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CASE REPORT
Year : 2022  |  Volume : 37  |  Issue : 1  |  Page : 68-70  

Benign metastasizing leiomyoma and findings on fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography


Department of Nuclear Medicine and Molecular Imaging, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission27-Jul-2021
Date of Decision09-Sep-2021
Date of Acceptance14-Sep-2021
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr. Sneha Shah
Department of Nuclear Medicine and Molecular Imaging, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_118_21

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   Abstract 


Benign metastasizing leiomyoma is a rare condition where benign smooth muscle tumors having a histological appearance similar to uterine leiomyoma are present at distant sites. This entity is commonly associated with a past history of hysterectomy done for uterine fibroids. The knowledge of the presence of significant fluorodeoxyglucose uptake in leiomyoma helped in the diagnosis of this condition in a 47-year-old patient who being evaluated for multiple unusual sites of metastases; this was further confirmed on histopathology.

Keywords: 18F-fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography, benign metastasizing leiomyoma, fibroid, hysterectomy


How to cite this article:
Gosavi A, Shah S, Purandare NC, Puranik A, Agrawal A, Rangarajan V. Benign metastasizing leiomyoma and findings on fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography. Indian J Nucl Med 2022;37:68-70

How to cite this URL:
Gosavi A, Shah S, Purandare NC, Puranik A, Agrawal A, Rangarajan V. Benign metastasizing leiomyoma and findings on fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography. Indian J Nucl Med [serial online] 2022 [cited 2022 Aug 18];37:68-70. Available from: https://www.ijnm.in/text.asp?2022/37/1/68/340860




   Introduction Top


FDG PET/CT is an established imaging modality in oncology practice due to its differential uptake in cells with high glucose metabolism like neoplastic cells. Therefore, FDG-PET is a sensitive modality for the diagnosis and staging of several types of malignancies. Benign metastasizing leiomyoma (BML) is a rare disease occurring predominantly in women of reproductive age and usually develops in women with history of hysterectomy or myomectomy for fibroids in past. Since FDG shows significant uptake in leiomyoma, we used this principle and picked up an unusual sites of metastases from BML which was further confirmed on histopathology.


   Case Report Top


A 47-year-old female with a past history of hysterectomy for dysfunctional uterine bleeding presented with complaints of abdominal pain and distention for 3 months. The patient was evaluated with routine blood parameters and tumor markers (including CA125, CA19-9, and CEA) and computed tomography (CT) which demonstrated a pelvic mass with size of 6 cm × 4.6 cm × 3.6 cm. A suspicion of a malignant etiology was raised and an 18F-fluorodeoxyglucose positron emission tomography/contrast-enhanced CT (18F FDG PET/CECT) was advised in search of possible primary and disease mapping. FDG PET CT MIP image [Figure 1]a showed low grade FDG uptake in the pelvic mass, (arrow) and right abdominal wall (arrow). Well demarcated homogenous lesions with low grade FDG uptakes are seen in the abdomino-pelvic region, largest in pelvis [Figure 1]f and [Figure 1]i and subcutaneous region of abdomen [Figure 1]g and lungs [Figure 1]h and [Figure 1]j in transaxial fused PET CT images & CT images [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e. The tumor markers were within the normal limits. Impressing further on past history, it was elicited that the patient had undergone two surgeries for fibroid removal (myoma resection), prior to hysterectomy. The characteristic well-demarcated homogeneous morphology of all lesions and prior history raised a strong suspicion of benign metastasizing leiomyoma (BML). A biopsy was suggested, which was suggestive of smooth muscle tumor confirming the functional radiological diagnosis of BML [Figure 1]k. Pathologically, BML consists of well-differentiated spindle-shaped cells and there is no disorganized growth pattern and mitotic figures. Besides these, Ki67 index for the BML is less than that for leiomyosarcoma.[1],[2] Estrogen/progesterone receptor (ER/PR) status was strongly positive, and thus the patient was started on medical castration using luteinizing hormone-releasing hormone analogs.
Figure 1: Fluorodeoxyglucose positron emission tomography and computed tomography maximum intensity projection image (a) showed low grade fluorodeoxyglucose uptake in the pelvic mass (arrow) and right abdominal wall (arrow). Well demarcated homogeneous lesions with low grade fluorodeoxyglucose uptakes are seen in the abdomino pelvic region, largest in the pelvis (b and c) and subcutaneous region of the abdomen (d) and lungs (i) in transaxial fused positron emission tomography computed tomography images and computed tomography images (e-h and j). Histopathology slides confirmed the same(k)

