Cervical and broad ligament fibroid

Cervical and broad ligament fibroids are rare; with incidence of only 2% and 1% respectively.

Cervical fibroid often present with pressure symptoms and often pose surgical difficulties due to its proximity to bladder and rectum.

Broad ligament fibroid though rare , but have the propensity of growing into large adnexal masses and may mimic ovarian malignancy.

1. TACKLING DIFFICULT BROAD LIGAMENT AND CERVICAL FIBROIDS

2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. INTRODUCTION Fibroids(Myoma, Leiomyoma, Fibromyoma) Most common Monoclonal Benign tumors of uterus arising in the smooth muscle cells of myometrium. Contain large aggregation of extracellular matrix consisting of collagen, elastin, fibronectin and proteoglycan. Each fibroid is derived from smooth muscle cells rests, either from vessel wall or uterine musculature.

4. INCIDENCE Incidence of cervical fibroid is 2-3% and broad ligament fibroid is < 1%. 5-20% women in their reproductive age are reported to have fibroids. Most common----77% specimen of hysterectomy were having Fibroids invariable number ,size (micro-macro) and site.

5. FIGO CLASSIFICATION in 2010 8 8

6. ETIOLOGY GENETIC FACTORS Monoclonal 40% have chromosomal abnormalities Translocation between chromosome 12 and 14, deletion of 7q, Trisomy of 12 HORMONAL FACTORS Both estrogen and progesterone stimulates growth De novo production of estrogen in fibroids Increased progesterone receptors GROWTH FACTORS They increase smooth muscle cell proliferation, DNA synthesis and angiogenesis

7. RISK FACTORS Age – incidence increases with age till on set of menopause. Endogenous Hormonal factors Early menarche Late menopause Hyper-estrogenic states Increased expression and responsiveness of progesterone receptors A & B. Family History—1 st degree relatives are having 3.5 times more risk of developing fibroids.

8. Body weight Diet—diet rich in red meat, ham, beef Exercise – women doing regular exercise low risk OCS --- no definite relationship. ERT—variable reports Pregnancy Smoking

9. BROAD LIGAMENT FIBROID

10. BROAD LIGAMENT FIBROID Extremely rare (< 1%). Broad ligament fibroids are divisible into two types: True broad ligament fibroids : These spring from the muscle fibers normally found in the mesometrium . Such tumors may be found in at least three situations, (1) In the round ligament, (2) In the utero-ovarian ligament, and (3) In the connective tissue surrounding the ovarian and the uterine vessels. False broad ligament fibroids : These originate mostly from the lateral walls of the uterus or cervix

11. BROAD LIGAMENT FIBROID True Broad Ligament False Broad Ligament Originates from the muscle fibres normally found in the mesometrium (in the round ligament, ovario-uterine ligament, and the connective tissue around the uterine and ovarian vessels) Arises from the lateral wall of the uterine corpus or of the cervix, and bulges outward between the layers of the broad ligament. Ureter is medial to mass Ureter is lateral to mass No groove felt between mass and uterus Groove felt between mass and uterus

12. BROAD LIGAMENT FIBROID: SYMPTOMS Often symptomatic Abdominal distension Menstrual irregularities Dysmenorrhoea Dyspareunia Broad ligament fibroids may extent laterally and compress the ureter , causing pressure symptoms like retention , increased frequency etc.

13. BROAD LIGAMENT FIBROID: DIAGNOSIS Transvaginal ultrasound : a typical leiomyoma usually has a whorled appearance is seen. “Bridging vessel sign” confirms uterine origin. Ultrasound-guided percutaneous biopsy of the tumour may be helpful for determining its exact histologic composition before surgery.

14. BROAD LIGAMENT FIBROID: DIAGNOSIS Magnetic resonance imaging (MRI), with its multiplanar imaging capabilities, may be extremely useful for differentiating broad ligament fibroids from masses of ovarian or tubal origin and from broad ligament cysts.

15. BROAD LIGAMENT FIBROID : DIFFERENTIAL DIAGNOSIS Parasitic leiomyoma involving the broad ligament Pedunculated subserosal leiomyoma projecting towards the broad ligament Tubo - ovarian mass Hydrosalphinx Ectopic Pregnancy

16. Solid ovarian neoplasms: particularly those with dominant fibrous components Ovarian fibroma: fibrothecoma: tend to inseparable from the ovary Brenner tumour: tend to be inseparable from the ovary Malignant ovarian tumour Other ligamentous mesenchymal tumours Neurofibroma in the pelvis

17. BROAD LIGAMENT FIBROID: COMPLICATIONS Torsion Psuedo meg syndrome Cystic degeneration mimicking ovarian malignancy As broad ligament fibroids grow very big in size, necrosis can occur in fibroid causing symptoms of acute abdomen Huge broad ligament fibroid may cause hydroureter and hydronephrosis.

