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SN Comprehensive Clinical Medicine

, Volume 1, Issue 11, pp 969–971 | Cite as

An Unusual Presentation of a Large Cervical Fibroid—Case Report

  • Kavita KhoiwalEmail author
  • Amrita Gaurav
  • Payal Kumari
  • Anupma Kumari
  • Jaya Chaturvedi
Surgery
  • 178 Downloads
Part of the following topical collections:
  1. Topical Collection on Surgery

Abstract

Uterine fibroids are the commonest pelvic tumors of reproductive-age women, while the incidence of cervical fibroid is only 1–2%. We noted the patient’s clinical history, examination findings, diagnostic tools, management, and outcome. We report a 53-year-old parous lady who was initially diagnosed with malignant ovarian tumor on the basis of clinical manifestations and imaging findings. Intraoperatively, it turned out to be a large cervical fibroid. Total abdominal hysterectomy was performed without any intraoperative complications. Anticipation of complications and preventive measures during surgery are the key of successful outcome in large cervical fibroids. To avoid ureteric injury, preoperative stenting, intra-operative delineation of ureters, and dissection inside the fibroid capsule are the best principles.

Keywords

Cervical fibroid Adnexal tumor Ureter Hysterectomy 

Introduction

Uterine fibroids are the commonest pelvic tumors of reproductive-age women (20%) [1]. Commonly the women with fibroids present with abnormal uterine bleeding, pain abdomen, or palpable mass per abdomen. The diagnosis of fibroid uterus usually made on clinical examination and on ultrasound (USG). USG preferably transvaginal scan is the first-line imaging modality in case of fibroid uterus. It has shown high sensitivity and specificity for the diagnosis [2]. Sometimes this condition is misdiagnosed as adnexal tumor. We present one such case of a large cervical fibroid which was initially misdiagnosed as adnexal tumor.

Case Report

A 53-year-old parous female presented with palpable mass and pain abdomen for 1 year. The patient also had complaint of decreased appetite. There was no complaint of menstrual abnormalities except decreased flow, no bladder and bowel complaint. Abdominal examination was suggestive of a large abdominopelvic mass corresponds to 32 weeks of pregnancy, firm to hard in consistency with restricted mobility. Per speculum, cervix was seen with difficulty, pulled upwards. Vaginal examination revealed a bulky, mobile uterus, which was pushed upwards and anteriorly by the abdominopelvic mass; bilateral fornices and pouch of Douglas were full of mass. USG pelvis was suggestive of bulky uterus with a large complex adnexal mass. CECT abdomen and pelvis (Fig. 1) reported a large 21 × 15 × 14 cm well-defined predominantly solid heterogeneously enhancing adnexal mass likely malignant. CA-125 was mildly raised (57 U/ml), and the rest of the tumor markers were within normal limit (CEA = 0.4, LDH = 217, CA19.9 = 29, hCG = 0.9). Informed and written consent was taken for exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-ovariotomy, and omentectomy with pelvic lymphadenectomy on the basis of provisional diagnosis of malignant ovarian tumor. On laparotomy, uterus and both ovaries were healthy; the presumed adnexal mass was actually a large cervical fibroid. The uterus was seen pushed upwards by the fibroid towards umbilicus (Fig. 2). Total abdominal hysterectomy and bilateral salpingo-ovariotomy was performed. The whole fibroid with uterus was removed in toto without any intra-operative complication. Bilateral ureters were dissected prior to hysterectomy and kept under vision throughout the surgery. The fibroid (25 × 25 cm; 4 kg) was arising from posterior lip of cervix. Postoperative course was uneventful. Histopathology confirmed the diagnosis of leiomyoma with areas of mucoid degeneration and hemorrhage.
Fig. 1

CECT abdomen and pelvis suggestive of a well-defined solid cystic lesion of size 21 × 15 × 14 cm (CC × AP × TR) with solid component measuring approximately 18 × 14 × 14 cm (CC × AP × TR) which shows heterogenous enhancement on post contrast study (a sagittal section, b transverse section)

