Uterine Leiomyoma-Like Inflammatory Myofibroblastic Tumor Without Myxoid Matrix or Inflammatory Cell Infiltration: A Case Report of a Potential Diagnostic Pitfall

Inflammatory myofibroblastic tumors (IMTs) of the uterus are relatively rare. Although most IMTs exhibit indolent biological behaviors, local recurrence, and metastasis may occur. Such patients may benefit from targeted therapy; therefore, precise diagnosis is essential for clinical follow up and treatment. Here, we describe a 33-year-old woman with a uterine mass that was detected 4 years previously during pregnancy. The morphology of the tumor resembled that of a uterine leiomyoma, lacking myxoid matrix, and inflammation. Following immunohistochemical and molecular analyses, the tumor was definitively identified as a uterine IMT based on its morphological features. The uterine IMT described in this case had a rare morphology, which can be easily misdiagnosed based on histology alone. Hence, understanding the morphological changes of IMTs in greater detail is imperative to facilitate their accurate diagnosis.

A urethral leiomyoma presenting with dysuria: A rare case report

RATIONALE

Leiomyoma is a benign smooth muscle tumor which is rarely found in urethra. We hereby report a case of a 44-year-old female who presented with complaints of dysuria.

PATIENT CONCERNS

A 44-year-old female patient presented to the urology outpatient clinic with symptoms of dysuria. The patient described the presence of a protrusion from the urethra during urination.

DIAGNOSIS

Urethral leiomyoma.

INTERVENTIONS

Physical examination confirmed a solid urethral mass. CT scan and USG reports indicated that the mass originated from the mid-urethra with vascularity at the base. We performed a complete resection of the urethral mass. The patient was discharged after 3 days of observation.

OUTCOME

During a follow-up after 1 month, the patient reported improved urinary flow and no occurrence of hematuria. The patient recovered well after discharge.

LESSON

Urethral leiomyoma is a rare benign tumor that is often misdiagnosed in clinical practice. Diagnosis requires careful clinical examination. Surgical removal usually works well. It is important to remember that in some cases of acute urinary retention, it can be caused by a complete obstruction of a mass in the urethra. Urologists should be more cautious and experienced in handling such cases.

Uterine Fibroids

This JAMA Insights in the Women’s Health series discusses the incidence, diagnosis, and treatment of uterine fibroids.

Primary omental smooth muscle tumor in an adult male: a diagnostic dilemma for leiomyoma: a case report

BACKGROUND

The greater omentum comprises peritoneal, adipose, vascular, and lymphoid tissues. Most omental malignancies are metastatic tumors, and the incidence of primary tumors is rare. We report on a prior omental smooth muscle tumor case in an adult male patient.

CASE PRESENTATION

A 54-year-old Japanese male patient with no relevant medical history was diagnosed with an abdominal mass during a routine medical checkup. Subsequent contrast-enhanced computed tomography revealed a mass of approximately 3 cm in size in the greater omentum, and a laparotomy was performed. A 27 × 25 × 20 mm raised lesion was found in the omentum. Microscopically, spindle cells were observed and arranged in whorls and fascicles. Individual tumor cells had short spindle-shaped nuclei with slightly increased chromatin and were characterized by a slightly eosinophilic, spindle-shaped cytoplasm. The mitotic count was less than 1 per 50 high-power fields. The tumor cells showed positive immunoreactivity for α smooth muscle actin, HHF35, and desmin on immunohistochemical examination. The Ki-67 labeling index using the average method was 1.76% (261/14806). No immunoreactivity was observed for any of the other tested markers. We considered leiomyoma owing to a lack of malignant findings. However, primary omental leiomyoma has rarely been reported, and it can be difficult to completely rule out the malignant potential of smooth muscle tumors in soft tissues. Our patient was decisively diagnosed with a primary omental smooth muscle tumor considering leiomyoma. Consequently, the patient did not undergo additional adjuvant therapy and was followed up. The patient was satisfied with treatment and showed neither recurrence nor metastasis at the 13-month postoperative follow-up.

DISCUSSION AND CONCLUSION

We encountered a primary smooth muscle tumor of the greater omentum with no histological findings suggestive of malignancy in an adult male patient. However, omental smooth muscle tumors are extremely difficult to define as benign, requiring careful diagnosis. Further case reports with long-term follow-up and case series are required to determine whether a true omental benign smooth muscle tumor (leiomyoma) exists. In addition, proper interpretation of the Ki-67 labeling index should be established. This case study is a foundation for future research.

Germline and Somatic Fumarate Hydratase Testing in Atypical Uterine Leiomyomata

Women with germline pathogenic variants (PV) in the fumarate hydratase (FH) gene develop cutaneous and uterine leiomyomata and have an increased risk of developing aggressive renal cell carcinomas. Many of these women are unaware of their cancer predisposition until an atypical uterine leiomyoma is diagnosed during a myomectomy or hysterectomy, making a streamlined genetic counseling process after a pathology-based atypical uterine leiomyoma diagnosis critical. However, the prevalence of germline pathogenic/likely PVs in FH among atypical uterine leiomyomata cases is unknown. To better understand FH germline PV prevalence and current patterns of genetic counseling and germline genetic testing, we undertook a retrospective review of atypical uterine leiomyomata cases at a single large center. We compared clinical characteristics between the FH PV, FH wild-type (WT), and unknown genetic testing cohorts. Of the 144 cases with atypical uterine leiomyomata with evaluable clinical data, only 49 (34%) had documented genetic test results, and 12 (8.3%) had a germline FH PV. There were 48 IHC-defined FH-deficient cases, of which 41 (85%) had FH testing and nine had a germline FH PV, representing 22% of the tested cohort and 18.8% of the FH-deficient cohort. Germline FH PVs were present in 8.3% of evaluable patients, representing 24.5% of the cohort that completed genetic testing. These data highlight the disconnect between pathology and genetic counseling, and help to refine risk estimates that can be used when counseling patients with atypical uterine leiomyomata.

PREVENTION RELEVANCE

Women diagnosed with fumarate hydratase (FH)-deficient uterine leiomyomata are at increased risk of renal cancer. This work suggests a more standardized pathology-genetic counseling referral pathway for these patients, and that research on underlying causes of FH-deficient uterine leiomyomata in the absence of germline FH pathogenic/likely pathogenic variants is needed.

Hypertension, Cardiovascular Risk Factors, and Uterine Fibroid Diagnosis in Midlife

Importance

Fibroids are benign neoplasms associated with severe gynecologic morbidity. There are no strategies to prevent fibroid development.

Objective

To examine associations of hypertension, antihypertensive treatment, anthropometry, and blood biomarkers with incidence of reported fibroid diagnosis in midlife.

Design, Setting, and Participants

The Study of Women's Health Across the Nation is a prospective, multisite cohort study in the US. Participants were followed-up from enrollment (1996-1997) through 13 semiannual visits (1998-2013). Participants had a menstrual period in the last 3 months, were not pregnant or lactating, were aged 42 to 52 years, were not using hormones, and had a uterus and at least 1 ovary. Participants with prior fibroid diagnoses were excluded. Data analysis was performed from November 2022 to February 2024.

