Diagnosis Of Leiomyoma Research Articles

Laparoscopic endoscopic cooperative surgery for gastric subepithelial lesion during laparoscopic sleeve gastrectomy for severe obesity

BackgroundThe frequency of pathologies detected incidentally before, during, and after a bariatric surgery, such as subepithelial lesion (SEL) of the stomach, is likely to rise as bariatric surgery becomes more common.Case presentationA 49-year-old female patient presented with severe obesity, for which laparoscopic sleeve gastrectomy (LSG) was planned. During a preoperative examination, endoscopy revealed a 10 mm SEL in the posterior wall of the upper body of the stomach. Excision of the SEL was performed simultaneously with the LSG. Endoscopy demonstrated that the SEL was situated on the remnant side of the stomach. Endoscopic resection using laparoscopic endoscopic cooperative surgery was performed for the SEL, and the thinned gastric wall was closed by hand-sewing. Thereafter, LSG was performed. Pathological analysis of the SEL led to a diagnosis of leiomyoma. The patient was discharged on postoperative day 6.ConclusionSurgeons should be prepared to manage incidentally detected pathologies before, during, and after bariatric surgery and to choose the surgical method most suitable to the individual patient.

Sinonasal Leiomyoma: A Case Report and a Review of the Literature

Abstract Sinonasal leiomyoma is an exceptionally rare neoplasm arising from smooth muscle cells within the sinonasal tract. This abstract presents a case study of a 43-year-old male patient diagnosed with sinonasal leiomyoma, a distinctive and challenging entity in otolaryngology. The patient presented with a complex clinical history, including a 2-year interval between initial evaluation and definitive diagnosis. Initial histology suggested a smooth muscle tumour of uncertain malignant potential, highlighting the diagnostic intricacies associated with this condition. The radiological assessment revealed an extensive soft tissue mass with the involvement of multiple adjacent structures. The patient subsequently underwent surgical resection, leading to a revised histological diagnosis of leiomyoma. This case underscores the diagnostic challenges associated with sinonasal leiomyoma, emphasising the importance of comprehensive evaluation, including clinical history, radiological imaging, and histopathological examination. Long-term follow-up is essential for monitoring potential recurrences and optimising patient outcomes. By presenting this rare case, we aim to contribute to the limited body of literature on sinonasal leiomyoma and highlight the complexities surrounding its diagnosis and management in clinical practice.

Evaluating for Racial Disparities in the Utilization of Minimally Invasive Hysterectomy for the Treatment of Uterine Leiomyoma

Introduction: Minimally invasive hysterectomy (MIH) for benign gynecologic indications has many patient advantages over traditional abdominal hysterectomy (AH) including decreased hospital stay, decreased mortality, and faster recovery. Although MIH has been shown to improve outcomes as compared with abdominal hysterectomy, racial and socioeconomic disparities can impact patient access to the minimally invasive procedure. Previous studies have demonstrated that Black and Hispanic-identifying patients are significantly less likely to receive a MIH when compared to White patients. One proposed contributor to this finding is the higher rate and delayed diagnosis of uterine leiomyoma in Black patients compared to White patients. This disparity could delay diagnosis, and cause a larger leiomyoma necessitating use of abdominal hysterectomy. Another explanation in disparity is the physician training at hospitals in underserved areas. This study aims to investigate if race impacts access to MIH for leiomyoma at Carle Foundation Hospital in Urbana, Illinois. Methods: This retrospective analysis studied patients from 2011-2020 who received a hysterectomy at Carle Foundation Hospital for a primary diagnosis of leiomyoma. MIH included laparoscopic, vaginal, and robotic-assisted. Hysterectomies for malignancy were excluded. The demographic data included age, race, body mass index (BMI), type of hysterectomy, insurance, history of previous obstetric and abdominal surgeries, and uterine weight. The race categories included White, Black, and Others. Hispanic and Asian patients were placed into the other category due to the limited sample size. Descriptive statistics were used to evaluate the demographic data. Odd ratios were calculated to determine if a patient received a MIH over an AH based on race. An adjusted odds ratio was calculated to account for BMI, uterine weight, history of cesarean section, and previous abdominal surgery. Results: A total of 324 hysterectomies from 2011-2020 were performed for leiomyoma. Abdominal hysterectomies accounted for 32.1% and MIH accounted for 68.9%, with 7.4% being laparoscopic, 5.6% being vaginal, and 55.9% being robotic-assisted. The average age of White patients was 46.7 years old, and was higher than Black patients, 43.6 years old (p<.01). The average BMI of Black patients was 34.6 kg/m2, and was higher than White patients, 30.3 34.6 kg/m2 (p<.01). More White patients had commercial insurance at 83.5% compared to Black patients at 48.1% (p<.01). More Black patients had Medicaid or Medicare at 50.6% compared to White patients at 14.8% (p<.01). Black patients had an average uterine weight at 579.8g compared to White patients at 438.6g (p<.05). The majority (73.7%) of White patients received a MIH, with 26.3% receiving an AH. Forty five percent of Black patients received an AH while 54.5% received a MIH. Conclusion: At Carle Foundation Hospital during the years 2011-2020, a lower percentage of African American patients, compared to white patients, received a minimally invasive hysterectomy in the treatment of uterine leiomyoma. Further analysis will investigate for the odds ratios of each group receiving a MIH and will adjust for BMI, uterine weight, obstetric and abdominal surgical history.

