Date: 26/3/13

Certificate by authors

“The undersigned authors hereby declare that the article is original, neither the article nor a part of it is under consideration for publication anywhere else and has not been previously published anywhere. We have declared all vested interests. We have meticulously followed the instructions. The article, if published, shall be the property of the Journal and we surrender all rights to the Editor. We agree to provide the latest follow-up of cases prior to the publication of case reports when requested.”

Yours sensior,

Dr.Manisha M. Laddad

Title: Unusual presentation of cervical fibroid two case reports.

Dr.Manisha M. Laddad, Dr.Rajkumar Patange, Dr .Gauri Shinde

1) Dr. Manisha M.Laddad, DGO, DNB.Assistant Professor in obgs and gynae.dept.

2) Dr.N.S.Kshisagar D.G.O.M.D. Professor in obg.and gynae.dep.

3) Dr.Gauri Shinde D.N.B.Assistant Professor in obgs and gynae.dept.

Department of Obstetrics and Gynecology Department, Krishna Institute of Medical Sciences, Deemed University Karad 415110

CORRESPONDING AUTHER

Dr. Manisha M. Laddad

75/A Block, Vithal Housing Society, Malkapur,

Karad (Dist. Satara) Maharashtra-415110

Email:

Ph.no.9960884191

Key words: Cervical fibroid, fibrosarcoma.

Abstract: Uterine fibroids are the most common tumors of the female reproductive tract. Although most fibroids are asymptomatic, about 25% are associated with symptoms that can have a significant impact on patient`s quality of life, including prolonged or excessive menstrual bleeding, pelvic pain or bulkiness, dyspareunia, increased urinary frequency, and infertility. Various treatment options available for symptomatic uterine fibroids include hysterectomy, myomectomy (abdominal or laparoscopic), and uterine artery embolization. Most of the uterine myomas are situated in the body of the uterus, but in 1 to 2% of cases fibroids are confined to cervix. And usually to supravaginal portion. A cervical leomyomas are usually single and subserosal or interstitial rarely it become sub mucus and polypoidal.(Kumar et al 2008).two cases were admitted in our institute with unusual presentation which mimics’ ovarian tumor in one case and one came with retention of urine..

INTRODUCTION

Fibroid is the most common benign tumor arising from uterus.96%are uterine fibroids,4% are cervical fibroid may present with unusual presentation. Cervical fibroid maybe responsible for technical problemsdue to distorted anatomy & increased vascularityduring surgery like bleeding injury to adjacent structures post operative infection. Large central cervical fibroids are very difficult to handle need expert hand to operate these cases.

CASE I

50 year nulliparous, widow women was admitted on 3rd December 2012 with complaints of retention of urine since 4 months on and off, pervaginal bleeding since 3 weeks,she has never used any contraceptives.

On examination she was averagely built with severe pallor and normal blood pressure. On per abdominalexamination it was distended, huge 24 week mass arising from pelvis, firm to hard in consistency with regular margin. On speculum examination doneunderanesthesia cervix was not visualized,large globular mass was seen in vagina,bled on touch, firm to hard in consistency, with smooth border, On pervaginal examination uterus was 22 to 24 weeks size hard in consistency, cervix moved with movement of tumor.On rectal examination-Rectalmucosa andparametrium were free .Our diagnosis was? Fibrosarcoma? Cervical fibroid?Ca cervix.

USG showed large 15cmhypo echoic solid mass in relation to uterine cervix? Large cervical fibroid? Fibro sarcoma.Uterus Normal. Hb was 6 gm% restreports were normal.

Laparotomy was done on 16th Dec.2012. At Laparotomy large 22-24 cm central cervical fibroid with degenerative changes with normal fundus sitting on it. (Figure 1)(Lantern on the dome of St. Paul’s).

Fig.1 Postoperative specimen showing large cervical fibroid with normal uterus

Bladder pulled up over the fibroid. Omentum was adherent to fibroid posterior. Ureters were displaced laterally. Tubes & Ovaries were normal. Total hysterectomy with bilateral salpingo-ophorectomy, with removal of big cervicalfibroid wasdone;ureters weretracedon both sides. Pt. received four units of blood.Post operative period was uneventful.

Histopathology report:

Histopathology report revealed leimyomata with degenerative changes.

