Benign Lesions of the Uterus and Adnexa 2012

5/24/2018 Benign Lesions of the Uterus and Adnexa 2012

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BENIGN LESIONS OF THE


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Benign smooth muscle tumor From myometrium

Fibrous consistency fibroids Incidence: 20-25% Symptoms depend on the location and size


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GROSS FINDINGS: Round, pearly white, firm, rubbery

Whorled pattern on cut section

Single or multiple mass/es with thin outer connectivetissue layer

HISTOLOGIC FINDING: Elongated smooth muscle cells

Aggregated in bundles

Swirl, intersect

Mitotic activity, rare


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Increase in size, compromised blood supply Pelvic pain due to ischemia and necrosis

No vascularization


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SINGLE PROGENITOR MYOCYTE

MULTIPLE TUMORS IN SAME UTERUS HAVEINDEPENDENT CYTOGENETIC ORIGINS

CHROMOSOME 6, 7, 12 AND 14


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ESTROGENS

Greater number of Estrogen Receptors

Greater Estradiol binding

Convert less Estradiol to weaker Estrone

Greater number of cytochrome P450

Converts androgen to estrogen


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Suberosal leiomyomas Pedunculated leiomyomas

Parasitic leiomyomas Intramural leiomyomas Submucous leiomyomas Cervical leiomyomas Rare: ovary, fallopian tubes, broad ligament,

vagina, vulva


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INTRAVENOUS

LEIOMYOMATOSIS

Rare, benign smooth muscletumor

Invades, extends

serpiginously

Uterine, pelvic veins, vena

cava, cardiac chambers


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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


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Hysterectomy with salpingo-oophorectomy Tumor debulking

GnRH agonists Aromatase inhibitors SERMs (seletive estrogen receptor

modulators)


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BLEEDING PAIN

PRESSURE SENSATION INFERTILITY


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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


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Enlarged uterus cause: Pressure sensation

Urinary frequency

Incontinence

Constipation

Obstruct ureter hydronephrosis

Dysmenorrhea Dyspareunia

Non cyclical pelvic pain


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2-3% of infertility cases

Occlusion of tubal ostia

Disruption of normal uterine contractions thatpropel sperm or ova

Distortion of endometrial cavity disrupt

implantation

Submucous myoma cause more subfertility Improved fertility with removal of SM myoma


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Transvaginal ultrasound Transrectal ultrasound


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Observation Drug therapy Uterine artery embolization

Surgery Hysterectomy Myomectomy

Hysteroscopic

Laparoscopic

Robotic Abdominal

Endometrial Ablation Myolysis


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Dysmenorrhea Menorrhagia

Dyspareunia Pelvic Pressure Infertility


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Dysmenorrhea; higher endometrial levels of Prostaglandins

F2 and E2 Menorrhagia ? Unknown benefit, conflicting

results


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Combination oral contraceptive pills

Induce endometrial atrophy

Decrease prostaglandin production Progestins

Not recommended due to unpredictable effects

on growth


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Danazol, Gestrinone Effectively shrink myoma

Hirsutism, acne


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Shrink myoma directly (GnRH receptors inmyoma)

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


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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


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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)


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Rapid and no flare involved Cetroreliz, Nal-glu

Subcutaneous injections effective Depot no effect on myoma


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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 (unopposedestrogen)

Inc. liver transaminases (4%)


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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


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Hysterectomy Abdominal

Laparoscopic

Vaginal Myomectomy

Laparoscopic

Hysteroscopic

Robotic Endometrial Ablation Myolysis


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Distended uterus

Trapped bloodInside due to obstructionin cervix or higher up

Hematocolpos

hematosalpinx


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Relief of obstruction Evacuation of blood Cervical dilatation Hysteroscopy

Access blood pockets

Lyse adhesions

Congenital anomaly correction


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Globally Enlarged uterus Ectopic rests of endometrium in myometrium

Diffuse adenomyosis Focal adenomyosispseudocapsule

Spongy with focal areas of hemorrhage oncut section


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Parous women 40s-50s Assoc with cytochrome P450 aromatase

expression Hyperestrogenism (ie., myoma,

endometriosis, endometrial cancer) Tamoxifen use


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Menorrhagia Dysmenorrhea Dyspareunia


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NSAIDS Combination oral contraceptive pills Progestin only pills Levonorgestrel containing IUD (Mirena) GnRH agonists (danazol)


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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


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

growth factor


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Common Follicles assoc hormonal dysfunction

(ovulation)

Follicular cysts

Corpus luteum cysts

Intrafollicular fluid


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RISK FACTOR

SMOKING PROTECTIVE

CONTRACEPTION IF COMBINATION,

PROTECTIVE

PROGESTIN ONLY , INC

NO. OF FOLLICULARCYSTS

TAMOXIFEN 15-30% risk


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Asymptomatic Vague pressure Pain

Cyclic (endometriosis, endometrioma)

Intermittent (early torsion)

Severe pain (torsion with ischemia)

Rupture

Tubo-ovarian abscess

Hormonal disruption (bleeding or hirsutism)


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Depends on age of patient and size of ovarianmass


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FEATURES

SEPTATION

MURAL NODULE

IRREGULAR WALL

THICKENING

SHADOWING

ECHODENISTY

REGIONAL, DIFFUSE,

BRIGHT ECHOESHYPERECHOIC LINES AND

DOTS

DIFFICULT TO DISTINGUISH

FROM MALIGNANCY

POSTMENOPAUSAL, MASS

IS REMOVED

PREMENOSPAUSAL

WOMEN IF PERSSISTENTCOMPLEX MASS, MAY

REMOVE


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Always remove


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Cystectomy Oophorectomy Exploratory Laparotomy TAHBSO Laparoscopic hysterectomy Mini laparoscopic hysterectomy


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Germ cell tumor 3 layers: ectoderm, mesoderm, endoderm


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Immature Teratoma (malignant) Mature Teratoma

Mature cystic dermoid

Mature solid

Fetiform or homunculus

Monodermal ex. Struma ovarii


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Common; 10-25% of all ovarian neoplasms Bilateral in 10% Rokitansky protuberance(where all germ

layers are found; area where malignanttransformation is seen)

1-3% have malignant transformation


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Torsion 15% Rupture peritonitis Chronic leakage granulomatous peritonitis


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Hair Rokitansky protuberance Tip of the iceberg sign Fat fluid or hair fluid levels


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Cystectomy Oophorectomy Total hysterectomy with bilateral salpingo-

oophorectomy


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

degree relative)


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

degree relative)


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


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BENIGN LESIONS OF THE

DR. ESTHER R.V. GANZON JRJANUARY 2 2014

Documents

Benign Lesions of the Uterus and Adnexa 2012