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   Discussion Top


Uterine leiomyoma, the most common gynecologic neoplasms, show clinical symptoms in approximately 20%–30% of women older than 35 years,[3],[4],[5],[6] and the characteristic features of a leiomyoma provide an unambiguous radiologic diagnosis. BML is a rare condition characterized by numerous well-differentiated leiomyomas at sites distant from the uterus, however are histologically identical. “Metastases” mostly affect the lungs,[7] whereas the others are the heart, brain, lymph nodes, bone, and skin. The presence of mild-to-moderate FDG uptake in multiple lung lesions without enlarged mediastinal and hilar nodes with or without a pelvic mass and other system involvement in a female patient with a past history of fibroids is predictive of BML as suggested by Lin et al.,[8] though this needs further larger cohort elucidation. The treatment modalities for BML are based on ER/PR suppression and include administering progesterone, medical castration using luteinizing hormone-releasing hormone analog, bilateral oophorectomy, radiation therapy to the ovary, and chemotherapy. If required, the combination of medical and surgical treatment has to be considered to arrive at an effective therapeutic plan.[9] Our case highlights the utility of F18 FDG PET/CT in characterizing the lesions both anatomically and functionally, mapping the disease extent thus helping in arriving at the diagnosis of BML. Thus, it can be said that F18 FDG PET/CT may prove useful in identifying the rare condition of BML.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mayerhofer K, Lozanov P, Bodner K, Bodner-Adler B, Kimberger O, Czerwenka K. Ki-67 expression in patients with uterine leiomyomas, uterine smooth muscle tumors of uncertain malignant potential (STUMP) and uterine leiomyosarcomas (LMS). Acta Obstet Gynecol Scand 2004;83:1085-8.  Back to cited text no. 1
    
2.
Gezginç K, Yazici F, Tavli L. Uterine smooth muscle tumors of uncertain malignant potential: A case presentation. Int J Clin Oncol 2011;16:592-5.  Back to cited text no. 2
    
3.
Lee AY, Poder L, Qayyum A, Wang ZJ, Yeh BM, Coakley FV. Imaging malignant and apparent malignant transformation of benign gynaecological disease. Clin Radiol 2010;65:1031-7.  Back to cited text no. 3
    
4.
Fasih N, Prasad Shanbhogue AK, Macdonald DB, Fraser-Hill MA, Papadatos D, Kielar AZ, et al. Leiomyomas beyond the uterus: Unusual locations, rare manifestations. Radiographics 2008;28:1931-48.  Back to cited text no. 4
    
5.
Szklaruk J, Tamm EP, Choi H, Varavithya V. MR imaging of common and uncommon large pelvic masses. Radiographics 2003;23:403-24.  Back to cited text no. 5
    
6.
Buttram VC Jr., Reiter RC. Uterine leiomyomata: Etiology, symptomatology, and management. Fertil Steril 1981;36:433-45.  Back to cited text no. 6
    
7.
Wolff M, Silva F, Kaye G. Pulmonary metastases (with admixed epithelial elements) from smooth muscle neoplasms. Report of nine cases, including three males. Am J Surg Pathol 1979;3:325-42.  Back to cited text no. 7
    
8.
Lin X, Fan W, Lang P, Hu Y, Zhang X, Sun X. Benign metastasizing leiomyoma identified using 18F-FDG PET/CT. Int J Gynaecol Obstet 2010;110:154-6.  Back to cited text no. 8
    
9.
Moon H, Park SJ, Lee HB, Kim SR, Choe YH, Chung MJ, et al. Pulmonary benign metastasizing leiomyoma in a postmenopausal woman. Am J Med Sci 2009;338:72-4.  Back to cited text no. 9
    


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