18. BROAD LIGAMENT FIBROID: MANAGEMENT Myomectomy VS Hysterectomy ?

19. Broad ligament myomectomy may be preferred: Large fibroids, or produce symptoms of oppression. Broad ligament fibroids are not associated with uterine fibroids, 3. Suspected degeneration particularly suspect. 4. Young patients, who need to preserve fertility. BROAD LIGAMENT FIBROID: MANAGEMENT

20. BROAD LIGAMENT FIBROID: MANAGEMENT Hysterectomy is preferred in following cases : Family complete Large no of fibroids in uteri along with broad ligament fibroid Suspected malignant fibroids. Associated with endometrial lesions. Severe cervical lesions.

21. CASE REPORT A 45yr old P2L2 presented with complaints of heaviness in abdomen, irregular heavy menses and dysmenorrhea , since 2 – 3 months On Examination: P/A – soft, non tender P/S - cervix , vagina healthy P/V – uterus bulky firm mobile, AV, soft to cystic mass 10X 8 cm in left and posterior fornix separate from uterus. Right fornix free and non tender. P/R – bogginess felt anteriorly, rectal mucosa and parametrium free. Tumor Marker - WNL

22. CASE REPORT USG Pelvis: solid, hypoechoic, well-circumscribed right adnexal mass of size 11.2 X 9 cm

23. CASE REPORT Intra-operatively, an abdomino -pelvic mass of size approximately 11cm × 8 cm × 5cm was seen with variable consistency and increased vascularity, arising from the left side of the uterus pushing the ureter laterally. Left fallopian tube, ovarian ligament, and round ligament stretched over the mass. Left ovary was normal. Right tube and ovary were normal. The mass was loosely adherent to the small bowel loops.

24. LAPAROSCOPIC BROAD LIGAMENT MYOMECTOMY

25. CERVICAL FIBROID

26. CERVICAL FIBROID Cervical myomas accounts for 2% of all uterine fibroids . They are classified depending on the location into anterior , posterior, lateral and central cervical myomas. Supravaginal cervical fibroid may be interstitial or sub-peritoneal variety and rarely polypoidal. Vaginal cervical fibroid is usually pedunculated and rarely sessile.

27. CERVICAL FIBROID : SYMPTOMS Chronic pelvic pain Menstrual irregularities Dyspareunia Pressure symptoms Anterior cervical fibroid produces symptoms like frequency or even retention of urine. Retention is more due to pressure than the elongation of the urethra. Rectal symptoms are more common with posterior cervical fibroid in the form of constipation Lateral cervical fibroid causes vascular obstruction which may lead to hemorrhoids and edema of legs (rare). Maternal dystocia, though rare during pregnancy

28. CERVICAL FIBROID: DIAGNOSIS ULTRASONOGRAPHY Most readily available and is least costly It is reasonably reliable for evaluation of uterine volume less than 375 cc and containing four or fewer fibroids. Transvaginal sonography (sensitivity 83%, specificity 90%) Saline infusion sonography (sensitivity 90%, specificity 89%) MRI Submucous fibroids are bets identifies with MRI. It can also evaluate the proximity of fibroid to the bladder, rectum and endometrial cavity, thus giving a fair idea what can be expected in surgery. CT SCAN

29. CERVICAL FIBROID :DIFFERENTIAL DIAGNOSIS Cervical polyp Pedunculated submucous fibroid Cervical cancer Lymphoma of the cervix: extremely rare Melanoma of the cervix: rare; usually involves the vagina with invasion into the cervix 

30. CERVICAL FIBROID : MANAGEMNT Treatment of cervical fibroid depends on the size , location and the desire for fertility of patients. Preoperative GnRH analogues administration for 3 months facilitate surgery and improve the haemoglobin status . In vaginal part fibroids if the tumour is sessile, myomectomy and if pedunculated ,polypectomy is done.

31. CERVICAL FIBROID : MANAGEMNT For lateral fibroids if patient is desirous of fertility, myomectomy may be attempted . For central fibroids, hysterectomy is required which may be done laparoscopically or by open surgery or by vaginal route if the size of the fibroid is small.

32. Victor Bonney was born in West London in 1872: both his father and his paternal grandfather were family doctors.  He was on the Council of the Royal College of Surgeons of England for a long time. Bonney's professional achievements and his fame among colleagues were firstly for his extraordinary performance of 500 Wertheim radical extended hysterectomy operations for cancer of the cervix and, secondly, for his development of the conservative operations of myomectomy and ovarian cystectomy.

