Obstetrics and Gynaecology Section
DOI: 10.7860/JCDR/2014/8195.4532
Case Report
Fibroid after Hysterectomy: A Diagnostic Dilemma
Pallavee P1, Seetesh Ghose2, Sunita Samal3, Jasmina Begum4, Mariyam Zabeen5
ABSTRACT Broad ligament fibroids are rare and often pose clinical diagnostic difficulties. We report a case of broad ligament fibroid in a woman after hysterectomy. The lady presented to us with continuous lower abdominal pain of seven months duration. Bimanual examination revealed a firm mass on the right side of the vaginal vault. Transvaginal sonogram and computed tomography scan was suggestive of possible parasitic leiomyoma or a broad ligament fibroid. Exploratory laparotomy and removal of the mass, followed by histological examination confirmed leiomyoma. Extra-uterine fibroid should be considered in the differential diagnosis of pelvic masses even in the post-hysterectomy state.
Keywords: Broad ligament fibroid, Extra-uterine leiomyoma, Post-hysterectomy
CASE REPORT A 48-year-old woman, para 1, living 1, presented to our outpatient department with continuous lower abdominal pain of seven months duration. She had undergone total abdominal hysterectomy six years back for multiple fibroids in the uterus. Speculum examination showed a healthy looking vagina. Bimanual examination revealed a firm mass measuring 4 x 4 cm on the right side of the vaginal vault. Transvaginal sonogram revealed a solid, hypoechoic, wellcircumscribed right adnexal mass of size 3.5 x 4.6 cm, and both ovaries could not be imaged separately [Table/Fig-1]. Computed tomography (CT) scan was done which showed post hysterectomy status with bilateral thin walled cystic lesions possibly ovarian cysts, right side measuring 4.6 x 5.3 x 5 cm and left side 1.8 x 2.5 x 2.3 cm [Table/Fig-2]. On the right side adjacent to the vaginal stump, a welldefined lesion isodense to the muscle (40 HU) was seen measuring 4.6 x 4 x 4.7 cm, with intense contrast enhancement (137 HU). Fat plane between the lesion and bladder, rectum, vagina and pelvic wall was maintained. There was no evidence of calcification or necrosis within the lesion and no retroperitoneal lymphadenopathy. The impression was that of possible parasitic leiomyoma or a broad ligament fibroid. Cancer antigen (CA-125) was reported normal with a value of 7.2 U/ml.
Patient was posted for exploratory laparotomy. Intra-operative findings revealed a pelvic mass on the right side of vaginal stump measuring 4 x 4 cm with both ovaries appearing normal. The mass was enucleated by opening the layers of broad ligament which were later resutured. Cut section of the mass revealed a whorled pattern and histopathological report was consistent with diagnosis of leiomyoma. Post-operative period was uneventful and patient was discharged on the sixth day.
Discussion Extra-uterine leiomyomas are rare [1], and post-hysterectomy broad ligament fibroids are rarer still. Broad ligament fibroids are of two types [2]. The first variety is the true broad ligament myoma, which originates from the muscle fibres normally found in the mesometrium (in the round ligament, ovario-uterine ligament, and the connective tissue around the uterine and ovarian vessels). The second variety is termed as ‘false’ broad ligament myoma as the tumour arises from the lateral wall of the uterine corpus or of the cervix, and bulges outward between the layers of the broad ligament. Sinha et al., reported two cases of multiple fibroids in the pelvis after laparoscopic hysterectomy [3]. Our case was that of a true broad ligament fibroid following total abdominal hysterectomy. Broad
[Table/Fig-1]: Transvaginal sonogram showing solid, hypoechoic, well-circumscribed right adnexal mass of size 3.5 x 4.6 cm [Table/Fig-2]: Axial contrast-enhanced computed tomographic scan section at the level of urinary bladder (white arrowhead) showing post-hysterectomy status, with intensely enhancing well-defined lesion (black arrow) on the right side with fat plane between the lesion and surrounding structures maintained
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): OD01-OD02
1
Pallavee P et al., Fibroid after Hysterectomy
ligament fibroid can be difficult to differentiate from ovarian tumours [4]. Bansal et al., reported a case of a massive broad ligament fibroid which mimicked an ovarian tumour because of its myxoid and cystic degenerations [5]. Our patient had hysterectomy several years back and the ovaries could not be imaged during transvaginal ultrasound examination leading to a doubt regarding origin of the pelvic mass. Though CA-125, done to differentiate from ovarian malignancy was normal, broad ligament fibroid can also cause pseudo-Meig’s syndrome with elevated CA-125 and mimic ovarian malignancies. Similar diagnostic dilemma has been reported by Gadre in a case of a broad ligament fibroid in an elderly postmenopausal lady [6]. As our patient was status post-hysterectomy with adnexal mass, our initial diagnosis was ovarian tumor, which subsequently was converted into a more benign diagnosis of broad ligament fibroid using higher imaging modalities like CT scan , and a simple removal of the fibroid sufficed. Diagnosis of extrauterine leiomyoma is by histo-pathological examination using standard histology and immuno-histochemistry using anti-desmin and anti–smooth muscleactin antibodies.
www.jcdr.net
The clinical symptoms and imaging features of extra-uterine fibroids depend on the location of the lesion and on its growth pattern. The differential diagnosis of an extra-uterine fibroid should be considered in cases of pelvic masses even in the post-hysterectomy state.