Leiomyomatosis: A Rare Case of Mistaken Identity

Abstract: Diffuse uterine leiomyomatosis (DUL) is a rare benign uterine pathology that is often misdiagnosed as uterine leiomyomas. We present a case of a woman with abnormal uterine bleeding treated with multiple medical therapies without symptomatic relief. She underwent two surgeries, almost a year apart, with the histopathologic diagnosis of leiomyomas. After numerous failed attempts at medical and surgical treatments, the patient requested definitive surgery and underwent a robotic-assisted laparoscopic hysterectomy. Histopathologic analysis of the entire uterine specimen confirmed diffuse uterine leiomyomatosis. Case Report: A 31-year-old female was referred to our office with a history of abnormal uterine bleeding and heavy menstrual bleeding who failed hormonal therapies. Levonorgestrel-releasing intrauterine devices were inserted at two different times and were expelled due to heavy menses. Pelvic magnetic resonance imaging reported leiomyomas. The patient underwent hysteroscopy and a robotic-assisted myomectomy. Pathology revealed leiomyomas. Seven months after her first surgery, her bleeding recurred, and the patient became severely anemic, requiring hospitalization and transfusion of 2 units of packed RBCs. Over a year later, the patient underwent a second hysteroscopic and robotic myomectomy after failed medical therapies of tranexamic acid, progesterone medication, and gonadotropin-releasing hormone antagonist with minimal symptom relief. Her quality of life suffered tremendously due to ongoing AUB-HMB. After seven months, the patient requested definitive surgical therapy and underwent a robotic-assisted laparoscopic hysterectomy. Pathology reported diffuse uterine leiomyomatosis. Diffuse uterine leiomyomatosis is a rare benign uterine pathology that is often misdiagnosed as uterine leiomyomas. Early diagnosis of DUL is challenging and often inconclusive. Less than 50 diffuse uterine leiomyomatosis cases have been reported in the literature. The myometrium in DUL is almost entirely replaced by numerous ill-defined benign smooth muscle tumors. MRI offers mapping of the size, site, and distribution of leiomyomas, but findings are difficult to differentiate from DUL. The pathophysiology of DUL development remains poorly understood, with patients frequently complaining of abnormal uterine bleeding, heavy menstrual bleeding, fertility issues, and dysmenorrhea. DUL is often misdiagnosed as leiomyomas or adenomyosis clinically, given the similarity in manifestations. Leiomyomatosis is histologically characterized by the proliferation of smooth muscle cells forming fascicles and nodules, which blend with normal myometrium tissue. Hysterectomy is the definitive treatment of DUL, with this case report demonstrating the close similarity between the two.

Machine Learning Applied to Pre-Operative Computed-Tomography-Based Radiomic Features Can Accurately Differentiate Uterine Leiomyoma from Leiomyosarcoma: A Pilot Study.

