Miliary pattern as presentation of leiomyomatosis of the lung

Novel developments in the study of estrogen in the pathogenesis and therapeutic intervention of lymphangioleiomyomatosis

OBJECTIVE

This study aimed to enhance the understanding of the role of estrogen in lymphangioleiomyomatosis(LAM) and to conclude the impact of estrogen-altering events on the condition and recent advances in estrogen-based treatments for LAM.

RESULTS

LAM development is strongly linked to mutations in the tuberous sclerosis gene (TSC1/2) and the presence of estrogen. Estrogen plays a significant role in the spread of TSC2-deficient uterine leiomyoma cells to the lungs and the production of pulmonary LAM. Menstruation, pregnancy, estrogen medication, and other events that cause an increase in estrogen levels can trigger the disorder, leading to a sudden worsening of symptoms. Current findings do not support using estrogen-blocking therapy regimens. However, Faslodex, which is an estrogen receptor antagonist, presents new possibilities for future therapeutic approaches in LAM.

CONCLUSION

Estrogen is crucial in the development and spread of LAM. The use of estrogen inhibitors or estrogen receptor antagonists alone does not provide good control of the disease or even poses a greater risk, and the use of a combination of mTOR receptor inhibitors, complete estrogen receptor antagonists, estrogen inhibitors, and autophagy inhibitors targeting important signaling pathways in LAM pathogenesis may be of greater benefit to the patient.

Benign metastasising leiomyoma: a rare disease and a diagnostic challenge

Benign metastasising leiomyoma (BML) is a rare tumour characterised by extrauterine metastasis of histologically benign leiomyomas. We present a case of BML with pulmonary involvement. A 49-year-old woman presented with large pelviabdominal masses complicated by gross abdominal and lower limb swelling 6 years following open myomectomy. Preoperative CT imaging showed pelviabdominal masses and multiple bilateral pulmonary nodules. Initial impression was that of a stage 4 gynaecological malignancy. Palliative total hysterectomy bilateral salpingo-oophorectomy was performed. Histopathology confirmed benign uterine leiomyomas. Biopsy of pulmonary nodules showed benign leiomyomas, strongly positive for oestrogen and progesterone receptors. Definitive diagnosis of BML was made on histopathology and immunohistochemistry. The patient declined letrozole treatment as she had just undergone bilateral oophorectomy. She opted for conservative monitoring of her lung nodules. CT imaging 7 months postsurgery showed disease regression. She will require long-term surveillance scans to detect disease progression.

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.

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.

Benign metastasizing leiomyoma presenting with miliary pattern and fatal outcome: Case report with molecular analysis & review of the literature

Benign metastasizing leiomyoma (BML) is a rare benign smooth muscle neoplasm that originates in the uterus and metastasizes to distant sites—most commonly the lungs. BMLs are often found incidentally in patients with a history of uterine leiomyoma(s) and tend to be indolent. Occasionally they may be symptomatic and rarely follow an aggressive clinical course.

We report an unusual case of BML presenting in a 46-year-old woman as a miliary nodular pattern bilaterally in the lungs and progressive respiratory failure. Her past medical history was significant for uterine “leiomyomas” of at least 9 years' duration. Post mortem histologic evaluation of the uterine and lung lesions revealed benign smooth muscle neoplasms (leiomyomas and BMLs, respectively), and molecular analyses demonstrated identical clonal MED12 mutation, though with greater mutant allelic frequency in the uterus. We document a rare aggressive clinical course in a patient with BML, which presented as a miliary radiologic pattern mimicking an infectious etiology or interstitial lung disease.

Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guidelines: Lymphangioleiomyomatosis Diagnosis and Management

BACKGROUND

Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease that primarily affects women. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of LAM.

METHODS

Systematic reviews were performed to summarize evidence pertinent to our questions. The evidence was summarized and discussed by a multidisciplinary panel. Evidence-based recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

After considering the panel's confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were formulated for or against specific interventions. These included recommendations for sirolimus treatment and vascular endothelial growth factor D testing and recommendations against doxycycline and hormonal therapy.

CONCLUSIONS

Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.

Imaging features of thoracic metastases from gynecologic neoplasms

Gynecologic malignancies are a heterogeneous group of common neoplasms and represent the fourth most common malignancy in women. Thoracic metastases exhibit various imaging patterns and are usually associated with locally invasive primary neoplasms with intra-abdominal spread. However, thoracic involvement may also occur many months to years after initial diagnosis or as an isolated finding in patients without evidence of intra-abdominal neoplastic involvement. Thoracic metastases from endometrial carcinoma typically manifest as pulmonary nodules and lymphadenopathy. Thoracic metastases from ovarian cancer often manifest with small pleural effusions and subtle pleural nodules. Thoracic metastases to the lungs, lymph nodes, and pleura may also exhibit calcification and mimic granulomatous disease. Metastases from fallopian tube carcinomas exhibit imaging features identical to those of ovarian cancers. Most cervical cancers are of squamous histology, and while solid pulmonary metastases are more common, cavitary metastases occur with some frequency. Metastatic choriocarcinoma to the lung characteristically manifests with solid pulmonary nodules. Some pulmonary metastases from gynecologic malignancies exhibit characteristic features such as cavitation (in squamous cell cervical cancer) and the "halo" sign (in hemorrhagic metastatic choriocarcinoma) at computed tomography (CT). However, metastases from common gynecologic malignancies may be subtle and indolent and may mimic benign conditions such as intrapulmonary lymph nodes and remote granulomatous disease. Therefore, radiologists should consider the presence of locoregional disease as well as elevated tumor marker levels when interpreting imaging studies because subtle imaging findings may represent metastatic disease. Positron emission tomography/CT may be helpful in identifying early locoregional and distant tumor spread.

