Accepted Manuscript Uterine Fibroids with Diffuse Abdominal Leiomyomatosis Luis E. Gallardo, MD Raul R. Arredondo, MD Juan J. Gallardo, MD

PII:

S1553-4650(14)00142-3

DOI:

10.1016/j.jmig.2014.02.004

Reference:

JMIG 2252

To appear in:

The Journal of Minimally Invasive Gynecology

Received Date: 6 November 2013 Revised Date:

5 February 2014

Accepted Date: 6 February 2014

Please cite this article as: Gallardo LE, Arredondo RR, Gallardo JJ, Uterine Fibroids with Diffuse Abdominal Leiomyomatosis, The Journal of Minimally Invasive Gynecology (2014), doi: 10.1016/ j.jmig.2014.02.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Gallardo et al. 1 Images in Gynecologic Surgery Uterine Fibroids with Diffuse Abdominal Leiomyomatosis

Luis E. Gallardo, MD* Raul R. Arredondo, MD and Juan J. Gallardo, MD

RI PT

From the Department of Obstetrics and Gynecology, Endometriosis and laparoscopic surgery clinic at Angeles Hospital (all authors) Mexico City

The authors have no commercial, proprietary, or financial interest in the products

SC

or companies described in this article.

Corresponding author: Luis Ernesto Gallardo Valencia, MD, Endometriosis and

M AN U

laparoscopic surgery clinic, Angeles del Pedregal Hospital. Santa Teresa road 1055 Heroes de Padierna C.P.10700 México D.F. E-mail: [email protected] Phone: +011-52-5551351975

TE D

+011-52-5551351975

Précis

We present some images in gynecologic surgery of a 40-year-old woman with Leiomyomatosis peritonealis disseminata (LPD) spread entirely on the omentum

AC C

EP

and mesentery.

ACCEPTED MANUSCRIPT Gallardo et al. 2

Leiomyomatosis

peritonealis

disseminata

(LPD)

or

diffuse

abdominal

leiomyomatosis is a rare benign condition of uncertain etiology with a genetic

RI PT

component, which occurs in reproductive age between the third and fourth decades, especially during pregnancy or in women with oral contraception.1,2 It is characterized by multiple peritoneal and subperitoneal smooth muscle tumors on the peritoneal surfaces; omentum and mesentery. These characteristics strongly

SC

suggest that hormonal stimulation initiates the multifocal smooth-muscle-cell proliferation that results in LPD. A current hypothesis is that DL could result from

M AN U

disruption of the COL4A6 gene or of an as yet unidentified gene lying in the second intron of COL4A6 and behaving as a tumor or proliferation suppressor gene. The same genetic mechanism seems to be operative in isolated oesophageal leiomyoma.3 Wilson and Pale first described in 1952.4 Today there are just over 100 cases reported in the literature. 5,6,7

A 40-year-old nulliparous woman attended our clinic with abnormal vaginal

TE D

bleeding and dysmenorrhea. The patient denied any family history of cancer, any previous abdominal or pelvic surgery, or contraceptive use. Normal physical examination. CA 125 concentration of 98 IU/ ml (normal range is less than 35 IU/mL). During the vaginal ultrasound examination uterus with intramural uterine

EP

myomas was detected. The patient was taken to the operating room for diagnostic laparoscopy and management of the fibroids. The laparoscopy revealed the uterus had multiple myomas in the anterior wall (Fig. 1) and we observed the presence of

AC C

multiple nodules between 30 and 60 mm in greatest dimension consistent with possible LPD spread entirely on the omentum and mesentery, these tumors do compromise the intestine. (Fig. 2).

ACCEPTED MANUSCRIPT Gallardo et al. 3 During the laparoscopy we performed a myomectomy and extracted fibroids through the umbilicus with a 12mm electronic morcellator, the mass coming from the omentum was taken by the colorectal surgeon applying mild traction in to the myoma using a tenaculum, then atraumatic grasper and bipolar tweezers were

RI PT

used to dissect the mesentery. Specimen was sent to pathology for intraoperative analysis. Reported findings were benign leiomyoma. Differential diagnoses for multiple peritoneal nodules include peritoneal carcinomatosis8,9, peritoneal leiomyosarcomatosis, mesothelioma, tuberculosis and lymphoma.10,11

SC

The correct diagnosis relies on pathology and usually run a benign course with spontaneous regression following withdrawal of ovarian hormone first by the