The accurate discrimination of uterine leiomyosarcomas and leiomyomas in a pre-operative setting remains a current challenge. To date, the diagnosis is made by a pathologist on the excised tumor. The aim of this study was to develop a machine learning algorithm using radiomic data extracted from contrast-enhanced computed tomography (CECT) images that could accurately distinguish leiomyosarcomas from leiomyomas. Pre-operative CECT images from patients submitted to surgery with a histological diagnosis of leiomyoma or leiomyosarcoma were used for the region of interest identification and radiomic feature extraction. Feature extraction was conducted using the PyRadiomics library, and three feature selection methods combined with the general linear model (GLM), random forest (RF), and support vector machine (SVM) classifiers were built, trained, and tested for the binary classification task (malignant vs. benign). In parallel, radiologists assessed the diagnosis with or without clinical data. A total of 30 patients with leiomyosarcoma (mean age 59 years) and 35 patients with leiomyoma (mean age 48 years) were included in the study, comprising 30 and 51 lesions, respectively. Out of nine machine learning models, the three feature selection methods combined with the GLM and RF classifiers showed good performances, with predicted area under the curve (AUC), sensitivity, and specificity ranging from 0.78 to 0.97, from 0.78 to 1.00, and from 0.67 to 0.93, respectively, when compared to the results obtained from experienced radiologists when blinded to the clinical profile (AUC = 0.73 95%CI = 0.62-0.84), as well as when the clinical data were consulted (AUC = 0.75 95%CI = 0.65-0.85). CECT images integrated with radiomics have great potential in differentiating uterine leiomyomas from leiomyosarcomas. Such a tool can be used to mitigate the risks of eventual surgical spread in the case of leiomyosarcoma and allow for safer fertility-sparing treatment in patients with benign uterine lesions.

Long-Term Risk of Reintervention After Surgical Leiomyoma Treatment in an Integrated Health Care System.

To compare long-term risk of reintervention across four uterus-preserving surgical treatments for leiomyomas and to assess effect modification by sociodemographic factors in a prospective cohort study in an integrated health care delivery system. We studied a cohort of 10,324 patients aged 18-50 (19.9% Asian, 21.2% Black, 21.3% Hispanic, 32.5% White, 5.2% additional races and ethnicities) who had a first uterus-preserving procedure (abdominal, laparoscopic, or vaginal myomectomy [referred to as myomectomy]; hysteroscopic myomectomy; endometrial ablation; uterine artery embolization) after leiomyoma diagnosis in the 2009-2021 electronic health records of Kaiser Permanente Northern California. We followed up patients until reintervention (second uterus-preserving procedure or hysterectomy) or censoring. We used a Kaplan-Meier estimator to calculate the cumulative incidence of reintervention and Cox regression models to estimate hazard ratios and 95% CIs comparing rates of reintervention across procedures, adjusting for age, parity, race and ethnicity, body mass index (BMI), Neighborhood Deprivation Index, and year. We also assessed effect modification by demographic characteristics. Median follow-up was 3.8 years (interquartile range 1.8-7.4 years). Index procedures were 18.0% (1,857) hysteroscopic myomectomies, 16.2% (1,669) uterine artery embolizations, 21.4% (2,211) endometrial ablations, and 44.4% (4,587) myomectomies. Accounting for censoring, the 7-year reintervention risk was 20.6% for myomectomy, 26.0% for uterine artery embolization, 35.5% for endometrial ablation, and 37.0% for hysteroscopic myomectomy; 63.2% of reinterventions were hysterectomies. Within each procedure type, reintervention rates did not vary by BMI, race and ethnicity, or Neighborhood Deprivation Index. However, rates of reintervention after uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy decreased with age, and reintervention rates for hysteroscopic myomectomy were higher for parous than nulliparous patients. Long-term reintervention risks for uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy are greater than for myomectomy, with potential variation by patient age and parity but not BMI, race and ethnicity, or Neighborhood Deprivation Index.

Vitamin D and its binding protein in patients with leiomyomas.

