Enigma of peritoneal masses – Disseminated peritoneal leiomyomatosis in a case of Ulcerative colitis

2015-06-15 18:42:41

Category: Abdominal Imaging, Region: Pelvis-Uterus, Plane: Axial

A 43 year old female, a known case of Ulcerative colitis, presented with history of lower abdominal pain since three days which was dull aching and continuous in nature, associated with low grade fever. She also complained of vaginal discharge with no history of loose stools or dysuria. She gave a history of laparoscopic myomectomy done twice in the past. All laboratory investigations were within normal limits. Clinical examination revealed firm mass of 16 weeks size in hypogastrium extending into the left iliac fossa with restricted mobility. Per vaginal examination showed uterus to be of 16 weeks size with restricted mobility. A firm mass was felt through both lateral fornices and posterior fornix separate from the uterus. Computed tomography (CT) of abdomen and pelvis showed fundal fibroid involving anterior wall with a large multilobulated soft tissue density mass posterior to the uterus (Fig 1A). Similar small mass lesions were noted to involve sigmoid mesocolon, left paracolic gutter and adjacent to ascending colon (Fig 1B). Post contrast imaging showed homogenous enhancement of the lesions similar to that of the fundal fibroid (Fig 1C). No evidence of bowel wall thickening, mesenteric hypervascularity or mesenteric fat proliferation was noted. Magnetic resonance imaging (MRI) showed multiple intramural fibroids exhibiting T1W and T2W hypointensity (Fig 2A). Similar signal intensity extrauterine lesions were noted in rectouterine pouch, sigmoid mesocolon and left paracolic gutter (Fig 2B). Right sided hydrosalphinx was also seen (Curved arrow in Fig 1A and 2B). There was no evidence of hydronephrosis. The imaging findings were suggestive of uterine leiomyoma with coexisting Disseminated peritoneal leiomyomatosis. She underwent total abdominal hysterectomy, bilateral salphingo oophorectomy and removal of peritoneal leiomyomata (Fig 3). Histology from the intrauterine lesions showed neoplasm composed of interlacing bundles and whorls of benign spindle cells with focal areas of hyalinization (Fig 4A). Multiple extrauterine lesions showed whorled pattern of smooth muscle bundles separated from each other by vascularised connective tissue and no pleomorphism (Fig 4B). Acute suppurative endosalphingitis producing pyosalphinx was noted involving right fallopian tube. Additional images available - Post operative specimen and histopathology.