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A
case is reported of a large round ligament fibroid showing degeneration.
It is the largest reported round ligament benign tumour in the English
world medical literature. |
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| INTRODUCTION |
Uterine
fibroids are common. Extra-uterine fibroids though do occur, but are
not common as uterine fibroids. Amongst the extra-uterine fibroids true
broad ligament fibroids are the most common, fibroids arising from the
round ligament are least common.1 |
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| CASE
REPORT1 |
Mrs.
X, a 45 yr old, married since 35 years, a G4P4L4 came in the emergency
services with complaints of chronic pain in abdomen with abdominal lump
since past 2 months. The lump in abdomen was not related to any menstrual
complaints, with past and present menstrual cycles being regular and
normal.
The patient had undergone cholecystectomy 9 years back under general
anaesthesia and peripheral tubal ligation 22 years back under spinal
anaesthesia.
The patient had four full term normal vaginal deliveries, the last one
being 22 years back.
On admission, her general condition was fair, the vital parameters were
within normal limits. On cardiovascular auscultation, there was a soft
pan systolic murmur in the mitral area confirmed to be that of mild
mitral stenosis and mitral regurgitation on 2-D echocardiography. On
per abdominal examination there was a mass of 28-30 weeks size arising
from the pelvis of variegated consistency and non-tender on palpation.
On per vaginal examination the uterine size was bulky, uterus being
displaced posteriorly. The whole of pelvis was occupied by the pelvic
mass and its size could not be exactly determined in view of obesity
of the patient. |
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| Investigation
revealed |
Haematocrit
= 37%, Total WBC count = 4,500/cmm, Neutrophils 66%, Lymphocytes 34%,
BUN = 5 mg%, S. biliruin = Non-icteric level. ECG = Within normal limits,
X-ray chest PA view = within normal limits. |
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| CT
SCAN of Abdomen |
| Suggestive
of Rt. ovarian solid mass with cystic areas |
| 2D-Echo |
Showed
mild mitral stenosis with mitral regurgitation with LVEF of more than
60%.
Exploratory laparotomy was performed through midline vertical incision. |
| In
situ Findings |
| • |
Uterus
enlarged, 8 weeks size. |
| • |
Small
follicular cysts on both ovaries |
| • |
A
dumb-bell shaped sessile fibroid tumour was seen arising from
the left round ligament. The superior cystic mass measured 17
cm x 16 cm x 10 cm. And the firm inferior are a measured 25 cm
x 24 cm x 18 cm. The lower posterior aspect was soft in consistency
suggesting a left round ligament sessile fibroid with degenerative
changes (Fig. 1). |
| • |
The
right round ligament was found to be normal. |
| • |
Peritoneal
washings were sent for cytological examination, which showed no
malignant cells. |
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The
mass was excised by dividing between two clamps, the fibroid
tumour was removed. Total abdominal hysterectomy with bilateral
salpingo-oophorectomy was performed. The patient had an uneventful
recovery. Suture removal was done on day 10. Patient was discharged
on day 14.
The excised left round ligament tumour weighed 7 kg. The superior
cystic end on cut section contained around 500 ml of blood tinged
fluid. Suggestive of cystic degeneration the lower solid area
on cut section showed homogeneous grey white appearance, on
pathological examination revealing myxoid degeneration focal
hyaline degeneration. The tumour revealed no abnormal mitosis
with no evidence of malignancy on microscopic examination. The
microscopy of uterus, fallopian tubes and ovary revealed normal
histological findings. |
|
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| DISCUSSION |
Myomas and fibromyomas are not uncommon in the round, ovarian and broad
ligaments, they are found often in association with similar uterine
tumours and their pathology and complications are the same as that of
uterine fibroids.1
In our case the huge fibroid measured approximately 40 cm x 24 cm x
18 cm in size, dumb bell shaped and weighed 7 kg, which is the first
reported huge round ligament fibroids in a thorough search of the medline
and internal in English Medical Literature. Only a single reference
of a case of round ligament fibroid weighing 4 kg has been reported.2
Degenerative changes in the leiomyomas are considered to be due to inadequate
blood supply and the type of degenerative changes seem to depend on
the degree and rapidity of the onset of vascular insufficiency. Hyaline
changes are the commonest form of degeneration. There is no particular
relationship between any presenting symptom on group of symptoms and
the incidence of degenerative changes. |
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| CONCLUSION |
The
round ligament benign tumour even though being the rarest of extra-uterine
tumours can grow to a large size as exemplified in this case. Degenerative
changes occur even in such extra-uterine fibroids and may have the same
underlying pathology. |
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| REFERENCES |
| 1. |
Jeffcoate’s
Principles of Gynaecology, edition V, 2001, Arnold Publishers, Chapter
27, page 500-3. |
| 2. |
MRI
of round ligament leiomyoma associated with Meyer - Rokitansky
- Kustner - Houser syndrome. RH Eecs - abdominal imaging 1999;
24 (2) : 202-4. |
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SCREENING
SIGMOIDOSCOPY FOR COLORECTAL CANCER
Flexible sigmoidoscopy provides a potentially greater yield but
is much more expensive than testing for faecal occult blood.
In 2000 the American College of Gastroenterology issued guidelines
recommending that adults over the age of 50 years should undergo
flexible sigmoidoscopy every 5 years to reduce their risk of colorectal
cancer.
A combined approach of flexible sigmoidoscopy and a stool-based
test seems sensible.
John H Scholefield, Sue Moss The Lancet 2003; 362 : 1168. |
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