Leiomyoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Shanshan Cen, M.D. [3]; Ammu Susheela, M.D. [4]

Synonyms and Keywords: Uterine myoma; Fibroid; Fibroids, Uterine; Fibroid Tumor; Fibroid Uterus; Uterine fibromyoma

Overview

Uterine leiomyoma was first discovered by Hippocrates in 460-375 B.C and called it “uterine stone”. Uterine leiomyoma may be classified according to their location into 3 subtypes: submucosal, subserous, and intramural. The pathogenesis of leiomyoma is characterized by benign smooth muscle neoplasm. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus. Chromosome aberrations such as t(12;14)(q14-q15;q23–24), del(7)(q22q32), rearrangements involving 6p21, 10q, trisomy 12, and deletions of 1p3q has been associated with the development of leiomyoma. Uterine leiomyoma must be differentiated from other diseases that cause uterine mass, such as: uterine adenomyoma, pregnancy, hematometra, uterine sarcoma, uterine carcinosarcoma, and metastasis. Leiomyoma is more commonly observed among patients aged 40 years and older. Common risk factors in the development of uterine leiomyoma include African-American race, early menarche, prenatal exposure to diethylstilbestrol, having one or more pregnancies extending beyond 20 weeks, obesity, significant consumption of beef and other reds meats, hypertension, family history, and alcohol consumption. Physical examination may be remarkable for enlarged, mobile uterus with an irregular contour on bimanual pelvic examination. The mainstay of therapy for uterine leiomyoma is oral contraceptive pills, either combination pills or progestin-only, Gonadotropin-releasing hormone analogs. Surgery is also part of mainstay therapy for uterine leiomyoma.

Historical Perspective

  • Uterine leiomyoma was first discovered by Hippocrates in 460-375 B.C and called it “uterine stone”.
  • In the second century AD, Galen described the lesion as "scleromas".[1]
  • In 1860 and 1863, Rokitansky and Klob coined the term fibroid.
  • In 1854, Virchow, a German pathologist demonstrated that those tumors originated from the uterine smooth muscle. Thus, the term "myoma" became current in clinical use.
  • In 1809, the first laparotomy consequent to myoma indication was conducted by Ephraim McDowell to treat leiomyoma in Danville, USA.
  • The first successful myomectomy was performed by Amussat in 1840, after a clinical diagnosis of ovarian tumor because pelvic examination showed a pediculate and large uterine leiomyoma.
  • The first scientific report of a uterus conserving myomectomy through the vagina appeared in 1845 in the American Journal of Medical Science, accomplished by Washington Atlee, in Pennsylvania.
  • In 1898, Alexander Adam presented 11 cases of myomectomy through an abdominal route, in Liverpool.
  • In 1940, Carlos R. Círio proposed a technique of the myometrium emptying, called myometrectomy.

Classification

  • Uterine leiomyoma may be classified into 3 subtypes according to location:

Pathophysiology

  • The pathogenesis of leiomyoma is characterized by benign smooth muscle neoplasm. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.
  • The chromosome aberrations such as t(12;14)(q14-q15;q23–24), del(7)(q22q32), rearrangements involving 6p21, 10q, trisomy 12, and deletions of 1p3q have been associated with the development of leiomyoma.[2]
  • On gross pathology, round, well circumscribed (but not encapsulated), solid nodules that are white or tan, and whorled are characteristic findings of leiomyoma .
  • On microscopic histopathological analysis, elongated, spindle-shaped cells with a cigar-shaped nucleus are characteristic findings of leiomyoma.

Uterine Leiomyomata

Uterine fibroids are leiomyomata of the uterine smooth muscle. As with other leiomyomata, they are benign, but may lead to excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Enucleation is removal of fibroids without removing the uterus (hysterectomy), which is also commonly performed. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative to surgery. Estrogen and progesterone usually stimulate their growth, and hormone suppression may hence decrease their size.

Esophageal

Leiomyoma of the esophagus is the most common benign esophageal tumour, though this accounts for less than 1% of esophageal neoplasms. The remainder consists mainly of carcinomas. Although the vast majority of benign esophageal tumors are clinically silent and go undetected, large or strategically located tumors may become symptomatic. [3]

Leiomyoma of Jejunum

Leiomyoma is the most common benign tumor of small bowel. Approximately 50% of cases are found in the jejunum, followed by the ileum in 31% of cases. Almost one half of all lesions are less than 5 centimeters. [4]

Causes

  • Chromosome aberrations such as t(12;14)(q14-q15;q23–24), del(7)(q22q32), rearrangements involving 6p21, 10q, trisomy 12, and deletions of 1p3q have been associated with the development of leiomyoma.

