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.

Unilateral primary ovarian leiomyoma masqueraded as ovarian fibroma: A histopathological diagnosis

Leiomyoma is the commonest benign mesenchymal tumor of the uterus, which can be developed at any site where smooth muscle cells are found. The broad ligament is the most common and ovary is one of the rarest extrauterine sites, accounting for 0.5–1% of all benign ovarian tumors. Herein, we report a case of ovarian leiomyoma in a perimenopausal female, clinically presented with heavy menstrual bleed, radiologically diagnosed as subserosal uterine fibroid. Intraoperatively, it was considered as ovarian fibroma but finally diagnosed as ovarian leiomyoma on histomorphology, which was confirmed on special stains and immunohistochemistry. A review of literature showed that less than 100 cases of primary ovarian leiomyomata have been reported until now. Ovarian leiomyoma is usually small, asymptomatic, and an incidental finding mostly, usually synchronously seen with uterine leiomyoma. Ovarian leiomyoma is a rare tumor, often misdiagnosed prior to surgical removal and it should be differentiated from other spindle cell neoplasm and solid tumors of the ovary.

Endometrial stromal sarcoma of the sigmoid colon: a case report and literature review

Endometrial stromal sarcoma (ESS) is a rare mesenchymal tumor of the uterus that accounts for 7-25% of uterine sarcomas and < 1% of uterine tumors. Previously reported sites include the ovary, bowel wall, abdomen, peritoneum, pelvis, and vagina; however, ESS in the extrauterine area is rare. We report a rare case of endometrial stromal sarcoma that developed in the sigmoid colon along the gonadal vasculature, which was difficult to distinguish from colon cancer. A large polyp was found in the sigmoid colon of a 74-year-old woman during a routine medical examination and was diagnosed as tubular adenoma. On colonoscopy 7 months later, the tumor had grown and blocked the lumen, causing stenosis. She was referred to our hospital for surgery. Although detailed examination at our hospital did not yield a definitive diagnosis, bowel obstruction was considered likely and we performed laparoscopic low anterior resection under a preoperative diagnosis of sigmoid colon cancer. The tumor protruded into the sigmoid colon from the stump of the ovarian arteries and veins outside the intestinal tract. As the left ovarian artery and vein were involved in the tumor, we extracted them as a lump. The tumor was diagnosed as low-grade ESS (LG-ESS). She had a history of hysterectomy and left salpingo-oophorectomy for uterine myoma 25 years ago, and radiation therapy was performed after surgery for an unknown reason. The postoperative course was uneventful, and follow-up was continued at the request of the patient. We report a rare case of ESS infiltrating the sigmoid colon, which was probably a lesion derived from endometriosis of the ovarian arteriovenous stump remaining after surgery 25 years ago.

A hierarchical procedure to select intrauterine and extrauterine factors for methodological validation of preterm birth risk estimation

Background

Etiopathogenesis of preterm birth (PTB) is multifactorial, with a universe of risk factors interplaying between the mother and the environment. It is of utmost importance to identify the most informative factors in order to estimate the degree of PTB risk and trace an individualized profile. The aims of the present study were: 1) to identify all acknowledged risk factors for PTB and to select the most informative ones for defining an accurate model of risk prediction; 2) to verify predictive accuracy of the model and 3) to identify group profiles according to the degree of PTB risk based on the most informative factors.

Methods

The Maternal Frailty Inventory (MaFra) was created based on a systematic review of the literature including 174 identified intrauterine (IU) and extrauterine (EU) factors. A sample of 111 pregnant women previously categorized in low or high risk for PTB below 37 weeks, according to ACOG guidelines, underwent the MaFra Inventory. First, univariate logistic regression enabled p-value ordering and the Akaike Information Criterion (AIC) selected the model including the most informative MaFra factors. Second, random forest classifier verified the overall predictive accuracy of the model. Third, fuzzy c-means clustering assigned group membership based on the most informative MaFra factors.

