Pedunculated leiomyoma of the uterus presenting as a big belly mass.OA Case Experiences

Authors affiliations

(1) Division of Surgical procedure, Put up graduate Institute of Medical Sciences, Rohtak, Haryana, India-124001

(2) Division of Pathology, Put up graduate Institute of Medical Sciences, Rohtak, Haryana, India-124001

* Corresponding writer E-mail: [email protected]

Summary

Introduction

This paper studies a case of pedunculated leiomyoma of the uterus presenting as a big belly mass.

Case report

A middle-aged pre-menopausal girl introduced with ache and a big intra-abdominal lump within the decrease stomach. Ultrasonography confirmed a big, rounded, hypoechoic mass with septations. Distinction-enhanced CT scan of the stomach demonstrated a big heterogeneous, predominantly hypodense mass lesion within the stomach and pelvis with heterogeneous irregular enhancing hypodensity inside it. Nonetheless, the organ of origin couldn’t be recognized with investigations and the affected person was explored with the potential for pseudopancreatic cyst or mesenteric cyst. Operative findings revealed a big pedunculated fibroid arising from the uterine fundus and occupying nearly entire of the stomach and pelvis.

Conclusion

Though fibroids normally have a attribute look on sonography, degenerating fibroids can have variable patterns and pose diagnostic challenges.

Introduction

Uterine leiomyomas are the most typical gynaecological neoplasms. The everyday appearances of leiomyomas are simply recognised on imaging. Nonetheless, the atypical appearances that comply with degenerative modifications could trigger confusion in prognosis. Right here we report a case of exophytic leiomyoma exhibiting intensive cystic degeneration on imaging, and simulating mesenteric cysts.

Case report

A forty-year-old multiparous girl introduced with a criticism of a progressively growing swelling and uninteresting aching ache within the decrease stomach for the final 4 months. She had no different signs associated to both genitourinary or decrease gastrointestinal observe. There was no important previous, household and private historical past. On examination, she had a big non-tender cystic mass of measurement 30 cm × 15 cm occupying the hypogastrium, umbilical area reaching as much as the epigastrium, having ill-defined margins, and clean floor with side-to-side mobility. Per vaginal and per rectal examination have been primarily regular. Routine haematological investigations have been regular. CA 125 degree was 46 IU (regular vary 2.0–35). Trans-abdominal sonography confirmed a big hypoechoic strong cystic lesion with septations, measuring 18 cm × 18 cm × 9 cm within the stomach and pelvis touching the anterior belly wall and pushing the intestine laterally. Bilateral ovaries and uterus have been regular. The organ of origin of the mass couldn’t be recognized on ultrasonography. Distinction enhanced computerised tomography revealed a big heterogeneous, predominantly hypodense mass lesion within the stomach and pelvis, measuring 16.9 cm × 9.6 cm × 13.5 cm and confirmed heterogeneous irregular enhancing hypodensity inside it. Superiorly it reached as much as the pancreas and inferiorly as much as the uterus. There was gentle hydronephrosis in each the kidneys probably as a consequence of stress impact of the mass. The left ovary was regular and the suitable ovary had a small cystic lesion in it (Determine 1). There was no free fluid within the stomach and lymphadenopathy. Based mostly on these findings, the prognosis of pseudopancreatic cysts or difficult mesenteric cysts was made and the affected person was explored.

Determine 1: CECT stomach exhibiting a big heterogenous hypodense mass lesion occupying nearly entire of the stomach and pelvis.

On exploration, a big cystic mass (of measurement, 25 cm × 20 cm × 18 cm) was seen within the decrease stomach and pelvis arising from the uterus and linked with its fundus with a small pedicle (Determine 2). Uterus and cervix have been primarily regular. There was minimal ascitic fluid within the peritoneal cavity. The ovaries and adnexa of either side have been regular. All different intra-abdominal viscera together with the pancreas and mesentery have been additionally regular. The cystic mass was excised after ligating the pedicle. On lower part, the mass had strong and cystic parts (Determine 3). Intra-operative frozen part examination was carried out and it confirmed a benign lesion. The stomach was closed with a pelvic drain. Put up-operative interval was uneventful. The ultimate biopsy report was a uterine leiomyoma with cystic degeneration.

Determine 2: Massive cystic mass hooked up to the uterus with a pedicle. Each ovaries are mendacity separate from the mass (arrows).

Determine 3: Reduce part of the mass exhibiting strong and cystic areas.

