The currently reported case is of a 46-year-old nulligravid female patient, of Middle Eastern ethnicity, who presented to the outpatient Gynaecology Clinic of our hospital one year ago. Her complaints included mild pelvic pain requiring the intake of non-steroidal anti-inflammatory drugs once a day two days a week at most. She also complained of pelvic heaviness combined with a gastrointestinal bloating sensation that required the daily intake of antiflatulent medication, which was not helpful in soothing the complaint. She had a past medical history of primary infertility for 20 years. She also had an abdominal myomectomy through a low-transverse abdominal incision 17 years earlier. A clinical examination revealed a huge pelvi-abdominal mass extending up to the level of her xiphisternum. A combined abdominal and vaginal ultrasound (US) revealed the presence of multiple leiomyomata with a huge subserous leiomyoma showing evidence of degeneration and extending to the level of the left lobe of her liver (Figure ). There was no evidence of ureteric obstruction or renal pelvic ectasia as shown by a renal US. For an abdominal US we used a curvilinear probe with a frequency of 5 MHz, while for the transvaginal US a 7.5 MHz probe was used. The long history of the mass and its slow growth rate constituted a low index of suspicion of a uterine sarcoma.
Figure 1 US and Doppler examination of the leiomyoma. US examination showing a heterogeneous echotexture of the mass and presence of multiple echo free areas, Doppler blood flow indices in and around the huge leiomyoma recorded a resistance index of 0.61 and pulsatility (more ...)
No further imaging investigations were requested due to the highly suggestive characteristics of the mass on US; accordingly the clinical diagnosis of a huge subserous uterine leiomyoma was made. An abdominal hysterectomy via a lower midline incision with left periumbilical extension was performed. Intraoperatively, the uterus was found to be of normal size with numerous variable sized pedunculated subserous leiomyomata diffusely attached to its surface (Figure ).
Uterine fibroids. Normal sized uterus with multiple subserous fibroids.
The huge degenerated leiomyoma previously delineated on sonography (Figure ) turned out to be a retroperitoneal mass extending from the left side of her pelvis through the infundibulopelvic ligament upwards to the lower border of her spleen, with no connections with the leiomyomata-studded uterus. The mass displaced her mesosigmoid and her descending colon medially and even the root of the mesentry was displaced towards the midline. General surgeons were involved; they dissected the mass from its retroperitoneal vascular connections. The mass was in close proximity to her descending colon which was reflected medially in order to gain better access to the mass. The mass was crossing her left kidney anteriorly to the level of her spleen. Dissection in this area was very meticulous due to the proximity to the tail of her pancreas. The hysterectomy specimen and the huge retroperitoneal mass were sent for pathological examination. The postoperative course of our patient was very smooth and she was safely discharged on the fourth postoperative day. She returned ten days later for wound care which showed very good healing.
Retroperitoneal leiomyoma. Large 18 cm × 23 cm retroperitoneal fibroid completely separable from the uterine fibroids. (A) Intraoperatively and (B) after resection.
The histopathologic examination revealed a non infiltrative growth with scant mitotic activity (one mitotic figure per 10 high power field) with no atypia, thus confirming the benign leiomyomatous nature of this huge retroperitoneal growth, with evidence of hyaline degeneration (Figure )
Figure 4 Histological examination of the leiomyoma. The retroperitoneal mass showed a whorled (fascicular) pattern of smooth muscle bundles separated by well vascularized connective tissue; smooth muscle cells were elongated with eosinophilic or occasional fibrillar (more ...)