Exposures

Blood pressure, anthropometry, biomarkers (cholesterol, triglycerides, and C-reactive protein), and self-reported antihypertensive treatment at baseline and follow-up visits were measured. Hypertension status (new-onset, preexisting, or never [reference]) and hypertension treatment (untreated, treated, or no hypertension [reference]) were categorized.

Main Outcomes and Measures

Participants reported fibroid diagnosis at each visit. Discrete-time survival models estimated hazard ratios (HRs) and 95% CIs for associations of time-varying hypertension status, antihypertensive treatment, anthropometry, and biomarkers with incident reported fibroid diagnoses.

Results

Among 2570 participants without a history of diagnosed fibroids (median [IQR] age at screening, 45 [43-48] years; 1079 [42.1%] college educated), 526 (20%) reported a new fibroid diagnosis during follow-up. Risk varied by category of hypertension treatment: compared with those with no hypertension, participants with untreated hypertension had a 19% greater risk of newly diagnosed fibroids (HR, 1.19; 95% CI, 0.91-1.57), whereas those with treated hypertension had a 20% lower risk (HR, 0.80; 95% CI, 0.56-1.15). Among eligible participants with hypertension, those taking antihypertensive treatment had a 37% lower risk of newly diagnosed fibroids (HR, 0.63; 95% CI, 0.38-1.05). Risk also varied by hypertension status: compared with never-hypertensive participants, participants with new-onset hypertension had 45% greater risk of newly diagnosed fibroids (HR, 1.45; 95% CI, 0.96-2.20). Anthropometric factors and blood biomarkers were not associated with fibroid risk.

Conclusions and Relevance

Participants with untreated and new-onset hypertension had increased risk of newly diagnosed fibroids, whereas those taking antihypertensive treatment had lower risk, suggesting that blood pressure control may provide new strategies for fibroid prevention.

Recurrent bladder leiomyoma: a case report

BACKGROUND

Bladder leiomyomas are rare benign growths in the bladder, comprising less than 0.5% of bladder tumors with only 250 cases reported globally. They are more common in women. This case involves a 70-year-old woman with recurrent leiomyoma, presenting with lower urinary tract symptoms and painless hematuria. A recurrent bladder leiomyoma is rarely reported, making its presence exceptionally rare.

CASE PRESENTATION

A 70-year-old Pakistani woman with hypertension and diabetes presented with lower urinary tract symptoms (LUTS) and painless hematuria. She had a history of similar symptoms in 2010, leading to a diagnosis of bladder leiomyoma via cystoscopy and biopsy. Imaging studies revealed a substantial 3.7 × 4 × 4.0 cm isodense mass with calcifications at the bladder base, along with bladder wall thickening and diverticula. Pathological examination during Transurethral Resection of Bladder Tumor (TURBT) confirmed the presence of bladder tissue with smooth muscle, ruling out malignancy. Immunohistochemical studies supported the diagnosis. A successful TURBT was performed, and the patient recovered well.

DISCUSSION

Recurrent bladder leiomyoma is a rarely-discussed topic in medical literature. This article primarily aims to review existing studies and present a detailed case study, shedding light on this rare phenomenon.

Chronic pelvic pain and dysmenorrhea disguising a rare submucosal leiomyoma of the urinary bladder

Representing 0.43% of all urinary bladder neoplasms, leiomyomas are rare mesenchymal tumours with a benign pathophysiology. There have only been approximately 250 cases published on this subject, necessitating further inquiry into this disease and effective management protocols. Treatment options may include a broad spectrum of surgical interventions, from minimally invasive resection to radical cystectomy, depending on the location, size and symptoms associated with the tumour. To date, few cases of leiomyoma have resulted in recurrence after removal, and zero have reported malignant transformation. Described here in detail is a woman in her early 40s who presented with a history of chronic pelvic pain and irregular vaginal bleeding. The urology team completed further evaluation after imaging discovered a concerning bladder lesion. Eventually, she underwent transurethral resection, with the subsequent pathology revealing a rare diagnosis of leiomyoma in the urinary bladder.

Myomatous erythrocytosis syndrome: a uterine fibroid associated with polycythaemia

Myomatous erythrocytosis syndrome (MES) is a rare form of secondary erythrocytosis seen with myomas. Here, we present a case of a postmenopausal, nulliparous woman in her 50s incidentally found to have asymptomatic erythrocytosis on routine laboratory work. She was found to have an 18.5 cm myoma and after surgical resection, the patient's haematological values returned to normal ranges after a few weeks. This established the diagnosis as MES. The aetiology of MES continues to remain unknown but is most likely caused by an autonomous production of erythropoietin from the myomatous tissue. This case highlights obtaining a detailed history and physical examination to differentiate between the different causes of erythrocytosis, considering MES as a rare cause of secondary erythrocytosis and to prevent unnecessary procedures such as phlebotomy as surgery is the mainstay of treatment.

Vulvar leiomyoma in a postmenopausal woman

Leiomyomas of the uterus are the most common benign tumours of women in the reproductive age group, affecting up to 40%-50% of women older than 35. In postmenopausal women, the incidence is much lower with an estimated incidence of 1%-2% in women in the 60-80 years old age group. Vulvar leiomyomas are much rarer than their uterine counterparts, accounting for only 0.03% of all gynaecological neoplasms and 0.07% of all vulvar tumours. These tumours are well-circumscribed, painless, solitary growths that affect females of all ages. Given the presentation and rarity of vulvar leiomyomas, they are often misdiagnosed as a Bartholin gland cyst, abscess or even cancer preoperatively. We present a case of a woman in her 70s with a 1.5 cm firm mass that was palpated on the left lower vaginal side wall and was initially suspected to be a Bartholin gland cyst or abscess. Initial treatment included antibiotics and an incision and drainage. Two weeks later, the mass had grown to 3 cm in size. Wide excisional biopsy revealed the mass to be a vulvar leiomyoma.

Effect of Uterine Leiomyomas on Noninvasive Prenatal Testing Parameters in the First Trimester

Uterine leiomyomas may affect the performance of cell-free DNA (cfDNA)-based noninvasive prenatal testing (NIPT). We conducted a retrospective cohort study of pregnant individuals with and without leiomyomas undergoing first-trimester cfDNA-based NIPT. Characteristics of NIPT in patients with leiomyomas (n=122) were compared with those in patients without leiomyomas (n=937). Mean fetal fraction was lower in patients with leiomyomas compared with patients without (10.0% vs 11.5%; P =.001); however, the rate of indeterminate results was different only in patients without obesity (body mass index [BMI] lower than 30) (5.3% vs 1.5%; P =0.03). Total cfDNA concentration was higher in patients with leiomyomas ( P =.002), suggesting possible dilution of the fetal fraction. Leiomyoma size did not affect NIPT metrics. In conclusion, uterine leiomyomas are associated with lower fetal fraction and, in patients without obesity, with a higher rate of indeterminate results independent of leiomyoma size.

