan-Meier analysis.

Results

A total of 361 IVL patients were included in this study, 38 patients from Qilu Hospital of Shandong University, and 323 patients from the published literature. Age ≤45 years was observed in 173 (47.9%) patients. According to the clinical staging criteria, stage I/II was observed in 125 (34.6%) patients, and stage III/IV was observed in 221 (61.2%) patients. Dyspnea, orthopnea, and cough were observed in 108 (29.9%) patients. Completed tumor resection was observed in 216 (59.8%) patients, and uncompleted tumor resection was observed in 58 (16.1%) patients. Median follow-up period was 12 months (range 0-194 months), and 68 (18.8%) recurrences or deaths were identified. The adjusted multivariable Cox proportional hazard analysis showed age ≤45 years (vs. >45) (hazard ratio [HR] = 2.09, 95% confidence interval [CI] 1.15-3.80, p = 0.016), and uncompleted tumor resection (vs. completed tumor resection) (HR = 22.03, 95% CI 8.31-58.36, p < 0.001) were high-risk factors related to the PFS.

Conclusion

Patients with IVL have a high probability of recurrence after surgery and a poor prognosis. Patients younger than 45 years and with uncompleted tumor resection are at higher risk of postoperative recurrence or death.

[Radiologic Evaluation of Uterine Lesions Using a Pattern Recognition Approach]

It is important to distinguish uterine lesions from other lesions occurring in the pelvic cavity for the proper management. The primary radiological evaluation of uterine lesions is performed using transvaginal ultrasonography, and if the lesion is too large or shows atypical benign imaging findings, magnetic resonance imaging should be performed. Analyzing radiological findings of uterine lesions through a pattern recognition approach can help establish the accurate diagnosis and treatment plan. In this pictorial assay, we describe imaging characteristics of various lesions arising from the uterus and evaluate them based on the pattern recognition approach.

Urinary Bladder Masses, Rare Subtypes, and Masslike Lesions: Radiologic-Pathologic Correlation

Urinary bladder masses are commonly encountered in clinical practice, with 95% arising from the epithelial layer and rarer tumors arising from the lamina propria, muscularis propria, serosa, and adventitia. The extent of neoplastic invasion into these bladder layers is assessed with multimodality imaging, and the MRI-based Vesical Imaging Reporting and Data System is increasingly used to aid tumor staging. Given the multiple layers and cell lineages, a diverse array of pathologic entities can arise from the urinary bladder, and distinguishing among benign, malignant, and nonneoplastic entities is not reliably feasible in most cases. Pathologic assessment remains the standard of care for classification of bladder masses. Although urothelial carcinoma accounts for most urinary bladder malignancies in the United States, several histopathologic entities exist, including squamous cell carcinoma, adenocarcinoma, melanoma, and neuroendocrine tumors. Furthermore, there are variant histopathologic subtypes of urothelial carcinoma (eg, the plasmacytoid variant), which are often aggressive. Atypical benign bladder masses are diverse and can have inflammatory or iatrogenic causes and mimic malignancy. ^© RSNA, 2022 Online supplemental material is available for this article.

Parasitic Leiomyoma with Lymphatic Dilatation in Trocar Port-Site of Abdominal Wall: A Case Report

Uterine leiomyoma is the most common benign pelvic tumor in female and being symptomatic is an indication for surgical removal. As laparoscopic surgery has been developed, some cases related to parasitic leiomyomas in the port site have been reported. A 40-year-old female who a history of previous laparoscopic surgery to remove uterine myoma 2 years ago visited in outpatient clinic of general surgery with palpable mass in left lower abdomen. Contrast enhanced abdomen CT and pelvis MRI were done to evaluate the mass. It was diagnosed parasitic leiomyoma in pathologic study after surgical removal and parasitic leiomyoma should be considered when patient visited presenting abdominal mass with the history of laparoscopic myomectomy.

