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Large (7.2 kg) Subserosal Fibroid with Monkenberg’s Calcification in a Postmenopausal Woman

Abstract
We Report an unusual case of very large uterine subserosal leiomyoma mimicking ovarian mass on diagnostic modalities. A 70 year old postmenopausal woman presented with gradual distension of abdomen and diffuse pain in abdomen since 2 months. Ultrasonography was suggestive of large extrauterine mass of 20 cm × 15 cm × 18 cm displacing uterus anteriorly not separately visualised from either ovaries neoplastic origin likely ovary. While on Computed
tomography scan was suggestive of 21 cm × 16cm × 19 cm mass of benign etiology possibility of subserosal fibroid with Histopathology correlation. Exploratory laparotomy with removal of huge subserosal fibroid with total abdominal hysterectomy with bilateral
Salpingoophrectomy is the surgery done in our case. The majority of uterine leiomyomas are confidently diagnosed sonographically. However, large, degenerated tumours like in our case may be a diagnostic challenge and postmenopausal uterine leiomyoma with degeneration and Mockenberg’s calcification in a postmenopausal
woman is rare and Computed Tomgraphy may help further characterize large pelvic masses and determine their organ of origin. As in our case its diagnosed in computized Tomography

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घे भरारीः 'ती'ची भरारी:ABP MAJHA 'ती'ची भरारी:ABP MAJHA

Large (7.2 kg) Subserosal Fibroid with Monkenberg’s Calcification in a Postmenopausal Woman: Extremely Rare Case with Review of Literature

Rajshree Dayanand Katke* Obstertrics and Gynaecology Department, Cama Albless Hospital, Mumbai, India


*Corresponding author: Rajshree Dayanand Katke, Associate Professor, Obstertrics and Gynaecology Department, Cama Albless Hospital, Mumbai, India, Tel: 91-022-22620390,


E-mail: drrajshrikatke@gmail.com


Received date: 15th June, 2016;

Accepted date: 29th July, 2016;

Published date: 1st August, 2016


Citation: Katke RD. Large (7.2 kg) Subserosal Fibroid with Monkenberg’s Calcification in a Postmenopausal Woman: Extremely Rare Case with Review of Literature, Gynecol Obstet Case Rep. 2016, 2:2.


Abstract

We Report an unusual case of very large uterine subserosal leiomyoma mimicking ovarian mass on diagnostic modalities. A 70 year old postmenopausal woman presented with gradual distension of abdomen and diffuse pain in abdomen since 2 months.

Ultrasonography was suggestive of large extrauterine mass of 20 cm × 15 cm × 18 cm displacing uterus anteriorly not separately visualised from either ovaries neoplastic origin likely ovary. While on Computed tomography scan was suggestive of 21 cm × 16cm × 19 cm mass of benign etiology possibility of subserosal fibroid with Histopathology correlation. Exploratory laparotomy with removal of huge subserosal fibroid with total abdominal hysterectomy with bilateral Salpingoophrectomy is the surgery done in our case. The majority of uterine leiomyomas are confidently diagnosed sonographically. However, large, degenerated tumours like in our case may be a diagnostic challenge and postmenopausal uterine leiomyoma with degeneration and Mockenberg’s calcification in a postmenopausal woman is rare and Computed Tomgraphy may help further characterize large pelvic masses and determine their organ of origin. As in our case its diagnosed in computized Tomography.

Keywords: Computed tomography; Ovarian mass; Uterine subserosal leiomyoma; Ultrasonography; Subserosal fibrioid Salpingoophrectomy; Hysterectomy.


Introduction

Leiomyomas or fibroids arise from overgrowth of the smooth muscle and connective tissue of the uterus, and most commonly involve the uterine corpus, although they may also occur in the cervix in a minority of instances. Typical fibroids are easily recognized on imaging. However, an atypical

presentation caused by degenerative changes can cause diagnostic confusion as in our case mimicking ovarian tumour [1,2]. The use of color Doppler ultrasonography (CDUS) to visualize interface vessels between the uterus and a juxtauterine mass is useful in the differential diagnosis. Also, magnetic resonance imaging (MRI) yielding multiplanar views can reveal the peduncle, or confirm the presence of a normal uninvolved ovary [3]. In this case report, we present multimodal abdominopelvic radiologic imaging findings of a patient with a huge giant subserosal uterine leiomyoma, in conjunction with histopathological findings.


