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Lesions of the Broad Ligament: A Review
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Heller, D. (2015). Lesions of the Broad Ligament: A Review. In Journal of Minimally Invasive Gynecology (Vol. 22, Issue 7, pp. 1163–1168). Rutgers University. https://doi.org/10.7282/T3CC12XM
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1 Lesions of the Broad Ligament -a review
2 Debra S. Heller, MD
3
4 From the Department of Pathology & Laboratory Medicine, Rutgers-New Jersey Medical School,
5 Newark, NJ
6
7
8
9 Address Correspondence to:
10 Debra S. Heller, MD
11 Dept of Pathology-UH/E158
12 Rutgers-New Jersey Medical School
13 185 South Orange Ave
14 Newark, NJ, 07103
15 Tel 973-972-0751
16 Fax 973-972-5724
18 Word count : 2123
19 Running title: Lesions of the Broad ligament
20 Funding: Departmentally funded
21 Disclosures:none
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22
23 Precis:
24 Lesions of the broad ligament are reviewed.
25
26 Key words: Broad ligament, uterine neoplasms, female genital tract
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27 Abstract:
28
29 The differential diagnosis of lesions arising in the broad ligament is quite large. Many of these
30 lesions can be clinically interpreted prior to surgery as adnexal or uterine neoplasms. While some
31 lesions are similar to those arising in other Müllerian sites, there are unique lesions as well. The
32 lesions are uncommon, and may prove challenging to clinicians. The purpose was to review the
33 scope of lesions affecting the broad ligament. A literature review was conducted. A Medline
34 search was used, using the terms broad ligament, mesosalpinx, and mesovarium. A review of the
35 scope of broad ligament lesions is presented to assist in developing a differential diagnosis if a
36 patient with such a lesion is encountered.
37
38
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45
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46 Introduction:
47 The differential diagnosis of lesions arising in the broad ligament is quite large. Many of these
48 lesions can be clinically interpreted prior to surgery as adnexal or uterine neoplasms. While some
49 lesions are similar to those arising in other Müllerian sites, there are unique lesions as well. The
50 lesions are uncommon, and may prove challenging to clinicians. The purpose was to review the
51 scope of lesions affecting the broad ligament. A literature review was conducted. A Medline
52 search was used, using the terms broad ligament, mesosalpinx, and mesovarium. A review of the
53 scope of broad ligament lesions is presented to assist in developing a differential diagnosis if a
54 patient with such a lesion is encountered.
55
56 Embryology, Anatomy & Histology
57 The broad ligament is a fold of peritoneum that drapes over the uterus and Fallopian tubes. It
58 has three components, the mesovarium, the mesosalpinx, and the portion below the adnexa, the
59 mesometrium, which is referred to as the broad ligament in common usage. The broad ligament
60 contains many structures, including vessels, the uterine arteries, the round ligaments, a portion of
61 the ureters, the uteroovarian ligament medially and suspensory ligament of the ovary laterally,
62 cardinal ligaments laterally, and uterosacral ligaments posteriorly.
63 Embryonic rests are normal components of the broad ligament, and may give rise to some of
64 the neoplasms that can occur there. Mesonephric(Wolffian) duct remnants may be seen in tissue
65 adjacent to the fallopian tube, sometimes invested in muscle(Figure 1).
66 Paramesonephric(Müllerian) remnants may also be present in the broad ligament near the
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67 ovary(1)(Figure 2). In addition, heterotopic hilar cell clusters, as well as adrenal cortical
68 rests(Figure 3) may be incidental findings in the broad ligament, often in a paratubal location(2).
69
70 Broad ligament defects
71 Defects in the broad ligament may permit small bowel, colon, adnexa, or ureter to pass
72 through, with subsequent strangulation, although this is uncommon(3,4,5). Defects may be
73 congenital or acquired, and may involve one leaf, both leaves with a through and through defect,
74 or an outpouching of intact peritoneum(5). The Masters Allen (or Allen Masters) syndrome
75 refers to traumatic laceration of the posterior leaf of the broad ligament, often after childbirth,
76 and is associated with an abnormally mobile cervix. It may cause pelvic pain and dyspareunia(6).
