Arch Gynecol Obstet DOI 10.1007/s00404-014-3580-2
CASE REPORT
Autoamputation of a pedunculated, subserosal uterine leiomyoma presenting as a giant peritoneal loose body Izumi Suganuma • Taisuke Mori • Tokuei Takahara • Hiroko Torii • Masanori Fujishiro • Tomohisa Kihira Yuko Urabe • Mamoru Urabe • Jo Kitawaki
•
Received: 28 February 2014 / Accepted: 5 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Peritoneal loose bodies (PLBs) are defined as fibrotic or calcified-free bodies within the peritoneal cavity; they commonly autoamputate from appendices epiploicae that have undergone torsion. Pedunculated, subserosal uterine leiomyomas (PSULs) are subserosal uterine leiomyomas connected to the uterus via a pedicle. In the present report, we describe the case of a PLB that originated from the autoamputation of a PSUL, confirmed based on histological evidence consistent with a uterine leiomyoma and the laparoscopic findings of a broken pedicle. This case clearly demonstrates the potential for a uterine leiomyoma to be the source of a PLB. Our findings contribute to the understanding of the etiological relationship between PLBs and uterine leiomyomas. Keywords Peritoneal loose body Pedunclated subserosal uterine leiomyoma Autoamputation Parasitic leiomyoma Laparoscopic surgery
Introduction Uterine leiomyomas are the most common pelvic tumors in women [1]. Subserosal uterine leiomyomas are located on
the serosal surface of the uterus and usually remain asymptomatic. There are two, well-known but rare, conditions that are derived from pedunculated, subserosal uterine leiomyomas (PSULs). One is a wandering leiomyoma, which has an extremely long pedicle that allows it to migrate [2]. Another is a parasitic leiomyoma, which detaches from the uterine wall with an auxiliary blood supply from the surrounding abdominal structures [2]. In contrast to these leiomyomas, which have connections to the uterus or surrounding tissues, intra-abdominal-free leiomyomas have not been described as having any uterine connection. Peritoneal loose bodies (PLBs) are fibrotic or calcifiedfree bodies located within the peritoneal cavity [3]. They are usually small (0.5–2 cm in diameter), although giant PLBs ([4 cm in diameter) may occur [4]. These structures are generally thought to originate from autoamputated appendices epiploicae that have undergone torsion [5]. Furthermore, autoamputated adnexa have also been reported as the origins of PLBs [6]. However, reports of PLBs originating from uterine leiomyomas have not been published. In the present report, we describe the case of an autoamputated PSUL presenting as a giant PLB.
Case presentation I. Suganuma (&) T. Mori J. Kitawaki Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan e-mail: [email protected] T. Takahara H. Torii M. Fujishiro T. Kihira Y. Urabe M. Urabe Department of Obstetrics and Gynecology, Kusatsu General Hospital, 1660 Yabase-cho, Kusatsu, Shiga 525-8585, Japan
A 35-year-old woman presented to our outpatient department at 13 weeks’ gestation. A pelvic ultrasound detected a homogeneous solid mass resembling a uterine leiomyoma. The mass was 6.0 9 5.0 cm in size, and located on the anterior wall of her uterus. She had never previously noted the mass or undergone surgery. Magnetic resonance imaging (MRI), after a normal vaginal
123
Arch Gynecol Obstet Fig. 1 A postpartum, sagittal magnetic resonance image showing a clear marginal mass with a homogeneous, hypointense T2 signal and an isointense T1 signal, compared with the myometrium of the anterior uterine wall. A thin pedicle is indicated by an arrow
a
b
Fig. 2 Laparoscopy revealed an isolated, white, smooth, solid mass in the pouch of Douglas (a) and the presumed broken pedicle (arrow) of the pedunculated, subserosal uterine leiomyoma on the anterior uterine wall (b)
delivery, indicated the presence of normal ovaries and a subserosal uterine leiomyoma, 6.0 9 7.0 9 7.5 cm in size, on the anterior wall of the uterus; there was no evidence of adhesion to or blood supply from the surrounding structures (Fig. 1). The patient desired continued observation. 11 months postpartum, a pelvic ultrasound showed that the mass had moved to the pouch of Douglas. An exploratory laparoscopy showed an isolated mass in the pouch of Douglas (Fig. 2a), and a white node on the anterior wall of the uterus was considered to be the broken pedicle that had originally connected the mass to the uterus (Fig. 2b). The mass was collected with morcellation, and a histological examination showed uniformly sized, spindle-shaped peripheral cells (Fig. 3a, b) and central calcification (Fig. 3c, d) consistent with a uterine leiomyoma.
