Left Sided Round Ligament Mass co-existing with High Grade Serous Epithelial Ovarian Carcinoma – A Case Report and Literature Review

Left Sided Round Ligament Mass co-existing with High Grade Serous Epithelial Ovarian Carcinoma – A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Left Sided Round Ligament Mass co-existing with High Grade Serous Epithelial Ovarian Carcinoma – A Case Report and Literature Review Sivalakshmi Ramu, Rudrika Chandra, Sarita Kumari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4722045/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Introduction: Leiomyoma of the round ligament has been reported as an isolated finding and more commonly over the right side. More than 50% of it is associated with fibroid uterus. There is no reported case in the literature of a left-sided leiomyoma of ligamentum rotundum, and its association with a high-grade serous carcinoma of the ovary. Case Presentation: We report a confirmed case of high-grade serous epithelial ovarian carcinoma of the ovary in a postmenopausal lady, with an intra-operative incidental finding of a round ligament mass. It was then surgically excised and sent for histopathological study. Conclusion: Round ligament leiomyoma coexisting with an invasive epithelial ovarian tumor is a rare entity. Round ligament leiomyomas can create diagnostic dilemmas of metastatic nodes in some cases. Case report leiomyoma ovarian neoplasms round ligament of uterus high grade serous ovarian carcinoma Figures Figure 1 Figure 2 Figure 3 Introduction The round ligament of the uterus originates at the uterine cornu of the uterus and blends with the tissue of the mons pubis and labia majora. It is also called the ligamentum teres uteri, and it consists of smooth muscle fibres, vessels, and nerves. The artery supplying the round ligament is known as Sampson's artery, a branch of the inferior epigastric artery. Masses arising from the ligamentum rotundum, intraperitoneally are uncommon entities. Among the reported cases, a leiomyomata arising from the round ligament is an infrequent presentation with an unknown incidence, More than 50% of it is associated with a fibroid uterus [ 1 , 2 ]. Round ligament masses can create diagnostic dilemmas of metastatic nodes, hernia, mesothelial cysts, endometriosis, etc. [ 3 , 4 ]. Leiomyoma of the round ligament has been reported as an isolated finding presenting as a unilateral mass and more commonly over the right side [ 2 ]. In this case report, we will describe an interesting presentation of a left-sided round ligament leiomyoma coexisting with an invasive epithelial ovarian tumor. In the case of ovarian carcinoma, its presence may be mistaken for lymph node metastasis or a tumor deposit; hence, histo-pathological confirmation becomes crucial in solving the enigma. A complete surgical excision is the best treatment option in such cases [ 3 ]. There is no reported case in the literature of a left-sided leiomyoma arising intraperitoneally from the ligamentum rotundum, and its association with a high-grade serous carcinoma of the ovary. Case Presentation Our patient, a multiparous postmenopausal lady, presented with symptoms of abdominal distention for the past six months, early satiety, and intermittent mild lower abdominal pain. As an agricultural landowner, she had noticed increasing fatigue, which led to an inability to perform her daily routine and drove her to seek treatment. She did not have difficulties passing urine or stool. There was no significant family history. A local practitioner performed an abdominal ultrasound, which revealed a pelvic mass, and she was referred to our oncologic center for further care. At presentation, a poor performance score (Eastern Cooperative Oncology Group Performance Score 3) was noted with hard adnexal masses detected in the fornices on per vaginal and per rectal examination. Diagnostic assessment PET/CT showed mild to moderate right pleural effusion, with subpleural atelectasis, multiple avid mediastinal lymph nodes, right patchy consolidation, and bilateral avid solid-cystic adnexal masses (right 8x7 cm and left 4x3). Neither acid-fast bacilli nor atypical cells were detected in the pleural fluid. Pleural fluid Adenosine deaminase levels were not raised. The adnexal mass was biopsied to reveal high-grade serous carcinoma, stage. Our patient received nine weekly doses of single-agent carboplatin (Area Under