ABSTRACT

CORRESPONDING AUTHOR:
Dr. B. Shilpa Shivanna,
Associate Professor,
Department of OBG,
Adichunchanagiri Institute of Medical Sciences,
B.G. Nagara, Mandya Dist, Karnataka State- 571448.
E-mail: shilpsdr@gmail.com

ABSTRACT: Uterine Leiomyomas are most common benign lesions of the female genital tract 20% in the reproductive age group. It is a sex steroid responsive tumour originating as clonal expansion of individual myometrial cells. Translocation between chromosome 12 and 14 are more likely in large myomas. Deletions of long arm of chromosome 7 are found in small tumors. The symptoms are location dependant. 20 -50% are symptomatic. 75% are intramural fibroids, 15% submucous .Symptoms like Menorrhagia 80%, dysmenorrhoea, pelvic pressure symptoms, infertility, abdominal distension, pelvic pain and rarely undergo sarcomatous degeneration, torsion, capsular rupture. Isthmic fibroids are uncommon, produce symptoms early. Here is a rare case and unusual case of isthmic fibroid without any symptoms. Hence this rare case is reported.
KEYWORDS: Uterine Fibroids, Multiple, Isthmic, Subserous, True Broad ligament

INTRODUCTION: Uterine fibroids are a major public and women's health problem. They are commonest tumors of the uterus. Fibroids commonly arise from the body of the uterus and cervix. Isthmic fibroids are uncommon and produce symptoms early. Here is a case of huge isthmic multiple fibroids which were asymptomatic.

CASE REPORT: A 45 year old woman married since 30 years, P2L2 came with complaints of mass per abdomen since 3 years. It was not associated with menstrual disturbances, or any pressure symptom like bowel or bladder disturbances or pain abdomen. Her past and present menstrual cycles were regular. Both her deliveries fullterm normal, last childbirth  was 25 years ago and tubectomised .Her past, family and personal history was not significant.
        On admission , her general condition was fair , vital parameters were within normal limits. Cardiovascular and respiratory system clinically normal. On per abdomen examination there was a mass of 32 weeks gestation, arising from pelvis extending to all quadrants of abdomen. Mass was of variable consistency from cystic to firm and it was nontender. On pervaginal examination, uterus was not made out separately from mass which was felt through all fornices, firm in consistency and nontender. On per rectal examination firm mass was felt , mucosa was free , no parametrial induration.

Investigations revealed : haemoglobin-8.4gm% , Blood urea : 22mg% , haematocrit: 24%, S. Creatinine :0.5mg% , Blood group: A positive, pap smear : normal.ECG and chest x-ray : normal.
USG: A large intraperitoneal mass with heterogenous echotexture extending from pubic symphysis to xiphisternum. uterus and both ovaries were not delineated.

PROVISIONAL DIAGNOSIS: Fibroid Uterus.
Differential diagnosis -Pseudomucinous cystadenoma ovary.

MANAGEMENT: She was taken up for Exploratory Laparotomy by vertical midline incision under general anaesthesia. Per operative findings: Uterus was enlarged upto 32 weeks size. Both ovaries and tubes were normal. Three subserous fibroids arising from isthmus measuring 30 x35 cm, 20 x 25 cms ,15 x 20 cm were found. UV fold of peritoneum stretched over the fibroids but without disturbing bladder and ureter. One true broad ligament fibroid measure 7 x 6 cm found on left side pushing ureter on that side medially.
        All the fibroids were enucleated and total abdominal hysterectomy was done. Postoperative period was uneventful and patient was discharged on 7th post operative day. The excised tumor weighed 10.2 kg HPR showed - Leiomyoma of uterus with no evidence of malignancy. Uterus and cervix showed normal histological findings.

Followup of the patient was uneventful over a 2 year period.

DISCUSSION: Fibroid is a benign solid tumor of the uterus composed of smooth muscles and fibrous connective tissue and mullerian tissue. More than 300000 hysterectomies and 20000 myomectomies are being done each year worldwide out of which 50% are symptomatic. Fibroid can arise from body of the uterus (subserous, intramural, and submucous) and cervix and rarely from isthmus. (INCIDENCE - 5% ).

ETIOLOGY: It represents aberrant clonal expansion of individual myometrial cell. Each one represents benign sex steroid responsive smooth muscle tumors. It has non Mendelian inheritance pattern with upto 50% recurrence rate after myomectomy .Mechanism of clonal expansion of individual myometrial cells involves interplay of gonadal steroids and subsequent expansion of autocrine, paracrine and endocrine growth factors.

MOLECULAR MECHANISM OF GENETIC DYSREGULATION : Most common aberrant patterns are translocation between chromosome 12 and 14, Deletion of short arm of chromosome 7,Rearrangement of long arm of Ch 6.Transcription - factor subgroup A2 is unregulated with expression of 12:14 translocation. Fibroids of uterus can grow into any size but those arising from isthmus will produce symptoms early like pressure on bladder and rectum. In the above case it was multiple subserous fibroids from isthmic region which is very rare (incidence -5%) and has grown to large size without producing any symptoms. Interestingly there was a true broad ligament fibroid making operability more difficult. Ureters delineated and enucleation of fibroids followed by hysterectomy done.

CONCLUSION: In cases of huge fibroids especially in isthmic origin it is imperative to have thorough preoperative evaluation and anticipate operative challenges and it is important to delineate ureters which will help to avoid injury to ureter and bladder.
 
REFERENCES:
1.    Rein MS, Barbieri RL, Friedman AJ Progesteron ; a critical role in the pathogenesis of uterine myomas. Am.J.Obst Gynae 1995 ; 172:14
2.    Leiomyomata uteri and myomectomy John D Thompson,John A Rock in Te Linde's Text book of operative gynaecology 9th edition.
3.    Berek JS Novak Gynaecology 13th edition Philadelphia :Lippincott
4.    Chapter -18,Benign lesions of the uterus,Text book of Gynaecology DC Dutta, 7th edition 2011 ,New central book agency (P) Ltd.
5.    Jeffcoates Principles of Gynaecology,edition 5,2001,Arnold Publishers,chapter 27:500:3.
6.    Myomas , obstetrics and gynaecology clinics of north america ,number 1 ,vol 33, march 2006, Elsevier sanders.