Leiomyoadenomatoid Tumour of the Uterus Presenting as Rare and Enigmatic Tumour: A Series of Three Cases

1002 Robot assisted laparoscopic staging surgery for early stage borderline ovarian tumour

Effect of intramural, subserosal, and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment

Uterine fibroids are often found in women of reproductive age. Different types of fibroids may affect reproductive outcome to a different extent, with submucous, intramural and subserosal fibroids being (in decreasing order of importance) a cause of infertility and pregnancy wastage. Fibroids may also produce a number of complications during pregnancy. Women who are scheduled for assisted conception should be advised to have submucous and possibly intramural fibroids removed prior to IVF. Large fibroids (>5 cm), wherever their location, should be considered individually, with the reproductive history being an important consideration. Miscarriage rates are significantly reduced following myomectomy. Open myomectomy should be the route of choice when there are large subserosal or intramural fibroids, multiple fibroids or entry into the uterine cavity is to be expected. Proper assessment of the benefits and risks of surgery for individual patients should be carefully considered before offering a procedure.

Laparoscopic myomectomy can be carried out in cases of subserosal and intramural fibroids. Laparoscopic myolysis can be proposed as an alternative to laparoscopic myomectomy in cases of large or multiple intramural fibroids in women aged over 40 or not desiring to bear more children but wishing to avoid a future hysterectomy. The authors report the technique and the long-term results in a series of 48 women with fibroids treated by myolysis. Because of the risk of bowel adhesions, further studies with another type of laser fiber are required.

Our objective was to investigate the effect of subserosal (SS), intramural (IM), and submucosal (SM) fibroids on the outcome of assisted reproductive technology (ART) treatment. A retrospective comparative study at a tertiary referral center for infertility was designed. The treatment outcome of 106 ART cycles in 88 patients with uterine fibroids (33 SS, 46 IM without cavity distortion, 9 SM) was compared with that of 318 ART cycles in age-matched patients without fibroids. The main outcome measure(s) were the findings on transvaginal uterine ultrasonography performed before the initiation of treatment and pregnancy and implantation rates. The pregnancy rates per transfer were 34.1, 16.4, 10, and 30.1% in the patients with SS fibroids, IM fibroids, SM fibroids, and no fibroids, respectively. The implantation rates were 15.1, 6.4, 4.3, and 15.7%, respectively. Both rates were significantly lower in patients with IM fibroids than in those with SS fibroids or no fibroids. We conclude that pregnancy and implantation rates were significantly lower in the groups of patients with IM and SM fibroids, even when there was no deformation of the uterine cavity. Pregnancy and implantation rates were not influenced by the presence of SS fibroids. Surgical or medical treatment should be considered in infertile patients who have IM and/or SM fibroids before resorting to ART treatment.

Recurrent IVF failure: other factors

Leiomyomas (fibroids or myomas) are benign uterine tumors of unknown etiology. Fibroids are most common in women aged between 30 and 40 years, but they can occur at any age. At present, laparoscopic myomectomy is the most appropriate surgical technique for patients with fertility disturbances. We conducted a prospective study, in which a number of 72 patients diagnosed with uterine fibromatosis and infertility were investigated for the impact of laparoscopic myomectomy (i.e. intramural and subserosal fibroids), the fertility rate and the average time for the appearance of pregnancy. The patients were randomly divided into 2 groups: Group 1, consisted of 36 patients with infertility and uterine fibroids associated in which laparoscopic myomectomy it was practiced, and Group 2, consisted of 36 patients, having the same diagnosis who refused surgical ablation. From the 36 patients which were operated, 11 had intramural fibroids and 25 had presented one or more subserosal fibroids (Group 1). The fertility rate was 25% for patients with no surgery (Group 2) comparing with 86.5% for patients with laparoscopic myomectomy (Group 1, 54.5% for patients with intramural fibroids and 32% for patients with subserosal fibroids). The average time of the appearance of the pregnancy was 23 months for the patients which were not operated (Group 2), and 35.2 months for patients with laparoscopic myomectomy (Group 1, 19.2 months for the patients with intramural fibroids and 16 months for the patients with subserosal fibroids). Our study shows that laparoscopic myomectomy improves the fertility rate compared to non-surgical treatment in the case of patients with uterine fibroids and infertility.

