Presentation and treatment of uterine leiomyoma in adolescence: a systematic review

Submucous leiomyoma: an uncommon cause of heavy menstrual bleeding in early adolescence

Uterine leiomyomas are rare in the paediatric population. This report describes a rare case of a submucous leiomyoma in an adolescent girl. The patient presented with a history of abnormal and painful period which was refractory to medical treatment. Sonographic findings revealed a uterine mass that protruded through the cervix until the upper third of the vagina. A hysteroscopic resection was performed, and a pathological examination confirmed a leiomyoma. 12 months after surgery, there were no signs of recurrence. Conservative sparing-fertility management, such as hysteroscopic resection, is the best option with a type 0 submucosal fibroid, especially in adolescents and young women.

To B or not to B: the application of uterine compression sutures to reduce blood loss after myomectomy

Introduction

The aim was to assess the hemostatic impact of B-Lynch sutures following an open myomectomy for efficacy.

Material and methods

In this prospective clinical research, performed in Alazhar university hospitals (Al-Hussain, Damietta, Assiut) and Minia University Maternity Hospital, 250 women scheduled for open myomectomy between January 2021 and January 2023 had multiple fibroid uteri with uterine sizes corresponding to 12-22 weeks. There were two groups of women. Group I (125) underwent standard open myomectomy surgery, whereas Group II (125) underwent normal open laparotomy surgery followed by B-Lynch sutures. Certain inclusion and exclusion criteria were applied to every patient. We recorded vital data, length of the procedure, complications (bleeding during the procedure, bleeding from multiple bites, bladder injury, fever, wound infection), complete blood count before and after surgery, need for blood transfusion, postoperative vital data, time until ambulation, passing flatus, and ability to eat and drink, as well as the amount of blood lost during and after the procedure.

Results

There was no statistically significant difference between the two groups in age, parity, weight, number of fibroids, or uterine size as measured by ultrasonography. Between groups I and II, there was a significant difference in the average intraoperative blood loss (Group I lost 562.6 ml, whereas Group II lost 411.3 ml) as well as the mean blood loss following surgery (205 ±82 ml in Group I and 117 ±41 ml in Group II). No significant difference was observed in the mean length of hospital stay between groups I and II (2 ±0.3 days and 2 ±0.6 days, respectively).

Conclusions

Using a B-Lynch suture can help minimize blood loss during and after an open myomectomy. Therefore, if the uterus is large and has a lot of fibroids, it is recommended to be done frequently.

Rare clinical entity of huge leiomyoma uteri in a 17-year-old adolescent managed with a fertility-sparing procedure: Case report and literature review

INTRODUCTION AND IMPORTANCE

The most frequent benign uterine tumor is uterine fibroids. Approximately, 20 to 30 % of women between the ages of 30 and 50 have them. Teenagers do, however, rarely experience them; the prevalence is less than 1 % in general population.

CASE PRESENTATION

We present a 17-year-old nulliparous female who was admitted to the hospital due to gradually increasing abdominopelvic pain. Transabdominal pelvic ultrasound showed massive uterine enlargement, with a heterogenous structure within the fundus measuring 9.8 cm in diameter. Pelvic MRI revealed an enlarged uterus with a heterogeneous complex mass measuring 10.78 cm by 8 cm that seemed to be compressing but was not attached to the endometrium The findings from the radiology review were concerning for leiomyoma. Intraoperative findings showed a 13-cm anterior intramural mass with normally appearing fallopian tubes and ovaries bilaterally. Resection of the mass was done, and the entire specimen was sent to pathology which confirmed the diagnosis of leiomyoma.

DISCUSSION

Occurrence of uterine fibroids in the young and adolescent age is extremely rare with an estimated prevalence of less than 1 %. Leiomyosarcoma is a less frequent diagnosis to take into account, but it can be identified histologically. Therefore, a myomectomy that preserves fertility enables a diagnostic chance to rule out a probable cancer.

CONCLUSION

When young women present with steadily worsening abdominopelvic discomfort, it is crucial to include leiomyomas in the differential diagnosis despite the rarity of leiomyomas in adolescents.

