Cotyledonoid Dissecting Leiomyoma of the Uterus

The clinical challenge of a uterine cotyledonoid dissecting leiomyoma with adenomyosis: A case report

Cotyledonoid dissecting leiomyoma (CDL) is a rare uterine tumor with unique clinical and histological features. We present a case of a 46-year-old woman with a 3-month history of left-flank pain radiating to the back. The patient had a history of infertility and a previous miscarriage. Ultrasound revealed a solid tissue mass suggestive of a degenerated fibroid. Laparoscopy identified subserosal leiomyoma and leiomyoma in the broad ligament. Histologically, CDL is characterized by disorganized smooth muscle with hyaline degeneration and no evidence of malignancy. Clinically, CDL can present with a variety of symptoms, including heavy menstrual bleeding, pelvic pain, and infertility. The coexistence of CDL and adenomyosis is exceedingly rare. This case highlights the importance of considering CDL in the differential diagnosis of pelvic mass, malignant neoplasms, and infertility, even with atypical symptoms. It also emphasizes the value of cooperation between clinicians and pathologists for accurate diagnosis and management of CDL. Adenomyosis in this case further complicated the diagnosis and highlighted the need for an index of suspicion for this rare condition.

Cotyledonoid dissecting leiomyoma of the uterus: a case report and review of the literature

BACKGROUND

Cotyledonoid dissecting leiomyoma, also named Sternberg tumor, is a rare variant of uterine leiomyoma. The tumor is benign, but the appearance and growth pattern are unusual and alarming. In this article, we report a case of cotyledonoid dissecting leiomyoma in a 55-year-old woman as well as review relevant literature.

CASE PRESENTATION

We report a case of cotyledonoid dissecting leiomyoma in a 55-year-old Iranian woman who presented with vaginal bleeding 4 months after menopause. Ultrasound showed two heterogeneous hypoechoic masses on the uterine fundus. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed for the patient. Macroscopically, a large heterogeneous intramural mass (140 mm × 120 mm × 120 mm) with a grape-like exophytic mass on the fundus was observed. Her health status was good after surgery, and the patient was discharged from the hospital after 2 days. In a 1-year follow-up period, no recurrence or any other related complications were found.

CONCLUSION

It is important to recognize this rare variant of leiomyoma to prevent aggressive and inappropriate overdiagnosis and overtreatment. It is suggested to try to use frozen sections for better diagnosis and to preserve fertility in young women suffering from this lesion.

Intraoperative Frozen Section Biopsy of Uterine Smooth Muscle Tumors: A Clinicopathologic Analysis of 112 Cases With Emphasis on Potential Diagnostic Pitfalls

Frozen sections of uterine smooth muscle tumors are infrequently required, and related diagnostic difficulties are seldom discussed. We analyzed the clinicopathologic features of 112 frozen sections of uterine smooth muscle tumors and determined the accuracy, reasons for deferrals, and causes of interpretational errors. Most patients (median age, 45 y) presented with pelvic mass symptoms (53%). The main reasons for a frozen section examination were an abnormal gross appearance including loss of the usual whorled pattern of leiomyoma (36 cases, 32.1%), and intraoperative discovery of an abnormal growth pattern and extrauterine extension of a uterine tumor (28 cases, 25%). There were 9 leiomyosarcomas and 103 leiomyomas, including 18 benign histologic variants. An accurate diagnosis of malignancy was achieved in all leiomyosarcomas, with the exception of a myxoid leiomyosarcoma. In 99 cases (88%), the frozen section diagnosis concurred with the permanent section diagnosis (false positives, 0.9%; false negatives, 0%). Misinterpretation of stromal hyalinization as tumor cell necrosis in a leiomyoma with amianthoid-like fibers was a major discrepancy. Two minor discrepancies did not lead to a change in management. The diagnosis was deferred in 10 cases (8.9%) because of stromal alterations, unusual cellular morphology, uncertain type of necrosis, and abnormal growth patterns. Thus, although various stromal and cellular alterations can cause diagnostic uncertainty, leading to deferrals, frozen section diagnosis of uterine smooth muscle tumors has a high accuracy rate. While a definitive frozen section diagnosis of malignancy may be made when there is unequivocal atypia, indisputable mitotic figures, and tumor cell necrosis, it is important to remember that nonmyogenic mesenchymal tumors may also mimic uterine smooth muscle tumors. In a frozen section setting, it would be sufficient to issue a diagnosis of "malignant mesenchymal tumor." For tumors that do not meet the criteria for malignancy, issuing a frozen section diagnosis of "atypical mesenchymal tumor and defer the histologic subtyping to the permanent sections" is appropriate.

