Massive Uterine Fibroid
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Viva et al. J Med Case Reports (2021) 15:344 https://doi.org/10.1186/s13256-021-02959-3 CASE REPORT Open Access Massive uterine fbroid: a diagnostic dilemma: a case report and review of the literature Wiesener Viva1, Dhanawat Juhi1,2* , Andresen Kristin1, Mathiak Micaela3, Both Marcus4, Alkatout Ibrahim1 and Bauerschlag Dirk1 Abstract Background: Fibroids of the uterus are the most common benign pelvic tumors in women worldwide. Their diag- nosis is usually not missed because of the widespread and well-established use of ultrasound in gynecological clinics. Hence, the development of an unusually large myoma is a rare event, particularly in frst-world countries such as Germany. It is even more uncommon that a myoma is misdiagnosed as a dietary failure. Case presentation: Herein, we report the case of a Caucasian woman with a giant fbroid that reached a size of over 50 cm, growing slowly over the past 15 years, and was misdiagnosed as abdominal fat due to weight gain. We aim to discuss the factors that lead to the growth of such a huge tumoral mass, including misdiagnosis and treatment, and the psychological impact. Through this case, we intend to increase the awareness among general physicians and gynecologists. Although menstrual disorders incorporate several pathologies, adequate assessment remains the primary responsibility of health care providers. A literature review revealed approximately 60 cases of giant uterine fbroids. Conclusion: The use of clinical and diagnostic devices, especially ultrasound, in this case, is indispensable. In conclu- sion, the growth of a giant fbroid can have disastrous efects on a woman’s health, including surgical trauma and psychological issues. Keywords: Uterine mass, Giant fbroid, Misdiagnosis, Surgery, Weight gain Introduction development of these tumors remains unclear, several Leiomyomas or fbroids are the most common benign risk factors, such as positive family history, genetic alter- pelvic tumors in females that grow monoclonally from ations, and lifestyle factors (smoking, obesity, dyslipi- the smooth muscle cells of the uterus. Such tumors occur demia, nutrition, exercise, and medical contraception), in nearly half of women over the age of 35 years, with have been identifed. Treatment of these lifestyle-associ- increased prevalence during the reproductive phase due ated risk factors with vitamin D supplementation, statin to hormone-stimulated growth [1]. At 50 years of age, use, and dietary modifcation appears to be protective, 80% of African and almost 70% of Caucasian women along with parity [1, 3]. Myomas may occur as a single have fbroids [2]. As the underlying pathogenesis of the lesion or as multiple lesions as reported in two-third of the cases, with variation in size from microscopic to large *Correspondence: [email protected] macroscopic extent [1, 4]. As the majority of women with 1 Department of Gynecology and Obstetrics, University Medical Center myomas remain asymptomatic [2], the number of undi- UKSH, Campus Kiel, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany agnosed uterine fbroids is high. Symptomatic women Full list of author information is available at the end of the article most likely sufer from abnormal uterine bleeding © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Viva et al. J Med Case Reports (2021) 15:344 Page 2 of 6 (meno- or metrorrhagia and polymenorrhea) as well as imaging methods, leaving the fbroid undiagnosed and dysmenorrhea. Other frequent symptoms include dys- untreated. pareunia or chronic acyclic pelvic pain [3]. Fibroids afect In our clinic, a preliminary physical examination was fertility [5] and can have a severe psychological impact on performed, which indicated good general condition a woman’s life [3]. With continued growth, myomas can and no evidence of pallor or pedal edema. Te patient’s cause compression-related symptoms, such as dyspnea, preoperative body mass index (BMI) was 32.1 kg/m2. frequent urination, or bowel complaints. Te growth rate Her abdomen was enormously enlarged and pendu- of myomas varies intra- and interindividually, thereby lous with fank fullness on both sides. An irregular mass regressing or gradually increasing in size until the climac- arose from the pelvis up to the xiphisternum and was teric period is possible [1]. Te identifcation of rapidly not discernible owing to abdominal wall obesity. Tere progressing growing fbroids requires close observational were no hernias or abdominal varices. Renal angle full- ultrasound