Overlap of Suspicious and Non-Suspicious Features in the Ultrasound Evaluations of Leiomyosarcoma: A Single-Center Experience

Leiomyosarcoma (LMS) is a rare type of mesenchymal tumor. Suspecting LMS before surgery is crucial for proper patient management. Ultrasound is the primary method for assessing myometrial lesions. The overlapping of clinical, laboratory, as well as ultrasound features between fibroids and LMS makes differential diagnosis difficult. We report our single-center experience in ultrasound imaging assessment of LMS patients, highlighting that misleading findings such as shadowing and absent or minimal vascularization may also occur in LMS. To avoid mistakes, a comprehensive evaluation of potentially overlapping ultrasound features is necessary in preoperative ultrasound evaluations of all myometrial tumors.

Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment

Uterine fibroids are benign monoclonal neoplasms of the myometrium, representing the most common tumors in women worldwide. To date, no long-term or noninvasive treatment option exists for hormone-dependent uterine fibroids, due to the limited knowledge about the molecular mechanisms underlying the initiation and development of uterine fibroids. This paper comprehensively summarizes the recent research advances on uterine fibroids, focusing on risk factors, development origin, pathogenetic mechanisms, and treatment options. Additionally, we describe the current treatment interventions for uterine fibroids. Finally, future perspectives on uterine fibroids studies are summarized. Deeper mechanistic insights into tumor etiology and the complexity of uterine fibroids can contribute to the progress of newer targeted therapies.

Preoperative Differentiation of Uterine Leiomyomas and Leiomyosarcomas: Current Possibilities and Future Directions

The distinguishing of uterine leiomyosarcomas (ULMS) and uterine leiomyomas (ULM) before the operation and histopathological evaluation of tissue is one of the current challenges for clinicians and researchers. Recently, a few new and innovative methods have been developed. However, researchers are trying to create different scales analyzing available parameters and to combine them with imaging methods with the aim of ULMs and ULM preoperative differentiation ULMs and ULM. Moreover, it has been observed that the technology, meaning machine learning models and artificial intelligence (AI), is entering the world of medicine, including gynecology. Therefore, we can predict the diagnosis not only through symptoms, laboratory tests or imaging methods, but also, we can base it on AI. What is the best option to differentiate ULM and ULMS preoperatively? In our review, we focus on the possible methods to diagnose uterine lesions effectively, including clinical signs and symptoms, laboratory tests, imaging methods, molecular aspects, available scales, and AI. In addition, considering costs and availability, we list the most promising methods to be implemented and investigated on a larger scale.

Benign Uterine Neoplasm as a Cause of Prepubertal Bleeding

BACKGROUND

Vaginal bleeding in the prepubertal child has several etiologies, including structural anomalies, endocrinologic dysfunction, infection, trauma, foreign body, and hematologic disorders.

CASE

An 8-year-old premenarcheal girl presented with vaginal bleeding. On ultrasound, she was found to have an intramural hyperechogenic mass in the left uterine fundus. This was biopsied and showed smooth muscle. She was subsequently started on a GnRH agonist to suppress bleeding and has since been followed with serial ultrasounds. We have 6 years of follow-up imaging showing a presumed adenomyoma versus fibroid that has been stable in size.

SUMMARY AND CONCLUSION

We present a novel case of adenomyosis presenting as prepubertal bleeding. Pelvic imaging is prudent to exclude structural etiologies as the cause of prepubertal vaginal bleeding.

Uterine leiomyomatosis in adolescents and young adults (AYAs) may represent a narrow phenotypic variant of FH tumour predisposition syndrome

FH Tumour Predisposition Syndrome, also known as Hereditary Leiomyomatosis and renal cell cancer (HLRCC), or Reed Syndrome, is an autosomal dominant condition clinically characterized by multiple cutaneous leiomyomas, multiple early-onset uterine leiomyomas and early-onset renal cell cancer. Here we report a young female with FH Tumour Predisposition Syndrome with no clinical features except early-onset uterine leiomyomas. Whilst there is a significant history of uterine leiomyomas in her family, there is no history of cutaneous leiomyomas or renal cell cancer (RCC). Uterine leiomyomatosis in young adults may represent a narrow phenotypic variant of FH Tumour Predisposition Syndrome. It is important that young women who present with multiple leiomyomata or leiomyomata with atypical features are referred for molecular genetic testing.