77 In one case, Masters Allen syndrome presented with signs suggestive of acute peritonitis(6). It
78 has been suggested that this peritoneal tear may permit development of deep infiltrating
79 endometriosis(7). It has also been argued that underlying endometriosis rather than pregnancy is
80 the etiology of the acquired defect(8)
81
82 Hemorrhagic lesions of the broad ligament
83 Pregnancy is a time of increased risk for the broad ligament. Hemoperitoneum has been
84 reported after rupture of a broad ligament varix(9), as well as with rupture of broad ligament and
85 uterine vessels(10). A spontaneous broad ligament hematoma has also been reported in the
86 absence of pregnancy, where it was attributed to venous injury associated with the combination
87 of large uterine fibroids and the exertion of mowing a lawn(11)
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88
89 Benign Tumors and Tumor-like Lesions
90
91 Intraligamentous pregnancy
92 Ectopic pregnancy arising in the broad ligament is rare, and usually associated with
93 pregnancy loss and maternal hemorrhage, although a rare viable pregnancy has been
94 reported(12). The authors postulated that the pregnancy was originally a tubal ectopic that had
95 ruptured and re-implanted in the broad ligament. A case in a woman who underwent IVF after
96 two prior ectopics had resulted in bilateral salpingectomies was postulated to have arisen either
97 by rupture of the uterus during the IVF procedure, or recanalization of the fallopian tube
98 stump(13)
99 Rare cases of uterine rupture with expulsion of the fetus into the broad ligament have been
100 reported, as in Dhont’s case where a second trimester termination utilizing prostaglandins was
101 complicated by this occurrence(14).
102 Broad ligament cysts
103 Cysts of the broad ligament may be of mesonephric or paramesonephric origin, with
104 epithelium similar to that described for the corresponding remnants, or of mesothelial origin.
105 Most of these cysts are paramesonephric(Müllerian)(15). Paratubal/Paraovarian broad ligament
106 cysts represent about 10% of adnexal masses(16). The distinction between paratubal and
107 paraovarian is sometimes arbitrary, with interchangeable usage, and these cysts are present in the
108 broad ligament between the tube and ovary. In terms of distinguishing cysts from rests, which
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109 can be dilated, cysts have been described as grossly visible lesions(1). Most of these cysts are
110 incidental findings, but they may torse with accompanying tube or ovary, rupture, or undergo
111 hemorrhage(16). In addition, epithelial neoplasms may arise in paramesonephric cysts, with the
112 same multipotentiality of Müllerian epithelium elsewhere, giving rise to benign, borderline, and
113 malignant epithelial neoplasms that usually arise in the ovary.
114
115 Leiomyoma of Broad Ligament
116 The most common broad ligament neoplasm is a leiomyoma(17), with similar presentation to
117 the uterine counterpart. Rarely, pseudo-Meig’s syndrome has occurred(18). A variant,
118 leiomyomatosis, with over 400 small smooth muscle nodules confined to the broad ligament has
119 also been reported(19). Angioleiomyomas, a benign tumor of smooth muscle and vessels, may be
120 a variant, or may be similar to the soft tissue neoplasms arising elsewhere, and these have
121 occasionally occurred in the broad ligament as well(20).
122 Mimics of leiomyoma that can arise in the broad ligament include extra-gastrointestinal
123 stromal tumors(e-GIST) and perivascular epithelioid tumors(PEComas). Both of these are
124 tumors of uncertain malignant potential, which can histologically mimic leiomyomas but are
125 positive for C-kit and Dog-1 for e-GIST (21), and HMB45 for PEComas (22). These
126 immunostains help distinguish these lesions from the much more common leiomyoma, which
127 would be negative for these stains, but stain for smooth muscle markers.
128 Adenomyomas may also occur, and should not be mistaken for adenosarcomas due to
129 overinterpretation of malignancy of the endometrial stroma surrounding glands(17). An
130 extremely rare mimic of a parasitic leiomyoma in endemic areas is a calcified guinea worm(23)
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131
132
133 Other rare benign tumor-like lesions and neoplasms
134 The broad ligament is a common site for endometriotic implants, however rarely,
135 endometriosis may actually form a tumor mass in the broad ligament(24).
136 Several cases of papillary serous cystadenoma, highly but not always associated with von
137 Hippel-Lindau(VHL) disease have been reported(25), and may be the first indication of the
138 condition(17). In addition to the association with VHL, it is important to be aware that the
139 histology of papillary serous cystadenoma can be confused with clear cell renal cell carcinoma.