Case Report

A 70 Year old postmenopausal woman presented to our hospital with a complaints of gradual distension of abdomen since 2 months and diffuse pain in abdomen since 3-4 months. All routine laboratory test values were within normal limits. On general examination patient was vitally stable. Per abdominal examination revealed large abdominal mass corresponding to 28 to 30 weeks Gestational size of uterus arising from pelvis, smooth surface, firm to hard in consistency, mobility slightly restricted. Its lower border could not be felt. Per speculum examination revealed cervical os was taken up. On per vaginal examination a mass of 28-30 weeks gestational size was palpable which was firm to hard in consistency, uterus could not be felt separately from the mass, bilateral fornices were free and there was no tenderness. Abdominal ultrasound examination showed a large heterogenous hypoechoic mass of size 20 cm × 15 cm × 18 cm in the pelvico abdominal region displacing the uterus anteriorly and is not separately visualised from either ovary query neoplastic origin likely ovary. Contrastenhanced computed tomography of the abdomen and pelvis demonstrated a large well defined lobulated soft tissue attenuating minimally and heterogeneously enhancing solid mass lesion of 21 cm × 16 cm × 19 cm with multiple foci of calcification seen within the pelvis. Computed tomography findings suggestive of benign etiology query subserosal fibroid. Laboratory tests including tumour markers CA-125 and CEA were within normal limits. Patient underwent exploratory laparotomy with Total Abdominal Hysterectomy with bilateral Salpingoophrectomy with removal of huge subserosal Fibroid. Laparotomy revealed a Huge mass of 28 cm × 18 cm × 20 cm arising from anterior serosal part of uterus and the part of peritoneum near the urinary bladder, the mass was highly vascular and adherent to bladder and large bowel (Figure 1).

A succenturiate mass of 15 cm × 10 cm × 10 cm was seen arising from the previous mass. Both mass were soft to firm in consistency. Bilateral ovaries were atrophic and the uterus and cervix was of normal size. Mass was firmly adherent to bowel and urinary bladder and had to be separated by sharp dissection. Abdominal hysterectomy with bilateral salpingoopherectomy was performed. On gross inspection the removed bilobed subserosal mass weighs 7.2 kg with atrophic uterus was seen (Figure 2). On histopathological examination revealed uterus was atrophic and myometrim showed thick walled blood vessel with Monckeberg’s calcification with subserosal leiomyomas. Sections through the mass revealved a tumor arranged in interlacing fascicles and bundles with ient areas of calcifications and degeneration. No significant atypia was evident (Figure 3). Final impression suggestive of subserosal fibroid. The Patient’s post-operative course was uneventful.

Discussion

Leiomyomas arise from overgrowth of the smooth muscle and connective tissue of the uterus. Around the menopause, leiomyomas decrease in size because their growth is thought to be estrogen dependent, but leiomyomas may still be newly diagnosed in postmenopausal women. A calcified

pedunculated leiomyoma in a postmenopausal woman is extremely rare; in such cases it is more difficult to predict the clinical symptoms and physical findings. In our case there was discrepancy between ultrasonography and computed tomography findings. Typical fibroids are easily recognized on imaging, but atypical presentation caused by degenerative changes can cause diagnostic confusion in postmenopausal women [2]. As leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degeneration: hyaline, myxomatous, calcific, cystic or red degeneration. As in our case it showed huge fibroid with calcific degeneration. In general, hyaline degeneration is the most common (63%) form of degeneration, while the others occur less frequently, such as myxomatous changes (13%), calcification (8%), mucoid changes (6%), cystic degeneration (4%), red degeneration (3%), and fatty changes (3%) [3]. The finding of a calcified leiomyoma is more common in postmenopausal woman. Over time, the blood supply within the myoma might decrease, and the tissue becomes ischemic. Calcium is deposited in the peripheral portion of the leiomyoma. As the degenerative changes progress, the leiomyoma may become calcified. Pedunculated leiomyomas can have obscure origins and may be mistaken for a lesion of ovarian origin. A sonographic diagnosis of a pedunculated, subserosal leiomyoma can be made if a vascular pedicle is demonstrated. On Ultrasonography fibroids appear as well-defined, solid masses with a whorled appearance. These are usually of similar echogenicity to the myometrium, but sometimes may be hypoechoic However, these features may not always be detected sonographically [4-6]. Computed tomography is not the primary modality for diagnosing leiomyomas. CT scan is not the investigation of choice for the characterization of pelvic masses. Uterine fibroids are often seen incidentally on CT scans performed for other reasons. The typical finding is a bulky, irregular uterus or a mass in continuity with the uterus. Degenerate fibroids may appear complex and contain areas of fluid attenuation [7,8]. MRI is the most accurate diagnostic test to assess the precise sizes of the fibroids and the position of each fibroid within the uterine wall (submucous, intramural,subserous).


