Massive Broad Ligament Cellular Leiomyoma with Cystic Change: A Diagnostic Dilemma

When it's not ovarian cancer: A case of a massive leiomyoma with hydropic change

Background

Uterine leiomyomas are benign tumors characterized by pelvic pain and abnormal bleeding. Their evolution can lead to degenerative changes, occasionally mimicking malignancies on imaging, presenting diagnostic challenges.

Case presentation

A 31-year-old nulliparous woman presented with symptoms of bloating, cramping, and abdominal distension. Imaging suggested an advanced ovarian malignancy, showing a complex adnexal mass and elevated CA-125 levels. During exploratory laparotomy, what was suspected to be ovarian cancer was instead identified as a large uterine mass on pathologic evaluation revealing a benign leiomyoma with extensive hydropic change.

Conclusion

This case highlights the diagnostic intricacies associated with large complex adnexal masses and illustrates how benign conditions like leiomyomas with hydropic degeneration can mimic ovarian cancer. This emphasizes the importance of comprehensive preoperative and intraoperative assessments to tailor management and avoid unindicated radical procedures.

Giant cellular leiomyoma in the broad ligament of the uterus: A case report

BACKGROUND

The treatment of large pelvic masses in postmenopausal women is a challenge in clinical practice. Although ultrasound or magnetic resonance imaging can be used to determine the size and location of the mass, it is still difficult to achieve a preoperative diagnosis. The majority of cellular leiomyomas are diagnosed by histopathology after surgery. We report the differential diagnosis and surgical management of a rare case of cellular leiomyoma in the broad ligament of the uterus.

CASE SUMMARY

A 52-year-old Chinese woman without sexual history was admitted to the First Affiliated Hospital of Guangzhou University of Chinese Medicine for the first time. The patient had a 1-year history of progressive abdominal enlargement as well as a 2-year history of menopause, and complained of frequent abdominal pain and low-grade fever. Computed tomography of the abdomen showed a solid cystic mass (29.4 cm × 18.8 cm × 37.7 cm) in the pelvis and abdomen. Moreover, routine blood test results indicated a baseline cancer antigen 125 (CA-125) level of 187.7 U/mL and C-reactive protein of 109.58 mg/L. Subsequently, retrograde hysterectomy and bilateral adnexectomy were performed in this patient. On histopathologic examination of the surgical specimen, a rare cellular leiomyoma in the broad ligament was diagnosed.

CONCLUSION

Clinicians need to constantly improve diagnosis and treatment for the challenges posed during clinical assessment, differential diagnosis, and surgical management.

Case Report: Myomatous erythrocytosis syndrome presenting as rapid growth of an extra-uterine mass

Objective

To report a case of myomatous erythrocytosis syndrome (MES) with an extra-uterine manifestation.

Case report

A 43-year-old woman presented with progressive abdominal distension and rapid enlargement of a pelvic mass. Upon survey, a high-level of hemoglobin (19.0 g/dl) was documented. The initial impression was an ovarian malignancy, but uterine sarcoma could not be ruled out because of its rapid growth. However, during exploratory laparotomy, the pelvic mass was found to be a 31 cm broad ligament leiomyoma; which is extremely rare for its size and location. The specimen was further studied immunohistochemically, which revealed excessive expressions of erythropoietin and erythropoietin receptors in addition to the diffusely matured blood vessels in the myoma tissue. The patient’s hemoglobin level resumed to normal three months post-surgery. The diagnosis of MES was confirmed both clinically and histologically.

Conclusion

A correct preoperative diagnosis is challenging when MES manifests as an extrauterine mass. The coexistence of MES should be considered in the management of all leiomyoma with polycythemia, regardless of locations.

Leiomyoma cellulare in the broad ligament of the uterus

There are only two reports on leiomyoma cellulare (LC) in the parametrium that have been published so far. Aim of the study was analysis of two cases of LC in the parametrium diagnosed postoperatively, and review of literature on the subject. Case 1: A 50-year-old patient was operated on for LC located in the right parametrium and concomitant malignant tumour in the right ovary. Leiomyoma cellulare was resected, hysterectomy and bilateral appendectomy performed, and bilateral iliac and obturator lymph nodes excised. Case 2: A 46-year-old patient was operated on for giant LC, on the left side, reaching the retroperitoneal space in the meso- and epigastrium. Leiomyoma cellulare was resected, and hysterectomy and bilateral appendectomy performed. The patient was reoperated twice due to haemorrhage within 24 hours following the operation. A literature review found reports on two cases of LC in 29- and 50-year-old patients with LC in the parametrium, located on the right and left side, respectively. Casuistic location of LC in the parametrium justifies reporting the cases in the literature. Preoperative diagnosis of LC in the parametrium is difficult. Conservative treatment, i.e. myomectomy should be reserved for those patients who wish to maintain fertility.

A subserosal, pedunculated, multilocular uterine leiomyoma with ovarian tumor-like morphology and histological architecture of adenomatoid tumors: a case report and review of the literature

Background

Uterine leiomyomas are common uterine tumors, and typical cases of leiomyoma are easily diagnosed by imaging study. However, uterine leiomyomas are often altered by degenerative changes, which can cause difficulty and confusion in their clinical diagnosis. We describe the 17th reported case of a uterine leiomyoma clinically diagnosed as an ovarian tumor; however, the present case shows the most detailed radiological evaluation, including contrast-enhanced magnetic resonance imaging. We first show that a uterine leiomyoma can histologically mimic an adenomatoid tumor.

Case presentation

A 47-year-old premenopausal, nulliparous Japanese woman with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia had lower abdominal pain. Ultrasonography confirmed a 6-cm mass in the right-sided space of the pelvic cavity. Magnetic resonance imaging evaluation showed that a multilocular mass was present near the uterus, and a mucinous ovarian tumor was considered. Emergency surgery due to acute abdomen was performed under the diagnosis of pedicle torsion of the ovarian tumor. During surgery, a pedunculated uterine mass without stalk torsion was seen. The mass grossly contained serous and hemorrhagic fluids in the cavities, and pathology examination confirmed that the mass was a leiomyoma with hydropic and cystic degeneration. Anastomosing thin cord-like arrangements of the leiomyoma cells mimicked the architecture of adenomatoid tumors. The tumor cells were positive for the microphthalmia transcription factor but negative for other melanoma markers. Three days postoperatively, she was discharged without sequelae.

Conclusions

Marked intratumoral deposition of fluids may induce the multilocular morphology of a tumor, and the cellular arrangement of the tumor cells with hydropic degeneration mimicked an adenomatoid tumor in this case. Clinicians need to be aware that a subserosal leiomyoma with cystic and hydropic degeneration can mimic an ovarian tumor, and pathologists should be aware that such leiomyomas can mimic adenomatoid tumors. Additionally, perivascular epithelioid cell tumors should not be diagnosed only based on its immunoreactivity for the microphthalmia transcription factor.