Fibroids are a condition commonly seen as part of routine gynaecological practice and generally present with menorrhagia, infertility, or pressure symptoms depending on their exact location. We report the case of a postmenopausal 57-year-old lady presenting with left-sided pain and frequency with a complex 15 cm mass mid pelvis and an adjacent additional 7 cm cyst but a risk of malignancy index suggesting benign pathology. She underwent total abdominal hysterectomy (TAH) and right-sided salpingo-oophrectomy (RSO) on recommendation of the multidisciplinary team (MDT) and histology confirmed leiomyomatosis peritonealis disseminata. This rare but important condition is often confused with peritoneal carcinomatosis on imaging. The mainstay of treatment involves lesion and omental excision followed by removal of hormonal stimuli although this approach must be personalised as many younger women may wish to retain their uteri. Long-term follow-up is essential due to the potential for malignant transformation.
Fibroids are one of the commonest benign gynaecological conditions, occurring in almost 1 in 3 women over the age of 30 [
A 57-year-old postmenopausal lady, para 0 with an unremarkable smear history, presented to the gynaecology department with a 3-month history of left-sided abdominal pain and frequency of micturition. She previously had a laparoscopic left-sided salpingo-oophrectomy for a benign mucinous cystoadenoma 3 years earlier. Clinical examination confirmed a pelvic mass arising from the pelvis. There were no features suggestive of an acute abdomen. An ultrasound scan demonstrated a large complex thick-walled cyst mid pelvis measuring 15 × 13 × 12 cm displacing the uterus to the right. There was an additional 7 × 6 cm complex cyst seen adjacent to this mass. Neither ovary was subsequently identified. The Ca125 was 8, giving a risk of malignancy index (RMI) of 24. A subsequent MRI pelvis was consistent with right ovarian cystic adenoma/cyst adenocarcinoma, and a bulky postmenopausal fibroid uterus containing multiple fibroids displaced to the right of the midline. The patient was referred to the MDT and total abdominal hysterectomy, right salpingo-oophrectomy, and omental biopsy were recommended in view of the potential for malignant diagnosis. This was completed uneventfully. At operation, the findings confirmed a multi-fibroid uterus with a large right-sided cystic mass. She made a good recovery postoperatively and a follow-up CT undertaken 6 months after surgery did not show any evidence of disease recurrence. She was commenced on letrozole 2.5mg daily in view of the histology results. Oestrogen results were not measured pre- or postoperatively.
Histology confirmed leiomyomatosis peritonealis disseminata–oestrogen receptor positive but no obvious malignant cells.
Psathas et al. [
The pathogenesis is currently uncertain, although multiple theories have been postulated by Yang et al. (2009) including peritoneal metaplasia, alterations in oestrogen and progesterone levels, genetics or iatrogenic factors, and most notably the dissemination of fragments of tissue through the peritoneal cavity secondary to fibroid morcellation at laparoscopic myomectomy.
Its appearance on imaging may be most commonly confused with peritoneal carcinomatosis, although other primary peritoneal malignancies, liposarcoma, lymphoproliferation, and disseminated endometriosis are also amongst the differentials [
Psathas et al. [
Although the majority of cases of LPD are benign, there remains potential for malignant transformation and, in view of the young age of many of these patients, long-term follow-up is essential [
LPD remains a rare but important differential for disseminated peritoneal carcinomatosis, particularly when seen in women of reproductive age. Although conservative management may be offered after surgery, long-term surveillance is essential to reduce the impact of progressive disease or malignant transformation.
The authors declare that they have no conflicts of interest.