Large uterine myoma with erythropoietin messenger RNA and erythrocytosis

Myomatous erythrocytosis syndrome: A case report

BACKGROUND

Uterine myoma is the most common benign tumor among women and is often accompanied by anemia. Here, we report the case of a patient with a very large leiomyoma but with a hemoglobin level as high as 197 g/L. After undergoing hysterectomy, all her hematological parameters returned to normal. Immunohistochemical staining of her myoma for erythropoietin showed strong positivity, which suggested that erythropoietin may be the cause of her erythrocytosis. A multidisciplinary team played a significant role in treating the disease.

CASE SUMMARY

A 47-year-old woman visited our department complaining that her abdomen had been continuously growing for the past 2 years. After careful examinations, she was suspected of having a very large leiomyoma. She was also diagnosed with erythrocytosis because her RBC count was 6.49 × 10¹²/L, hemoglobin was 197 g/L. Following a multidisciplinary team consultation, bilateral ureteral stents were placed, and 800 mL blood was removed by phlebotomy. The patient then underwent hysterectomy and bilateral salpingectomy. She recovered well from the operation, and her hemoglobin level decreased sharply following the surgery. Low-molecular-weight heparin was administered daily to prevent postoperative thrombosis. She was discharged from the hospital on the fourth postoperative day. Two months later, all her hematological parameters returned to normal. Pathological analysis of the myoma revealed that it was a benign leiomyoma, with partial hyalinization, and strong positivity for erythropoietin in immunohistochemical staining suggested that erythropoietin may be responsible for the erythrocytosis.

CONCLUSION

Erythropoietin ectopically produced from the myoma was responsible for the erythrocytosis in this patient. A multidisciplinary team is strongly recommended.

Myomatous Erythrocytosis Syndrome: Case Report and Review of the Literature

Myomatous Erythrocytosis Syndrome is defined as erythrocytosis, myomatous uterus, and the return of normal hematologic values following surgical resection. The exact role of erythropoietin in disease pathogenesis is unknown. In this study we report the case of a 49 year old premenopausal woman who was found to have an enlarged heterogeneous mass arising from the uterus concerning for malignancy. Her RBC count was 5.75 T/L, hemoglobin was 17.6 g/dL and hematocrit was 54.3%. Pre-operative erythropoietin levels were 24.6 mIU/mL and JAK2 mutation was not detected. She underwent Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy. The pathology was consistent with a uterine leiomyoma. Laboratory evaluation performed eight weeks after surgery showed a RBC count of 4.5 T/L, hemoglobin of 13.6 g/dL, hematocrit of 40.5%. Post-operative erythropoietin level was 5.4 mIU/mL. The tissue showed diffuse moderate to strong cytoplasmic immunopositive for Erythropoietin. Erythropoietin plays an important role in this condition, however the exact mechanism is still under investigation. The theory of erythropoietin secreting tumor autonomously without negative feedback is the most credible so far. However, further studies with use of blood erythropoietin level, tissue erythropoietin detection using immune-stain and new molecular biology techniques need to be done and compared to uterine myoma patients with no erythrocytosis. Usually, no further treatment is required following surgical removal.

A case of myomatous erythrocytosis syndrome associated with a large uterine leiomyoma

Several etiologies have been proposed for erythrocytosis associated with uterine leiomyoma. We report a case of erythrocytosis associated with a large uterine leiomyoma, in which specific immunostaining for erythropoietin was positive. A 55-year-old woman, gravida 0, para 0, was referred to our hospital for treatment for a large uterine myoma and erythrocytosis. She had no vaginal bleeding after she reached menopause at 50 years old. She had severe polycythemia: hemoglobin (Hb), 19.9 g/dL; red blood cell count (RBC), 6.65 × 10⁶/mm³; hematocrit, (Hct) 59.1%. An abdominal simple hysterectomy was performed, and a pathological examination confirmed the diagnosis of leiomyoma of the uterus. In addition, immunostaining demonstrated that the cytoplasm of the leiomyoma cells was strongly positive for erythropoietin. After the operation, the patient's hemoglobin and hematocrit levels normalized, and we diagnosed her condition as myomatous erythrocytosis syndrome.

[Polycythemia and fibromyoma. Case report]

Leiomyoma of the uterus is a frequent benign tumor of non menopausal women. Among possible complications, polycythemia is rare and often unrecognised. We report a very demonstrative case, that of a 52-year-old woman, who presented initially an episode of metrorrhagia. The difficulty of diagnosis and the treatment are detailed. The different physiopathological hypotheses are discussed in order to ameliorate our knowledge about this association between fibromyoma and polycythemia, and to optimise therapeutic management.

Expression profile of the tumorigenic factors associated with tumor size and sex steroid hormone status in uterine leiomyomata

OBJECTIVE

To use tissue microarray in combination with dendrogram cluster analysis to characterize some potential tumorigenic factors in association with tumor size and sex steroid hormone status in uterine leiomyomata.

DESIGN

Expression analysis of 21 selected potential tumorigenic factors in 60 patients with uterine leiomyomata.

SETTING

University clinical research laboratory.

PATIENT(S)

Hysterectomy specimens from 60 patients with uterine leiomyomata of different ages and tumor sizes.

INTERVENTION(S)

Tissue cores from normal myometrium and leiomyomata were examined by immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Semiquantitative immunointensity was scored and analyzed by net gain and loss between normal myometrium and leiomyomata and integrated into dendrogram cluster tree view.

