Importância do diagnóstico por imagem em pacientes com sangramento uterino anormal / Importance of diagnostic imaging in patients with abnormal uterine bleeding

O sangramento uterino anormal é diagnóstico sindrômico comum no consultório do ginecologista e pode comprometer substancialmente a qualidade de vida. O objetivo no diagnóstico de sangramento uterino anormal é distinguir pacientes com causas estruturais (anatômicas), como pólipo, adenomiose, leiomioma, malignidade e hiperplasia, de pacientes que apresentam anatomia normal, nas quais o sangramento pode ser devido a alteração dos mecanismos de coagulação, distúrbios ovulatórios, distúrbios primários do endométrio, iatrogenia, ou ter outra causa não classificada. O diagnóstico se inicia a partir de anamnese detalhada e exame físico geral e ginecológico completos, seguidos da solicitação de exames complementares (laboratoriais e de imagem), conforme indicado. O exame de imagem de primeira linha para identificação das causas estruturais inclui a ultrassonografia pélvica. Histerossonografia, histeroscopia, ressonância magnética e amostragem endometrial para exame de anatomia patológica são opções que podem ser incluídas no diagnóstico a depender da necessidade. O objetivo deste artigo é apresentar a relevância dos exames de imagem na investigação das causas de sangramento uterino anormal.

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office and may substantially affect quality of life. The aim in the diagnosis of abnormal uterine bleeding is to distinguish women with anatomic causes such as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia from women with normal anatomy where the cause may be coagulopathy, ovulatory disorders, endometrial, iatrogenic and not otherwise classified. Diagnosis begins with a thorough history and physical examination followed by appropriate laboratory and imaging tests as indicated. The primary imaging test for the identification of anatomic causes include ultrasonography. Saline infusion sonohysterography, magnetic resonance, hysteroscopy, endometrial sampling are options that can be included in the diagnosis depending on the need. The aim of this article is to present the relevance of imaging exams in the investigation of the causes of abnormal uterine bleeding.

Leiomioma ovárico primario

El leiomioma es un tumor mesenquimal benigno común que puede desarrollarse allí donde haya músculo liso; raro como tumor ovárico primario, su origen aún es controversial. El leiomioma ovárico primario es uno de los tumores benignos más raros del ovario, representa 0,5% a 1% de los tumores benignos y suele observase en mujeres entre 20 y 65 años. Generalmente, son asintomáticos y se les encuentra de forma incidental durante el examen pélvico o la cirugía por otra causa, pero en ocasiones puede manifestarse por dolor abdominal y masa palpable. El diagnóstico definitivo es difícil antes de la extirpación quirúrgica. Debido a que no existen síntomas patognomónicos ni tiene imágenes características, los principales diagnósticos diferenciales incluyen fibroma, tecoma, tumor estromal esclerosante y leiomiosarcoma. La tinción inmunohistoquímica es fundamental para el diagnóstico preciso y debe considerarse en el diagnóstico diferencial de los tumores ováricos de células fusiformes. Se presenta un caso de leiomioma ovárico primario.

Leiomyoma is a common benign mesenchymal tumor that can develop wherever smooth muscle is present; rare as a primary ovarian tumor, its origin is still controversial. Primary ovarian leiomyoma is one of the rarest benign ovarian tumors, accounting for 0.5% 1% of benign tumors and is usually seen in women between 20 and 65 years of age. They are usually asymptomatic and appear incidentally during a pelvic examination or surgery for another cause but can occasionally manifest by abdominal pain and palpable mass. Definitive diagnosis is difficult before surgical removal. Because there are no pathognomonic symptoms and no characteristic imaging, the main differential diagnoses include fibroma, thecoma, sclerosing stromal tumor and leiomyosarcoma. Immunohistochemical staining is essential for accurate diagnosis and should be considered in the differential diagnosis of ovarian spindle cell tumors. A case of primary ovarian leiomyoma is presented.

Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning / Relato de miomas uterinos em exames de ultrassonografia: um modelo de relatório ilustrado com foco no planejamento cirúrgico

Abstract Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Resumo Os miomas uterinos são os tumores ginecológicos benignos mais comuns em mulheres em idade reprodutiva, sendo a ultrassonografia a modalidade de imagem de primeira linha para seu diagnóstico e caracterização. A Federação Internacional de Ginecologia e Obstetrícia desenvolveu um sistema para descrever e classificar os miomas uterinos de forma uniforme e consistente. Uma descrição precisa dos miomas no laudo ultrassonográfico é essencial para o planejamento do tratamento cirúrgico e prevenção de complicações. Neste artigo, revisamos os achados ultrassonográficos de miomas, detalhando os principais pontos a serem relatados para avaliação pré-operatória. Além disso, propomos um modelo de relatório estruturado e ilustrado para descrição de miomas, com base nos pontos críticos para o planejamento cirúrgico.

