Although uterine myomas are the most common benign tumours of the female pelvis in the reproductive age group, they rarely grow in menopausal women. Parasitic fibroids without prior history of laparoscopic myomectomy are even a rarer presentation particularly in menopausal women. The case presented is a 58-year-old grand-multiparous, menopausal lady with progressive abdominal swelling of three-year duration. She had excision of a huge parasitic fibroid attached to omentum. She had partial omentectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. The parasitic fibroid mass weighed 5.2kg and histopathology confirmed leiomyoma uteri with cystic degeneration and lymph nodes with reactive lymphoid hyperplasia. She had uneventful postoperative recovery and follow-up has so far been uneventful.
Uterine fibroids are the most common tumours of the female genital tract in women within the reproductive age and it has been documented that they occur in over 70% of women by the onset of menopause [
Spontaneous parasitic fibroids are a rare subset of subserous fibroids that become adherent to other structures, obtain their blood supply from such structures, and usually do not retain vascular connection with the uterus [
A 58-year-old menopausal woman, para 6+0, presented to the gynecology clinic with progressive abdominal swelling of three-year duration. There was no associated pain, vaginal bleeding/discharge, weight loss, gastrointestinal symptoms, or respiratory difficulties. She was eight years postmenopause. She was a known diabetic on oral medication and had been previously managed medically for uterine fibroids prior to menopause. She had no history of previous surgery. She had no family history of malignancy: breast, ovarian, or endometrial.
Examination revealed a markedly distended abdomen that moved with respiration. An abdominopelvic mass that extended to the xiphisternum was palpated. It was firm, nontender, and slightly mobile in the transverse plane. Other organs were not palpable and there was no demonstrable ascites.
Haemogram, electrolytes, urea, creatinine, and liver function tests were all normal. Serum Ca-125 was 21.3u/ml. Urinalysis showed no abnormality. Chest X-ray and ECG were normal. Abdominopelvic ultrasound scan showed a bulky nongravid anteverted uterus with multiple uterine fibroids with degenerative changes and a mid-line echo. A huge mass extending up to the epigastrium with mixed echogenicity and areas of cystic changes was seen. The liver, gall bladder, spleen, pancreas, and kidneys were grossly normal without focal mass lesion. No ascites was seen. The ovaries were not visualized.
Abdominopelvic computerized tomographic scan with intravenous contrast (Figures
Presurgical evaluation showing the sagital slice of the abdominopelvic CT scan.
Presurgical evaluation outlining the kidneys, ureters, and bladder on contrast CT scan.
She had exploratory laparotomy and findings at surgery were a huge mass with cystic and solid areas filling up the entire abdominal cavity up to the epigastrium pushing the bowels loops up and to the left (Figure
Intraoperative finding of a huge parasitic fibroid wrapped around and deriving its blood supply from the omentum.
She had excision of the huge parasitic fibroid, partial omentectomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy. The histology report (Figure
The microscopic slide of the histology.
Very rarely, a subserous fibroid may detach from the uterus to attach and receive its blood supply from other structures in the abdomen. When this occurs in a woman without previous history of surgery as in the case presented, it is the considered opinion of the authors that this should be regarded as a primary or spontaneous parasitic fibroid. Primary parasitic fibroids are a rare variant of subserous fibroids that often pose diagnostic dilemma with diagnosis made mostly during surgery and/or following histopathology assessment of the tumour [
Secondary or iatrogenic parasitic fibroids are the more common form of parasitic fibroids and are seen as a complication of previous myomectomy particularly following laparoscopy using morcellator. The literature on parasitic fibroids is sparse and most reported cases have been linked to previous laparoscopic surgeries.
This case report of parasitic myoma occurred without history of prior abdominal procedure. Although this is not common, but few similar cases have been reported by others. Abdulwahid and associates reported parasitic fibroids in a 46-year-old lady without previous history of surgery [
Parasitic fibroids have been reported in premenopausal women without primary uterine fibroids; this however appears to be extremely rare in menopausal women as uterine fibroids seem to be a prerequisite for presence of parasitic fibroids in this group of women. The reason for this is unknown. This hypothesis is strengthened by Nappi and colleagues who reported parasitic leiomyoma coexisting with uterine leiomyoma in a 58-year-old postmenopausal woman similar to the case presented [
Although most parasitic myomas occur in the pelvis, index case was located on the greater omentum in the abdominal cavity which appears to be the most common source of blood supply. This finding is similar to what has been reported by other authors. More rare locations like the urethra and sigmoid colon have also been reported [
Clinical features of parasitic fibroids are usually nonspecific. Although they may be asymptomatic, symptoms when present depend on the size and location of the fibroids and are mostly due to pressure. Our patient presented with abdominal swelling. Management is usually surgical resection either via laparotomy or laparoscopy.
A high index of suspicion for parasitic fibroids should be entertained in women presenting with intraabdominal swelling with benign clinical features especially for those with previous history of uterine fibroids. This report also raises questions for further discourse and research on the growth and persistence of uterine fibroids after menopause.
The authors declare that they have no conflicts of interest.
Osegi Nkencho carried out follow-up of patient, final review, and approval of the manuscript. E. Oku Yilaiba did follow-up of patient and review of the manuscript. C. Uwazuoke Stanley did follow-up of patient and review of the manuscript. K. Alawode Timothy analysed and reported histopathology sample. S. Afolabi Adeniyi did manuscript writing and literature review.
Figure 5 shows the huge parasitic leiomyoma occupying the entire abdominal cavity. Figure 6 shows a huge parasitic leiomyoma.