Fig. 2

Intraoperative image shows large cervical fibroid pushing the uterus upwards

Discussion

Though fibroid is the most common pelvic tumors among reproductive-age women (20%), the incidence of cervical fibroid is only 1–2% [1]. Cervical fibroid may develop in both vaginal and supra vaginal part of cervix, but usually develops in the supra vaginal part of cervix. They are classified as anterior, posterior, lateral, and central or multiple according to their site of origin. In the present case, the fibroid was arising from supra vaginal part of posterior cervical wall. Each fibroid presents differently on the basis of location. Most common complaints at the time of presentation are urinary retention, constipation, and menstrual abnormalities, and rarely it may present as palpable mass per abdomen and misdiagnosed as an ovarian tumor [3]. In our case also, the large cervical fibroid was initially misdiagnosed as ovarian tumor. Usually ovarian mass can be easily differentiated from uterine mass on clinical examination. If a groove felt between the mass and uterus on vaginal examination is suggestive of ovarian mass and if no groove is felt, most likely it is a uterine mass. Imaging modalities such as USG, CT scan, or MRI are sensitive to differentiate between uterine and ovarian mass. But diagnostic errors can happen in identification of solid masses [4]. Color Doppler could have been done in present case to differentiate ovarian malignancy from benign mass like fibroid. Color Doppler is reported to be more specific in differentiation of benign and malignant adnexal masses [5]. We did not go for Doppler preoperatively as large cervical fibroid was not kept in differential diagnosis. This is the learning point from this case; one should be vigilant about rare conditions.

Another misleading point in our case was raised value of Ca-125. It is not a specific marker for ovarian cancer, as it is elevated in several benign conditions such as peritonitis, pelvic inflammatory disease, or endometriosis [6].

Large cervical fibroid is a rare phenomenon, poses surgical difficulties, and has an increased risk of urinary tract injuries and intraoperative bleeding due to distorted anatomy. Sharma et al. reported a case of large cervical fibroid (30 × 26 × 22 cm) which was initially mimicking an ovarian tumor. They encountered ureteric injury during surgery, diagnosed intraoperatively and managed well with ureteric anastomosis [7]. Similar ureteric injury was also managed by Kavitha et al. in a case of huge cervical fibroid (20 × 14 cm) [8]. Another case of a large cervical fibroid (30 × 14 × 10 cm) reported by Basnet et al. [9], bladder injury was noted during surgery. In addition, they had to ligate bilateral internal iliac arteries in order to achieve hemostasis. In the present case, we were able to complete the surgery without any complication. The idea behind the successful outcome was to remain within the capsule of fibroid and always keep the ureter under vision. Preoperative ureteric stenting is also a good option to avoid ureteric injury. Removal of fibroid before proceeding to hysterectomy is a reasonable and safer alternative.

To emphasize, rare conditions such as cervical fibroid should be kept in mind in cases of solid adnexal masses. Anticipation of complications and preventive measures during surgery are the key of successful outcome in large cervical fibroids. To avoid ureteric injury, preoperative stenting, intra-operative delineation of ureters, and dissection inside the fibroid capsule are the best principles.

Notes

Authors’ Contribution

Dr. Kavita Khoiwal, Dr. Amrita Gaurav, and Dr. Anupma Kumari have conceived the case report and performed the surgery. Dr. Payal Kumari retrieved and prepared CT scan images and HPE report. Dr. Kavita Khoiwal prepared the figures and wrote the manuscript. Dr. Jaya Chaturvedi guided throughout the patient management as well as in manuscript preparation. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Informed Consent

Consent was obtained from the patient for publication of this case report and any accompanying images.

Conflict of Interest

The authors declare that they have no conflict of interest.

References

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyAll India Institute of Medical SciencesRishikeshIndia

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