Leiomyomatosis peritonealis disseminata associated with endometriosis: A case report and review of the literature

Abstract

Leiomyomatosis peritonealis disseminata (LPD) is a specific type of leiomyomatosis with an unclear pathogenesis that is rarely diagnosed by clinical evaluation. To date, <200 cases have been reported. The majority of the patients have a medical history of laparoscopic myomectomy for uterine fibroids. The use of laparoscopic power morcellation may be a contributor to the development of LPD, therefore, the specific surgical approach used in laparoscopic myomectomy should be carefully considered, and protective measures should be taken to prevent myoma fragments spreading if laparoscopic power morcellation is used. The present study reviewed and analyzed the medical history, diagnostic process and treatment strategy of a case of LPD to improve our understanding of the disease. In this report, the case of a 34 year-old female who underwent laparoscopic myomectomy to remove a uterine fibroid is presented. During the surgery, a myoma was resected using morcellators. Three years after surgery, exploratory laparotomy was performed due to uterine fibroid recurrence. During surgery, myoma was identified at the uterine bladder peritoneal reflection, where several unequally sized leiomyoma tubercles were identified on the uterine surface. Subsequently, myomectomy was performed. Postoperative pathology diagnosed leiomyoma. Two years later, gynecological ultrasound revealed a mass in the abdomen. Exploratory laparotomy was subsequently performed. During surgery, compact myoma tubercle-like cysts were identified on the surface of the intestine and mesentery, and an endometriotic cyst was identified on the left ovary. As the myomas were too compact to remove completely, the majority of leiomyoma on the intestine and mesentery was resected. The endometriotic cyst on the left ovary was also resected. Considering the patient's medical history, observations during surgery and pathological results, the final diagnosis was LPD. Following surgery, the patient was treated with the gonadotropin-releasing hormone agonist, triptorelin acetate (3.5 mg, once every four weeks), for three months and followed-up every six months. In October 2014, a gynecological sonography examination revealed no abnormalities and at the time of writing, the patient remains alive and well.

Keywords: hysteromyomectomy; laparoscope; laparoscopic power morcellators; leiomyomatosis; peritonealis disseminata; uterine fibroid.

Figure 1

(A) Concentrated myoma tubercle-like cysts on the surface of the intestine and mesentery. (B) Following removal of the myoma tubercle-like cysts, small myoma tubercles remained, as they were too small to be removed.

Figure 2

Post-operative pathological analysis to determine a diagnosis of leiomyomatosis peritonealis disseminata. Hematoxylin and eosin staining at (A) ×40 magnification and (B) ×100 magnification. Positive immunohistochemical staining for (C) Ki67 (positive rate, 1%), (D) h-caldesmon, (E) α-smooth muscle antibody, (F) desmin, (G) estrogen receptor and (H) progesterone receptor (magnification, ×100).