Benign metastasizing leiomyoma of the lung: A case report and literature review

Pulmonary benign metastasizing leiomyoma (BML) is a rare event characterized by benign soft-tissue tumors that occur when uterine leiomyomas metastasize to the lung. The present study reports the case of a 47-year-old female patient who presented with multiple bilateral pulmonary nodules on a chest X-ray during a health checkup nine years after a hysterectomy due to uterine fibroids. Chest computed tomography (CT) revealed multiple well-defined nodular shadows in the lung. One tumor of the left upper lung was resected by thoracoscopic surgery. Pathologically, the resected lesion consisted of benign spindle cells and was diagnosed as BML. The post-operative course was uneventful. Other lung nodules have been meticulously monitored at follow-up, and repeat CT two years later showed that these nodules had not increased at all in size and that no new lobe nodules had appeared. The present study indicates that pulmonary BML occurs in a low proportion of female with a history of uterine leiomyoma and treatment methods for it are diverse and controversial.

Benign metastasizing leiomyomatosis of the lungs presenting a miliary pattern

Benign metastasizing leiomyomatosis is a very rare and significantly interesting pathology of the lungs. It is a challenge to clinicians when presenting a miliary pattern in preoperative radiologic imaging because it could be any other interstitial disease or infectious in etiology such as miliary tuberculosis. We report a case of innumerable tiny nodular densities spread evenly throughout both lungs in a patient with history of hysterectomy for a fibroid uterus.

Benign metastasizing leiomyoma of the lung

Benign leiomyomas of the uterus are uncommonly found in association with benign smooth muscle tumors beyond the confines of the uterus. Benign metastasizing leiomyoma (BML) is a rare disease in which the lung is described to be the most afflicted extrauterine organ. We present a brief review of the literature, along with case reports for four patients who were followed up after resection of a pulmonary lesion or after pathological confirmation by biopsy. The clinical course of BML varies from chronic asymptomatic appearance to rapid progression, leading to respiratory failure and death. Our BML patients did not complain of pulmonary symptoms, such as cough, dyspnea, or chest tightness. Pathology revealed benign leiomyomas with no atypia and mitotic activity <5 per 10 high-power field. Immunohistochemical staining was positive for actin and desmin. A standard treatment for BML has not yet been established. Because of the hormone-sensitive characteristics of BML, treatments are based on hormonal manipulation along with either surgical or medical oophorectomy. Benign metastasizing leiomyoma can be observed in postmenopausal women. We observed four patients who did not receive adjuvant hormonal therapy because they were postmenopausal or perimenopausal. All patients are still healthy and show no evidence of recurrence or progression of the disease.

Benign metastasizing leiomyoma: a rare cause of multiple pulmonary nodules

Benign metastasizing leiomyoma (BML) is a rare cause of pulmonary nodules that occurs when uterine leiomyomas metastasize to the lung. The management of these lesions varies from resection and hysterectomy to nonsurgical treatments such as hormonal therapy. We report a case of a 45-year-old woman with multiple nodules of the right lung identified during preoperative imaging before her hysterectomy for uterine fibroids.

Histologically benign but clinically malignant neoplasms in the thorax: CT-pathological overview

The purpose of this article is to review the computed tomography (CT) and histopathological features of uncommon primary neoplasms of the thorax that can manifest clinically malignant features (multiplicity of pulmonary nodules, an invasive nature, and metastases or recurrence after surgery) with little evidence of histological malignancy.

Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy

Uterine smooth muscle tumors are classified according to their morphologic features that include architecture, growth pattern, cellular characteristics and constituents of the intercellular stroma. While terminologies used for the pathologic diagnosis of various subtypes may be eloquent and histologically accurate, some of these are confusing for the clinician and may also be open to interpretation by different pathologists: the labeling of atypical leiomyomas epitomizes this intricate system. Clinically, it is probably more useful to classify them as either tumors with or tumors without recurrent and/or metastatic potential. The term "atypical leiomyoma" has been used to label tumors that have a low risk of recurrence and is synonymous with benign tumors. The latter are known variously as leiomyoma with bizarre nuclei, symplastic leiomyoma, or pleomorphic leiomyoma. Variants of benign uterine smooth muscle tumors, such as mitotically active leiomyoma, cellular and highly cellular leiomyoma, epithelioid leiomyoma, and myxoid leiomyoma each have distinctive hallmarks that enable subclassification. Nevertheless, they may occasionally possess one or more unusual features that are cause for alarm. Tumors that have a dissecting growth pattern, with or without extrauterine extension, may mimic malignancy both grossly and microscopically. The current review discusses the pathologic diagnosis of and terminology applied to selected variants of uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas with emphasis on unusual reported features that may indicate malignancy. This includes an update on uterine smooth muscle tumor of uncertain malignant potential (STUMP), intravenous leiomyomatosis, benign metastasizing leiomyoma, and diffuse leiomyomatosis. Their clinicopathologic features, differential diagnoses, and management options based on findings in the previously reported cases will also be reviewed.

