BENIGN LESIONS OF THE

Benign smooth muscle tumor

From myometrium
Fibrous consistency fibroids
Incidence: 20-25%
Symptoms depend on the location and size
GROSS FINDINGS:
Round, pearly white, firm, rubbery
Whorled pattern on cut section
Single or multiple mass/es with thin outer connective
tissue layer
HISTOLOGIC FINDING:
Elongated smooth muscle cells
Aggregated in bundles
Swirl, intersect
Mitotic activity, rare


Increase in size, compromised blood supply
Pelvic pain due to ischemia and necrosis
No vascularization
SINGLE PROGENITOR MYOCYTE
MULTIPLE TUMORS IN SAME UTERUS HAVE
INDEPENDENT CYTOGENETIC ORIGINS
CHROMOSOME 6, 7, 12 AND 14
ESTROGENS
Greater number of Estrogen Receptors
Greater Estradiol binding
Convert less Estradiol to weaker Estrone
Greater number of cytochrome P450
Converts androgen to estrogen


Suberosal leiomyomas
Pedunculated leiomyomas
Parasitic leiomyomas
Intramural leiomyomas
Submucous leiomyomas
Cervical leiomyomas
Rare: ovary, fallopian tubes, broad ligament,
vagina, vulva
INTRAVENOUS
LEIOMYOMATOSIS
Rare, benign smooth muscle
tumor
Invades, extends
serpiginously
Uterine, pelvic veins, vena
cava, cardiac chambers

BENIGN METASTASIZING
LEIOMYOMATOSIS
Dessiminate hematogenously
Found in lungs, GI tract, spine, brain
History of pelvic surgery
DISSEMINATED PERITONEAL
LEIOMYOMATOSIS
Multiple small nodules on peritoneal surfaces of
abdominal cavity
Reproductive age; 70% assoc with pregnancy or OCP
Hysterectomy with salpingo-oophorectomy
Tumor debulking
GnRH agonists
Aromatase inhibitors
SERMs (seletive estrogen receptor
modulators)
BLEEDING
PAIN
PRESSURE SENSATION
INFERTILITY
Dilatation of venules
Myoma exert pressure, impinge on venous
system
Dysregulation of local vasoactive growth
factors promote vasodilatation
During menses, bleeding fm markedly dilated
venules overwhelms hemostatic mechanisms



Enlarged uterus cause:
Pressure sensation
Urinary frequency
Incontinence
Constipation
Obstruct ureter hydronephrosis
Dysmenorrhea
Dyspareunia
Non cyclical pelvic pain
2-3% of infertility cases
Occlusion of tubal ostia
Disruption of normal uterine contractions that
propel sperm or ova
Distortion of endometrial cavity disrupt
implantation
Submucous myoma cause more subfertility
Improved fertility with removal of SM myoma

Transvaginal ultrasound
Transrectal ultrasound

Observation
Drug therapy
Uterine artery embolization
Surgery
Hysterectomy
Myomectomy
Hysteroscopic
Laparoscopic
Robotic
Abdominal
Endometrial Ablation
Myolysis

Dysmenorrhea
Menorrhagia
Dyspareunia
Pelvic Pressure
Infertility
Dysmenorrhea;
higher endometrial levels of Prostaglandins
F2 and E2
Menorrhagia ? Unknown benefit, conflicting
results
Combination oral contraceptive pills
Induce endometrial atrophy
Decrease prostaglandin production
Progestins
Not recommended due to unpredictable effects
on growth
Danazol, Gestrinone
Effectively shrink myoma
Hirsutism, acne
DRUG NAME GENERIC NAME DOSE AND
ADMINISTRATION
DECAPEPTYL TRIPTORELYN 3.75mg depot IM,
monthly
LUPRON LEUPROLIDE
ACETATE
3.75 mg depot IM,
monthly
ZOLADEX GOSERELIN 3.6 mg depot SC
monthly
SYNAREL NARARELIN 200 mg BID, spray
intranasal
Shrink myoma directly (GnRH receptors in
myoma)
Feedback mechanism:
Stimulate receptors on pituitary gonadotropes
Release LH and FSH (flare); 1 week
Downregulate receptors in gonadotropes
Desensitization to GnRH stimulation
Decrease gonadotropin secretion
Decrese estrogen and progesterone
1-2 weeks after

