[Extra-uterine pelvic leiomyoma: diagnosis and practical management]

OBJECTIVES

To analyze the possibilities of setting up a therapy for extra-uterine pelvic leiomyomas.

METHODS

Three cases of leiomyomas of the broad ligament, of the round ligament and of the ovary, and literature review.

RESULTS

Little is known about physiopathology of extra-uterine leiomyoma. The diagnosis of extra-uterine leiomyoma is based on histopathological analysis, using standard histology, and immunohistochemistry with anti-desmin and anti smooth muscle actin antibodies. The main differential diagnoses are fibroma, fibrothecoma, ovarian fibrosarcoma, and gastrointestinal stromal tumors. To define criteria of malignancy, we use Bell's classification without being sure that the uterine and extra-uterine models are comparable. So there is a risk of ignoring a low grade leiomyosarcoma. Providing therapy depends on the clinicopathologic features: the so called "parasitic leiomyoma", a tumor developed at the expense of local smooth muscle cells, metastasis of a benign metastasizing leiomyoma or leiomyomatosis peritonealis disseminata.

CONCLUSION

The extra-uterine leiomyoma has no precise nosologic status and no specific criteria of benignity; thus no precise evolution can be predicted. We must be extremely careful, and the issue of the monitoring and long-term therapy of patients must come up.

Incarcerated internal hernia of the small intestine through a breach of the broad ligament: two cases and a literature review

Two cases of internal herniation through a defect in the broad ligament of the uterus are described. Both were successfully treated laparoscopically. This rare condition should be borne in mind when a middle-aged woman presents with colicky lower abdominal pain. The cause is unknown, but both congenital and acquired origins have been proposed. As far as emergency situations are concerned, laparoscopy has proven to be both a diagnostic and a therapeutic tool.

Broad ligament hernia-associated bowel obstruction

BACKGROUND AND OBJECTIVE

We present the case of a female patient 29 years of age with antecedents of laparoscopic laser ablation for endometriosis, laparoscopic appendectomy, and umbilical hernioplasty.

METHODS

The patient was admitted to the hospital's emergency room for abdominal pain in the epigastrium, transfixing, irradiating to both upper quadrants and to the lumbar region, accompanied by nausea and gastrobiliary vomiting. Lipase determination was 170 mg/dL. Other laboratory findings were normal. Plain abdominal films on the patient's admission were normal, and computed tomography (CT) showed data compatible with acute pancreatitis. Without improvement during the patient's hospital stay, pain and vomiting increased in intensity and frequency.

RESULTS

New abdominal x-rays revealed dilatation of small bowel loops. Management was begun for intestinal obstruction, with intravenous hydration and placement of a nasogastric tube without a good response. At 48 hours, a diagnostic laparoscopy was performed, revealing a 3-cm internal hernia in the left broad ligament in which a 20-cm segment of terminal ileum was encased. We performed liberation of the ileal segment and closed the hernial orifice by using the laparoscopic approach.

CONCLUSION

The patient's evolution was excellent.

Internal hernia through the broad ligament presenting with acute on chronic intestinal obstruction: A case report

BACKGROUND

Internal hernias are rare. Their occurrence through the broad ligament is one of the rarest forms. We present a report of a 45 year Nigerian female with acute on chronic intestinal obstruction due to an internal hernia of the broad ligament.

METHODS

Patients case notes and a review of relevant literature using manual library and Medline search was used.

RESULTS

A 45-year-old multiparous woman presented with a ten-year history of features of partial intestinal obstruction, and no previous abdominal surgery. Examination revealed right iliac fossa tenderness and a plain abdominal radiograph showed air fluid levels. Conservative management was not successful and laparatomy confirmed an internal hernia of the right broad ligament which was repaired with satisfactory outcome.

CONCLUSION

This report is to highlight the fact that though rare, internal hernia should be considered in the differential diagnosis of intestinal obstruction.

Granulosa cell tumor arising in the wall of müllerian cyst of the broad ligament: report of a case and immunohistochemical study

CASE

A unique case of granulosa cell tumor arising in a müllerian cyst of the broad ligament in a 57-year-old woman is presented. The surgically resected unilocular cyst, measuring 9.5 x 9.5 x 6.5 cm3, situated within the right broad ligament. The inner surface of the cyst was lined by a single layer of ciliated columnar cells. Solid cell sheath of the spindled cells were demonstrated in this cystic wall. Immunohistochemically, these spindled cells were diffusely positive for cytokeratin 7, AE1/AE3, vimentin, smooth muscle actin, calretinin and weakly positive for inhibin, but negative for cytokeratin 20, epithelial membrane antigen and CD10.