Torsión uterina causada por miomatosis: reporte de un caso / Uterine torsion caused by myomatosis: A case report

Resumen ANTECEDENTES: La torsión uterina es una rotación del útero sobre su eje mayor de más de 45°; por lo general sucede en torno del istmo uterino. Los leiomiomas son el factor predisponente más frecuente en úteros no grávidos. OBJETIVO: Reportar el caso de una paciente con torsión uterina cervical y miomatosis de grandes elementos. CASO CLÍNICO: Paciente de 42 años, nuligesta, con antecedente de miomatosis uterina de grandes elementos de 27 x 27 cm. Los síntomas se iniciaron con síndrome doloroso abdominal intenso, tipo cólico, localizado en el hipogastrio y la fosa iliaca. En la exploración física el abdomen se percibió doloroso a la palpación superficial y profunda, con una tumoración cercana a la cicatriz umbilical (25 cm), móvil y dolorosa. En la laparotomía exploradora se encontró líquido peritoneal hemorrágico y se observó una torsión uterina (una vuelta) cerca del cuello del útero, además de un mioma subseroso en la cara posterior, de 27 x 27 cm. El útero, los anexos y las salpinges se advirtieron con datos francos de daño vascular, con áreas de isquemia. Por lo anterior se decidieron la histerectomía total abdominal y la salpingooforectomia bilateral. El informe histopatológico reportó: útero con cambio isquémico extenso panmural, sin evidencia de neoplasia maligna. CONCLUSIONES: El dolor abdominal es el síntoma más común de la torsión uterina que puede variar de leve a agudo. El diagnóstico preoperatorio rápido y preciso de torsión uterina es decisivo y se justifica la intervención quirúrgica de urgencia.

Abstract BACKGROUND: Uterine torsion is a rare entity that is defined as a rotation of the uterus on its major axis of more than 45°, generally occurring at the level of the uterine isthmus. Leiomyomas are the most frequent predisposing factor in non-gravid uterus. OBJECTIVE: Report of a case of a gynecological patient with uterine torsion at the cervical level in a uterus with uterine myomatosis of large elements. CLINICAL CASE: A 42-year-old patient, nulliparous, with a history of uterine myomatosis with large elements of 27 x 27 cm. The symptoms began with intense abdominal pain syndrome, colic type, located in the hypogastrium and the iliac fossa. On physical examination, the abdomen was perceived as painful on superficial and deep palpation, with a mobile and painful tumor close to the umbilical scar (25 cm). In the exploratory laparotomy, hemorrhagic peritoneal fluid was found and a uterine torsion (one turn) was observed near the cervix, as well as a subserous myoma on the posterior face, measuring 27 x 27 cm. The uterus, the annexes and the salpinges were noted with frank data of vascular damage, with areas of ischemia. Therefore, total abdominal hysterectomy and bilateral salpingo-oophorectomy were decided. The histopathological report reported: uterus with extensive panmural ischemic change, without evidence of malignancy. CONCLUSIONS: In uterine torsion, abdominal pain is the most common symptom and can range from mild to severe abdominal symptoms. Therefore, a prompt and accurate preoperative diagnosis of uterine torsion is crucial and urgent surgical intervention is warranted.

Leiomioma submucoso de gran tamaño: una presentación inusual. Reporte de Caso / Large submucosal leiomyoma: an unusual presentation

Se ha postulado que más del 70 % de las mujeres antes de la menopausia son diagnosticadas de leiomiomas; de estas un 25 % presentan sintomatología grave. La ecografía es la modalidad de imagen de primera elección para su estudio. Se tiene registros de progresión de leiomiomas a leiomiosarcomas, que conllevan a un mal pronóstico y son responsables de una cuarta parte de las muertes por neoplasias uterinas, con una sobrevida a 5 años que van desde 46-53 %, lo cual incentiva el diagnóstico precoz y eficaz de masas uterinas. El caso reportado es una presentación inusual de un leiomioma de gran tamaño, que por los hallazgos de imagen se reportó como una neoplasia maligna, su aspecto macroscópico totalmente atípico reforzaba la sospecha imagenológica. Solo se pudo determinar el diagnóstico definitivo mediante estudio histopatológico posterior a histerectomía. Las evaluaciones ginecológicas de rutina deben incluir exámenes especializados de imagen pélvica, la ausencia de presentación típica o síntomas característicos de una patología no debe ser motivo para obviar exámenes complementarios que permitan un diagnóstico oportuno y tratamiento eficiente de leiomiomas, incluso en casos de presentaciones inusuales y desafiantes para el diagnóstico, como el que se ha reportado en esta obra.

It has been postulated that more than 70% of premenopausal women are diagnosed with leiomyomas; Of these, 25% have severe symptoms. Ultrasound is the imaging modality of choice for its study. There are reports of progression from leiomyomas to leiomyosarcomas, which leads to a poor prognosis, and is responsible for a quarter of deaths from uterine neoplasms, with a 5-year survival ranging from 46-53%; this should encourage early and effective diagnosis of uterine masses. The reported case is an unusual presentation of a large leiomyoma, which due to its imaging characteristics, was reported as a malignant neoplasm. Its completely atypical macroscopic appearance reinforced the imaging diagnosis suspicion. The definitive diagnosis could only be determined by histopathological study after hysterectomy. Routine gynecological evaluations should include specialized pelvic imaging exams, the absence of a typical presentation or characteristic symptoms of a pathology should not be a reason to obviate ancillary testing that would allow a timely diagnosis and effective treatment of leiomyomas, even in unusual and challenging presentations, such as with the patient in this case report.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids / Embolização de miomas uterinos com microesferas calibradas de alta compressibilidade

