Fertility preservation in a large broad ligament leiomyoma: a case report.

A 27 year-old Syrian woman, gravida 3 para 3, presented to the oncology clinic at the University Maternity Hospital in Damascus. Her chief complaint was lower abdominal pain and a feeling of heaviness that had persisted for 1 year. She also reported heavy menstrual periods, though her medical, surgical, and oncological histories were unremarkable. Her last delivery was 9 months prior, during which her abdominal pain was not addressed. Physical examination revealed a smooth, irregular, immobile, and nontender mass extending from the right iliac region to the umbilical region. Subsequent ultrasound imaging revealed a heterogeneous mass measuring 10 cm × 15 cm, most likely indicating an adnexal mass. The mass demonstrated minimal peripheral flow, with no evidence of central neovascularity or features suggestive of malignant transformation. In addition, grade 3 hydronephrosis according to the Society of Fetal Urology Scale (SFU) was detected in the right kidney, while the left kidney showed grade 2 hydronephrosis. The bladder, uterus, and ovaries appeared normal, with no free fluid detected in the peritoneal cavity. Laboratory tests, including CA-125, complete blood count, electrolytes (sodium, potassium, calcium), liver enzymes, urea, creatinine, uric acid, prothrombin time (PT), and partial thromboplastin time (PTT), were conducted and were all within normal ranges. We discussed surgical options with the patient, who expressed a strong preference to preserve the uterus if possible. She was informed about the possibility of a hysterectomy if deemed necessary, and she provided consent for that. The medical team opted for an open surgery approach. We opened through a Pfannensteil incision and dissected between the round ligament and the broad ligament (Fig.  1 ). The mass was located on the broad ligament and was carefully dissected after isolating the ureter. There were no adhesions to adjacent organs, and no additional fibroids were detected. The vascular connections to the uterus were carefully detached and coagulated, enabling the successful resection of the mass while preserving the uterus and the adnexa on both sides (Fig.  2 ). Some oozing surfaces occurred in the peritoneum, which were coagulated and gelfoam was applied. The following day, the CBC test was within normal limits, the drainage tube was removed, and the patient was discharged after recovery. The histopathological examination confirmed the diagnosis of leiomyoma with hyaline degeneration. No mitotic figures, nuclear atypia, or necrosis were identified. Fig. 1 The mass measuring 10 cm × 15 cm on the broad ligament. a Superior medial view. b Anterior inferior view Fig. 2 The resected degenerated leiomyoma. a Gross appearance of the resected mass. b Cross-sectional view of the mass The mass measuring 10 cm × 15 cm on the broad ligament. a Superior medial view. b Anterior inferior view The resected degenerated leiomyoma. a Gross appearance of the resected mass. b Cross-sectional view of the mass

