Uterine leiomyomas are highly common. Their incidence is generally cited as 20-25%, but has been shown to be as high as 70-80% in studies using histologic or sonographic examination. Distant metastasis is extremely rare and is of unknown etiology. It primarily affects women of reproductive age and might appear years after gynecological procedures such as myomectomy or hysterectomy. The most common theory of metastasis is though hematogenous spread. The most common sites are the lungs, heart, lymph nodes, omentum, peritoneum, pelvic cavity, breast, bone, mediastinum and nervous system. In our case the patient presented with abdominal pain with a history of a 9 cm leiomyoma which was removed 2 years prior via open myomectomy. On CT scan, a heterogenous uterus measuring 19x14x19cm was visualized along with multiple vertebral sclerotic/blastic lesions. Due to increased concern for metastatic disease, additional imaging was performed unmasking multiple nodules in the lungs, pleura, sternum and mediastinum. A pleural biopsy was performed which revealed a pathological structure of benign leiomyomata. There are no randomized studies which were conducted on the best way to manage these cases. 100 cases were described so far in the English literature, and were generally milder and did not involve lesion spread to such an extent.
35y/o G0, last menstrual period 07/11/2016, presented to the ER complaining of new onset left upper quadrant pain 9/10 on the pain scale starting on the day of presentation. Patient also reported episodes of nausea without vomiting. Patient denied any history of similar symptoms. Patient denied vaginal bleeding or discharge and could not recall any recent changes in her weight or appetite. The last time the patient visited an Obstetrician Gynecologist was one and a half years ago. Past medical history included asthma, controlled on albuterol nebulizer and diabetes mellitus controlled on Metformin. The patient had one abdominal myomectomy two years prior. On admission the patient had a transvaginal ultrasound (US) and an abdominal and pelvic CAT scan (CT). The impression on the CT was of a large heterogeneous lobular uterus measuring 19x14x19cm that occupied most of the pelvic (figure 1).
In addition, there was a separate mass measuring 4×3.6cm which was adjacent to the uterus. This could represent a pedunculated fibroid on a stalk or multiple enlarged lymph nodes through the iliac chain. Furthermore, the US detected vertebral body sclerotic lesions at L1,2,3,5,T6,10,11,12. No gross reduction or expansion was seen. The radiologist reported that the findings seemed unusual for endometrial carcinoma but that leiomyosarcoma could not be excluded. The US indicated that there was a huge heterogenous lobular uterus with a structure typical of fibroid uterus. The adnexa and ovaries were not visualized. CBC, chemistry 7, liver function test were drawn on admission. The only abnormal level detected was an elevated Hemoglobin. Tumor markers were drawn as well. HCG, CA 19-9, Alfa-fetoprotein, testosterone total/free/bioavailable and SHBG were all within normal limits. In addition, serum albumin, CA 125 and CEA were all normal. The only nonspecific marker which was found to be elevated was LDH at 1592 IU/L. On hospital day (HD) two, a chest CT without contrast was performed. The impression was of sternal lesions, focal area of pleural thickening at the costophrenic angle, 3 nodules in the right and 8 in the left lung, lytic lesions in the distal end of the left clavicle, mixed lytic and sclerotic lesions in the right fourth rib, sclerotic and destructive changes seen in the anterior aspect of the vertebral body with associated soft tissue mass in the superior mediastinum anterior to the vertebral body. The soft tissue mass measured 4.2 cm. The patient was kept for pain management and work-up in an attempt to establish a diagnosis. Interventional radiology was consulted for a possible CT guided biopsy. A CT guided biopsy was performed on hospital day 2 from a pleural lesion (figure 2). The final histologic report including all specific dyes were of smooth muscle cells with 0 mitotic figures, consistent with benign Leiomyoma (figure 3).