Differentiating Leiomyoma from other Diseases

Leiomyoma is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

Clinical Features Physical Examination Diagnostic Findings
Endometriosis
  • Increased serum cancer antigen-125 
  • Nodules of the recto vaginal septum and hypoechoic, vascular mass on MRI
  • Laproscopic visualization confirms the diagnosis
Adenomyosis[5]
  • Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of gestation
Submucous uterine leiomyomas[6]
  • Mobile uterus with an irregular contour
Pelvic Inflammatory disease[7]
  • Seen in patients with history of sexually transmitted disease
  • History of multiple sexual partners 
  • Common in women younger than 25 years of age
Pelvic congestion Syndrome[8]
  • Shifting lower abdominal pain
  • Deep dyspareunia
  • Post-coital pain
  • Exacerbation of pain after prolonged standing 

Epidemiology and Demographics

Age

  • Leiomyoma is more commonly observed among patients aged 40 years and older.

Race

  • Leiomyoma usually affects African-American women.

Risk Factors

  • Common risk factors in the development of uterine leiomyoma include:
    • African-American race
    • Early menarche
    • Prenatal exposure to diethylstilbestrol
    • Having one or more pregnancies extending beyond 20 weeks
    • Obesity
    • Significant consumption of beef and other reds meats
    • Hypertension
    • Alcohol consumption

Natural History, Complications and Prognosis

  • The majority of patients with uterine leiomyoma remain asymptomatic for decades
  • Common complications of uterine leiomyoma include:

Diagnosis

Symptoms

  • Leiomyoma is usually asymptomatic.
  • Symptoms of uterine leiomyoma may include the following:

Physical Examination

  • Physical examination may be remarkable for:
  • Enlarged, mobile uterus with an irregular contour on bimanual pelvic examination

Imaging Findings

  • On ultrasound imaging, uterine leiomyoma is characterized by the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam.

Other Diagnostic Studies

Patient #1: MR images demonstrate large degenerating leiomyomas

Patient #2: MR images demonstrate a leiomyoma prolapsing into the endometrial canal

Hysterosalpingogram(HSG) reveals a submucosal leiomyoma

Treatment

Medical Therapy

Surgery

  • Surgery is the mainstay of therapy for uterine leiomyoma.
  • Uterine artery embolization in conjunction with laparotomic myomectomy is the most common approach to the treatment of leiomyoma.
  • Hysteroscopic myomectomy can also be performed for patients with uterine leiomyoma.

References

  1. Bozini, Nilo; Baracat, Edmund C (2007). "The history of myomectomy at the Medical School of University of São Paulo". Clinics. 62 (3). ISSN 1807-5932. doi:10.1590/S1807-59322007000300002. 
  2. Genetics of Uterine Leiomyomas. glowm (2016). http://www.glowm.com/section_view/heading/Genetics%20of%20Uterine%20Leiomyomas/item/363 Accessed on April 19, 2016
  3. James C. Chou, MD & Frank G. Gress, MD. "Benign Esophageal Tumors". Esophageal Cancer Overview (Cancer of the Esophagus). Retrieved 2007-03-21.  Unknown parameter |publsiher= ignored (|publisher= suggested) (help)
  4. By Michael P. Buetow, M.D. "Leiomyoma of Jejunum". Retrieved 2007-03-21.  Unknown parameter |publsiher= ignored (|publisher= suggested) (help)
  5. Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P (2006). "Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis.". Fertil Steril. 86 (3): 711–5. PMID 16782099. doi:10.1016/j.fertnstert.2006.01.030. 
  6. Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J; et al. (2016). "Long-term medical management of uterine fibroids with ulipristal acetate.". Fertil Steril. 105 (1): 165–173.e4. PMID 26477496. doi:10.1016/j.fertnstert.2015.09.032. 
  7. Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections (2014). "2012 European guideline for the management of pelvic inflammatory disease.". Int J STD AIDS. 25 (1): 1–7. PMID 24216035. doi:10.1177/0956462413498714. 
  8. Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES (2001). "Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women.". AJR Am J Roentgenol. 176 (1): 119–22. PMID 11133549. doi:10.2214/ajr.176.1.1760119. 

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