References
[1] Fasih N, Shanbhogue AKP, Macdonald DB, Fraser-Hill MA, Papadatos D, Kielar AZ, et al. Leiomyomas beyond the uterus: unusual locations, rare manifestations. Radiographics. 2008;28:1931-48. [2] Monaghan JM, Lopes T, Naik R. Total hysterectomy for cervical and broad ligament fibroids. In: Monaghan JM, Lopes T, Naik R, 10th edn. Bonney’s Gynaecological Surgery. MA: Blackwell Publishing. 2004: 74-86. [3] Sinha R, Sundaram M, Mahajan C, Sambhus A. Multiple leiomyomas after laparoscopic hysterectomy: report of two cases. J Minim Invasive Gynecol. 2007;14:123-7. [4] Rajanna DK, Pandey V, Janardhan S, Datti SN. Broad ligament fibroid mimicking as ovarian tumor on ultrasonography and computed tomography scan. J Clin Imaging Sci. 2013;3:8. [5] Bansal P, Garg D. Case of Massive Broad Ligament Leiomyoma Imitating an Ovarian Tumour. J Clin Diagn Res. 2014;8:136-7. [6] Gadre S. Broad ligament myoma at 75 causing clinical, ultrasonic and intraoperative diagnostic dilemma. Int J Reprod Contracept Obstet Gynecol. 2014;3:279-81.
PARTICULARS OF CONTRIBUTORS: 1. Associate Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 2. Professor and Head, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 3. Associate Professor Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 4. Assistant Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 5. Post-graduate Resident, Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Pallavee P, Qr. No. D(II) 18, JIPMER Campus, Dhanvantari Nagar, Puducherry – 605006, India. Phone: +919489693270, E-mail: [email protected] Financial OR OTHER COMPETING INTERESTS: None.
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Date of Submission: Dec 05, 2013 Date of Peer Review: Mar 29, 2014 Date of Acceptance: May 03, 2014 Date of Publishing: Jul 20, 2014
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): OD01-OD02
Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
DOI: 10.7860/JCDR/2014/8195.4532
Case Report
Fibroid after Hysterectomy: A Diagnostic Dilemma
Pallavee P1, Seetesh Ghose2, Sunita Samal3, Jasmina Begum4, Mariyam Zabeen5
ABSTRACT Broad ligament fibroids are rare and often pose clinical diagnostic difficulties. We report a case of broad ligament fibroid in a woman after hysterectomy. The lady presented to us with continuous lower abdominal pain of seven months duration. Bimanual examination revealed a firm mass on the right side of the vaginal vault. Transvaginal sonogram and computed tomography scan was suggestive of possible parasitic leiomyoma or a broad ligament fibroid. Exploratory laparotomy and removal of the mass, followed by histological examination confirmed leiomyoma. Extra-uterine fibroid should be considered in the differential diagnosis of pelvic masses even in the post-hysterectomy state.
Keywords: Broad ligament fibroid, Extra-uterine leiomyoma, Post-hysterectomy
CASE REPORT A 48-year-old woman, para 1, living 1, presented to our outpatient department with continuous lower abdominal pain of seven months duration. She had undergone total abdominal hysterectomy six years back for multiple fibroids in the uterus. Speculum examination showed a healthy looking vagina. Bimanual examination revealed a firm mass measuring 4 x 4 cm on the right side of the vaginal vault. Transvaginal sonogram revealed a solid, hypoechoic, wellcircumscribed right adnexal mass of size 3.5 x 4.6 cm, and both ovaries could not be imaged separately [Table/Fig-1]. Computed tomography (CT) scan was done which showed post hysterectomy status with bilateral thin walled cystic lesions possibly ovarian cysts, right side measuring 4.6 x 5.3 x 5 cm and left side 1.8 x 2.5 x 2.3 cm [Table/Fig-2]. On the right side adjacent to the vaginal stump, a welldefined lesion isodense to the muscle (40 HU) was seen measuring 4.6 x 4 x 4.7 cm, with intense contrast enhancement (137 HU). Fat plane between the lesion and bladder, rectum, vagina and pelvic wall was maintained. There was no evidence of calcification or necrosis within the lesion and no retroperitoneal lymphadenopathy. The impression was that of possible parasitic leiomyoma or a broad ligament fibroid. Cancer antigen (CA-125) was reported normal with a value of 7.2 U/ml.