RESULT(S)

We found that upregulation of estrogen and progesterone receptors was reverse associated with tumor size. Upregulation of some factors (HMGA2, sex steroid receptor cofactors, proteins in insulin pathway, and CD24) were identified in a group of patients in their later forties, were associated with large fibroids, and were weakly affected by the SSH status (illustrated by endometrial phases and menopause). Downregulation of tuberin and glucocorticoid receptor was mostly isolated in a second group of women at their late reproductive age.

CONCLUSION(S)

Analyses of the sex steroid hormone receptors and the nonsex steroid hormone factors in leiomyomata and the matched myometrium showed different expression patterns in different tumor sizes and patients' ages. A group of patients in their late forties with the larger leiomyomata contributes largely by upregulation of nonsex steroid hormone factors. Adenomyosis is a protective factor preventing large leiomyomata.

Erythropoietin and erythropoietin receptor system in a large uterine myoma of a patient with myomatous erythrocytosis syndrome: possible relationship with the pathogenesis of unusual tumor size

The rare condition of women with erythrocytosis and a concurrent myomatous uterus has been classified as "myomatous erythrocytosis syndrome". Substantial myoma size has been noted as a common denominator in this condition in which recent evidence have confirmed erythropoietin (Epo) production by myoma tissues themselves. Apart from its primary endocrine role in controlling erythropoiesis, Epo has been demonstrated to mediate several cellular processes such as angiogenesis, mitogenesis, and inhibition of apoptosis by autocrine and paracrine mechanisms. Recently, Epo and its receptor (Epo-R) have been shown to be involved in the growth, viability, and angiogenesis of several malignant tumors including human female reproductive organ malignancies. In this paper, we researched on Epo and, as a first in the literature, Epo-R immunoexpression in a large uterine myoma of a term pregnant patient suffering from the myomatous erythrocytosis syndrome. Eight nongravidic leiomyomas and 8 gravidic leiomyomas were used as control group samples. Apart from confirming Epo production by myoma smooth muscle cells in the myomatous erythrocytosis syndrome, we reveal in this pathologic condition a characteristic strong Epo-R expression in myoma endothelial cells and a weak and sporadic Epo-R expression in myoma smooth muscle cells. The striking presence of Epo-R within myoma tissues in the case of the myomatous erythrocytosis syndrome allows us to speculate that myoma Epo production, besides determining erythrocytosis through systemic effects, may contribute, acting by autocrine and paracrine mechanisms, in determining the large myoma size almost always observed in this condition. Finally, we confirm a less but specific immunostaining for Epo in uterine myomas of patients without erythrocytosis and, as a first in the literature, we prove a weak and sporadic Epo-R expression in these lesions. These last results may contribute to knowledge of the yet unclear etiopathogenesis of the most common human gynecologic neoplasm.

Erythrocytosis due to an Erythropoietin-Producing Large Uterine Leiomyoma

BACKGROUND

Various etiologies of myomatous erythrocytosis syndrome (erythrocytosis associated with a uterine leiomyoma), one of which is altered production of erythropoietin, have been proposed. We report a case of erythrocytosis associated with a large uterine leiomyoma in which erythropoietin activity and immunostaining for erythropoietin in the leiomyoma were found.

CASE

A 64-year-old woman, gravida 2, para 1, was referred to our department for treatment of a large uterine myoma and erythrocytosis with elevated levels of erythropoietin. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the results of the pathological examination confirmed the diagnosis of leiomyoma of the uterus, which weighed 920 g. The patient's postoperative course was satisfactory, and the levels of hemoglobin and erythropoietin were normalized and remained within normal ranges. The level of erythropoietin in the uterine leiomyoma measured by radioimmunoassay was elevated (372 mU/wet gram), and specific immunostaining for erythropoietin was found in the cytoplasm of leiomyoma cells. The levels of erythropoietin extracted from uterine leiomyomas of other patients who did not have erythrocytosis (control patients, n = 5) were lower (65 +/- 15.3 mU/wet gram), but specific immunostaining for erythropoietin was also found in the cytoplasm of leiomyoma cells from those patients.

CONCLUSIONS

Our case was typical of myomatous erythrocytosis syndrome in which uterine leiomyoma was proved to produce erythropoietin. Our results also suggest that erythropoietin is produced in uterine leiomyomas of patients with and without erythrocytosis. Leiomyoma of the uterus may affect the production of erythropoietin and may develop into myomatous erythrocytosis syndrome when the level of erythropoietin exceeds the normal range.

Neuroblastoma with expression of erythropoietin resulting in erythrocytosis

We report the detection of erythropoietin mRNA in the tumor from a patient with neuroblastoma and erythrocytosis. A 2-year-old girl with neuroblastoma presented with hemoglobin 21.3 g/dL, red blood cells 8.03 x 1012/L, and hematocrit 0.641. The serum erythropoietin level was 26.54 mU/mL. The hemoglobin, hematocrit, and serum erythropoietin level were within normal ranges 3 months after surgical excision of the tumor. RT-PCR analysis showed that erythropoietin mRNA expression in the tumor tissue was as high as that of normal renal tissue. These results conclusively demonstrated that the tumor was the site of the ectopic erythropoietin production.

CT and MRI of retroperitoneal edema associated with large uterine leiomyomas

Two cases of retroperitoneal edema surrounding the left ovarian vein that were associated with large uterine leiomyoma are presented. This finding was not associated with any specific lateralizing symptoms or with any evidence of malignancy. One patient underwent hysterectomy with surgical exploration of the retroperitoneum that confirmed the absence of malignancy. The CT and MR findings in this entity are described and possible etiological mechanisms discussed. Recognition that large leiomyoma can be associated with benign retroperitoneal edema may help avoid inappropriate management.