The Management of the Cotyledonoid Leiomyoma of the Uterus: A Narrative Review of the Literature

Cotyledonoid leiomyoma is an unusual uterine myoma due to some ultrasound features that mimic a malignant lesion facilitating the choice of radical surgery. This study aims to summarize the ultrasound and the magnetic resonance imaging aspects of this atypical lesion, and also discuss surgical treatment and pathological exam. It included all English case reports or case series until August 2021 found through PubMed, Google Scholar, and Scopus. A total of 94 cotyledonoid leiomyomas were reported, with a median tumor size of 12 cm. The typical ultrasound image is characterized by a large solid heterogeneous mass, with high vascularity, no shadowing, and indistinct margins within the myometrium. Magnetic resonance imaging shows the presence of merging isointense nodules to the myometrium in T1-weighted images, hyperintense in T2-weighted images, and contrast agent enhancement. Surgical treatment consists of hysterectomy (75 cases, 80%) or myomectomy (19 cases, 20%), without evidence of recurrence if complete. The placenta-like appearance observed during surgery supports this rare fibroid hypothesis. The intraoperative frozen section can be considered. Microscopically, no atypical cells, signs of mitotic activity or cell necrosis are found. To conclude, some preoperative and intraoperative aspects of this lesion are distinctive and may lead surgeons to opt for conservative surgery.

Cotyledonoid Leiomyoma Clinical Characteristics, Imaging Features, and Review of the Literature

Cotyledonoid leiomyoma of the uterus is a rare variant of benign uterine leiomyoma. It has a favorable attitude, despite some ultrasound presentations. A bulky uterus with a heterogeneous mass with irregular margins, high vascularity, and infiltration of the myometrium can induce the suspicion of a malignant mesenchymal tumor and lead to a radical surgical treatment. If present, some imaging features may suggest this rare type of leiomyoma, thus avoiding extensive surgery, especially in young nulliparous women. We report 13 cases of cotyledonoid leiomyoma with clinical characteristics, imaging features, and a literature review.

Massive cotyledenoid leiomyoma treated with uterine-conserving surgery

Objective

To describe and illustrate a massive cotyledenoid leiomyoma treated with uterine-conserving surgery.

Design

Case report.

Setting

Medical center.

Patient(s)

A 39-year-old woman with a large abdominal mass and a magnetic resonance imaging scan showing a 28-cm multi-lobulated mass.

Intervention(s)

Laparotomy and myomectomy.

Main Outcome Measure(s)

Recurrence and need for repeat surgery.

Result(s)

No recurrence at 8 years of follow-up.

Conclusion(s)

Cotyledonoid leiomyomas are rare. These benign tumors may be suspected preoperatively based on MRI appearance. Frozen section suggests a benign process and uterine-conserving surgery may be successfully accomplished.

An unusual case of uterine cotyledonoid dissecting leiomyoma with adenomyosis

Background

Cotyledonoid dissecting leiomyoma is a rare variant of uterine smooth muscle tumor with an unusual growth pattern that shows intramural dissection within uterine myometrium and often a placenta-like appearance in its extrauterine components.

Case presentation

We present a unique case of cotyledonoid dissecting leiomyoma with adenomyosis. A 40-year-old Japanese female presented with prolonged menorrhagia and severe anemia. She had a pelvic mass followed-up for 6 years with a diagnosis of leiomyoma. However, increase in tumor size and cystic changes with hemorrhage were found by magnetic resonance imaging, and total abdominal hysterectomy with bilateral salpingectomy was performed. Macroscopically, the placenta-like exophytic mass protruding from the posterior uterine wall was composed of multiple nodules containing numerous hemorrhagic cysts. The mass showed continuity as a white multinodular dissecting mass infiltrating the posterolateral myometrium. Microscopically, both extra–and intrauterine portions of the mass were composed of nodules that contained swirled neoplastic smooth muscle cells with marked hyalinized degeneration, as observed in cotyledonoid dissecting leiomyomas of conventional type. In addition, numerous non–neoplastic glands of endometrial type surrounded by abundant endometrium–like stromal cells and non–neoplastic smooth muscle cells were found in the tumor, suggesting that it involved a part of concomitant adenomyosis originating from the nontumoral myometrium.