Single Incision Laparoscopic Surgery for Leiomyoma in the Adolescent Patient: A Case Report

BACKGROUND

Single-incision laparoscopic surgery (SILS) is an exciting new modality in the field of minimal access surgery. This case illustrates the feasibility of single-incision laparoscopic surgery for uterine pathology in the pediatric and adolescent population.

CASE

A 19-year-old girl presented with pelvic pain. Transabdominal pelvic ultrasound and magnetic resonance imaging revealed multiple fibroids with rapid enlargement over a year. In collaboration with the Minimally Invasive Gynecologic Surgery team, single incision laparoscopic myomectomy was performed with satisfactory results.

SUMMARY AND CONCLUSION

Complex uterine pathology can be managed with minimally invasive surgery with excellent clinical outcomes. SILS is a rapidly developing field that may represent the future of laparoscopic surgery and can be used to treat reproductive pathology in the pediatric and adolescent population.

The importance of compression sonoelastography in improving the diagnostics of the pathology of myometrium

The diversity of the clinical picture and the asymptomatic nature of the clinical manifestations of myometrial pathology cause difficulties in diagnosis. There is a lack of reliable diagnostic criteria for this pathology, in particular, imaging, especially with the simultaneous combination of adenomyosis and leiomyoma. The aim of the research. Determination of the possibility of compression sonoelastography in the diagnosis of myometrial pathology and determination of its sonoelastography characteristics in leiomyoma and adenomyosis, as well as comparison of sonoelastography results with histological data. Materials and methods. Elastography images of 155 patients with adenomyosis and leiomyoma, as well as combined pathology, were analyzed, the elastography diagnosis of which was confirmed by histological examination. Results. Leiomyoma and adenomyosis had different elastography characteristics (strain ratios) with different color mapping; their specific characteristics and main differences are determined. Based on sonoelastography, the majority of patients (n=30) were suspected of having uterine fibroids, 14 had adenomyosis, and 42 had adenomyosis and fibroids. Sonoelastography revealed histological signs of adenomyosis in 3 patients with uterine leiomyoma. Conclusions. Ultrasound examination using compression sonoelastography in such pathological conditions of the myometrium as adenomyosis and leiomyoma, as well as unchanged myometrium, makes it possible to determine changes in the degree of elasticity of the myometrium in the corresponding pathology. Sonoelastography allows the identification of clear distinguishing features of fibroids and adenomyosis. The unchanged myometrium has a certain elasticity, which can be equated to a specific numerical value – the coefficient of deformation. This indicator has different meanings in myoma and adenomyosis, which makes it possible to differentiate these pathological conditions of the myometrium. Compression sonoelastography is able to identify clear distinguishing features of leiomyoma and adenomyosis, and consistency of diagnoses based on sonoelastography and histology is significant but not optimal.

Uterine Fibroid in a 16-Year-Old Adolescent Managed with a Fertility-Sparing Approach: A Case Report and Review of the Literature

BACKGROUND

Uterine fibroids are the most common benign tumor of the uterus in adult women. However, it is exceedingly rare in adolescents.

CASE

A 16-year-old girl presented with severe anemia and abnormal uterine bleeding. MRI of the pelvis demonstrated a 9-cm mass within the uterus concerning for leiomyoma or leiomyosarcoma. A fertility preserving myomectomy led to the final diagnosis of a benign uterine fibroid.

SUMMARY AND CONCLUSION

Despite the rare incidence of leiomyomas in adolescents, it is imperative that it is included in the differential diagnosis when young women present with abnormal uterine bleeding. A less common diagnosis to consider is leiomyosarcoma; however, this is histologically diagnosed. Thus, a fertility-preserving myomectomy permits for a diagnostic opportunity to rule out a potential malignancy.