STUDY QUESTIONDo small and asymptomatic intramural and subserosal uterine fibroids affect female fertility?SUMMARY ANSWERSmall and asymptomatic fibroids that do not encroach the endometrial cavity appear to not markedly affect female fertility.WHAT IS KNOWN ALREADYThe available evidence on uterine fibroids and fertility is limited. Most information has been obtained in IVF settings by comparing the success in women affected and not affected by fibroids. These studies have shown a detrimental effect of submucosal and possibly intramural fibroids. However, this study design provides information only on embryo implantation, not on female fertility in general.STUDY DESIGN, SIZE, DURATIONA retrospective observational case–control study on 200 women whose partner was diagnosed with severe male infertility and 200 women with unexplained infertility was conducted. If the null hypothesis (that fibroids do not affect fertility) is valid, one would expect a similar prevalence of fibroids in the two study groups. Conversely, if fibroids do impact fertility, one would expect a higher prevalence among women with unexplained infertility. The study was carried out at the Infertility Unit of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico covering a 5-year period between January 2014 and June 2020.PARTICIPANTS/MATERIALS, SETTING, METHODSWe retrospectively recruited women seeking pregnancy whose partner was repeatedly documented to have a sperm concentration below 1 million/ml and matched them by age and study period to a group of women with unexplained infertility. The latter group of women was considered as a case group (infertile subjects), while the former group of women was considered as a control group (reflecting the general female population). Women with fibroids could be included in both study groups; only those with submucosal lesions were excluded.MAIN RESULTS AND THE ROLE OF CHANCEFibroids were diagnosed in 31 women (16%) with unexplained infertility and in 32 women (16%) with severe male factor infertility. The adjusted odds ratio of carrying fibroids in women with unexplained infertility was 0.91 (95% CI: 0.52–1.58). Subgroup analyses according to number, dimension and location of fibroids failed to highlight an increased risk of infertility in any group.LIMITATIONS, REASONS FOR CAUTIONThis is a retrospective study and some inaccuracies in fibroids detection cannot be ruled out. Moreover, the relatively small sample size hampers robust subgroup analyses. Even though we excluded women with patent causes of infertility, some women with specific causes of infertility could have been included among controls (yet are expected to account for <10% of the group).WIDER IMPLICATIONS OF THE FINDINGSThis study suggests that small fibroids that do not encroach the endometrial cavity do not markedly affect female fertility. This information is clinically relevant when counseling infertile women with small fibroids and an otherwise unremarkable diagnostic work-up. Surgery may still be considered but only in selected cases.STUDY FUNDING/COMPETING INTEREST(S)This study was partially funded by Italian Ministry of Health: current research IRCCS. E.S. reports grants from Ferring, grants and personal fees from Merck, and grants and personal fees from Theramex outside the submitted work. All the other authors do not have any competing interest to declare.TRIAL REGISTRATION NUMBERN/A.

Fibroids and infertility: an updated systematic review of the evidence

Hysteroscopic myomectomy for menorrhagia using Versascope™ bipolar system: Efficacy and prognostic factors at a minimum of one year follow up

Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization–intracytoplasmic sperm injection

BackgroundInflammatory pseudotumour refers to a non-malignant tumour-like mass resulting from an inflammatory reaction that is composed of granulation tissue with leukocyte infiltration that commonly occurs in the paediatric or young adult population. These tumours occur more commonly in the lungs and the orbit but rarely does it affect the gastrointestinal tract. It poses a clinical diagnostic challenge since it is a benign condition than can mimic the malignant counterpart. Our case is a rare presentation of the caecal pseudotumour in the presence of a right undescended abdominal testis evaluated as a caecal tumour with a differential diagnosis of a testicular malignancy.Case presentationWe report a 53-year-old male who presented with clinical signs suggestive of right colon tumour and undescended right testis. Intra-operatively, a caecal mass was found with no clearly discernable appendix and extensive adhesion of the right colon to the retroperitoneum, to the liver and gall bladder. A testis was found adherent to the posterior aspect of the caecum and terminal ileum. A right hemicolectomy was performed. Histopathology findings revealed an inflammatory mass with abundant fibroblast proliferation and chronic inflammatory cells infiltrate, involving bowel wall and periceacal adipose tissue; no malignant cells were identified. The testis had within it an adenomatoid tumour nodule. He had uneventful recovery and was discharged home 7 days post-operatively. At the moment, he is symptoms free.ConclusionsThe occurrence of right colonic inflammatory pseudotumour and co-existent adenomatoid testicular tumour arising from a cryptorchid testis is very unusual. This would make one incline towards a malignant testicular lesion in the presence of cryptorchidism. Testicular adenomatoid tumour is a rare benign neoplasm, mostly affecting fully descended testis and usually does not warrant orchidectomy for purposes of preserving testicular function. On the other hand, surgical resection remains the only safe and curative treatment option available for inflammatory pseudotumours.

