Journal of Genital System & Disorders

Aydin et al., J Genit Syst Disor 2015, 4:1
http://dx.doi.org/10.4172/2325-9728.1000134
Journal of Genital System
& Disorders
Case Report
A SCITECHNOL JOURNAL
Is it an Adnexal Mass or a Broad
Ligament Leiomyoma?
Cetin Aydin, Halime Sen Selim*, Selda Uysal, Serenat Eris and
Yakup Yalçın
Gynecology and Obstetrics Department of Ataturk Training and Research
Hospital, Basin Sitesi, Yesilyurt, 35360 Izmir-Turkey
*Corresponding
Author: Halime Sen Selim, MD, Gynecology and Obstetrics
Department of Ataturk Training and Research Hospital, Basin Sitesi, Yesilyurt,
35360 Izmir-Turkey, Tel: 00902322444444/2433, Mob: 05354916607, Fax:
00902322431530; E-mail: [email protected]
Rec date: February 11, 2014 Acc date: April 15, 2015 Pub date: April 20, 2015
Abstract
Uterine Leiomyomas and adnexal masses are the most
common causes of pelvic masses arising from the female
urogenital system. We present a case that demonstrates the
similarity between the leiomyoma and malign adnexal cyst. A
51 year-old, post-menopausal women presented with lower
abdominal pain and a pelvic mass (6x7 cm diameter). The
sonographic appearance of the mass was multi-cystic with
some solid area, indistinct margin on the right side of the uterus
and intra-abdominal fluid, similar to typical malign ovarian
cysts. We performed exploratory laparotomy and found that the
mass was a pedunculated subserosal myoma arising from right
side of the uterine corpus, which extending between the folds
of the broad ligament. Histopathological examination revealed
subserosal leiomyoma with cystic degeneration. Postmenopausal cystic degenerative leiomyoma can be a good
imitation of ovarian neoplasms, resulting in diagnostic
confusion.
Keywords: Leiomyoma;
Ultrasonography;
Pelvic
Tuberculosis
Ovarian Neoplasms; Ascitic Fluid;
Inflammatory
Disease;
Peritoneal
Introductıon
Adnexal masses are common in all age groups, from in the fetus to
post-menauposal women. To determine the origin of an adnexal mass
is generally difficult. The adnexal area contains the ovary and fallopian
tube, associated vessels, ligaments, and connective tissue. Masses of
this area often from the ovary or fallopian tube however, the broad
ligament, uterus, bowel, or retro peritoneum can also produce an
adnexal mass.
Uterine leiomyoma are the most common type of pelvic mass
arising from the female urogenital system [1]. A subserosal leiomyoma
of the adnexal area can cause diagnostic confusion. Generally, during
ultrasound examination the uterus and uterine Leiomyomas appear to
be of the same density and diagnosis is simple. However, the
appearance of cystic degenerated leiomyoma can be similar to adnexal
masses, which can lead to diagnostic confusion.
complexity or solidity of the mass upon ultrasound examination, or
with the presence of ascites.
The source of the mass and possibility of malignancy is predictable
according to the age of the patient, clinical findings, ultrasound
examination and tumor markers level. However, definitive diagnosis
can be determined only after surgery.
In the present case, rare location and unusual sonographic reveals
the importance for differential diagnosis of an adnexal mass.
Case Presentation
A 51 year-old, gravida3, para2, post-menopausal was admitted to
our hospital, complaining of lower abdominal pain. Her last menstrual
cycle was 6 years previously.
A pelvic examination revealed a semi-Mobil mass consistent with a
6–8 week gestational uterus. The mass was in the right adnexal area,
and there was no clear border between the mass and right side of the
uterus. The left ovary was non-palpable.
Ultrasound examination revealed a 8×7×6 cm heterogeneous mass,
the sonographic appearance of the mass was multi-cystic with some
solid area, an indistinct margin with the right side of the uterus and
intra-abdominal fluid, resembling a malign ovarian cyst. The left ovary
appeared normal but right ovary could not be visualized.