123
Discussion To our knowledge, these observations demonstrate the first clinical evidence of a uterine leiomyoma acting as the origin of a PLB. Considering the increasing frequency of laparoscopic surgeries, the idea that a uterine leiomyoma has the potential to be the origin of a PLB may be important. Similarly, iatrogenic parasitic leiomyomas are now considered to be complications of uterine surgery, especially following laparoscopic myomectomy and morcellation [7], because there is often a need for surgical intervention, particularly for giant PLBs. This type of intervention is necessary both to confirm the pathological characteristics of the PLB and to prevent possible complications, such as intestinal obstructions related to the volume of the PLB.
Arch Gynecol Obstet
Fig. 3 A microscopic view of the mass shows uniformly sized and shaped peripheral fibrous cells (a 94, b 920, hematoxylin and eosin stain). Central calcification (c 94, d 920, Von Kossa stain) is also evident
This case provides an important contribution to our understanding of the etiological relationship between PLBs and uterine leiomyomas by demonstrating the role of uterine leiomyomas as potential origins of PLBs. Furthermore, from a clinical perspective, clinicians should conduct myomectomies with the consideration of potential leiomyoma remnants becoming iatrogenic parasitic leiomyomas or iatrogenic PLBs. Conflict of interest The authors declare that they do not have conflicts of interest related to this manuscript.
2. Robbins SL, Cotran RS, Kumar V (1984) Pathologic basis of disease. WB Saunders, USA 3. Mc CE, Stewart I (1958) Peritoneal mice. Am J Surg 96:588–589 4. Jang JT, Kang HJ, Yoon JY, Yoon SG (2012) Giant peritoneal loose body in the pelvic cavity. J Korean Soc Coloproctol 28:108–110. doi:10.3393/jksc.2012.28.2.108 5. Ghosh P, Strong C, Naugler W, Haghighi P, Carethers JM (2006) Peritoneal mice implicated in intestinal obstruction: report of a case and review of the literature. J Clin Gastroenterol 40:427–430 6. Koga K, Hiroi H, Osuga Y, Nagai M, Yano T, Taketani Y (2010) Autoamputated adnexa presents as a peritoneal loose body. Fertil Steril 93:967–968. doi:10.1016/j.fertnstert.2009.03.038 7. Kho KA, Nezhat C (2009) Parasitic myomas. Obstet Gynecol 114:611–615. doi:10.1097/AOG.0b013e3181b2b09a
Ethical standards We obtained the patient’s informed consent prior to submission of this case report.
References 1. Parker WH (2007) Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 87:725–736. doi:10.1016/j.fertnstert. 2007.01.093
123
CASE REPORT
Autoamputation of a pedunculated, subserosal uterine leiomyoma presenting as a giant peritoneal loose body Izumi Suganuma • Taisuke Mori • Tokuei Takahara • Hiroko Torii • Masanori Fujishiro • Tomohisa Kihira Yuko Urabe • Mamoru Urabe • Jo Kitawaki
•
Received: 28 February 2014 / Accepted: 5 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Peritoneal loose bodies (PLBs) are defined as fibrotic or calcified-free bodies within the peritoneal cavity; they commonly autoamputate from appendices epiploicae that have undergone torsion. Pedunculated, subserosal uterine leiomyomas (PSULs) are subserosal uterine leiomyomas connected to the uterus via a pedicle. In the present report, we describe the case of a PLB that originated from the autoamputation of a PSUL, confirmed based on histological evidence consistent with a uterine leiomyoma and the laparoscopic findings of a broken pedicle. This case clearly demonstrates the potential for a uterine leiomyoma to be the source of a PLB. Our findings contribute to the understanding of the etiological relationship between PLBs and uterine leiomyomas. Keywords Peritoneal loose body Pedunclated subserosal uterine leiomyoma Autoamputation Parasitic leiomyoma Laparoscopic surgery
Introduction Uterine leiomyomas are the most common pelvic tumors in women [1]. Subserosal uterine leiomyomas are located on
the serosal surface of the uterus and usually remain asymptomatic. There are two, well-known but rare, conditions that are derived from pedunculated, subserosal uterine leiomyomas (PSULs). One is a wandering leiomyoma, which has an extremely long pedicle that allows it to migrate [2]. Another is a parasitic leiomyoma, which detaches from the uterine wall with an auxiliary blood supply from the surrounding abdominal structures [2]. In contrast to these leiomyomas, which have connections to the uterus or surrounding tissues, intra-abdominal-free leiomyomas have not been described as having any uterine connection. Peritoneal loose bodies (PLBs) are fibrotic or calcifiedfree bodies located within the peritoneal cavity [3]. They are usually small (0.5–2 cm in diameter), although giant PLBs ([4 cm in diameter) may occur [4]. These structures are generally thought to originate from autoamputated appendices epiploicae that have undergone torsion [5]. Furthermore, autoamputated adnexa have also been reported as the origins of PLBs [6]. However, reports of PLBs originating from uterine leiomyomas have not been published. In the present report, we describe the case of an autoamputated PSUL presenting as a giant PLB.