"Deciduoid" Change in Uterine Leiomyomas in Pregnancy: Aberrant Expression of Sex Cord Markers Inhibin and Calretinin

Leiomyomas are common hormone-responsive uterine neoplasms which can exhibit a variety of morphologic changes secondary to hormonal agents such as progestogens. They may increase in size during pregnancy as a result of hormonal stimulation but surprisingly the morphologic features of leiomyomas in pregnancy are not well described in the literature. In this report, we describe the morphologic features of a series of 29 uterine leiomyomas in pregnancy. The features include in decreasing order of frequency infarct-type necrosis, decidualization of the serosal surface, hyalinization, myxoid alteration of the stroma, edema (sometimes with cyst formation), and dystrophic calcification. We also report a feature which we term "deciduoid" change (seen in 10 of 29 leiomyomas) which takes the form of altered smooth muscle cells with an epithelioid morphology with abundant eosinophilic or clear cytoplasm. Furthermore, we show that the "deciduoid" cells commonly exhibit expression of sex cord markers inhibin and calretinin. We speculate on the pathogenesis of the "deciduoid" change which together with its "aberrant" immunophenotype may result in diagnostic problems and consideration of other neoplasms.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Neutrophil to lymphocyte ratio as an assessment tool to differentiate between uterine sarcoma and myoma: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to determine the potential value of neutrophil to lymphocyte ratio (NLR) as an assessment tool in the clinical distinction between uterine sarcoma and uterine leiomyoma.

METHODS

We comprehensively searched Web of Science, Scopus, and PubMed for relevant papers published before March 19, 2023. The standardized mean difference (SMD) was provided, along with a 95% confidence interval (CI). The random-effects model was employed to derive pooled effects due to the high levels of heterogeneity. The Newcastle-Ottawa scale was used for the quality assessment. Our study was registered in PROSPERO (CRD42023478331).

RESULTS

Overall, seven articles were included in the analysis. A random-effect model revealed that patients with uterine sarcoma had higher NLR levels compared to those with uterine myoma (SMD = 0.60, 95% CI = 0.22-0.98; p = 0.002). In the subgroup analysis according to sample size, we found that patients with uterine sarcoma had elevated levels of NLR compared to those with uterine myoma in either large studies (SMD = 0.58, 95% CI = 0.04-1.13; P < 0.001) or small studies (SMD = 0.64, 95% CI = 0.33-0.96; P = 0.32). In the sensitivity analysis, we found that the final result was not significantly changed when single studies were removed, suggesting that the finding of this meta-analysis was stable. The pooled sensitivity of NLR was 0.68 (95% CI = 0.61-0.73), and the pooled specificity was 0.64 (95% CI = 0.59-0.69).

CONCLUSION

NLR might be utilized as an assessment tool in clinics to help clinicians differentiate between patients with uterine sarcoma and those with myoma.

[A Renal Leiomyoma --A Case Report-]

A 49-year-old female was incidentally found to have a left renal tumor during a medical check-up. The tumor was too small to be fully diagnosed using computed tomography (CT) or magnetic resonance imaging (MRI). Since it was small and showed a homogenous enhancement pattern on contrast-enhanced CT, which made it difficult for us to distinguish the malignancy of the tumor, we performed regular CT follow-up. On the fifth year of her regular follow-up, the tumor had grown apparently larger and showed a heterogenous enhancement pattern, which suggested a malignant tumor. Since the tumor was exophytic, we decided to perform a laparoscopic partial nephrectomy. The operation was performed without any serious complications, and her renal function remained unchanged. The histopathology of the tumor was leiomyoma. Here, we discuss the characteristics of this tumor and the role of immunohistopathology in the diagnosis.

Metrics of uterine myomatosis symptomatology in clinical practice

AIM

A review of diagnostic options and standardized methods for specifying clinical symptoms associated with uterine myomatosis.

METHODS

A literature search of databases aimed at finding validated metrics for assessing myomas symptomatology.

RESULTS

Summary of obligatory and optional examination methods in the diagnosis of uterine fibroids and methods of examination of reproductive parameters of the couple in relation to myomatosis. Defining the metrics of bleeding manifestations of myomatosis with emphasis on the "Pictorial Bleeding Assessment Chart". Reviewing metrics of algic manifestations of myomatosis and quality of life with emphasis on the "Quality of Life Questionnaire - Myomatosis - Severity Symptom Scale".

CONCLUSION

The purpose of the applicable metrics, which summarize objective findings and subjective complaints of patients, is to describe and evaluate possible correlations and dynamics of changes in the health status, depending on the chosen therapy.

[A clinical case of piloleiomyoma]

The article describes a clinical case of a benign tumor from smooth muscle cells - piloleiomyoma. The incidence of leiomyoma in the skin is 3-5% of all leiomyomas. A 27-year-old patient applied to a medical institution with complaints about an intradermal formation in the ear region that occurred repeatedly within 5 months after surgical treatment. After the first surgical intervention, the patient was consulted in various medical organizations, where the following diagnoses were made: «nodular fasciitis», «smooth muscle tumor without signs of malignancy» and «non-epithelial spindle cell neoplasm». According to ultrasound examination, the formation with dimensions of 11×9×5 mm reached the mastoid process of the temporal bone and was characterized by increased internal blood flow. After surgical removal of the neoplasm, taking into account the difficulties of differential diagnosis, an immunohistochemical study was conducted. An accumulation of smooth muscle cells was detected in the surface layers of the dermis under the epidermis by the immunohistochemical study with the use of the marker SMA. A study on CD34 protein revealed a high density of blood capillaries and the absence of its expression in smooth muscle cells. The proliferative index (Ki-67) and mitotic activity (PHH-3) of cells was also studied. The index of proliferative activity was less than 2%, mitoses were isolated. Thus, the results of immunohistochemical study proved the conclusion of piloleiomyoma.

A differential diagnosis between uterine leiomyoma and leiomyosarcoma using transcriptome analysis

BACKGROUND

The objective of this study was to estimate the accuracy of transcriptome-based classifier in differential diagnosis of uterine leiomyoma and leiomyosarcoma. We manually selected 114 normal uterine tissue and 31 leiomyosarcoma samples from publicly available transcriptome data in UCSC Xena as training/validation sets. We developed pre-processing procedure and gene selection method to sensitively find genes of larger variance in leiomyosarcoma than normal uterine tissues. Through our method, 17 genes were selected to build transcriptome-based classifier. The prediction accuracies of deep feedforward neural network (DNN), support vector machine (SVM), random forest (RF), and gradient boosting (GB) models were examined. We interpret the biological functionality of selected genes via network-based analysis using GeneMANIA. To validate the performance of trained model, we additionally collected 35 clinical samples of leiomyosarcoma and leiomyoma as a test set (18 + 17 as 1st and 2nd test sets).

