Leiomyomatosis peritonealis disseminata: A case report and meticulous review of the literature

Advances in the understanding and management of leiomyomatosis peritonealis disseminata: A narrative review

Leiomyomatosis peritonealis disseminata (LPD) is a rare gynecologic disorder characterized by the presence of multiple smooth muscle nodules dispersed across the peritoneal surface. While its precise cause remains unknown, studies indicate a role for hormonal, genetic, and molecular influences in disease progression. Advances in imaging, particularly magnetic resonance imaging (MRI) and computed tomography (CT), have enhanced diagnostic precision by differentiating LPD from malignancies, while immunohistochemical markers like smooth muscle actin (SMA), desmin, and estrogen/progesterone receptors (ER/PR) offer valuable pathologic insights. Management strategies include hormonal therapy (e.g., gonadotropin-releasing hormone [GnRH] agonists) and surgical intervention, with treatment plans tailored to disease severity and patient-specific factors. Emerging research suggests the potential role of targeted molecular therapies in managing refractory cases. Despite these advances, LPD remains a complex condition, and further research is needed to clarify its pathogenesis, identify reliable biomarkers, and establish standardized treatment protocols. This review synthesizes current knowledge on LPD to enhance clinical awareness and guide future research on its pathogenesis, biomarkers, and treatment strategies.

Disseminated Peritoneal Leiomyomatosis: Two Rare Cases With Diagnostic Mimics and a Novel Central Nervous System Disease Association

Disseminated peritoneal leiomyomatosis (DPL) is a rare benign smooth muscle tumor that proliferates along the peritoneal surface and is mostly reported in young women. Our cases highlight the wide clinical and radiologic mimics of DPL, including primary peritoneal (mesothelial) entities and malignant processes like metastasis or pseudomyxoma peritonei. Both cases shared common findings of premenopausal age (hormonal influence) and a history of prior abdominal surgery. One case was clinically thought to be benign multicystic mesothelioma, while the other had a history of medulloblastoma as a child, followed by recurrent meningiomas. The presentation of multiple previous tumors in the latter case is an unusual association with DPL that has not been previously described. Here, we discuss the existing literature on the etiology and differential diagnosis of DPL, report our histopathologic findings, and highlight novel central nervous system (CNS) disease associations with DPL.

Combination therapy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent leiomyomatosis peritonealis disseminata with endometriosis: A case report

BACKGROUND

Leiomyomatosis peritonealis disseminata (LPD) is a non-metastatic, homologous, multicentric benign disorder characterized by small leiomyomas scattered over the peritoneum and omentum. It is a rare and benign disease with invasive potential. LPD mainly attacks women of childbearing age but has also been reported in post-menopausal women, men, and young children. Non-specific clinical and imaging findings of LPD lead to difficult diagnoses and treatment.

CASE PRESENTATION

This study reports the case of a patient with recurrent LPD with endometriosis after multiple myomectomies and hysterectomy, who presented recurrent abdominal pain with progressive exacerbation. Imaging examinations showed irregular shadows in the pelvic cavity and multiple nodular changes in the peritoneum, which were considered malignant lesions. A solid mass sized 10 cm × 9 cm × 10 cm in the inferior pelvis and nodules scattered over the surface of pelvic and abdominal organs and the peritoneum were detected during the surgery. The patient was treated with cytoreductive surgery (CRS), peritonectomy, ovarian ablation, and hyperthermic intraperitoneal chemotherapy (HIPEC). The surgery was challenging, and the intraoperative bleeding reached 900 ml. However, the patient recovered well and achieved a tumor-free survival of 13 months.

CONCLUSIONS

It was concluded that a combination of CRS, ovarectomy, and HIPEC might be one of the therapeutic strategies for recurrent LPD.

Extrauterine leiomyomatosis, the great mimicker

OBJECTIVES

Describe the radiographic features of the different forms of extrauterine leiomyomatosis.

CONCLUSIONS

Leiomyomas with a rare growth pattern occur most often in women of reproductive age and with a history of hysterectomy. Extrauterine leiomyomas present a greater diagnostic challenge because they may mimic malignancies, and serious diagnostic errors may result.