Abstract Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Resumo Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Urethral leiomyoma: combined vaginal and abdominal approach - a case report / Mioma uretral: abordagem combinada vaginal e abdominal - um relato de caso

Abstract Introduction: leiomyomas are benign mesenchymal tumors of smooth muscle origin that can develop in various locations. Urethral leiomyomas are rare, with approximately only 120 cases reported in the literature. These tumors often occur in the third and fourth decades of life but are rare in menopausal patients. In general, treatment involves surgery, only three recurrence reports in the literature. Description: a case report on a 56-year-old woman; the patient had type II diabetes mellitus and chronic high blood pressure, was overweight (body mass index, 27.1 kg/m2), and a smoker. Besides this, the patient presented symptoms of urinary obstruction and had a large urethral leiomyoma. The tumor was completely removed with no associated urethral lesions using a complex, combined abdominalvaginal surgical approach. Discussion: the management and treatment on urethral leiomyomas is challenging and have not been established yet due to the rarity of these tumors.

Resumo Introdução: os leiomiomas são tumores mesenquimais benignos de origem muscular lisa, podendo manifestar-se em diversas localizações. Os leiomiomas uretrais são raros, tendo apenas aproximadamente 120 casos relatados na literatura. São mais comuns na terceira e quarta décadas de vida, sendo raros em pacientes menopausadas. Em geral, são tratados cirurgicamente, com apenas três relatos de recidivas na literatura. Descrição: relato de caso de uma paciente do sexo feminino, 56 anos, portadora de diabetes mellitus do tipo II, hipertensão arterial crônica, sobrepeso (IMC 27,1Kg/m2) e tabagismo. Além disso, com quadro de sintomas obstrutivos urinários e portadora de um grande leiomioma uretral, este que foi completamente removido, através de uma desafiadora abordagem cirúrgica combinada (abdominal e vaginal), sem lesões uretrais associadas. Discussão: os leiomiomas uretrais são tumores raros e seu manejo é desafiador e ainda não foi estabelecido.

Angioleiomioma en cavidad oral «una neoplasia rara en un sitio poco común¼. Reporte de un caso y revisión de la literatura / Angioleiomyoma in the oral cavity «a rare neoplasm in an unusual site¼. Case report and literature review

El angioleiomioma (AL) es una neoplasia benigna, bien circunscrita y de crecimiento lento, que representa 5% de las neoplasias de tejidos blandos y cuya etiología es desconocida. Se origina del músculo liso, mayormente de las paredes de los vasos sanguíneos; su localización es más frecuente en extremidades, siendo raros en la región de cabeza y cuello, y más aún en cavidad bucal. Histológicamente la lesión se caracteriza por ser un nódulo bien encapsulado con proliferación de fascículos de músculo liso maduro alrededor de la luz de los vasos sanguíneos, cuyas células suelen ser positivas a marcadores de inmunohistoquímica como alfa actina de músculo liso, desmina, HHF35, miosina, calponina y H-caldesmon. El tratamiento actual es la escisión quirúrgica completa con una tasa de recurrencia prácticamente nula. El objetivo es resaltar la importancia del diagnóstico y el manejo correcto de las lesiones intraorales a través de la presentación de un caso clínico de un leiomioma vascular localizado en región nasolabial, además de hacer la revisión de la literatura correspondiente (AU)

The angioleiomyoma (AL) is a benign neoplasm, well circumscribed and slow growing, that represents 5% of the soft tissue neoplasms, whose etiology is unknown. It originates from smooth muscle, mostly from the walls of blood vessels; regarding its location, it more frequently appears in the extremities, being rare in the head and neck region, and even more so in the oral cavity. Histologically, the lesion is characterized by being a well encapsulated nodule with proliferation of mature smooth muscle bundles around the lumen of the blood vessels, whose cells are usually positive for immunohistochemical markers such as alpha smooth muscle actin, desmin, HHF35, myosin, calponin and H-caldesmon. The current treatment is complete surgical excision having zero recurrence rate. The objective of the following article is to educate on the importance of correct diagnosis and management of intraoral lesions through the presentation of a clinical case of a vascular leiomyoma located in the nasolabial region, in addition to reviewing the corresponding literature (AU)

Leiomioma disecante cotiledóneo del útero / Cotyledonoid dissecting leiomyoma of the uterus

RESUMEN Los tumores benignos de músculo liso son los tumores más frecuentes en el aparato genital femenino. El leiomioma disecante cotiledóneo del útero es una variante rara de leiomioma benigno, que presenta patrones de crecimiento inusuales y comparte algunas características con otras variantes de leiomioma disecante. Tiene un patrón de crecimiento inusual caracterizado por disección intramural dentro del miometrio y con apariencia similar de sus componentes extrauterinos a los cotiledones placentarios. Su aspecto sarcomatoide y carácter inusual dan la impresión de malignidad. El diagnóstico se realiza por los hallazgos histopatológicos característicos de la lesión. Se presenta un caso de leiomioma disecante cotiledóneo del útero.