RESULTS

We discovered genes expressed in a highly variable way in leiomyosarcoma while these genes are expressed in a conserved way in normal uterine samples. These genes were mainly associated with DNA replication. As gene selection and model training were made in leiomyosarcoma and uterine normal tissue, proving discriminant of ability between leiomyosarcoma and leiomyoma is necessary. Thus, further validation of trained model was conducted in newly collected clinical samples of leiomyosarcoma and leiomyoma. The DNN classifier performed sensitivity 0.88, 0.77 (8/9, 7/9) while the specificity 1.0 (8/8, 8/8) in two test data set supporting that the selected genes in conjunction with DNN classifier are well discriminating the difference between leiomyosarcoma and leiomyoma in clinical sample.

CONCLUSION

The transcriptome-based classifier accurately distinguished uterine leiomyosarcoma from leiomyoma. Our method can be helpful in clinical practice through the biopsy of sample in advance of surgery. Identification of leiomyosarcoma let the doctor avoid of laparoscopic surgery, thus it minimizes un-wanted tumor spread.

Assessment of a Digital Symptom Checker Tool's Accuracy in Suggesting Reproductive Health Conditions: Clinical Vignettes Study

BACKGROUND

Reproductive health conditions such as endometriosis, uterine fibroids, and polycystic ovary syndrome (PCOS) affect a large proportion of women and people who menstruate worldwide. Prevalence estimates for these conditions range from 5% to 40% of women of reproductive age. Long diagnostic delays, up to 12 years, are common and contribute to health complications and increased health care costs. Symptom checker apps provide users with information and tools to better understand their symptoms and thus have the potential to reduce the time to diagnosis for reproductive health conditions.

OBJECTIVE

This study aimed to evaluate the agreement between clinicians and 3 symptom checkers (developed by Flo Health UK Limited) in assessing symptoms of endometriosis, uterine fibroids, and PCOS using vignettes. We also aimed to present a robust example of vignette case creation, review, and classification in the context of predeployment testing and validation of digital health symptom checker tools.

METHODS

Independent general practitioners were recruited to create clinical case vignettes of simulated users for the purpose of testing each condition symptom checker; vignettes created for each condition contained a mixture of condition-positive and condition-negative outcomes. A second panel of general practitioners then reviewed, approved, and modified (if necessary) each vignette. A third group of general practitioners reviewed each vignette case and designated a final classification. Vignettes were then entered into the symptom checkers by a fourth, different group of general practitioners. The outcomes of each symptom checker were then compared with the final classification of each vignette to produce accuracy metrics including percent agreement, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

A total of 24 cases were created per condition. Overall, exact matches between the vignette general practitioner classification and the symptom checker outcome were 83% (n=20) for endometriosis, 83% (n=20) for uterine fibroids, and 88% (n=21) for PCOS. For each symptom checker, sensitivity was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, and 100% for PCOS; specificity was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 75% for PCOS; positive predictive value was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, 80% for PCOS; and negative predictive value was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 100% for PCOS.

CONCLUSIONS

The single-condition symptom checkers have high levels of agreement with general practitioner classification for endometriosis, uterine fibroids, and PCOS. Given long delays in diagnosis for many reproductive health conditions, which lead to increased medical costs and potential health complications for individuals and health care providers, innovative health apps and symptom checkers hold the potential to improve care pathways.

Fibroids-related complications in pregnancy: a twelve-year long experience at a maternal-fetal medicine referral center

BACKGROUND

Uterine fibroids are the most frequent female benign tumor, which can cause complications during pregnancy, mainly pain. Differential diagnosis may be challenging and a standardized management approach is lacking. We aim to propose an algorithm for the differential diagnosis of pain during pregnancy and for management of fibroid-related pain.

METHODS

A retrospective cohort study of all pregnant women admitted to our center for complications related to fibroids between 2008 and 2019. Data regarding clinical examination, laboratory results, imaging parameters, as well as perinatal outcomes, were collected and assessed (Fisher's Exact Test).

RESULTS

Twenty-four pregnant patients were admitted for fibroid-related complications. Six patients were admitted more than one times, for a total of 34 admissions. The main cause of hospital admission was pain (N.=33, 94.1%), which was successfully managed with acetaminophen and/or ketoprofen in 91.2%. In two cases, conservative management failed and a surgical approach was undertaken. Most women (N.=20, 90.9%) delivered at term, with a cesarean delivery and post-partum hemorrhage rate of 22.7%. All newborns had normal APGAR score, umbilical artery pH and birth weight.

CONCLUSIONS

Pain is the most common complication of fibroids during pregnancy. Accurate differential diagnosis and adequate management are pivotal to ensure good perinatal outcomes.

Fibroids and Fertility

Uterine fibroids significantly impact women's reproductive health, influencing fertility potential and pregnancy outcomes. Their growth, often facilitated by hormonal influences like estrogen and progesterone, can cause considerable disruptions in the uterus, leading to symptoms and complications that impact the quality of life and reproductive prospects of women.This article provides an exhaustive discussion of uterine fibroids, including pathophysiology, their impact on endometrial function, receptivity, fertility, and pregnancy outcomes, and the management of infertility in patients with uterine fibroids. It underlines the critical role of uterine fibroids in women's reproductive health, emphasizing the importance of effective diagnosis and treatment to promote fertility and improve pregnancy outcomes.

Association of genital talc and douche use in early adolescence or adulthood with uterine fibroids diagnoses

BACKGROUND

Genital talc and douching are practices that can involve exposure to chemical compounds linked to certain gynecologic cancers. However, it is unclear if they are associated with fibroid risk or age at fibroid diagnosis among women.

OBJECTIVE

This study aimed to evaluate the impact of early-adolescence genital talc use and douching on prevalence of fibroids diagnosed before the age of 35 and 50 years among Black/African American and non-Hispanic White women.

STUDY DESIGN

Data were derived from the Sister Study (2003-2020), a prospective cohort of 50,884 US women aged 35 to 74 years at enrollment. Participants were asked if they ever had a fibroid diagnosis and at what age, and if they used genital talc and/or douched between the ages of 10 and 13 years or in the past 12 months. After applying predefined exclusion criteria, our analytical sample size was n=46,316 (Black, n=4310; non-Hispanic White, n=42,006). Multivariable logistic regression was used to compute adjusted odds ratios and 95% confidence intervals for having vs not having early-onset fibroids diagnosed before age 35 among women aged 35 to 74 years at enrollment, and fibroids diagnosed before age 50 among women aged 50 to 74 years at enrollment. We adjusted for early life factors (in utero diethylstilbestrol exposure, singleton or multiple birth, fed soy formula during infancy), childhood socioeconomic status, and relative weight and height compared with peers at age 10. We used multiple imputation (<10% missing in all analyses). Results were stratified by race/ethnicity given that Black women are more likely to develop fibroids at a younger age than non-Hispanic White women.