CONCLUSION

Immunohistochemical findings suggested solid cell sheath surrounding the cyst was granulosa cell tumor. Granulosa cell tumor coexisted with müllerian cyst in the current case was recognized a unique histological feature.

Leiomyosarcoma of the broad ligament: a case report and review of literature

Leiomyosarcoma of the broad ligament is a rare tumor, since only 12 cases have been reported so far in the literature. A 53-year-old patient was diagnosed with leiomyosarcoma of the broad ligament at the Department of Gynecology Oncology of the National Cancer Research Institute in Genoa. The tumor had low mitotic activity and less than ten mitotic figures were found for ten high-power fields. The treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy with bilateral ureteral neoanastomosis and omentectomy. The patient has not received either radiotherapy or chemotherapy, considering the low grade of malignancy, but she is only followed up on an outpatient basis. No evidence of metastasis has been noted after a follow-up of 13 months. It is concluded that low-grade leiomyosarcoma of the broad ligament should be treated only with surgery.

Female adnexal tumor of probable wolffian origin: clinicopathological, immunohistochemical and cytofluorimetric analyses of a 22-year-old virgin. case report

The term female adnexal tumor of probable Wolffian origin "FATWO" designs this tumor wich arises by the rare persisting remnants of the mesonephric duct (Wolffian duct). About 40 cases have been reported in literature. Few cases of recurrence have been reported, FATWO usually shows no signs of hormonal activity. We report a case of the youngest patient affected by FATWO in October 2002. At laparotomy the left adnexa were deformed by a well-capsulated mass, totally removed and sent to the pathologist with a specimen of peritoneal fluid and of the omentum. The histological examination showed a prevalent tubular structure with focal retiform area, without intraluminal mucines. Immunohistochemical findings of the case reported are similar to those described by other authors, except for inhibin which has not been detected by us. The cytofluorimetry showed the low presence of aneuploid cells, with a very low prolifing component (< 1%).

Primary papillary serous cystadenocarcinoma of broad ligament

A rare case of an advanced primary broad ligament carcinoma is discussed, with a review of the literature regarding its incidence, presentation and management. This patient showed a complete response to adjuvant cisplatin-based chemotherapy following panhysterectomy and is presently without any evidence of disease, 15 months after completion of her treatment.

Internal herniation through a defect of the broad ligament of the uterus

Internal herniation through a defect of the uterine broad ligament is rarely encountered. We report a case of a 52-year-old woman in whom a closed bowel loop with approximation of its ends to the uterus was the definitive computed tomographic finding. This type of internal herniation should be considered in the differential diagnosis of female patients presenting with ileus.

Loss of caspase-2, -6 and -7 expression in gastric cancers

Female adnexal tumor of probable Wolffian origin (FATWO) is a rare entity which is believed to originate from mesonephric (Wolffian) remnants on the basis of its location where the remnants are abundant. Its behavior is usually indolent, although some cases can recur or metastasize. The authors present the clinicopathological features of two cases of FATWO arising in the broad ligament, and focus on the expression of adhesion molecules and proliferative marker. Mesonephric duct remnants are also examined in an attempt to elucidate the histogenesis of FATWOs. The two FATWOs were well-circumscribed solid masses arising in the leaves of the broad ligament and histological examination revealed a mixture of cysts and tubules imparting a sieve-like pattern and mucin-negative eosinophilic secretion within these tubules. Immunohistochemically, the tumors showed the expression of cytokeratin 7 and 20, high-molecular-weight cytokeratin, and calretinin, which closely resembled that of the mesonephric duct remnants. Regarding CK 20, CD 10, EMA, S-100 protein, and vimentin their expression was in part not identical with previous studies. E-cadherin, alpha and beta-catenin were strongly expressed along the cell membrane of the tumor cells. The Ki-67 labeling index of FATWO was 0% and 3.2% in each case. The preservation of the E-cadherin-catenin complex and low Ki-67 labeling index could explain the indolent behavior and low malignant potential of this tumor.

A Simple Procedure for the Prevention of Ureteral Injury in Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE

To introduce a surgical technique to minimize the chance of ureteral injury during laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

Retrospective case review (Canadian Task Force classification II-3).

SETTING

Show Chwan Memorial Hospital, Changhua, Taiwan.

PATIENTS

Two thousand and six women who underwent LAVH between January 1992 and June 2001.

INTERVENTION

A simple step of creating a "window" over the anterior and posterior broad ligaments to push inferolaterally the areolar tissue (in which the ureter is embedded) on the posterior broad ligament.

MEASUREMENTS AND MAIN RESULTS

No ureteral injury occurred in patients whose cases were reviewed. There were, however, five bladder injuries (0.25%) and three nerve pareses (0.15%). Other minor complications, including fever, abscess or hematoma of the vaginal cuff, subcutaneous emphysema, and delayed vaginal cuff bleeding, occurred in less than 5% of patients.

