Degenerated broad ligament fibroid mimicking ovarian cyst: A case report

The commonest diagnosis of a cystic mass in the pelvis is ovarian cyst, here we report a case of cystic degeneration of broad ligament fibroid mimicking as a ovarian cyst. A 45-year-old lady presented with abdominal discomfort. On evaluation, a pelvic mass of 20 weeks size of varying consistency was noted. Ultra sonogram and Magnetic Resonance Imaging gave a differential diagnosis of right sided broad ligament fibroid and ovarian cyst. Anticipating possible ovarian mass owing to its size, laparotomy was performed and noted a large false broad ligament fibroid which has undergone cystic degeneration. Total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed, however a differential diagnosis of ovarian mass should always be made before surgery.

Hematoma espontáneo del ligamento ancho luego de un parto vaginal normal: reporte de caso / Spontaneous hematoma of the broad ligament after a normal vaginal delivery: case report / Hematoma espontâneo do ligamento largo após um parto vaginal normal: apresentação de um caso clínico

La hemorragia posparto es una de las principales causas de muerte materna con una elevada morbimortalidad. El hematoma del ligamento ancho representa una entidad inusual, de difícil diagnóstico y alta sospecha clínica. Se presenta el caso clínico de una paciente con un hematoma del ligamento ancho espontáneo luego de un parto vaginal. Se optó por una conducta activa con laparotomía y antibioticoterapia obteniendo una buena evolución con egreso hospitalario a los 30 días. Se realiza la discusión del caso luego de revisar la bibliografía disponible.

Postpartum hemorrhage is one of the main causes of maternal death with high morbidity and mortality. The broad ligament hematoma represents an unusual entity, difficult to diagnose, in which clinical suspicion is determinant. The clinical case of a patient with a spontaneous broad ligament hematoma after a vaginal delivery is presented. An active management with laparotomy and antibiotic therapy was chosen, obtaining a satisfactory evolution with hospital discharge at 30 days. The case is discussed, after reviewing the available bibliography.

A hemorragia pós-parto é uma das principais causas de morte maternal com alta morbidade e mortalidade. O hematoma do ligamento largo representa uma entidade incomum, de difícil diagnóstico e alto suspeita clínica. A presentamos o caso clínico de uma paciente com hematoma espontâneo do ligamento largo, após parto vaginal. Foi optada por conduta ativa com laparotomía e antibioticoterapia, obtendo boa evolução com alta hospitalar após 30 dias. O caso é discutido depois de revisar a bibliografia disponível.

Tumors of the broad ligament: what and when to suspect such rare location / Tumores do ligamento largo: o que e quando suspeitar tão rara localização

Abstract Although secondary involvement of the broad ligament by malignant tumors arising elsewhere in the abdomen and pelvis is common, primary tumors in this location are rare. Tumors of the broad ligament can be of mesenchymal and mixed nature, such as leiomyoma, the most common neoplasm; epithelial tumors of Müllerian type, imposing a challenge to differentiate them from other adnexal masses; unique tumors from mesonephric origin; and tumor-like lesions. Most neoplasms in this region, whether benign or malignant, usually present clinically with vague symptoms and are often discovered during a routine gynecological examination. Suspicion of such location and knowledge of the potential range of lesions of this region may allow for planning minimally invasive surgical interventions. To be considered tumor from the broad ligament, it should not be connected with either the uterus or the ovary. Thus, the imaging approach to establish the differential diagnosis includes excluding an ovarian, uterine, or tubal origin by recognizing these separately and by rebutting imaging clues pointing to these origins. This pictorial essay reviews some of the imaging findings that may suggest such location and presents some of the possible differential diagnoses by means of illustrative confirmed cases.

Resumo Embora o envolvimento secundário do ligamento largo por tumores malignos abdominais e pélvicos seja comum, os tumores primários são raros. Os tumores do ligamento largo podem ser de natureza mesenquimal e mista, como o leiomioma, que é a neoplasia mais comum; tumores epiteliais do tipo mülleriano, constituindo um desafio diferenciá-los de outras massas anexiais; tumores únicos de origem mesonéfrica; e lesões tumor-like. A maioria das neoplasias nessa região, seja benigna ou maligna, geralmente apresenta-se com sintomas clínicos vagos, sendo frequentemente apenas descobertos durante exame ginecológico de rotina. A suspeita de tal localização e o conhecimento do potencial de lesões dessa região podem permitir o planejamento de intervenções cirúrgicas minimamente invasivas. Para ser considerado tumor do ligamento largo, este não deve de forma alguma estar relacionado com o útero, o ovário ou a trompa e, portanto, a abordagem radiológica do diagnóstico diferencial inclui excluir uma origem ovariana, uterina ou tubária, reconhecendo-os separadamente e refutando os sinais radiológicos apontando para essas origens. Este ensaio iconográfico revisa alguns dos achados radiológicos que podem sugerir tal localização e apresenta alguns dos possíveis diagnósticos diferenciais, por meio de casos ilustrativos confirmados.

