UTERINE LEIOMYOMA AND NEOPLASIA Department of Obstetrics and Gynecology Wu Jie

Key Points Introduction Symptoms Diagnosis Treatment

INTRODUCTION Leiomyoma is common in clinical practice. It is estimated that up to 30% of American women have these benign tumors, although the majority do not present with significant symptoms and do not require therapy.

INTRODUCTION Leiomyomas are present in 20-25% of reproductive-age women. ? Leiomyomas are 3-9 times more frequent in black than white women. About 50% of black women will have leiomyoma.

INTRODUCTION Leiomyomas are the most common indication for hysterectomy, accounting for approximately 30% of all such cases. Leiomyomas account for a large number of more conservative operations including myomectomy, uterine curettage, and operative hysteroscopy.

INTRODUCTION Histologically, these benign tumors represent localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers.

INTRODUCTION Most frequent clinical manifestations include: Mass: irregular enlargement of the uterine Pain: torsion or degeneration Bleeding, hypermenorrhea and dysmenorrhea Pressure: symptoms from neighboring organs

INTRODUCTION Leiomyomas are considered hormonally responsive tumors because the growth potential of these tumors is related to estrogen production, often with rapid growth occurring in pregnancy or high estrogen states. Menopause generally brings about cessation of tumor growth and even some atrophy.

INTRODUCTION In 0.1% of cases, malignancy such as leiomyosarcoma may develop. These are not thought to represent “degeneration” of a fibroid, but rather a new neoplasm. Uterine malignancy is more typical in older patients.

INTRODUCTION Be evaluated with considerable more concern for malignancy: Rapidly enlarging uterine masses Postmenopausal bleeding Unusual vaginal discharge Pelvic pain

Key Points Introduction Symptoms Diagnosis Treatment

SYMPTOMS The symptoms associate with uterine leiomyomas frequently lead women to seek medical advice.

SYMPTOMS Bleeding It is the most common presenting symptom in uterine fibroids. Progressively heavier menstrual flow that lasts longer than the normal duration. Resulting from significant distortion of the endometrial cavity by the underlying tumor.

SYMPTOMS Submucous leiomyoma endometrial cavity of uterus. The smooth muscle tumor projects toward the endometrial cavity of uterus. Subserous leiomyoma Intramural leiomyoma It may contribute to excessive bleeding if they become large enough to significantly distort the endometrial cavity.

SYMPTOMS Anemia Blood loss from submucous leiomyoma may be heavy enough to contribute to chronic iron-deficiency anemia.

SYMPTOMS Pelvic pressure This may be a sense of progressive pelvic fullness, and/or the sensation of a pelvic mass. Most commonly, this is caused by slowly enlarging intramural or subserous myomas. This type of leiomyoma is the most easily palpated on bimanual or abdominal examination.

SYMPTOMS Pelvic pain The pain may be the result of rapid enlargement of leiomyoma (areas of tissue necrosis or areas of subnecrotic vascular ischemia).

SYMPTOMS Pelvic pain Tortion of a pedunculated myoma Acute pain: Tortion of a pedunculated myoma Dull, intermittent low midline cramping pain: Submucous myoma becomes pedunculated and progressively prolapses through the internal os of the cervix

SYMPTOMS Degeneration Red degeneration hemorrhagic changes associated with rapid growth Hyaline degeneration hyalinization of the smooth muscle elements, occurring commonly after menopause Calcification calcific replacement of inactive smooth muscle elements, occurring after menopause.

SYMPTOMS Infertility Spontaneous abortion Enlarging uterine masses

Key Points Introduction Symptoms of uterine fibroids Diagnosis Treatment

DIAGNOSIS Clinical examination (including abdominal and bimanual palpation) A large mobile pelvic mass with an irregular contour The mass usually ‘hard feel” or solid quality The degree of enlargement is usually stated in terms (weeks size)

DIAGNOSIS Clinical examination The mass is often appreciated as separate from adnexal disease, although on occasion pedunculatedly subserosal myoma may be difficult to distinguish from a solid adnexal mass.

DIAGNOSIS Pelvic ultrasound For confirmation of uterine myomas Hypoechogenic areas (to indicate myomas undergoing degeneration) Adnexal structures, including the ovaries (separating from these masses) (Obese women)

DIAGNOSIS CT MRI ( magnetic resonance imagine)

DIAGNOSIS Biopsy or dilation & curettage Irregular uterine bleeding Patient’s clinical presentation or age makes endometrial carcinoma significant probability

DIAGNOSIS Hysteroscopy It may be used to evaluate the enlarged uterus by directly visualizing the endometrial cavity. Submucous fibroids can be visualized and removed. Long-term follow-up suggests that up to 20% of patients require additional treatment.

DIAGNOSIS Laparoscopy It may be used in cases in which physical examination and ultrasound imagine techniques are not clear as to whether the patient has a leiomyoma or other potentially more serious diseases.