Curve 2) and achieved a good clinical benefit. Contrast enhanced computed tomography (CECT) performed after chemotherapy was suggestive of mild atelectasis with pleural thickening in the posterior basal region of the right lower lobe, no enlarged mediastinal lymph nodes, and bilateral adnexal masses of size 6 x 4.5, 4 x 2.6 cm (Fig. 1 ). Cancer antigen (CA 125) levels were 301 and 126.4 IU/L before and after chemotherapy. In view of the resolution of pleural effusion and mediastinal lymph nodes but persistent bilateral adnexal masses, the patient was deemed to have a partial response to chemotherapy. Persistent adnexal masses appeared to arise either from the ovaries or the fallopian tube. The left mass was also considered to be a metastatic lymph node in view of its solid appearance on CECT. Therapeutic Intervention: The patient underwent interval cytoreductive surgery, where a 5 x 4 cm solid cystic right ovarian mass and a normal-sized left ovary were found, as well as a 4 x 3 cm left round ligament fibroid (Fig. 2 A, B). Omental and peritoneal surfaces were free of disease, and an optimal cytoreduction (no gross residual disease) was achieved. Our patient tolerated the procedure well and completed nine remaining weekly doses of adjuvant chemotherapy. Histology confirmed the finding of leiomyoma in the left-round ligament (Fig. 3 ). Follow up and Outcome The patient is on a regular three-month follow-up at our center. She is currently disease-free after 15 months of her treatment completion (CA 125–7 IU/L) and has resumed her work and is actively doing her daily activities. There were no adverse or any unanticipated events during the follow up period. Discussion The round ligament of the uterus is the structure that leads to the descent of the ovary starting from the posterior abdominal wall and ending up in the uterus. Its major components include smooth muscle fibres, connective tissue, vessels, and nerves with a mesothelial coating. Round ligament leiomyomas most commonly arise from the extraperitoneal end of round ligaments, commonly on the right side. Leiomyoma of the round ligament is rare and can present as adnexal, inguinal, or vulvar masses [ 3 , 5 ]. It has been found in both reproductive-aged and postmenopausal women. More than 50% of round ligament fibroids are associated with a fibroid uterus [ 1 , 2 ]. Oestrogen and progesterone receptors are present in the round ligament and they enhance the growth of myoma arising from it [ 6 ]. Progestin, present in combined hormonal replacement therapy given to postmenopausal women, plays a crucial role in the development of fibroid in the hormonally responsive tissue of the round ligament [ 7 ]. Round ligament leiomyoma is a rare condition that can mimic an incarcerated or irreducible hernia or inguinal lymphadenopathy, and it should be considered a differential diagnosis for inguinal swellings in females [ 4 , 8 ]. The appearance of a well-circumscribed lesion with fairly bright but somewhat heterogeneous enhancement is nonspecific but typical of leiomyomas. The solid-enhancing nature of the lesion would distinguish it from mesenteric and endometrial cysts. Femoral pseudoaneurysm and round ligament varices also demonstrate bright enhancements, the lack of communication with the femoral artery and proximal extension can help in differentiation. Metastatic adenopathy, however, could have this appearance and require pathologic examination for exclusion [ 9 ]. Leiomyoma appeared as an encapsulated heterogeneous tumor on contrast CT images and on post-gadolinium contrast MRI. Lack of specificity hinders diagnosis before surgery [ 10 ]. In the current case, it was considered a metastatic lymph node in a high-grade epithelial ovarian tumor due to its intraperitoneal location and a solid, well-encapsulated mass. There are no reported cases of isolated intraperitoneal left-sided round ligament myoma along with ovarian carcinoma that we could find. Histopathological assessment is always conclusive of diagnosis and also differentiates between a benign and malignant mass, a malignant picture has mitotic figures, necrosis, and nuclear atypia [ 2 , 11 ]. The strength of this case study is that it is the first ever reported case of a left-sided round ligament mass proven to be a fibroid coexisting with a high-grade serous tumor of the ovary. But generalizing the validity of the study is of question and the cause-effect