140 An immunohistochemical panel will help distinguish the two, with clear cell papillary
141 cystadenomas more likely to stain for CK 7 and be negative for renal cell carcinoma antigen
142 RCC and CD10, while the opposite is true for renal cell carcinomas(26). However,
143 immunohistochemical as well as phenotypic overlap has been shown with papillary cystadenoma
144 and clear cell papillary renal cell carcinoma, which is a different variant of renal cell carcinoma
145 than clear cell carcinoma(27). Benign cystic teratoma has occurred in the broad ligament, and in
146 one case herniated through the greater sciatic foramen, presenting as a gluteal mass(28). A
147 variety of other unusual lesions such as Brenner tumor and fibrothecoma have been reported in
148 the broad ligament (29,30) . Osseous metaplasia has been reported to be able to form nodules in
149 the mesosalpinx(31). Placental site nodule, usually seen in the endometrium, has also been
150 reported in the broad ligament near the fallopian tube, where it may be a marker for a
151 subinvoluted and unsuspected prior ectopic pregnancy(32).
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152 A rare case of an oncocytic adrenal cortical adenoma arising in an adrenal rest of the broad
153 ligament was reported(33). Pheochromocytoma, a usually benign neoplasm generally arising in
154 the adrenal, has also occurred in the broad ligament, presenting with abnormal urinary
155 catecholamines and hypertension(34).
156 A uterus-like mass, composed of smooth muscle with an endometrial-lined cavity is a rare
157 occurrence in the ovary, but has also been reported in the broad ligament(35). The lesion
158 presents with pelvic or abdominal pain, which may be cyclic. Histogenesis is unclear, but
159 theories have included congenital anomaly of the Müllerian ducts, metaplasia or heterotopia(35).
160 Hydatid disease has been reported in the broad ligament and ovary of a child(36),as well as an
161 adult(37), and echinococcosis is something to consider in the differential of patients from
162 endemic areas.
163 Müllerianosis, the presence of mixed endometrioid, serous(tubal) and/or endocervical
164 benign glands of the Müllerian system, have been reported in a variety of locations.
165 Mullerianosis has been reported in the mesosalpinx(38), comprised mainly of endocervical
166 glands with some tubal epithelium. The lesion occurred, as it not infrequently does, in
167 association with borderline ovarian neoplasms, and the authors stress the importance of not
168 interpreting the finding as metastatic.
169
170
171
172
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173 Malignant Neoplasms:
174 Primary malignancies of the broad ligament are defined as tumors in the broad ligament
175 completely separate from the uterus, ipsilateral tube and ovary(39).
176
177 Female adnexal tumor of probably Wolffian origin(FATWO)
178 This neoplasm is uncommon, but usually arises in the broad ligament. FATWO occurs over a
179 wide age range, and presents as solid and cystic masses that can be small, but some have been up
180 to 25 cm(40). They have a variety of histologic patterns, but the most recognizable is sieve-
181 like(figure 4). A helpful finding is the staining with c-kit(CD117). Although most of these
182 lesions do not metastasize, they are capable of aggressive behavior. A potential rare mimic that
183 can arise in the broad ligament is a granulosa cell tumor. While inhibin is a significant marker
184 for granulosa cell tumor, there can be overlap of this and other markers in FATWO, and the
185 finding of nuclear grooves would favor a granulosa cell tumor(41).
186
187 Epithelial Malignancies
188 Müllerian-derived malignancies, including mucinous, serous, clear cell and endometrioid
189 carcinoma, borderline tumors, as well as endometrial stromal sarcoma have arisen in the broad
190 ligament, sometimes in association with endometriosis(40, 42, 43), although some authors
191 postulate that these neoplasms can arise in Müllerian remnants(44). Malignant mixed Müllerian
192 tumor has also been reported(45). Theories reviewed by Aslani et al(43) for the derivation of a
193 serous borderline tumor in this location included invaginated fallopian tube epithelium,
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194 Müllerian remnant, or mesothelial origin. A paratubal transitional cell carcinoma was speculated
195 to have arisen from a Walthard’s rest, paratubal cyst, or tubal serosa(46).
