Leiomyoma of the uterine body: what it is, treatment, causes, symptoms, signs, prognosis. How to treat uterine leiomyoma and how dangerous is it? Intramural and other types of leiomyomas Bizarre leiomyomas

Article last updated 12/07/2019

Leiomyoma of the uterine body is a pathological muscular growth of the walls of the organ, leading to oncology. The tumor itself has a benign structure, but with neglected treatment it can become malignant. Medicine also calls this pathology myoma or fibroids of the uterus.

The disease can appear in one in four women aged 30-40 years. The disease is hormone-dependent and can go away on its own. But most often, leiomyoma requires appropriate treatment.

To have a concrete understanding of fibroids, it is necessary to study the anatomical structure of the reproductive organ. The uterus is a hollow organ that can carry a baby and push it out of the body during childbirth. This complex mechanism of work is carried out due to the myometrium, the inner layer of the organ. This strong frame is formed from different types of muscle fibers in combination with connective tissue.

Outside, the myometrium is covered with a serous membrane, reminiscent in its composition of the abdominal cavity. The inner layer of the uterus is called the endometrium, consisting of several layers of epithelium. At the appropriate phase of the cycle, this layer is renewed, and menstruation occurs. All endometrial processes are controlled by female hormones produced in the ovaries.

What is nodular uterine leiomyoma?

This disease is characterized by the appearance of a myomatous node. If there are several of these appearances at once, then the fibroid is called multiple. Multiple growths vary in size, structure and type. The nodular form often does not manifest itself in any way, and a woman does not know about it for years if she does not visit a gynecologist on a regular basis.

The tumor has no special symptoms in the early stages. The clinical picture is similar to many gynecological diseases. Therefore, ultrasound and hysteroscopy are considered to be the most reliable and accurate diagnostic methods.

Doctors do not always prescribe treatment for uterine leiomyoma. As a rule, if a woman has reached menopause, the tumor freezes or regresses. Therefore, it requires simple regular monitoring.

The disease is hormone dependent. In this regard, it is easily influenced by hormonal drugs. Small fibroids may disappear completely or stop developing under the influence of medications. Surgery to remove fibroids is prescribed in cases where there is a risk of serious complications, the woman feels severe pain or the functioning of nearby organs is impaired. But even after surgery, the disease can return. This occurs due to incorrect treatment tactics to eliminate the cause of cancer.

Types of leiomyoma

We have already figured out what leiomyoma is. Now let's look at the classification of oncology.

Depending on the location of the formation of myomatous nodes, the tumor has the following names:

• Intramural leiomyoma of the uterus occurs more often than other species. It is formed in the inner part of the muscle layer, quite deep. Symptoms include pain in the pelvic area, irregular menstruation, and disruption of the functioning of neighboring organs.
• Submucosal leiomyoma is the growth of tissue under the mucous membrane of the uterus. Often this type of tumor grows inside the organ and it becomes difficult to conceive a child.
• Subserous leiomyoma of the uterus is formed under the serous membrane, as is clear from the name itself. It is located on the outside of the organ and grows towards the abdominal cavity. The difference between this type is its asymptomatic nature. The only thing a woman may notice is slight discomfort in the lower abdomen.
• Multiple leiomyoma – this is the formation of several myomatous nodes at once, which differ in volume, tissue composition and place of attachment to the uterus.
• Unspecified form of uterine leiomyoma - This is essentially a hidden form of a tumor that cannot be confirmed through diagnostics. This happens extremely rarely due to the small size of the fibroid or its slow growth. Gynecologists can only suspect the presence of oncology. A woman needs to be regularly monitored by a specialist so as not to miss the onset of the disease.

In the photo above you can see what types of tumors are found and what they look like in life.

Any leiomyomatosis forms in the myometrium of the uterus and goes through specific stages of maturation:

• First of all a muscle knot is formed. It grows from smooth muscle and fibrous fibers around small vessels. At this stage, there are still no clinical manifestations, since the tumor is small.

• What follows maturation stage. During this cycle, the fibroid actively grows, forming a ball of muscle fiber, which becomes denser over time. Adjacent tissues gather around it, forming a special capsule. The node becomes isolated, and its volume increases. This process is also called “maturation” of the tumor. When diagnosed, fibroids are easy to detect, and the patient already has clinical symptoms.
• The next stage comes aging leiomyoma. Since the tissues degenerate due to the pathological process, the node stops growing, or even decreases altogether.

In each case, oncology behaves differently. You should not expect the same manifestations in all women diagnosed with leiomyomatosis.

Causes of leiomyoma

The detected uterine cancer largely depends on the woman’s hormone levels. Therefore, with a large amount of estrogen in the blood, cells begin to divide pathologically, and during menopause this process stops.

Then the question arises, why not all women with hormonal disorders are diagnosed with leiomyomatosis?

The true reasons are not fully understood, but there are a number of provoking factors:

• Central factor– brain injuries, vascular pathologies and psycho-emotional disorders. Hormones from the pituitary gland and hypothalamus control ovarian function. The ovaries are responsible for the process of follicle maturation and the onset of ovulation. Therefore, any malfunction in the brain can lead to dysfunction of the reproductive system.

• Classic factor– chronic infectious and inflammatory diseases of the ovaries, including polycystic disease. The production of estrogen and progesterone is complicated. The imbalance of these hormones increases, which leads to the diagnosis of leiomyomatosis. In practice, the classical factor occurs more often than others.
• Uterine factor– any mechanical injury to the reproductive organ can provoke cancer. Even with good functioning of the ovaries, the uterus may not perceive female hormones due to damage to the integrity of the receptors. Such trauma is caused by complicated childbirth, abortion, and surgery.