The patient’s tumor markers level was within the normal range
(e.g., Ca125 was 4IU/ml). The haemoglobin level was 12.6 g/dl and
there was no indication of urine infection.
An exploratory laparotomy was performed to investigate this postmenopausal pelvic mass of unknown origin. On inspection, there were
bilateral normal ovaries, a post-menauposal uterus with multiple
subserosal myxomatous nodules (ranging from 1 to 3 cm), and a pelvic
mass in the right broad ligament with some free fluid in the pelvic
cavity (Figure 1a).After dissection of the broad ligament, we identified
a 6×7 cm diameter degenerated subserosal myoma arising from the
right-side of the uterine corpus (Figure 1b). We performed a total
hysterectomy with bilateral salpingo-oophorectomy.
Histopathological examination revealed multiple subserosal
leiomyoma, the largest one (6×7cm) was with cystic degeneration and
bigger than corpus of the uterus (Figure 2). Peritoneal cytology was
benign. The post-operative course was uneventful 5 days after surgery
the patient was discharged from hospital in good condition.
Discussion
A post-menopausal woman was admitted to the hospital
complaining of abdominal pain. At this point many diseases could be
considered for diagnosis, including pelvic inflammatory disease (PID),
urinary system pathologies, many intestinal diseases, and possibly a
pelvic mass.
A pelvic mass can be recognized after a bimanual pelvic
examination, although the origin can sometimes remain unclear.
Otherwise, pelvic inflammatory disease could be excluded by absence
of fever, purulent cervical discharge, and cervical motion tenderness.
Likelihood of malignancy of an adnexal mass increases from the
pre-pubescent to post-menopausal period, as well as with the
All articles published in Journal of Genital System & Disorders are the property of SciTechnol and is protected by
copyright laws. Copyright © 2015, SciTechnol, All Rights Reserved.
Citation:
Aydin C, Selim HS, Uysal S, Eris S, Yalçin Y (2015) Is it an Adnexal Mass or a Broad Ligament Leiomyoma?. J Genit Syst Disor 4:1.
doi:http://dx.doi.org/10.4172/2325-9728.1000134
Figure 1a: bilateral normal ovaries, a postmenauposal uterus with multiple subserosal myomatous nodules (ranging from 1-3 cm), and a
pelvic mass in the right broad ligament, Figure1b: dissection of the broad ligament; a 6x7 cm in diameter degenerated subserosal myoma arise
from right side of the uterine corpus.
because the broad ligaments are not generally visualized on ultrasound
examination.
Uterine Leiomyomas are the most common pelvic masses arising
from the female urogenital system [1]. Generally, they present
abnormal uterine bleeding or pelvic pain. Uterine Leiomyomas are
classified according to their location (i.e., intramural, submucosal,
subserosal or cervical), with intramural being the most common form.
Subserosal leiomyomas which originate from the myometrium at the
serosal surface of the uterus are less frequent and rarely extend
between the folds of the broad ligament.
Figure-2: Pathological examination of the specimen (macroscopic
& microscopic)
Imaging modalities are often helpful for certain diagnosis.
Ultrasound is the most common approach because of its relative cost
effectiveness and absence of ionizing radiation exposure, however, its
diagnostic performance is not perfect. A multicenter study reported
that 90% of extra uterine masses could be correctly classified by the
ultrasonography as benign or malignant, but the remaining 10% were
unclassifiable by their ultrasound findings [2].
The origin of a mass which is in the adnexal area may be attributed
to either the ovary or uterus (the most common masses of this area)
Volume 4 • Issue 1 • 1000134
Upon ultrasound examination, if an adnexal mass includes a solid
component or septation, it is more likely to be malignant. In addition,
the presence of ascites in the peritoneal cavity, and adnexal masses
larger than 8 to 10 cc volume in post-menopausal women, also raise
the suspicion of malignancy. Pedunculated fibroids usually appear as
heterogeneous, hypo echoic, solid masses. Cystic degeneration of a
fibroid can result in the appearance of a complex mass on ultrasound,
so that their appearance is more likely to be a malign ovarian cancer
[3]. Visualization of the ipsilateral ovary or additional studies with
magnetic resonance imaging can also help with diagnosis.
