|Year : 2019 | Volume
| Issue : 1 | Page : 24-27
Parasitic leiomyoma with myxoid degeneration mimicking malignancy: A case report and review of literature
Alfa A Sule1, Ibrahim B Sule2, Mohammed A Gana2, Amina L Abubakar2, Aminu Magaji2, Chijoke C Umelo2, Ilyasu Garba3
1 Department of Pathology, General Hospital, Minna, Nigeria
2 Department of Obstetrics and Gynaecology, General Hospital, Minna, Nigeria
3 Department of Radiology, General Hospital, Minna, Nigeria
|Date of Submission||09-Jan-2019|
|Date of Acceptance||01-Oct-2019|
|Date of Web Publication||16-Apr-2020|
Dr. Alfa A Sule
Department of Pathology, General Hospital, Minna
Source of Support: None, Conflict of Interest: None
Parasitic leiomyoma is a rare, benign smooth muscle tumor occurring in an extrauterine location. Their unusual growth pattern may mimic malignancy and, hence, could pose diagnostic and management challenges. Myxoid degeneration is further rarer finding in leiomyoma. There are few published cases of parasitic leiomyoma in our setting, hence, this report. A 52-year-old female presented with 4-year history of painless, progressive abdominal swelling with associated anorexia, weight loss, and body weakness. Abdominal examination revealed non-tender, nodular mass of 24 weeks size. Ultrasound scan showed a large well-defined heterogeneously hyperechoic right pelvic tumor crossing the midline. She had exploratory laparotomy; however, the histology confirmed parasitic leiomyoma with myxoid degeneration. Parasitic leiomyoma is an uncommon extrauterine benign tumor that mimics abdominopelvic malignancies. Meticulous clinical evaluation with radiologic and pathologic findings is the key to the otherwise challenging diagnosis.
Keywords: Myxoid degeneration, parasitic leiomyoma, tumor
|How to cite this article:|
Sule AA, Sule IB, Gana MA, Abubakar AL, Magaji A, Umelo CC, Garba I. Parasitic leiomyoma with myxoid degeneration mimicking malignancy: A case report and review of literature. Arch Int Surg 2019;9:24-7
|How to cite this URL:|
Sule AA, Sule IB, Gana MA, Abubakar AL, Magaji A, Umelo CC, Garba I. Parasitic leiomyoma with myxoid degeneration mimicking malignancy: A case report and review of literature. Arch Int Surg [serial online] 2019 [cited 2020 Aug 6];9:24-7. Available from: http://www.archintsurg.org/text.asp?2019/9/1/24/282579
| Introduction|| |
Leiomyoma is a benign smooth muscle tumor and it is the most common benign pelvic tumor affecting women of reproductive age group with an incidence of 20 to 30% in women older than 35 years. The size varies from microscopic to giant and could be intrauterine or extrauterine. Parasitic leiomyoma is a very rare extrauterine benign smooth muscle tumor that developed an auxiliary blood supply and lose their original attachment to the uterus, thus becoming parasitic. Their unusual growth pattern may mimic malignancy and pose diagnostic and management challenges. The etiology is unknown; however, iatrogenic causes following uterine myomectomy, especially when morcellators are used for retrieval or unintentional seeding of the fragments during the procedure, were suggested. Myxoid degeneration is also uncommon finding in leiomyoma. There are scanty published reports on parasitic leiomyoma with myxoid degeneration in sub-Saharan Africa, more so from Nigeria. Here, we are reporting a rare case of parasitic leiomyoma with myxoid degeneration.
| Case Report|| |
A 52-year-old female, para 8 with 7 living children and 3 years postmenopausal, presented with 4-year history of painless, progressive abdominal swelling with associated anorexia, weight loss, and body weakness. There was no history of vaginal or rectal bleeding, and no foul-smelling vaginal discharge. Abdominal examination revealed non-tender, nodular mass of 24 weeks size, can get above but not below it. Ultrasound scan showed a well-defined right-sided solid pelvic mass, which crosses the midline and measured 22 cm in diameter. The mass was closely related to the uterus, appear heterogeneously hyperechoic with irregular cystic component but no demonstrable vascular connection with the uterus, and was suspected to be a malignant pelvic tumor. No ascites or abdominal lymphadenopathy was seen. CA 125 was 12 mIU/mL and other biochemical investigations were essentially normal.