• Related factors– disruption of the endocrine system, such as diabetes, thyroid diseases and others cause the growth of myomatous nodes.

If you know in advance about your predisposition to one of the factors, it is recommended to visit a gynecologist more often and carefully monitor your women's health.

Symptoms of the disease

The clinical picture depends on the growth of the tumor, the number of nodes, their location and the progression of the disease. Small interstitial muscle nodes are usually not dangerous to the body. But submucosal uterine leiomyoma or submucous form, even having a small size, significantly manifests itself in the form of the following symptoms:

• Menstrual irregularities. Menstruation becomes irregular, longer and more abundant. In the early stages, such manifestations are relieved with medications, so the patient does not immediately consult a doctor. But gradually the blood loss becomes significant, causing discomfort and pain. Against this background, anemia occurs, and it is no longer possible to do without the help of a specialist.

• Pain syndrome appears due to difficult contraction of the myometrium. A large fibroleiomyoma does not allow the epithelium to peel off, and pain occurs. Severe pain can occur with subserous fibroids, and with the intramural form it can be nagging and aching. If necrosis occurs in the tissues of the uterus, a sharp pain is felt, called “acute abdomen”.
• Disruption of neighboring organs. Leiomyomatosis causes problems with the bowels and bladder. In this case, the woman feels a constant urge to go to the toilet or, on the contrary, has difficulties with defecation and urination. The size of the nodes is large.

• Reproductive organ dysfunction. Against the background of leiomyoma and its accompanying pathologies, as well as hormonal imbalance, infertility develops and ovulation is disrupted. The reason is the unfortunate location of myomatous nodes in the organ cavity, preventing the normal attachment of the egg. Uterine leiomyoma during pregnancy can have unpleasant consequences such as premature termination and arbitrary miscarriage. But according to statistics, such cases occur rarely.

Diagnosis of the disease

At the initial appointment, the gynecologist performs a manual examination of the uterus and collects all the patient’s complaints. A two-handed examination determines the deformation of the organ, its density and size. It is the size of the uterus that is of great importance. The specialist selects a specific day of the cycle and every year at this time the examination takes place. If over a one-year period the uterus has not increased in size by more than four weeks of pregnancy, then the disease is said to be slowly progressing.

Using a speculum, it is possible to detect submucosal nodes when they grow towards the cervix. For a more accurate result, the colposcopy method is used.

Ultrasound is considered the most reliable way to diagnose oncology. With it you can install:

• Number of myomatous nodes, their characteristics
• Structure, duration, type of fibroids
• Endometrial pathology
• Functioning of the ovaries

In addition to ultrasound, they perform MSG, hysteroscopy, and also take smears for flora and biopsy for oncocytology.

Treatment of leiomyoma

We have studied in detail what the diagnosis of uterine leiomyoma is. Now let's turn to the treatment of oncology. In practice, tumors are usually treated with conservative methods. Often, fibroids disappear on their own or regress during menopause. Therefore, doctors are in no hurry to prescribe surgical removal of the tumor. The choice of appropriate therapy depends on the results of the examination and the patient’s well-being. Conditions for treatment with traditional methods are:

• Tumor size up to 3 cm and uterine enlargement up to 12 weeks of pregnancy
• Asymptomatic, minimally symptomatic course of the disease
• Planning a future pregnancy
• Intramural and subserous type of fibroids

Surgical intervention is indicated in such cases as:

• Advanced disease, fibroids up to 36 weeks of gestation
• Submucosal nodes
• Torsion of the legs of the nodes, necrosis of the uterine walls
• Subserous fibroids with severe symptoms
• Lneumyoma on the cervix
• Hyperplastic processes
• Lack of effect from conservative treatment

Leiomyoma is one that is formed from the smooth muscles of the mucous membranes. The tumor forms in any organ with a smooth muscle fiber type, but in most cases it is localized in the uterus. Uterine leiomyoma is the most common type of tumor, so let’s take a closer look at it.

What is leiomyoma?

Benign formations have the form of single nodes, which can be localized in any area of ​​the mucosa. The node has a round shape. The color of the neoplasm is white or brown. The node branches on the sides. Size - from a few millimeters to the diameter of a grapefruit.

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Leiomyoma can appear in organs:

• Uterus;
• Stomach;
• Rectum;
• On the skin;
• In the walls of blood vessels;
• On the palate;
• On the tongue;
• Bladder.
• Prostate.

Origin of the disease

Scientists have proven the theory of a genetic predisposition to uterine leiomyoma. There is a special gene that causes mutation of muscle fibers at the cellular level. If the mother has gynecological diseases, the daughter has a high risk of developing similar disorders.

Since the tumor is predominantly muscle tissue, the name used in medicine is uterine fibroids. The neoplasm also contains fibrous tissue. Therefore, gynecologists sometimes call the tumor fibroids.

Peculiarities

Uterine leiomyoma is the most common disease of the female reproductive system. According to some data, up to 70% of women have encountered pathology. The disease is called a tumor conventionally, because leiomyoma has only some signs of tumor formations.

Distinctive features:

• Goodness;
• Dependence on hormone levels - the “behavior” of the neoplasm is determined by estrogens;
• Tendency to disappear without a trace - in some cases, the tumor goes away without treatment or surgery.

The uterus is an organ with a unique structure. During pregnancy, it increases many times over.

After birth, it quickly returns to its original size. Such changes occur due to the myometrium, a muscle layer located in the wall of the organ. The layer consists of several types of fibers. They intertwine with each other, forming a spiral. The result is a durable structure.