relationship cannot be proven. Moreover, it remains in the lowest status in the evidence hierarchy. Conclusion In conclusion, we present a unique case of a round ligament mass that was noted intra-operatively during an interval cytoreductive surgery, which was later confirmed pathologically, to be a leiomyoma, which was coexisting with an invasive epithelial ovarian tumor. These masses can create a diagnostic dilemma and can masquerade as a metastatic node, hernia, mesothelial cyst, etc. CT and MRI can add value to a diagnosis, but specificity is in question. This case also highlights that surgical excision is the main treatment option and histopathology always aids in solving the enigma of such rare masses which are noticed intra-operatively. Patient Perspective It was altogether a big relief for me after surgery. My symptoms have reduced a lot. My quality of life has improved after the surgery. I would like to extend my gratitude to the doctors for helping me out. Declarations Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of interest/Competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethics approva l - Not applicable Consent to participate – Informed written consent was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review on request Availability of data and material (data transparency) – Not applicab Code availability - Not applicable Authors' contributions Sivalakshmi Ramu : Conceptualization and Project administration, Writing - Original draft, Sarita Kumari : Writing - Review & Editing, Rudrika Chandra : Writing - Review & Editing. References Bhosale PR, Patnana M, Viswanathan C, Szklaruk J. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics. 2008 May-Jun;28(3):819-35; quiz 913. doi: 10.1148/rg.283075110. Breen JL, Neubecker RD. Tumors of the round ligament: A review of literature and a report of 25 cases. Obstet Gynecol. 1962;19:771–80. S. M. Ali, K. A. Malik, H. Al-Qadhi, and M. Sha7q, “Leiomyoma of the round ligament of the uterus: case report and review of literature,” Sultan Qaboos University MedicalJournal, vol. 12, no. 3, pp. 357–359, 2012. Christodoulou, I. M., Angelopoulos, A., Siaperas, P., Ioannidis, A., Skarpas, A., Tellos, A., Karanikas, I. (2018). Leiomyoma of the Round Ligament of the Uterus Mimicking Inguinal Hernia. Case Reports in Surgery, 2018, 1–3. doi:10.1155/2018/6702494 Fasih N., Prasad Shanbhogue A. K., Macdonald D. B. et al., Leiomyomas beyond the uterus: unusual locations, rare manifestations, Radiographics. (2008) 28, no. 7, 1931–1948, https://doi.org/10.1148/rg.287085095. Smith P, Heimer G, Norgren A, Ulmsten U. The round ligament: a target organ for steroid hormones. Gynecol Endocrinol. 1993 Jun;7(2):97-100. doi: 10.3109/09513599309152487. Lösch A, Haider-Angeler MG, Kainz C, Breitenecker G, Lahodny J. Leiomyoma of the round ligament in a postmenopausal woman. Maturitas. 1999 Jan 4;31(2):133-5. doi: 10.1016/s0378-5122(98)00105-4. E Harish, N S Sowmiya, P B Indudhara. A rare case of round ligament leiomyoma: an inguinal mass. J Clin Diagn Res. 2014 Oct;8(10):NJ05-6. doi: 10.7860/JCDR/2014/9178.4989. Warshauer DM, Mandel SR. Leiomyoma of the extraperitoneal round ligament: CT demonstration. Clin Imaging. 1999 Nov-Dec;23(6):375-6. doi: 10.1016/s0899-7071(98)00021-7. Michel P, Viola D. Abdomino-pelvic leiomyoma of the round ligament: contribution of computed tomography and magnetic resonance imaging. J Gynecol Obstet Biol Reprod. 2003;32(6):571-4. S. W. Bell, R. L. Kempson, and M. R. Hendrickson, “Problematic uterine smooth muscle neoplasms. A clinicopatho-logic study of 213 cases,” American Journal of SurgicalPathology, vol. 18, no. 6, pp. 535–558, 1994 Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Decline and Transfer to *Transfer Desk* 09 Feb, 2025 Reviewers agreed at journal 16 Aug, 2024 Reviewers invited by journal 24 Jul, 2024 Editor assigned by journal 19 Jul, 2024 First submitted to journal 18 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4722045","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331090573,"identity":"452b6b60-d569-4d93-8e9f-2e0b95f726a8","order_by":0,"name":"Sivalakshmi Ramu","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-7703-5947","institution":"All India Institute of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sivalakshmi","middleName":"","lastName":"Ramu","suffix":""},{"id":331090574,"identity":"63e8929f-1323-4a33-b887-0e3eaaf2e171","order_by":1,"name":"Rudrika