Huge (9 Kg) Broad Ligament Fibroid Mimicking Sarcoma of Uterus: A Case Report and Review of Literature.

Fibroids are most common benign tumors of the uterus, mostly situated in the body of the uterus. Rarely, they arise from extrauterine sites with broad ligament fibroids being uncommon. We present a case of a 47-year-old female, multipara who presented in outpatient department in CAMA hospital with a history of sudden development of dysuria 10 days back. Intraoperatively, uterus was pushed to side and large broad ligament fibroid of 25 cm × 20 cm × 20 cm seen arising from right-sided broad ligament. The fibroid was densely adherent to bowel and bladder. Exploratory laparotomy with excision of broad ligament fibroid of 9 Kg with total abdominal hysterectomy with right salpingo-oophorectomy was done.

INTRODUCTION

We present a case of a 47-year-old female, multipara who presented in outpatient department in CAMA hospital with ultrasound suggestive of 26 cm × 10 cm × 18 cm well-defined hypoechoic lesion in right adnexal area with multiple internal echoes with solid component in the lesion suggestive of broad ligament fibroid. Patient gave history of sudden development of dysuria 10 days back for which she consulted doctor. Ultrasound Doppler and magnetic resonance imaging (MRI) were suggestive of large size highly vascular fibroid in the right broad ligament of size 26 cm × 12 cm × 20 cm with venous congestion. Intraoperatively, uterus was pushed to side and large broad ligament fibroid of 25 cm × 20 cm × 20 cm seen arising from right-sided broad ligament. The fibroid was densely adherent to bowel and bladder. Both ovaries were normal sized. Exploratory laparotomy with excision of broad ligament fibroid of 9 Kg with total abdominal hysterectomy was done. Left ovary was saved. Right-sided ovary was difficult to save as it is adherent to the fibroid. Frozen section revealed broad ligament leiomyoma. This confirmed on the histopathology report as benign leiomyoma of right broad ligament.

CASE REPORT

A 47-year-old female multigravida presented in CAMA and ALBLESS hospitals, Mumbai, with complaint of pain in abdomen for 2–3 weeks with associated abdominal mass and dysuria which was acute in onset for last 3 weeks. On examination, she had abdominal mass of 28 weeks' size, hard in consistency with smooth surface. She was investigated further. Her MRI A+P revealed 26 cm × 12 cm × 20 cm well-defined mass arising from pelvis from the right side pushing uterus to the left with intense vascularity and heterogeneous enhancement; the mass is separate from uterus mostly suggestive of vascular broad ligament fibroid [Figure 1]. Her CA 125 levels revealed normal values as 10IU/ml. The patient was taken for exploratory laparotomy. Intraoperatively, large mass of 25 cm × 20 cm × 20 cm was seen arising from the right broad ligament the pushing uterus to left side. Soft to hard in consistency, fixed, and impacted with large dilated many vessels on the surface of the fibroid [Figure 2]. There were dense adhesions present between mass and bowel and bladder. The bladder separated with the use of cautery carefully. Bowel separated with blunt and sharp dissection without any damage to them. Both sided ureters were identified and the course was traced. Mass was highly vascular. Exploratory laparotomy with removal of right-sided broad ligament fibroid was done. Total abdominal hysterectomy with right-sided salpingo-oophorectomy was done. The frozen section report revealed benign broad ligament fibroid; the fibroid weighed of 9 Kg [Figures 3–5]. Postoperatively, the patient was stable. Her histopathology report revealed broad ligament leiomyoma with chronic cervicitis with right simple ovarian cyst.

Figure 1

MRI showing huge broad ligament fibroid of the left side

Figure 2

Picture showing large broad ligament fibroid with adherent bladder

Figure 3

Picture showing normal-sized uterus with large broad ligament fibroid of 25 cm × 20 cm × 20 cm with dilated vessels

Figure 5

Picture showing huge fibroid of 9 Kg

Huge broad ligament fibroid with right side ovary adherent to it and the uterus and cervix are normal and separated from the fibroid

DISCUSSION

Fibroids are most common benign tumors of the uterus, mostly situated in the body of the uterus. Rarely, they arise from extrauterine sites with broad ligament fibroids being uncommon. The broad ligament is the most common extrauterine site for the occurrence of leiomyoma but with a very low incidence rate. Because of its overall low incidence rate, it poses both clinical and radiological difficulty in differentiating with an ovarian tumor.[1] Clinically, broad ligament fibroids may manifest as extrauterine pelvic masses that compress the urethra, bladder neck, or ureter producing symptoms of varying degrees of urinary outflow obstruction. Studies have shown that round ligament is the guiding factor to go in the anatomical plane in cases of huge fibroids and guides us for further surgery.[2] On ultrasound, a typical leiomyoma usually has a whorled appearance, with variable echogenicity depending on the extent of degeneration, fibrosis, and calcification.[3] The differential diagnosis for broad ligament fibroids includes masses of ovarian origin, broad ligament cyst, and lymphadenopathy. Pedunculated leiomyomas should be considered in the differential diagnosis of a solid adnexal mass.[4] Transvaginal ultrasound may be of help in diagnosing broad ligament fibroid because it allows clear visual separation of the uterus and ovaries from the mass. MRI, with its multiplanar imaging capabilities, may be extremely useful for differentiating broad ligament fibroids from masses of ovarian or tubal origin and from broad ligament cysts. Typical fibroids demonstrate low to intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Hyalinization is the most common type of degeneration occurring in 60% of cases. Cystic degeneration occurs in 4% of cases.[5] Cystic lesions in female pelvis most often originate in the ovary. Nonovarian cystic pelvic lesions may include peritoneal inclusion cysts, paraovarian cysts, mucocele of appendix, hydrosalpinx, subserosal, or broad ligament leiomyomas with cystic degeneration, cystic adenomyosis, cystic degeneration of lymph nodes, hematoma, abscess, spinal meningeal cysts, and lymphoceles.[6] Four percentage of fibroids undergo cystic degeneration with extensive edema forming cystic, fluid-filled spaces. In such cases, vessels bridging the mass and the myometrial tissue, termed bridging vessel sign, is useful in diagnosing the case as leiomyoma. Fibroid uterus may have a spectrum of presentations and sometimes the rarest of presentations may give rise to a clinically confusing scenario. Although fibroids usually have a characteristic ultrasound appearance, in cases of the huge size and in cases of degenerations, it may create some confusion at the diagnosis.[7]

CONCLUSION

Broad ligament fibroids of huge size can displace the uterus and anatomy is distorted so great; surgical expertise is required to avoid injuries to structures and as this tumor was highly vascular on Doppler and extensively huge in size, so possibility of sarcoma was kept in mind while operating. Hence, such tumors are extremely rare and good clinical hand and use of Doppler and MRI will help in planning surgical management. At the end, we conclude that extreme surgical expertise is required for successful outcome which in this case is achieved.

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Conflicts of interest

There are no conflicts of interest.