RESULTS

Among Black/African American women, 29% had fibroids diagnosed before age 35. Both genital talc use at age 10 to 13 (adjusted odds ratio, 1.23; confidence interval, 1.06-1.41) and douching (adjusted odds ratio, 1.19; 95% confidence interval, 0.95-1.48) were associated with higher odds of having a fibroid diagnosed before age 35. Douching without talc use was not associated with increased odds, but combined use of genital talc and douche was associated with 52% increased odds of fibroids (confidence interval, 1.14-2.01). Among non-Hispanic White women, 9% reported fibroids diagnosed before age 35. Genital talc use (1.31; 1.20-1.44) but not douching (0.96; 0.77-1.20) at age of 10 to 13 years was associated with having a fibroid diagnosed before age 35. We observed similar patterns for non-Hispanic White women when we considered fibroids diagnosed before age 50, but neither practice was associated with fibroids diagnosed before age 50 in Black women.

CONCLUSION

Genital talc use in early adolescence, alone and in combination with douching (but not douching alone), is associated with prevalence of fibroids diagnosed before age 35 among Black/African American women and before ages 35 and 50 among non-Hispanic White women. Early adolescence may be a window of susceptibility for fibroid development, suggesting that adolescent girls should be educated on abstention from or alternatives to talc use and douching.

Managing Inflammatory Myofibroblastic Tumor of the Uterus: A Case Report and Comprehensive Review of Pathological and Therapeutic Approaches

BACKGROUND Inflammatory myofibroblastic tumor (IMT) is a rare disease, and uterine IMT is even rarer. IMT is hard to distinguish from endometrial polyp and submucous myoma. The treatment of IMT is still controversial. Here, we report a case of uterine IMT, discussing both pathological and therapeutic aspects. CASE REPORT A 32-year-old woman was admitted to our hospital for a uterine mass, hypermenorrhea, and anemia. She had been suffering from these symptoms for almost a year. Pelvic ultrasound and MRI revealed a mass about 7 cm in diameter at the bottom of the uterus. Serum tumor markers were negative. She was diagnosed with submucous fibroids of the uterus. Then she underwent hysteroscopic mass resection. Histopathological and immunohistochemistry stain analysis revealed IMT of the uterus. Due to the malignant potential of IMT, she was advised to undergo a total hysterectomy, but she refused because she wanted to retain the uterus and fertility. A watch-and-wait strategy without any therapy was chosen, and the patient is currently disease-free after 18-month follow-up. CONCLUSIONS IMT is a disease with malignant potential and may recur at a late stage; hence, a correct diagnosis is essential for patients with IMT. Surgery is the preferred treatment for IMT. For early-stage, young women who want to preserve fertility, conservative surgery is acceptable, but close follow-up is required to avoid recurrence and metastasis. If a patient cannot undergo surgery or the disease has metastasized extensively, targeted therapy for ALK gene, immunotherapy, and other methods can be considered.

Uterine torsion with degeneration and infarction of giant leiomyoma in a postmenopausal woman: A case report

RATIONALE

Uterine torsion and giant leiomyoma are both rare diseases. Uterine torsion combined with giant leiomyoma with degeneration or infarction is easy to be misdiagnosed. We wrote this case to increase the accuracy and timeliness of medical staff's diagnosis and treatment of uterine fibroids combined with uterine torsion.

PATIENT CONCERNS

We present a case of uterine torsion with degeneration and infarction of giant leiomyoma in a 66-year-old postmenopausal woman, who had a lump in her pelvis 10 years ago and suffered from acute abdominal pain half a day before hospitalization.

DIAGNOSIS

The patient was considered as uterine torsion with huge abdominal mass by computed tomography and enhanced magnetic resonance imaging, and finally diagnosed as uterine torsion with giant leiomyoma through surgery and pathological examination.

INTERVENTIONS AND OUTCOMES

The patient underwent exploratory laparotomy. In addition to the removal of huge uterine fibroids, the hysterectomy with double appendages was conducted. The histopathologic analysis showed "(Uterine tumor) leiomyoma with extensive edema, degeneration, infarction and calcification." The patient recovered well after operation and kept healthy in the follow-up to date.

LESSONS

Although uterine torsion is extremely rare, early diagnosis and treatment are essential to prevent serious complications.

Evidence-Based Approach for Secondary Prevention of Uterine Fibroids (The ESCAPE Approach)

Uterine fibroids (UFs) are common tumors in women of reproductive age. It is imperative to comprehend UFs' associated risk factors to facilitate early detection and prevention. Simple relying on surgical/pharmacological treatment of advanced disease is not only highly expensive, but it also deprives patients of good quality of life (QOL). Unfortunately, even if the disease is discovered early, no medical intervention is traditionally initiated until the disease burden becomes high, and only then is surgical intervention performed. Furthermore, after myomectomy, the recurrence rate of UFs is extremely high with the need for additional surgeries and other interventions. This confused approach is invasive and extremely costly with an overall negative impact on women's health. Secondary prevention is the management of early disease to slow down its progression or even halt it completely. The current approach of watchful observation for early disease is considered a major missed opportunity in the literature. The aim of this article is to present an approach named the ESCAPE (Evidence-Based Approach for Secondary Prevention) of UF management. It comprises simple, inexpensive, and safe steps that can arrest the development of UFs, promote overall reproductive health, decrease the number of unnecessary surgeries, and save billions of health care systems' dollars worldwide.

Transvaginal excision of vaginal paraurethral leiomyoma: A video case report

INTRODUCTION AND HYPOTHESIS

Vaginal leiomyomas are uncommon benign tumors of the genital district that appear as a circumscribed, mobile, and nontender mass along the vaginal tube. The gold standard of vaginal leiomyoma management is surgical treatment. We aimed to present a clinical case of vaginal leiomyoma successfully treated throughout a transvaginal excision and layered repair.

METHODS

A 44-year-old woman was referred to our division for vaginal bulging symptoms and dyspareunia. Clinical examination revealed a 4-5 cm hard bulging mass in the anterior vaginal wall, below the urethra, compatible with vaginal leiomyoma. After proper counseling, the patient was admitted to transvaginal leiomyoma excision plus primary layered repair.

RESULTS

No surgical complications were observed. The indwelling catheter was removed the day after the surgery. The patient was successfully discharged home on postoperative day 1. The patient is currently asymptomatic and there are no signs of recurrence.

CONCLUSION

The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this uncommon condition.