The main function of the myometrium is to provide contractile movements in the organ during childbirth, when the fetus is expelled and during menstruation, to cleanse the contents. The source of development is elastic muscle and connective tissue structures. One or more nodes may form in the myometrium. Sometimes they differ in structure, size and time of appearance.

A tumor of the uterus has the ability to exist for a long time without manifesting itself or increasing in size.

Reasons for development

Women aged 35-45 years are at risk. In young women, uterine disease is less common.

The main cause of tumors in the uterus is increased levels of the hormone estrogen and genetic predisposition. There are also provoking factors.

Along with heredity, they cause the appearance of nodes in the organ:

Types of leiomyoma

Depending on the number of nodes there are:

• Single;
• Multiple (75% of cases).

Depending on the location of the leiomyoma to the muscle fibers, There are several types of formations:

These tumors are typical. There are variants of neoplasms that are classified according to the structure of microparticles:

If the node does not grow or increases in size at a slow pace, it does not bother the woman for a long time. When it grows, it moves to other layers of the organ walls.

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Tumor stages

Any type of leiomyoma goes through several stages of development:

1. Formation of a node in the structure of the muscle layer. Regardless of the final location of the tumor, it initially forms in this “framework”. Smooth muscle and fibrous fibers begin to grow next to the smallest vessels. At this stage, the node has not yet formed, the woman is not bothered by pain.
2. Maturation stage. The active growth of leiomyoma starts. A small node becomes denser and enlarges. A clear border without a capsule is formed around it. At this stage, the tumor makes itself felt with painful symptoms. The nodes are already clearly visible during examination.
3. Stage of “aging” of leiomyoma. Tumor growth stops. Depletion occurs in its tissues. In some cases, the diameter of the tumor decreases.

Symptoms

Often, signs of the disease are absent or mild. Symptoms of the disease:

• Heavy bleeding during menstruation;
• Sudden weight gain;
• Spotting after sexual intercourse and between periods;
• Nagging pain in the lower abdomen;
• Irregularity of the menstrual cycle;
• Infertility;
• Sensation of squeezing in the pelvis;
• Bleeding not associated with menstruation;
• Urinary incontinence.

If the node is large, it puts pressure on the ureter, causing kidney failure. As a result, stones can form in the kidneys.

Diagnostics

If the gynecologist suspects a fibroid, the patient is prescribed an examination:

1. Blood test;
2. Smears on the flora and;
3. Ultrasound of the uterus;
4. Colposcopy;
5. MRI - examination using x-rays;
6. Biopsy. The method allows you to determine the stage and spread of the tumor.

Sometimes a specialist discovers fibroids during a gynecological examination. In this case, research is also carried out to determine its type, size and degree.

Treatment

The choice of therapy is influenced by factors:

• Tumor growth rate;
• The presence of painful symptoms;
• Woman's age;
• Plans regarding pregnancy.

Drug treatment

1. Calcium antagonists. These drugs are prescribed for pain caused by leiomyoma. Extracellular calcium ions stimulate contraction of muscle fibers. The pain goes away.
2. Drugs that block the sensitivity of nerve endings. They relieve attacks of pain when exposed to tactile stimuli.
3. Birth control pills. Therapy is effective at the initial stage of leiomyoma and before surgery.

If the tumor does not exceed 5 cm, drug therapy is effective. After treatment it decreases in size. Older women are more likely to stop growing due to menopause.

Surgical removal of the tumor

1. Laparoscopy. The advantage of the operation: quick rehabilitation of the patient.
2. Radiofrequency exposure. A catheter is inserted into the blood vessels of the tumor. It ensures the supply of the drug. Under the influence of the drug, the vascular networks of the node are destroyed. As a result, the leiomyoma dies.
3. Surgery. Pathological tissues are completely removed during the intervention. During postmenopause, the tumor is removed along with the uterus.

Chemotherapy

Antitumor drugs are used only for malignant processes. The dose of chemotherapy drugs is prescribed based on the patient's condition.

Like all tumors, leiomyoma requires timely treatment. Removal of a benign tumor is not life-threatening. The prognosis is favorable. The course of malignant leiomyoma depends on whether there are metastases. After the operation, they undergo a preventive examination 2 times a year.

The exact etiology is unknown, but hormonal causes, as well as inactivation of androgen receptor genes and the X chromosome, have been suggested.

Clinical manifestations depend on the number, size and location of tumor nodes and are absent in most patients; menorrhagia and pelvic pain occur in 30% of cases. Rarely, uterine leiomyoma manifests itself as ascites and erythrocytosis due to the production of erythropoietin by the tumor.

Leiomyoma in most cases is represented by multiple nodes (> 75%). The node often has a fibrous appearance, whitish color and bulges above the cut surface as the leiomyoma grows expansively, pushing apart the surrounding myometrium and creating a pressure gradient in the tissues. There is a clear boundary between the tumor and the surrounding myometrium, but the capsule does not form. The consistency of typical leiomyomas is densely elastic, but in the presence of myxomatosis, edema, or cellular leiomyoma, the tumor may be soft. Sometimes areas of hemorrhage and necrosis are detected, especially in large nodes.

Microscopically, the tumor consists of intricately intertwined bundles of smooth muscle cells. The cells are spindle-shaped with eosinophilic fibrillar cytoplasm and cigar-shaped nuclei. In a typical leiomyoma, the nuclei are monomorphic, mitoses are absent or extremely rare. The cells in a typical leiomyoma have scant cytoplasm and lie closer together than the cells of normal myometrium. Sometimes palisade-shaped structures are formed that resemble a neurilemmoma and are called neurinomatous. Often, areas of hyalinosis and sclerosis are found in leiomyoma, which can be so extensive that they almost completely replace tumor cells. Sometimes areas of hyalinosis in typical leiomyomas undergo myxoid transformation.

