Open Access

Disseminated peritoneal leiomyomatosis

Gynecological SurgeryEndoscopic Imaging and Allied Techniques20107:562

https://doi.org/10.1007/s10397-010-0562-7

Received: 24 December 2009

Accepted: 15 January 2010

Published: 23 February 2010

Abstract

We present a case of a 35-year-old lady with disseminated uterine leiomyomatosis diagnosed during laparoscopic uterine myomectomy, 7 years after a laparoscopy performed for the same reason. The disease should be kept in mind in order to avoid aggressive treatment due to the fact that the peritoneal myomas mimic malignant peritoneal tumors.

Keywords

Uterine myomasLeiomyomatosisPeritoneumDisseminated peritoneal leiomyomatosis

Introduction

Disseminated peritoneal leiomyomatosis (DPL) is a rare disease characterized by multifocal proliferation of smooth muscle-like cells that are histologically similar to uterine myomas, occurring predominantly in women of childbearing age. It is usually diagnosed during operations performed for other reasons due to its generally indolent course. We present a case of a patient with DPL and uterine myomas and the suggested treatment.

Case study

A 35-year-old lady was referred to our clinic due to uterine myomas. The patient had a previous myomectomy 7 years before and had never been under hormonal treatment. Transvaginal ultrasound detected four uterine myomas and a laparoscopic myomectomy was scheduled.

During the laparoscopy performed using the three-chip Standard System Analogue Camera (Karl Storz Gmbh, Tuttlingen, Germany), the uterine myomas were visualized, confirming the diagnosis (Fig. 1). Disseminated small nodules mimicking malignant tumors were visualized on the peritoneum of the pelvic wall (Fig. 2) and small bowel (Fig. 3). A biopsy was taken from the peritoneum. The uterine myomas were excised; hemostasis was assured by a single layer of Vicryl 1 hemostatic sutures over the uterine scars (Fig. 4) and a site-specific adhesion barrier (SprayShield™ Covidien Mechelen Belgium) was used (Fig. 5).
Fig. 1

Uterine myomas

Fig. 2

Malignant tumors visualized on the peritoneum of the pelvic wall

Fig. 3

Malignant tumors visualized on the small bowel

Fig. 4

Vicryl 1 hemostatic sutures over the uterine scars

Fig. 5

A site-specific adhesion barrier (SprayShield™)

Histological examination of the excised peritoneal specimen showed it was a myoma, and the diagnosis of disseminated peritoneal leiomyomatosis was made.

A second look performed 8 weeks later using the three-chip High Definition Digital Camera (Karl Storz Gmbh, Tuttlingen, Germany) visualized the same peritoneal myomas (Figs. 6, 7, and 8) and only a few de novo adhesions between the intestine and the uterine fundus which were cut (Fig. 9). Inspection of the upper abdomen showed no evidence of peritoneal tumors highlighting in our patient the exclusive presence of the disease in the pelvis (Fig. 10). A long-term follow-up was recommended and no medical treatment was given postoperatively.
Fig. 6

Peritoneal myomas visualized 8 weeks later

Fig. 7

Peritoneal myomas visualized 8 weeks later

Fig. 8

Peritoneal myomas visualized 8 weeks later

Fig. 9

De novo adhesions between the intestine and the uterine fundus which were cut

Fig. 10

Inspection of the upper abdomen showing no evidence of peritoneal tumors

Discussion

Disseminated peritoneal leiomyomatosis occurs primarily in premenopausal women and malignant transformation is extremely rare. The importance of recognizing the disease relies basically on the treatment options. Excision of all myomas has been tried and suggested by some authors [1], while medical treatment with GnRH analogs, aromatase inhibitors [2] or chemotherapeutic agents [3] was suggested by others for unresectable or metastatic disease. In most cases though, conservative treatment and long-term follow-up is recommended because of DPL's generally indolent clinical course [4]. Although it is a rare disease, it must be kept in mind whenever a patient presents with abdominal masses following myomectomy or hysterectomy.

Notes

Authors’ Affiliations

(1)
Ob/Gyn Department, ETCA (Endoscopic Training Centre Antwerp) Ziekenhuis Netwerk Antwerpen (ZNA) Stuivenberg-Sint Erasmus Lange
(2)
Ob/Gyn Department, Università degli Studi dell’Insubria

References

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  2. Takeda T, Masuhara K, Kamiura S (2008) Successful management of a leiomyomatosis peritonealis disseminata with an aromatase inhibitor. Obstet Gynecol 112(2 Pt 2):491–493PubMedGoogle Scholar
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  4. Hardman WJ 3rd, Majmudar B (1996) Leiomyomatosis peritonealis disseminata: clinicopathologic analysis of five cases. South Med J 89(3):291–294View ArticlePubMedGoogle Scholar

Copyright

© Springer-Verlag 2010

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