Primary broad ligament adenocarcinoma

Primary broad ligament carcinoma is a very rare occurrence with 28 reported cases worldwide, to date. The epidemiology, treatment strategy and prognosis are still uncertain because of the scarcity of cases. Currently, all broad ligament carcinomas are managed similar to epithelial ovarian cancer. We report the case of a 43-year-old female with a prolonged complaint of abdominal pain and intermittent urinary retention, requiring frequent catheterization. She was diagnosed with obstructive right hydroureteronephrosis. The abdominal Contrast Enhanced Computed Tomography (CECT) revealed a well-defined heterogeneous lesion of 2.1х3х3.2cm size in the right lateral and posterior wall of the cervix. An ultrasound (USG)-guided Fine Needle Aspiration Cytology (FNAC) of the mass was done and it was suspected to be malignant. The patient underwent total abdominal hysterectomy, right salpingo-oophorectomy, pelvic lymph-nodal sampling, and peritoneal washing. Histological examination depicted an endometrioid adenocarcinoma of the broad ligament. She received adjuvant chemotherapy, followed by hormonal therapy. It has been five years since her surgery, and she is now alive and disease free.

Primary extraneural ependymoma of the broad ligament: A rare entity

Extraneural broad ligament ependymoma is a rare entity. Herein, we present a case of unusually large broad ligament ependymoma in a 32-year-old female with pain and lump in the lower abdomen. Contrast-enhanced computed tomography abdomen revealed multiple heterogeneously enhancing pelvic masses with lobulated surface in bilateral adnexa along with multiple peritoneal nodules. Her relevant serum tumor markers were unremarkable. Core biopsy revealed tumor composed of elongated cells arranged predominantly in true and pseudoperivascular rosettes. The histopathological differentials included ependymoma, primitive neuroectodermal tumor, and teratoma with neural differentiation. Results of immunohistochemistry favored the diagnosis of ependymoma. Surgical exploration and optimal cytoreduction were done, and a final diagnosis of primary broad ligament ependymoma with peritoneal metastasis was made. The patient received six cycles of adjuvant chemotherapy and is doing well after 8-month follow-up. The present case highlights the diagnostic workup and management of a rare and an unusually large broad ligament ependymoma with peritoneal metastasis

A case report on broad ligament fibroid mistaken as pregnancy

Leiomyoma is the commonest benign uterine condition arising from smooth muscles. Extra uterine leiomyoma is rare. The incidence of broad ligament fibroid is less than 1%. Because of its rarity broad ligament fibroid poses specific diagnostic difficulties causing an error in making the final diagnosis and therefore the management. Here we report a case of rare broad ligament fibroid got neglected sadly in this modern era, where the facilities like USG which can easily diagnose this rare entity are readily available. Presented as ANC with no labor pains and accidentally diagnosed as a case of huge broad ligament fibroid. Managed surgically by myomectomy with conservation of uterus and bilateral internal iliac artery ligation for minimizing bleeding.

Broad ligament term pregnancy in an unscarred uterus: misdiagnosis and the challenges

A broad ligament pregnancy is a rare condition, but full term broad ligamnet pregnancy especially in an unscarred uterus is extremely rare. It is often misdiagnosed and usually finally diagnosed during surgery. Here is case of full term broad ligament pregnancy, which remained undiagnosed throughout her pregnancy, unfortunately had IUFD. Patient was referred to our hospital in view of failure of induction with increased BP records. No ultrasound was available on admission. On clinical assessment it appeared as transverse lie with IUFD. So cesarean was decided as a mode of delivery. Emergency ultrasound could just confirm IUFD with pelvic mass? Fibroid (actually deviated uterus). On laparotomy the broad ligament pseudosac had occupied entire abdomen. After delivery of baby, anatomy was found completely distorted. Highly vascular omental adhesions on fundus with difficulty in placental removal. Placenta could be traced reaching abdomen posteriorly. The first clinical impression was suspicion of placenta percreta. Uterus appeared non salvageable and hysterectomy was decided. Placenta was found lying in abdomen, adhered to bowel, omentum and fundus of uterus. The final diagnosis of broad ligament pregnancy could be made after the cut section of the uterus and anatomic evaluation. Patient required blood transfusions preoperatively .She remained stable and discharged on postoperative day nine. This case holds importance because may be outcome was different if it was a booked and investigated pregnancy. May be baby and uterus were salvageable with better outcome.