Depending on their location in the myometrium, leiomyomas are divided into submucosal, intramural and subserous. Submucosal leiomyomas are located directly under the endometrium, causing its atrophy. Therefore, the presence in scrapings of fragments of the functional layer of the endometrium without glands, indicating the presence of dysfunctional uterine bleeding, may indirectly indicate the presence of submucous leiomyoma.

The prognosis of typical uterine leiomyoma and most variants is usually favorable. For some rare variants, there is insufficient information in the literature.

Cellular leiomyoma

Macroscopically, the color and shape may be no different from a typical leiomyoma, although cellular leiomyomas often have a yellowish color on section. The consistency is often soft, which may suggest sarcoma. In this case, the neoplasm should be examined especially carefully.

The cells are similar to those of a typical leiomyoma and vary from spindle-shaped to round depending on the angle of section, the cytoplasm is scanty, the nuclei are densely packed, dark but not enlarged. Nuclear atypia is absent, mitotic activity is variable, but generally low, which allows it to be differentiated from leiomyosarcoma. Unlike typical leiomyoma, the edge of the tumor is not always clear; focal invasion into the adjacent myometrium is observed. Sometimes the cells are arranged so compactly that the tumor resembles an endometrial stromal node. Cellular leiomyoma can be distinguished by the tufted structure of the tumor, spindle-shaped cells, the presence of large-caliber thick-walled blood vessels, slit-like spaces and the absence of foam cells, which are often detected in uterine stromal tumors. It is also possible to use immunohistochemical research: cellular leiomyomas express smooth muscle actin, h-caldesmon, and desmin.

Stromal tumors are characterized by the expression of CD10, CD99, inhibin and calretinin, focal smooth muscle actin, desmin is not detected. Most cellular leiomyomas have similar genetic disorders, including 1p deletion and 10q22 translocation.

Bizarre leiomyoma

Synonyms: atypical leiomyoma, symplastic leiomyoma, pleomorphic leiomyoma.

The tumor is benign; conservative myomectomy is currently used for treatment; however, if the atypia is diffuse and the tumor size exceeds 5 cm, the risk of progression to leiomyosarcoma increases.

Macroscopically, it may be indistinguishable from a typical leiomyoma, but some tumors have a yellowish tint on section, areas of hemorrhage, or myxoid degeneration.

It is characterized by the presence of bizarre polymorphic cells with atypical nuclear characteristics and eosinophilic cytoplasm. It should be noted that to make a diagnosis of atypical leiomyoma, it is necessary that nuclear atypia be evident even at low microscope magnification (50 or 100 times). Most fancy cells are multinucleated or have a clawed nucleus. There are mononuclear cells with an enlarged hyperchromic nucleus, as well as changes in the form of karyorrhexis and karyopyknosis, often imitating mitotic figures. Typical mitoses can be detected, the number of which does not exceed 5 in 10 fields of view. Areas of edema, degeneration, and necrosis are often observed, around which cellular symplasts are predominantly localized. So-called geographic necrosis, typical of leiomyosarcoma, is uncharacteristic.

Mitotically active leiomyoma

Benign smooth muscle tumor with a large number of mitoses. More often, these tumors are detected in patients of reproductive age, are usually submucosal and are sometimes associated with hormone therapy.

Microscopic examination reveals more than 10 typical mitoses in 10 fields of view. Increased mitotic activity is often observed uniformly throughout the tumor. Pathological mitoses, necrosis and cellular atypia are uncharacteristic. There is an increase in proliferative activity, which reflects the biological characteristics of the tumor, however, only an increase in the expression of Ki-67 cannot serve as a basis for diagnosis.

The tumor is often small, the average diameter is 2-3 cm, in all the described cases the maximum size did not exceed 8 cm. With a tumor diameter of more than 8 cm, high proliferative and mitotic activity, the presence of cellular atypia and necrosis, a diagnosis of leiomyosarcoma should be made.

In our opinion, this variant of leiomyoma is controversial, and diagnosis is very problematic. Additional molecular genetic studies should be used to categorically exclude leiomyosarcoma in the presence of a large number of mitoses.

Hydropic leiomyoma

This variant is characterized by pronounced focal watery edema of the stroma. There are areas of hyalinosis. Such tumors often contain a large number of vessels and have a characteristic nodular structure.

Apoplectic leiomyoma

Synonym: degenerative leiomyoma, hemorrhagic cellular leiomyoma.

Large smooth muscle tumors often undergo degenerative changes; in addition, progestin therapy can induce “apoplectic” phenomena with the development of hemorrhagic infarction. The most common is hyaline degeneration, characterized by the expansion of fibrous septa with the loss of fibrillar structures, weakly eosinophilic coloring, and the appearance of a resemblance to “ground glass.” There may be swelling or cystic degeneration, as well as large areas of hemorrhage. Tumor cells around the hemorrhage areas are located radially, mitotic activity in these zones may increase, but there is no atypia. Necrobiosis or hemorrhagic impregnation develops as a result of malnutrition of the tumor, since the rate of vascular development lags behind the rate of tumor growth. Calcification is more common in postmenopausal women. Sometimes degenerative changes in leiomyomas can occur during pregnancy or taking progestin medications.

Lipomatous leiomyoma

Synonym: lipoleiomyoma.