Key Points Introduction Symptoms of uterine fibroids Diagnosis Treatment

TREATMENT Observation Biopsy might rule out endometrial hyperplasia or cancer. Bleeding is not heavy enough to cause significant alteration in lifestyle and is not contributing to iron-deficiency anemia.

TREATMENT Observation Assessment of further uterine growth may be done by repeat pelvic examinations and assisted by serial pelvic ultrasound measurements.

TREATMENT Hormonal supplementation To make to minimize uterine bleeding by using intermittent progestin supplementation and/or prostaglandin synthetase inhibitors, which decrease the amount of secondary dysmenorrhea.

TREATMENT Surgical measures Myomectomy is occasionally warranted in younger patients whose fertility is compromised by the presence of myomas.

TREATMENT Surgical measures Potential complications of myomectomy: Excessive intraoperative blood loss Risk of postoperative hemorrhage

TREATMENT Surgical measures Criteria for myomectomy have been published to help guide the clinician’s decision making.

Confirmation of indication Leiomyoma in infertility patients, as a probable factor in failure to conceive or in recurrent pregnancy loss Confirmation of indication In the presence of failure to conceive or in recurrent pregnancy loss: 1.Presence of leiomyoma of sufficient size or specific location to be a probable factor 2.No more likely explanation exists for the failure to conceive or in recurrent pregnancy loss Actions before procedure 1.Evaluate other causes of male and female infertility or recurrent pregnancy loss 2.Evaluate the endometrial cavity and fallopian tubes 3.Document discussion that complexity of disease process may require hysterectomy

TREATMENT Surgical measures Hysterectomy is commonly performed for uterine myomas in symptomatic women who have completed childbearing. Indications should be specific and well documented.

Criteria for Hysterectomy for Leiomyoma Indication Leiomyoma Confirmation of indication Presence of 1, 2, or 3: 1. Asymptomatic leiomyomas of such size that they are palpable abdominally and are a concern to the patient 2. Excessive uterine bleeding evidenced by either of the following: a.Profuse bleeding with flooding or clots or repetitive periods lasting>8 days b.Anemia caused by acute or chronic blood loss 3. Pelvic discomfort caused by myoma: a.Acute and severe b.Chronic lower abdominal or low back pressure c.Bladder pressure with urinary frequency not caused by urinary tract infection

Criteria for Hysterectomy for Leiomyoma Actions before procedure 1.Confirm the absence of cervical malignancy 2.Eliminate anovulation and other causes of abnormal bleeding 3.When abnormal bleeding is present, confirm the absence of endometrial malignancy 4.Assess surgical risk from anemia and need for treatment 5.Consider patient’s medical and psychological risks concerning hysterectomy Contraindications 1.Desire to maintain fertility, in which case myomectomy should be considered 2.Asymptomatic leiomyomata of size <12 weeks’ gestation determined by physical examination or ultrasound examination

TREATMENT Other measures “estrogen-dependent” benign neoplasms Gonadotropin-releasing hormone agonists Used for 3 to 6 months before planned hysterectomy A temporizing medical therapy

TREATMENT Other measures GnRH agonists not only can result in a reduction in uterine size, often by as much as 40% to 60%, but also can lead to a technically easier surgery with markedly diminished blood loss should surgery be undertaken.

TREATMENT Other measures Myolysis Arterial embolization Further investigation is required before they may be considered a “mainstream” therapeutic modality.

TREATMENT Pregnancy with leiomyoma Patients with leiomyoma do become pregnant and clinical findings are unremarkable. Myomas may grow or become symptomatic, associated with red degeneration. Bed rest and strong analgesics are usually sufficient as treatment.

TREATMENT Pregnancy with leiomyoma Vaginal birth after myomectomy is controversial and must be decided on a case-by-case basis. Cesarean birth: myomas are located below the fetus in the lower uterine segment or cervix, causing a soft tissue dystocia.

LEIOMYOSARCOMA Uterine sarcomas accounted for approximately 3% of cancers involving the body of the uterus. Progressive uterine enlargement Postmenopausal bleeding Unusual pelvic pain coupled with uterine enlargement An increase in unusual vaginal discharge

LEIOMYOSARCOMA When uterine sarcoma is suspected, patients should undergo typical tumor survey to include assessment for distant metastatic disease. Hysterectomy, it is necessary to thoroughly explore the abdomen and sample commonly affected node chains.

LEIOMYOSARCOMA The staging for uterine sarcoma is surgical and identical to that for endometrial adenocarcinoma. The overall rate of survival is considerable worse than that for those with endometrial adenocarcinoma. Only 50% patients survive 5 years.

LEIOMYOSARCOMA Surgical removal is the method of most reliable diagnosis. Adjunctive radiation therapy and chemotherapy provide little additional benefit. Uterine sarcoma is not responsive to hormonal treatment with high-dose progestins.

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