Association between breast diseases and symptomatic uterine fibroids by using South Korean National Health Insurance database

Both the uterus and breasts have sex hormone dependence, yet there are few studies on the association between breast disease and uterine fibroids (UFs). The purpose of this study was to investigate the incidence of benign breast disease (BBD), carcinoma in situ (CIS), and breast cancer (BC) in women treated for UFs compared to women who were not treated for UFs. This retrospective cohort study used national health insurance data from January 1st, 2011, to December 31st, 2020. We selected women between 20 and 50 years old who (1) were treated for UFs (UF group) or (2) visited medical institutions for personal health screening tests without UFs (control group). We analyzed independent variables such as age, socioeconomic status (SES), region, Charlson comorbidity index (CCI), delivery status, menopausal status, menopausal hormone therapy (MHT), endometriosis, hypertension (HTN), diabetes mellitus (DM), and dyslipidemia based on the first date of uterine myomectomy in the UF group and the first visiting date for health screening in the non-UF group. There were 190,583 and 439,940 participants in the UF and control groups, respectively. Compared with those of the control group, the RRs of BBD, CIS, and BC were increased in the UF group. The hazard ratios (HRs) of BBD, CIS, and BC in the UF group were 1.335 (95% confidence interval (CI) 1.299-1.372), 1.796 (95% CI 1.542-2.092), and 1.3 (95% CI 1.198-1.41), respectively. When we analyzed the risk of BC according to age at inclusion, UFs group had the increased risk of BCs in all age groups in comparison with control group. Women with low SES (HR 0.514, 95% CI 0.36-0.734) and living in rural areas (HR 0.889, 95% CI 0.822-0.962) had a lower risk of BC. Our study showed that women with UFs had a higher risk of BBD, CIS, and BC than those without UFs. This result suggests that women with UFs should be more conscious of BC than those without UFs. Therefore, doctors should consider recommending regular breast self-exams, mammography, or ultrasound for the early detection of BC in women with UFs.

Acute abdomen caused by internodular bleeding from a multiple myoma pseudocapsule in a postmenopausal woman

A woman in her 50s presented with lower abdominal pain. She had a diagnosis of multiple uterine myomas 3 years earlier, followed by menopause. CT showed a pelvic mass of 19.5×9.4×10.2 cm in size, containing a haemorrhagic component. It was assumed that the tumour was the previously diagnosed myoma, and that it had increased to 150% of the size noted 3 years ago. An emergent hysterectomy was performed, and the pathological diagnosis was a uterine leiomyoma, with no components suggestive of sarcoma or degeneration. We witnessed a rare case of acute abdomen caused by internodular bleeding of multiple myomas. We assumed that the source of bleeding was the vessels of the myoma pseudocapsule. These cases may be more likely to occur in patients with multiple myomas presenting around the commencement of menopause. For symptomatic relief, emergent hysterectomy is considered to be the best treatment.

Impact of diagnosis and treatment of uterine fibroids on quality of life and labor productivity: The Japanese online survey for uterine fibroids and quality of life (JOYFUL survey)

AIM

To investigate the impact of uterine fibroid diagnosis/treatment status on quality of life (QOL) and work productivity in women living in Japan.

METHODS

Women aged 20-49 years who registered on Macromill were recruited via the opt-in method. They completed an online survey on demographic and uterine fibroid diagnosis/treatment status, 36-Item Short-Form Health Survey, Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire (UFS-QOL), and World Health Organization Health and Work Performance Questionnaire.

RESULTS

There were 4120 respondents: 1362 untreated, 249 with ongoing treatment, 449 with past treatment, 1030 with no uterine fibroids, and 1030 with unknown uterine fibroid status. A high proportion of women with ongoing treatment had moderate to severe uterine fibroid-like symptoms (symptom severity score of UFS-QOL ≥40 points), accompanied by reduced QOL. QOL was improved in women with past treatment. Uterine fibroids had a significant impact on physical and psychosocial aspects in the ongoing treatment group versus other groups. Using classification and regression tree analysis, anemia was identified as a plausible predictor of reduced QOL in the ongoing treatment group. Approximately 20% of women-even in groups other than the ongoing treatment group-experienced moderate to severe uterine fibroid-like symptoms. However, the diagnosis and treatment status of uterine fibroids had no clear impact on work productivity.

CONCLUSIONS

Uterine fibroids, especially in association with anemia, were related to reduced QOL. Given that uterine fibroid-related reduced QOL is likely improved by appropriate treatment, women with uterine fibroid-like symptoms, such as menorrhagia, should be examined and treated.

POTENTIAL LIFE PROGNOSTIC MARKER FOR MESENCHYMAL TUMOR RESEMBLING UTERINE LEIOMYOSARCOMA

Benign uterine leiomyoma (U.LMA) and malignant uterine leiomyosarcoma (U.LMS), both uterine mesenchymal tumors, are distinguished by the number of cells exhibiting mitotic activity. However, uterine mesenchymal tumors contain tumor cells with various cell morphologies; therefore, making a diagnosis, including differentiating between benign and malignant tumors, is difficult. For example, cotyledonoid dissecting leiomyoma (CDL) or uterine smooth muscle tumors of uncertain malignant potential (STUMPs) are a group of uterine mesenchymal tumors for which a differential diagnosis is challenging. To date, a standardized classification system for uterine mesenchymal tumors has not yet been established. Furthermore, definitive preoperative imaging techniques or hematological examinations for the potential inclusion of CDL or STUMP in the differential diagnosis have not been defined. Several clinical studies have reported that there is no correlation between biomarker expression and mitotic rate or tumor recurrence. The immunohistochemical biomarkers reported so far cannot effectively help determine the malignant potential of CDL or STUMPs in patients who wish to become pregnant in the future. The establishment of gene expression profiles or detection of pathogenic variants by using next-generation molecular techniques can facilitate disease prediction, diagnosis, treatment, and prognosis. We examined the oncological properties of STUMP in adults using molecular pathological techniques on tissue excised from patients with uterine mesenchymal tumor. In a clinical study conducted by our medical team, the results of gene expression profiling indicated factors that may be associated with malignancy of uterine mesenchymal tumors. We herein describe the problems in diagnosing uterine mesenchymal tumors along with the results of the latest clinical studies. It is expected that the establishment of a diagnostic method targeting the characteristics of mesenchymal tumor cells will lead to the treatment of malignant tumors with a low risk of recurrence and metastasis.

Diagnostic considerations and surgical techniques for a large prolapsing submucosal myoma

OBJECTIVE

To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive and uterine-sparing combined vaginal and hysteroscopic myomectomy. Submucosal myomas can present with various symptoms, including vaginal bleeding, pelvic pain, and abnormal discharge, and can also contribute to infertility. This type of myoma has the potential to prolapse through the cervical canal, and prompt identification and management are essential to avoid serious sequelae, including hemorrhage, infection, and sepsis.

DESIGN

A case report. Patient consent was received to publish. This publication received an exemption from institutional review board approval from the institution as this was a case report. The investigators have no conflicts of interest.

SETTING

Academic medical center.

PATIENTS

We present a 33-year-old G5P2032 patient with pelvic pain and vaginal bleeding. Her clinical course involved multiple encounters with inaccurate diagnoses, leading to worsening symptoms. She was found ultimately to have a large, prolapsing submucosal myoma. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites.

