Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Removal of Extrauterine Fibroid on the Mons Pubis: A Case Report Rakhi Mira Patel, BS, Claire Estep, MA, Joel Snipe, MD VCOM Carolinas Campus, Spartanburg, SC

Abstract

Conclusions

Results

Uterine fibroids are a common gynecological complaint that typically presents with pain and abnormal uterine bleeding. They are most often classified as intramural and are found in the epithelial lining with submucosal and subserosal being less common and extramural being least common. Extramural or extrauterine fibroids are rare but have been reported following trauma to the uterus such as prior uterine surgical procedures. Currently, no literature exists that documents extrauterine fibroids of the vulva at the mons pubis without prior trauma or connection to the uterus (e.g., herniation of uterine tissue through the inguinal canal). This report is of a 41-year-old African American woman who presented for surgical removal of a 7 cm mass on their mons pubis. It had been present for the last 2 years, was relatively painless, and was initially worked up with an ultrasound-guided biopsy. The pathology report found evidence of leiomyomatis bundles that were consistent with an extrauterine fibroid. Myomectomy was delayed until 2023 due to a pregnancy at which time the mass increased in size. The mass was surgically excised and found to be completely without attachment to the uterus or other structures. Pathology confirmed diagnosis of vulvar leiomyoma with hyalinization and degenerative changes. Uterine leiomyomas, also known as uterine fibroids, are the most common benign neoplasms of the female reproductive tract (1). They originate from uterine smooth muscle and are found in 25-30% of reproductive-aged women, especially those 30-50 years of age (1-2). The prevalence of fibroids increases during reproductive age and decreases after menopause (1, 3). Risk factors for developing leiomyomas include early age at menarche, family history of uterine leiomyomas, obesity, nulliparity, and hypertension (3, 4). Black race can also increase the risk of having fibroids (4, 5). By 50 years of age, 80% of African-American women and around 70% of white women have uterine fibroids (5). Generally, uterine leiomyomas can range in size from microscopic neoplasms to large, bulky masses (1). Most small leiomyomas do not cause any symptoms and do not require treatment (1). In fact, a majority of women with fibroids are asymptomatic and many are discovered incidentally (3). When uterine leiomyomas are symptomatic they often cause abnormal uterine bleeding that is heavy and prolonged, non-cyclic pelvic pain, and dyspareunia (3). Fibroids can also affect fertility (5). Very large fibroids that distort and distend the uterus can also cause compression-related symptoms such as increased urination, bowel dysfunction, and dyspnea (1, 5). Medical treatment with oral contraceptives or progestins is used to manage bleeding (3). Fibroids typically originate within the uterine wall; about 70% of all cases are classified as intramural or inside the myometrium (5). 10% of cases are classified as submucosal where the fibroid is located in the inner lining of the uterus (5). The other 20% of cases are subserosal or outside of the uterus (5). These are most commonly either directly apart of the uterus or attached via a peduncle (5). Vulvar leiomyomas are rare variations of fibroids that are present most often as a labial mass (6). As of 2020, only around 160 cases have been reported in English literature (6. They are typically painless, solitary, and well-circumscribed that consist of spindle-shaped cells (7). These are often misdiagnosed as Bartholin cysts (7). Due to the challenge of diagnosing these neoplasms, immunohistochemistry plays an important role in differentiating between diagnoses (8). They are often positive for anti-smooth muscle antibodies, desmin, and vimentin (8). Some, but not all cases will stain positively for estrogen receptors and/or progesterone receptors (7.8). Introduction or Methods

The patient is a 41-year-old G7P5025 African American woman who presented for surgical removal of a 7 cm mass on the mons pubis that has been present for over 2 years (Fig. 1). Pathology of ultrasound-guided biopsy in 2021 found evidence of leiomyomatis bundles of smooth muscle compatible with an extrauterine fibroid. A computed tomography was performed and could not rule out the possibility of herniation.

References 1.Aksoy H, Aydin T, Özdamar Ö, Karadag ÖI, Aksoy U. Successful use of laparoscopic myomectomy to remove a giant uterine myoma: a case report. J Med Case Rep . 2015;9:286. Published 2015 Dec 17. doi:10.1186/s13256-015-0771-9 2.Maharjan S, Thapa M, Pokhrel M. Nulligravida with Large Uterine Leiomyoma: A Case Report. JNMA J Nepal Med Assoc . 2022;60(250):577-580. Published 2022 Jun 1. doi:10.31729/jnma.7333 3.Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health . 2012;12:6. Published 2012 Mar 26. doi:10.1186/1472-6874-12-6 4.Yang Q, Ciebiera M, Bariani MV, et al. Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment [published correction appears in Endocr Rev. 2022 Mar 02;:] [published correction appears in Endocr Rev. 2022 Mar 02;:]. Endocr Rev . 2022;43(4):678 719. doi:10.1210/endrev/bnab039 5.Viva W, Juhi D, Kristin A, et al. Massive uterine fibroid: a diagnostic dilemma: a case report and 6.Bettamer N, Lange R, Elghazal Z, Ali FB, Alkikhia L. Leiomyoma of the Vulva. Obstet Gynecol Cases Rev. 2020;7:185. Published 2020. doi:10.23937/2377 9004/1410185. 7.Kurdi S, Arafat AS, Almegbel M, Aladham M. Leiomyoma of the Vulva: A Diagnostic Challenge Case Report. Case Rep Obstet Gynecol . 2016;2016:8780764. doi:10.1155/2016/8780764 Zhao T, Liu X, Lu Y. Myxoid Epithelial Leiomyoma of the Vulva: A Case Report and Literature Review. Case Rep Obstet Gynecol . 2015;2015:894830. doi:10.1155/2015/894830 A patient presented for the removal of a large mass on her mons pubis that had increased in size during pregnancy. It was surgically excised and sent to pathology which confirmed the diagnosis of vulvar leiomyoma. An extrauterine fibroid of the vulva in the mons pubis without any uterine attachment is an exceptionally rare presentation of a leiomyoma that can be considered when evaluating pelvic masses. Providers should be aware of the existence and occurrence of these rare, atraumatic extrauterine fibroids and consider them as a differential diagnosis for masses in female patients. review of the literature. J Med Case Rep . 2021;15(1):344. Published 2021 Jul 13. doi:10.1186/s13256-021-02959-3

Figure 1

Figure 2

Survey of the abdomen and pelvis revealed no signs of herniation. The pseudocapsule of the fibroid was incised, and the myoma was injected with 10mL of dilute vasopressin for hemostasis. Sharp and blunt dissection was used to shell out the myoma. There were no attachments to the mass as it was dissected out (Fig. 2). The myoma was white-tan to pink-tan and multinodular. The mass removed was 271.5 g measuring 9.2 x 7.2 x 6.5 cm (Fig. 3). The pathology report found a spindle cell lesion with fascicular architecture with observed hyaline and degenerative changes. There was no apparent atypia or necrosis and minimal mitotic activity. The immunohistochemical stains were positive for desmin and SMA, negative for CD10 and P16, and Ki-67 had a nuclear positivity of 3%. The final diagnosis was vulvar leiomyoma with hyalinization and degenerative changes.

Figure 3

Figure 4

The patient followed up at 2 and 7 weeks post-operation (Fig 4). There were no postoperative complications; the incision site was healing well. Almost all of her sensation to the incision area and the vulva had returned.

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2024 Research Recognition Day