Molecular differential analysis of uterine leiomyomas and leiomyosarcomas through weighted gene network and pathway tracing approaches

Uterine smooth muscular neoplastic growths like benign leiomyomas (UL) and metastatic leiomyosarcomas (ULMS) share similar clinical symptoms, radiological and histological appearances making their clinical distinction a difficult task. Therefore, the objective of this study is to identify key genes and pathways involved in transformation of UL to ULMS through molecular differential analysis. Global gene expression profiles of 25 ULMS, 25 UL, and 29 myometrium (Myo) tissues generated on Affymetrix U133A 2.0 human genome microarrays were analyzed by deploying robust statistical, molecular interaction network, and pathway enrichment methods. The comparison of expression signals across Myo vs UL, Myo vs ULMS, and UL vs ULMS groups identified 249, 1037, and 716 significantly expressed genes, respectively (p ≤ 0.05). The analysis of 249 DEGs from Myo vs UL confirms multistage dysregulation of various key pathways in extracellular matrix, collagen, cell contact inhibition, and cytokine receptors transform normal myometrial cells to benign leiomyomas (p value ≤ 0.01). The 716 DEGs between UL vs ULMS were found to affect cell cycle, cell division related Rho GTPases and PI3K signaling pathways triggering uncontrolled growth and metastasis of tumor cells (p value ≤ 0.01). Integration of gene networking data, with additional parameters like estimation of mutation burden of tumors and cancer driver gene identification, has led to the finding of 4 hubs (JUN, VCAN, TOP2A, and COL1A1) and 8 bottleneck genes (PIK3R1, MYH11, KDR, ESR1, WT1, CCND1, EZH2, and CDKN2A), which showed a clear distinction in their distribution pattern among leiomyomas and leiomyosarcomas. This study provides vital clues for molecular distinction of UL and ULMS which could further assist in identification of specific diagnostic markers and therapeutic targets.Abbreviations UL: Uterine Leiomyomas; ULMS: Uterine Leiomyosarcoma; Myo: Myometrium; DEGs: Differential Expressed Genes; RMA: Robust Multiarray Average; DC: Degree of Centrality; BC: Betweenness of Centrality; CGC: Cancer Gene Census; FDR: False Discovery Rate; TCGA: Cancer Genome Atlas; BP: Biological Process; CC: Cellular Components; MF: Molecular Function; PPI: Protein-Protein Interaction.

Does Big Mean Evil? Giant, but Benign Uterine Leiomyoma: Case Report and Review of the Literature

Uterine leiomyoma is the most prevalent benign type of gynecological tumor. It affects more than 80% of women worldwide and, within this group, more than 50% may be asymptomatic. However, large fibroid volumes may be associated with symptoms of extrinsic compression, and most of the cases do not present atypical cells. We present the case of a 49-year-old woman who underwent a total abdominal hysterectomy of a 13.5-kg uterine leiomyoma with no malignancies at histopathology and review the literature about giant uterine leiomyomas and their clinical repercussion. We concluded that large volumes do not always pose a threat regarding malignancy; however, future molecular studies are needed to investigate giant uterine fibroids.

Association of benign gynaecological diseases and risk of endometrial and ovarian cancers

Objective: Gynaecologic benign diseases such uterine fibroids share similar pathogeneses with endometrial and ovarian cancers. Whether a history of uterine fibroids increases the risk of developing endometrial or ovarian cancers is controversial, due to uterine fibroids was self-reported in those studies. Methods: In our current case-control study, 268 women with endometrial cancer and 108 women with ovarian cancer were included. In addition, 500 women without gynaecological cancers were randomly selected as a control group. Uterine fibroids in both groups were clinically diagnosed by pelvic examination and ultrasound. Data on age, parity, gravida, stages of cancers and history of uterine fibroids, endometriosis and adenomyosis were collected from hospital database. Results: After adjusted age and parity, the odds of women with history of uterine fibroids or endometriosis were lower in women with endometrial cancer than controls (odds ratio: 0.148, 95% CI: 0.097, 0.225, or 0.360, 95% CI: 0094, 1.381, respectively). The odds of women with a history of uterine fibroids or endometriosis were lower in women with ovarian cancer than controls (odds ratio: 0.141, 95% CI: 0.085, 0.235, or 1.057, 95% CI: 0.377, 2.963, respectively). However, the odds of women with a history of adenomyosis were higher in women with endometrial or ovarian cancers than controls (odd ratio: 3.757, 95% CI: 1.858, 7.599 or 2.341, 95% CI: 1.086, 5.045, respectively). Conclusion: Our observational data suggested that uterine fibroids or endometriosis may be not associated with the increased risk of developing endometrial or ovarian cancer. However, a history of adenomyosis may do.