This study examined the levels of VitD, VitD binding protein (DBP), and free VitD in leiomyomas patients and their association with the quantity, dimensions, and site of fibroid growths. Additionally, we evaluated the potentiality of employing these factors as a biomarker tool for the diagnosis and assessment of uterine fibroid progression. This study involved the participation of 55 women with leiomyomas and 50 healthy women. We utilized commercial ELISA kits to measure the levels of total VitD and DBP in their serum. Additionally, we calculated the levels of free VitD and the ratio of VitD to DBP. Moreover, we determined the number, size, and location of the leiomyomas in the patients. There were no significant differences in the levels of total VitD between the groups. However, patients had significantly lower levels of free VitD and higher levels of DBP compared to the control group. The size of the largest leiomyomas showed a negative relationship with free VitD and a positive relationship with DBP. Receiver operating characteristic analyses, showed that the cut-off value for free VitD was 4.47 pg/mL, with a sensitivity of 75.6% and a specificity of 74.4%. The cut-off value for DBP was 256.2 μg/mL, with a sensitivity of 86% and a specificity of 70.3%. Free VitD and DBP potentially contribute to the development of leiomyomas and are linked to the size of these tumors. The measurement of serum levels of these factors could serve as additional biomarkers for the diagnosis of leiomyomas.

Resection of intracardiac leiomyoma originating from the inferior vena cava through a single median sternotomy incision using a silk suture snare technique: a case report

BackgroundIntracardiac leiomyoma is a rare benign right heart tumor that usually extends from the intravenous system. The patient often has a history of uterine leiomyoma.Case presentationWe report a 46-year-old female patient who presented to us with exertional dyspnea, chest tightness, and shortness of breath for two weeks and had a history of uterine leiomyoma resection. Echocardiography showed a pedunculated solid mass in the right heart with the pedicle attached to the inferior vena cava. The surgery was performed under cardiopulmonary bypass established through the femoral artery and vein with a probable diagnosis of leiomyoma. The tumor was removed by ingenious surgical technique: a snare made of silk suture in which the tumor’s pedicle was trapped, and the tumor with its pedicle was carefully removed with the help of a scalpel along the silk suture. The histopathology report confirmed the diagnosis of intravenous leiomyoma. The postoperative course was uneventful and the patient was discharged a week later.ConclusionIntracardiac leiomyoma is a rare benign smooth muscle tumor. Surgery is the mainstay of treatment with different surgical approaches available. It is possible to completely remove cardiac leiomyomas through sternotomy without the need for an abdominal incision if the leiomyoma is originated in the inferior vena cava not far from the right atrium.

Adenomatoid tumor with extensive reactive smooth muscle: a diagnostic dilemma

Abstract Introduction/Objective Adenomatoid tumors are slow-growing benign tumors of mesothelial origin. They comprise 30% of all tumors of the paratesticular area. In this location, they commonly involve the epididymis, spermatic cord, ejaculatory duct and rarely testicular parenchyma. Histologically, a spectrum of growth patterns can be seen, such as adenoid, tubular, glandular, solid, or cystic. In some cases, a smooth muscle component can also be present. The purpose of this report is to describe a case of adenomatoid tumor with exuberant smooth muscle component, mimicking leiomyoma. Methods/Case Report A 28-year-old male presented with painless left inguinal bulge. He noticed it five years prior, and it had been slowly growing since then. Examination revealed a paratesticular mass which was subsequently excised. Grossly, the tumor was firm with smooth, white-tan cut surfaces. Microscopically, the tumor was well- circumscribed, showing predominance of smooth muscle bundles and rare cuboidal to ovoid cells in tubular growth pattern. In the background there was little intervening stroma. Immunohistochemical stains showed the cuboidal cells to be positive for WT1 and calretinin, confirming the mesothelial origin. Diagnosis of adenomatoid tumor was rendered. In contrast to adenomatoid tumors, leiomyomas are whiter and firmer on gross examination and lack the characteristic tubules or cystic spaces lined by mesothelial cells. Results (if a Case Study enter NA) N/A Conclusion Exuberant smooth muscle differentiation in adenomatoid tumor can mislead to diagnosis of leiomyoma. Careful inspection for tubules of mesothelial origin and appropriate immunohistochemical stains are key to accurate diagnosis. Pathologists need to be aware of this potential pitfall.

A contrast-enhanced CT-based radiomic nomogram for the differential diagnosis of intravenous leiomyomatosis and uterine leiomyoma.