Exploratory laparotomy revealed a huge mass arising from the right iliac fossa, adherent to the ascending and transverse colon and the posterior wall of the uterine fundus; it measured about 25 × 20 cm and firm. Grossly, it was nodular with well-demarcated borders, measured 20 × 14 × 10 cm and weighed 1.3 kg; cut surface showed myxoid appearance with intervening grayish-white whorled surface. Histology revealed well-demarcated lesions composed of bundles of interlacing fascicles of spindle cells having elongated bland nuclei disposed within an edematous myxoid stroma. Diagnosis of parasitic leiomyoma with myxoid degeneration was made. She recovered fully postoperatively and was also seen at the Gynecology clinic for follow-up and has been clinically stable.
[Figure 1] and [Figure 2] show the photomicrograph of gross appearance and histology of leiomyoma with myxoid degeneration respectively.
| Discussion|| |
Parasitic leiomyoma is a rare, benign smooth muscle tumor occurring in an extrauterine location. They can be found in pelvic peritoneum, omentum, cul-de-sac, and broad ligament. Pedunculated subserosal leiomyomas can be twisted on the uterine pedicle and lose their original attachment to the uterus, thus becoming “parasitic” survives by revascularization from adjacent structures which includes colon as observed in the index case, omentum, inferior mesenteric artery, and common iliac artery.
Several reports have also shown that parasitic leiomyomas are common following laparoscopic myomectomy, especially in those cases where tumors are morcellated for removal. Cucinella et al. conducted a retrospective study to show the development of parasitic leiomyoma after the application of a morcellator over three years, out of 423 patients who had morcellation, 0.9% developed parasitic leiomyoma. Kimberly et al. documented 12 cases of parasitic leiomyomas, 10 had previous abdominal surgery and 8 had morcellation procedures. Lu et al. reported six cases of parasitic leiomyoma, all of whom had the history of laparoscopic hysterectomy or myomectomy with power morcellation. It is noteworthy that the importance of inspection and thorough washing of abdominopelvic cavity after procedure cannot be overemphasized. The index case had no history of previous surgery as in most reported reviews. There are very few of such cases documented; Salih et al. reported parasitic leiomyoma in a 46-year-old female without history of prior abdominal procedure. Zaitoon reported a parasitic leiomyoma in a 40-year old morbidly obese female devoid of previous abdominopelvic surgery. Abdel-Gadir et al. also documented a 35-year-old female with secondary infertility with no past operation.
Furthermore, parasitic leiomyoma has the preponderance of occurrence in pelvic (93%). Ghamande et al. reported a 32-year old female with parasitic leiomyoma occurring in right para-rectal area displacing the right adnexa, appendix, and caecum anteromedially. The index case was found on the colon which is in accord with the report by Pezzuto et al. Parasitic leiomyomas are usually asymptomatic and at times may present with pressure symptoms such as abdominal swelling, discomfort, easy satiety, and nausea. These symptoms were observed in the current case.
When leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degeneration which includes hyaline, myxoid, calcification, fatty, cystic, and red degeneration. Hyaline degeneration is the most common and accounted for 60% of cases; the myxoid changes is an infrequent and composed of smooth muscle cells, with a large amount of a cellular material rich in acid mucins. The present case exhibits myxoid degeneration.