INTERVENTION(S)

Given the severity of her symptoms and her desire for uterine preservation for future fertility, the patient was counseled on the need for surgical intervention and elected to proceed with a combined vaginal and hysteroscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Preoperative considerations discussed in this video include common mimics of this condition, the importance of a thorough pelvic examination and preoperative imaging, as well as recommendations for surgical management.

RESULT(S)

We reviewed the following surgical techniques: (1) adequate exposure; (2) clamping of the myoma stalk; (3) morcellation "cone" technique; (4) use of intracervical vasopressin; (5) hysteroscopic evaluation; and (6) insertion of an intrauterine balloon.

CONCLUSION(S)

Prolapsing submucosal myomas can present as common gynecologic complaints but can lead to serious sequelae when timely diagnosis and treatment are not performed. Appropriate evaluation, accurate diagnosis, preoperative imaging, and knowledge of surgical techniques are critical for optimizing patient outcomes and avoiding complications in patients with a prolapsed myoma.

Non-Puerperal Chronic Inversion of Uterus Due to Big Fibroid Uterus in a Post-Menopausal Woman

Uterine inversion occurs in puerperal and non-puerperal conditions; non-puerperal uterine inversion (NPUI) may run acute and chronic clinical course. Most on the NPUI are chronic variety while a few are acute variety. NPUI occurs if there is long standing big sub-mucosal fibroid and it is very rare to present in acute setting. Here we report a case of acutely presented NPUI. A 58-year-old widow of lower socioeconomic status presenting to the emergency center of Chittagong medical college Hospital with complaints of sudden protrusion of a big mass through introitus in an attempt of passing out hard stool during defecation on the day of admission with a history of per vaginal watery discharge for a long time and severe anemia. Anemia was corrected and a broad-spectrum antibiotic was given prior to operative management. Under general anesthesia vaginal myomectomy followed by vaginal hysterectomy was performed in the same sitting. Pathological examination revealed a fibroid uterus. Postoperatively patient recovered without any residual problem. Infection should be suspected and treated with appropriate broad-spectrum antibiotics before planning surgery. Vaginal route restoration of NPUI is very difficult but possible with careful attempt. During a vaginal hysterectomy, care to locate and salvage the bladder and distal urinary collecting system is warranted. So, a high index of suspicion is the key to limit morbidity and approach for proper management of such rare clinical condition.

A rare case of benign metastasizing leiomyoma at vertebrae

ABSTRACT

Benign metastasizing leiomyoma (BML) is a rare disease that usually occurs in women of reproductive age, with a history of uterine leiomyoma treated with hysterectomy. This may present as lesions in lungs, lymph nodes, bones, brain, mediastinum, and soft tissues. However, the most commonly affected site is the lung. Here is a case report of a patient who presented with BML at vertebral body with distant metastasis to lungs, brain, and bones. A 37-year-old female, with no known comorbidities, presented with pain in the upper back, urinary and bowel incontinence, and weakness in the bilateral lower limbs. Radiological, multiple metastases were present at D2 and D9 vertebral bodies, multiple nodular lesions were present in the lungs, and solitary lesion was found in the right frontal lobe of the brain. Histology proved it to be of myoepithelial origin with low Ki-67 index. The treatment in this case was based on hormone production suppression and radiotherapy, with no signs of progression at follow-up.

Assessment of Uterine Fibroid Knowledge and Educational Interests Among Health Care Professionals

BACKGROUND

Uterine fibroid diagnosis and management can be delayed by a lack of access to care. To combat this barrier, this study aimed to determine gaps in knowledge and investigate areas of education interest.

METHODS

Obstetrics-gynecology, family medicine, and internal medicine resident and attending physicians received an electronic survey via RedCap. Descriptive statistics were performed in Mintab and Excel.

RESULTS

Seventy of the 316 physicians (22%) who received the survey completed it. Most participants answered questions regarding diagnosis timing, instruments for validated reported outcomes, and risk factors incorrectly. Seventy-six percent of respondents desired more education about treatment options and guidelines.

DISCUSSION

This study provides insight regarding current knowledge of uterine fibroids and areas of educational interest among different physicians.

An unusual coincidence of giant cervical leiomyoma and incidental ovarian granulosa cell tumor: A case report

RATIONALE

Leiomyomas are the most common benign tumors of smooth muscle origin in women. They are most frequently found in the submucosal tissue of the uterine corpus; however, they also occur in other areas of the uterus, including the cervix. Their size usually varies between 0.5 to 1.0 cm; however, they can reach great dimensions. A strong correlation between the onset and growth of leiomyomas and estrogen levels was observed. Granulosa cell tumor (GCT) is an infrequent sex cord-stromal ovarian neoplasm. Despite their malignancy, GCTs have a good long-term prognosis. In this study, we present a unique case of coincidence of 2 tumors: leiomyoma of rare location (cervix uteri) and extraordinary size (9, 04 cm diameter) with an adult granulosa cell tumor.

PATIENT CONCERNS

A 67-year-old Caucasian woman was transported from an emergency ward to a gynecological surgery department due to a massive vaginal hemorrhage.

DIAGNOSES

Preliminary examination showed a presence of an enormous uteri cervix tumor.

INTERVENTIONS

Initially, the patient underwent physical and ultrasound examinations. To prevent further bleeding, an urgent surgery (hysterectomy) with bilateral salpingo-oophorectomy was performed.

OUTCOME

Postoperative histopathological examination revealed a cervical leiomyoma and the incidental occurrence of an adult GCT in the right ovary.

LESSONS

This case shares an interesting coincidence between a rare variant of leiomyoma and GCT. The study suggests that the potential reason for this can be estrogen secreted by the GCT, which causes the enormous size of the patient's cervical leiomyoma and the severe vaginal bleeding. Therefore, we advise it is important in abnormal cases to search for other hidden explanations, as in cases of GCT.

Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Comprehensive Multidisciplinary Update

Background and Objectives: The uterine smooth muscle tumors of uncertain malignant potential (STUMP) are tumors with pathological characteristics similar to leiomyosarcoma, but that do not satisfy histological criteria for leiomyoma. These are problematic lesions with intermediate morphologic features; thus, diagnosis and treatment are difficult. This narrative review aims to review data in the literature about STUMPs, particularly focusing on management and therapeutic options and strategies for women who desire to preserve fertility. Material and Methods: authors searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed and Scopus databases, from 2000 to March 2023. Pertinent articles were obtained in full-text format and screened for additional references. Only articles in English language were included. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: The median age was 43 years old. Symptoms are similar to those of leiomyomas, with a mean diameter of 8.0 cm. Total hysterectomy with or without bilateral salpingo-oophorectomy is the standard care for women if fertility desire is satisfied. Myomectomy alone can be considered for young patients. Although these tumors have not a high malignant potential, several studies described recurrence and metastases. Conclusions: STUMPs are complex uterine smooth muscle tumors, with a rare but reasoned clinical-diagnostic management. Considering the high clinical and histological complexity of these tumors, high level of expertise is mandatory.