Volume decrease by 40-50%
Pain relief
Diminished menorrhagia; amenorrhea
Repair red cell mass
Increase iron stores
Give 3-6 months
Resume menses 4-10 weeks after
Myoma may grow back upon stopping
Vasomotor symptoms
Libido changes
Vaginal epithelium dryness
Dyspareunia
~6% dec in trabecular bone
Dont give > 6 months
ADD BACK THERAPY
1-3 months upon starting GnRH
MPA 10 mg (D16-25) + equine estrogen 0.625 mg (D1-25)
Continuous daily MPA 2.5 mg + EE 0.625 mg
SERMS (tibolone, raloxifene)



Rapid and no flare involved
Cetroreliz, Nal-glu
Subcutaneous injections effective
Depot no effect on myoma
Mifepristone / RU 486
Progestins bind to either Progesterone receptor A or
B
Favors progesterone receptor A
Given 5, 10, 25, 50 mg orall, daily x 12 weeks
Better tolerated than leuprolide acetate
Vasomotor symptoms
Simple hyperplasia in endometrium (unopposed
estrogen)
Inc. liver transaminases (4%)


Angiographic, interventional procedure
Polyvinyl alcohol into both uterine arteries
Necrosis, pain Postembolization Syndrome
2-7 days
Pelvic pain, cramping
Nausea and vomiting
Low grade fever
malaise

Hysterectomy
Abdominal
Laparoscopic
Vaginal
Myomectomy
Laparoscopic
Hysteroscopic
Robotic
Endometrial Ablation
Myolysis
Distended uterus

Trapped blood
Inside due to obstruction
in cervix or higher up
Hematocolpos
hematosalpinx
Neoplasms, uterine or cervical cancer
Radiation
Post surgery in endometrium or cervix
Prolonged hypoestrogenism / atrophy
Asherman syndrome


Cyclic, midline pain
Amenorrhea (total obstruction)
Scanty dark bleeding (partial obstrcution)
Fever, tachycardia if infected (pyometra)
Enlarged corpus
Do Transvaginal ultrasound!
Relief of obstruction
Evacuation of blood
Cervical dilatation
Hysteroscopy
Access blood pockets
Lyse adhesions
Congenital anomaly correction
Globally Enlarged uterus
Ectopic rests of endometrium in myometrium
Diffuse adenomyosis
Focal adenomyosis pseudocapsule
Spongy with focal areas of hemorrhage on
cut section
Downward invagination of endometrial
basalis layer into myometrium
No intervening submucosa between myometrium
and endometrium
Myometrial weakness caused by prior
pregnancy, surgery or dec immunologic
activity at the myometrial-endometrial
interface
Metaplasia of pluripotent mullerian tissues

Parous women
40s-50s
Assoc with cytochrome P450 aromatase
expression
Hyperestrogenism (ie., myoma,
endometriosis, endometrial cancer)
Tamoxifen use

Menorrhagia
Dysmenorrhea
Dyspareunia
NSAIDS
Combination oral contraceptive pills
Progestin only pills
Levonorgestrel containing IUD (Mirena)
GnRH agonists (danazol)
Hysterectomy
Endometrial ablation
Hysteroscopy
Uterine artery embolization ?
High parity
Global enlargement of uterus
No identifiable pathology in specimens
Myometrial fiber enlargement
120 gm nulliparas
210 gm for multiparas
Menstrual irregularities; menorrhagia
Rare, ballooned sacculations
from uterine or cervical wall
extend out of the endometrial cavity or
endocervical canal
Collect blood during menses
Pain, intermenstrual bleeding
Infection
Transvaginal UTZ, hysterosalpingogram,
hysteroscopy, MRI
Excision of diverticulum or hysterectomy
Common
Benign or malignant
Surface epithelial tumors
Germ cell tumors
Sex cord stromal tumors
Limited diagnostics to differentiate benign
from malignant

Functional ovarian cysts
Ovarian cystic neoplasms
Require excision to rule out malignancy
Angiogenesis due to vascular endothelial
growth factor

Common
Follicles assoc hormonal dysfunction
(ovulation)
Follicular cysts
Corpus luteum cysts
Intrafollicular fluid
RISK FACTOR
SMOKING PROTECTIVE