CONCLUSION

The technique proposed is simple and very effective in preventing ureteral injury during LAVH.

Successful laparoscopic treatment of an abdominal pregnancy in the broad ligament

Laparoscopic management of tubal ectopic pregnancy is the ideal form of treatment in most tertiary centres. Approximately 1% of ectopic pregnancies are abdominal pregnancies and these are usually managed by laparotomy. We present the first report of successful laparoscopic treatment of a 6.5 cm abdominal pregnancy located in the broad ligament of a 25-year-old woman.

Endothelin-1 and endothelial nitric oxide synthase immunoreactivity in lymphatic vessels of the uterine broad ligament during the estrous cycle in the pig

Immunohistochemical localization and distribution of endothelin (ET-1) and nitric oxide synthase (eNOS) were investigated in precollector and collector lymphangions of lymphatic vessels leaving the ovary and were found in the vascular subovarian plexus (mesovarium) as well as in those emanating from the oviductal isthmus and uterine horn (mesosalpinx and mesometrium, respectively) forming the paraovarian lymphatic plexus in the broad ligament of the uterus during different phases of the estrous cycle in pigs. The polyclonal antibody for ET-1 and the monoclonal antibody for eNOS isoform were used for studies on the light-microscopic level. Immunoreactivities to both ET-1 and eNOS were observed in the endothelial cell cytoplasm of precollector and collector lymphangions and were not demonstrated in smooth muscle cells of the lymphatics examined. In the endothelium, the intensity of immunostaining for ET-1 and eNOS was found to be estrous phase-dependent and differed between precollector and collector lymphangions. In general, immunoreactivity to ET-1 was more intense in the endothelium of shrunken lymphangions, whereas that for eNOS was more intense in lymphangions with the large lumen. These results suggest that ET-1 and eNOS can play a role in mechanisms regulating the vascular contractile activity promoting lymph flow during the estrous cycle in the porcine broad ligament.

Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: report of a case

Intestinal herniation through a defect in the broad ligament of the uterus is uncommon among internal herniations. We herein report a 59-year-old woman with intestinal obstruction, who had no previous history of surgical treatment except for an appendectomy. The laparotomy revealed an incarceration of the small bowel herniation through the defect of the right broad ligament. This possibility should therefore be considered in the differential diagnosis for female patients presenting with an intestinal obstruction without any history of a prior laparotomy.

Leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma

A 35-year-old woman presented with an adnexal mass which came out as a leiomyosarcoma of the broad ligament arising in a pre-existing pure neurilemmoma-like leiomyoma. This is the first reported case of leiomyosarcoma arising in a pure neurilemmoma-like leiomyoma, the third reported case at an unusually young age showing evidence of a pre-existing leiomyoma and the 12th reported case of leimyosarcoma of the broad ligament. Is the likelihood of malignant transformation, especially in large leiomyomas of the broad ligament, a rare event?

Small bowel incarceration in a broad ligament defect

We report the case of a 33-year-old woman whose medical history included three normal pregnancies without previous abdominal or pelvic surgery. She presented with small bowel obstruction. An abdominal computed tomography (CT) scan study revealed air fluid levels in the pelvis. Laparoscopic exploration revealed a viable ileal loop incarcerated through the mesoligamentum teres. The intestinal loop was reduced and the broad ligament defect was closed with a laparoscopic absorbable clip. Among internal hernias, hernias through a defect in the broad ligament represent only 4-7%. Defects within the broad ligament can be either congenital (ruptured cystic structures reminiscent of the mesonephric or mullerian ducts) or secondary to operative trauma, pregnancy and birth trauma, or prior pelvic inflammatory disease. CT scan may be diagnostic by showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels. This is the first reputed case of a totally laparoscopic repair of a bowel incarceration through a broad ligament defect.

Malignant epithelial tumor of unknown origin of the broad ligament

Malignant epithelial tumor of the broad ligament is rare and to our knowledge only 17 cases have been reported. We report a 54-year-old Japanese woman in whom transvaginal sonography (TVS) and magnetic resonance imaging (MRI) showed a left adnexal tumor. Serum CA125 was elevated to 10,000 U/ml. Preoperatively, we diagnosed this tumor was a left ovarian malignant tumor though, it was confirmed a the 47x57 mm tumor in the left broad ligament at laparotomy. Histologically most of the tumor showed serous papillary adenocarcinoma with changes similar to poorly differentiated carcinoma and as seen in transitional cell carcinoma on hematoxylin-eosin staining. After three courses of platinum based adjuvant chemotherapy, the patient is alive with no recurrence at 18 months postoperatively.