Chandra","email":"","orcid":"","institution":"All India Institute of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rudrika","middleName":"","lastName":"Chandra","suffix":""},{"id":331090575,"identity":"a3a8623a-a28b-48a4-8825-0c5d275fc4af","order_by":2,"name":"Sarita Kumari","email":"","orcid":"https://orcid.org/0000-0003-4687-1058","institution":"All India Institute of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sarita","middleName":"","lastName":"Kumari","suffix":""}],"badges":[],"createdAt":"2024-07-11 05:56:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4722045/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4722045/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63288002,"identity":"745f3c72-de29-478a-92f5-134dfa75ad49","added_by":"auto","created_at":"2024-08-26 13:54:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":229599,"visible":true,"origin":"","legend":"\u003cp\u003eCECT pelvis post neoadjuvant chemotherapy – Arrow pointing towards left sided adnexal mass likely residual ovarian tumour or a metastatic node\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4722045/v1/0249834435f989e6afc0fe8e.png"},{"id":63289018,"identity":"7422cd67-932a-4c1e-bdc7-a8d3ca5cbad0","added_by":"auto","created_at":"2024-08-26 14:02:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":234480,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative picture,\u003c/p\u003e\n\u003cp\u003eA - Arrow pointing a left sided round ligament leiomyoma;\u003c/p\u003e\n\u003cp\u003eB – Leiomyoma and normal sized left ovary\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4722045/v1/465d5c6797c89ee97306a366.png"},{"id":63288001,"identity":"85b607c1-5db9-4add-9b54-0859e8904294","added_by":"auto","created_at":"2024-08-26 13:54:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":293943,"visible":true,"origin":"","legend":"\u003cp\u003eHematoxylin and eosin stained slide on 40X magnification showing spindle shaped cells without nuclear atypia suggestive of leiomyoma\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4722045/v1/dac286d4661215a13a5fdaf0.png"},{"id":63290086,"identity":"62e19f5c-9c19-4ebf-a200-576c24a54c3d","added_by":"auto","created_at":"2024-08-26 14:10:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1227152,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4722045/v1/5d1b3de2-ad02-44ba-88f2-c4afed077c79.pdf"},{"id":63288004,"identity":"3f19daaa-ea10-468e-ae56-381dd4f62f3a","added_by":"auto","created_at":"2024-08-26 13:54:10","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":738091,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4722045/v1/b4d0dc3773490a157df3b7b8.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003e\u003cstrong\u003eLeft Sided Round Ligament Mass co-existing with High Grade Serous Epithelial Ovarian Carcinoma – A Case Report and Literature Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe round ligament of the uterus originates at the uterine cornu of the uterus and blends with the tissue of the mons pubis and labia majora. It is also called the ligamentum teres uteri, and it consists of smooth muscle fibres, vessels, and nerves. The artery supplying the round ligament is known as Sampson's artery, a branch of the inferior epigastric artery. Masses arising from the ligamentum rotundum, intraperitoneally are uncommon entities. Among the reported cases, a leiomyomata arising from the round ligament is an infrequent presentation with an unknown incidence, More than 50% of it is associated with a fibroid uterus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Round ligament masses can create diagnostic dilemmas of metastatic nodes, hernia, mesothelial cysts, endometriosis, etc. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Leiomyoma of the round ligament has been reported as an isolated finding presenting as a unilateral mass and more commonly over the right side [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In this case report, we will describe an interesting presentation of a left-sided round ligament leiomyoma coexisting with an invasive epithelial ovarian tumor. In the case of ovarian carcinoma, its presence may be mistaken for lymph node metastasis or a tumor deposit; hence, histo-pathological confirmation becomes crucial in solving the enigma. A complete surgical excision is the best treatment option in such cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There is no reported case in the literature of a left-sided leiomyoma arising intraperitoneally from the ligamentum rotundum, and its association with a high-grade serous carcinoma of the ovary.