Intravascular leiomyoma‑A rare case in the context of Covid‑19 outbreak: A case report

The present study reported a case of a uterine leiomyoma with an unusual growth pattern featuring areas of intravascular leiomyomatosis, rarely described in the international literature available in English. It presented the case of a 44-year-old woman who, fearing the Covid-19 outbreak, postponed the recommended surgical intervention to remove a uterine leiomyoma. The two-year delay worsened the symptoms, doubled the size of the tumor, and facilitated the development of intravascular leiomyomatosis. It was possible to establish the correct diagnosis only after the histopathological examination of the excised uterine myoma, as it was not suspected prior to surgery. No other vascular tumors were identified via magnetic resonance imaging and computed tomography imaging investigations. The careful follow-up of recovering patients is essential because of the high recurrence rate of such tumors and their potential to behave aggressively, possibly even fatally. Clinicians should be aware of this rare condition and its cardiovascular implications to improve the initial and long-term management of such cases.

Peritoneal karsinomatozisi taklit eden dissemine peritoneal leiomyomatozis

Dissemine peritoneal leiomyomatozis (DPL) genellikle premenopozal kadınları etkileyen iyi huylu ve çok nadir bir hastalıktır. 39 yaşında intramural leiomyomu ve dissemine peritoneal leiomyomatozisi olan bir kadın hastayı sunuyoruz. DPL'in kesin tedavisi hastalığın derecesine göre değişen derecede cerrahi olarak yapılmaktadır. Agresif tedavi kararı verilmeden önce peritoneal fibroidlerin malign peritoneal tümörleri taklit edebileceği akılda tutulmalıdır.

The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature

The cyst of the canal of Nuck is an extremely rare female hydrocele, usually occurring in children, but also in adult women. It is caused by pathology of the canal of Nuck, which is the female equivalent to the male processus vaginalis. Due to its rarity and the lack of awareness among physicians, the cyst of the canal of Nuck is a seldom-encountered entity in clinical practice and is commonly misdiagnosed. We report on a case of cyst of the canal of Nuck in a 42-year-old woman, who presented with a painful swelling at her right groin. In addition, we conducted a review of the current available literature. This review gives an overview of the anatomy, pathology, diagnostics, and treatment of the cyst of the canal of Nuck. The aim of this review is not only to give a survey, but also to raise awareness of the cyst of the canal of Nuck and serve as a reference for medical professionals.

Intravascular leiomyomatosis: a continuing diagnostic challenge

We report the case of a woman in her 60s with intravascular leiomyomatosis. She suffered from numerous non-specific symptoms including weight loss, anaemia and sudden swelling of the left lower extremity. CT imaging showed the presence of an enlarged left ovary and a thrombus extending from the left ovarian venous plexus intruding into the right atrium of the heart. Cancer antigen 125 was 20 U/mL. Pelvic transvaginal ultrasound examination identified two normal ovaries and a mass adjacent to the left ovary. A second opinion on the CT scan was requested at a oncogynaecological multidisciplinary team meeting, where the radiologist of the team identified an intervascular leiomyomatosis. After further investigation, surgical treatment was planned and completed in collaboration with the departments of cardiothoracic and vascular surgery. The patient recovered fully.

Robot-assisted tumorectomy for an unusual pelvic retroperitoneal leiomyoma: A case report

RATIONALE

Extrauterine leiomyoma occasionally occurs in rare locations with unusual growth patterns, especially pelvic retroperitoneal leiomyoma, which brings great challenges for surgeons to make a diagnosis. It is essential to distinguish benign from malignant retroperitoneal neoplasms according to the imaging manifestations. Laparotomy and laparoscopy are the common options for pelvic retroperitoneal neoplasms, while they may cause side effects during operation such as secondary damage. Appropriate surgical techniques should be adopted to ensure the complete excision of neoplasms meanwhile preserve the urination, defecation, and sexual function.

