Benign metastasizing leiomyoma: Case report and review of the literature

Cardiac benign metastatic leiomyoma- a comprehensive review

Cardiac benign metastatic leiomyoma (BML) is a rare cardiac tumor that is usually asymptomatic, frequently misdiagnosed and may result in serious complications, including embolization, heart failure and death. This review highlights the importance of considering cardiac BML in the differential diagnosis of cardiac masses, especially in women with a history of uterine leiomyomas. This review summarizes the current knowledge about cardiac BML, including its demographics, clinical presentation, etio-pathogenesis, diagnosis, and management. The authors discuss the challenges associated with diagnosing cardiac BML and emphasize the importance of a thorough history, physical examination, and imaging studies. They also review the different treatment options for cardiac BML, including surgical resection and role of medical and surgical castration. Early diagnosis and management of cardiac BML is crucial to prevent complications. This review provides valuable insights for clinicians who may encounter this rare condition. By raising awareness of cardiac BML and its management strategies, this review can improve patient care and outcomes.

Multiple benign metastasizing leiomyoma in the abdominal wall: a case report and literature review

Benign metastasizing leiomyoma (BML) is a rare disease that results from metastasis of uterine leiomyoma to distant sites with benign pathologic features. The lung is the most common metastatic site for BML. This report describes the case of a 49-year-old woman who presented with a mass in the abdominal wall with a surgical history of uterine myomectomy. Ultrasound and Magnetic resonance imaging (MRI) revealed multiple mass lesions. The histopathology of the mass specimen indicated BML. The imaging and clinical features of BML are discussed based on the characteristics of this case and related literature reports.

A Rare Case of Benign Metastasizing Leiomyoma Causing T11 Spinal Cord Compression: A Report and Literature Review

Diagnosis of uterine smooth muscle tumors depends upon histologic characteristics as both benign and malignant share clinical features such as metastases. A benign metastasizing leiomyoma is a rare benign smooth muscle tumor that metastasizes to extrauterine sites with simultaneous uterine leiomyoma or previously biopsy-proven leiomyoma during myomectomy or hysterectomy. Benign metastasizing leiomyoma metastasizes outside the uterus, predominantly to the lungs and lymph nodes. However, the involvement of other organs, such as the heart, liver, spine, and soft tissue, is also reported. Here, we present a case of a 42-year-old woman with a history of uterine leiomyoma with prior myomectomy and hysterectomy, who presented with worsening back pain and lower extremity weakness and was found to have an acute cord compression, a serious complication caused by mass effect and a medical emergency that requires prompt attention to prevent permanent spinal cord damage. Sacral soft tissue biopsy and T11 spinal bone biopsy both demonstrated leiomyoma with immunostains positive for desmin, smooth muscle actin, and positive estrogen and progesterone receptors. No atypia, necrosis, and mitosis were identified. The patient had hepatic and pulmonary metastasis on imaging. The final diagnosis was benign metastasizing leiomyoma. There is no standard treatment for benign metastasizing leiomyoma. Both surgical and pharmacological approaches are employed. Although most cases are benign, there is a possibility for life-threatening complications. Benign metastasizing leiomyomas can be considered when multiple soft tissue tumors are found in premenopausal women with a history of uterine leiomyomas. Multidisciplinary discussion between oncologists, gynecologists, and relevant specialists is crucial in the optimal evaluation and treatment of benign metastasizing leiomyoma.

Benign Metastasizing Leiomyoma Causing Severe Tricuspid Regurgitation and Heart Failure

We present the case of a 51-year-old woman with severe tricuspid valve regurgitation due to aseptic tricuspid valve vegetation. She presented with bilateral lower extremity edema and a tricuspid valve vegetation was found on echocardiography. Initially, infectious and autoimmune causes of valve vegetation were considered; however, on biopsy, the mass was ultimately found to be a benign metastasizing leiomyoma (BML). Additional history revealed clinical features consistent with uterine leiomyomas, which metastasized to all leaflets the tricuspid valve, causing symptoms of heart failure. Benign metastasizing leiomyoma is rare itself, but when found, typically presents as asymptomatic pulmonary nodules. Mechanism of spread is unknown. Diagnosis is typically made long after a hysterectomy or fibroidectomy, but in our case, the BML was found prior to an actual fibroid diagnosis. By comparison, metastasis to the heart is extremely rare and has a higher potential for morbidity. Our patient required open heart surgery and tricuspid valve replacement for management of her symptoms, but her risk of further or recurrent metastasis going forward is unknown. Management strategy to prevent metastases in such cases of aggressive disease is not an established protocol and needs to be further studied.