A Case of a Prolapsed Fibroid in a 12-Year-Old Girl

BACKGROUND

Uterine fibroids are a common cause of abnormal uterine bleeding in adult women, but are extremely rare in the adolescent years.

CASE

A 12-year-old nulliparous girl presented with abnormal uterine bleeding and was found to have a prolapsing submucosal fibroid. The fibroid and her symptoms were successfully removed using an Endosnare.

SUMMARY AND CONCLUSION

The most common cause of abnormal uterine bleeding in adolescent bleeding is due to anovulation. Though rare, fibroids should remain on the differential as the cause of abnormal uterine bleeding in the adolescent population, particularly if symptoms persist despite initial therapy. Fibroids can be managed successfully with minimally invasive techniques.

Targeted sequencing of FH-deficient uterine leiomyomas reveals biallelic inactivating somatic fumarase variants and allows characterization of missense variants

Uterine leiomyomas (ULs) constitute a considerable health burden in the general female population. The fumarate hydratase (FH) deficient subtype is found in up to 1.6% and can occur in hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome. We sequenced 13 FH deficient ULs from a previous immunohistochemical screen using a targeted panel and identified biallelic FH variants in all. In eight, we found an FH point mutation (two truncating, six missense) with evidence for loss of the second allele. Variant allele-frequencies in all cases with a point mutation pointed to somatic variants. Spatial clustering of the identified missense variants in the lyase domain indicated altered fumarase oligomerization with subsequent degradation as explanation for the observed FH deficiency. Biallelic FH deletions in five tumors confirm the importance of copy number loss as mutational mechanism. By curating all pathogenic FH variants and calculating their population frequency, we estimate a carrier frequency of up to 1/2,563. Comparing with the prevalence of FH deficient ULs, we conclude that most are sporadic and estimate 2.7-13.9% of females with an FH deficient UL to carry a germline FH variant. Further prospective tumor/normal sequencing studies are needed to develop a reliable screening strategy for HLRCC in women with ULs.

Pathogenomics of Uterine Fibroids Development

We review recent studies dealing with the molecular genetics and basic results of omics analysis of uterine leiomyoma (LM)-a common benign muscle tumor of the uterus. Whole genome studies of LM resulted in the discovery of many new gene nets and biological pathways, including its origin, transcriptomic, and epigenetic profiles, as well as the impact of the inter-cell matrix in LM growth and involvement of microRNA in its regulation. New data on somatic cell mutations ultimately involved in the origin, distribution and growth of LM are reviewed. Putative identification of LM progenitor SC (stem cells) giving rise to maternal fibroid nodes and junctional zones provide a new clue for hypotheses on the pathogenomics of LM. The reviewed data are consistent with at least two different but probably intimately interacted molecular mechanisms of LM. One of them (the genetic hypothesis) is focused primarily on the MED12 gene mutations and suggests its onset in the side population of embryonic myoblasts of the female reproductive system, which later gave rise to multiple small and medium fibroids. The single and usually large-size fibroids are induced by predominantly epigenetic disorders in LM SC, provoked by enhanced expression of the HMGA2 gene caused by its hypomethylation and epigenetic deregulation enhanced by hypoxia, muscle tension, or chromosome instability/aberrations. The pathogenomics of both genetic and epigenetic programs of LM with many peculiarities at the beginning later became rather similar and partly overlapped due to the proximity of their gene nets and epigenetic landscape. Pathogenomic studies of LM open ways for elaboration of novel strategies of prevention and treatment of this common disease.