PATIENT CONCERNS

A 30-year-old woman was referred to our hospital because of dull pain in the perianal region for 1 month. Laboratory results including tumor markers were all within normal limits. The digital rectal examination revealed a huge and tough mass with smooth mucosa protruding into the rectal cavity from the rear area of rectum.

DIAGNOSIS

Imaging examinations were performed. Contrasted computed tomography (CT) of pelvis showed an enhanced retroperitoneal solid mass in the space between sacrum and rectum, and very close to the levator ani muscle. The mass was about 11.0*8.0 cm in size. Computerized tomography angiography (CTA) showed the distal branches of bilateral internal iliac artery went into the mass. Endoscopic ultrasonography (US) showed the mass compressed the rectum, as well as a clear boundary to the rectal wall. A histopathologic examination confirmed the mass was a pelvic retroperitoneal leiomyoma.

INTERVENTIONS

The patient underwent an operative resection with da Vinci Si surgical system after routine preoperative preparation. Anorectal motility was weekly monitored postoperation. No additional adjuvant therapy was performed.

OUTCOMES

The patient could walk after 1 day and defecate normally on the third day after operation. She was discharged on the seventh postoperative day. No adverse events including pelvic floor hernia or defecation dysfunction occurred in the follow-up period. At 4 weeks follow-up, the patient was pain-free and recovered well.

LESSONS

Although imaging examinations were crucial for retroperitoneal neoplasms, histopathological examination remains the "gold standard" for making a definite diagnosis. This case highlights the possibility of retroperitoneal leiomyoma occurring in a woman of reproductive age and the advantages of robotic surgical system in pelvic retroperitoneal surgeries.

A rare case of benign vulvovaginal leiomyoma: Case report and literature review

Introduction

Smooth muscle tumors of the vulva are more difficult to diagnose and are frequently mistaken as Bartholin cysts prior to surgery.

Case presentation

A 41-year-old female presented with a left vulvar mass that increased in size compared to the previous year. The patient had normal urination and a regular menstrual cycle. The presentation was not associated with dyspareunia, abnormal bleeding, and signs of infection (e.g., fever, vaginal discharge). The history of any sexually transmitted disease was inconclusive. There was also no family history of malignancy. Physical examination showed a solitary swelling mass, measuring 5 × 2 cm in the left labia majora at the site of the Bartholin gland. The mass was firm in consistency, partially movable, and non-tender with no inguinal lymphadenopathy. Histopathology after surgical removal revealed a benign vulvar leiomyoma.

Discussion

Labia majora leiomyoma at the site of the Bartholin gland is rather uncommon. Some cases can develop into atypical leiomyoma or even leiomyosarcoma with local tissue infiltration.

Conclusion

If the clinical picture is unusual, it is better to send the patient for ultrasound and MRI to exclude other causes followed by performing wide local surgical excision of the mass to allow proper histopathological and/or immunohistochemistry examination to differentiate between benign and malignant tumors.

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Vulval leiomyoma is rather an uncommon neoplasm.

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Careful clinical examination should be done for any suspicious vulval mass.

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Preoperative imaging should be done to check for adjacent tissue involvement.

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Preoperative counseling of the patient about possible recurrence should be done.

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Excision with normal tissue safety margin is recommended.

Iatrogenic Parasitic Leiomyomas: A Late and Uncommon Complication After Laparoscopic Morcellation

Parasitic leiomyoma (PL) is an extremely rare variant of uterine leiomyomas that occurs outside of the uterus and can often present like intra-abdominal tumors. The aim of this study is to report a case of PL and compare it with current literature. We present a rare case of a 45-year-old female who presented with bloating and spasmodic abdominal cramps for a two-month duration. She had a previous laparoscopic myomectomy six years ago. Transvaginal ultrasound (TVUS) showed solid vascular masses in the pelvis, the largest being 6 cm. Computed tomography (CT) of the thorax, abdomen, and pelvis (CTTAP) revealed further peritoneal masses in the left paracolic gutter suggesting peritoneal distant metastasis. Laparoscopy was completed, and biopsy and histopathological examination confirmed the diagnosis of parasitic leiomyoma. The patient opted for a bilateral salpingo-oophorectomy (BSO) creating iatrogenic menopause. One-year follow-up CT showed a reduction in the size of fibroids. PL can present with vague symptoms, typically nonspecific abdominal pain and cramping. It can often be confused with intra-abdominal tumors. It should be suspected in patients with previous uterine procedures. Histopathological examination is crucial for diagnostic and surgical management.

