Miomectomía durante el embarazo: leiomioma gigante con degeneración / Miomectomy during pregnancy: giant leiomyoma with degeneration

Resumen ANTECEDENTES: Los leiomiomas son los tumores pélvicos más comunes, con múltiples presentaciones clínicas a lo largo de la vida de la mujer. Es inusual que aparezcan durante el embarazo y que ameriten tratamiento quirúrgico, sobre todo por abdomen agudo secundario a degeneración. OBJETIVO: Aportar y exponer el proceso de diagnóstico, tratamiento quirúrgico y desenlace obstétrico en una paciente con un leiomioma gigante con degeneración asociado al embarazo. CASO CLÍNICO: Paciente de 34 años, primigesta, con 22.1 semanas de embarazo. Acudió a Urgencias con abdomen agudo, fiebre y daño ventilatorio secundario a un leiomioma gigante que ocupaba la totalidad del abdomen y comprimía las estructuras abdominales y torácicas. Debido al deterioro clínico se decidió la intervención quirúrgica para extraer los dos miomas: el mayor de 35 x 20 cm y 9150 g. La evolución posoperatoria fue favorable lo mismo que el control prenatal. La finalización del embarazo fue por cesárea electiva a las 38.1 semanas, sin complicaciones maternas ni perinatales. CONCLUSIÓN: La miomectomía durante el embarazo es un procedimiento seguro para disminuir la morbilidad y la mortalidad materna y fetal en casos seleccionados.

Abstract BACKGROUND: Leiomyomas are the most common pelvic tumors, with multiple clinical presentations throughout a woman's life. It is unusual for them to appear during pregnancy and to merit surgical treatment, especially for acute abdomen secondary to degeneration. OBJECTIVE: To provide and expose the process of diagnosis, surgical treatment and obstetric outcome in a patient with a giant leiomyoma with pregnancy-associated degeneration. CLINICAL CASE: A 34-year-old primigravida patient, 22.1 weeks pregnant. She came to the emergency department with acute abdomen, fever and ventilatory impairment secondary to a giant leiomyoma that occupied the entire abdomen and compressed abdominal and thoracic structures. Due to the clinical deterioration, surgery was decided to remove the two fibroids: the larger one measuring 35 x 20 cm and weighing 9150 g. The postoperative evolution was favorable. The postoperative evolution was favorable as well as the prenatal control. The pregnancy was terminated by elective cesarean section at 38.1 weeks, without maternal or perinatal complications. CONCLUSION: Myomectomy during pregnancy is a safe procedure to reduce maternal and fetal morbidity and mortality in selected cases.

Leiomiomatosis vulvovaginal: reporte de un caso y revisión bibliográfica / Vulvo-Vaginal Leiomyomatosis: Case Report and Review of the Literature

Resumen ANTECEDENTES: Los leiomiomas son los tumores pélvicos más frecuentes en la mujer; sin embargo, su localización vaginal es excepcional. Suelen ser asintomáticos y encontrarse como un hallazgo clínico. En los últimos 20 años solo se han reportado 85 casos, y solo dos han sido recurrentes. OBJETIVO: Reportar un caso de miomatosis vaginal recurrente en una paciente histerectomizada y revisar la bibliografía al respecto. CASO CLÍNICO: Paciente de 58 años, histerectomizada, con una tumoración vaginal. El reporte histopatológico informó una proliferación fusocelular, debidamente delimitada, dispuesta en haces entrecruzados. Los núcleos eran alargados, monomorfos y de extremos romos. El estroma era escaso y colagénico. No se observaron atipias citonucleares ni necrosis. El estudio inmunohistoquímico de la lesión con actina de anticuerpos antimúsculo liso y desmina se reportó positivo. Se diagnosticó miomatosis vulvovaginal recurrente. Se trató mediante resección quirúrgica. CONCLUSIÓN: Los leiomiomas vulvovaginales son extremadamente raros y la bibliografía al respecto es poca; su recurrencia es verdaderamente excepcional. De ahí la importancia de la publicación de estos casos, que aporta información que pueden tomar en cuenta otros clínicos al momento del diagnóstico.