A tumor containing, along with smooth muscle elements, a large number of fat cells. Sometimes there are areas of chondroid differentiation. More often observed in older women. There are several theories of the origin of lipoleiomyoma: fatty degeneration of tumor tissue with the accumulation of fats in the cytoplasm of myocytes and fatty metaplasia with the appearance of true adipocytes. The tumor was found to have a dysfunction of the HMGA2 gene, which determines its similarity to cutaneous lipoma and uterine leiomyoma.

Epithelioid leiomyoma

Smooth muscle tumor with a predominance of round epithelial-like cells. Its malignant potential is currently being actively debated. Variants: leiomyoblastoma, clear cell leiomyoma, plexiform tumor.

On macroscopic examination, this tumor is practically no different from typical leiomyomas; it is also clearly demarcated from the surrounding myometrium, but sometimes it can have a softer consistency and a yellowish color.

Leiomyoblastoma consists of round cells with eosinophilic, slightly vacuolated cytoplasm.

Clear cell leiomyoma is represented predominantly by cells with large vacuoles containing glycogen and lipids.

IN plexiform tumor large epithelioid cells and islets or chains of small round cells are detected, sometimes these tumors are multiple and microscopic plexiform tumorlets.

Epithelioid leiomyomas with clear, smooth edges, pronounced hyalinosis and a predominance of clear cells are benign. However, in the presence of foci of necrosis, large size of the node (> 6 cm), the presence of mitoses and cellular atypia, the tumor should be classified as a neoplasm with uncertain malignant potential, and the patient should be closely monitored. With high mitotic activity, the likelihood of distant metastasis significantly increases, so such a tumor should be regarded as epithelioid leiomyosarcoma.

Myxoid leiomyoma

A benign smooth muscle tumor with severe myxoid degeneration, containing large amounts of amorphous mucus-like material between bundles of smooth muscle cells or between individual groups of cells. There is no cellular atypia, mitoses are uncharacteristic. Often, individual blood vessels are identified in areas of myxomatosis. Unlike myxoid leiomyosarcoma, there is no invasion into the adjacent myometrium and cellular atypia, but the differential diagnosis is extremely difficult.

In some cases, myxoid leiomyomas, especially large ones, have a poor prognosis.

Dissecting leiomyoma

A benign tumor characterized by separation of the surrounding myometrium by smooth muscle “tongues” and extension to the broad ligament of the uterus and pelvic wall. This growth pattern can also be observed with intravenous leiomyomatosis. Macroscopically similar to the maternal surface of the placenta.

Vascular leiomyoma

Leiomyoma containing a large number of blood vessels with a thick muscle wall. Along with an abundance of vessels, such tumors usually contain areas of a typical structure.

Differential diagnosis includes hemangioma and arteriovenous malformation, which extremely rarely develop in the uterus.

Leiomyoma with lymphoid infiltration

Smooth muscle tumor with abundant lymphoid infiltration. The infiltrate is represented predominantly by small lymphocytes with an admixture of plasma cells, and sometimes occurs for no apparent reason. In some cases, infiltration may be associated with the therapy being performed. With widespread bacterial infection, abscesses can develop in leiomyomas. Extensive lymphoid infiltration may mimic lymphoma. Peculiar infiltrates are formed with extramedullary hematopoiesis, an abundance of histiocytes or mast cells and eosinophils. Prognosis unknown. It is not distinguished in the WHO classification.

Palisade leiomyoma

It is characterized by a peculiar arrangement of muscle fibers that form palisade-like structures and make the tumor look like a neurilemma. Most authors question the existence of this tumor variant, since it is unknown whether it differs prognostically from typical leiomyoma, and consider the formation of palisade-like structures to be a characteristic characteristic of typical leiomyoma.

Diffuse leiomyomatosis

A condition in which the uterus diffusely and uniformly enlarges due to multiple myomatous nodules. The analysis shows that each tumor is a separate independent clone of cells, confirming that patients have a unique tendency to initiate tumor growth. An observation is described in which diffuse leiomyomatosis was complicated by uterine rupture and the formation of lytic metastasis in the bones during pregnancy.

Macroscopically, the uterus is symmetrically enlarged and can reach significant sizes and significant weight (up to 1 kg). The surface of the organ is lumpy. In the myometrium, multiple nodules ranging in size from microscopic to 2-3 cm are detected, paler than the surrounding myometrium, trabecular or fibrous in appearance.

Microscopically, the nodules consist of cellular bundles of smooth muscle fibers with an indistinct border. In the center of the nodules, tangles of blood capillaries are detected, surrounded by hyalinized stroma. Mitoses are rare, cellular atypia is absent.

The differential diagnosis is low-grade endometrial stromal sarcoma, but stromal sarcoma is characterized by endometrial involvement, lymphatic invasion, and diffuse vasculature of arterioles and capillaries.

Intravenous leiomyomatosis

Synonym: intravascular leiomyomatosis.

A rare condition in which smooth muscle tumors with benign morphological characteristics are detected in the lumens of the veins.

Intravenous leiomyomatosis is usually clearly visible on gross examination. The uterus is enlarged; on a section, convoluted grayish cords of soft elastic tissue are found in the dilated vessels.

Microscopically, in the presence of uterine leiomyoma, it is sometimes possible to detect a transition from the tumor to the vessels. In some cases, the primary tumor is completely absent, and smooth muscle cords are located only in the vessels, confirming a possible vascular origin. The histological structure resembles a typical leiomyoma, sometimes with fibrosis and hyalinosis; areas of vascular or myxoid leiomyoma can be detected. Various types of leiomyomas have been described in intravenous leiomyomatosis, including cellular, epithelioid, atypical, myxoid, and lipoleiomyoma. Intravenous leiomyomatosis differs from leiomyosarcoma by the absence of atypia, foci of necrosis, low mitotic activity, and from endometrial stromal sarcoma by a smooth muscle immunophenotype.