examinations. Extremely large myomas can ness was not observed. Because of the patient’s anxiety, involve serious complications such as respiratory failure a vaginal examination could not be performed. Transab- due to diaphragmatic compression [6] or incarcerated dominal ultrasound showed a huge intraabdominal abdominal wall hernia [7]. mass. Te right kidney showed impaired cirrhosis, while In Germany, universal access to healthcare services the left kidney showed compensatory enlargement. A is guaranteed by law [8]. Te German ambulatory care small amount of ascites was observed. An urgent com- sector is densely structured with accessibility of general puted tomography (CT) scan was performed revealing physicians in less than 30 minutes in more than 90% of a large tumor that occupied the abdominopelvic cav- all cases [9]. Utilization of gynecological services in Ger- ity completely. On the CT scan, the mass measured many usually begins between the ages of 15 and 16 years 32 × 27 × 34 cm (intralesion diameter) and could not be [10] and continues at age 20 with annual visits for pre- visibly separated from the uterine cavity, bladder, or liver vention of cervical carcinoma [11], followed by recur- (Fig. 1). Te tissue of origin and extent of tumor inva- rent examinations for breast cancer prevention [12]. Te sion remained unclear. Te mass appeared heterogene- self-reported prevalence of myomas is high in German ous, containing cystic and necrotic areas along with solid women (8.0%), with a mean age of 33.5 years at diagnosis. components. It compressed the intestines, right kidney, After the USA, Germany has the second-highest hyster- and both ureters. Te spleen was mildly enlarged. Te ectomy rate among women with uterine fbroids (29.1% hepatorenal recess (Morison’s pouch) showed minimal versus 21.8%) [3]. Although diagnosis of a giant myoma ascites. No lymph nodes were observed. Due to the slow is difcult with several possible diferential diagnoses, the growth of the tumor, few ascites, and negative lymph majority of uterine myomas are confdently diagnosed in nodes, malignancy was highly unlikely. the (pre-)clinical routine [1]. Herein, we present a rare A midline longitudinal incision was made from the case of a German woman whose uterine tumor was mis- xiphisternum to the pubic symphysis, and the abdomen diagnosed and remained untreated for the past 15 years, was opened. A large mass arising from the uterus up growing into a giant fbroid (16.4 kg) with a size over to the xiphisternum, frm in consistency with enlarged 50 cm. superfcial veins, was seen. Te mass extended later- ally to both fanks and occupied the right and left hypo- chondrium. No adhesions to the intestinal organs were Case report observed. Te bilateral ovaries were enlarged to twice the A nulligravid, 46-year-old German woman presented to normal size, with ovarian artery pulsation seen on both the gynecology clinic because of abnormal uterine bleed- sides. Additionally, the bilateral fallopian tube round liga- ing and a slowly increasing abdominal extent in the past ments were thickened (Fig. 2a and b). Due to the in situ 15 years. She had no bowel or bladder complaints. Te fndings, a total abdominal hysterectomy en bloc with patient reported two episodes of polymenorrhea and bilateral salpingectomy was performed, and both ovaries menorrhagia in the past years. Due to the patient’s gen- were left intraabdominally. Postoperatively, bilateral ure- eral fear of physicians and absence of frequent symptoms, teric peristalsis was confrmed. Intraoperative blood loss she consulted her gynecologist and general physician was 400 ml. Te patient’s postoperative clinical course sporadically. Te gynecologist did not use ultrasound within 5 days of hospital stay remained complication-free to clarify the uterine pathology. Te general physician with quick recovery. She was discharged after 5 days of attributed her progressive abdominal extent to weight surgery and had good overall health. gain and advised dietary change and physical exercise Pathology confrmed a myomatous uterus measuring as management. Both primary health care providers did 52 × 37 × 3 cm and weighing 16.4 kg. Te tumor con- not perform a thorough physical examination, including sisted of two separate myomas with diameters of more Viva et al. J Med Case Reports (2021) 15:344 Page 3 of 6 Fig. 1 CT reveals extensive abdominal enlargement in the scout view (a). Sagittal CT reconstruction depicts a giant tumor in contact with the liver (black arrow, b) and with the urinary bladder (black arrowhead, b).