Uterine leiomyoma is the most common benign tumor in the female reproductive tract [ 3 ]. While leiomyoma is typically located in the uterus, it can also arise from the smooth muscle of other structures, including the ovary, round ligament, broad ligament, cervix, vagina, abdominal wall, and may even be found in the lungs due to hematogenous spread [ 5 ]. Among extra uterine locations, the broad ligament is the most common site, though its overall incidence remains low, which makes its diagnosis challenging both radiologically and clinically [ 3 ]. Although epithelial cell tumors are the most common neoplasms of the broad ligament, mesenchymal tumors—though rare—do occur, with leiomyomas representing the most prevalent mesenchymal subtype [ 6 ]. Broad ligament leiomyoma may extend from the uterus, known as a false broad ligament leiomyoma, where the uterine vessels and the ureter are lateral, or it may originate from the broad ligament itself, known as a true broad ligament leiomyoma, where the uterine vessels and the ureter are medial [ 7 ]. The pathophysiological mechanism of leiomyoma is the clonal proliferation of a single smooth muscle cell, where sensitivity to estrogen levels plays a key role [ 3 ]. For extrauterine leiomyomas, several theories have been proposed, including endomyometriosis, which causes smooth muscle hyperplasia and metaplasia, mesenchymal stem cell metaplasia, and iatrogenic morcellation, where remnants of fibroids implant in the peritoneal cavity following hysterectomy or myomectomy [ 8 ]. Typically, fibroids in the broad ligament are asymptomatic, but they tend to grow to large sizes, at which point they may present with lower abdominal pain, a sensation of heaviness, or symptoms of compression, such as compression of the ureter, bladder, or intestines [ 9 ]. In some cases, they may mimic ovarian tumors, further complicating the clinical picture [ 10 ]. When it reaches a large size, it undergoes degeneration or necrosis due to decreased blood supply. Hyaline degeneration is the most common form, occurring in 63% of cases, followed by myxomatous degeneration at 13%, calcification at 8%, cystic degeneration at 4%, red degeneration at 3%, and fatty degeneration at 3% [ 11 ]. In our case, the patient presented with lower abdominal pain and a sensation of heaviness that she had experienced for approximately a year, along with hydronephrosis. Despite the hydronephrosis and obstruction, she did not, however, mention obstructive urinary symptoms in her complaint. Ultrasound imaging can assist in diagnosing uterine leiomyomas, as these tumors often have a distinctive appearance, being well-circumscribed and distinguishable from the uterus and ovaries, particularly with transvaginal ultrasound imaging [ 12 ]. However, owing to the rarity of broad ligament leiomyomas, they may be misinterpreted on ultrasound imaging as other differential diagnoses of adnexal masses, including benign or malignant ovarian tumors, tubo-ovarian abscesses, broad ligament cysts, or lymphadenopathy [ 13 ]. Jha et al . also reported that it can be difficult to make diagnoses using ultrasound imaging [ 14 ]. Magnetic resonance imaging (MRI), with its high sensitivity, can provide additional diagnostic clarity and aid in surgical planning [ 15 ]. Unfortunately, in Syria, the ongoing war and financial crisis have severely limited access to advanced imaging modalities such as computed tomography (CT) and MRI, making it difficult to routinely utilize these tools. Therefore, in our case, owing to limited resources, the decision for surgical intervention was made after the ultrasound imaging revealed an adnexal mass. Measuring CA-125 levels can aid in the diagnostic process, as elevated levels have been reported in cases of broad ligament leiomyomas. For instance, Yan et al . documented elevated CA-125 in a patient with broad ligament leiomyoma, underscoring its potential utility in the diagnosis workup [ 16 ]. However, CA-125 is a nonspecific marker, as it can also be elevated in conditions such as endometriosis, serous ovarian tumors, and other malignancies [ 16 ]. In addition, when CA-125 levels are elevated, broad ligament leiomyomas may be associated with pseudo-Meigs syndrome, which can further complicate the diagnostic picture [ 10 ]. In our case, the CA-125 level was within the normal range. While CA-125 can provide useful information, it cannot definitively confirm the diagnosis of broad ligament leiomyoma. As such, histopathological examination following surgical excision remains the gold standard for definitive diagnosis [ 15 ]. Histopathological examination after excision revealed that the leiomyoma had undergone hyaline degeneration. The management of broad ligament leiomyomas presents a significant challenge due to the proximity of pelvic organs such as the ureter and ovary, as well as the abundant blood supply to the broad ligament. Therefore, it requires an experienced surgical team [ 17 ]. Surgical excision may be associated with complications such as injury to the blood vessels, ureter, or uterus, as well as occult hematoma [ 12 ]. In our case, the broad ligament leiomyoma was excised, but the uterus was preserved, as the patient desired to maintain her fertility.

Uterine leiomyomas, commonly known as fibroids, are the most common tumors of the uterus [ 1 ]. They are classified on the basis of their origin and growth direction into submucosal, intramural, and subserosal types [ 2 ]. In addition, fibroids may occur in the broad ligament, which is recognized as the most frequent extrauterine site; however, their occurrence in this location is relatively rare, estimated at less than 1% [ 1 ]. Fibroids, whether inside or outside the uterus, are usually asymptomatic. However, they may present with menstrual disturbances, a sensation of heaviness, or urinary symptoms. In rare cases, they might also present with degenerative symptoms such as pain, swelling, and fever [ 2 ]. Estrogen and progesterone play a role in the growth of fibroids, as evidenced by the hormonal influence in the management of fibroid conditions [ 2 , 3 ]. Various growth factors also contribute to the growth of fibroids, including transforming growth factor (TGF-β), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), and prolactin [ 4 ]. The diagnosis and management of extrauterine fibroids pose a challenge owing to their rarity, location, and the rich surrounding vascularity, particularly in cases where the patient wishes to preserve fertility, as in our case.