Broad ligament fibroids—a radiological and surgical challenge

Abstract

Currently, there is limited data on the ease of imaging of broad ligament fibroids and their safe laparoscopic management. We aimed to review all laparoscopic myomectomies over an 8-year period, focusing on intraoperative findings and corresponding pre-operative imaging. All laparoscopic myomectomies performed between 2004 and 2012 were reviewed. Cases with broad ligament fibroids were identified. Presenting symptoms, imaging, intraoperative findings, complications and 6-month follow-up were noted. Ten broad ligament fibroids were identified from 185 cases of laparoscopic myomectomies. Mean broad ligament fibroid diameter was 8.1 cm, and the largest was 15 cm. Mean combined fibroid weight was 267 g (range 30-560 g). Blood loss was associated with the total number of fibroids excised rather than the diameter of the broad ligament fibroid (range 30-400 ml). Accurate pre-operative diagnosis at imaging was made in only one of the ten broad ligament fibroids. Of the remainder, one was thought to be an ovarian mass, one fibroid was missed entirely and seven were reported non-specifically as 'lateral'. This case series indicates the challenge posed by broad ligament fibroids at pre-operative imaging. Underreporting may reflect a lack of awareness of the surgical significance of broad ligament fibroids. There should be a high level of suspicion for location within the broad ligament if a fibroid reported is as lateral. With adequate operator experience, large fibroid size should not contraindicate laparoscopic management of broad ligament fibroids.

Is It an Ovarian Tumor or Broad Ligament Leiomyoma?

“…Nevertheless, this wasn't the case in our patient were MRI confirmed what ultrasound showed [5]. As per Kindiger, et al accurate preoperative diagnosis was made only in 1 in 10 broad ligament leiomyomas, thus the challenge posed by broad ligament leiomyomas at preoperative imaging [8].…”

“…As ultrasound is least invasive and most cost effective, it is the preferred imaging modality for initial evaluation [6][7][8]. A leiomyoma has a typical pattern: a whorled appearance with variable echogenicity depending on the extent of degeneration, fibrosis and calcification [5][6][7][8]. Transvaginal ultrasound is superior to transabdominal ultrasound as it may help in a clear visualization of the ovaries and uterus from the mass [5].…”

“…It may be confused with ovarian tumor by appearing adnexal in location [8]. This is very crucial as broad ligament leiomyomas are associated with pseudo-Meigs syndrome and produce high level of CA-125 pointing towards a metastatic ovarian carcinoma causing thereby diagnostic confusion [5].…”

Broad ligament myoma at 75 causing clinical, ultrasonic and intraoperative diagnostic dilemma

“…Seniority of the reporting radiologist & route of ultrasonography may not improve the detection of broad ligament fibroid. 2 As reported by Pinar Yildizi et al 1 laparotomy was done with a preoperative clinical & ultrasonic diagnosis of a solid adnexal mass suggesting an ovarian malignancy, whereas it turned out to be a broad ligament fibroid on opening the abdomen.…”

Broad ligament fibroid as an incidental finding in an unruptured ectopic

“…Anatomical location within the broad ligament has previously been associated with an increased complication risk at myomectomy. The rarity of broad ligament fibroids, and the potential for misdiagnosis as ovarian or retroperitoneal tumours makes the development of standardized ultrasound criteria extremely difficult [6] . MR imaging, with its multiplanar imaging capabilities, also may be extremely useful for differentiating broad ligament leiomyomas from masses of ovarian or tubal origin and from broad ligament cysts [4] .…”