Multiple Leiomyomas in a Patient with Benign Metastasizing Leiomyoma: A Case Report

INTRODUCTION

Benign metastasizing leiomyoma (BML) is a rare disease and mostly affects females with a history of uterine leiomyoma, particularly the presence of multiple leiomyomas in BML patients is extremely rare.

CASE PRESENTATION

This paper reported the clinical and imaging data of a BML patient with multiple leiomyomas involving bilateral pulmonary, mediastinum, pericardium, spine, peritoneum, and left thigh. Multiple BML lesions exhibited consistent imaging examinations, significantly improving the delayed phase enhancement. After multi-stage targeted therapy for multiple systemic metastases and the development of drug resistance, the patient was treated with hysterectomy and bilateral adnexectomy along with letrozole-based endocrine therapy. BML lesions, both pulmonary and mediastinum, became significantly smaller than before.

CONCLUSION

This paper aims to analyze the imaging and clinical features of multiple leiomyomas in this BML case, thus strengthening the understanding of the rare type of leiomyoma for effective preoperative diagnosis and clinical treatment. Furthermore, it is noteworthy that gynecologists should avoid the manifestation of BML when performing uterine fibroids surgery.

Extra-Uterine Leiomyoma Presenting After Hysterectomy

Leiomyomas are a common gynaecological finding affecting 20-30% of women over the age of 35, with prevalence decreasing following menopause. Around 25% of women present clinically with a leiomyoma, which are most commonly found within the uterus. Rarer extra-uterine locations include the broad ligament, cervix, and vagina. We present a rare case of an extra-uterine leiomyoma located in the perineum of a 59-year-old female. Our case highlights the importance for extra-uterine leiomyoma to be considered as a differential diagnosis in patients presenting with a pelvic mass following hysterectomy.

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.

Spinal Cord Compression Secondary to Benign Metastasizing Leiomyoma

Benign metastasizing leiomyoma is an extremely rare disease characterized by the presence of extrauterine spread of smooth muscle cells with histological, molecular, and immunological patterns similar to those of benign uterine leiomyomas. Benign metastasizing leiomyoma is often asymptomatic, and it presents as an incidental radiology finding of well-defined multiple pulmonary nodules with varying sizes. It is more frequent in premenopausal women, and a previous history of uterine leiomyomas resected in the past is found in most of the cases. There are very few case reports of benign metastasizing leiomyoma causing spinal cord compression. The authors report an uncommon case of a premenopausal woman with spinal cord compression one year after the diagnosis of benign metastasizing leiomyoma to the lung. Given that spinal cord compression is an oncologic neurosurgical emergency, rapid diagnosis and management are essential to prevent irreversible neurological deficits.

Brenner tumors

Brenner tumors are rare ovarian neoplasms composed of ovarian transition cells surrounded by dense fibrous tissue. Most of them are small tumors (<2 cm), detected incidentally in asymptomatic women. Its predominantly fibrous content results in relatively low signal on T₂ weighted images, establishing differential diagnosis with ovarian fibroma and thecoma. Their imaging features are very similar, the differentiation is based on secondary characteristics, such as signs or symptoms of estrogen excess and the presence of a second ovarian neoplasm, which has been reported in up to 30% of patients with Brenner tumor. Although originally thought to be universally benign, there have been scattered reports in the past decades of borderline and malignant forms of Brenner tumors.