196
197 Other rare malignancies and tumors of uncertain potential:
198 Sex cord stromal tumors have occurred in the broad ligament, including granulosa cell
199 tumor(41), as well as steroid cell tumor. A case of steroid cell tumor, a sex cord stromal tumor
200 of low malignant potential was reported in the broad ligament of an 11 year old female, who had
201 associated virulization(47), and one in an adult , also masculinized, had evidence histologically
202 of arising in an accessory ovary in the broad ligament(48). Carcinoid has been reported(49). A
203 few cases of extraspinal ependymoma have arisen in the broad ligament(50). In the CNS,
204 ependymoma is considered a low grade malignancy with recurrence and rare metastatic
205 potential, but the number of broad ligament cases is too rare to prognosticate. In the literature
206 review of Matsuyama et al, they found 3 cases with initial dissemination, although they were
207 tumor free up to 27 months after surgery, one case that developed spread many years after initial
208 surgery, and two with no documented spread(50). Solitary fibrous tumor has arisen in the broad
209 ligament(51). Ewing’s sarcoma has occurred in the broad ligament(52). As this raises the large
210 differential of small round blue cell tumors, cytogenetics as well as immunohistochemistry is
211 important in making the diagnosis. It is important for clinicians to be aware that unusual tumors
212 may need to be submitted to their Pathology department fresh, so that cytogenetics can be
213 performed, although PCR and FISH modalities may have utility in some tumors, and can be
214 performed after fixation.
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215 Another example of the utility of genetic analysis was a case of choriocarcinoma in the
216 fallopian tube and broad ligament of a young adult patient with a recent pregnancy. While it was
217 initially felt that the choriocarcinoma was gestational, DNA genotyping matching normal patient
218 tissue proved that the lesion was nongestational choriocarcinoma of germ cell origin, which has
219 therapeutic and prognostic significance(53). Gestational choriocarcinoma has also occurred in
220 the broad ligament, presumably from an ectopic pregnancy in that location(54). More unusual
221 forms of GTD have also occurred in the broad ligament. A case of epithelioid trophoblastic
222 tumor in the broad ligament of a 41 year old woman who had been treated ten years earlier for
223 gestational trophoblastic disease was reported(55).
224 Other rare malignancies have included undifferentiated pleomorphic sarcoma(56), malignant
225 fibrous histiocytoma(57) and leiomyosarcoma(58). In one case, broad ligament leiomyosarcoma
226 metastasized to the pancreas(59). It has been suggested that the criteria for malignancy in a broad
227 ligament leiomyosarcoma is that of soft tissue, not uterus(17). Uterine leiomyosarcoma has also
228 spread to the vessels of the broad ligament in a pattern that mimics intravenous leiomyomatosis,
229 and the authors termed this condition intravenous leiomyosarcomatosis(60).
230
231 Conclusions:
232 The broad ligament can show a wide range of pathology. Preoperatively, these lesions may be
233 thought to arise in the adnexa or uterus. At laparoscopy, as many of the lesions arise between the
234 leaves of the broad ligament, they may be similar in appearance(figure 5), although preoperative
235 imaging may be helpful in establishing a differential diagnosis. Broad ligament masses may be
236 amenable to laparoscopic excision. In one case of broad ligament leiomyoma, the broad
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237 ligament was opened, and the leiomyoma was morcellated(1), Knowledge of the potential for
238 the range of lesions of the region will be helpful if such a patient is encountered, and may allow
239 for planning minimally invasive surgical interventions.
240
241 Acknowledgments: None
242 Disclosures: None
243
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381
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382
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385 61- Theodoridis TD, Zepiridis L, Grimbizis G, Bontis J. Laparoscopic management of broad
386 ligament leiomyoma. J Minim Invasive Gynecol 2005;12:469
387
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388 Legends:
389 Figure 1-Mesonephric(Wolffian) remnant showing cuboidal epithelium with eosinophilic
390 secretions
391 Figure 2-Paramesonephric(Müllerian) remnant showing a lining similar to Fallopian tube
392 Figure 3-Adrenal cortical rest shows cells with vacuolated cytoplasm in a well circumscribed
393 nodule.
394 Figure4-FATWO, showing characteristic sieve-like pattern.
395 Figure 5-Leiomyoma of the broad ligament seen at laparoscopy. Reprinted from J Minim
396 Invasive Gynecol 12(6), Theodoridis TD, Zepiridis L, Grimbizis G, Bontis J. Laparoscopic
397 management of broad ligament leiomyoma.p469, 2005, with permission from Elsevier.
398
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