Treatment involves extirpation of the uterus and appendages and the maximum possible removal of the intravascular component using endovascular surgery. The tumor is hormone-dependent, and with non-radical surgical treatment it is possible to use analogues of gonadotropin-releasing hormone and tamoxifen. The prognosis of intravenous leiomyomatosis is largely determined by the extent of vascular damage. Cases of death have been reported with cardiac chamber involvement.

Metastatic leiomyoma

“Metastases” are actively growing tumors, most often occurring in women of reproductive age who have uterine leiomyoma at the time of detection of “metastases” or in history. Since the localization of these tumors is different, the terminology varies from “disseminated peritoneal leiomyomatosis” to “intravenous leiomyomatosis” (with spread into the vessels and cavities of the heart).

Risk factors are not clearly defined, but there is evidence that most patients underwent exploratory curettage, myomectomy, or hysterectomy before detection of “metastases,” which is considered a predisposing factor for the development of ML. Another confirmation of the metastasis theory is that lung leiomyomas are extremely rare, and in the case of ML, tumors in the lung contain ER and regress with treatment.

The pathogenesis of ML remains unclear but is thought to be similar to that of endometriosis. This disease often, as already mentioned, occurs in women of reproductive age and is closely related to hormonal stimulation. Therefore, such links in the pathogenesis of endometriosis as hormonal stimulation, lymphogenous and hematogenous spread, coelomic metaplasia and intraperitoneal implantation can also be considered in relation to ML.

Hormonal stimulation. In some cases of ML, receptors not only for estrogen, but also for progesterone and luteinizing hormone were found in the tumor. There is an increase in ML when exposed to estrogens or increased endogenous levels of estrogens, and regression of the tumor during pregnancy is described. Reversal has been observed following oophorectomy to enopause with the use of gonadotropin-releasing hormone agonists, megestrol, P450 aromatase inhibitors, and selective estrogen modulators. However, in a small number of reported cases, ML occurred in women of reproductive age who were not receiving hormone replacement therapy. Thus, the hormonal stimulation theory cannot explain all cases of ML.

Peritoneal spread. In the last 3 years, there have been more and more reports of ML occurring after diagnostic curettage of the uterine cavity or laparoscopic or abdominal myomectomy and hysterectomy for leiomyoma of the uterine body. It is possible that fragments of fibroids are implanted in the area where the laparoport is located when the tumor is removed or are fixed on the walls of the abdominal cavity and pelvic cavity when the node is fragmented. This theory can also explain only isolated cases of peritoneal leiomyomatosis.

Lymphogenous and hematogenous spread. It is possible that fragments of leiomyoma enter the venous or lymphatic vessels during surgery and subsequently spread to other organs.

Coelomic metaplasia. Disseminated peritoneal leiomyomatosis may present with lesions originating from the submesothelial mesenchyme. These tumors probably arise from subcoelomic mesenchymal cells that differentiate into myoblasts under the influence of hormonal factors.

ML is often asymptomatic and discovered incidentally during laparotomy, laparoscopy, ultrasound, or radiography. Occasionally, patients complain of discomfort in the abdominal area, bleeding from the genital tract; some independently detect space-occupying lesions in the abdominal cavity. Most patients have a history of uterine leiomyoma, myomectomy, or hysterectomy for leiomyoma.

The size of the nodes varies from 0.5 to 50 mm. Histologically, ML is a typical or cellular leiomyoma, which is characterized by proliferation of smooth muscle cells, sometimes with single mitoses, minimal nuclear atypia, and the absence of foci of necrosis. The nodes may contain fibroblasts, decidu-like cells, and occasionally endometrial stromal cells.

Immunohistochemical examination reveals smooth muscle cell markers: desmin, smooth muscle actin, muscle-specific actin, caldesmon, as well as vimentin, estrogen, progesterone and luteinizing hormone receptors.

ML is characterized by slow growth, but has a potential risk of recurrence and malignancy. Sometimes relapses occur during menopause, despite a previous oophorectomy. Cases of repeated laparotomies for recurrent ML have been described. In all cases, progression or relapse within the first year should be considered as a possible sign of malignancy. With adequate treatment, the prognosis is favorable.

Benign ML must be differentiated from leiomyosarcoma. The main criteria for diagnosing uterine leiomyosarcoma are high mitotic activity, the presence of foci of necrosis, and cellular atypia. However, these indicators are not specific enough. Therefore, morphological criteria are not always effective in the differential diagnosis of ML with leiomyosarcoma. Necrosis and cellular atypia are often observed in benign tumors, and counting mitotic figures requires careful cutting of material and high quality preparations. In addition, difficulties arise in assessing the nature of the process with a “borderline” number of mitoses. Assessment of tumor proliferative activity (Ki-67 index) can only serve as an auxiliary method.

Leiomyomatosis and renal cell carcinoma syndrome

An inherited autosomal dominant disease associated with a terminal mutation of the fumarate hydratase (FH) gene located on chromosome 1q42.3-q43. It is characterized by the presence of multiple leiomyomas of the uterus and skin, the development of bilateral renal cell carcinoma and early leiomyosarcomas of the uterus. Papillary cancer type II, G3-4, usually develops in the kidneys. Uterine leiomyomas are usually cellular, with cell atypia, the presence of multinucleated cells, nuclei with red or orange nucleoli surrounded by a light rim.