Disseminated peritoneal leiomyomatosis with malignant transformation involving right ureter: A case report

BACKGROUND

Disseminated peritoneal leiomyomatosis (DPL) with myxoid leiomyosarcoma is a rare variant of leiomysosarcoma, and hematuria as a presenting symptom has never been reported. Through this case report, we emphasize the investigation of the etiology, clinical presentation, diagnosis, treatment, and prognosis of DPL with malignant changes mimicking metastatic urinary tract cancer and to help develop further clinical management.

CASE SUMMARY

We describe a case of DPL with malignant transformation involving the right ureter after laparoscopic hysterectomy. An exploratory laparotomy was performed and all visible nodules were surgically removed. DPL with focal malignant transformation to myxoid leiomyosarcoma was confirmed based on pathology results.

CONCLUSION

Professionals who preoperatively diagnose DPL with malignant change to myxoid leiomyosarcoma involving the genitourinary tract should consider symptoms of abdominal pain, hematuria, and imaging of disseminated pelvic tumors in women, especially those with prior history of laparoscopic hysterectomy. Early complete removal of all tumors is the cornerstone to prevent DPL from malignant changes.

Benign Metastasizing Leiomyomatosis to the Skin and Lungs, Intravenous Leiomyomatosis, and Leiomyomatosis Peritonealis Disseminata: A Series of Five Cases

Benign metastasizing leiomyomatosis (BML) is a rare disease that typically occurs in women with a history of uterine leiomyomatosis. Benign metastasizing leiomyomatosis occurs more frequently in the lungs but may also develop in other organs and tissues. Other unusual variants of extra-uterine leiomyomatosis include intravenous leiomyomatosis (IVL) and leiomyomatosis peritonealis disseminata (LPD). In this article, three cases of BML are presented. One case, in a premenopausal woman, presented cutaneous metastases. We also present a case of IVL and a case of LPD, which occurred in postmenopausal women. Given the rarity of BML, IVL, and LPD, the authors reviewed the literature and herein discuss the implications for treatment in all five cases. Evidence for treating BML, IVL, and LPD is still scarce, and data available from our series and other small series seem to point to the patient’s hormonal status playing a fundamental part in the treatment plan. Furthermore, a collecting bag when performing excision of uterine leiomyomas may help avoid the potential spreading of leiomyomatosis. Hysterectomized patients with chronic cough, frequent respiratory infections, abdominal discomfort, right heart failure, or non-specific symptoms should be actively screened for BML, IVL, and LPD. Treatment should be individualized according to each patient’s hormonal status and desires.

Treatment of leiomyomatosis peritonealis disseminata with goserelin acetate: A case report and review of the literature

BACKGROUND

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition characterized by multiple pelvic and abdominal nodules, which are composed of smooth-muscle cells. To date, no more than 200 cases have been reported. The diagnosis of LPD is difficult and there are no guidelines on the treatment of LPD. Currently, surgical excision is the mainstay. However, hormone blockade therapy can be an alternative choice.

CASE SUMMARY

A 33-year-old female patient with abdominal discomfort and palpable abdominal masses was admitted to our hospital. She had undergone four surgeries related to uterine leiomyoma in the past 8 years. Computed tomography revealed multiple nodules scattered within the abdominal wall and peritoneal cavity. Her symptoms and the result of the core-needle biopsy were consistent with LPD. The patient refused surgery and was then treated with tamoxifen, ulipristal acetate (a selective progesterone receptor modulator), and goserelin acetate (a gonadotropin-releasing hormone agonist). Both tamoxifen and ulipristal acetate were not effective in controlling the disease progression. However, the patient achieved an excellent response when goserelin acetate was attempted with relieved syndromes and obvious shrinkage of nodules. The largest nodule showed a 25% decrease in the sum of the longest diameters from pretreatment to posttreatment. Up to now, 2 years have elapsed and the patient remains asymptomatic and there is no development of further nodules.

CONCLUSION

Goserelin acetate is effective for the management of LPD. The long-term use of goserelin acetate is thought to be safe and effective. Hormone blockade therapy can replace repeated surgical excision in recurrent patients.

Leiomyomatosis peritonealis dissemianata five years after laparoscopic uterine myomectomy: A case report

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose. In this report, we present a case of LPD arising 5 years after laparoscopic uterine myomectomy using a power morcellator.