Conclusions

Thus far, over 30 cases of cotyledonoid dissecting leiomyoma have been reported, none of which have described the presence of adenomyosis within the tumor. The present case suggested that cotyledonoid dissecting leiomyoma might have a unique clinical presentation involving concomitant uterine adenomyosis. It is critical for pathologists, gynecologists, and radiologists to be cognizant of cotyledonoid dissecting leiomyoma variants for timely and appropriate diagnosis and treatment.

Cotyledonoid dissecting leiomyoma of the uterus: A report of four cases and a review of the literature

Cotyledonoid dissecting leiomyoma (CDL), also termed Sternberg tumor, is a variant of uterine leiomyoma that is rarely diagnosed by clinical evaluation. At present, ~43 cases of CDL have been reported in the literature written in the English language. Due to the distinctive grapelike gross appearance of an exophytic mass resembles placental tissue, CDL is often misdiagnosed clinically as an ovarian tumor or uterine sarcoma. Therefore, an awareness of the features of the disease is important to prevent misdiagnosis and overtreatment. The present study reports 4 cases of CDL of the uterus that were treated at the Second Hospital of Jilin University between January 2009 and December 2011. All 4 patients in the current study presented with a palpable asymptomatic pelvic mass, which was detected during physical examinations, and cancer antigen 125 tumor marker levels that were within the normal range. The exploratory laparotomy of the 4 patients revealed lobulated tumors with a grapelike appearance extending from the lateral uterine wall into the ligament or the adjacent tissues. The frozen section and postoperative pathology were diagnosed as CDL. A total abdominal hysterectomy was performed in the first case of a 55-year-old woman that had been in menopause for 7 years. The patient was well and showed no evidence of disease subsequent to 48 months of follow-up. A total abdominal hysterectomy and right salpingo-oophorectomy were performed in the second case of a 43-year-old woman, who was well and showed no evidence of disease subsequent to 26 months of follow-up. A subtotal abdominal hysterectomy and bilateral salpingectomy were performed in the third case of a 37-year-old woman, who was well and showed no evidence of disease subsequent to 27 months of follow-up. A total abdominal hysterectomy and right-salpingectomy were performed with the removal of a retroperitoneal fibroid extension in the fourth case of a 48-year-old woman, who was well and showed no evidence of disease subsequent to 32 months of follow-up.

Cotyledonoid dissecting leiomyoma of the uterus: report of two cases

BACKGROUND

Cotyledonoid dissecting leiomyoma (Sternberg tumor) is a rare variant of the uterine smooth muscle tumor. Although this tumor is a benign tumor clinically and pathologically, the appearance and growth pattern is unusual, so it may be misdiagnosed as malignancy.

CASE REPORTS

We report two cases of cotyledonoid dissecting leiomyoma of the uterus that occurred in two 44- and 31-year-old women, respectively. Total hysterectomy and bilateral salpingo-oophorectomy were performed in one of the patients, and myomectomy was done in the other one. Macroscopically, both tumors were grape-like exophytic masses resembling placental tissue. The patients were well after surgery, and one patient gave birth. To our knowledge, this is the first case report of a successful delivery after myomectomy of this tumor.

CONCLUSION

To prevent aggressive surgery it is important to recognize that this tumor is a benign and unusual appearing variant of leiomyoma. A fertility-sparing surgical procedure should be considered if the patient wishes to preserve her fertility.