ABSTRACT Benign smooth muscle tumors are the most common tumors in the female genital tract. Cotyledonoid dissecting leiomyoma of the uterus is a rare variant of benign leiomyoma, which presents unusual growth patterns and shares some features with other variants of dissecting leiomyoma. It has an unusual growth pattern characterized by intramural dissection within the myometrium and with similar appearance of its extrauterine components to placental cotyledons. Its sarcomatoid appearance and unusual character give the impression of malignancy. The diagnosis is made by the characteristic histopathologic findings of the lesion. A case of cotyledonoid dissecting leiomyoma of the uterus is presented.

Leiomioma primario de páncreas en una gestante: presentación de caso / Primary pancreatic leimyoma in a pregnant woman: case report

RESUMEN Introducción: Los tumores pancreáticos en el embarazo son muy raros, el diagnóstico y tratamiento en este grupo de pacientes es complejo. Objetivo: Presentar el primer caso de un leiomioma primario del páncreas en una gestante. Caso clínico: Embarazada de 26 años de edad, sin antecedentes relevantes. Primigesta, que se encontraba cursando la semana 13 de gestación. Durante una evaluación ecográfica de rutina, se le detecta una tumoración en la glándula pancreática. Se remitió a la consulta multidisciplinaria de atención a la materna y en conjunto deciden realizar la interrupción voluntaria del embarazo. Luego la paciente fue remitida a la consulta de la especialidadde Cirugía General. Al recibir a la misma, se quejaba de dolor en epigastrio e hipocondrio izquierdo, además de hipo ocasional. Al examen físico se encontró una tumoración palpable en epigastrio. Se realizaron exámenes analíticos básicos sin encontrarse alteraciones, en los estudios de imagen realizados, ecografía abdominal y tomografía contrastada de abdomen se demostró una tumoración en el cuerpo y cola del páncreas. Se planificó tratamiento quirúrgico electivo, se realizó pancreatectomía distal con esplenectomía, por invasión del estómago, se complementó con gastrectomía subtotal. La paciente evoluciona sin complicaciones. La biopsia informó un tumor mesenquimal benigno primario de páncreas, tipo leiomioma, bien encapsulado. Conclusiones: Se presenta el primer caso de un leiomioma primario del páncreas en una gestante. Los tumores pancreáticos en embarazadas son enfemedades raras, el manejo por un equipo multidisciplinario es la mejor forma de obtener resultados satisfactorios para la paciente.

ABSTRACT Introduction: Pancreatic tumors during pregnancy are very rare, diagnosis and treatment are always difficult. Objective: To present the first case of a primary pancreatic leiomyoma in a pregnant woman. Case report: A 26 years old primiparous pregnant is reported, with no relevant backgrounds. She was in her first trimesters of pregnancy. Diagnosed with a pancreatic tumor during a routine evaluation. She was referred to a multidisciplinary consult, deciding the voluntary interruption of pregnancy, then she is evaluated by the General Surgery specialty clinic for complaining of epigastric pain and hiccup. On physical examination an epigastric tumor was found. Auxiliary exams were normal. Imagenologic studies confirm a tumor in the pancreatic body and tail. Surgical treatment was scheduled, distal pancreatectomy with splenectomy, due to invasion of gastric wall subtotal distal gastrectomy was performed. Patient evolution without complications. Biopsy reported a well capsulated, leiomyoma type, primary mesenchymal pancreatic tumor. Conclusions: The first case of a primary pancreatic leiomyoma in a pregnant woman is presented. Pancreatic tumors during pregnancy are rare. Multidisciplinary approach is the best way to improve results.

Leiomioma parasitario retroperitoneal: reporte de un caso / Retroperitoneal parasitic leiomioma: A case report

Resumen ANTECEDENTES: Los leiomiomas parasitarios son una variante poco común de la miomatosis uterina. Se han identificado en la pared abdominal, intestino delgado, muñón cervical o vaginal, vasos iliacos, ovarios, colon sigmoides y en el omento mayor. OBJETIVO: Reportar un caso clínico de leiomioma parasitario retroperitoneal y revisar la bibliografía al respecto. CASO CLÍNICO: Paciente de 57 años, con diagnóstico de NIC-III y hemorragia uterina anormal. Acudió a consulta debido a una sensación de masa y dolor abdominal, pérdida de peso subjetiva, hiporexia, disfagia y plenitud gástrica de cuatro meses de evolución. En los estudios de extensión se documentó una masa retroperitoneal grande y elevación de los marcadores tumorales Ca 125 y Ca 19-9. La resección de la masa se efectuó mediante laparotomía, con hallazgo histopatológico de mioma parasitario. CONCLUSIÓN: Los leiomiomas parasitarios deben considerarse en el diagnóstico diferencial de pacientes con antecedente de histerectomía o miomectomía, sobre todo en el contexto de la morcelación. El tratamiento consiste en cirugía o inhibidores de la aromatasa y análogos de la hormona liberadora de gonadotropina (leiomiomatosis peritoneal diseminada).

