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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 4  |  Page : 390-392
De novo growth of leiomyoma from rectus sheath: A rare presentation


1 Department of General Surgery, KS Hegde Medical College, Mangalore, Karnataka, India
2 Department of Pathology, KS Hegde Medical College, Mangalore, Karnataka, India

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Date of Web Publication8-Oct-2012
 

   Abstract 

Abdominal wall leiomyomas are a rare finding and are thought to follow seeding following surgical resection of uterine fibroids. There is paucity of findings of isolated abdominal wall fibroids in the literature without previous surgeries for myomectomies or presence of uterine fibroids. We present a case of a 34-year-old parous lady with no previous abdominal or gynecological surgeries presenting with a periumbilical lump of 1 year duration. The operative findings revealed a large mass in the parietal layers of the anterior abdominal wall attached to the right rectus sheath with no intra-abdominal attachments. Histopathology revealed features suggestive of a leiomyoma. We conclude that rectus sheath leiomyomas do exist and can present in a woman with no previous surgeries and hence should be borne in mind while diagnosing an anterior abdominal wall mass.

Keywords: Fibroid, leiomyoma, rectus sheath

How to cite this article:
Dísouza C, Bhat S, Purushothaman, Dhanej. De novo growth of leiomyoma from rectus sheath: A rare presentation. Ann Trop Med Public Health 2012;5:390-2

How to cite this URL:
Dísouza C, Bhat S, Purushothaman, Dhanej. De novo growth of leiomyoma from rectus sheath: A rare presentation. Ann Trop Med Public Health [serial online] 2012 [cited 2018 Aug 15];5:390-2. Available from: http://www.atmph.org/text.asp?2012/5/4/390/102082

   Introduction Top


Fibroids or the leiomyoma is the commonest benign tumor of the female reproductive tract, occurring most commonly in the uterus. Other sites include the broad ligament, ovaries, vagina, and very rarely found in the anterior abdominal wall. These are usually thought to follow seeding following surgical resection of uterine fibroids. We present a rare case of isolated leiomyoma of the anterior abdominal wall in a patient with no previous history of any gynecological surgeries.


   Case Report Top


A 34-year-old female presented with periumbilical lump of 1 year duration, which was gradually increasing in size. She gave history of dull aching pain in the abdomen with no relation to her menstrual cycles. There was no previous history of abdominal surgery. She had 1 living child through normal vaginal delivery. On examination of her abdomen, the mass measuring about 15 cm x 18 cm was found occupying the umbilical, right lumbar, right iliac, left lumbar, and hypogastric regions [Figure 1]. It had a smooth surface and firm in consistency and was not attached to the overlying skin. All margins were palpable. Her hematological parameters were within normal limits. Ultrasonography showed a heterogeneous hypoechoic lesion measuring 13.5 x 10 x 17.5 cm region in the lower abdomen with probable origin from the broad ligament. Both ovaries and uterus was normal. Computed tomography (CT) scan showed a relatively well-circumscribed soft tissue mass measuring 13.5 x 10.5 x 17 cm within the parietal wall of abdomen in the periumbilical region. There was no attachment found with the intra-abdominal organs [Figure 2].
Figure 1: Inspectory finding

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Figure 2: Computed tomography scan

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The patient was posted for exploratory laprotomy. The abdomen was entered via a midline incision.

The incision was developed into the subcutaneous tissue and rectus sheath, and the mass was enucleated from its capsule. The operative findings were a periumbilical mass situated between the subcutaneous tissues and the rectus sheath, its capsule also attached to the right rectus abdomnis muscle. The pelvic organs were inspected and found to be normal. Abdomen was closed in layers with a drain in the subcutaneous plane. The mass weighed 6 kilograms [Figure 3]. The histopathology of the patient showed spindle-shaped smooth muscle cells in interlacing bundles and whorls. No mitosis, necrosis, or atypia was seen. These features were suggestive of leiomyoma [Figure 4].
Figure 3: Operative specimen

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Figure 4: Histology slide

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The immediate post-operative period was uneventful. Patient was discharged on the 6 th day. Sutures were removed on the 10 th day.