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eOur patient, a multiparous postmenopausal lady, presented with symptoms of abdominal distention for the past six months, early satiety, and intermittent mild lower abdominal pain. As an agricultural landowner, she had noticed increasing fatigue, which led to an inability to perform her daily routine and drove her to seek treatment. She did not have difficulties passing urine or stool. There was no significant family history. A local practitioner performed an abdominal ultrasound, which revealed a pelvic mass, and she was referred to our oncologic center for further care. At presentation, a poor performance score (Eastern Cooperative Oncology Group Performance Score 3) was noted with hard adnexal masses detected in the fornices on per vaginal and per rectal examination.\u003c/p\u003e\n\u003ch3\u003eDiagnostic assessment\u003c/h3\u003e\n\u003cp\u003ePET/CT showed mild to moderate right pleural effusion, with subpleural atelectasis, multiple avid mediastinal lymph nodes, right patchy consolidation, and bilateral avid solid-cystic adnexal masses (right 8x7 cm and left 4x3). Neither acid-fast bacilli nor atypical cells were detected in the pleural fluid. Pleural fluid Adenosine deaminase levels were not raised. The adnexal mass was biopsied to reveal high-grade serous carcinoma, stage. Our patient received nine weekly doses of single-agent carboplatin (Area Under Curve 2) and achieved a good clinical benefit. Contrast enhanced computed tomography (CECT) performed after chemotherapy was suggestive of mild atelectasis with pleural thickening in the posterior basal region of the right lower lobe, no enlarged mediastinal lymph nodes, and bilateral adnexal masses of size 6 x 4.5, 4 x 2.6 cm (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Cancer antigen (CA 125) levels were 301 and 126.4 IU/L before and after chemotherapy.\u003c/p\u003e\n\u003cp\u003eIn view of the resolution of pleural effusion and mediastinal lymph nodes but persistent bilateral adnexal masses, the patient was deemed to have a partial response to chemotherapy. Persistent adnexal masses appeared to arise either from the ovaries or the fallopian tube. The left mass was also considered to be a metastatic lymph node in view of its solid appearance on CECT.\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eTherapeutic Intervention:\u003c/h2\u003e\n \u003cp\u003eThe patient underwent interval cytoreductive surgery, where a 5 x 4 cm solid cystic right ovarian mass and a normal-sized left ovary were found, as well as a 4 x 3 cm left round ligament fibroid (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA, B). Omental and peritoneal surfaces were free of disease, and an optimal cytoreduction (no gross residual disease) was achieved. Our patient tolerated the procedure well and completed nine remaining weekly doses of adjuvant chemotherapy. Histology confirmed the finding of leiomyoma in the left-round ligament (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eFollow up and Outcome\u003c/h3\u003e\n\u003cp\u003eThe patient is on a regular three-month follow-up at our center. She is currently disease-free after 15 months of her treatment completion (CA 125\u0026ndash;7 IU/L) and has resumed her work and is actively doing her daily activities. There were no adverse or any unanticipated events during the follow up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe round ligament of the uterus is the structure that leads to the descent of the ovary starting from the posterior abdominal wall and ending up in the uterus. Its major components include smooth muscle fibres, connective tissue, vessels, and nerves with a mesothelial coating. Round ligament leiomyomas most commonly arise from the extraperitoneal end of round ligaments, commonly on the right side. Leiomyoma of the round ligament is rare and can present as adnexal, inguinal, or vulvar masses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It has been found in both reproductive-aged and postmenopausal women. More than 50% of round ligament fibroids are associated with a fibroid uterus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Oestrogen and progesterone