Aydin et al., J Genit Syst Disor 2015, 4:1 http://dx.doi.org/10.4172/2325-9728.1000134 Journal of Genital System & Disorders Case Report A SCITECHNOL JOURNAL Is it an Adnexal Mass or a Broad Ligament Leiomyoma? Cetin Aydin, Halime Sen Selim*, Selda Uysal, Serenat Eris and Yakup Yalçın Gynecology and Obstetrics Department of Ataturk Training and Research Hospital, Basin Sitesi, Yesilyurt, 35360 Izmir-Turkey *Corresponding Author: Halime Sen Selim, MD, Gynecology and Obstetrics Department of Ataturk Training and Research Hospital, Basin Sitesi, Yesilyurt, 35360 Izmir-Turkey, Tel: 00902322444444/2433, Mob: 05354916607, Fax: 00902322431530; E-mail: [email protected] Rec date: February 11, 2014 Acc date: April 15, 2015 Pub date: April 20, 2015 Abstract Uterine Leiomyomas and adnexal masses are the most common causes of pelvic masses arising from the female urogenital system. We present a case that demonstrates the similarity between the leiomyoma and malign adnexal cyst. A 51 year-old, post-menopausal women presented with lower abdominal pain and a pelvic mass (6x7 cm diameter). The sonographic appearance of the mass was multi-cystic with some solid area, indistinct margin on the right side of the uterus and intra-abdominal fluid, similar to typical malign ovarian cysts. We performed exploratory laparotomy and found that the mass was a pedunculated subserosal myoma arising from right side of the uterine corpus, which extending between the folds of the broad ligament. Histopathological examination revealed subserosal leiomyoma with cystic degeneration. Postmenopausal cystic degenerative leiomyoma can be a good imitation of ovarian neoplasms, resulting in diagnostic confusion. Keywords: Leiomyoma; Ultrasonography; Pelvic Tuberculosis Ovarian Neoplasms; Ascitic Fluid; Inflammatory Disease; Peritoneal Introductıon Adnexal masses are common in all age groups, from in the fetus to post-menauposal women. To determine the origin of an adnexal mass is generally difficult. The adnexal area contains the ovary and fallopian tube, associated vessels, ligaments, and connective tissue. Masses of this area often from the ovary or fallopian tube however, the broad ligament, uterus, bowel, or retro peritoneum can also produce an adnexal mass. Uterine leiomyoma are the most common type of pelvic mass arising from the female urogenital system [1]. A subserosal leiomyoma of the adnexal area can cause diagnostic confusion. Generally, during ultrasound examination the uterus and uterine Leiomyomas appear to be of the same density and diagnosis is simple. However, the appearance of cystic degenerated leiomyoma can be similar to adnexal masses, which can lead to diagnostic confusion. complexity or solidity of the mass upon ultrasound examination, or with the presence of ascites. The source of the mass and possibility of malignancy is predictable according to the age of the patient, clinical findings, ultrasound examination and tumor markers level. However, definitive diagnosis can be determined only after surgery. In the present case, rare location and unusual sonographic reveals the importance for differential diagnosis of an adnexal mass. Case Presentation A 51 year-old, gravida3, para2, post-menopausal was admitted to our hospital, complaining of lower abdominal pain. Her last menstrual cycle was 6 years previously. A pelvic examination revealed a semi-Mobil mass consistent with a 6–8 week gestational uterus. The mass was in the right adnexal area, and there was no clear border between the mass and right side of the uterus. The left ovary was non-palpable. Ultrasound examination revealed a 8×7×6 cm heterogeneous mass, the sonographic appearance of the mass was multi-cystic with some solid area, an indistinct margin with the right side of the uterus and intra-abdominal fluid, resembling a malign ovarian cyst. The left ovary appeared normal but right ovary could not be visualized. The patient’s tumor markers level was within the normal range (e.g., Ca125 was 4IU/ml). The haemoglobin level was 12.6 g/dl and there was no indication of urine infection. An exploratory laparotomy was performed to investigate this postmenopausal pelvic mass of unknown origin. On inspection, there were bilateral normal ovaries, a post-menauposal uterus with multiple subserosal myxomatous nodules (ranging from 1 to 3 cm), and a pelvic mass in the right broad ligament with some free fluid in the pelvic cavity (Figure 1a).After dissection of the broad ligament, we identified a 6×7 cm diameter degenerated subserosal myoma arising from the right-side of the uterine corpus (Figure 1b). We performed a total hysterectomy with bilateral salpingo-oophorectomy. Histopathological examination revealed multiple subserosal leiomyoma, the largest one (6×7cm) was with cystic degeneration and bigger than corpus of the uterus (Figure 2). Peritoneal cytology was benign. The post-operative course was uneventful 5 days after surgery the patient was discharged from hospital in good condition. Discussion A post-menopausal woman was admitted to the hospital complaining of abdominal pain. At this point many diseases could be considered for diagnosis, including pelvic inflammatory disease (PID), urinary system pathologies, many intestinal diseases, and possibly a pelvic mass. A pelvic mass can be recognized after