Benign metastasizing leiomyoma of the lung: PET findings

We report the case of pulmonary benign metastasizing leiomyoma in an asymptomatic 64-year-old woman who underwent hysterectomy for a uterine leiomyoma 26 years earlier. Routine chest radiograph revealed bilateral diffuse nodular opacities within the pulmonary lobes. Thoracic computed tomography (CT) scan showed peripheral lung nodules that do not display contrast enhancement. Positron emission tomography (PET)-CT with 18F-fluorodeoxyglucose (18F-FDG PET-CT) demonstrated no significant metabolic activity of the nodules. The lesions were diagnosed as benign metastasizing leiomyoma by histopathologic examination. To our best knowledge, this is the first case studied combining CT and FDG PET-CT technique.

Benign metastasising leiomyoma: a rare cause of breathlessness following caesarean section

We describe the case of a 31-year-old patient with pregnancy-induced hypertension who became breathless following an emergency caesarean section performed at 31 weeks' gestation. Initially, it was thought her symptoms were due to pulmonary oedema as a result of fluid overload, but there was little improvement with diuretic therapy. Further investigations revealed a diagnosis of benign metastasising leiomyoma, a rare condition associated with uterine fibroids but not often seen in association with pregnancy. The differential diagnosis and management are discussed.

Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation

OBJECTIVE

We describe the clinical presentation and the radiographic and CT findings of benign metastasizing leiomyoma.

CONCLUSION

Benign metastasizing leiomyoma is an asymptomatic disease characterized by well-defined, numerous, pulmonary lesions without a preponderant distribution.

Intravenous leiomyomatosis of the uterus with multiple pulmonary metastases associated with large bullae-like cyst formation

We present a case of uterine intravenous leiomyomatosis associated with multiple pulmonary metastases with bullae-like cystic change. A 53-year-old woman who had undergone hysterectomy 5 years previously underwent an operation for multiple pulmonary nodules with bullae formation. After resection of several large bullae, a subsequent extirpation of the pulmonary nodules was performed, and a pathological examination showed multiple leiomyomatous nodules with occasional cystic change. A review of the previous slides of the uterus and immunohistochemical analysis of the proliferating ability using anti-Ki-67 and anti-proliferating cell nuclear antigen (PCNA) antibodies were performed. Proliferating cells of the uterus had very few mitotic figures for their high cellularity, and the labeling indices of Ki-67 and PCNA indicated very low levels in both uterine neoplasm and pulmonary nodules. From these findings, an intravenous leiomyomatosis associated with multiple pulmonary metastases was diagnosed.

Immunohistological detection of estrogen and progesterone receptors in multiple and well differentiated leiomyomatous lung tumors in women with uterine leiomyomas (so-called benign metastasizing leiomyomas). A report on 5 cases

Seventy-four cases of so-called "benign metastasizing uterine leiomyomata" are reported in the literature. In these cases, well differentiated, leiomyomatous lung tumors developed, usually after a period of several years. Histologically, these tumors appear to be benign. We report on five more such cases in which we investigated the contents of estrogen and progesterone receptors in the pulmonary tumors by immunohistological procedures. All the lung tumors exhibited a high content of progesterone receptors, and in 4 out of the 5 cases a high estrogen receptor content was also found. Modern immunohistological techniques permit the investigation of routinely fixed tissue blocks, and it is thus recommended that the contents of these hormone receptors should be determined in well differentiated, leiomyomatous lung tumors from women. This would both provide information on the pathogenesis of these tumors and establish a basis for possible later institution of hormone treatment. It is likely that the majority of these lung tumors are in fact metastases of extremely well differentiated leiomyosarcomas of the uterus. The possibility that lung tumors of this type may constitute a small group that develop in situ as hormone-sensitive proliferations cannot, however, be fully excluded.

Treatment of lymphangioleiomyomatosis. A meta-analysis

Lymphangioleiomyomatosis is a rare disease which afflicts young women of childbearing age. It is sufficiently uncommon that randomization or any other systematic evaluation of regimens of treatment has been difficult. Review of scattered case reports implies that a number of hormonal manipulations may be equally effective. A comprehensive review of the literature revealed 30 cases of LAM treated with eight regimens of treatment. Evaluation with predetermined criteria (meta-analysis) shows that administration of progesterone or oophorectomy or both are the most effective treatments, resulting in improvement or stabilization of the disease in the majority of cases.