Patient was posted for exploratory laparotomy. Intra-operative findings revealed a pelvic mass on the right side of vaginal stump measuring 4 x 4 cm with both ovaries appearing normal. The mass was enucleated by opening the layers of broad ligament which were later resutured. Cut section of the mass revealed a whorled pattern and histopathological report was consistent with diagnosis of leiomyoma. Post-operative period was uneventful and patient was discharged on the sixth day.
Discussion Extra-uterine leiomyomas are rare [1], and post-hysterectomy broad ligament fibroids are rarer still. Broad ligament fibroids are of two types [2]. The first variety is the true broad ligament myoma, which originates from the muscle fibres normally found in the mesometrium (in the round ligament, ovario-uterine ligament, and the connective tissue around the uterine and ovarian vessels). The second variety is termed as ‘false’ broad ligament myoma as the tumour arises from the lateral wall of the uterine corpus or of the cervix, and bulges outward between the layers of the broad ligament. Sinha et al., reported two cases of multiple fibroids in the pelvis after laparoscopic hysterectomy [3]. Our case was that of a true broad ligament fibroid following total abdominal hysterectomy. Broad
[Table/Fig-1]: Transvaginal sonogram showing solid, hypoechoic, well-circumscribed right adnexal mass of size 3.5 x 4.6 cm [Table/Fig-2]: Axial contrast-enhanced computed tomographic scan section at the level of urinary bladder (white arrowhead) showing post-hysterectomy status, with intensely enhancing well-defined lesion (black arrow) on the right side with fat plane between the lesion and surrounding structures maintained
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): OD01-OD02
1
Pallavee P et al., Fibroid after Hysterectomy
ligament fibroid can be difficult to differentiate from ovarian tumours [4]. Bansal et al., reported a case of a massive broad ligament fibroid which mimicked an ovarian tumour because of its myxoid and cystic degenerations [5]. Our patient had hysterectomy several years back and the ovaries could not be imaged during transvaginal ultrasound examination leading to a doubt regarding origin of the pelvic mass. Though CA-125, done to differentiate from ovarian malignancy was normal, broad ligament fibroid can also cause pseudo-Meig’s syndrome with elevated CA-125 and mimic ovarian malignancies. Similar diagnostic dilemma has been reported by Gadre in a case of a broad ligament fibroid in an elderly postmenopausal lady [6]. As our patient was status post-hysterectomy with adnexal mass, our initial diagnosis was ovarian tumor, which subsequently was converted into a more benign diagnosis of broad ligament fibroid using higher imaging modalities like CT scan , and a simple removal of the fibroid sufficed. Diagnosis of extrauterine leiomyoma is by histo-pathological examination using standard histology and immuno-histochemistry using anti-desmin and anti–smooth muscleactin antibodies.
www.jcdr.net
The clinical symptoms and imaging features of extra-uterine fibroids depend on the location of the lesion and on its growth pattern. The differential diagnosis of an extra-uterine fibroid should be considered in cases of pelvic masses even in the post-hysterectomy state.
References
[1] Fasih N, Shanbhogue AKP, Macdonald DB, Fraser-Hill MA, Papadatos D, Kielar AZ, et al. Leiomyomas beyond the uterus: unusual locations, rare manifestations. Radiographics. 2008;28:1931-48. [2] Monaghan JM, Lopes T, Naik R. Total hysterectomy for cervical and broad ligament fibroids. In: Monaghan JM, Lopes T, Naik R, 10th edn. Bonney’s Gynaecological Surgery. MA: Blackwell Publishing. 2004: 74-86. [3] Sinha R, Sundaram M, Mahajan C, Sambhus A. Multiple leiomyomas after laparoscopic hysterectomy: report of two cases. J Minim Invasive Gynecol. 2007;14:123-7. [4] Rajanna DK, Pandey V, Janardhan S, Datti SN. Broad ligament fibroid mimicking as ovarian tumor on ultrasonography and computed tomography scan. J Clin Imaging Sci. 2013;3:8. [5] Bansal P, Garg D. Case of Massive Broad Ligament Leiomyoma Imitating an Ovarian Tumour. J Clin Diagn Res. 2014;8:136-7. [6] Gadre S. Broad ligament myoma at 75 causing clinical, ultrasonic and intraoperative diagnostic dilemma. Int J Reprod Contracept Obstet Gynecol. 2014;3:279-81.
PARTICULARS OF CONTRIBUTORS: 1. Associate Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 2. Professor and Head, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 3. Associate Professor Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 4. Assistant Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 5. Post-graduate Resident, Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India. NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Pallavee P, Qr. No. D(II) 18, JIPMER Campus, Dhanvantari Nagar, Puducherry – 605006, India. Phone: +919489693270, E-mail: [email protected] Financial OR OTHER COMPETING INTERESTS: None.
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Date of Submission: Dec 05, 2013 Date of Peer Review: Mar 29, 2014 Date of Acceptance: May 03, 2014 Date of Publishing: Jul 20, 2014
Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): OD01-OD02
Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
