Natural history of leiomyomas beyond the uterus

Abstract

Rationale: Most leiomyomas are located in the uterus. Leiomyomas are rarely found outside the uterus and classified as leiomyoma beyond the uterus (LBU). This group consists of disseminated peritoneal leiomyomatosis, benign metastasizing leiomyoma, intravenous leiomyomatosis, parasite leiomyoma located in the broad ligament and retroperitoneal space. The descriptions of the patients who suffer from these types of leiomyomas are presented mainly in case reports.

Patient concerns: A 34-year-old multiparous woman was operated on multiple recurrent uterine leiomyoma in parametrium. At one time, 32 leiomyomas were removed. Thirteen months following it, in next laparotomy, 132 leiomyomas were excised. Histologically, both were intravenous leiomyomas (IVLs).

Diagnosis and interventions: In follow-up, computed tomography (CT) and magnetic resonance imaging scans were performed to look for next recurrent leiomyoma. Accidentally, the mass was found in inferior vena cava which was diagnosed as intravenous vena cava leiomyoma. The mass was removed and the final diagnosis of intravenous myoma was confirmed in histopathology.

Outcomes: CT scan performed 3 months after the surgery for leiomyoma in vena cava revealed no pathology. Next 10 months' follow-up was uneventful.

Lessons: The recurrent multiple uterine leiomyoma precede LBU. The uterine leiomyoma spreads intravenously route to parametria as parasite leiomyoma, then to vena cava. It has to be taken into account in follow-up.

Figure 1

Hematoxylin and Eosin, objective ×10. A typical microscopic view of a benign leiomyoma, with sparse mitosis (2 mitosis/10 HPF), with no necrosis and without marked atypia.

Figure 2

(A) Pelvic axial scan ( B = bladder, C = leiomyoma conglomerate, R = rectum U = corpus uteri, VT = dilated venal plexes wider,). (B) Pelvic and lower abdominal frontal scan (B = bladder, C = leiomyoma conglomerate, U = corpus uteri, VT = dilated venal plexes).

Figure 3

Hematoxylin and Eosin, objective ×5. This very small in size leiomyoma is within the vascular lumen (the arrows show the thin wall of this vascular space)—the phenomenon called intravenous leiomyomatosis.

Figure 4

(A) Sagittal lower abdominal and pelvic scan (B = bladder, C = leiomyoma conglomerate sized 6, 5 × 8, 5, OS = os sacrum, R = rectum, U = corpus uteri). Fig. 4B. Axial pelvic scan (B = bladder, C = leiomyoma conglomerate, U = corpus uteri, VT = dilated venal plexes).

Figure 5

Postoperative view of removed leiomyomas which constituted the conglomerate on the Figure (A and B).

Figure 6

A Anterior lower abdomen and pelvic scan (IVL = intravenous leiomyomatosis inside the vena cava posterior). (B) NMR frontal scan.

Figure 7

Scheme illustrated location of intracaval leiomyoma and basic steps during its removal. 1,2,3 = subsequent internal vena cava incisions, EIN = external iliac vein, IIV = interior iliac vein, IV = common iliac veins, IVC = inferior vena cava , IVL = intravenous leiomyoma, L = temporary ligature, RV = renal vein.

Figure 8

(A) IVL evacuation—intraoperative view: (1) cephalad leiomyoma section, (2) dissected vena cava inferior, (3) the ureter on the right, (4) vessel clump closing the lumen of the vena cava inferior. (B) Status post IVL evacuation—intraoperative view: (1) the vena cava inferior sutured after IVL evacuation, (2) ureter on the right. IVL = intravenous leiomyoma.

Figure 9

Computed tomography frontal scan of the abdomen and pelvis 3 months after the surgery of IVL evacuation in vena cava. arrow = staplers on IVL, IV = left iliac vein, RV = renal vein, VC = vena cava.