Primary Parasitic Leiomyoma : A Case Report

A vertical scar of undergoing laparoscopic tubal occlusion was present below the umbilicus. On Palpation a mass arising from the pelvis extending up to xiphisternum and occupying all quadrants of the abdomen was felt. The mass was non-mobile, non-tender, smooth surfaced and firm to cystic in consistency. The upper and lower border of the mass could not be felt but the lateral border could be felt which is suggestive of a pelvic tumor. The external genitalia appeared normal. The cervix appeared pulled up and the utero-cervical length was 4 inches. After taking a PAP smear bimanual examination showed restricted mobility of the mass. Uterus was not felt separately from the mass and bilateral fornicial fullness was present and non tender.


Introduction
Uterine leiomyomas forms the most common type of benign tumor found in women in reproductive age roup and tumor of the female pelvis. [1]About 20% of all women have one or more leiomyomas present in the uterus at death.Diagnosis is usually straightforward, unlike when they undergo various kinds of pathologic changes they pose both diagnostic and management difficulties.
When a subserous fibroid becomes adherent to other structures like the omentum from which they obtain their blood supply, the uterine pedicle either disappears completely or becomes avascular.In such wandering or parasitic leiomyoma following which the diagnosis is not certain and are rarely reported.

Case report
A 41 year old lady presented with pain abdomen of 1 week duration.She was para two with two living children delivered vaginal-

Journal of Clinical and Biomedical Sciences
abdomen extending from epigastrium up to the pelvis, containing large cystic and solid components and with minimal free fluid in paracolic gutter.CECT abdomen and pelvis showed a pelvi abdominal mass measuring 30.0x15.4x26.0cms(CCxAPxTR) demonstrating solid and cystic components.Post contrast images demonstrated significant enhancement of the solid components.Uterus and ovaries were not separately seen from the mass.The lesion extended superiorly into the epigastrium up to the level of celiac artery origin abutting and displacing the bowel loops and abutting the anterior abdominal wall on the anterior and left lateral aspects.The lesion was noted abutting the left lower ureter posteriorly.
Trace free fluid was noted in peritone-um and presence of a fibroid uterus was confirmed.
In view of huge size of the mass pre operatively bilateral DJ Stenting was done.Laparotomy revealed a parasitic fibroid of 35 x 25cms partly cystic in the upper part and firm in the lower part, densely adherent to the omentum and bowel which was vascular.Cystic part of the tumor ruptured spontaneously and haemorrhagic fluid of about 400-500ml was drained.Posterior and superior surface of the tumor was adherent to the bowel getting its vascular supply.Leash of blood vessels were seen coursing over the posterior surface coming from the sigmoid colon over superior part of mass.Following the removal of the mass by dissection a subserosal fibroid with pedicle of size 6x 6cms was seen.Total abdominal hysterectomy with right salphingoopherectomy was performed.The mass weighed 4 kg.Histopathological findings were consistant with leiomyoma.The patient had uneventful post operative period and was discharged on the 10 th day.Colostomy closure was done 3months later.

Discussion
Leiomyoma are benign smooth muscle tumors clinically apparent in 20-25% of women of reproductive age.In most cases the diagnosis is straightforward but when they undergo pathological changes diagnostic and management difficulties occur.Our patient falls into the latter group.When a subserous leiomyoma outgrows its blood supply from the uterus it acquires its new blood supply from the structures adherent to it.Such leiomyomas referred to as "parasitic leiomyomas" survives by revascularization from adjacent structures. [6]Such structures include sigmoid colon (as seen in this case), omentum, common iliac artery and inferior mesenteric artery. [2]In most of the reported cases of parasitic leiomyoma the diagnosis were at surgery.As leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degenerations namely hyaline degeneration, calcification, cystic degeneration or red degeneration. [4]In general, hyaline degeneration is the most com- mon (63%) form while the others occur less frequently, such as myxomatous changes (13%), calcification (8%), mucoid changes (6%), cystic degeneration (4%), red degeneration (3%) and fatty changes (3%). [5]rasitic myomas are rare occurence, which can prove to be a diagnostic delimma and may even present in the acute setting and sometimes a malignancy.Even though parasitic leiomyomata are rare they should be included in the differential diagnosis of pelvic or abdominal tumors in females. [3]Advances in retrival system have made laparoscopic myomectomy a feaseible option, irrespective of the size, site or number of myomas. [8]There are increasing reports of parasitic fibroids being recognized after laparoscopic myomectomy, especially in cases where tumors are morcellated for removal.
In a reported case series of parasitic myomas over a three year period 4 cases were detected in 423 women where electric morcellators were used for tumor removal.The overall prevalence of developing parasitic myoma was reported to be 0.9 and 1.2 % for those who had laparoscopic myomectomies. [9]There are also cases in the literature in which parasitic leiomyomas have been found attached to the bowel and anterior abdominal wall after laparoscopic myomectomy. [10,11]

Conclusion
Primary parasitic leiomyomas are rare occurrences.However, parasitic leiomyomas, which are iatrogenically caused, may be diagnosed more commonly in this laparoscopic era.Essence of this case with parasitic leiomyoma is the massive size and its rarity.