receptors are present in the round ligament and they enhance the growth of myoma arising from it [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Progestin, present in combined hormonal replacement therapy given to postmenopausal women, plays a crucial role in the development of fibroid in the hormonally responsive tissue of the round ligament [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRound ligament leiomyoma is a rare condition that can mimic an incarcerated or irreducible hernia or inguinal lymphadenopathy, and it should be considered a differential diagnosis for inguinal swellings in females [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe appearance of a well-circumscribed lesion with fairly bright but somewhat heterogeneous enhancement is nonspecific but typical of leiomyomas. The solid-enhancing nature of the lesion would distinguish it from mesenteric and endometrial cysts. Femoral pseudoaneurysm and round ligament varices also demonstrate bright enhancements, the lack of communication with the femoral artery and proximal extension can help in differentiation. Metastatic adenopathy, however, could have this appearance and require pathologic examination for exclusion [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Leiomyoma appeared as an encapsulated heterogeneous tumor on contrast CT images and on post-gadolinium contrast MRI. Lack of specificity hinders diagnosis before surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the current case, it was considered a metastatic lymph node in a high-grade epithelial ovarian tumor due to its intraperitoneal location and a solid, well-encapsulated mass. There are no reported cases of isolated intraperitoneal left-sided round ligament myoma along with ovarian carcinoma that we could find.\u003c/p\u003e \u003cp\u003eHistopathological assessment is always conclusive of diagnosis and also differentiates between a benign and malignant mass, a malignant picture has mitotic figures, necrosis, and nuclear atypia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe strength of this case study is that it is the first ever reported case of a left-sided round ligament mass proven to be a fibroid coexisting with a high-grade serous tumor of the ovary. But generalizing the validity of the study is of question and the cause-effect relationship cannot be proven. Moreover, it remains in the lowest status in the evidence hierarchy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, we present a unique case of a round ligament mass that was noted intra-operatively during an interval cytoreductive surgery, which was later confirmed pathologically, to be a leiomyoma, which was coexisting with an invasive epithelial ovarian tumor. These masses can create a diagnostic dilemma and can masquerade as a metastatic node, hernia, mesothelial cyst, etc. CT and MRI can add value to a diagnosis, but specificity is in question. This case also highlights that surgical excision is the main treatment option and histopathology always aids in solving the enigma of such rare masses which are noticed intra-operatively.\u003c/p\u003e\n\u003ch3\u003ePatient Perspective\u003c/h3\u003e\n\u003cp\u003eIt was altogether a big relief for me after surgery. My symptoms have reduced a lot. My quality of life has improved after the surgery. I would like to extend my gratitude to the doctors for helping me out.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approva\u003c/strong\u003e\u003cstrong\u003el\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e \u0026ndash; Informed written consent was obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review on request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e (data transparency) \u0026ndash; Not applicab\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e \u0026nbsp;- Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSivalakshmi Ramu : Conceptualization and Project administration, Writing - Original draft, Sarita Kumari : Writing - Review \u0026amp; Editing, Rudrika Chandra : Writing - Review \u0026amp; Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBhosale PR, Patnana M, Viswanathan C, Szklaruk J. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics. 2008 May-Jun;28(3):819-35; quiz 913. doi: 10.1148/rg.283075110.\u003c/li\u003e\n\u003cli\u003eBreen JL, Neubecker RD. Tumors of the round ligament: A review of literature and a report of 25 cases. Obstet Gynecol. 