Abstract BACKGORUND: Parasitic leiomyomas are a rare entity, defined as an unusual variant of uterine myomatosis. Have been documented in the abdominal wall, small intestine, cervical or vaginal stump, iliac vessels, ovaries, sigmoid colon, and greater omentum. OBJECTIVE: To report a clinical case of retroperitoneal parasitic leiomyoma and review the literature. CLINICAL CASE: A 57-year-old patient with a diagnosis of CIN-III and secondary abnormal uterine bleeding, who consulted for a sensation of abdominal mass and pain, subjective weight loss, hyporexia, dysphagia and gastric fullness, of four months of evolution. Extension studies document a large retroperitoneal mass and elevation of tumor markers Ca 125 and Ca 19-9. We practice surgical management of her gynecological pathology and resection of the mass by laparotomy, with histopathological finding of myoma. CONCLUSION: Parasitic leiomyomas should be suspected in patients with a detected mass and a history of hysterectomy or myomectomy, especially in the context of morcellation. The treatment of this condition is surgical and, in cases of disseminated peritoneal leiomyomatosis, pharmacological treatments have been used with aromatase inhibitors and gonadotropin-release hormone analogues.

Tratamiento laparoscópico de una paciente con un leiomioma uterino gigante cavitado, con cambio degenerativo mucomixoide / Laparoscopic treatment of a patient with a cavitated giant uterine leiomyoma with mucomyxoid degenerative change

Resumen INTRODUCCIÓN: Un leiomioma con cambios degenerativos poco frecuentes es un desafío diagnóstico difícil de diferenciar de sus homólogos malignos, si se pretende fundamentarlo solo en lo advertido en las imágenes. CASO CLÍNICO: Paciente de 40 años de edad, enviada al servicio de Cirugía de mínima invasión en marzo del 2021 debido al aumento del perímetro abdominal, disminución del apetito y disnea de medianos esfuerzos. El ultrasonido abdomino-pélvico reportó que el útero estaba aumentado de tamaño, con miomas intramurales de medianos elementos. El endometrio heterogéneo. El ovario derecho tenía un quiste complejo, gigante, de 276 mm x 250 mm x 276 mm, con volumen de 10 000 cc. Además, esplenomegalia, hidronefrosis derecha y litiasis renal izquierda. Los marcadores tumorales se reportaron normales. En la cirugía por laparoscopia se observó un tumor que ocupaba toda la cavidad abdominal de 40 x 30 cm, adherido a la pared posterior del útero, con ambos ovarios sin alteraciones, sin líquido libre; se procedió a la histerectomía total. CONCLUSIONES: Los cambios degenerativos en los leiomiomas uterinos pueden distorsionar la estructura habitual del tumor y reflejarla en imágenes típicas de una tumoración quística de ovario; en el estudio inicial esto representa un desafío para el cirujano y debe considerarse parte del diagnóstico diferencial de las masas anexiales. En la paciente del caso, con cirugía de mínima invasión, se consiguió la resección completa de la pieza, a pesar del tamaño aumentado, con menores riesgos de complicaciones en la herida y menos dolor posoperatorio; las incisiones son pequeñas y con desenlaces estéticos favorables y menos días de estancia intrahospitalaria.

Abstract INTRODUCTION: A leiomyoma with rare degenerative changes is a diagnostic challenge difficult to differentiate from its malignant counterparts, if it is intended to be based only on imaging findings. CLINICAL CASE: 40-year-old female patient referred to the Minimally Invasive Surgery service in March 2021 due to increased abdominal perimeter, decreased appetite and dyspnea on medium exertion. Abdomino-pelvic ultrasound reported that the uterus was enlarged, with medium-element intramural fibroids. The endometrium was heterogeneous. The right ovary had a complex, giant cyst, 276 mm x 250 mm x 276 mm, with a volume of 10,000 cc. In addition, splenomegaly, right hydronephrosis and left renal lithiasis. Tumor markers were reported normal. Laparoscopic surgery showed a tumor occupying the entire abdominal cavity measuring 40 x 30 cm and attached to the posterior wall of the uterus, with both ovaries unaltered, with no free fluid; total hysterectomy was performed. CONCLUSIONS: Degenerative changes in uterine leiomyomas can distort the usual tumor structure and reflect it in images typical of an ovarian cystic tumor; in the initial study this represents a challenge for the surgeon and should be considered part of the differential diagnosis of adnexal masses. In the case patient, with minimally invasive surgery, complete resection of the specimen was achieved, despite the increased size, with less risk of wound complications and less postoperative pain; the incisions are small and with favorable esthetic outcomes and fewer days of in-hospital stay.