33. PICTORIAL REPRESENTATION OF MYOMECTOMY FOR CENTRAL CERVICAL FIBROID FROM BONNEY’S MONOGRAM

34. Bisecting the uterus, Bonney’s original method Low Uterine incision, alternate method, avoiding the use volsella

35. Application of Bonney’s Myomectomy Clamp and Cutting away the redundant cervical wall

36. A 55 year old female P3 L3 presented in September, 2010 in Dr N N Chavan Unit with complaints of mass coming out of vagina with acute retention of urine . Case was suspected to a case of chronic uterine inversion. The mass was ulcerated for which Acriflavine – glycerine packing was done daily for a week. Patient was prepared for vaginal hysterectomy. CASE REPORT 1

37. CASE REPORT 1 Intraoperatively, 6cm x 6cm huge central cervical fibroid was seen.

38.   A 48-year old female P2L2, presented in 2013 in Dr N N Chavan Unit with gradual abdominal distension for one year, with acute retention of urine for 1 day. She had no menstrual complaints. Abdominal examination revealed a huge mass of 16 week size uterus with well-defined margins except the lower poles which cannot be reached, restricted mobility from above downwards but can be moved from side to side, non-tender and solid in inconsistency. CASE REPORT 2

39. On per speculum examination, a pinkish mass seen protruding through the vagina high up with minimal bleeding and cervix was not visualized. On per vaginal examination , a soft to firm mass of 16 weeks size was made out, cervix not felt and uterus could not be felt separately. Fullness was noted in all vaginal fornixes. CASE REPORT 2

40. Ultrasound revealed a 15 x 12 x 10 cm abdominopelvic mass with solid and cystic component. Uterus was visualised separately from the mass. CASE REPORT 2

41. CT Abdomen and pelvis showed a large well encapsulated, lobulated soft tissue dense lesion of 15*12.6*10.7cm with few areas of cystic degeneration noted in anterior, posterior and right lateral walls of lower body and cervix suggestive of cervical fibroid. CASE REPORT 2

42. CASE REPORT 2 At laparotomy, large mass of size 15*12*10cm was seen occupying the pelvis with normal uterus on top with typical appearance of Lantern on top of St.Paul’s cathedral . Bilateral ureters identified and laterally placed away from the area of dissection to prevent accidental injury. Whole fibroid along with uterus were removed in toto. The mass with uterus weighed 2.1kg

43. LAPAROSCOPIC CERVICAL FIBROID MYOMECTOMY

44. CONCLUSION Cervical and broad ligament fibroids are rare; with incidence of only 2% and 1% respectively. Cervical fibroid often present with pressure symptoms and often pose surgical difficulties due to its proximity to bladder and rectum. Broad ligament fibroid though rare , but have the propensity of growing into large adnexal masses and may mimic ovarian malignancy.

45. The choice of operation depends on the size , location and the family status of the concerned patient. Both cervical and broad ligament can be managed by myomectomy or hysterectomy either by laparoscopy or by open surgery .

46. FIBROIDS ARE REWARDS OF VIRTUE CHILDREN ARE FRUITS OF SIN

47. REFERENCES Uterine leiomyomata. American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin. Number 192, May 1994  Monaghan JM, Lopes AB, Naik R. Total hysterectomy for cervical and broad ligament fibroids. In: Huxley R, Taylor S, Chandler K, editors. Bonney's Gynaecological Surgery, 10th ed. Maiden, USA: Blackwell Publishing Company; 2004. p.74-86. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology , symptomatology, and management. Fertil Steril 1981; 36:433.  1.Tiltman, Andrew J. Leiomyomas of the uterine cervix: A Study of frequency. International Journal of Gynecological Pathology 1998; 231-4. 2.Kumar P, Malhothra N. Tumours of the corpus uteri. In: Jeffcoate’s Principles of Gynecology . 7th Ed.; Jaypee Brothers Medical Publisher ( Pvt. ) Ltd. New Delhi. 2008;p 487-516.   Barek JS.  Novack's Gynaecology. 15th ed. New Delhi: Lippincott Williams and Wilkins, Wolters Kluwer (India); 2007. Benign diseases of the female reproductive tract; p. 470. 3.  Fasih N, Prasad Shanbhogue AK, Macdonald DB, Fraser-Hill MA, Papadatos D, Kielar AZ, et al. Leiomyomas beyond the uterus: Unusual locations, rare manifestations.  Radiographics . 2008;28:1931–48.