1962;19:771\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eS. M. Ali, K. A. Malik, H. Al-Qadhi, and M. Sha7q, \u0026ldquo;Leiomyoma of the round ligament of the uterus: case report and review of literature,\u0026rdquo; Sultan Qaboos University MedicalJournal, vol. 12, no. 3, pp. 357\u0026ndash;359, 2012. \u003c/li\u003e\n\u003cli\u003eChristodoulou, I. M., Angelopoulos, A., Siaperas, P., Ioannidis, A., Skarpas, A., Tellos, A., Karanikas, I. (2018). Leiomyoma of the Round Ligament of the Uterus Mimicking Inguinal Hernia. Case Reports in Surgery, 2018, 1\u0026ndash;3. doi:10.1155/2018/6702494 \u003c/li\u003e\n\u003cli\u003eFasih N., Prasad Shanbhogue A. K., Macdonald D. B. et al., Leiomyomas beyond the uterus: unusual locations, rare manifestations, Radiographics. (2008) 28, no. 7, 1931\u0026ndash;1948, https://doi.org/10.1148/rg.287085095. \u003c/li\u003e\n\u003cli\u003eSmith P, Heimer G, Norgren A, Ulmsten U. The round ligament: a target organ for steroid hormones. Gynecol Endocrinol. 1993 Jun;7(2):97-100. doi: 10.3109/09513599309152487.\u003c/li\u003e\n\u003cli\u003eL\u0026ouml;sch A, Haider-Angeler MG, Kainz C, Breitenecker G, Lahodny J. Leiomyoma of the round ligament in a postmenopausal woman. Maturitas. 1999 Jan 4;31(2):133-5. doi: 10.1016/s0378-5122(98)00105-4.\u003c/li\u003e\n\u003cli\u003eE Harish, N S Sowmiya, P B Indudhara. A rare case of round ligament leiomyoma: an inguinal mass. J Clin Diagn Res. 2014 Oct;8(10):NJ05-6. doi: 10.7860/JCDR/2014/9178.4989.\u003c/li\u003e\n\u003cli\u003eWarshauer DM, Mandel SR. Leiomyoma of the extraperitoneal round ligament: CT demonstration. Clin Imaging. 1999 Nov-Dec;23(6):375-6. doi: 10.1016/s0899-7071(98)00021-7. \u003c/li\u003e\n\u003cli\u003eMichel P, Viola D. Abdomino-pelvic leiomyoma of the round ligament: contribution of computed tomography and magnetic resonance imaging. J Gynecol Obstet Biol Reprod. 2003;32(6):571-4.\u003c/li\u003e\n\u003cli\u003eS. W. Bell, R. L. Kempson, and M. R. Hendrickson, \u0026ldquo;Problematic uterine smooth muscle neoplasms. A clinicopatho-logic study of 213 cases,\u0026rdquo; American Journal of SurgicalPathology, vol. 18, no. 6, pp. 535\u0026ndash;558, 1994\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Case report, leiomyoma, ovarian neoplasms, round ligament of uterus, high grade serous ovarian carcinoma","lastPublishedDoi":"10.21203/rs.3.rs-4722045/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4722045/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeiomyoma of the round ligament has been reported as an isolated finding and more commonly over the right side. More than 50% of it is associated with fibroid uterus. There is no reported case in the literature of a left-sided leiomyoma of ligamentum rotundum, and its association with a high-grade serous carcinoma of the ovary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report a confirmed case of high-grade serous epithelial ovarian carcinoma of the ovary in a postmenopausal lady, with an intra-operative incidental finding of a round ligament mass. It was then surgically excised and sent for histopathological study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u003cbr\u003e\nRound ligament leiomyoma coexisting with an invasive epithelial ovarian tumor is a rare entity. Round ligament leiomyomas can create diagnostic dilemmas of metastatic nodes in some cases.\u003c/p\u003e","manuscriptTitle":"Left Sided Round Ligament Mass co-existing with High Grade Serous Epithelial Ovarian Carcinoma – A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 13:54:06","doi":"10.21203/rs.3.rs-4722045/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Decline and Transfer to *Transfer Desk*","date":"2025-02-10T04:22:45+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-08-16T04:50:04+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-24T07:59:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-19T13:48:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2024-07-18T11:00:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"43c7742e-deb0-434b-8a76-6db28460625e","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-26T13:54:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-26 13:54:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4722045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4722045","identity":"rs-4722045","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}