Abstract BACKGROUND: Leiomyomas are the most frequent pelvic tumors in women; however, their vaginal location is unusual. They are usually asymptomatic and present as a clinical finding. In the last 20 years only 85 cases have been reported, and only two have been recurrent. OBJECTIVE: To report a case of recurrent vaginal myomatosis in a hysterectomized patient and review the literature. CLINICAL CASE: A 58-year-old hysterectomized patient with a vaginal tumor. The histopathologic report reported a fusocellular proliferation, properly delimited, arranged in crisscross bundles. The nuclei were elongated, monomorphous and blunt ended. The stroma was sparse and collagenous. No cytonuclear atypia or necrosis were observed. Immunohistochemical study of the lesion with anti-smooth muscle antibody actin and desmin was reported positive. Recurrent vulvovaginal myomatosis was diagnosed. It was treated by surgical resection. CONCLUSION: Vulvovaginal leiomyomas are extremely rare, and the literature is sparse; their recurrence is truly exceptional. Hence the importance of publishing these cases, providing information to be considered by other clinicians at the time of diagnosis.

Mioma uterino mimetizando neoplasia do trato genital com miomectomia anteparto bem sucedida: relato de caso / Uterine leiomyoma mimicking a tumor of the genital tract with successful antepartum miomectomy: case report

JUSTIFICATIVA E OBJETIVOS: Os miomas são tumores benignos, estrogênio-dependentes, atingindo suas dimensões máximas durante o menacme e são encontrados em até 4% das gestações.A miomectomia na gravidez é discutível, intervir ou não depende da possível lesão à gestação. O objetivo deste estudo foi apresentar um caso de mioma subseroso que simulou neoplasia em primigesta com miomectomia anteparto bem sucedida. RELATO DO CASO: Nulípara, 38 anos, encaminhada à Oncologia Ginecológica por distensão abdominal progressiva, protusão umbilical e amenorreia há três meses e desconforto respiratório.O abdômen demonstrava massa endurecida, fixa, ocupando região pélvica e abdominal até apêndice xifoide. Trazia ultrassonografia (US) transvaginal relatando útero aumentado de volume (2305 cc), textura difusamente heterogênea com múltiplos nódulos sólidos; colo uterino e canal cervical normais; ovários não visualizados e presença de ascite. Solicitou-se fração Beta da gonadotrofina coriônica humana (BetaHCG), marcadores tumorais e ressonância magnética nuclear (RMN) para investigação etiológica. Os resultados demonstraram BetaHCG: 57684 mUI/mL; CA125: 161,1 U/mL; CA:19,9:0,8 U/mL; alfafetoproteína: 2,56 KUI/mL; US: feto vivo pesando 580 g e 22 semanas. RMN mostrava imagem compatível com útero gravídico e placenta corporal. Na parede uterina existia a presença de mioma intramural. A paciente foi submetida à laparotomia exploradora onde foi observada presença de massa pediculada única de aproximadamente 30 cm com pedículo vascular de 5 cm. O exame perioperatório revelou lesão benigna, provável leiomioma. O exame anatomopatológico revelou leiomioma, pesando 7925 g e dimensões de 27 x 24 x 12 cm, negativo para células neoplásicas. Após a miomectomia, a gestação evoluiu sem qualquer intercorrência, com parto a termo por cesariana. CONCLUSÃO: A miomectomia pode ser um procedimento seguro durante a gravidez, se indicada.