Case presentation I. Suganuma (&) T. Mori J. Kitawaki Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan e-mail: [email protected] T. Takahara H. Torii M. Fujishiro T. Kihira Y. Urabe M. Urabe Department of Obstetrics and Gynecology, Kusatsu General Hospital, 1660 Yabase-cho, Kusatsu, Shiga 525-8585, Japan
A 35-year-old woman presented to our outpatient department at 13 weeks’ gestation. A pelvic ultrasound detected a homogeneous solid mass resembling a uterine leiomyoma. The mass was 6.0 9 5.0 cm in size, and located on the anterior wall of her uterus. She had never previously noted the mass or undergone surgery. Magnetic resonance imaging (MRI), after a normal vaginal
123
Arch Gynecol Obstet Fig. 1 A postpartum, sagittal magnetic resonance image showing a clear marginal mass with a homogeneous, hypointense T2 signal and an isointense T1 signal, compared with the myometrium of the anterior uterine wall. A thin pedicle is indicated by an arrow
a
b
Fig. 2 Laparoscopy revealed an isolated, white, smooth, solid mass in the pouch of Douglas (a) and the presumed broken pedicle (arrow) of the pedunculated, subserosal uterine leiomyoma on the anterior uterine wall (b)
delivery, indicated the presence of normal ovaries and a subserosal uterine leiomyoma, 6.0 9 7.0 9 7.5 cm in size, on the anterior wall of the uterus; there was no evidence of adhesion to or blood supply from the surrounding structures (Fig. 1). The patient desired continued observation. 11 months postpartum, a pelvic ultrasound showed that the mass had moved to the pouch of Douglas. An exploratory laparoscopy showed an isolated mass in the pouch of Douglas (Fig. 2a), and a white node on the anterior wall of the uterus was considered to be the broken pedicle that had originally connected the mass to the uterus (Fig. 2b). The mass was collected with morcellation, and a histological examination showed uniformly sized, spindle-shaped peripheral cells (Fig. 3a, b) and central calcification (Fig. 3c, d) consistent with a uterine leiomyoma.
123
Discussion To our knowledge, these observations demonstrate the first clinical evidence of a uterine leiomyoma acting as the origin of a PLB. Considering the increasing frequency of laparoscopic surgeries, the idea that a uterine leiomyoma has the potential to be the origin of a PLB may be important. Similarly, iatrogenic parasitic leiomyomas are now considered to be complications of uterine surgery, especially following laparoscopic myomectomy and morcellation [7], because there is often a need for surgical intervention, particularly for giant PLBs. This type of intervention is necessary both to confirm the pathological characteristics of the PLB and to prevent possible complications, such as intestinal obstructions related to the volume of the PLB.
Arch Gynecol Obstet
Fig. 3 A microscopic view of the mass shows uniformly sized and shaped peripheral fibrous cells (a 94, b 920, hematoxylin and eosin stain). Central calcification (c 94, d 920, Von Kossa stain) is also evident
This case provides an important contribution to our understanding of the etiological relationship between PLBs and uterine leiomyomas by demonstrating the role of uterine leiomyomas as potential origins of PLBs. Furthermore, from a clinical perspective, clinicians should conduct myomectomies with the consideration of potential leiomyoma remnants becoming iatrogenic parasitic leiomyomas or iatrogenic PLBs. Conflict of interest The authors declare that they do not have conflicts of interest related to this manuscript.
2. Robbins SL, Cotran RS, Kumar V (1984) Pathologic basis of disease. WB Saunders, USA 3. Mc CE, Stewart I (1958) Peritoneal mice. Am J Surg 96:588–589 4. Jang JT, Kang HJ, Yoon JY, Yoon SG (2012) Giant peritoneal loose body in the pelvic cavity. J Korean Soc Coloproctol 28:108–110. doi:10.3393/jksc.2012.28.2.108 5. Ghosh P, Strong C, Naugler W, Haghighi P, Carethers JM (2006) Peritoneal mice implicated in intestinal obstruction: report of a case and review of the literature. J Clin Gastroenterol 40:427–430 6. Koga K, Hiroi H, Osuga Y, Nagai M, Yano T, Taketani Y (2010) Autoamputated adnexa presents as a peritoneal loose body. Fertil Steril 93:967–968. doi:10.1016/j.fertnstert.2009.03.038 7. Kho KA, Nezhat C (2009) Parasitic myomas. Obstet Gynecol 114:611–615. doi:10.1097/AOG.0b013e3181b2b09a
Ethical standards We obtained the patient’s informed consent prior to submission of this case report.
References 1. Parker WH (2007) Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 87:725–736. doi:10.1016/j.fertnstert. 2007.01.093
123
