207

Int J Gynecol Obstet. 1992. 37: 207-210 International Federation of Gynecology

and Obstetrics

Giant broad ligament leiomyoma V. Gowri, Departments Pondicherry

R. Sudheendra,

of Obstetrics

A. Oumachigui

and Gynecology

and “Pathology.

Jawaharlal

of Postgraduate

Medical

Education

and Research.

1991)

Abstract Giant fibroids are known to arise from the uterus, but occasionally from the broad ligament also. A case of giant broad ligament fibroid is reported for its rarity, and the diagnostic difJiculties it posed are discussed.

Keywords: Giant fibroid.

fibroid;

Broad

ligament

Introduction Most fibroids are situated in the body of the uterus. In l-2% of cases tumors arise from the cervix. Myomas in the broad ligament are found in association with similar uterine tumors but they are generally confined to the pelvis. This particular case is unique in that the tumor had grown out of the pelvis to occupy the entire peritoneal cavity. Hence, a clinical diagnosis of a massive ovarian tumor was made. At laparotomy it was thought to be ligament a broad but the cyst, histopathological study proved it to be a leiomyoma. Case report Mrs. M, a 35-year-old, nulliparous lady, married for 2 years, was admitted with a history of abdominal distension of 3 years

1992 International

Federation and Published in Ireland

duration, and nagging abdominal pain of 1 year duration. The mass had been progressively increasing in size. There was no bowel or bladder dysfunction. She had no history of fever or sudden increase in the size of the mass. She experienced difficulty in walking and had to use a stick for support. Her menstruation stopped 1 year ago. There was no evidence of any surgical or medical disorder in the past. The patient delayed seeking medical attention. On examination the patient was malnourished, pale, measured 140 cm and weighed 65 kg. There was no icterus or pedal edema. No significant lymphadenopathy was present. Her pulse rate was 90/min, blood pressure 130/90 mmHg. Her cardiovascular system and respiratory system were normal. Examination of the abdomen revealed a large cystic tumor extending from the xiphisternum to the symphysiopubis and it measured 88 x 72 cm. Abdominal girth was 134 cm at the level of the umbilicus. Prominent veins were present over the abdominal wall (Fig. 1). Pelvic examination revealed a healthy cervix and a small uterus. On rectal examination there were no nodules in the pouch of Douglas. In view of the cachexia, the size and the consistency of the tumor, a provisional diagnosis of giant ovarian cyst was made. A complete blood count was performed: hemoglobin 6.6 gm%, total leucocyte count 9400/mm3, neutrophils 58%, eosinophils 17%, Case Report

0020-7292/92/$05.00

Printed

Institute

605 006 (India)

(Received March 22nd. 1991) (Revised and accepted July 30th,

0

and V. Sankarana

of Gynecology

and Obstetrics

208

Gowri et ul.

At laparotomy, there was a massive cystic tumor arising from the right broad ligament; it was delivered with an intact capsule. The right tube was stretched over the mass. The right ovary was atrophic; the left ovary and tube were normal and the uterus was atrophic. The tumor measured 66 x 46 x 24.5 cm and weighed 32 kg (Fig. 2). Moderate degree of hydroureters was present bilaterally (Fig. 3). Abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Conservative surgery was impossible because of the enormous size of the mass and anatomical changes. Four units of blood were transfused. Intraoperative and postoperative periods were uneventful. The patient was discharged in good condition with an abdominal corset 15 days later. Discussion

Fig. I. Preoperative

picture

of the patient.

lymphocytes 24% platelets 210 000/mm3. Peripheral smear showed normocytic, normochromic and hypochromic RBCs with mild anisocytosis and few burr cells. Chest X-ray was normal. ECG showed nonspecific T wave inversion due to positional shift of the T wave axis. Renal function tests and liver function tests were within normal limits. Pap smear from the cervix was negative for malignant cells. Intravenous urogram revealed normal kidneys, bilaterally dilated ureters and compression of the bladder by the tumor mass. She was given a preoperative blood transfusion and prepared for laparotomy keeping four units of matched blood ready. Int J Gynecol Obstet 37

Uterine fibroids weighing 8.5 kg and 7.2 kg have been reported in the literature because of their mammoth size [ 1,2]. Although myomas are the commonest tumors in the broad ligament [3], they do not grow to a massive size. Whether primary or secondary, the broad ligament myoma remains confined to the pelvis. Because of the anatomical situation they are likely to produce displacement and hydroureter on the side of the tumor. There is likely to be markedly increased vascularity. The clinical presentation of this case was characteristically suggestive of a massive ovarian tumor. This can be explained by the fact that the tumor had grown out of the pelvis, occupying the entire peritoneal cavity and also because the tumor had undergone cystic degeneration. The calibre of the ureters at laparotomy was almost 2 cm; care was taken to keep as close to the tumor as possible and vessels were ligated to minimize the blood loss. The tumor was not adherent to the pelvic vessels as anticipated. Hypotension was expected intra-operatively, but this patient did not have any anesthetic problems. We reviewed the world literature for the past two decades and found that a fibroid

Fig. 2. Macroscopic

Fig. 3. Histopathology

picture

of the specimen.

of the specimen.

210

Gowri et al.

weighing 32 kg has not been reported either from the uterus or broad ligament. The case is being reported for the size, rarity and the diagnostic and surgical problems it posed.

References I

Bhattacharjee AK, Das RK: Mammoth fibromyomas uterus. J Obstet Gynecol India 40: 130, 1990.

2

Benjamin G, Louis B, Krishnan N. Rao R, Raghavan S. Prasad B: Giant fibroid uterus complicating pregnancy. Acta Obstet Gynecol Stand 60: 437, 1984. Shaw’s Text Book of Gynecology, 9th edn, p 793, B.I.

Acknowledgment 3

We are grateful to Dr. P. Rajaram, Head of the Department of Obstetrics and Gynaecology and Dean and to Dr. S. Chandrasekhar, Director, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, for permitting us to publish this case report.

Int J Gynerol Ohstrl

37

Publications

Pvt Ltd., New Delhi, India,

Address for reprints: V. Gowri Department of Obstetrics and Gynaecology JIMPER. Pondicherry 605 006 India

1985.

of the

Giant broad ligament leiomyoma.

Giant fibroids are known to arise from the uterus, but occasionally from the broad ligament also. A case of giant broad ligament fibroid is reported f...
2MB Sizes 0 Downloads 0 Views