Uterine intravenous leiomyomatosis (IVL) is a rare and unique leiomyoma that is difficult to surgery due to its ability to extend into intra- and extra-uterine vasculature. And it is difficult to differentiate from uterine leiomyoma (LM) by conventional CT scanning, which results in a large number of missed diagnoses. This study aimed to evaluate the utility of a contrast-enhanced CT-based radiomic nomogram for preoperative differentiation of IVL and LM. 124 patients (37 IVL and 87 LM) were retrospectively enrolled in the study. Radiomic features were extracted from contrast-enhanced CT before surgery. Clinical, radiomic, and combined models were developed using LightGBM (Light Gradient Boosting Machine) algorithm to differentiate IVL and LM. The clinical and radiomic signatures were integrated into a nomogram. The diagnostic performance of the models was evaluated using the area under the curve (AUC) and decision curve analysis (DCA). Clinical factors, such as symptoms, menopausal status, age, and selected imaging features, were found to have significant correlations with the differential diagnosis of IVL and LM. A total of 108 radiomic features were extracted from contrast-enhanced CT images and selected for analysis. 29 radiomics features were selected to establish the Rad-score. A clinical model was developed to discriminate IVL and LM (AUC=0.826). Radiomic models were used to effectively differentiate IVL and LM (AUC=0.980). This radiological nomogram combined the Rad-score with independent clinical factors showed better differentiation efficiency than the clinical model (AUC=0.985, p=0.046). This study provides evidence for the utility of a radiomic nomogram integrating clinical and radiomic signatures for differentiating IVL and LM with improved diagnostic accuracy. The nomogram may be useful in clinical decision-making and provide recommendations for clinical treatment.

Clinical Presentation of Uterine Leiomyoma and the Outcome of Surgical Management Options in a Nigerian Tertiary Health Facility

Background: Effective treatment intervention for uterine leiomyoma is essential to prevent morbidities and associated potential mortalities. Objective: To determine the prevalence, clinical presentation of uterine leiomyoma and the outcome of surgical management options at the Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos, Nigeria. Methods: This was a descriptive retrospective study of cases of uterine leiomyoma from 01 January 2012 to 31 December 2016. The medical records of all patients with the diagnosis of leiomyoma were retrieved. Information was obtained on socio-demographics, clinical presentation, types of surgical treatment and associated postoperative complications. Results: Three hundred and thirty-five cases of leiomyoma were managed out of 1835 major gynaecological cases giving a period prevalence of 18.3%. However, only 134 case folders were available for analysis. The mean age of the women was 38.5±6.7 years. Only 21 (15.7%) cases presented within a year of the onset of symptoms. The surgical interventions used included myomectomy and hysterectomy but the former was the commonest with a frequency of 73.4%. There were no significant differences in the prevalence of postoperative complications between patients who had myomectomy and hysterectomy (p>0.05 in each case). Conclusion: Uterine leiomyoma is a common gynaecological condition. There is a need to create awareness of the need to present early to the hospital so that less invasive treatment options can be explored.

Beta blockers reduce uterine fibroid incidence in hypertensive women

ObjectiveIs prior beta blocker (BB) use associated with reduced odds of the clinical incidence of leiomyomas? What is known alreadyIn-vitro and in-vivo evidence has supported the role of beta receptor blockade in reducing leiomyoma cell proliferation and growth. However, no population-based study to date has investigated this potential association. Study design, size, durationA nested case-control study was conducted in a population of women aged 18–65 with arterial hypertension (n = 699,966). Cases (n = 18,918) with a leiomyoma diagnosis were matched to controls (n = 681,048) with no such diagnosis at a 1:36 ratio by age and region of origin within the United States. Participants/materials, setting, methodsThis population was assembled from the Truven Health MarketScan® Research Database, which includes health insurance claims from January 1st, 2012 to December 31st, 2017. Prior use of BB wasdetermined fromoutpatient drug claims and leiomyoma development was indicated by a first-time diagnosis code. We conducted a conditional logistic regression to determine the odds of uterine fibroid development in women with prior use of BB compared to women with no such history. We then conducted subset analyses, stratifying the women by age group and by type of BB. ResultsWomen on a BB experienced 15% reduced odds of developing clinically recognized leiomyoma compared to non-users (OR 0.85, 95% CI 0.76–0.94). This association was significant for the 30–39 age group (OR 0.61, 95% CI 0.40–0.93) but no other age group. Of the BBs, propranolol (OR 0.58, 95% CI 0.36–95) demonstrated a significant association with reduced leiomyoma incidence and metoprolol (OR 0.82, 95% CI 0.70–0.97) was associated with lower uterine fibroid incidence after adjustment for comorbidities. ConclusionsHypertensive women with prior BB use experienced reduced odds of developing clinically recognized leiomyoma compared to non-users. A key predisposing risk factor for uterine leiomyoma is elevated blood pressure. Thus, the results of this analysis may have clinical relevance to women with hypertension, as the use of this drug may introduce a dual benefit of managing hypertension as well as curbing an increased risk of leiomyomas.