Leiomyoma of the palatine tonsil - report of a rare and unusual tumor at this site

A leiomyoma is a remarkably rare cause of a benign, one-side tonsillar enlargement. The diagnosis is essentially histologic and will not normally be suspected clinically. Immunohistochemistry is needed for substantiation of the morphology and confirmation. We submit this illustrative case report.

Is endometrial sampler SAP-1 a good way to diagnose the common intrauterine occupying lesions?-A diagnostic study

Background

Intrauterine occupying lesion is clinically common in the female reproductive organs. Endometrial cancer is the most critical one among intrauterine occupying lesions, which accordingly is considered as the main indication for endometrial cancer screening, for which endometrial sampler SAP-1 was recommended as an effective sampling tool.

Objective

This study aimed to evaluate the diagnostic efficacy of SAP-1 for endometrial polyp and uterine submucous myoma.

Materials and Methods

From August 2018 to June 2022, patients who were hospitalized for undergoing hysteroscopy examination were enrolled in this study. Before the procedure, endometrial samples were collected by the method of SAP-1. The histological results were compared with those by hysteroscopy sampling to analyze the diagnostic efficacy of SAP-1.

Results

The qualified rate for the SAP-1 sampling was 92.1%, which is a bit lower than that by method of hysteroscopy (95.3%). And the difference was not statistically significant (P > 0.05). Endometrial polyp (47.5%) and uterine submucous myoma (7.1%) accounted for the majority of endometrial lesions, while only 11.3% endometrial polyps (17/151) and 0% submucous myomas (0/23) were detected by SAP-1 sampling.

Conclusion

Endometrial sampler SAP-1 is not effective in detection of solid intrauterine lesions indicated by the imaging examination. Hysteroscopy is recommended for definite diagnosis.

Giant leiomyoma management during elective cesarean section: a case report

We present the unique case of a 44-year-old gravida 3 para 2 woman with complaints of monolateral perception of fetal movements who underwent elective cesarean section and hysterectomy for the presence of an exceptionally voluminous infralegamentary leiomyoma. Cesarean section required in-depth preoperative planning and was possible only after gravid uterus exteriorization. Myomectomy and hysterectomy were then necessary to reestablish the physio-anatomical pelvic environment. The patient was discharged after regular and uncomplicated postoperative time. In recent years, the paradigma of avoiding cesarean myomectomy due to fear of hemorrhage has been questioned by many authors and in certain cases cesarean myomectomy may even be undeferrable. We describe an innovative surgical technique which could be useful to obstetricians approaching similar uterine masses during cesarean sections.

Structural Gynecological Disease: Fibroids, Endometriosis, Ovarian Cysts

Fibroids, endometriosis, and ovarian cysts are common conditions. Fibroids can be asymptomatic or present with heavy menstrual bleeding, pelvic pressure, and pain. Endometriosis is a common cause of cyclical pelvic pain. Ovarian cysts are generally diagnosed incidentally. Transvaginal ultrasound is the performed imaging modality for all structural gynecological disease. Symptomatic management is recommended for each condition. Fibroids can be managed medically or surgically depending on the patient's symptoms and desire for future fertility. Nonsteroidal anti-inflammatory drugs are the first-line therapy for endometriosis followed by oral contraceptives and surgical management. Ovarian cysts can be managed expectantly.

A case of misdiagnosed leiomyoma of the vulva: A case report

RATIONALE

Leiomyoma of the vulva is a rare, benign mass that is present on the vulva. Most commonly, they are described as painless, well-circumscribed, solitary tumors that are misdiagnosed as Bartholin cysts before surgery.

PATIENT CONCERNS

A 45-year-old woman presented with a case of vulvar leiomyoma misdiagnosed as Bartholin cyst preoperatively. A solitary swelling mass measuring 3 cm × 2 cm was found in the left labia majora at the Bartholin gland site on physical examination.

DIAGNOSES

A vulvar mass extent and vascularity may be determined by imaging. A color doppler flow imaging of the posterior vaginal wall revealed abundant blood flow.

INTERVENTION

To confirm vulvar leiomyoma, surgery and histopathology were performed.

OUTCOME

After 2 months of follow-up, there were no signs of recurrence in the patient.

LESSONS

Rare vulvar leiomyomas are often mistaken for Bartholin's cysts. It is also difficult to distinguish benign from malignant forms, making vulvar leiomyoma a difficult diagnosis. As there are a few techniques used to differentiate between the nature of the tumor, excisional biopsy seems to be the best current procedure employed in addition to being the treatment of choice for such tumors.

Orbital leiomyoma presenting as inverse globe retraction syndrome: a unique presentation of a rare disease

Inverse globe retraction syndrome is a rare ocular motility disorder characterized by limited abduction, with globe retraction and up- or downshoots on attempted abduction, differentiating it from globe retraction due to Duane retraction syndrome, seen on attempted adduction. It can be congenital or acquired. We report the case of a 3-year-old girl who presented with classical features of inverse globe retraction syndrome secondary to an underlying orbital tumor involving the medial rectus muscle. Incisional biopsy confirmed the diagnosis of a leiomyoma. At 10 months' follow-up, vision, ocular alignment, and ocular motility had improved.

Age of first diagnosis and incidence rate of uterine fibroids in Ghana. A retrospective cohort study

BACKGROUND

Uterine fibroids are benign tumors that grow in or on the uterus of women. Globally, they occur in more than 80% of women of African ancestry and 70% in white women. Uterine fibroid requires much attention because of its high incidence rate among women of all races and ages. This study sought to document the age of first diagnosis and incidence rates of uterine fibroids in our urban setting.

METHODS

This study reviewed and analyzed the ages and year of diagnosis of all 2,469 patients with the first diagnosis of uterine fibroids from 1st January 2018 to 31st December 2021 in South-Central Ghana. The obtained data were analyzed using GNU PSPP, Python on Jupyter Notebook and Libre Office Calc with statistical significance level set at p≤0.05.

RESULTS

The overall average age was 36.29±8.08 years, with age range 17-61 years and the age groups with the highest frequencies were 35-39 years (n = 642, 26.00%), 30-34 years (n = 563, 22.80%) and 40-44 years (n = 381, 15.43%). The mean ages of the patients in 2018, 2019, 2020 and 2021 were 36.70±8.00 years (95%CI = 35.97-37.43), 37.07±7.66 years (95%CI = 36.45-37.70), 35.92±7.87 years (95%CI = 35.30-36.53) and 35.78±8.54 years (95%CI = 35.19-36.38) respectively. The incidence rate (per 100,000) of uterine fibroids in 2018, 2019, 2020 and 2021 were 66.77 (95% CI = 60.63-72.90), 81.86 (95%CI = 75.19-88.58), 85.60 (95%CI = 78.85-92.35) and 92.40 (95%CI = 85.88-98.92) respectively, with 35-39 age group recording the highest in all years.

CONCLUSION

The incidence rate of uterine fibroids increased as the years progressed and it is mostly high in 35-39 years age category, with a decreasing annual mean age trend indicative of early diagnosis.