Case report: Cardiac metastatic leiomyoma in an Asian female

Background

Uterine leiomyomas are the most common gynecological tumors in women of child-bearing age and premenopausal women, while benign metastasizing leiomyomas of the heart are rare.

Case presentation

We report a rare case of metastasizing leiomyoma in the heart of a 54-year-old woman 10 years after a uterine leiomyoma was discovered during hysterectomy. Echocardiography, cardiac plain scan and enhanced MRI at presentation showed a soft tissue signal mass in the right ventricle. A large cardiac mass attached to the chordae of the tricuspid valve and later shown to be histopathologically consistent with uterine leiomyoma was successfully resected through a right atriotomy.

Conclusions

Our case report highlights a rare type of tumor of the heart and suggests that metastasizing leiomyoma should be considered in the differential diagnosis of right-sided cardiac tumors. The complete surgical resection of the tumor was considered to be the best treatment.

Robot-assisted tumorectomy for an unusual pelvic retroperitoneal leiomyoma: A case report

RATIONALE

Extrauterine leiomyoma occasionally occurs in rare locations with unusual growth patterns, especially pelvic retroperitoneal leiomyoma, which brings great challenges for surgeons to make a diagnosis. It is essential to distinguish benign from malignant retroperitoneal neoplasms according to the imaging manifestations. Laparotomy and laparoscopy are the common options for pelvic retroperitoneal neoplasms, while they may cause side effects during operation such as secondary damage. Appropriate surgical techniques should be adopted to ensure the complete excision of neoplasms meanwhile preserve the urination, defecation, and sexual function.

PATIENT CONCERNS

A 30-year-old woman was referred to our hospital because of dull pain in the perianal region for 1 month. Laboratory results including tumor markers were all within normal limits. The digital rectal examination revealed a huge and tough mass with smooth mucosa protruding into the rectal cavity from the rear area of rectum.

DIAGNOSIS

Imaging examinations were performed. Contrasted computed tomography (CT) of pelvis showed an enhanced retroperitoneal solid mass in the space between sacrum and rectum, and very close to the levator ani muscle. The mass was about 11.0*8.0 cm in size. Computerized tomography angiography (CTA) showed the distal branches of bilateral internal iliac artery went into the mass. Endoscopic ultrasonography (US) showed the mass compressed the rectum, as well as a clear boundary to the rectal wall. A histopathologic examination confirmed the mass was a pelvic retroperitoneal leiomyoma.

INTERVENTIONS

The patient underwent an operative resection with da Vinci Si surgical system after routine preoperative preparation. Anorectal motility was weekly monitored postoperation. No additional adjuvant therapy was performed.

OUTCOMES

The patient could walk after 1 day and defecate normally on the third day after operation. She was discharged on the seventh postoperative day. No adverse events including pelvic floor hernia or defecation dysfunction occurred in the follow-up period. At 4 weeks follow-up, the patient was pain-free and recovered well.

LESSONS

Although imaging examinations were crucial for retroperitoneal neoplasms, histopathological examination remains the "gold standard" for making a definite diagnosis. This case highlights the possibility of retroperitoneal leiomyoma occurring in a woman of reproductive age and the advantages of robotic surgical system in pelvic retroperitoneal surgeries.