Disparities and Patterns of Pain Management, Pharmacologic Therapies, and Surgical Treatments for Leiomyomas in the 2017–2019 National Survey of Family Growth [ID: 1380252

INTRODUCTION: Leiomyomas affect most women throughout their lifetime with an incidence of roughly 80%. Approximately 30% of these women develop symptomology that warrants intervention. With such a large prevalence, it is important to highlight patterns in treatment modalities to guide effective management for all women with this condition. METHODS: We utilized weighted survey results from the Centers for Disease Control and Prevention’s 2017–2019 National Survey of Family Growth. After isolating data to those who reported a leiomyoma diagnosis, we performed a test of equal proportions (P<.05) among the nine listed therapies compared to the following socioeconomic factors: race, age, education, and insurance status. RESULTS: The incidence of leiomyomas was 7.3% (449/6,141). Hispanic women and those with state-sponsored or uninsured status were more likely to report receiving none of the listed treatments (P=.05 and .02). Women who marked “Other” were most likely to seek alternative medicine (P=.03). Hysterectomy was most likely for Black, White, and 40- to 49-year-old women (P=.02 and P<.001). Nonhysterectomy procedures were most seen with government-sponsored health care, private insurance, and women with graduate degrees (P<.001 and P=.02). Pharmacologically, White women were more likely to receive progesterone-releasing intrauterine devices (P=.02), women 19–29 were more likely to use hormonal medicine (P<.001), and those with government insurance were more likely to receive narcotics (P=.006). CONCLUSION: All socioeconomic factors held significant inconsistencies in the utilization of various leiomyoma treatments. As this condition will affect most women, this analysis highlights the need for future standardization to ensure optimal treatment implementation and patient outcomes.

Benign in radiology bombshell in cytology

Smooth muscle tumor of uncertain malignant potential is a surprise post-operative histopathological finding after myomectomy or hysterectomy. These are aligned between benign and malignant which shares but does not fulfil the complete diagnostic criteria of leiomyosarcoma. Preoperative diagnosis by clinical or radiological examination is uncertain and the diagnosis is only by histopathology. Among women undergoing myomectomy or hysterectomy for a presumed diagnosis of leiomyoma, 0.01% receive a diagnosis of STUMP. Once diagnosed as STUMP, the gold standard treatment option is surgical removal of uterus. As there are no strict accurate protocols for the management of STUMP, the treatment choices should be based on the age of the patient, status and desire to preserve fertility, location of the tumor, metastases, recurrences and pathologic types. Here with we are presenting a case of nulligravida admitted for abnormal uterine bleeding with severe anaemia diagnosed as STUMP on histopathological examination, managed by myomectomy followed by regular follow up for the sake of fertility status. Post operative regular clinical and radiological follow up is mandatory for early pick up of recurrence or metastases.

Reducing blood loss during laparoscopic myomectomy using a tourniquet loop around the lower uterine segment

