MYXOMA OF THE BROAD LIGAMENT

(A Case Report)

by LAxMI 1. AsHAR*, M.D., F.C.P.S., D.G.O., D.F.P. V. N. PuRANDARE**, M.D., F.R.C.S.

The solid tumours ~of the broad domen. There was no history of retention ligament are a rarity, the most com­ of urine in the past. She did give a history mon .of these being a fibroma. The of loss of weight and appetite. Her menstrual history revealed that she other solid tumours are lipoma, was menopausal for 20 years. Her past haemangioma, adenomyoma, sar­ menstrual history was within normal limits. coma, dermoid and carcinoma. Only She had two full-term normal deliveries, a passing remark has been made the last confinement being 25 years ago. about the myxoma of the broad liga­ On examination, she appeared to be ment. Gardner et al (1957) have rather pale. She had marked oedema of presented a series of 27 solid tumours the right lower limb which was covered all over by eczema. The vital signs were with­ of the broad ligament with not a in normal limits and systemic examination single case of myxoma. According to did not show any abnormality. them the definition of a broad liga­ Abdominal examination revealed a lump ment tumour on the basis of its loca­ in the lower abdomen, occupying the hypo­ tion is 'the tumour which occurs in gastrium, both iliac fossae and the umbili­ cal region, arising from the pelvis. It was or on the broad ligament but is com- well-defined, about 8" x 10" in diameter, . pletely s.eparate from and is no way fixed and variegated in consistency. The in connection with either the uterus skin over it was oedematous. or the ovary'. On vaginal examination, the cervix ap­ peared to be out of reach. The mass which Case Report was palpable per abdomen could be palpat­ Mrs. S. L., aged 60 years, w :dow, was ed through all the fornices. The uterus admitted on 6th March, 1969, to King could not be felt separately. Edward VII Memorial Hospital, Bombay, The following investigations were carried with a history of swelling in the lower ab­ out: haemoglobin-10 gms. per cent; urine domen of 6 months' duration and oedema' -8-10 pus cells/H.P.F., and 8-10 R.B.Cs./ of feet for one month. The patient seeked H.P.F.; stooi:_ova of ascariasis lumbricoi­ a.dmission mainly for retention of urine for des; blood urea 12.5 mgms. per cent; blood one day. sugar 83 mg. per cent; Kahn test negative. There was no history of vomitirig, bleed­ A clinical diagnosis of ovarian malig~ ing per vaginam or acute pain in the ab- nancy was made from the above mentioned findings. *Registrar. An exploratory laparotomy was carried . **Han. Professor. out on 15tl:J. March, 1 !}69, mainly from. the Dept. of Obst. and Gynec. K. E. M. diagnostic ·point of view. The findings at the time of laparotomy were as follows: · Hospital, Parel, Bombay 12. The uterus and the adne:Xae· were ri'or­ Received for publication on 7-_7-:1969 . mal. There was a mass arising- from: the

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right broad ligament. It was markedly coma with clusters of embryonic adherent to the anterior abdominal wall in its lower part. There were huge dilated cells. Most mesodermal mixed vessels running on its surface. It was diffi­ tumours arise in sites distant from cult to define the lateral extent of the Gartner's ducts, whereas .they have tumour. not been found in the broad ligament Initially, the origin of the tumour appear­ (Meikle, 1936). Wurtz (1949; quoted ed to be obscure. A possibility of the tumour arising from the urinary bladder by Taylor) and Ober and Edgcombe was also kept in mind, but on careful ( 1954) have reported such tumours examination at a later stage, this possibility of the broad ligament. was ruled out. The myxoma in its structure re­ Hysterectomy with bilateral salpingo­ sembles the primitive mesenchyme oophorectomy and removed of the tumour was contemplated. While attempting this, or the mucoid tissue (Wharton's the tumour wall was injured and the jelly)) of the umbilical cord. It was tumour tissue was scooped out as the gene­ Ewing (quoted by Anderson) who ral condition of the patient and the mar­ postulated that it arises from the kedly adherent tumour in the broad liga­ embryonic rests, since this tissue is ment did not permit any further manipu­ lations. The tumour tissue was gelatinous. not seen in an adult. According to The abdomen was closed without any fur­ Willis ( 1960), it represents the re­ ther procedure. appearance of mucin in the inter­ Histopathological report: Microscopic cellular matrix of some fibroblastic examination revealed stellate cells which growths. were separated by loose homogenous ap­ pearing stroma. The stroma was stained Stout (1948), who including• his pink on H.E. staining, suggesting its mucoid own cases, has reviewed 140 cases of nature. Fine reticulum fibres could be ~een myxomas, other than those of the traversing through the stroma. heart, from the world literature, But for the mild fever, the post-operative defines myxoma as follows: period was uneventful. She was discharged 'It is a true neoplasm, composed of on 11th post-operative day. She did not have any urinary complaints and the stellate cells, set in a loose mucoid oedema of right lower limb had also re­ stroma through which course very duced. delicate reticulin fibres in various The patient was seen repeatedly after the directions.' surgery over a priod of 3 months. The re­ The resemblance of this tumour to sidual tumour mass, which was palpable primitive mesenchyme has been in the suprapubic region at the time of noted by Greco, Harris, Hogenaver, discharge remained the same. Thereafter, she never had any bladder symptoms. The Saturski and others. The mucoid sub­ oedema of the lower limb and the abdo­ stance is not mucin but is hyaluronic minal wall had completely disappeared. acid. According to Meyer (quoted by Stout), it is this property which Discussion suggests that the myxoma is a neo­ The myxoma may be present as plastic reproduction of primitive such or may be a part of a mixed mesenchyme. Occasionally, there 1 mesodermal tumour. Taylor (1958) may be formation of denser areas due has reviewed 40 cases of mixed to a thickening of the delicate con­ mesodermal tumours of the female nective tissue. This may resemble genital tract, the histological exami­ fibrosarcoma, but no other metaplas­ nation of which showed myxosar- tic changes occur. MYXOMA OF THE BROAD LIGAMENT 271