Conclusion

In the literature, calcified pedunculated subserous leiomyoma in a postmenopausal woman is rare. Pedunculated leiomyomas with calcified degeneration should be considered in the differential diagnosis of a solid and calcified adnexal mass. Our case is one of the rarest presentation of huge subserosal fibroid with calcific degeneration which was mimicking an ovarian mass in postmenopausal female.


Acknowledgement:

Dr Nishtha Tripathi (Resident Doctor).


References

1. Katke RD (2014) Torsion of huge cystic teratoma of ovary with multiple fibroids uterus: a case report and review of literature.Int J Reprod Contracept Obstet Gynecol 3(3): 793-795.

2. Ciarmela P, Ciavattini A, Giannubilo SR, Lamanna P, Fiorini R, et al. (2014) Management of leiomyomas in perimenopausal women. Maturitas 78: 168- 173.

3. Hwang JH, Modi GV, Jeong Oh M, Lee NW, Hur JY, et al. (2010) An unusual presentation of a severely calcified parasitic leiomyoma in a postmenopausal woman. JSLS 14: 299-302.

4. Samal SK, Rathod S, Rani R, Anandraj R (2014) An unusual presentation of a severely calcified subserous leiomyoma in a postmenopausal woman: a case report. Int J Reprod Contracept Obstet Gynecol 3: 463-465.

5. Singh K, Prasad D, Pankaj S, Suman S, Kumar A, et al. (2014) Postmenopausal massive subserous calcified fibroid: a case report. J of Evolution of Med and Dent Sci 3: 2255-2257.

6. Caoili EM, Hertzberg BS, Kliewer MA, DeLong D, Bowie JD (2000) Refractory shadowing from pelvic masses on sonography: a useful diagnostic sign for uterine leiomyomas. AJR Am J Roentgenol 174: 97-101.

7. Rajanna DK, Pandey V, Janardhan S, Datti SN (2013) Broad ligament fibroid mimicking as ovarian tumor on ultrasonography and computed tomography scan. J Clin Imaging Sci.

8. Owen C, Armstrong AY (2015) Clinical management of leiomyoma. Obstet Gynecol Clin North Am 42: 67-85.


For Article Link:

https://www.researchgate.net/publication/306253806

Torsion of Huge Cystic Teratoma of Ovary with Multiple Fibroids Uterus: A Case Report and Review of Literature

Rajshree Dayanand Katke
Department of Obstetrics & Gynaecology, Cama & Albless Hospital, Govt. Grant Medical College, Mumbai, Maharashtra, India

Received: 18 June 2014
Accepted: 5 July 2014

DOI: 10.5455/2320-1770.ijrcog20140931

*Correspondence: Dr. Rajshree D. Katke,
  E-mail: drrajshrikatke@gmail.com

For Article Link:
https://www.researchgate.net/publication/266208268

ABSTRACT
Ovarian teratomas and leimyomas are tumours of reproductive age group. But simultaneous occurrence of these tomours is rare. Here we present a rare case of benign cystic teratoma which underwent torsion along with multiple uterine fibroids.
Keywords: Teratoma, Torsion, Leiomyoma.

INTRODUCTION
Leiomyoma is the most common tumor of reproductive age group occurring in 20-40% of women in reproductive age group. Leiomyomas are more common in nulliparous, infertile women. Another pathology common in these women are ovarian cysts. Hence the two pathologies may co-exist in a woman adding up to pose a twin diagnostic dilemma and operative challenge to the gynaecologist. More than 80% of benign cystic teratomas occur during the reproductive years. The risk of torsion with dermoid cysts is approximately 15% and it occurs more frequently in dermoid cysts than with other ovarian tumors, perhaps because of their high fat content allowing them to float in the pelvic and abdominal cavity.

CASE REPORT
A 48 year old multiparous female, married since 26 years, came to us with complaint of pain in abdomen since 4 months, distension of abdomen since 1 month and generalized weakness. Her past menstrual cycles were regular, moderate, painless. She had 2 full term normal deliveries, no significant medical / surgical illness in past.