To present a simple and effective hemostatic technique using a tourniquet loop during laparoscopic myomectomy. Pericervical tourniquet has been proven to be a safe and effective measure to reduce blood loss during open myomectomy. However, the use of a tourniquet in laparoscopic myomectomy has been rarely reported probably because the application is difficult and troublesome. In our technique, a prefabricated tourniquet loop, adapted from a Foley catheter, is applied around the lower segment of the uterus. It is easy to apply a tourniquet loop around the lower uterine segment during laparoscopic myomectomy. There is no need to make a window in the broad ligament to apply a pericervical tourniquet or triple tourniquets. Meanwhile, complete blockage of blood supply from the uterine artery and utero-ovarian anastomoses may ensure better hemostasis. A tertiary hospital. The patient was a 34-year-old woman with uterine leiomyoma and a desire for future fertility. She had been suffering from urinary frequency and chronic bladder pressure for the past 6 months. Magnetic resonance imaging confirmed 2 intramural masses measuring 96 mm × 91 mm and 25 mm × 13 mm at the anterior uterine wall. Institutional review board and ethics committee approval was obtained. Laparoscopic myomectomy was performed with the application of a tourniquet loop around the lower segment of the uterus (step-by-step video demonstration): homemade tourniquet loop formation using a 14-Fr latex Foley catheter; trocar placement with 2 umbilical ports (10 mm and 5 mm) and a 5-mm port at the lower-left quadrant of the abdomen; application of a tourniquet loop around the lower uterine segment; tumor enucleation and myometrial closure; removal of the tourniquet loop and a check for bleeding; contained specimen extraction via the merged umbilical incision; and inspection of the abdominal cavity and closure of the merged umbilical incision. Feasibility of using a tourniquet loop as an effective hemostatic technique in laparoscopic myomectomy. The surgery lasted for approximately 90 minutes, and the tourniquet time was approximately half an hour. The estimated blood loss was only 20 mL. Her hemoglobin value on day 1 after the surgery was 131 g/L, the same as the preoperative level. Pathology confirmed the diagnosis of leiomyoma. The patient was discharged 2 days after the surgery with no complications. During follow-up, the patient reported that there was no discomfort and that her menses were normal. Her fallopian tubes were patent in the hysterosalpingogram. Her ovarian function, which was assessed by serum follicle-stimulating hormone concentration (5.34 mIU/mL) on day 3 of her menstrual cycle and antimüllerian hormone level (2.01ng/mL), was in the normal range. She was suggested to conceive 1 year after the procedure. Application of a tourniquet loop around the lower uterine segment is a simple and effective hemostatic technique during laparoscopic myomectomy. Randomized prospective studies are needed to determine the hemostatic effect of the laparoscopic use of a tourniquet loop and its impact on fertility and ovarian function.

A Rare Case of a Primary Leiomyoma of the Clivus in an Immunocompetent Patient and a Review of the Literature Regarding Clival Lesions

Leiomyomas are common lesions that are usually located in the genitourinary and gastrointestinal tracts. Primary leiomyomas at the skull base are uncommon. They are composed of well-differentiated smooth muscle cells without cellular atypia. The diagnosis of a leiomyoma has to be confirmed by immunohistochemistry. The tumor tissue is immunoreactive for SMA, S100 and cytokeratin. Leiomyomas mainly occur in immunocompromised patients. Most tumor tissues are positive for EBV. The presented case is that of a 56-year-old immunocompetent woman with a tumor on the clivus. The radiological images suggested chordoma or fibrous dysplasia. Transnasal transsphenoidal surgery was performed. The tumor tissue consisted of well-differentiated smooth muscle cells with elongated nuclei. Immunohistochemistry revealed a positive reaction for desmin, SMA and h-Caldesmon and a negative reaction for S100, beta-catenin, PGR and Ki67. The leiomyoma diagnosis was subsequently established. To the best of our knowledge, the case of a primary leiomyoma on the clivus of an immunocompetent patient is the first to be described. We also extensively reviewed the literature on the immunohistopathological and radiological differential diagnosis of clival lesions.

Case Report of Dermoscopic Aspects and Reflectance Confocal Microscopy Description of Segmental Leiomyoma and Relative Management

Cutaneous leiomyoma is a benign tumor, mainly composed of smooth muscle cells and arising from the arrector pili muscle of hair follicles. The diagnosis of leiomyomas is of paramount importance, as they can often be associated with underlying malignancies (e.g., renal cell carcinoma, leiomyosarcoma) and specific genetic mutations. We report the case of a 27-year-old Caucasian male patient that presented to our attention with a rare segmental and Zoosteriform type II leiomyoma. We performed an analysis of the cutaneous lesions using dermoscopy, reflectance confocal microscopy (RCM) and histology. We found that, using dermoscopy, the leiomyomas showed a dermatofibroma-like appearance with a central hypopigmented area, peripheral delicate hyperpigmentation and also erythematous areas and ectatic vessels. RCM, although not specific, showed groups of hypo-reflective areas distributed in the most superficial papillary dermis, which in histology and immunohistochemistry corresponded to the most superficial protrusions in the papillary dermis of the tumoral bundles. Finally, we discuss the management of patients with multiple leiomyomas and stress the fact that, in the cases of multiple leiomyomas, an annual sonography of the kidneys associated with dermatological and (in women) gynecological consultations are needed to ensure the early identification of an underlying tumor. A genetic consultation to detect an eventual FH mutation is recommended, but since in some cases the FH result may be negative, the above recommended controls remain always of paramount importance.

