Does Big Mean Evil? Giant, but Benign Uterine Leiomyoma: Case Report and Review of the Literature

Brito, Luiz Gustavo Oliveira; Ueno, Natalia Lysei; Machado, Maira Rossmann

doi:10.1055/s-0040-1721351

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Revista Brasileira de Ginecologia e Obstetrícia

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Case Report • Rev. Bras. Ginecol. Obstet. 43 (01) • Jan 2021 • https://doi.org/10.1055/s-0040-1721351 copy

Does Big Mean Evil? Giant, but Benign Uterine Leiomyoma: Case Report and Review of the Literature

Será que grande significa maligno? Leiomioma gigante, porém benigno: Relato de caso e revisão de literatura

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Uterine leiomyoma is themost prevalent benign type of gynecological tumor. It affects more than 80% of women worldwide and, within this group, more than 50% may be asymptomatic. However, large fibroid volumes may be associated with symptoms of extrinsic compression, and most of the cases do not present atypical cells. We present the case of a 49-year-old woman who underwent a total abdominal hysterectomy of a 13.5-kg uterine leiomyoma with no malignancies at histopathology and review the literature about giant uterine leiomyomas and their clinical repercussion. We concluded that large volumes do not always pose a threat regarding malignancy; however, future molecular studies are needed to investigate giant uterine fibroids.