Uterine leiomyoma in a 13-year-old adolescent successfully treated with laparoscopic myomectomy: A case report

RATIONALE

Uterine leiomyoma, which is very common gynecological tumor in the reproductive years, is extremely rare in adolescence. We herein report a case of a uterine leiomyoma treated with laparoscopic surgery in an adolescent.

PATIENT CONCERNS

A 13-year-old girl with no gravida and her first menses at 11 years of age reported feeling bloated. She had a regular menstrual cycle but felt increased abdominal distension.

DIAGNOSIS

Transabdominal ultrasound and magnetic resonance imaging revealed uterine leiomyoma with a diameter of 10 cm.

INTERVENTION

Laparoscopic myomectomy was performed.

OUTCOMES

The total weight of the leiomyoma removed was 660 g with pathological diagnosis of uterine leiomyoma. The postoperative course was uneventful. The patient was free of disease at the follow-up consultation 18 months after the treatment.

LESSONS

Laparoscopic approach is a very useful and minimally invasive surgery for symptomatic leiomyoma in adolescents.

Burden of Uterine Fibroids: An African Perspective, A Call for Action and Opportunity for Intervention

Black women carry the burden of uterine fibroids, (AKA uterine leiomyomas), at a much higher rate than their racial counterparts. Thus, increasing awareness and discovering a solution to an endemic problem that plagues Sub-Saharan Africa is of critical importance, not only for the region itself, but also for the medical community globally. A collaborative, patient oriented, cost effective, and culturally sensitive approach must be at the forefront of this endeavor. While the exact pathogenesis of uterine fibroid development remains elusive, the racial disparity is well documented. Moreover, in the developed world, women are able to seek treatment through surgical and non-surgical means; however, sub-Saharan regions face their own challenges that, if not addressed, can ultimately extinguish the lives of many suffering women. Unfortunately, the literature is scarce on how to prevent fibroid development, which may be critical for women who do not have access to effective interventions. Recent research from our group and others has shown that vitamin D deficiency plays an important role in fibroid development and may be a preventable risk factor. Daily vitamin D supplementation is a low cost, effective intervention that could be implemented throughout the Sub-Saharan region. Similarly, education and increased awareness as to the nature and symptoms of uterine fibroids could improve the quality of life, remove negative social stigma, and reduce morbidity and mortality rates in women who seek medical care with advanced uterine fibroids.

Abnormal uterine bleeding in adolescents: ultrasound evaluation of uterine volume

OBJECTIVE

To evaluate ultrasonographic measurements of internal genitalia in girls suffering from abnormal uterine bleeding (AUB) and to compare the appearances with those of healthy girls. DESIGN Prospective case - control study.

METHODS

One hundred and five not sexually active adolescent girls were enrolled - 67 patients were suffering from AUB and there were 38 healthy peers. The groups did not differ in chronological age, or in postmenarcheal age. All girls underwent assessment of their history, clinical data and transabdominal pelvic ultrasound to evaluate their uterus and ovaries. In order to avoid the impact of endometrium cycle fluctuations, the uterine volume was calculated including and excluding its thickness.

RESULTS

The uterine volume among the girls suffering from AUB was significantly larger than in the control group. The mean uterine volume including endometrium in the study and control groups was 63.2 ± 24.8 and 47.8 ± 17.5 cm³, respectively (p=.001), and excluding the endometrium was 34.7 ± 13.1 and 29.1 ± 13.8 cm³ (p=.043). We did not find any significant difference in ovarian volume between the groups.

CONCLUSIONS

The girls in the AUB group have significantly larger uterine volume than healthy girls. This finding does not depend on endometrial thickness.

Intravascular (post-hysterectomy) leiomyoma (IVL) as late tumor thrombus within the inferior vena cava (IVC)-A rare case primarily imposing as IVC thrombus originating from left renal vein after former left nephrectomy status

INTRODUCTION

Intravascular leiomyoma is a rare type of myoma. It was firstly described by Birch-Hirschfeld in 1896, however, its intracardiac subtype was firstly reported by Durck in 1907. Most patients are asymptomatic. The tumor invades mostly the tributaries of the inferior vena cava (IVC) with upward extension that may approach the intracardiac space.