BACKGROUND AND OBJECTIVES: Leiomyomas are benign estrogen-dependent tumors, that occur in up to 4% of pregnancies with maximum dimensions during the reproductive period. Although myomectomy during pregnancy is still controversial, the decision whether to intervene or not depends mainly on the location of the fibroid and the surgeon's experience. We report here the case of a massive, symptomatic leiomyoma successfully managed by antepartum myomectomy. CASE REPORT: A 38-year-old, nulliparous patient was referred to the Gynecological Oncology outpatient clinic complaining of progressive abdominal distension, umbilical protrusion, 3-months amenorrhea and respiratory distress. On physical examination, her abdomen showed a hardened, fixed mass, occupying the whole pelvic and abdominal region up to the xiphoid appendix. A previous transvaginal ultrasound showed an enlarged uterus (2305 cc), a diffusely heterogeneous texture with multiple solid nodules, cervix and cervical channel without alterations; ovaries not visualized and presence of ascites. We requested Human chorionic gonadotropin (BetaHCG), tumor markers and Nuclear magnetic resonance (NMR) for the etiology investigation. The tests showed QHCG: BetaHCG:57684 mUI/mL; CA125: 161.1 U/mL; CA:19.9: 0.8 U/mL; alpha-fetoprotein: 2.56 KUI/mL; Ultrasonogram: single live fetus,weight 580 g, estimated gestational age 22w. NMR showed image consistent with gravid uterus and corporal placenta. The presence of an intramural leiomyoma in the uterine wall was observed. The patient was submitted to an exploratory laparotomy that showed the presence of a single pediculated mass of approximately 30 cm with a 5 cm vascular pediculus.(...)

Eficiencia diagnóstica del ca-125 como predictor preoperatorio de malignidad en tumores pélvicos / Diagnostic efficacy of the ca-125 as preoperatory predictor of malignancy in pelvic tumours

El objetivo de esta investigación fue evaluar la eficacia diagnóstica del CA-125 como predictor de malignidad en tumores pélvicos. Se seleccionaron en forma prospectiva las pacientes que se ingresaron con diagnóstico de tumoración pélvica que tenían evaluación ecográfica y determinación de las concentraciones de CA-125 antes de la cirugía. La histología de la tumoración pélvica fue el punto final del estudio y se dividió en dos grupos: lesiones benignas. El promedio de edad de las pacientes fue de 42,1 ± 12,9 años. Se encontraron 13 neoplasias malignas en las 110 pacientes evaluadas, de estas tumoraciones, 10 eran tumoraciones malignas de ovario. La sensibilidad del CA-125 fue de 61%, la especificidad de 70%, el valor predictivo positivo y negativo fue de 46% y 93%, respectivamente. El incremento del valor de corte a 65 Ul/mL no mejoró la precisión. Las pacientes con neoplasias malignas presentaron un valor promedio de CA-125 de 1557 ± 346 Ul/mL y las pacientes con neoplasias benignas de 110 ± 73 Ul/mL (p<0,05). Se concluye que el CA-125 tiene una moderada eficacia diagnóstica como predictor preoperatorio de malignidad en tumores pélvicos

The obejtive of the research was to evaluate the diagnóstic efficacy of CA-125 as predictor of pre-surgical malignacy in pelvic tumors. Patients were selective prospectively and who were admitted with diagnosis of pelvic tumors who had ultrasound evaluation and CA-125 concentration were assessed before surgery. Histology of pelvic tumors was the final point of research and was divided in two groups: bening and malignacy. Mean age of patients was 42.1 ± 12.9 years old. There were found 13 malignancies in 110 patients, from these tumors, 10 were malignancies of ovaries. CA-125 sensitivity was 61%. specificity 70%, positive and negative predictive value was 46% and 93%, respectively. Increasing the cur off value to 65 Ul/mL did not improve accuracy. Patients with malignancy presented a mean CA-125 concentration of 1557 ± 346 Ul/mL and patients with bening tumor of 110 ± 73 Ul/mL(p<0,05). It is concluded that CA-125 has a moderate diagnostic efficacy as predictor of malignancy in pelvic tumors