Peritoneal disease: key imaging findings that help in the differential diagnosis

The peritoneum is a unique serosal membrane, which can be the site of primary tumors and, more commonly, secondary pathologic processes. Peritoneal carcinomatosis is the most common malignant condition to affect the peritoneal cavity, and the radiologist plays an important role in making the diagnosis and assessing the extent of disease, especially in sites that may hinder surgery. In this review, we address the role of the radiologist in the setting of peritoneal pathology, focusing on peritoneal carcinomatosis as this is the predominant malignant process, followed by revising typical imaging findings that can guide the differential diagnosis.We review the most frequent primary and secondary peritoneal tumor and tumor-like lesions, proposing a systemic approach based on clinical history and morphological appearance, namely distinguishing predominantly cystic from solid lesions, both solitary and multiple.

Benign Metastasizing Leiomyomatosis to the Skin and Lungs, Intravenous Leiomyomatosis, and Leiomyomatosis Peritonealis Disseminata: A Series of Five Cases

Benign metastasizing leiomyomatosis (BML) is a rare disease that typically occurs in women with a history of uterine leiomyomatosis. Benign metastasizing leiomyomatosis occurs more frequently in the lungs but may also develop in other organs and tissues. Other unusual variants of extra-uterine leiomyomatosis include intravenous leiomyomatosis (IVL) and leiomyomatosis peritonealis disseminata (LPD). In this article, three cases of BML are presented. One case, in a premenopausal woman, presented cutaneous metastases. We also present a case of IVL and a case of LPD, which occurred in postmenopausal women. Given the rarity of BML, IVL, and LPD, the authors reviewed the literature and herein discuss the implications for treatment in all five cases. Evidence for treating BML, IVL, and LPD is still scarce, and data available from our series and other small series seem to point to the patient’s hormonal status playing a fundamental part in the treatment plan. Furthermore, a collecting bag when performing excision of uterine leiomyomas may help avoid the potential spreading of leiomyomatosis. Hysterectomized patients with chronic cough, frequent respiratory infections, abdominal discomfort, right heart failure, or non-specific symptoms should be actively screened for BML, IVL, and LPD. Treatment should be individualized according to each patient’s hormonal status and desires.

Mimics and Pitfalls of Primary Ovarian Malignancy Imaging

The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa.

A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas

Uterine leiomyomas are the most common gynecological and pelvic neoplasm, reported in up to 80 percent of women by age 50. While the majority are asymptomatic, uterine leiomyomas, depending on size, number, and location can result in bulk symptoms, abnormal uterine bleeding (AUB), infertility or recurrent pregnancy loss. Ultrasonography (USG) remains first-line for the diagnosis of leiomyomas and is the most appropriate imaging modality for the initial assessment of abnormal uterine bleeding. In an effort to standardize nomenclature and identify causes of AUB, the International Federation of Gynecology and Obstetrics (FIGO) developed a classification system based on the acronym PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified). For the L category of leiomyoma, when present, a secondary and tertiary subclassification system is described distinguishing submucosal masses from others and categorizing the relationship of the mass to the endometrium and serosa. With advancements in newer minimally to non-invasive techniques developed for the management of leiomyomas, uniform characterization, mapping, and classification of leiomyomas is necessary to decide the optimal therapeutic approach. While this classification system has recently been reviewed on MR, to our knowledge, it has not been reviewed on ultrasound in the radiology literature. We hereby present a pictorial review of USG images of all the FIGO categories of leiomyomas to provide a standard guide for radiology reporting.

Benign metastasizing leiomyoma, a rare imposter of metastatic cervical cancer

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Differential for necrotic pelvic mass with pulmonary nodules.

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Benign metastasizing leiomyoma in woman with limited surgical history.

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Efficacy of estrogen depletion therapy for benign metastasizing leiomyoma.