Dialogue

Leiomyoma of the uterus arises from the uterine clean muscle groups and is the most typical uterine neoplasm in girls of reproductive age. It might be single or a number of and its measurement could differ from microscopic to massive leiomyoma. The dimensions, quantity and placement of leiomyoma decide their medical behaviour. In 50% of the circumstances, there aren’t any signs^[1]. The prognosis is commonly made as an incidental discovering on ultrasound however the sufferers can also current with menorrhagia, pelvic discomfort, belly bloating, urinary retention /frequency or constipation as a consequence of stress impact, or acute stomach as a consequence of torsion of a pedunculated fibroid. As well as, they might compromise reproductive operate, probably contributing to subfertility, early being pregnant loss and later being pregnant problems reminiscent of acute ache as a consequence of crimson degeneration, preterm labour, malpresentations, elevated want for caesarean part, and postpartum haemorrhage. Sarcomatous change is uncommon and is normally related to speedy development^[1,2]. The uncommon problems in a uterine leiomyoma embrace thrombo-embolism, acute vaginal or intra-peritoneal haemorrhage, mesenteric vein thrombosis, and intestinal gangrene^[3].

A big, cystic, pedunculateduterine leiomyoma of the uterus could mimic a main malignant ovarian tumour on sonography and CT and would possibly bear intensive surgical procedure like complete hysterectomy and bilateral salpingo-oopherectomy by mistake^[4]. Not often, gradual enlargement of a pedunculated myoma could happen throughout being pregnant, worsening after supply and inflicting hypovolemic shock, with out proof of exterior or intra-abdominal haemorrhage. The doable mechanism is that partial occlusion obstructs the venous return, however not arterial blood move resulting in speedy enlargement of the myoma^[5]. A big subserosal uterine leiomyoma could very hardly ever result in small bowel obstruction as a consequence of entrapment of the bowel between pedunculated fibroids, adhesions to infarcted leiomyomas, or from compression of the small bowel by the big mass^[6].

Within the current case, the affected person introduced with a progressively growing belly lump that was solid-cystic in nature. It gave the impression to be a benign mass after investigations, though the organ of origin couldn’t be decided. Different frequent benign lots in such medical settings embrace mesenteric cyst, pseudopancreatic cyst, renal cyst, renal angiomyolipoma, adrenal incidentalomas, retroperitoneal cyst, ovarian cyst, and dermoid. Nonetheless, the ultimate prognosis in our case was established on exploration.

Ultrasonography is the first modality for diagnosing clinically suspected uterine fibroids^[7]. It generally exhibits a hypoechoic or heterogeneous uterine mass, whose texture is determined by the relative ratio of fibrous tissue to clean muscle and the presence and kind of degeneration^[8]. CT scan will not be the first modality of prognosis for leiomyoma. The most typical CT findings are uterine enlargement with related focal lots and uterine contour deformity. Leiomyoma which have undergone degenerations present decrease attenuation look with diminished distinction materials enhancement^[8].

For administration, myomectomy is the therapy of alternative for big symptomatic fibroids in fertile girls and could also be carried out by laparoscopy or laparotomy. For perimenopausal girls, vaginal or laparoscopic hysterectomy is the best therapy for symptomatic fibroids and is related to a excessive price of affected person satisfaction. Uterine artery embolisation is an efficient therapy for symptomatic fibroids with low long-term morbidity and will be provided as an alternative choice to myomectomy and hysterectomy^[9]. Security and effectiveness of uterine artery embolisation in pedunculated fibroids was assessed in 716 girls and it was discovered to be protected and efficient^[10]. MR-guided targeted ultrasound has been lately used to deal with a pedunculated fibroid, the place solely the fibroid is focused and the stalk is spared. This has been claimed to be a protected and efficient therapy for pedunculated subserosal fibroids, however the suitability must be confirmed by massive potential research^[11].

Conclusion

Though fibroids normally have a attribute look on sonography, degenerating fibroids can have variable patterns and pose diagnostic challenges. A pedunculated, subserosal uterine leiomyoma needs to be stored as a medical risk in such circumstances.

Consent

Written knowledgeable consent was obtained from the affected person for publication of this case report and accompanying pictures. A duplicate of the written consent is obtainable for overview by the Editor-in-Chief of this journal.

Authors contribution

All authors contributed to the conception, design, and preparation of the manuscript, in addition to learn and accredited the ultimate manuscript.

A.M.E

All authors abide by the Affiliation for Medical Ethics (AME) moral guidelines of disclosure.