Full term broad ligament pregnancy: a case report

A broad ligament pregnancy is extremely rare form of ectopic pregnancy with high maternal and perinatal mortality. The eventuality of such pregnancies reaching full term is even rarer. Although ultrasonography is helpful in making diagnosis, but it is mostly established during laparotomy. Our patient is an unbooked case, G2P1 reported to us at 39 weeks of pregnancy with abdominal pain. Ultrasonography showed viable foetus with severe intrauterine growth restriction (estimated fetal weight of 1.98 kg), transverse lie, severe oligohydramnios with complete placenta praevia. Patient was taken for caesarean section. Intraoperative diagnosis of left broad ligament pregnancy was made, foetus was removed alive and broad ligament along with placenta, left fallopian tube and ovary was excised. Post-operative period was uneventful.

Aggressive angiomyxoma of broad ligament: an uncommon mesenchymal tumor

Aggressive angiomyxoma is a rare mesenchymal tumor occurring predominantly in the pelviperineal region. Authors present a case of a 70 years female presented with history of distention of lower abdomen with recurrent pain since 6 months. On clinical examination there was suspicion of fibroid. On USG it was reported as huge fleshy, soft tissue mass measuring 20x10x9 cm in lower abdominal flanks and pelvis with vascular pedicle attached to right parametrium. Pan-hysterectomy was performed. Right broad ligament showed mass measuring 18.5x10x6 cm. On histopathological examination it was diagnosed as a case of Aggressive angiomyxoma of broad ligament. We are presenting this case for its extreme rarity, clinicohisto-pathological and radiological findings.

True broad ligament fibroid mimicking ovarian mass in a postmenopausal woman

Fibroids are benign smooth muscle tumors. Large fibroids are known to arise from the uterus, but occasionally from the broad ligament.  Here, we report a case of true broad ligament fibroid which is rare and difficult to diagnose in a 57 year old postmenopausal women with a large mass of 24 weeks size gravid uterus. Patient presented with pain lower abdomen and mass in abdomen with no other co-morbidity. This broad ligament fibroid was mimicking as ovarian tumor on ultrasonography and MRI as left ovary was not visualised separately, thus leading to diagnostic dilemma of ovarian malignancy. Mass resection with total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed. No local or distant metastasis observed, and Histopathology showed true broad ligament fibroid of left side weighing 3.57 kilograms.

A case report on ruptured interstitial ectopic pregnancy: diagnostic dilemma

The ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Interstitial ectopic pregnancies are gestations that implant within the proximal, intramural portion of the fallopian tubes with high vascularity. Ectopic pregnancy in the interstitial part of the fallopian tubes can be life-threatening considering the thin myometrial tissue surrounding the gestational sac and high vascularization which may result in catastrophic haemorrhage when interstitium is ruptured. Being a hazardous type of ectopic pregnancy, it becomes extremely important to diagnose and manage it. This condition presents a challenge for clinical as well as radiological diagnosis. Generally, a case of interstitial ectopic pregnancy has typical radiological features distinguishing it from other ectopic. The ultrasonographic finding of interstitial line has better sensitivity (80%) and specificity (98%) than eccentric gestational sac location (sensitivity, 40%; specificity, 88%) and myometrial thinning (sensitivity, 40%; specificity, 93%) for the diagnosis of interstitial ectopic pregnancy. Ultrasound is the mainstay of diagnosis, but magnetic resonance imaging can be helpful in unusual or complicated cases. Interstitial ectopic pregnancy rupturing into the leaves of broad ligament and creating a tamponade effect to alter the clinical presentation is a rare event which presents as a diagnostic challenge. Here authors present a case of ruptured interstitial ectopic pregnancy confined to the leaves of broad ligament, with atypical presentation and radiological features which led to difficulty in diagnosing the interstitial ectopic pregnancy. After laparoscopic confirmation of ruptured interstitial ectopic pregnancy, the patient was managed successfully by laparoscopic cornual resection.