CASE II

55 years old post menopausal,G3P3L3A0 admitted on 11thDec.2012 as an emergency with complaints of lump in abdomen since 1½ month, excessive PV bleeding since 3 weeks, loss of appetite and weight since 1 month. Her last child was 25 years old. She had never used any contraceptives. Previous menstrual cycles were regular.Operated for three LSCS.H/o bloodtransfusion ten days back.

On examination she was severely pallor. On abdominal examination three scars were seen in infraumbilical region. Large 16 to 18 wks mass arising from pelvis extending up to right iliac fossa,it was fixed,hard in consistency showing smooth margins. Lower margin wasnot felt, no ascites.On per speculumexamination- active bleeding seen through cervix.Vagina was pale. On pervaginal examination 18 wks uterus, firm in consistency. Cervix moved with movement of uterus. There was fullness in right fornices, one separate hard mass felt away from uterus.

Sonography

Shows 14x11 cm large mass involving entire uterus S/o large uterine fibroid, right ovary with 9x8x6 cm well defined lesion with septations? Cystadenocarcinoma, Hb was 5gm% ,Sr.CA 125- 14.7U/ml. Provisional diagnosis was? ca ovary?fibro sarcoma of uterus.

After correction of her anemia by giving four units of blood transfusion.Laprotomy was done. Intraoperatively findings were normal uterus with large central cervical fibroid 18 to 20weeks, posteriorly adherent to the bowel and omentum, deviated to left side. Left sided anatomy was distorted. On right side 9x9x6 cm ovarian cyst with smooth margins, showing clear fluid. Left sided ovary normal. Bladdernormal. Total hysterectomy left sided salphingo oophorectomy with removal of right ovarian cyst and cervical fibroid was done Figure2.Post operative period was uneventful.

Fig.2 Cervical fibroid with ovarian tumour

DISCUSSION

Uterine myomas are the most frequent indication for hysterectomy.1 The common symptoms are abnormal uterine bleeding and pelvic discomfort mostly caused by mass effect.1, 2 The transformation of myomas to leiomyosarcoma is a very rare event.1 Leiomyosarcomas may be suspected in postmenopausal women with rapidly growing solid symptomatic pelvic mass.

Cervical fibroid with excessive growth are uncommon.2,3,5 They give rise to greater surgical difficulty by virtue of their relative inaccessibility and close proximity to the bladder and uterus. Enlargement causes upward displacement of the uterus and the fibroid may become impacted in the pelvis causing primary retention and ureteric obstruction.3

In the cases presented, cervical fibroid grew not only to occupy the pelvic cavity but become a huge abdominal mass pushing the uterus near umbilicus.3,4It is very easy to diagnose and treat benign condition like fibroid1,2,4 but as the above cases suggest, there may diagnostic dilemma .3,4These cases have thrown light on the rare presentation of cervical fibroid. Even after clinical examination and investigations we were not able to differentiate between cervical fibroid and ovarian tumor initially.3,4 We have done Sr. CA125 for one case. Final diagnosis was made after Laparotomy. Now a days because of availability of different modalities of investigations i.e. USG, Laparoscopy, Doppler, MRI, we can diagnose such cases earlier and accurately.1,5 Cervical fibroid is sometimes very difficult to operate because of distortion of pelvic anatomy. Ureters may be injured, Profuse Intraoperatively bleeding may occur. In modern era we can handle these cases with laproscopic surgery also. Uterine artery embolisation has also some role to minimize the size of fibroid.5

REFERNCES

1)Orhan Bukulmez, Kevin J Doody. Clinical features of myomas. Obstet Gynecol Clin N Am 33(2006), 69-84.

2)Wallach EE, VlahosNF. Uterine myomas; an overview of development, clinical features and management. Obstet Gynecol 2004; 104; 393-406.

3)Kaur AP et al. Huge Cervical Fibroid: unusual presentation. The Journal of Obstet & Gynecol of India 2005 Jan-Feb; 5291):164.

4)Kumar p:Malhotra:Tumors of corpus uteri:in jeffcots principle of gynaecology 7th Edn.Jaypee Brothers publisher(pvt)New Delhi:pp 487-516

5)Amita Sunja et al. Incarcerated procedentia due to cervical fibroid. An unusual presentation. Australian and New Zealand Journal of Obstetrics & Gynecology. 2003; 43: 252-253.

6)Paul B. Marshburn, Michelle L. Mathews, Bradley S. Hurst. Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin N Am 33(2006): 125-144.

Legend

Fig.1 Postoperative specimen showing large cervical fibroid with normal uterus

Fig.2 Cervical fibroid with ovarian tumour