The myxoma occurs in the heart, place in some region where vital skin, subcutaneous and aponeurotic structures can be affected, such as tissues, certain bones and the genito­ the bladder and retroperitoneal urinary tract. It is usual to find them region, a fatal outcome ·may be the in other situations. In the genito­ result. urinary tract, the urinary bladder, In the comment, we would like to the spermatic cord and the vulva are stress. the importance of a diagnostic most commonly affected. In the laparotomy in cases of a lump in the urinary bladder, the trigone is the abdomen. As diagnosis should al­ most commonly affected site and it ways precede treatment, it is worth is an infant who commonly suffers taking at least an open biopsy rather from it. than subject the patient directly Jonas. (1937) has reported the lar­ to radiotherapy. A case of myxoma gest authentic myxoma. After 3 of broad ligament was thus diagnosed years of abdominal enlargement, a and the patient relieved of her com­ tumour weighing about 5 kg. was plaints. Short of laparotomy, she removed from a 36 year old woman. would have been passed off as a case The tumour originated from the para­ of ovarian malignancy. metrium and extended upwards to both sides of the diaphragm. It was Summary gelatinous with cystic areas and his­ A case of myxoma of the broad tologically a vascular myxoma. ligament is presented. The natural history of a myxoma is A review of the literature on that it grows very slowly and may myxoma is. also given. suddenly enlarge rapidly. At times there may be a rapid growth follow­ Acknowledgement ed by inactivity. Metastasis has never We thank Dr. S. V. Joglekar, Dean, been reported except from myxoma K.E.M. Hospital, Bombay, for allow­ of the heart. ing us to publish the hospital data. Surgical excision is the only line of treatment. Radiotherapy has been References entirely (or partly) unsuccessful. 1. Ewing: As quoted by Anderson, Stout (1948) is of the opinion that W. A. D.: The C. V. Mosby Co., the only proper way of dealing with Maruzeri Co., Ltd. the various tumours derived from the 2. Gardner, George H., Green, R. R. mesenchyme, is to biopsy them be­ and Peckham Ben: Am. J. Obst. & fore undertaking treatment. This Gynec., 73: 536, 1957. would serve as a guide. In order to preyent recurrence, it is necessary to 3. Greco, T.: As quoted by 11. remove a generous amount of ap­ 4. Harris, H. A.: As quoted by 11. parently uninvolved surrounding 5. Hogenauer, F.: As quoted by 11. tissue. Since the tumours infiltrate, 6. Jonas, E.: As quoted by ll. excision of the tumour close to the 7. Meikle, C. J.: J. Obst. & Gynec. apparent junction of the tumour and Brit. Emp., 43: 821, 1936. the normal tissue has frequently been 8. Meyer, R.: Personal communica­ followed by recurrence. If this takes tion, as quoted by Stout, A. P.

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9. Ober, W. B. and Edgcombe, J. H.: Gynec. Brit. E'mp., 615: 177, 1958. Cancer, 7: 75, 1954. 13. Willis, R. A.: Pathology of 10. Saturski, A.: As quoted by 11. Tumours, London, (1960), Butter­ 11. Stout, Arthur Purdy: Annals of worths & Co. Surgery, 127: 706, 1948. 14. Wurtz, K. G.: As qu~ted by Tay­ 12. Taylor, Claud W.: J. Obst. & lor, C. W.

See Fig. on Art Paper VII