Broad ligament ectopic pregnancy: a dilemma to diagnose

Broad ligament ectopic pregnancy is a rare and serious form of extrauterine pregnancy with a high risk of maternal mortality. There are no specific clinical features. Ultrasonography may help in diagnosis, but definitive diagnosis is made only during surgery. Authors are reporting a case of 30 years female G3P1L1A1 seven weeks pregnancy with previous lower segment cesarean section and previous history of right sided salpingectomy with no complaints. Ultrasound was advised to know the location of sac this time, in which, she was diagnosed as a case right sided unruptured live ovarian ectopic pregnancy. On examination, signs and symptoms of ectopic pregnancy were absent. On laparoscopy, she was diagnosed as a case of right sided live unruptured broad ligament ectopic pregnancy as her right ovary was absent because of previous surgery.  With advances in sonography and laparoscopic skills, more cases can be diagnosed in the first trimester and can be safely managed laparoscopically.

Internal Hernia through a Defect in the Broad Ligament of Uterus: Laparoscopic Management Using a Self-Anchoring Barbed Suture

The occurrence of internal hernia through a defect in the broad ligament is a very rare condition, which may cause small bowel obstruction. This is a case of a 50-year-old woman who developed intestinal obstruction induced by internal hernia and who had undergone laparoscopic myomectomy 7 years prior to visiting our emergency room. Abdominopelvic computed tomography showed luminal narrowing of the ileum and dilatation of the pelvic loop of the small bowel at the left side of the uterus. We detected internal hernia through the defect in the broad ligament and managed it successfully by performing a laparoscopic procedure using a barbed suture, V-Loc (Covidien, Mansfield, MA).

Rare huge serous cystadenoma of broad ligament: A case report and literature review / 吉林大学学报(医学版)

Objective: To analyze the clinical data and surgical treatment procedures of a patient vyith rare huge serous cystadenoma of broad ligament, to clarify its diagnostic and treatment characteristics, and to explore the present situation and advantages of laparoscope in the operation of broad ligament tumor. Methods: The patient vyas admitted to hospital due to abdominal distension for 2 years and aggravated ulness for 2 months. The diagnosis result vyas pelvic and abdominal mass arising from ovarian according to the preoperative color Doppler ultrasound and physical examination. Based on the laparotomy and intraoperative rapid pathological results, the patient was diagnosed as huge serous cystadenoma of broad ligament. The location of ureter and uteri artery and vein were carefully identified during the operation and they were ligated for hemostasis at the basal part of tumor. The operation was successful Results: The ultrasonography image of the huge serous cystadenoma of broad ligament was very similar to that of large ovarian tumor. The misdiagnosis rate of ultrasound was high, and CT and MRI were important for the identification of large broad ligament tumor; the accuracy rate of preoperative diagnosis could be improved by CT and MRI Carefully blunt separation close to the tumor surface during the operation could avoid the ureteral injury. The patient recovered well and discharged from hospital. Conclusion: The symptoms of huge serous cystadenoma of broad ligament patient are lack of specificity. The accuracy rate of preoperative diagnosis should be improved in combination with the medical history and imageological findings of the patient The operation plan should be chosen reasonably and the operation should be carefully performed to avoid the occurrence of secondary injuries.

Pathological features of spindle cell tumor of the uterine and broad ligament in 145 cases / 中国医师进修杂志

Objective To explore the types, clinical pathologic and immunohistochemical features of spindle cell tumors of the uterine and broad ligament. Methods Clinical pathological files of spindle cell tumors in the uterine and broad ligament from 2007.12 to 2015.12 were reviewed. Results The primary sites of the 145 cases was cervical in 11 cases (7.58%), uterine body in 119 cases (82.07%), the broad ligament in 12 cases (8.28%), and uterine or cervix and the abdominal wall in 3 case (2.07%). Histopathological types of the 145 cases was smooth muscle origin in 126 cases (86.90%), of which 120 cases had benign leiomyoma, 3 cases had uncertain malignant potential and 3 cases had leiomyosarcoma;endometrial stromal origin in 15 cases (10.34%), including endometrial stromal nodule (5 cases), endometrial stromal sarcoma (10 cases); endometrial stromal- variant (3 cases, 2.07%), including endometrial stromal nodule associated with smooth muscle differentiation (2 cases), endometrial stromal sarcoma associated with smooth muscle differentiation (1 case); gastrointestinal stromal tumor (1 case, 0.68%). Conclusions Origin of spindle cell tumors of the uterine and broad ligament is mainly smooth muscle, endometrial stromal origin, and endometrial stromal tumor variants, and gastrointestinal stromal tumors in rare cases. We need to combine the clinical site, pathological morphology and immunohistochemistry for diagnosis and differential diagnosis.