Epithelioid cotyledonoid leiomyoma of uterus

A 42-year-old para 2 women underwent laparotomy with a preoperative diagnosis of leiomyoma uterus and ovarian endometrioma. At laparotomy, uterus was 12-week size and bilateral tubes and ovaries were normal. There was a large friable reddish-brown mass dissecting the leaves of broad ligament with extension into pelvic cavity and retroperitoneal spaces. Total abdominal hysterectomy with bilateral salpingo-oophorectomy with resection of tumour was performed as there was concern about the possibility of malignancy. Histopathological examination revealed a cotyledonoid leiomyoma epithelioid variant. These tumours, though benign, raise the possibility of malignancy at the time of surgery due to their bizarre and sarcoma-like appearance. It is important for the pathologist and gynaecologist to be aware of this rare variant of leiomyoma to avoid an overtreatment.

Cotyledonoid dissecting leiomyoma treated by laparoscopic surgery: a case report

A cotyledonoid dissecting leiomyoma is categorized as a leiomyoma with an unusual growth pattern, which is characterized by remarkable extrauterine bulbous growth in continuity with a dissecting myometrial component. A 36-year-old patient was preoperatively diagnosed with a mature cystic teratoma of the left ovary, and according to MRI, the tumor protruded from the uterus into the right broad ligament and was 10 cm in diameter. She underwent laparoscopic surgery to resect ovarian teratoma and the tumor under the right broad ligament. The tumor was almost completely resected and diagnosed as a cotyledonoid dissecting leiomyoma based on intraoperative and pathological findings. Recurrence was not seen for 26 months postoperatively in our case. Gross specimens are often mistaken for malignant lesions, but this was a benign disease. Even if some remnants of the leiomyoma remained postoperatively, recurrence has never been reported. When a cotyledonoid dissecting leiomyoma is resected laparoscopically, intrapelvic structures around it, such as the ureter, uterine artery, bladder, rectum and external iliac vessels, must be given careful attention.

Cotyledonoid Dissecting Leiomyoma of the Uterus

Cotyledonoid dissecting leiomyoma is a rare benign uterine tumor whose gross and radiological appearance may raise the possibility of a malignancy. The authors summarize herein the clinical, radiological, and pathological features of the 41 previously reported cases. The patients typically presented with menorrhagia or symptoms that were ultimately relatable to the presence of a pelvic mass. The median patient age was 46 years (range 23-73). The average tumor size was 15.4 cm (range 4-41); most were exophytic, multinodular, occasionally cystic masses with a congested, spleen or placenta-like color, protruding over the uterine serosa and, variably, the broad ligaments and adjacent organs. In most cases, the exophytic component was contiguous with the intramural dissecting leiomyomatous components. Histological features suggestive of malignancy, such as cytological atypia, necrosis, or increased mitotic activity were absent. Intravascular growth, as assessed histologically, was present in 20% of reported cases, and this finding is apparently devoid of clinical significance based on limited data. Reported information on radiological features is limited. However, these lesions are typically isointense to myometrium on T1-weighted MRI and are in general less heterogeneous on T2 and postcontrast-imaging than sarcomatous lesions. The tumor may display extension to but not frank invasion of surrounding organs. Ultrasound features are nonspecific. Follow-up information was available in 25 (61%) of 41 reported patients: none experienced a tumor recurrence or metastases during the follow-up period, which ranged from 1 month to 41 years. This affirms the benign nature of this tumor, its alarming gross appearance and growth patterns notwithstanding.

Cotyledonoid dissecting leiomyoma of the uterus with intravascular growth in postmenopausal woman: a case presentation

Cotyledonoid dissecting leiomyoma ("Sternberg tumor") is an unusual type of a benign uterine smooth-muscle tumor with a distinctive gross appearance. A 57-year-old woman (gravida 7, para 6), in menopause for 3 years, presented with a 3-4-year history of increased pelvic pain. The transvaginal ultrasound scan showed a 2.5 cm sized heterogenic mass in the uterus cavity and 4 × 5 cm sized irregular contoured mass in the right lateral aspect of the uterus. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed with removal of the pelvic tumor extension. Definite pathologic examination result was cotyledonoid dissecting leiomyoma of the uterus with intravascular growth. The patient is receiving follow-up care every 6 months, and she has no evidence of disease after 22 months of follow-up. The worrying appearance of the gross specimen is often mistaken for malignant or non-uterine lesions that may result in overtreatment. It is important to be aware of this entity to prevent overly aggressive treatment for this benign smooth-muscle neoplasm.