Benign metastasizing leiomyoma (BML) is a rare variant of common benign smooth muscle neoplasm. We report a case of BML in a 45-year-old premenopausal woman with a significant smoking history and no previous history of cervical cancer screening. The patient presented with vaginal bleeding, abdominal pain, a necrotic mass in the vagina, and an incidental finding of diffuse pulmonary nodules on chest imaging. A total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) was performed for symptomatic management and adequate tissue sampling followed by fine needle biopsy of a pulmonary lesion. The pedunculated uterine mass and the pulmonary nodule were both consistent with smooth muscle neoplasm suggestive of myoma. Six-months following surgery, the patient is asymptomatic with partial regression of her lung nodules and no evidence of new or enlarging lesions while on treatment with Megestrol.

Ectopic uterus? A rare presentation of a giant leiomyoma in the posterior mediastinum

Leiomyomas are benign mesenchymal tumors derived from smooth muscles. Uterus is the commonest site of origin for leiomyomas; however, unusual growth patterns and locations have been reported posing diagnostic challenges, clinically and radiologically. Histological diagnosis remains the gold standard of diagnosis. Here, we present a 17-year-old female with a 3-month history of chest pain, cough, difficulty in breathing and chest tightness. Chest CT scan showed a 12.3 cm × 14.4 cm × 22.8 cm mass occupying the entire left posterior hemithorax. The patient underwent thoracotomy and recovered well after surgery. Histopathology of the excised specimen confirmed it to be leiomyoma. Despite its rarity, primary mediastinal leiomyoma should be considered in the differential diagnosis of an unexplained mediastinal mass. Its accurate pre-operative diagnosis is difficult. Respiratory compromise and risk of transformation to sarcoma mandate complete surgical resection for a definitive diagnosis and good prognosis.

Metastatic uterine fibroid in postmenopausal woman suspected of leiomyosarcoma: A case report and literature review

Benign metastatic leiomyoma is a unique event presenting most commonly in premenopausal women especially those with a previous history of gynecological surgery as management of uterine fibroids. In this case report, we investigate a rare case of benign metastatic leiomyoma in a 54-year-old postmenopausal female presented with a huge pelvic mass that was rapidly growing along with pulmonary nodules. The patient is suspected to have leiomyosarcoma which is eventually confirmed pathologically as benign metastatic leiomyoma. Although rare, describing the challenging diagnostic and management approach of such entity is essential and to consider it one of the differential diagnoses of patients who present with similar history.

Update on MR Imaging of Soft Tissue Tumors of Head and Neck

This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.

An Intraluminal Parasitic Leiomyoma of the Sigmoid Colon and Potential Pathogenetic Mechanisms

Uterine leiomyomas are the most common benign tumor of the female pelvis. Parasitic leiomyomas are an extremely rare entity of leiomyoma occurrence found at extrauterine sites. They are mostly diagnosed in patients with a history of gynecologic procedures and morcellators use during laparoscopic leiomyoma resection. Here we present an extraordinary case of an intraluminal leiomyoma of the sigmoid colon that was incidentally discovered during total abdominal hysterectomy and bilateral salpingo-oophorectomy, performed due to leiomyomatous uterus in a female patient with no history of previous gynecologic operations. Potential pathogenetic mechanisms that can explain the co-occurrence of leiomyomas in the uterus and the sigmoid colon are also reviewed and include genetic predisposition, the stem cell theory of leiomyomas formation, and lymphatic and vascular spread.

Uterine leiomyomas revisited with review of literature

Uterine leiomyomas, more commonly known as fibroids, are the most common neoplasms of the uterus. These tumors have a profound effect on health care and cost worldwide. Depending on the race, uterine leiomyomas can be seen in 70-80% of all women. Although majority of the women with uterine leiomyomas remain asymptomatic, approximately 30% can present with symptoms. Diagnosing typical leiomyomas on imaging is straightforward. However, when large, located extrauterine and especially with degeneration, the diagnosis can be challenging on imaging. In this article, apart from reviewing the demographics and management of patients with leiomyomas, we describe in detail the imaging appearance of various atypical leiomyomas, uncommon locations outside the uterus and their important differential diagnosis that can have a profound effect on patient management.