Gran mioma uterino: manejo prequirúrgico con uso de agonistas de gnrh: reporte de un caso / Large uterine myoma: presurgical management with the use of gnrh agonists: case report

Introducción: Los leiomiomas uterinos son los tumores pélvicos benignos más comunes entre las mujeres. Se estima que 60% de las mujeres llegan a tener miomatosis a lo largo de la vida (1). La necesidad de tratamiento médico y/o quirúrgico es muy importante de evaluar, ya que los fibromas son una fuente importante de morbilidad ginecológica. Objetivos: Describir el caso de un gran mioma uterino con manejo prequirúrgico de análogos de GnRH, analizando los hallazgos obtenidos en el caso según la evidencia actual. Discusión: Se reporta el caso de una mujer de 29 años sin antecedentes mórbidos conocidos, con presencia de una gran masa abdominal, motivo por el cual se realizó una ecotomografía abdominal que evidenció una masa sugerente de un gran mioma uterino subseroso. Se realizó miomectomía vía laparotomía previo tratamiento médico con análogos de GnRH. Actualmente la frecuencia de miomas de gran tamaño es poco frecuente, por lo que se busca discutir el impacto del tratamiento médico previo a la cirugía en mujeres jóvenes. Conclusiones: La experiencia con el uso prequirúrgico de agonistas de GnRH indica una ventaja en el trabajo bien definida y su uso como tratamiento coadyuvante a la cirugía está bien establecido. Sin embargo, se debe tener en cuenta la posibilidad de recurrencia de los miomas

Introduction: Uterine leiomyomas are the most common benign pelvic tumors in women. It is estimated that 60% of women develop myomatosis throughout life (1). The need for medical and / or surgical treatment is very important to assess, since fibroids are an important source of gynecological morbidity. Objectives: To describe the case of a large uterine myoma with presurgical management of GnRH analogues and to summarize updated evidence on their use. Discussion: The case of a 29-year-old woman with no known morbid history is reported, with the presence of a large abdominal mass, which is why an abdominal ultrasound scan was performed, which revealed a mass suggestive of a large subserous uterine myoma. Myomectomy was performed via laparotomy after medical treatment with GnRH analogues. Currently, the frequency of large fibroids is rare, so we seek to discuss the impact of medical treatment prior to surgery in young women. Conclusions: Experience with the presurgical use of GnRH agonists indicates a well-defined treatment advantage and its use as adjunctive treatment to surgery is well established. However, the possibility of recurrence of fibroids should be taken into account

Tumores gástricos peculiares: tumor glómico, schwannoma, leiomioma y cistoadenoma en el páncreas ectópico. Serie de casos y revisión de la literatura / Unusual gastric tumors: Glomus tumor, schwannoma, leiomyoma, and cystadenoma in ectopic pancreas. A case report and literature review

Resumen Introducción: la patología gástrica es excepcionalmente benigna, se registra a nivel mundial un porcentaje de aparición de las mismas del 0,005 %-4 %. Además de lo anterior, suele plantearse como primer diagnóstico diferencial un carcinoma gástrico, por lo que la mayoría de los pacientes termina en un procedimiento quirúrgico mayor. El objetivo de este estudio fue describir una serie de casos registrados en una institución de alta complejidad, así como la revisión de la literatura al respecto del tema. Pacientes y métodos: se realizó la revisión de las bases de datos del servicio de cirugía general de la Clínica Universitaria Colombia y se encontraron 4 tumores gástricos de presentación inusual, de los cuales se hizo revisión de la historia clínica y las imágenes disponibles (diagnósticas y de las piezas de cirugía). Resultados: en la revisión de la base de datos, se encontraron 4 casos, 2 de sexo femenino y 2 de sexo masculino, con una media de edad de 51 años (26-75 años). El 100 % de los pacientes tenía una lesión en la región antral y solo uno de ellos tenía una segunda lesión a nivel prepilórico. La totalidad de los pacientes fue llevada a gastrectomía subtotal con reconstrucción en Y de Roux por abordaje laparoscópico y la media de estancia hospitalaria fue de 3,5 días (2-6 días). Conclusión: para determinar la mejor opción de tratamiento en general en pacientes con lesiones gástricas siempre hay que considerar tanto las características endoscópicas y endosonográficas como las histológicas.

Abstract Introduction: Gastric pathology is exceptionally benign with a percentage of appearance between 0.005% - 4% worldwide. Moreover, gastric carcinoma is often suggested as the first differential diagnosis and for that reason, the outcome for a vast majority of admitted patients is a major surgical procedure. This study aims to describe a series of cases recorded in a high complexity medical institution and to carry out a literature review related to that subject. Patients and Methods: Databases from the general surgery service of the Clínica Universitaria Colombia were reviewed, and four unusual gastric tumors were found. A review of the related medical records and available images (diagnostic images and surgical elements) was performed. Results: After the database review, four cases were found: two female cases and two male cases, with a mean age of 51 years (26-75 years). All the patients had lesions in the antrum area and only one of them has an additional lesion in the prepyloric region. All patients were treated with a laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction and the mean length of hospital stay was 3.5 days (2-6 days). Conclusion: It is required to consider the endoscopic, endosonographic, and histological examinations and their features to determine the best treatment for patients with gastric lesions.