Mono-(2-ethyl-5-hydroxyhexyl) phthalate promotes uterine leiomyoma cell survival through tryptophan-kynurenine-AHR pathway activation

Uterine leiomyoma is the most common tumor in women and causes severe morbidity in 15 to 30% of reproductive-age women. Epidemiological studies consistently indicate a correlation between leiomyoma development and exposure to endocrine-disrupting chemical phthalates, especially di-(2-ethylhexyl) phthalate (DEHP); however, the underlying mechanisms are unknown. Here, among the most commonly encountered phthalate metabolites, we found the strongest association between the urine levels of mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), the principal DEHP metabolite, and the risk of uterine leiomyoma diagnosis (n = 712 patients). The treatment of primary leiomyoma and smooth muscle cells (n = 29) with various mixtures of phthalate metabolites, at concentrations equivalent to those detected in urine samples, significantly increased cell viability and decreased apoptosis. MEHHP had the strongest effects on both cell viability and apoptosis. MEHHP increased cellular tryptophan and kynurenine levels strikingly and induced the expression of the tryptophan transporters SLC7A5 and SLC7A8, as well as, tryptophan 2,3-dioxygenase (TDO2), the key enzyme catalyzing the conversion of tryptophan to kynurenine that is the endogenous ligand of aryl hydrocarbon receptor (AHR). MEHHP stimulated nuclear localization of AHR and up-regulated the expression of CYP1A1 and CYP1B1, two prototype targets of AHR. siRNA knockdown or pharmacological inhibition of SLC7A5/SLC7A8, TDO2, or AHR abolished MEHHP-mediated effects on leiomyoma cell survival. These findings indicate that MEHHP promotes leiomyoma cell survival by activating the tryptophan-kynurenine-AHR pathway. This study pinpoints MEHHP exposure as a high-risk factor for leiomyoma growth, uncovers a mechanism by which exposure to environmental phthalate impacts leiomyoma pathogenesis, and may lead to the development of novel druggable targets.

Rare Vaginal Leiomyoma with Rare Microscopic Findings

Leiomyoma is the most common benign tumor of uterus and rarely may be seen in other parts female reproductive system like the round ligament, utero-sacral ligament, inguinal canal and vagina. Only a few examples of fibroid with vaginal origin have been documented in the literature. With only roughly 300 recorded occurrences, vaginal leiomyomas are still a rare condition. These vaginal fibroids arise most commonly from the anterior vaginal wall causing varied clinical presentations. We report a case of vaginal lateral wall fibroid of 8 cm size and extending into paraurethral space. The vaginal mass was surgically excised and histopathology confirmed the diagnosis of leiomyoma with cartilaginous degeneration.

A critical review of “uterine leiomyoma” with subsequent recurrence or metastasis: A multicenter study of 62 cases

Histopathologic diagnosis of a subset of uterine smooth muscle tumors is challenging. We report a critical review regarding the clinicopathological point of view of 62 cases of subsequently recurred or metastasized leiomyoma. Medical records and glass slides of 62 cases of uterine smooth muscle tumor diagnosed as leiomyoma, which subsequently recurred or metastasized, were critically reviewed by pathologists specializing in gynecologic pathology and oncology. In 47 (75.8%) of 62 cases, the diagnosis of leiomyoma was confirmed, including 11 intravascular leiomyomatosis (IVL) and benign metastasizing leiomyoma (BML). In 29 cases (46.8%) laparoscopic surgery was performed, of which morcellator without a bag was employed in 23 cases. Fifteen cases (24.2%) appeared to be underestimated and were re-classified as smooth muscle tumor of uncertain malignant potential (STUMP), leiomyosarcoma, or other malignant mesenchymal tumors. Recurrences in seven cases (11.3%) were interpreted to be a malignant transformation, and one STUMP recurred as STUMP. The recurrence or metastasis in cases of "leiomyoma" is attributed to iatrogenic or under-evaluation of primary tumors, although a subset of cases is a rare example of biological progression.