On examination, her general condition was fair, vitals were stable. On per abdomen examination, mass arising from pelvis, 30 weeks size, firm, tense, minimal tenderness was present with no guarding / rigidity, margins were ill defined. On per speculum white discharge was present. On per vaginal examination uterus was 12-14 weeks size, a similar 28wk size mass was felt which was separate from the uterus. Her Pap smear was suggestive of inflammatory smear with no malignant cells. Her tumour markers were CA 125 - 44.40 (0-30.2 units/ml), CEA - 0.5 (0.21-2.5), alpha feto protein - 2.73 IU, beta HCG - 16.54 mIU.

Her USG pelvic Doppler was suggestive of enlarged Uterus of size 14 cm x 11 cm x 12 cm with multiple welldefined hypoechoic lesions on posterior wall, largest 6.3 cm x 5.3 cm x 4 cm. A large cystic lesion arising from pelvis, upto supraumbilical region of size 20 cm x 18 cm x 12 cm was present with right ovary not seen separately from lesion, the lesion showed central vascularity with low resistance flow RI = 0.5, PI = 1.2

Her CT scan was suggestive of soft tissue density lesion probably arising from ovary of size 14 cm x 10 cm x 7.6 cm with calcification within, mostly dermoid, multiple uterine fibroids were also noted.

DISCUSSION 

A teratoma is an encapsulated tumour with tissue or organ components resembling normal derivatives of more than one germ layer. The tissues of a teratoma, although normal in themselves, may be quite different from surrounding tissues and may be highly disparate; teratomas have been reported to contain hair, teeth, bone and, very rarely, more complex organs or processes such as eyes, hands, feet, or other limbs.1 

Teratomas are usually benign; although they can be malignant rarely in 2% of cases. Benign teratomas are mostly in the form of large fluid filled cysts. A mature teratoma; also called as dermoid cyst is typically benign and found more commonly in women, while an immature teratoma is typically malignant and is more often found in men. Mature cystic teratomas account for 10-20% of all ovarian neoplasms. They tend to be identified in young women, typically around the age of 30 years2 and are also the most common ovarian neoplasm in patients younger than 20 years. They can rarely undergo torsion, rupture or infection.

These cysts are usually asymptomatic and are identified incidentally during either physical or radiological examination of the abdomen. 3 Our patient had presented with pain in abdomen.

The incidence of torsion in a case of ovarian teratoma is approximately 15%. The reason may be the high fat content of teratomas, causing them to float in the peritoneal cavity, promoting twisting or torsion of the adnexa with trunkal movement or physical activity. Torsion produces tissue ischemia leading to pain; as had occurred in our case. Adnexectomy is usually required in such cases.4

CONCLUSION 

Our case was a rare combination of a huge benign mature cystic teratoma with multiple fibroid uterus presenting as a twin pathology. Below the age of 20 years, 60% of the tumours are of germ cell origin but at the age of 48 years such huge teratomas are rare. A huge teratoma with a long pedicle in a state of torsion in the limited peritoneal space was a surprise on the operating table.

Torsion of ovarian cyst usually presents with acute symptoms and requires emergency surgical intervention or can usually be diagnosed on Doppler. In this case however though the patient had such a huge ovarian cyst torsion she had no symptoms suggestive of torsion .Sheer neglect towards personal health and lack of awareness on the part of the patient added to the magnitude of her problems and delay in seeking medical attention. This is thus an interesting complicated case of dual pathology which needed expert surgical skills and clinical expertise in order to be dealt with.

Funding: No funding sources 

Conflict of interest: None declared 

Ethical approval: Not required 

REFERENCES 

1. NBC News. Tumor in baby’s brain contained tiny foot, 2008. Available at: msnbc.msn.com. Accessed 19 December 2008. 

2. Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 2001;21(2):475-90.

3. Raeed Deen, Asantha de Silva, Ruwan Wijesuriya. Twisted benign ovarian teratoma presenting with pain and generalized pruritus: a case report. J Med Case Rep. 2013 May;7(1):130. 

4. Ding DC, Chen SS. Conservative laparoscopic management of ovarian teratoma torsion in a young woman. J Chin Med Assoc. 2005 Jan;68(1):37-9.

DOI: 10.5455/2320-1770.ijrcog20140931 Cite this article as: Katke RD. Torsion of huge cystic teratoma of ovary with multiple fibroids uterus: a case report and review of literature. Int J Reprod Contracept Obstet Gynecol 2014;3:793-5.