Angioleiomioma uterino: a propósito de un caso / Uterine angioleiomyoma: report of clinical case

Resumen El angioleiomioma es un tumor benigno perivascular que raramente se localiza en el útero. Se expone el caso de un angioleiomioma de gran tamaño en una mujer de 30 años con sangrado menstrual abundante y masa abdominal palpable. La paciente fue sometida a miomectomía y diagnosticada de angioleiomioma por el estudio histológico. Ante síntomas persistentes, la angiomiomectomía o la histerectomía simple son eficaces.

Abstract Angioleiomyoma is a benign perivascular tumor that is rarely located in the uterus. This paper presents a case of a large angioleiomyoma in a 30-year-old woman with heavy menstrual bleeding and a palpable abdominal mass. The patient underwent myomectomy and was diagnosed with angioleiomyoma by histological examination. For persistent symptoms, angiomyomectomy or simple hysterectomy are effective.

Leiomioma de cúpula vaginal posterior a histerectomía. Reporte de caso / Vaginal vault leiomyoma after hysterectomy. Case report

RESUMEN Los leiomiomas son tumores benignos, mesenquimales que generalmente surgen de las células del músculo liso uterino, pero también pueden aparecer en sitios atípicos como vagina, pulmones y estructuras vasculares. Los leiomiomas de cúpula vagina posterior a la histerectomía son muy raros y su etiología no ha sido determinada. La ecografía transvaginal, tomografía computarizada y la resonancia magnética son herramientas útiles para el diagnóstico y seguimiento de estas pacientes. El tratamiento definitivo es la extirpación total del tumor para evitar la diseminación o derrame inadvertido de células neoplásicas malignas ocultas. La administración de análogos de la hormona liberadora de gonadotropina o la embolización intravascular pueden ser métodos alternativos para reducir la pérdida hemática intraoperatoria. Se presenta un caso de leiomioma de cúpula vaginal posterior a histerectomía.

ABSTRACT Leiomyomas are benign, mesenchymal tumors that usually arise from uterine smooth muscle cells, but can also occur in atypical sites such as the vagina, lungs and vascular structures. Post-hysterectomy vaginal vault leiomyomas are very rare and their etiology has not been determined. Transvaginal ultrasound, computed tomography and magnetic resonance imaging are useful tools for the diagnosis and follow-up of these patients. The definitive treatment is total removal of the tumor to avoid dissemination or inadvertent spillage of occult malignant neoplastic cells. Administration of gonadotropin-releasing hormone analogs or intravascular embolization may be alternative methods to reduce intraoperative blood loss. A case of vaginal vault leiomyoma following hysterectomy is presented.

Leiomioma vesical. A propósito de un caso / Bladder leiomyoma. A case report

RESUMEN Fundamento: El leiomioma vesical es un tumor de origen mesenquimal, benigno, derivado de las fibras del músculo liso, su diagnóstico definitivo es por estudio histológico; su tratamiento es quirúrgico con pronóstico excelente. Son pocos los casos que se presentan en la bibliografía consultada por la escasa incidencia de este tipo de tumor. Objetivo: Reportar un caso diagnosticado con un leiomioma vesical. Presentación del caso: Se presenta el caso de una paciente femenina de 48 años de edad, atendida en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, que fue diagnosticada con ureterocele izquierdo. La paciente a los 7 años acudió con síntomas de polaquiuria, goteo posmiccional y sensación de repleción después de la micción. A la exploración física sin alteraciones en general. Ecografía renovesical con imagen quística en uréter distal izquierdo, de gran tamaño, con paredes gruesas, que ocupa casi la totalidad de la vejiga, con ureterohidronefrosis severa izquierda. Se le realizó cirugía definitiva, cistectomía parcial con reimplante ureteral izquierdo, con buena evolución. El resultado del diagnóstico anatomopatológico fue un leiomioma vesical. Conclusiones: El leiomioma vesical es una neoplasia poco frecuente en vejiga; en el caso reportado al realizarle el tratamiento quirúrgico se observó un excelente pronóstico.

ABSTRACT Background: Bladder leiomyoma is a benign tumor of mesenchymal origin, derived from smooth muscle fibers, its definitive diagnosis is by histological study; its treatment is surgical with excellent prognosis. Few cases are presented in the literature due to the low incidence of this nature. Objective: To report a case diagnosed with a bladder leiomyoma. Case report: A 48-year-old female patient, assisted at Camilo Cienfuegos General Provincial Hospital in Sancti Spíritus, diagnosed with left ureterocele. The patient came to consulting 7 years after have presented symptoms of pollakiuria, post-mictional drip and repletion sense afterwards urination. Physical examination showed no general alterations. Renovesical ultrasound showed a cystic image in the left distal ureter, large, thick-walled, occupying almost the entire bladder, with severe left ureterohydronephrosis. Definitive and partially cystectomy surgery was performed with left ureteral reimplantation, presenting good evolution. The result of the anatomopathological diagnosis was a bladder leiomyoma. Conclusions: Bladder leiomyoma is a rare neoplasm in the bladder; in the reported case, after surgical treatment, an excellent prognosis was observed.