CONTRACEPTION IF COMBINATION,
PROTECTIVE
PROGESTIN ONLY , INC
NO. OF FOLLICULAR
CYSTS
TAMOXIFEN 15-30% risk

Asymptomatic
Vague pressure
Pain
Cyclic (endometriosis, endometrioma)
Intermittent (early torsion)
Severe pain (torsion with ischemia)
Rupture
Tubo-ovarian abscess
Hormonal disruption (bleeding or hirsutism)
hCG
fetoprotein
LDH
CA-125
CA 19-9
Transvaginal ultrasound + Doppler
Transabdominal UTS
Transrectal UTS
Depends on age of patient and size of ovarian
mass

PREMENOPAUSAL WOMAN
< 3 CM DIAMETER FUNCTIONAL; OBSERVE
> 3 CM DIAMETER REPEAT TVS 6-8 WEEKS
REMOVE IF PERSISTENT
POSTMENOPAUSAL WOMAN
< 5 CM OBSERVE IF NORMAL CA 125
AND NO GROWTH
BENIGN, REPEAT TVS
> 5 CM REMOVE IF PERSISTENT OR
SYMPTOMATIC
FEATURES
SEPTATION
MURAL NODULE
IRREGULAR WALL
THICKENING
SHADOWING
ECHODENISTY
REGIONAL, DIFFUSE,
BRIGHT ECHOES
HYPERECHOIC LINES AND
DOTS
DIFFICULT TO DISTINGUISH
FROM MALIGNANCY

POSTMENOPAUSAL, MASS
IS REMOVED

PREMENOSPAUSAL
WOMEN IF PERSSISTENT
COMPLEX MASS, MAY
REMOVE
Always remove
Cystectomy
Oophorectomy
Exploratory Laparotomy TAHBSO
Laparoscopic hysterectomy
Mini laparoscopic hysterectomy
Germ cell tumor
3 layers: ectoderm, mesoderm, endoderm

Immature Teratoma (malignant)
Mature Teratoma
Mature cystic dermoid
Mature solid
Fetiform or homunculus
Monodermal ex. Struma ovarii
Common; 10-25% of all ovarian neoplasms
Bilateral in 10%
Rokitansky protuberance (where all germ
layers are found; area where malignant
transformation is seen)
1-3% have malignant transformation

Asexual reproduction
Thought to develop from single oocyte
Oocyte arrested in Meiosis I, capable of
forming tissues from all layers
46 XY karyotype
Starts at birth may be seen in children
Common in pregnancy 10%


Torsion 15%
Rupture peritonitis
Chronic leakage granulomatous peritonitis

Hair
Rokitansky protuberance
Tip of the iceberg sign
Fat fluid or hair fluid levels
Cystectomy
Oophorectomy
Total hysterectomy with bilateral salpingo-
oophorectomy
Results from incomplete oophorectomy
Develop pathology
Pain
Mass
Dense adhesions during surgery
Endometriosis
Pelvic inflammatory disease
History of previous pelvic surgery
Can manage most benign ovarian neoplasms
If suspicious of malignancy, MUST REFER to
gynecologic oncologists

CA 125 > 200 mg U/ml
Ascites
Evidence of abdominal or distant metastases
Family history of breast or ovarian cancer (1
st

degree relative)
CA 125 > 35 U/ml
Ascites
Nodular or fixed pelvic mass
Evidence of abdominal or distant metastasis
Family history of breast or ovarian cancer (1
st

degree relative)
Twisting of ovary and fallopian tube around
broad ligament
20-25% occur in pregnancy
Long ovarian ligaments
6-10 cm size
Congested and edematous
Infarction, necrosis
Sudden sharp abdominal pain, worsens over
time
Radiate to legs
Nausea, vomiting



Hydatid of Morgagni fimbriated end
< 3cm
Remnant of mesonephric duct
Rarely cause symptoms unless big or twisted

Seen as routine finding on UTS
Chronic swelling of fallopian tube due to PID
Infertility
Sausage shaped adnexal mass
TREATMENT:
Salpingectomy
Expectant
Neosalpingostomy

Result from PID, endometriosis,
pyelonephritis, malignancy
Polymicrobial with anaerobic predominance
Actinomyces infection
Pelvic Tuberculosis
Lower abdominal pain
Severe if ruptured
Fever, chills, malaise, vomiting, nausea
Oophorocystectomy
Pelvic clean up surgery
BENIGN LESIONS OF THE
DR. ESTHER R.V. GANZON, JR
JANUARY 2, 2014