Leiomyomatosis peritonealis disseminata with features of carcinomatosis on laparoscopy: a case report

Leiomyomatosis peritonealis disseminata [LPD], also known as diffuse peritoneal leiomyomatosis, is a rare disease characterised by subperitoneal proliferation of benign nodules mainly composed of benign smooth muscle cells, macroscopically mimicking peritoneal carcinomatosis. We report a 43 year-old woman who presented with menorrhagia, pelvic pressure and pain. Ultrasound of the pelvis showed uterine fibroids and an ovarian cyst. She was scheduled to have a laparoscopic hysterectomy and left salpingo-oophorectomy for symptomatic relief. A picture of carcinomatosis was seen on laparoscopy so multiple biopsies were taken and the patient was referred to the gynaecological oncology team. Definitive surgery was performed and final pathology was consistent with LPD with no evidence of malignancy. No hormone replacement therapy was offered after surgery. Macroscopically, LPD has features of malignancy; it usually pursues a benign course. To review current management of LPD and the risk of malignant transformation, we conducted a search in Medline, EMBASE, and the Cochrane Database of systematic reviews using the keywords: leiomyomatosis peritonealis disseminata, management and malignant transformation. LPD is a diagnostic challenge. Although rare, malignant transformation can occur since hormones play an important role in the pathogenesis of LPD, following surgery, patients should be followed carefully if they are on hormone replacement as these tumours could re-grow and cause symptoms or transform to malignancy

Endometrioid adenocarcinoma 13 years after total abdominal hysterectomy and bilateral salpingo-oophorectomy

Malignant transformation is an infrequent complication of endometriosis. As endometriosis is an ectopic endometrium, hyperestrogenism may cause hyperplasia or transformation into cancer. We describe a case of a 68-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She was subsequently placed on estrogen-only replacement therapy. She presented with left-sided pelvic mass and shortness of breath. Computed tomography of chest, pelvis, and abdomen, demonstrated right-sided pleural effusion and soft tissue mass in the pelvis. Pleural effusion was tapped and biopsy from the peritoneal mass showed metastatic adenocarcinoma; immunohistochemistry findings favored endometrioid adenocarcinoma. She was treated by 6 cycles of Carboplatin/Paclitaxel and responded well. Unopposed estrogen stimulation may lead to premalignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestins to estrogen replacement therapy should be considered in women who have undergone hysterectomy with oophorectomy due to endometriosis

Management of ovarian cysts in postmenopausal women

Ovarian cysts in postmenopausal women are not uncommon and the majorities are asymptomatic. The primary goal in case of an ovarian cyst in a postmenopausal woman is to exclude malignant disease. Evidence is emerging that most of these ovarian cysts in postmenopausal women are benign, and many of these cysts resolved spontaneously. Therefore, surgical exploration of these cysts in postmenopausal women, who might have multiple co-morbidities, can be avoided in a large proportion of these patients. The aim of this review was to provide an evidence-based guideline about the management of ovarian cysts in postmeopausal women according to clinical, ultrasonographic, and biochemical features. Articles concerning ovarian cysts in postmenopausal women from a Medline literature search for the past 10 years were included. Using different imaging tools and serum marker CA125 are used. Size and consistency of the cyst found on benign appearing criteria on ultrasound and Doppler in addition to normal CA125, can be managed conservatively by repeated ultrasound and CA125, majority of cyst in postmenopausal women are benign and disappear spontaneously. Operative laparoscopy can be safely used to remove persistent cyst with normal CA125. Suspicious cyst by imaging and elevated CA125 should be manage in the traditional way as ovarian cancer. Discrimination between benign and malignant ovarian cyst is challenging. No single test can achieve this, for this reason multiple diagnostic modalities can be used together to optimize the accuracy of prediction of malignancy in a cyst. More work is needed on Doppler and three-dimensional ultrasound hoping to improve the sensitivity to discriminate between benign and malignant cysts in the future