Leiomioma parauretral: manifestación clínica inusual, primer reporte de caso en literatura colombiana / Parauretral leiomioma: unusual clinical manifestation, first case report in colombian literatura

RESUMEN El leiomioma parauretral es una neoplasia benigna con pocos casos descritos en la literatura. El leiomioma abarca el 5% de los casos de las masas parauretrales, ocupando el cuarto lugar como una de las causas menos frecuentes, después del divertículo parauretral. Se presenta el caso de una paciente de 43 años con antecedente de infección urinaria a repetición, con una masa de 8 cm en pared vaginal anterior de cuatro años de evolución. La cistoscopia fue normal y la ecografía mostró una lesión sólida parauretral. Se realizó resección por colpotomía sin complicaciones, con resultado de patología de leiomioma. Control postquirúrgico y uroflujometría normal. Dentro de las posibilidades diagnósticas ante una masa parauretral, el leiomioma debe considerarse. La sintomatología es variable, siendo los síntomas urinarios los más frecuentes. La ecografía y la resonancia son herramientas fundamentales y el manejo se basa en la resección quirúrgica, generalmente vía vaginal. MÉD.UIS.2021;34(2): 77-82.

ABSTRACT Introduction: Paraurethral leiomyoma is a rare benign neoplasm, with few cases described in the literature. Most of the data on prevalence are based on case series, the leiomyoma covers 5% of the paraurethral masses, occupying the fourth place as one of the less frequent causes, after parurethral diverticulum. Case: 43 years old patient with antecedents of recurring urinary infections and a previous 8 cm mass on the vaginal walls with 4 years of clinical evolution course. Cystoscopy was normal and ultrasound with a solid paraurethral injury. Colpotomy resection was performed without complications, resulting in leiomyoma pathology. Post-surgical control and normal uroflowmetry. Discussion and conclusion: leiomyomas should be considered as a possible diagnosis in case of a periurethral mass presence. Symptomatology is variable. The urinary symptoms are the most frequent as in this case. Ultrasonography and resonance are essential tools treatment are based on surgical resection which is usually vaginally. MÉD.UIS.2021;34(2): 77-82

Miomectomía múltiple por vía abdominal / Multiple abdominal myomectomy

RESUMEN Se presentaron dos pacientes a las cuales se les realizó una miomectomía en los meses de enero y marzo de 2017, en la localidad de Luanda, Angola. Ambas fueron atendidas en la consulta de Ginecología por: aumento de volumen del abdomen, sangramiento genital durante la menstruación y fuera de ella, síntomas compresivos caracterizados por urgencia miccional y estreñimiento, además de infertilidad. Se les realizaron: exámenes de laboratorio, ultrasonido ginecológico y renal, así como histerosalpingografía. Después del análisis de estos exámenes se les diagnosticó una miomatosis uterina múltiple; fueron remitidas al salón de operaciones con previo consentimiento informado y se les practicó una miomectomía múltiple sin complicaciones transoperatorias. Se conservó el útero en ambas pacientes, las cuales tuvieron una recuperación postoperatoria satisfactoria. Una de estas pacientes logró un embarazo cinco meses después de la cirugía.

ABSTRACT We present two patients who had a myomectomy in January and March 2017, in Luanda, Angola. Both were treated in the Gynecology consultation due to increased abdominal volume, genital bleeding during and between periods, compressive symptoms characterized by urinary urgency, constipation and infertility. Laboratory tests, gynecological and renal ultrasound, as well as hysterosalpingography were performed. After the analysis of these tests, they were diagnosed with multiple uterine myomas, referred to the operating room with prior informed consent and underwent a multiple myomectomy without transoperative complications. The uterus was preserved in both patients, who had a satisfactory postoperative recovery. One of these patients got pregnant five months after surgery.

Does big mean evil? Giant, but benign uterine leiomyoma: case report and review of the literature / Será que grande significa maligno? Leiomioma gigante, porém benigno: Relato de caso e revisão de literatura

Abstract Uterine leiomyoma is themost prevalent benign type of gynecological tumor. It affects more than 80% of women worldwide and, within this group, more than 50% may be asymptomatic. However, large fibroid volumes may be associated with symptoms of extrinsic compression, and most of the cases do not present atypical cells. We present the case of a 49-year-old woman who underwent a total abdominal hysterectomy of a 13.5-kg uterine leiomyoma with no malignancies at histopathology and review the literature about giant uterine leiomyomas and their clinical repercussion. We concluded that large volumes do not always pose a threat regarding malignancy; however, future molecular studies are needed to investigate giant uterine fibroids.

Resumo Leiomioma uterino é o tumor benigno ginecológico de maior prevalência. Ele afeta mais de 80% das mulheres no mundo e, deste grupo, mais de 50% podem ser assintomáticas. Contudo, miomas de grande volume podem ser associados com sintomas de compressão extrínseca, e a maioria dos casos não apresentam células atípicas. Nós apresentamos o caso de uma mulher de 49 anos que foi submetida a histerectomia total abdominal de um espécime de 13,5 quilos sem malignidades ao exame histopatológico. Também revisamos a literatura sobre leiomiomas uterinos de grande volume e sua repercussão clínica. Concluímos que grandes volumes nem sempre representam um risco relacionado à malignidade; contudo, estudos moleculares futuros são necessários para investigar leiomiomas uterinos gigantes.