Keywords:
uterine leiomyoma; giant tumors; gynecological tumors

Author	Uterine weight	Age (years)	Duration of symptoms	Symptoms	Preoperative assessment to rule out malignancy	Surgery and complications	Observations
Behrend⁴4 BehrendM. Report of a case of fibromyoma of the uterusweighing 133 pounds removed at operation. Am J Obstet Gynecol. 1930;20 (05):699-702. Doi: 10.1016/S0002-9378(30)90197-4 https://doi.org/10.1016/S0002-9378(30)90...	60.7 kg (133.8 lb)	35	9 years	Enlargement of the abdomen	Not performed	Removal of the tumor, no details	Patient died from pneumonia 48 hours after the surgery
Oelsner et al.⁷7 Oelsner G, Elizur SE, Frenkel Y, Carp H. Giant uterine tumors: two cases with different clinical presentations. Obstet Gynecol. 2003; 101(5 Pt 2):1088-1091. Doi: 10.1016/s0029-7844(02)02621-2 https://doi.org/10.1016/s0029-7844(02)02...	Two cases: 43.176 kg and 13.116 kg	49 and 54	10 and 7 years	1^st case - Slow progressive enlargement of the abdomen, respiratory insufficiency with intubation prior to surgery. 2^nd case - abdominal pain and enlargement, weight loss, cachexia	1^st case – urgent laparotomy and no pre-op performed2^nd case – tumor size was big and patient could not undergo CT	1^st case – TAH-BSO2^nd case – mass removal + TAH-BSO	1^st case evolved well. 2^nd case evolved with grand mal convulsions
Reddy et al.⁸8 Reddy BV, Lee J, Cunningham PL. Giant uterine leiomyoma with air-fluid levels. J Am Coll Surg. 2004;198(05):844-845. Doi: 10.1016/j.jamcollsurg.2003.11.027 https://doi.org/10.1016/j.jamcollsurg.20...	17.69 kg (39 lb)	67	20 years	Increasing abdominal distension + low back pain. Tumor with air-fluid levels preop image	Only CT – no endometrial bx	TAH-BSO	Fibroid with septic degeneration – cefuroxime + metronidazole
Pérez and Ramón⁹9 Pérez M, Ramón JM. Large abdominal mass due to a giant uterine leiomyoma. Mayo Clin Proc. 2006;81(11):1415. Doi: 10.4065/ 81.11.1415 https://doi.org/10.4065/...	27 kg	40	12 months	Weight loss, increasing abdominal distension	Normal tumor markers (did not specify). CT-guided fine-needle aspiration biopsy (mesenchymal tumor).	TAH-BSO + segment of jejunum	No malignancies – post op uneventful
Nappi et al.¹⁰10 Nappi L, MatteoM, Giardina S, Rosenberg P, Indraccolo U, Greco P. Management of uterine giant myoma. Arch Gynecol Obstet. 2008; 278(01):61-63. Doi: 10.1007/s00404-007-0523-1 https://doi.org/10.1007/s00404-007-0523-...	27.7 kg		18 months	Abdominal enlargement, weight gain of 25 kg	MRI + US – multilocular mass, undetermined origin. Normal CEA, CA-125, AFP. No endometrial bx	TAH-BSO + omentectomy	None
Amber et al.¹¹11 Amber I, Kennedy G, Martinez H, Pearson JM, Jimenez E. A leiomyomain a cachecticwomanpresenting as a giantabdominalmass. J Radiol Case Rep. 2009;3(10):23-29. Doi: 10.3941/jrcr.v3i10.324 https://doi.org/10.3941/jrcr.v3i10.324...	26.94 kg	47	3 years	Cachexia, giant abdominal mass	CT with contrast – suspicious of leiomyosarcoma. AFP, CA 19–9 and CEA with normal levels. CA-125 slightly elevated.	TAH-BSO, appendectomy and partial omentectomy	Reoperated after 24 hours – hemorrhagic shock – Discharge 3POD
Semczuk et al.¹²12 Semczuk A, Skorupski P, Olcha P, Skomra D, Rechberger T, Gogacz M. Giant uterine leiomyomas causing bilateral hydronephrosis coexisting with endometrial cancer in polyp: a case study. Eur J Gynaecol Oncol. 2009;30(03):344-346	15.2 kg	50	Not reported	Bilateral hydronephrosis by abdominal tumor	No pre-op assessment.	TAH-BSO. Bilateral double-J catheters insertion before surgery	Coexisting with endometrial cancer deriving from a polyp
Savulescu et al.¹³13 Savulescu F, Iordache I,AlbitaO,HristeaR,DumitruC, IordacheA,etal. Giant uterine leiomyoma. Chirurgia (Bucur). 2011;106(05):665-668	18.1 kg	45	10 months	Increased abdominal size, constipation, urinary loss, urinary frequency, back pain	US and CT. No endo bx.	TAH-BSO	Discharge at POD #6;
Mate et al.¹⁵15 Máté S, Szatmári E, Sipos N, Széll J, Szánthó A, Rigó J Jr. [Giant uterine leiomyoma causing acute symptoms]. OrvHetil. 2013;154 (10):387-390. Doi: 10.1556/oh.2013.29563 https://doi.org/10.1556/oh.2013.29563...	13.5 kg	71	Not informed	Increased abdominal distension, cachexia	CT. Normal CEA, AFP, B-HCG. CA-125 94 U/mL.	TAH-BSO	No complications
Orazulike et al.¹⁶16 Orazulike NC, Green KI, Uzoigwe SA. Giant uterine fibroids: consequences ofdelay in presentation.Eur JObstetGynecolReprodBiol. 2015;194:251-252. Doi: 10.1016/j.ejogrb.2015.06.034 https://doi.org/10.1016/j.ejogrb.2015.06...	15.5 kg	43	14 years	Increasing abdominal distention + pelvic pain	Only ultrasound. Normal CA-125. No endometrial biopsy	TAH-BSO	Discharged POD #7
Ezugwu et al.¹⁷17 Ezugwu EC, Iyoke CA, Ezugwu FO, Ugwu G. Successful pregnancy following myomectomy for giant uterine fibroid in an infertile woman. J Reprod Infertil. 2014;15(04):233-236	16.8 kg	31	8 years	Progressive abdominal swelling, infertility, weight loss and dyspnea	Transabdominal US. Authors considered doing CA-125, CT and MRI but did not have funds to request for patient. No endo bx	Myomectomy	Elective cesarean section at 38 weeks
Moris and Vernadakis¹⁸18 Moris D, Vernadakis S. Giant uterine leiomyoma mimicking pregnancy. Mayo Clin Proc. 2014;89(06):e53-e54. Doi: 10.1016/j.mayocp.2013.06.029 https://doi.org/10.1016/j.mayocp.2013.06...	28.1 kg	39	4 months	Progressive constipation, increasing abdominal size, back pain, urinary frequency	Transabdominal US and CT – no ascites, metastases, or enlarged pelvic or para-aortic lymph nodes. No endo bx	Midline incision – ASH-BSO – Postop uneventful – 10^th day	None
Sonoo et al.¹⁹19 Sonoo T, Tokunaga K, Fukuda T, Nakamura K. Cardiac arrest induced by a giant uterine leiomyoma. BMJ Case Rep. 2015; 2015:bcr2015213370. Doi: 10.1136/bcr-2015-213370 https://doi.org/10.1136/bcr-2015-213370...	17.4 kg	37	3 years	Fatigue for 2 weeks – Hyperkalemia (10.3) and arrived in CPA	Post-mortem laparotomy – not performed any pre-op	Post-mortem laparotomy for mass resection	Death
Lim et al.²⁰20 Lim PT, Tan CH, Chia HL, Phoon J. Management of a giant uterine leiomyoma. BMJ Case Rep. 2018;2018:bcr2017224052. Doi: 10.1136/bcr-2017-224052 https://doi.org/10.1136/bcr-2017-224052...	27.8 kg	53	Not reported	Massive uterine mass complicating restrictive lung disease		TAH-BSO	Coagulopathy and hemorrhagic shock

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[1] Address for correspondence Luiz Gustavo Oliveira Brito, MD, MsC, PhD, Rua Alexander Fleming, 101, Campinas, SP, 13083-881, Brazil (e-mail: lgobrito@unicamp.br).