Results

The most informative and parsimonious model selected through AIC included Placenta Previa, Pregnancy Induced Hypertension, Antibiotics, Cervix Length, Physical Exercise, Fetal Growth, Maternal Anxiety, Preeclampsia, Antihypertensives. The random forest classifier including only the most informative IU and EU factors achieved an overall accuracy of 81.08% and an AUC of 0.8122. The cluster analysis identified three groups of typical pregnant women, profiled on the basis of the most informative IU and EU risk factors from a lower to a higher degree of PTB risk, which paralleled time of birth delivery.

Conclusions

This study establishes a generalized methodology for building-up an evidence-based holistic risk assessment for PTB to be used in clinical practice. Relevant and essential factors were selected and were able to provide an accurate estimation of degree of PTB risk based on the most informative constellation of IU and EU factors.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12884-021-03654-3).

Hysteroscopic Intact Removal of Angular and Caesarean Scar Pregnancy: A Novel and Markedly Less Invasive Surgical Treatment

INTRODUCTION

Ectopic pregnancy is the most common cause of mortality during the first trimester of pregnancy, and intrauterine ectopic pregnancies show significantly higher morbidity and mortality than extrauterine ones. Despite being less invasive, safety and effectiveness of the hysteroscopic treatment are still unclear. Moreover, such approach is not standardized. We aimed to evaluate safety and effectiveness of hysteroscopic intact removal of angular or cesarean section scar pregnancies, defining a novel and markedly less invasive hysteroscopic technique with a 5-mm Bettocchi hysteroscope or a 3.5-mm Versascope hysteroscope.

MATERIALS AND METHODS

Medical records and video archives were reviewed for all the patients with angular or caesarean scar pregnancies treated with hysteroscopic intact removal technique from January 2000 to December 2018 at our Department. Success and complication rates were assessed.

RESULTS

Four patients with angular (n = 1) or cesarean scar pregnancy (n = 3) met inclusion criteria. Case #1 was treated with bipolar resectoscope, cases #2 and #3 with 5-mm Bettocchi hysteroscope, and case #4 with 3.5-mm Versascope hysteroscope. Cases #2-4 did not require cervical dilatation. Before hysteroscopic treatment, cases #2-4 underwent unsuccessful medical therapy with multiple-dose methotrexate. Hysteroscopic treatment success rate was 100%, while complication rate was 0%. All patients were treated with a novel technique: hysteroscopic intact removal of angular or cesarean scar pregnancies. Such technique was described step-by-step.

CONCLUSIONS

Hysteroscopic treatment of angular and cesarean scar pregnancies may be a safe and effective minimally invasive option. The novel technique of hysteroscopic intact removal technique may allow a markedly less invasive approach.

Extrauterine adenomyomas presenting in a 47 year old woman with a previous cesarean section

•Extrauterine adenomyoma cannot be solely diagnosed on the basis of radiographic appearance.•There are five theories for the pathophysiology of extrauterine adenomyomas.•Surveillance and treatment range from none to ovarian suppression.

Diagnostic challenges: low-grade adenosarcoma on deep endometriosis

Background

Müllerian adenosarcoma is a rare malignancy. These tumors occur mainly in the uterus, but also in extrauterine locations, usually related to endometriosis. Because of their rarity, there is limited data on optimal management strategies.

Case presentation

We present a 44-year-old woman with a history of endometriosis who consults for chronic pelvic pain. In the imaging tests, a heterogeneous mass is observed that impresses endometriosis, encompassing the uterus and left appendage. Surgery is performed by finding an extrauterine adenosarcoma that affected the uterus, ovary and bladder wall.

Conclusion

This is a rare case but should be considered in a patient with atypical clinical characteristics or preoperative pathology, so we show the diagnostic and therapeutic strategies carried out for the resolution of the case.