M AN U

administration of GnRH analogs, aromatase inhibitor or finally with bilateral oophorectomy particularly in those cases that not response to hormonal blockage. Some authors propose hysterectomy with bilateral salpingo-oophorectomy and removal of all tumors in order to eliminate the hormonal influence. In our case therapeutic approach might contemplate uterine myomectomy. The authors believe that the LPD treatment should be conservative so radical excisions are

TE D

unnecessary. The most common condition of LPD has been myomas involving the uterus; uterosacral ligaments and pelvic sidewalls but a few associated cases involving the intestines have been reported.12 In summary we present a rare case

AC C

EP

of LPD in omentum and mesentery.

Fig.1 Laparoscopy demonstrated nodular omentum and mesentery tumors, consistent with peritoneal myomas

ACCEPTED MANUSCRIPT

M AN U

SC

RI PT

Gallardo et al. 4

Fig. 2 Laparoscopy demonstrated nodular omentum and mesentery big tumor,

AC C

EP

TE D

consistent with peritoneal myoma of 6 cm

ACCEPTED MANUSCRIPT Gallardo et al. 5 References

1. Robbou SJ, Bentrey RC, Butnor K, et al. Pathology and pathophisiology of

RI PT

uterine smooth muscle tumors. Environ Health Perspect. 108 (5): 779, 200.

2. Al-Talib A, Tulandi T. Pathophysiology and possible iatrogenic cause of leiomyomatosis peritonealis disseminata. Gynecol Obstet Invest. 2010; 69:

SC

239-44.

3. Garcia-Torres R, Cruz D, Orozco L, Heidet L, Gubler MC. Alport syndrome

M AN U

and diffuse leiomyomatosis. Clinical aspects, pathology, molecular biology and extracellular matrix studies. A synthesis. Nephrologie. 2000; 21 (1): 912.

4. Wilson JL, Peale AR. Multiple peritoneal leiomyomas associated with a

TE D

granulosa-cell tumor of the ovary. Am J Obstet Gynecol. 1952; 64: 204-8.

5. Bekkers RL, Willemsen WN, Schijf CP, Massuger LF, Bulten J, Merkus JM. Leiomiomatosis peritonealis disseminata: does malignant transformation

EP

occur? A literatura review. Gynecol Oncol 1999;75(1): 158-63

6. Baez-Giangreco A, Afzal M, El Sharkawy T, Alamri A, Al Harbi O, Haddad R. Leiomyomatosis peritonealis disseminata. Ann Saudi Med 2000; 20(5-

AC C

6):440-2

7. Halama N,

Grauling-Halama SA, Daboul

I. Familial

clustering of

leiomyomatosis peritonealis disseminata: an unknown genetic syndrome? BMC Gastroenterol 2005;5:33

ACCEPTED MANUSCRIPT Gallardo et al. 6 8. Abulafia 0, Angel C, Sherer DM, et al. Computed tomography of leiomyomatosis peritonealis disseminata with malignant transformation. Am J Obstet Gynecol. 1993; 169: 52-54.

RI PT

9. Florian Mueller, Kerstin Kuehn, Hermann Neudeck, et al. Disseminated Peritoneal Leiomyomatosis With Endometriosis. Mueller, Florian; Kuehn, Kerstin; Neudeck, Hermann; Siedentopf, Nina; Ulrich, Uwe. The Journal of

SC

Minimally Invasive Gynecology. 2012; 19 (3): 380-382.

10. Hamrick-Tumer JE, Chiechi MV, Abbitt PL, et al. Neoplastic and

M AN U

inflammatory processes of the peritoneum, omentum and mesentery. Diagnosis Radiographics. 1992; 12 (6): 1051-68.

11. Dimitris Tourlakis, Benedikt Tas, Bruno Van Herendael. Disseminated peritoneal leiomyomatosis. Gynecological Surgery, September 2010; 7 (3):

TE D

241-243.

12. Fredericks S, Russel P, Cooper M, et al. Smooth muscle in the female pelvic peritoneum: a clinicopathological analysis of 31 women. Pathology.

AC C

EP

2005: 37 (1): 14-21.

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

Uterine myomas with diffuse abdominal leiomyomatosis.

Uterine myomas with diffuse abdominal leiomyomatosis. - PDF Download Free
233KB Sizes 2 Downloads 0 Views