Lipoleiomyoma of the left broad ligament with dermoid cyst in ipsilateral ovary and synchronous multiple benign lesions of female genital tract: An unusual association.

Lipoleiomyoma of the uterus is a rare variant of leiomyoma, and lipoleiomyoma of the broad ligament is still rarer, with only a handful of cases being reported. The present case was a perimenopausal woman who presented with a huge lower abdominal mass. Ultrasonography and computed tomography showed a heterogeneous solid mass in the left adnexa. The histopathological findings confirmed the nature of the lesions as a benign lipoleiomyoma with dermoid cyst of the left ovary and its other associated benign lesions, were the interesting features seen in this case which were not suspected clinically and radiologically.

Candida Haemulonii : An Emerging Pathogen in Immunocompromised Patient Showing Resistance to Azoles and Susceptibily to Echinocandins.

Emergence of a new species of non-albicans Candida species in Immunocompromised patient is a very alarming and life threatening trend. Accurate identification and prompt treatment in such patients is necessary to curtail mortality. Candida haemulonii as the name suggests is mostly isolated from blood culture. Susceptibility pattern of such isolates is important as most of them are not susceptible to the commonly used azole group of drugs rather they are susceptible to newer drugs like echinocandins. In such patient automated blood culture and susceptibility should be preferred over conventional blood culture so that early diagnosis and treatment can to some extent decrease the percentage of mortality.

Primary Broad Ligament Pregnancy: A Case Report

Primary broad ligament pregnancy is a rare form of extrauterine pregnancy with a high maternal and perinatal mortality. Early diagnosis is important to prevent life threatening hemorrhage but can be missed on antenatal ultrasonography. The diagnosis is usually established during laparotomy. We present a case of 22 year old female with ectopic gestation in broad ligament which was missed on ultrasonography and diagnosed during surgery.

Internal hernia of the Broad Ligament leading to acute intestinal obstruction: a case report.

Acute intestinal obstruction is a frequently encountered surgical emergency but cases arising from internal herniation through the broad ligament are very rare. We report a case of a middle aged lady with intestinal obstruction due to internal herniation of small bowel through the right side of broad ligament and managing her successfully by timely and immediate surgical intervention.

Síndrome de Allen Master: causa excepcional de abdomen agudo en el embarazo / Allen Master syndrome: exceptional cause of acute abdomen in pregnancy

Se presenta un caso de abdomen agudo en una gestante de 20 semanas, por una torsión anexial. Ante la ausencia de signos ecográficos compatibles con patología en los primeros momentos y el empeoramiento clínico, se solicitó una RMN que permitió la aproximación diagnóstica y facilitó la indicación urgente de cirugía abdominal. En el curso de la laparotomía se diagnosticó una hernia interna del anexo, con marcado componente vascular a través de un defecto del ligamento ancho, que obligó a la anexectomía. Tras el diagnóstico y el tratamiento realizado, la gestación continúa con buenos resultados materno-fetal. Estos orificios han sido presentados excepcionalmente como causa de hernias internas digestivas, urológicas y anexiales, siendo controvertido su origen, congénito, inflamatorio o traumático. Se repasan las pruebas complementarias indicadas en el manejo diagnóstico del dolor abdominal en el embarazo, incluyendo las últimas recomendaciones de la European Society of Urogenital Radiology-ESUR.

A case of acute abdomen in a pregnant 20 weeks is presented with an adnexal torsion. In the absence of pathologic ultrasound signs with in the early stages and clinical worsening, was requested an MRI that allowed the diagnostic approach and the indication for urgent abdominal surgery. During laparotomy was observed an internal adnexal hernia through a defect in the broad ligament, with marked vascular component which forced the adnexectomy. After the diagnosis and treatment performed, the pregnancy continues with good maternal and fetal outcomes. These defects were presented exceptionally as a cause of digestive, urological and adnexal internal hernias. The origin remains controversial, congenital, inflammatory or traumatic. Complementary tests in the diagnostic management of abdominal pain in pregnancy are reviewed, including the latest recommendations of the European Society of Urogenital Radiology-ESUR.