AIM

By means of a scientific case report, a patient with the very rare diagnosis of an endocaval leiomyoma thrombus post-hysterectomy is described based on the clinical experiences obtained in the specific case management and selective references from the literature.

CASE PRESENTATION

A 48-years old female was diagnosed with intravascular tumor growth within the IVC with intracardiac extension using chest and abdominal CT scan, ECG and echocardiography which was approached by an interdisciplinary (vascular and cardiothoracic) surgical intervention (278 min) including heart-lung machine (99 min) with favorable postoperative result (R0 resection status with mid-term outcome, no recurrent tumor growth). Histopathological investigation diagnosed leiomyoma origin already from ovarian vein most likely in context to the former hysterectomy (3 years ago).

DISCUSSION AND CONCLUSION

Intravascular leiomyoma is a benign tumor with invasive tendency, which can be considered a diagnostic and therapeutic challenge. It should be thoroughly investigated to be planned for a radical surgical removal. By possible adherence to the intraabdominal or -thoracic organs, an interdisciplinary and eventually step-wise surgical approach (combining vascular, abdominal, thoracic and heart surgery as well as gynecology and urology), which can be demanding, is recommended to be seriously considered to i) reliably achieve R0 resection status and, thus, ii) provide best outcome, quality of life and prognosis.

The Usefulness of Immunohistochemistry in the Differential Diagnosis of Lesions Originating from the Myometrium

Uterine leiomyomas (LMs), currently the most common gynecological complaint around the world, are a serious medical, social and economic problem. Accurate diagnosis is the necessary prerequisite of the diagnostic-therapeutic process. Statistically, mistakes may occur more often in case of disease entities with high prevalence rates. Histopathology, based on increasingly advanced immunohistochemistry methods, is routinely used in the diagnosis of neoplastic diseases. Markers of the highest sensitivity and specificity profiles are used in the process. As far as LMs are concerned, the crux of the matter is to identify patients with seemingly benign lesions which turn out to be suspicious (e.g., atypical LM) or malignant (e.g., leiomyosarcoma (LMS)), which is not uncommon. In this study, we present the current state of knowledge about the use of immunohistochemical markers in the differential diagnosis of LM, atypical LM, smooth muscle tumors of uncertain malignant potential (STUMP), and LMS, as well as their clinical predictive value.

Expanded Somatic Mutation Spectrum of MED12 Gene in Uterine Leiomyomas of Saudi Arabian Women

MED12, a subunit of mediator complex genes is known to harbor genetic mutations, (mostly in exon 2), causal to the genesis of uterine leiomyomas among Caucasian, African American, and Asian women. However, the precise relationship between genetic mutations vs. protein or disease phenotype is not well-explained. Therefore, we sought to replicate the MED12 mutation frequency in leiomyomas of Saudi Arabian women, who represents ethnically and culturally distinct population. We performed molecular screening of MED12 gene (in 308 chromosomes belonging to 154 uterine biopsies), analyzed the genotype-disease phenotype correlations and determined the biophysical characteristics of mutated protein through diverse computational approaches. We discovered that >44% (34/77) leiomyomas of Arab women carry a spectrum of MED12 mutations (30 missense, 1 splice site, and 3 indels). In addition to known codon 44, we observed novel somatic mutations in codons 36, 38, and 55. Most genetically mutated tumors (27/30; 90%) demonstrated only one type of genetic change, highlighting that even single allele change in MED12 can have profound impact in transforming the normal uterine myometrium to leiomyomas. An interesting inverse correlation between tumor size and LH is observed when tumor is positive to MED12 mutation (p < 0.05). Our computational investigations suggest that amino acid substitution mutations in exon-2 region of MED12 might contribute to potential alterations in phenotype as well as the stability of MED12 protein. Our study, being the first one from Arab world, confirms the previous findings that somatic MED12 mutations are critical to development and progression of uterine leiomyomas irrespective of the ethnic background. We recommend that mutation screening, particularly codon 44 of MED12 can assist in molecular diagnostics of uterine leiomyomas in majority of the patients.