Neoplasms in the uterus are one of the most common types of benign tumors in women. Fibroids vary in structure, location, symptoms and other factors. Uterine leiomyoma is quite common and has a number of its own characteristic features. They are described in this material.

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Peculiarities

What is uterine leiomyoma? Leiomyoma is a benign non-oncological neoplasm in the uterus. It can be located both on the cervix and in the uterine cavity. It develops and grows when the body's hormonal balance is disrupted. It is completely hormone dependent. For this reason, it may disappear completely with the onset of menopause.

Varies greatly in size. Leiomyoma of the uterine body can be only a few millimeters in diameter. And it can weigh up to several kilograms. The node has a round shape. It can be on a wide base or on a stalk. The second option is more dangerous, since such nodular uterine leiomyoma can undergo necrosis after torsion of the pedicle.

According to its morphological composition, it consists of muscle and connective (fibrous) tissue. It is, in fact, a ball of woven fibers of these fabrics. Causes symptoms of varying intensity, depending on the location and size of the tumor. You can see what it looks like in the photo below.

Leiomyomatosis disease

The diagnosis of leiomyomatosis is made after detection of this neoplasm as a result of ultrasound or visual examination. At the initial stage of diagnosis, it is impossible to make a precise diagnosis, since all neoplasms look the same. But when a node is detected, the doctor prescribes a histological test.

Using the laparoscopic method, part of the fibroid tissue is removed for examination. If the formation is small, then this is not done. After histological examination, it is possible to determine exactly the type of fibroid based on its composition.

Histology

Most often, several nodes are found on the walls and cervix of the uterus. They may be different sizes or approximately the same. In this case, a diagnosis of multiple leiomyoma is made. Single nodes are quite rare.

All women of reproductive age are susceptible to the disease. However, it is especially widespread among patients aged 35 to 50 years. Although recently there has been a tendency towards the development of myomatosis at an earlier age. Almost every second woman over the age of 35 has a benign tumor in the uterus. At the same time, the nodular form of leiomyoma is one of its most common types.

Differences from other fibroids

Mainly, submucosal leiomyoma of the uterus (or any other) differs from other types of fibroids in composition. It contains fibers of connective and muscle tissue. Fibroma contains only fibrous fibers, while fibromyoma contains predominantly fibrous and muscle fibers. In some types of neoplasms, nerves and blood vessels are also present in large numbers.

Types by localization

It can be localized in different parts of the uterus. The following types are distinguished on this basis:

Types of fibroids

• Submucosal uterine leiomyoma (or submucosal) is localized under the mucous membrane. Has the most pronounced symptoms and is the most dangerous;
• Cervical leiomyoma is localized on the cervix. Usually, it is diagnosed quite early, as it is located in a place that is regularly examined by a gynecologist;
• Intramural is located in the muscle layer. It can only be removed surgically. Occurs quite often;
• The interligament is located in the muscle layer between the ligaments. It also gives very strong symptoms. In particular, pain;
• The subserous is located under the inner lining of the uterus. It is quite rare.

The localization of the tumor is often visible on ultrasound and visual examination.

Leiomyoma on ultrasound

Types by type

Fibroids can be classified into two other categories.

• By quantity. They talk about a single fibroid when there is only one node. And about multiple - in the presence of two nodes or more. The first option is quite rare and mainly occurs in young women;
• By size. There are small, medium and large neoplasms. For convenience, doctors use an analogy with the increase in the size of the uterus during pregnancy. Small nodes correspond to the enlargement of the uterus at 2-4 weeks of pregnancy and have a diameter of up to 20 mm. Medium - from 4 to 6-8 weeks and up to 80 mm in diameter. Large - from 6 to 12 weeks or more, which corresponds to 100 or more millimeters in diameter.

Reasons for appearance and growth

A neoplasm of this type is completely hormone dependent. If there is a hormonal imbalance, a woman’s body begins to produce too much estrogen. It accumulates in the blood.

It is its presence in excess that triggers the processes of active cell division in the uterus. Thickening of the endometrium occurs. You may even develop endometriosis. There is also increased division of muscle and connective tissue cells. As a result, fibroids are formed.

If the balance of hormones is not normalized, then it continues to grow. Hormonal medications cause a temporary stop in estrogen production. As a result, the node may not only stop growing, but also shrink. Submucosal leiomyoma of the uterus (or another) can also grow under the influence of an unhealthy lifestyle, in the presence of excess weight, and changes in metabolism.

Symptoms

Symptoms vary in severity depending on the size of the tumor and its type. The most severe symptoms are caused by large fibroids at 6-10 weeks (similar to changes in the size of the uterus during pregnancy). Also, submucous uterine leiomyoma usually manifests itself more actively. The following symptoms appear:

1. Menstrual irregularities;
2. Heavy bleeding during menstruation;
3. Bleeding not associated with the cycle;
4. Pain in the lower abdomen and lower back (both sharp and nagging);
5. Increase in the size of the abdomen with a large nodule;
6. Large tumors put pressure on neighboring organs, which can result in constipation and an increased urge to urinate.

For a long time, the presence of a neoplasm of any type is asymptomatic.

Pregnancy

Leiomyoma of the cervix or its body can become a serious obstacle to pregnancy.

1. The structure of the endometrium changes, which interferes with the attachment of the embryo;
2. The hormonal balance is even more disrupted and pregnancy does not occur;
3. A large node can physically block sperm access to the egg.

However, sometimes fertilization does occur. Pregnancy with fibroids is quite dangerous. There is constant hypertonicity of the uterus. This significantly increases the likelihood of miscarriage or premature birth at any stage. Also for this reason, fetal hypoxia may develop. There is a high probability of having a baby with developmental defects.