Presentation of case

A 32-year-old woman was admitted to our hospital with complaints of vaginal bleeding and abdominal discomfort. Five years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. Pelvic ultrasonography and magnetic resonance imaging demonstrated multiple pelvic tumors closely attached to peritoneum with no indication of malignancy. An exploratory laparotomy revealed multiple sites of leiomyomatosis in the peritoneum, especially on the parietal peritoneum at the port site of the previous laparoscopic surgery. We surgically removed all visible tumors and performed a total hysterectomy. Histologic examination confirmed the diagnosis of LPD.

Discussion

The use of a power morcellator without in-bag containment system might have played a role in the pathogenesis of LPD in our case. Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

Conclusion

The physicians need to combine medical history, clinical findings, imaging techniques and histopathological examination to establish a correct diagnosis of LPD. The application of containment bags in the setting of power morcellation should be considered to reduce the risk of developing LPD. The optimal intervention strategy should be chosen according to the particular features of each patient.

•

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose.

•

The physician should suspect LPD when the woman has a history of hysterectomy or myomectomy, particularly if a power morcellator was used.

•

Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies.

•

Tumor markers such as CEA, CA19-9 and CA-125 seem not to be useful for the differential diagnosis, since LPD are sometimes associated with elevated levels of these markers.

Leiomyomatosis peritonealis disseminata mimicking peritoneal carcinomatosis 13 years after laparoscopic uterine myomectomy: A case report

•

Leiomyomatosis peritonealis disseminata (LPD) is a rare clinical condition.

•

It is challenging to diagnose because its clinical features mimic other conditions.

•

LPD often mimics peritoneal carcinomatosis or metastatic lesions.

•

LPD should be considered in women with disseminated intraabdominal or pelvic tumors.

•

A history of gynecologic surgery, if present, may offer a pointer to the diagnosis.

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a rare clinical condition that can be challenging to diagnose because its clinical features mimic other conditions. We present a case of LPD mimicking peritoneal carcinomatosis 13 years after laparoscopic uterine myomectomy using a power morcellator. The aim of this paper is to report a rare case which surgeons can learn from and to provide more clinical information for further studies to investigate LPD.

Presentation of Case

A 49-year-old woman was referred to us because sonography revealed abnormal abdominal and pelvic nodules. Thirteen years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. An exploratory laparotomy revealed nodules on the peritoneum, greater omentum, intestinal mesentery, and terminal ileum. We surgically removed all visible nodules and performed bilateral salpingo-oophorectomy. LPD was confirmed based on the morphology and immunohistochemistry results.

Discussion

Diagnosing LPD preoperatively may be difficult because its clinical manifestations resemble peritoneal carcinomatosis or metastatic lesions. Abdominal pain due to diffuse tumor growth is a common manifestation. LPD degenerating into malignancy is rare, but possible. The probable etiological factors, clinical manifestations, and treatment options which may aid when dealing with LPD have been described in this report.

Conclusion

LPD should be considered in women, particularly those with a history of gynecologic surgery presenting with disseminated intraabdominal or pelvic tumors.

Leiomyomatosis peritonealis disseminata: a rare disease with a difficult diagnosis

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition, characterised by the proliferation of peritoneal smooth muscle nodules. LPD is a benign disease with a low rate of malignant degeneration. We describe the case of a 46-year-old, asymptomatic, woman presenting with a mass on the left renal hilum, identified by ultrasound. A CT scan showed three nodules near the left kidney, a mass anterior to the vena cava and bilateral iliac nodules. Biopsy revealed a mesenchymal low-grade tumour. The patient underwent a left nephrectomy and excision of the other masses. The histological diagnosis revealed smooth muscle nodular proliferation with no malignant features, compatible with LPD. The differential diagnosis between LPD and metastatic leiomyosarcoma is sometimes very difficult because they are clinically very similar and even on histology the diagnosis can be tricky. Treatment is conservative in most cases, with surgical excision reserved for high-risk patients.