Concurrent Benign Metastasizing Leiomyoma in the Abdominal Wall and Pelvic Cavity: A Case Report and Review of the Literature

Benign metastatic leiomyoma (BML) is a histologically benign disease with invasive biological behavior. Most patients are women of childbearing age with a history of uterine leiomyoma. The progress of the disease is relatively slow, the prognosis is good, and most patients can survive for a long time. The lung is the common metastatic site, and BML with metastatic lesions outside the lung is very rare. A 37-year-old woman with multiple BML in the abdominal wall and pelvic cavity after uterine leiomyoma surgery was admitted to our hospital. Combined with the clinical data of this case and reviewing the relevant literature, this paper discusses the pathological characteristics, diagnosis, differential diagnosis, and treatment of BML.

Benign Metastasizing Leiomyoma in the Heart of a 45-Year-Old Woman

We report a rare case of benign metastasizing leiomyoma in the heart of a 45-year-old woman 2 years after a uterine leiomyoma had been discovered during hysterectomy. Computed tomograms at presentation showed a large mixed cystic mass in the pelvis and bilateral lung nodules suggestive of metastatic disease. A large cardiac mass, attached to the chordae of the tricuspid valve and later shown to be histopathologically consistent with uterine leiomyoma, was successfully resected through a right atriotomy. This case suggests that benign metastasizing leiomyoma should be considered in the differential diagnosis of right-sided cardiac tumors.

Right heart failure due to benign metastasizing leiomyoma: a case report of this exceedingly rare condition and review of the literature

BACKGROUND

Benign metastasizing leiomyoma (BML) is a smooth muscle tumour of genital origin occurring in women with a history of uterine or pelvic leiomyoma. Although histologically benign, it exhibits metastatic behaviour. Lungs are the most common site of metastasis. The heart is a rare site and metastasis at this location has been described in just few cases.

CASE SUMMARY

A 42-year-old woman with a resected uterine leiomyoma and a subsequent and still not-resected left periovarian solid mass began complaining of shortness of breath 2 weeks before presentation. Echocardiography showed a mass located in the right ventricular cavity, enlargement of the right ventricle, and severe tricuspid regurgitation. Cardiac magnetic resonance revealed two masses suggestive of tumours in the right ventricle causing right ventricular outflow tract obstruction. Cardiac surgery was performed and, intraoperatively, a third small mass was detected on the tricuspid valve. The masses were resected, and tricuspid valve replacement was performed. Ten days later, the patient underwent an abdominal surgery for the pelvic mass resection. Immunohistochemical analysis of the cardiac and pelvic masses corroborated the diagnosis of benign leiomyomas. The patient was discharged in good clinical condition.

DISCUSSION

Benign metastasizing leiomyoma to the heart is a rare condition. The pathogenesis remains controversial and includes: (i) vascular or lymphatic spread of myomatous tissue cells when leiomyoma resection or hysterectomy is performed and (ii) smooth muscle cell proliferation in multiple regions. The more usual locations of BML in the heart seem to be the tricuspid valve and the right face of the interventricular septum.

Molecular Profiling of Benign Metastasizing Leiomyoma of the Uterus Revealing Unique Novel Therapeutic Targets

Extra-uterine manifestations of benign uterine leiomyoma (fibroids) are rare. Benign metastasizing leiomyoma (BML) comprises an uncommon variant characterized by metastatic lung nodules. The pathologic characteristics for BML are well known in the literature; however, the underlying biology and molecular mechanisms remain poorly understood. We present a case of a 43-year-old woman who presented to the hospital complaining of dyspnea and lower extremity edema. Medical history includes a previous hysterectomy for leiomyomata two years prior. A reduced ejection fraction and right atrium globular filling defect are seen on transthoracic echo (TTE). CT scans of the chest, abdomen, and pelvis reported pelvic mass with an extensive inferior vena cava (IVC) thrombus extending into the right atrium, which was subsequently completely resected. Subsequent histopathology for the thrombus reported intravascular leiomyomatosis (IVL) and pelvic mass reported benign leiomyoma. Two years later, the symptoms recurred, and a chest CT revealed new pulmonary nodules. Subsequent pathology from a biopsy of these nodules was consistent with BML with ER+/PR+ on immunohistochemical staining. Genetic testing showed amplification of JUN, cyclin-dependent kinase 4 (CDK4), and MCL1, and loss of SUFU, AT-rich interaction domain 1A (AR1D1A), RB transcriptional corepressor 1 (RB1), and hepatocyte nuclear factor 1-alpha (HNF1A). The patient deemed to be a poor surgical candidate, and, therefore, she was started on hormonal treatment with leuprolide and letrozole. The disease remained stable upon follow-up at 48 months. Here, we report novel genomic profiling findings for the first time in a patient with a newly diagnosed BML. These findings may suggest molecular evidence that IVL may not be as benign as previously thought.  Our study further highlights the value of genetic profiling in the understanding of this tumor's behavior and identification of new patient-specific therapeutic targets.