Retroperitoneal low grade endometrial stromal sarcoma with florid endometrioid glandular differentiation: Cytologic-histologic correlation and differential diagnosis

Low grade endometrial stromal sarcoma (LGESS) is a rare neoplasm that typically arises in the uterine corpus and accounts for less than 1% of uterine sarcomas. Infrequently, extra-uterine LGESS can occur. Histologically, LGESS is characterized by a monotonous population of cells that resemble the proliferative phase of endometrial stroma and in their classic form they exhibit tongue-like growth pattern of infiltration and/or lymphovascular invasion. Infrequently LGESS can demonstrate various morphologic differentiation patterns, including endometrioid-type glands. We report the first fine needle aspiration (FNA) case of a periduodenal mass that was incidentally discovered on Computed Tomography (CT) scan of a 60-year-old female. The cytomorphologic and histologic findings and the immunohistochemical staining were consistent with a LGESS with endometrioid glandular differentiation. We are presenting the correlation between the cytologic, radiologic and pathologic features.

An unexpected diagnosis of primary omental endometrial stromal sarcoma in a patient with acute right abdominal pain: A case report and review of literature

•

Only case in literature without history of endometriosis, on Hormone replacement therapy.

•

Only the second case with isolated omental lesion.

•

Extrauterine Endometrial Stromal Sarcoma (EESS) is an extremely rare mesenchymal tumour.

•

This condition can simulate chronic or acute abdominal pathologies.

•

The tumour can occur without preceding endometriosis, and in upper abdominal location.

•

Biopsy showing typical immunohistochemistry markers is the best way to achieve diagnosis.

•

Hormone replacement therapy may be an independent risk factor for EESS occurrence.

Introduction

Extrauterine Endometrial Stromal Sarcoma (EESS) is an extremely rare mesenchymal tumour that simulates other pathologies, and therefore poses a diagnostic challenge. This report outlines a case of EESS arising from the greater omentum mimicking a colonic tumour, with review of literature.

Presentation of case

A 47-year-old woman, with history of hysterectomy for menorrhagia and hormone replacement therapy (HRT), presented with right sided abdominal pain and localized peritonism. On exploratory laparoscopy an omental tumour, suspected to arise from the transverse colon was identified and biopsied. The histological features suggested an EESS. Colonoscopy ruled out colonic lesion. A laparoscopic tumour resection and bilateral salpingo-oophorectomy (BSO) was performed. Immunohistochemistry confirmed the diagnosis. No additional lesions or associated endometriosis were found. Resection was followed by adjuvant medroxyprogesterone-acetate therapy.

Discussion

We reviewed 20 cases of EESS originating from extragenital abdominopelvic organs reported since 1990. Acute presentation is rare, as well as upper abdominal occurrence. Isolated omental involvement was previously reported in only one case. Endometriosis is a risk factor for development of EESS and history and/or histological evidence for endometriosis is usually present. HRT is another acknowledged risk factor, mostly on the background of endometriosis. To our knowledge, this is the only report of EESS occurring in a woman on HRT treatment without background of endometriosis.

Conclusion

EESS can occur without endometriosis and HRT may be an aetiological factor. The condition can mimic a chronic or acute abdominal pathology and laparoscopic core biopsy is the best way to achieve a diagnosis and formulate management.

Primary extrauterine endometrial stromal sarcoma in the sigmoid colon

An endometrial stromal sarcoma (ESS) is an uncommon uterine neoplasm, and its primary occurrence in the intestine as an extrauterine ESS (EESS) is exceedingly rare. We hereby report a primary EESS arising in the sigmoid colon with a review of the literature. A 52-year-old woman presented with bloody stool and underwent a colon fiberscopy, which revealed a fungating mass obstructing the lumen at the distal sigmoid. A laparoscopic low anterior resection was performed, and an umbilicated polypoid mass was identified; on section, it had infiltrated the mesocolic fat and measured 3.8 cm × 2.5 cm. The tumor showed geographic sheets or nests composed of relatively monotonous stromal cells, expansion or infiltration to the proper muscle and mesocolic fat, and extensive lymphovascular invasion and metastasis to regional lymph nodes and the pelvic peritoneum. The tumor cells were strongly and diffusely immunoreactive for CD10, but negative for c-kit, CD34, and Dog1. Two months later, a hysterectomy with a bilateral salpingo-oophorectomy was performed, and no evidence of an ESS was found in the uterus.