[Extra uterine leiomyomatosis: Review of the literature]

Extra-uterine leiomyomatosis is a rare pathology defined by the presence of benign smooth uterine muscle cells in unusual localizations, including different entities. It mainly affects premenopausal women with a medical history of uterine myoma with or without surgical treatment. Three main types are discribed: intraveinous leiomyomatosis, benign metastatisizing leiomyoma and leiomyomatosis peritonealis disseminata. The diagnosis may be complex with many differential diagnosis, and relies on histology. The treatment depends on multiple factors such as age, localization, size, symptoms and associated comorbidities. It is based on surgical resection and hormonal privation, surgical (adnexectomy) or medical (hormonotherapy). There is a high risk of recurrence. Some malignant evolutions have been reported, mostly leiomyosarcoma following peritoneal disseminated leiomyomatosis. Long term follow-up of these patients is mandatory. A particular manifestation of extra-uterine leiomyomatosis is the hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome. It is an autosomal dominant disorder which confers an increased risk of cutaneous and uterine leiomyomas and renal cell cancer, with a poor prognosis due to the urologic tumor.

A Novel Case of Fibroids after Menopause

Fibroids are a condition commonly seen as part of routine gynaecological practice and generally present with menorrhagia, infertility, or pressure symptoms depending on their exact location. We report the case of a postmenopausal 57-year-old lady presenting with left-sided pain and frequency with a complex 15 cm mass mid pelvis and an adjacent additional 7 cm cyst but a risk of malignancy index suggesting benign pathology. She underwent total abdominal hysterectomy (TAH) and right-sided salpingo-oophrectomy (RSO) on recommendation of the multidisciplinary team (MDT) and histology confirmed leiomyomatosis peritonealis disseminata. This rare but important condition is often confused with peritoneal carcinomatosis on imaging. The mainstay of treatment involves lesion and omental excision followed by removal of hormonal stimuli although this approach must be personalised as many younger women may wish to retain their uteri. Long-term follow-up is essential due to the potential for malignant transformation.

Leiomyomatosis peritonealis disseminata: A case report of recurrent presentation and literature review

INTRODUCTION

Leiomyomatosis peritonealis disseminata (LPD) is an uncommon disease featured by the presence of multiple nodules of smooth muscle cells scattered in the abdominal cavity. To date only about 150 cases have been reported in literature. We report a case of recurrent LPD after laparotomy.

CASE PRESENTATION

In March 2016 a 36-year-old female, with a history of multiple previous laparoscopic myomectomies, consulted her gynaecologist complaining abdominal pain; a MRI was performed and reported multiple pelvic masses, subsequently excised during laparotomy. The patient refused a total hysterectomy with bilateral salpingo-oopherectomy so a close follow-up was recommended. In November 2017 when a new MRI revealed recurrency of the disease, a second laparotomy is performed and all visible nodules are excised. The histological exam confirms LPD diagnosis. On follow-up after three months the patients is completely asymptomatic.

DISCUSSION

Differential diagnosis of LPD is challenging due to its similarity to carcinomatosis and to other benign abdominal disorders. Malignant transformation is rare, but it may occur, so a close follow-up is necessary. Even if there is no consensus regarding the treatment, hormonal therapy is probably the best first line approach, while surgery should be the second choice.

CONCLUSIONS

LPD is an uncommon but potentially severe disease. In our opinion larger studies are necessary to improve our diagnostic effectiveness and to define the best therapeutic strategy.

[Benign metastasizing leiomyoma: An unusual cause of aggressive femoral bone tumor]

BACKGROUND

Benign metastasizing leiomyoma (BML) is a rare condition characterized by histologically benign "metastatic" smooth muscle tumors, which can affect women with history of uterine surgery. We report the case of a patient with bone metastases of BML.

CASE REPORT

A 78-year-old woman who had undergone uterine surgery six years before hospital admission, was diagnosed with large pulmonary and pleural metastases that necessitated surgical removal. Pathological examination allowed the diagnosis of BML with positive staining for estrogen and progesterone receptors. Three years later, a BML metastasis in the right femoral diaphysis was unexpectedly discovered and treated by osteosynthesis because of a high risk of fracture. Despite an aromatase-inhibitor treatment, new lungs lesions appeared in the next few months.

CONCLUSION

BML is a potential cause of aggressive, although histologically benign, bone tumor in women with a history of uterine surgery.