Vulvar myoma: A case report and review of literature

OBJECTIVE

To present a case of vulvar myoma and the factors differentiating this tumor from Bartholin's cyst.

CASE REPORT

A 50-year-old woman presented with a nodule over the left labia majora. Pelvic examination showed swelling and redness of the left labia majora. A 2-cm nodule with firm consistency was found near the vaginal opening. There was no inguinal lymphadenopathy. Bartholin's cyst was suggested, and oral cephalexin was prescribed for 1 week, but no improvement was seen. Therefore, she underwent excision of the nodule. Pathology revealed it to be a benign vulvar myoma. The patient recovered well, and no recurrence was noted after 2 months of follow-up.

CONCLUSION

Vulvar myoma is rare. Sexual history, nodule consistency, and imaging are helpful, but the final diagnosis of vulvar myoma is usually made following surgical excision and histopathological analysis.

Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check!

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET¹T²ER Check! to help identify key features more suggestive of a uterine sarcoma.

Intravenous leiomyomatosis: Case series and review of the literature

Introduction

Intravenous leiomyomatosis (ILV) is a rare pathology, part of leiomyoma beyond the uterus (LBU), characterized by benign smooth muscle cell tumor outside of the uterus and mainly affecting premenopausal woman with a medical history of leiomyoma or gynecologic surgical treatment. The treatment depends on the localization of the tumor, age of the patient, initial size, symptoms and the suitability for surgery but should always aims in toto surgical resection.

Case presentation

Retrospective case series and review of literature.

Clinical discussion

Symptoms presented by the patient were aspecific and only localized in the pelvic area. All cases were fortuitous histopathological diagnosis. No relapse was. Two out of 5 patients have pulmonary nodules, only one was biopsied and diagnosed with PBML (pulmonary benign metastasizing leiomyoma).

Conclusion

IVL and BML are rare disease that can co-exist. Because of tumoral hormonal receptors, hormonotherapy could be an optional treatment but to date no clear efficacy is demonstrated. In case of high recurrence risk such as voluminous initial mass, impairment of broad ligament, failure of total surgical resection, adjuvant hormonotherapy could be useful. Recurrence rate is about 16.6-30% and can occur even dozen years later and even after radical surgery, justifying a regular follow up.

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Leiomyomas beyond the uterus (LBU) is defined by benign smooth muscle cell tumor outside of the uterus. Sub classification of this entity are intravenous leiomyomatosis (IVL), benign metastasizing leiomyomas (BML), diffuse peritoneal leiomyomatosis (DPL), retroperitoneal leiomyomas and parasitic leiomyomas.

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The differential diagnosis of IVL should include benign myoma, thrombus, leiomyosarcoma, soft tissue sarcoma, lymphoma, cardiac myxoma, tumor thrombosis of Wilms tumor or metastasis.

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Treatment of IVL is usually surgery but there is no consensus about the the optimal approach. Adjuvant therapy sur as bilateral salpingoophorectomy followed by hormonothetherapy have to be balanced with their side effects.

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Despite being histologically benign, BML shows the metastatic potential of LBU.

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Because of a high rate of recurrence estimated of 16.6% to 30%, long term follow up is recommended even after radical surgery.

Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance

The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ^©RSNA, 2021.

Primary intracranial leiomyoma - A case report and literature review

Primary intracranial leiomyoma is a rare tumour of mesenchymal origin, with less than 30 cases reported in literature including two cases from the Indian subcontinent. In this article, we describe a case of primary intracranial leiomyoma in an immunocompromised patient with a brief review of literature.

Radiologic-Pathologic Correlation of Primary Retroperitoneal Neoplasms

An earlier incorrect version of this article appeared in print. The online version is correct.