   Discussion Top


Leiomyoma are said to be the commonest benign tumor of the reproductive tract and are found in 20% of women of reproductive age. Fibroids are usually asymptomatic, but if symptomatic, are associated with cyclical pain in relation to the menstrual cycles. A combination of hyper-responsiveness to estrogen and progesterone, and a variety of secondary paracrine and autocrine mediators is responsible for the increased pain and growth of the fibroid. [1]

Leiomyomas are found in as many as 70% of uteri removed during hysterectomy. [2],[3] They are commonly seen in the uterus, but they are also found in the broad ligament, ovaries, and vagina and rarely on the anterior abdominal wall. [3] Abdominal wall fibroids are a rare finding and are thought to follow seeding following surgical resection of uterine fibroids. [3] There are very few reported cases of isolated abdominal wall fibroids in the literature without previous surgeries for myomectomies or presence of uterine fibroids. [3]

The commonest primary diseases of the rectus muscle sheath, which are encountered in the clinical setting, are desmoid tumor and rectus sheath hematoma. Secondary disorders of the rectus muscle sheath are abscesses from diverticulitis, perforated sigmoid carcinoma, gallbladder empyema, and disseminated actinomycosis. Leiomyoma of rectus muscle sheath is extremely rare. [4],[5]

It was often believed that leiomyomas of deep soft tissue are rare or non-existent. [6] Although the existence of leiomyomas of soft tissue has been questioned in the past, it is now found that they do exist but are rare, and must be diagnosed using stringent histologic criteria. [4],[6],[7] These are of 2 types: First type occurring in patients of either sex in deep somatic soft tissue with predilection to the extremities, and the second type occurring primarily in women in the pelvic retro-peritoneum during the peri-menopausal period. [4],[6],[7]

Somatic leiomyomas often present as localized masses. They tend to be much larger than those of skin and are discovered at a relatively later stage due to absence of symptoms. Macroscopically, deep soft tissue leiomyomas tend to be well-defined and are usually surrounded by a fibrous pseudo-capsule. Histologically, somatic soft tissue leiomyomas are composed of interlacing bundles of mature smooth muscle cells with abundant eosinophilic cytoplasm, which by definition, lack atypia and necrosis and are mitotically inactive. [1],[4]

The retroperitoneal leiomyomas share a histologic similarity to uterine leiomyomas. Among the 2 types, Leiomyosarcomas occur more commonly in the retro-peritoneum, followed by deep somatic soft tissue, and are diagnosed by the presence of nuclear atypia and essentially any level of mitotic activity. Leiomyosarcomas of deep somatic tissue commonly arise from small veins, and their behavior can be predicted by a number of factors including age, grade, and "disruption" of tumor. [7]

Reliable prediction of the behavior of smooth muscle tumors is very difficult at many anatomic locations. Atypia appears to be the most useful way in separating benign smooth muscle tumors from malignant ones. Somatic leiomyomas tend to have little or no mitotic activity (< 1/50 HPF). Abdominal / retroperitoneal leiomyomas may have low levels of mitotic activity (1- 4 / 50 HPF), similar to uterine leiomyomas. [4]

To conclude, leiomyomas of rectus sheath do exist and should be kept in mind while evaluating a patient with a parietal wall mass.

 
   References Top

1.Amber I, Kennedy G, Martinez H, Pearson JM, Jimenez E. A leiomyoma in a cachectic woman presenting as a giant abdominal mass. J Radiol Case Rep 2009;3:23-9.  Back to cited text no. 1
[PUBMED]    
2.Yeh HC, Kaplan M, Deligdisch L. Parasitic and pedunculated leiomyomas. J Ultrasound Med 1999;18:789-94.  Back to cited text no. 2
[PUBMED]    
3.Igberase OG, Mabiaku OT, Ebeigbe PN, Abedi HO. Solitary anterior abdominal wall leiomyoma in a 31-year-old multipara woman: A case report. Cases J 2009;2:113.  Back to cited text no. 3
    
4.Goyal N, Khurana N. Leiomyoma of rectus sheath: An uncommon entity: Report of two cases. Indian J Pathol Microbiol 2010;53:597-8.  Back to cited text no. 4
    
5.Tueche SG, Trono M, Guiramand J, Cesari J. A bizarre giant leiomyoma. Ann Med Intern 2001;152:137-8.  Back to cited text no. 5
[PUBMED]    
6.Billings SD, Folpe AL, Weiss SW. Do leiomyomas of deep soft tissue exist? An analysis of highly differentiated smooth muscle tumors of deep soft tissue supporting two distinct subtypes. Am J Surg Pathol 2001;25:1134-42.  Back to cited text no. 6
[PUBMED]    
7.Weiss SW. Smooth muscle tumors of soft tissue. Adv Anat Pathol 2002;9:351-9.  Back to cited text no. 7
[PUBMED]    

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Correspondence Address:
Caren Dísouza
Department of General Surgery, KS Hegde, Medical College, Deralakatte, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.102082

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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