The birth process is also complicated. There is a possibility of developing very heavy and difficult to stop bleeding.

Treatment

Treatment or removal of this type of node is carried out strictly as prescribed by the attending physician. There are two treatment approaches:

• Conservative. It is applicable for small and medium-sized nodes, as well as for the expected onset of menopause. Because during this period the node may disappear on its own. It is carried out with the help of hormonal drugs that stop the production of hormones in the body. As a result, menopause occurs and the tumor stops growing;
• Surgical. Laparoscopic or abdominal surgical removal of the tumor is performed. If there is no need to preserve reproductive function, part of the uterus or all of it may be removed. You can learn more about this from the article “Surgery to remove uterine fibroids.”

A separate type of procedure is. Simply put, this is a local blockage of the arteries and stopping the blood supply to the node. This is a low-traumatic intervention, performed laparoscopically. Prescribed for active growth of fibroids or severe bleeding. Allows you to fully preserve reproductive function.

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Malignant leiomyoma(leiomyosarcoma, metastatic leiomyoma, multisarcoma) is localized similarly to leiomyoma. It is extremely malignant. Early, abundant hematogenous metastases usually occur; relapses after removal are rare. It has the shape of a knot that can reach a diameter of 15-20 cm or more. Infiltrating growth is not always obvious. Some authors recommend distinguishing between typical malignant leiomyomas and atypical or polymorphic cell leiomyosarcoma. Typical malignant leiomyomas are characterized by great similarity to leiomyomas. Only when examining the peripheral parts does infiltrating tumor growth become apparent. However, a false picture of infiltrative growth can also be observed in mature “young” leiomyomas. Atypical malignant leiomyomas are characterized by severe cataplasia of tumor cells, which can reach large sizes and are characterized by polymorphism. The cytoplasm loses acidophilia; Multifibrils are sometimes found in it, often only with electron microscopy. It is rare in children. When localized under the skin, it can ulcerate, bleed, and grow exophytically. It is most often localized retroperitoneally, in the organs of the gastrointestinal tract, and usually contains amorphous calcifications.

Microscopically It is represented by polymorphic spindle-shaped cells folded into vaguely contoured bundles. Contains numerous giant cells with bizarre hyperchromic nuclei and basophilic cytoplasm 6, the latter when stained with phosphotungstic hematoxylin, myofibrils are revealed. Mitoses are atypical, numerous.

Leiomyosarcoma should be differentiated from benign smooth muscle tumors; the decisive sign is the abundance of atypical mitoses. It is difficult to distinguish it from schwannomas and neurosarcomas; only the central location of the nuclei, especially clearly visible on cross sections, and the more ordered nature of the argyrophilic stroma help in differentiating it from fibro- and liposarcomas.

A frequent connection of the tumor node with blood vessels is noted; intravascular growth of tumor cells is possible, which allows these cases to be interpreted as angiomyosarcoma. The incidence of tumors in the femoral triangle near the vascular bundle, in the adductor canal, popliteal fossa, and medial groove of the biceps is observed. The tumor often metastasizes early and rapidly hematogenously, sometimes by subcutaneous dissemination followed by distant hematogenous metastases.

Stroma In contrast to fibroids, it is represented by an uneven, loose network of argyrophilic fibers that thickens around the vessels; vessels are sinusoidal and capillary type, often with hyalinosis of the walls. Muscle tumor cells form bundles of unequal size, arranged randomly, often with the formation of rhythmic structures of nuclei. Along with this, over large areas, atypia reaches such a degree that the cells become extremely polymorphic. Multinucleated cells are not uncommon.

Clarification of tissue accessories of malignant leiomyomas extremely difficult and possible only when it is possible to find less cataplastic areas with clear muscle differentiation. Detection in tumor cells of some tinctorial features characteristic of myosin and associated, according to R. Masson (1956), with the presence in the cytoplasm of a special protein substance, unstructured in myofibers, acidophilia of the cytoplasm, dark staining with iron hematoxylin, blue-violet or purple with Mallory hematoxylin helps with differentiation. The presence of multinucleated symplasts, characteristic of tumors of muscle origin, should also be taken into account.

Malignancy of leiomyoma observed rarely, but exceptions are possible. Against the general background of a typically constructed leiomyoma, microscopically it is possible to identify multiple foci of pronounced polymorphism of tumor cells with nuclear hyperchromatosis, giant cells, the presence of nuclear fission figures, etc.

For subcutaneous localization leiomyosarcoma The origin of this tumor may be polar or angioleiomyoma. Difficulties are noted in some cases in determining the presence of malignant transformation in a tumor and its difference from leiomyoma, for which it is necessary to examine numerous preparations from different areas of the tumor node.

It is noted that all smooth muscle tumors, in which lesions arise with increased mitotic activity and which reach a diameter of 0.5 cm, should be regarded as malignant.

For forecasting it is important to distinguish tumors in accordance with Grading Thus, G1,2,3 can be established based only on the frequency of occurrence of atypical mitoses up to 2-40 in the field of view, one should keep in mind the fragmentation of such areas in the tumor G3 is characterized by increasing cellular cataplasia, an abundance of vessels with the formation around them of cellular palisades and structures resembling hemangiopericytoma. G3 is also distinguished by a high degree of cellular atypia, loss of the tuft structure of the tumor, and sometimes the appearance of numerous giant cells, which together gives similarities to the histological structure of rhabdomyosarcoma. Such tumors should be differentiated from polymorphic rhabdomyosarcoma, malignant schwannoma, fibrous malignant histocytoma, and fibrosarcoma.