Surgical Planning and Counseling in Adolescence: A Case Report of a 16-Year-Old with an Aborting Pelvic Mass

This case illustrates a rare finding and successful treatment of an aborting fibroid in a virginal adolescent. Careful consideration for the exam process, specific counseling, surgical planning and approach in this case are presented.

Unexpected uterine sarcomas in 4478 patients with electric power morcellation for leiomyomas

OBJECTIVES

Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas.

STUDY DESIGN

We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016.

RESULTS

Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months.

CONCLUSIONS

Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation.

Heavy Menstrual Bleeding in Adolescents

Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.

Laparoscopic Myomectomy of a Symptomatic Uterine Leiomyoma in a 15-Year-Old Adolescent

BACKGROUND

Although adnexal masses and ovarian torsion are common causes of acute pain in the female adolescent, fibroids are an uncommon etiology and little is reported in the literature. Because of the rarity of adolescent leiomyomas, the best surgical management is still unknown.

CASE

To our knowledge, this is the first case report of a laparoscopic myomectomy in the adolescent population. The removed fibroid is one of the largest documented cases of uterine leiomyoma in adolescents.

SUMMARY AND CONCLUSION

Degenerative fibroids, albeit less common, should be kept on the differential diagnosis, as a possible cause of pelvic mass and pain in the adolescent population. Fibroids in the adolescent patient, like the adult, can be managed with minimally invasive surgery with excellent clinical outcomes.

Heavy Menstrual Bleeding as a Common Presenting Symptom of Rare Platelet Disorders: Illustrative Case Examples

Heavy menstrual bleeding (HMB) is a common symptom in patients who present to the obstetrician-gynecologist or adolescent medicine specialist and might result from an underlying inherited bleeding disorder. Whereas relatively common bleeding disorders such as von Willebrand disease are often included in standard laboratory assessments, rarer platelet function disorders can be challenging to diagnose. Additionally, HMB can be a particularly difficult symptom to manage in adolescents with platelet function disorders, and it is associated with decreased quality of life. We review the diagnostic and management issues of patients with platelet function disorders through the presentation of 2 patient case reports, with a focus on a diagnosis of Glanzmann thrombasthenia, an inherited qualitative disorder that affects platelet function. Whereas the first patient presented to the emergency department before the diagnosis of a bleeding disorder and required a hematologic referral and extensive laboratory assessments, the second patient had been diagnosed with Glanzmann thrombasthenia as a child but experienced severe management challenges at the onset of menarche. In both patients, collaboration between the obstetrician-gynecologist or adolescent medicine specialist and the hematologist was critical for achieving acute management of the bleeding symptoms and for ensuring optimal long-term disease management. Together, these cases highlight the importance of properly identifying females with HMB who might have an undiagnosed bleeding disorder and of consulting with a hematologist to determine an appropriate management plan throughout all life stages.

Comparative systems genetics view of endometriosis and uterine leiomyoma: Two sides of the same coin?

Endometriosis (EM) and uterine leiomyoma (UL) are two most frequent benign tumors of monoclonal origin affecting about 30% of all women in their reproductive age. Modern molecular technologies have made a tremendous impact in understanding both disorders. Here is the first comparative analysis of molecular mechanisms underlying development of EM and UL as it looks from the platform of systems genetics. Similarities and differences of EM and UL at their incipient stages are enlightened with special emphasis on their gene networks, gene expression, and epigenetic regulation, of pathologic development. The analysis substantiates a new hypothesis postulating tumors as outgrowths of the stem cells with mesenchymal commitment lineage (mSC) which migrate from the endometrium/myometrium junctional zone of the uterus. Comparative analysis has revealed basic similarities of molecular pathogenesis of EM and UL suggesting molecular syntropy of both disorders. Peculiarities of the epigenetic landscape determining development of mSC may explain the existence of different clinical forms of EM and UL as well as their unique clinical manifestation. Some perspectives for practical and scientific application in EM and UL studies of this new hypothesis are outlined.