In this case, because of our patient’s age, presence of intraperitoneal
fluid, largeness and complex appearance of the mass, as well
localization, there was doubt regarding whether this could be a
malignant ovarian mass. In addition, the presence of a pelvis mass and
ascites, but without elevated Ca125 levels, peritoneal tuberculosis can
also be considered for diagnosis . Generally Serum CA 125 is elevated
but sometimes it could be in normal range [4,5].
The Ca125 levels and clinical appearance of the patient had
suggested that the mass could be benign.
Ultrasound and magnetic resonance imaging (MRI) are the most
useful imaging modalities for the diagnosis of leiomyoma [6].
Although their sensitivity and specificity are decreased in the diagnosis
• Page 2 of 3 •
Citation:
Aydin C, Selim HS, Uysal S, Eris S, Yalçin Y (2015) Is it an Adnexal Mass or a Broad Ligament Leiomyoma?. J Genit Syst Disor 4:1.
doi:http://dx.doi.org/10.4172/2325-9728.1000134
of cystic degenerative subtypes MRI is more sensitive and specific than
ultrasound, but because of availability and cost-effectiveness,
ultrasound is the most widely used imaging modality.
In the present case, we used ultrasound for diagnosis. Due of cystic
degeneration and intraligamentary location of the subserosal subtypes
of leiomyoma; the mass was of an adnexal cyst [7]. Although MRI
might have been used for correct diagnosis prior to operation, due to
the localization and thin peduncle of the subserosal leiomyoma, MRI
may also have been insufficient.
2.
3.
4.
Conclusıon
Postmenopausal cystic degenerative leiomyomas can be a good
imitation of ovarian neoplasms and a cystic degenerative,
pedunculated uterine leiomyoma, which lies between the folds of the
broad ligament, should be considered in the differential diagnosis of
an adnexal mass [8].
5.
6.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
7.
References
8.
1.
Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM
(2003) High cumulative incidence of uterine leiomyoma in black
Volume 4 • Issue 1 • 1000134
and white women: ultrasound evidence. Am J Obstet Gynecol
188: 100-107.
Valentin L, Ameye L, Jurkovic D, Metzger U, Lécuru F, et al.
(2006) Which extrauterine pelvic masses are difficult to correctly
classify as benign or malignant on the basis of ultrasound
findings and is there a way of making a correct diagnosis?.
Ultrasound Obstet Gynecol 27: 438-444.
Dancz CE, Macdonald HR (2008) Massive cystic degeneration of
a pedunculated leiomyoma. Fertil Steril 90: 1180-1181.
Devi L, Tandon R, Goel P, Huria A, Saha PK (2012) Pelvic
tuberculosis mimicking advanced ovarian malignancy. Trop
Doct 42: 144-146.
Liu Q, Zhang Q, Guan Q, Xu JF, Shi QL (2014) Abdominopelvic
tuberculosis mimicking advanced ovarian cancer and pelvic
inflammatory disease: a series of 28 female cases. Arch Gynecol
Obstet 289: 623-699.
Mayer DP, Shipilov V (1995) Ultrasonography and magnetic
resonance imaging of uterine fibroids. Obstet Gynecol Clin
North Am 22: 667-725.
Yarwood RL, Arroyo E (1999) Cystic degeneration of a uterine
leiomyoma masquerading as a postmenopausal ovarian cyst. A
case report. J Reprod Med 44: 649-652.
Yıldız P, Cengiz H, Yıldız G, Sam AD, Yavuzcan A, et al. ( 2012)
Two unusual clinical presentations of broad-ligament
leiomyomas: a report of two cases. Medicina (Kaunas) 48:
163-165.
• Page 3 of 3 •