Radiologic studies are vital in making a diagnosis. In ultrasonography, degenerative leiomyoma is usually hypoechogenic and excessive degeneration may be recognized as a cystic pattern. In our case, ultrasound scan showed heterogeneous hyperechoic echo pattern with cystic component. The myxoid component is heterogeneous, high intensity on MRI T2 weighted images. The definitive diagnosis is by histological examination which also rules out malignancy. The distinction of myxoid leiomyoma from myxoid leiomyosarcoma is based on nuclear atypia, mitotic figure, and necrosis. Myxoid liposarcoma will in addition to atypical features show variable number of small lipoblasts. Immunohistochemistry is also useful in distinguishing them. In the index case, no atypical changes were seen.
| Conclusion|| |
Parasitic leiomyoma is an uncommon extrauterine benign tumor that mimics abdominopelvic malignancies. Meticulous observation of the patient's history, location of the mass, high index of suspicion, and radiologic and pathologic conclusions are the key to this challenging diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gompel C, Silverberg SG. The corpus uteri. In: Gompel C, Silverberg SG, editors. Pathology in Gynecology and Obstetrics. 4th
ed. Philadelphia, PA: Lippincott; 1994. p. 163-283.
Kho KA, Nezhat C. Parasitic myomas. Obstet Gynecol 2009;114:611-5.
Murase E, Siegelman ES, Outwater EK, Perez-Jaffe LA, Tureck RW. Uterine leiomyomas: Histopatologic features, MR imaging findings, differential diagnosis, and treatment. Radiographics 1999;19:1179-97.
Okoro I, Ododo N, Egejuru R. Parasitic leiomyoma: A diagnostic dilemma: A case report. Niger J Clin Pract 2007;10:349-51.
Odofin O, Nasir N, Satyadas T, Lower AM, Akle C. An unusual case of ectopic or “parasitic” leiomyoma excised by laparoscopic surgery. Int Surg 2004;89:161-3.
Cucinella G, Granese R, Calagna G, Somigliana E, Perino A. Parasitic myomas after laparoscopic surgery: An emerging complication in the use of morcellator? Description of four cases. Fertil Steril 2011;96:e90-6.
Kimberly A, Nezhat C. Parasitic myomas. Obstet Gynecol 2009;114:611-5.
Lu B, Xu J, Pan Z. Iatrogenic parasitic leiomyoma and leiomyomatosis peritonealis disseminata following uterine morcellation. J Obstet Gynaecol Res 2016;42:990-9.
Salih AM, Kakamad FH, Dahat AH, Habibullah IJ, Rauf GM, Najar KA. Parasitic leiomyoma: A case report with literature review. Inter J Surg Case Reports 2017;41:33-5.
Zaitoon MM. Retroperitoneal parasitic leiomyoma causing unilateral ureteral obstruction. J Urol 1986;135:130-1.
Abdel-Gadir A, Arancis ND, Oyawoye OO, Chander BP. Secondary amenorrhoea with high inhibin B level caused by parasitic ovarianleiomyoma. Gynecol Endocrinol 2010;26:93-5.
Sarmalkar M, Nayak A, Singh N, Mehendale M, Dixit P. A rare case of primary parasitic leiomyoma mimicking as ovarian mass: A clinical dilemma. Int J Reprod Contracept Obstet Gynecol 2016;5:545-8.
Ghamande SA, Eleonu B, Hamid AM. High levels of CA-125 in a case of a parasitic leiomyoma presenting as an abdominal mass. Gynecol Oncol 1996;61:297-8.
Pezzuto A, Serboli G, Ceccaroni M, Ferrari B, Nardelli GB, Minelli LL. Two case reports of bowel leiomyomas and review of literature. Gynecol Endocrinol 2010;26:894-6.
Jones HW, Rock JA. Leiomyomata uteri and myomectomy. In: Jones HW, editors. Te Linde's Operative Gynecology. 11th
ed. Philadelphia, PA: Wolters Kluwer; 2015. p. 658-62.
Clement PB, Young RH, Scully RE. Diffuse, perinodular, and other patterns of hydropic degeneration within and adjacent to uterine leiomyomas. Problems in differential diagnosis. Am J Surg Pathol 1992;16:26-2.
Karasick S, Lev-Toaff AS, Toaf ME. Imaging of uterine leiomyomas. Am J Roentgenol 1992;158:799-5.
Kurman RJ, Blausten's pathology of the female genital tract. Berlin Cancer Genet Cytogenet 1994;77:65-8.
[Figure 1], [Figure 2]