a bimanual pelvic examination, although the origin can sometimes remain unclear. Otherwise, pelvic inflammatory disease could be excluded by absence of fever, purulent cervical discharge, and cervical motion tenderness. Likelihood of malignancy of an adnexal mass increases from the pre-pubescent to post-menopausal period, as well as with the All articles published in Journal of Genital System & Disorders are the property of SciTechnol and is protected by copyright laws. Copyright © 2015, SciTechnol, All Rights Reserved. Citation: Aydin C, Selim HS, Uysal S, Eris S, Yalçin Y (2015) Is it an Adnexal Mass or a Broad Ligament Leiomyoma?. J Genit Syst Disor 4:1. doi:http://dx.doi.org/10.4172/2325-9728.1000134 Figure 1a: bilateral normal ovaries, a postmenauposal uterus with multiple subserosal myomatous nodules (ranging from 1-3 cm), and a pelvic mass in the right broad ligament, Figure1b: dissection of the broad ligament; a 6x7 cm in diameter degenerated subserosal myoma arise from right side of the uterine corpus. because the broad ligaments are not generally visualized on ultrasound examination. Uterine Leiomyomas are the most common pelvic masses arising from the female urogenital system [1]. Generally, they present abnormal uterine bleeding or pelvic pain. Uterine Leiomyomas are classified according to their location (i.e., intramural, submucosal, subserosal or cervical), with intramural being the most common form. Subserosal leiomyomas which originate from the myometrium at the serosal surface of the uterus are less frequent and rarely extend between the folds of the broad ligament. Figure-2: Pathological examination of the specimen (macroscopic & microscopic) Imaging modalities are often helpful for certain diagnosis. Ultrasound is the most common approach because of its relative cost effectiveness and absence of ionizing radiation exposure, however, its diagnostic performance is not perfect. A multicenter study reported that 90% of extra uterine masses could be correctly classified by the ultrasonography as benign or malignant, but the remaining 10% were unclassifiable by their ultrasound findings [2]. The origin of a mass which is in the adnexal area may be attributed to either the ovary or uterus (the most common masses of this area) Volume 4 • Issue 1 • 1000134 Upon ultrasound examination, if an adnexal mass includes a solid component or septation, it is more likely to be malignant. In addition, the presence of ascites in the peritoneal cavity, and adnexal masses larger than 8 to 10 cc volume in post-menopausal women, also raise the suspicion of malignancy. Pedunculated fibroids usually appear as heterogeneous, hypo echoic, solid masses. Cystic degeneration of a fibroid can result in the appearance of a complex mass on ultrasound, so that their appearance is more likely to be a malign ovarian cancer [3]. Visualization of the ipsilateral ovary or additional studies with magnetic resonance imaging can also help with diagnosis. In this case, because of our patient’s age, presence of intraperitoneal fluid, largeness and complex appearance of the mass, as well localization, there was doubt regarding whether this could be a malignant ovarian mass. In addition, the presence of a pelvis mass and ascites, but without elevated Ca125 levels, peritoneal tuberculosis can also be considered for diagnosis . Generally Serum CA 125 is elevated but sometimes it could be in normal range [4,5]. The Ca125 levels and clinical appearance of the patient had suggested that the mass could be benign. Ultrasound and magnetic resonance imaging (MRI) are the most useful imaging modalities for the diagnosis of leiomyoma [6]. Although their sensitivity and specificity are decreased in the diagnosis • Page 2 of 3 • Citation: Aydin C, Selim HS, Uysal S, Eris S, Yalçin Y (2015) Is it an Adnexal Mass or a Broad Ligament Leiomyoma?. J Genit Syst Disor 4:1. doi:http://dx.doi.org/10.4172/2325-9728.1000134 of cystic degenerative subtypes MRI is more sensitive and specific than ultrasound, but because of availability and cost-effectiveness, ultrasound is the most widely used imaging modality. In the present case, we used ultrasound for diagnosis. Due of cystic degeneration and intraligamentary location of the subserosal subtypes of leiomyoma; the mass was of an adnexal cyst [7]. Although MRI might have been used for correct diagnosis prior to operation, due to the localization and thin peduncle of the subserosal leiomyoma, MRI may also have been insufficient. 2. 3. 4. Conclusıon Postmenopausal cystic degenerative leiomyomas can be a good imitation of ovarian neoplasms and a cystic degenerative, pedunculated uterine leiomyoma, which lies between the folds of the broad ligament, should be considered in the differential diagnosis of an adnexal mass [8]. 5. 6. Declaration of Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. 7. References 8. 1. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM (2003) High cumulative incidence of uterine leiomyoma in black Volume 4 • Issue 1 • 1000134 and white women: ultrasound evidence. Am J Obstet Gynecol 188: 100-107. Valentin L, Ameye L, Jurkovic D, Metzger U, Lécuru F, et al. (2006) Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis?. Ultrasound Obstet Gynecol 27: 438-444. 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