Epithelioid cotyledonoid dissecting leiomyoma: a case report and review of the literature

A 63-year-old mother of two, presented with blood-stained vaginal discharge and right sided lower abdominal pain. A MRI examination confirmed a right parametrial mass, abutting the lateral margin of the uterus and the patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histological examination diagnosed a cotyledonoid leiomyoma, but with a new epithelioid variant. Cotyledonoid leiomyom's usually have a large, fungating appearance and demonstrate apparent widespread infiltrative growth and extension into the pelvic cavity, broad ligament and retroperitoneal space which may raise significant concern about the possibility of a malignant neoplasm. As these tumours are rare and infrequently encountered, it is imperative that clinicians be aware of this entity as they may pose a significant diagnostic and management challenge when encountered. Awareness of this newly described epithelioid cell variant of cotyledonoid dissecting leiomyoma is necessary for an accurate diagnosis and to facilitate appropriate management decisions at the time of surgery. This new variant further emphasizes the need for meticulous histopathological assessment which should be undertaken to circumvent misdiagnosis. This has direct clinical relevance to all operating gynaecologists and may have implications for litigation because patients may be inappropriately and inadvertently over-treated for an essentially benign condition.

Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy

Uterine smooth muscle tumors are classified according to their morphologic features that include architecture, growth pattern, cellular characteristics and constituents of the intercellular stroma. While terminologies used for the pathologic diagnosis of various subtypes may be eloquent and histologically accurate, some of these are confusing for the clinician and may also be open to interpretation by different pathologists: the labeling of atypical leiomyomas epitomizes this intricate system. Clinically, it is probably more useful to classify them as either tumors with or tumors without recurrent and/or metastatic potential. The term "atypical leiomyoma" has been used to label tumors that have a low risk of recurrence and is synonymous with benign tumors. The latter are known variously as leiomyoma with bizarre nuclei, symplastic leiomyoma, or pleomorphic leiomyoma. Variants of benign uterine smooth muscle tumors, such as mitotically active leiomyoma, cellular and highly cellular leiomyoma, epithelioid leiomyoma, and myxoid leiomyoma each have distinctive hallmarks that enable subclassification. Nevertheless, they may occasionally possess one or more unusual features that are cause for alarm. Tumors that have a dissecting growth pattern, with or without extrauterine extension, may mimic malignancy both grossly and microscopically. The current review discusses the pathologic diagnosis of and terminology applied to selected variants of uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas with emphasis on unusual reported features that may indicate malignancy. This includes an update on uterine smooth muscle tumor of uncertain malignant potential (STUMP), intravenous leiomyomatosis, benign metastasizing leiomyoma, and diffuse leiomyomatosis. Their clinicopathologic features, differential diagnoses, and management options based on findings in the previously reported cases will also be reviewed.

Cotyledonoid dissecting leiomyoma of the uterus associated with endosalpingiosis

Cotyledonoid dissecting leiomyoma (CDL) may create a diagnostic challenge. A 47-year-old woman underwent laparotomy for a large pelvic mass associated to vaginal bleeding. During operation, a bulky deep red mass protruding from the uterus and projecting into the pelvic cavity was discovered. Allowing to sarcoma- like appearance, a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed with removal of the pelvic tumor extension. The diagnosis of cotyledonoid dissecting leiomyoma of the uterus associated with endosalpingiosis was performed. To the best of our knowledge, this association has never been encountered in the English literature.

Cotyledonoid dissecting leiomyoma of the uterus with intravascular growth: report of two cases

We present two cases of cotyledonoid dissecting leiomyoma of the uterus with intravascular involvement, which occurred in women aged 73 and 48 years. Grossly and microscopically, both neoplasms had an extrauterine cotyledonoid part and intrauterine dissecting fascicles of disorganized, swirled neoplastic smooth muscle with hydropic degeneration and foci of an intravascular growth (the latter was identified histologically). To our knowledge, the intravascular component of such a neoplasm is a very rare feature that has previously been described only in three cases in the literature.