Suspicious Right Heart Mass: A Rare Case of Benign Metastasizing Leiomyoma of the Tricuspid Valve

Benign metastasizing leiomyoma is a rare condition usually affecting women of reproductive age with a history of uterine leiomyoma and characterized by soft tissue masses in various extrauterine sites. We report a case of a 46-year-old woman with previously resected uterine leiomyoma with subsequent pulmonary and tricuspid valve lesions. (Level of Difficulty: Intermediate.)

Multisystemic Benign Metastasizing Leiomyoma: An Unusual Condition with an Atypical Clinical Presentation

Benign metastasizing leiomyoma (BML) is a rarely found entity with few documented cases in the literature, usually occurring in women of reproductive age with a history of myomectomy or hysterectomy. The leiomyomas can metastasize to several organs, the lungs being the most commonly affected. We report a case of a 40-year-old female patient who presented at our institution with low back pain. She underwent a lumbar MR that revealed the presence of an expansive and compressive mass in the body of L4. This mass was biopsied, corresponding to a metastasizing leiomyoma with no malignant characteristics. Subsequently, a CT examination showed several soft tissue density round masses in both lungs, but the most striking feature was a 12 cm mass located in the left iliac crest. There was asymmetrical uterus enlargement, caused by the presence of several leiomyomas. Since the lesions were estrogen and progesterone positive, hormone suppression consisting of oophorectomy followed by anastrozole was the chosen treatment. No signs of progression were observed at the 6-month follow-up. This case is one of the very few that occurred in a woman with no previous uterine intervention, adding further evidence that surgery is not an essential condition for this entity to develop.

Concurrent benign metastasizing leiomyoma in the lung and lumbar spine with elevated standardized uptake value level in positron-emission tomography computed tomography: A case report and literature review

RATIONALE

Benign metastasizing leiomyoma (BML) is rare condition involving distant metastases secondary to benign uterine leiomyoma, and it is most commonly found in the lungs. It rarely metastasizes to the spine to cause osteolytic damage and spinal canal compression.

PATIENT CONCERNS

A 51-year-old woman with low back and bilateral leg pain and paresthesia was admitted to our ward. She has a previous medical history of uterine leiomyomas. Magnetic resonance imaging of the lumbar spine revealed vertebral body osteolytic destruction and soft tissue mass in the L4/5 with a secondary lumbar spinal stenosis. Positron emission tomography computed tomography showed moderately intense accumulation of 18F-fluorodeoxyglucose in the L4/5 mass, as well as multiple nodules with increased metabolic activity in both lungs.

DIAGNOSES

Pulmonary and spinal BML.

INTERVENTIONS

The patient underwent a computed tomography-guided percutaneous needle biopsy of the lung nodule and lumbar corpectomy, tumor excision, and vertebroplasty in the L4/5.

OUTCOMES

Pathologically, both pulmonary nodule and vertebral mass were diagnosed as leiomyomas without any malignant evidence. Estrogen and progesterone receptors were both positive in the metastatic tumors. The patient's symptoms completely disappeared after the surgery. The patient is currently receiving outpatient anti-estrogen tamoxifen treatment for a BML.

LESSONS

Through this case, we suggest that BML should be regarded as part of differential diagnosis in female patients with a previous medical history of uterine leiomyomas presenting with multiple nodules in any parts of the body.