Malignant transformation in leiomyoma is rare, with a few documented cases of sarcomatous transformation in leiomyomas. However, carcinosarcomatous transformation in leiomyomas is extremely infrequent. A 45-year-old female presented with a mass sensation per abdomen for the last five months. An abdominal ultrasound revealed multiple uterine fibroids. Contrast-enhanced magnetic resonance imaging revealed a large multiloculated abdominopelvic mass arising from the fundus of the uterus, along with multiple smaller subserosal fibroids. A total abdominal hysterectomy with bilateral salpingectomy was performed. Grossly, the uterus was bosselated with multiple subserosal fibroids. The larger degenerated fibroid showed a smooth outer surface; however, the cut surface was predominantly cystic and filled with necrotic material. Microscopically and immunohistochemically, the larger mass showed a high-grade biphasic tumor comprising carcinomatous and sarcomatous components with the peripheral solid areas showing compressed smooth muscle bundles representing the residual leiomyomatous areas. A final diagnosis of carcinosarcomatous transformation in leiomyoma was rendered. The index report highlights the significance of systematic gross and microscopic examination of all the uterine masses in patients with multiple leiomyomata.

Background: Round ligament fibroids are rare benign tumors that might manifest as vulvar, adnexal, or inguinal masses primarily because of their anatomical extension. Case Report: A 44-year-old lady who was not a known case of any medical illness was referred to the outpatient clinic in May 2022, after an incidental ultrasound finding of a subserosal fibroid. Upon examination, a hard mass was felt in the suprapubic area around 12 weeks size, yet due to the obese body type, proper examination was not possible. An ultrasound scan of the pelvis revealed multiple fibroids in the uterus, measuring 7x6 cm anteriorly, 4.5x3.5 cm posteriorly, and fundal 4.2x2.4 cm. After 12 months of conservative follow-up, another pelvic ultrasound scan was done, which revealed an anteverted bulky uterus measuring 11.9 x 8 cm, with multiple fibroids, the largest measuring 4.8x 4.5 cm at the lower uterine segment and 5.5x 4 cm at the fundus. These findings suggested a growing sessile subserosal uterine fibroid with extensions, dimensions, and relations. Finally, the patient was diagnosed with leiomyoma with cystic and hyaline degeneration, negative for atypia and malignancy. Laparotomy myomectomy was done, and the specimen consisted of a single oval mass weighing 410 gm and measuring 11x8x7.5 cm. Conclusion: The diagnosis of round ligament fibroid is often challenging due to its anatomical position. Keywords: Round ligament fibroid, laparotomy myomectomy, leiomyoma, case report

Los fibromas son relativamente comunes en las pacientes en edad reproductiva y son exclusivamente responsables de infertilidad y abortos en una pequeña (5%) pero significante proporción de pacientes. Aproximadamente el 50% de las mujeres con infertilidad y miomas uterinos se embarazan después de miomectomía. Una proporción relativamente alta de mujeres con historia de abortos recurrentes se embaraza después miomectomía. Lo más importante, hay una disminución significativa en la tasa de abortos en el primer y segundo trimestre. La evidencia sugiere que la mayoría de mujeres que desean embarazarse son capaces de hacerlo en el primer año, con una caída de estas tasas en forma aguda después de este tiempo. Esto se puede atribuir a la recurrencia de los fibromas. Por tanto, la cirugía se debería realizar cuando la mujer esté lista para iniciar una familia. El sitio, número y tamaño de los miomas así como la experiencia del cirujano junto con la preferencia de la paciente puede influenciar la opción del manejo.Son indicaciones para realizar cirugía en una mujer que esté considerando la posibilidad de embarazo por los métodos naturales o por reproducción asistida la presencia de un mioma submucoso o un mioma intramural que distorsione la cavidad uterina, fibromas mayores de 5 centímetros y múltiples fibromas. Para fibromas intramurales menores de 5 centímetros y múltiples fibromas. Para fibromas intramurales menores de 5 centímetros y fibromas subserosos la historia reproductiva debe ser una consideración importante en la determinación en lo tocante a la necesidad de una intervención quirúrgica.