Benign metastasizing leiomyoma: A review of current literature in respect to the time and type of previous gynecological surgery

INTRODUCTION

Benign metastasizing leiomyoma (BML) is a rare disorder that affects women with a history of uterine leiomyoma, which is found to metastasise within extrauterine sites. The aetiology of BML remains unexplained. Because BML is rare, and most publications contain descriptions of single cases, no statistically determined time relations were found between the primary and secondary surgeries, which may have aetiological implications.

OBJECTIVES

To determine age before BML surgery, age during diagnosis of BML, type of prior surgery, and location of metastasis based on the literature.

METHODS

A systematic review of four databases (Medline/PubMed, Embase, Web of Science, and Cochrane) covering articles published from 1 January 1965 to 10 April 2016. The inclusion criteria were full-text articles in English and articles containing case reports. Articles in languages other than English (39), articles containing incomplete data (14), i.e. no information regarding the time of surgery and/or the site of metastasis, articles bereft of case studies (25), and articles with access only to summaries, without access to the complete text (10) were excluded. Of 321 titles identified, only 126 articles met the aforementioned criteria.

RESULTS AND CONCLUSIONS

The mean age during primary surgery and BML diagnosis was 38.5 years and 47.3 years, respectively. The most common surgery was total hysterectomy. The most frequent site of metastasis was the lungs; other organs were affected less frequently.The site of metastases and their number were not related to the longer time span between the patient's initial surgery and occurrence of metastasis. The analysed data, such as the age during primary surgery, age during BML diagnosis, site and type of metastasis, do not provide us a clear answer. Thus, BML pathogenesis is most probably complex in nature and requires further multidirectional research.

Benign Metastasizing Leiomyoma

Benign metastasizing leiomyoma (BML) is a rare and poorly characterized disease affecting primarily premenopausal women. Asymptomatic patients are often diagnosed incidentally by radiographs or other lung-imaging procedures performed for other indications, and the diagnosis is eventually confirmed by biopsy. Patients with BML are usually treated pharmacologically with antiestrogen therapies or surgically with oophorectomy or hysterectomy. Antiestrogen therapy is typically efficacious and, in general, most patients have a favorable prognosis. Asymptomatic patients with a confirmed diagnosis of BML, may be followed conservatively without treatment.

Benign Metastasizing Leiomyomas to the Lungs: An Institutional Case Series and a Review of the Recent Literature

BACKGROUND

Benign metastasizing leiomyomas (BMLs) represent the extrauterine spread of a benign uterine process. Pulmonary BMLs are the most common example of distant spread of uterine leiomyomas and are usually found incidentally in premenopausal women. The rarity of BMLs accounts for the limited literature that currently exists regarding their underlying pathophysiology, disease course, and management.

METHODS

A retrospective analysis was performed of all BML cases diagnosed and managed at Brigham and Women's Hospital during a 22-year period. The demographic and clinical characteristics of these patients were compared with a PubMed-derived cohort of BML cases reported since 2006.

RESULTS

Benign metastasizing leiomyoma tumors were identified in 10 Brigham and Women's Hospital patients, whereas 57 cases were reported in the literature. The average age at diagnosis was 54.1 and 46.7 years, respectively. Mean interval time from a pertinent gynecologic procedure to BML diagnosis was 23 years at Brigham and Women's Hospital. All patients demonstrated positivity for actin, desmin, and estrogen/progesterone receptors, confirming the diagnosis of uterine leiomyomas. Management primarily consisted of diagnostic resection with subsequent observation with or without hormonal suppression for residual pulmonary nodules. Progression of residual BMLs was noticed in 30% and 8.3% of Brigham and Women's Hospital and literature patients, respectively, when follow-up was reported. One patient in our series required further surgical management.

CONCLUSIONS

Benign metastasizing leiomyomas are a rare cause of pulmonary nodules. They likely represent a clonal spread of uterine leiomyomas to the lungs. Management includes pathologic diagnosis with long-term surveillance with or without hormonal manipulation.