An exceptional case of Leiomyomatosis peritonealis disseminata which occurred in a perimenopausal woman was mistaken for ovarian malignancy at laparotomy as it had extensive involvement of the pelvic peritoneum without a trace of leiomyoma in uterus and cervix

Bhattacharya, S

Dey, S

Naskar, A

Pati, S

English

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Case Report:
An Atypical Case of Pelvic Leiomyomatosis Peritonealis Disseminata
Sohini Bhattacharya, Associate professor,
Shyamapada Pati, Professor and Head
Animesh Naskar, RMO cum Clinical Tutor,
Samiron Dey, Medical officer,
Dept of Gynecology & Obstetrics, North Bengal Medical College, Darjeeling; West Bengal
Address For Correspondence:
Dr. Sohini Bhattacharya,
76, Rashbehari Sarani, 
Khelaghor More; Hakimpara,
Siliguri, Darjeeling – 734001, India
E-mail: drsohinibhattacharya@yahoo.co.in
Citation: Bhattacharya S, Pati S, Naskar A, Dey S. An Atypical Case of Pelvic Leiomyomatosis Peritonealis Disseminata. Online J 
Health Allied Scs. 2010;9(2):12
URL: http://www.ojhas.org/issue34/2010-2-12.htm
Open Access Archives: http://cogprints.org/view/subjects/OJHAS.html and http://openmed.nic.in/view/subjects/ojhas.html
Submitted: May 14, 2010; Accepted: Jun 25, 2010; Published: Jul 30, 2010
Abstract:
An  exceptional  case  of  Leiomyomatosis  peritonealis  dis-
seminata  which  occurred  in  a  perimenopausal  woman  was 
mistaken for ovarian malignancy at laparotomy as it had ex-
tensive involvement of the pelvic peritoneum without a trace 
of leiomyoma in uterus and cervix.
Key Words:  Leiomyomatosis  peritonealis  disseminata,  peri-
toneal leiomyomatosis 
Introduction:
Leiomyomatosis  peritonealis  disseminata (also called diffuse 
peritoneal leiomyomatosis)  is a rare, benign entity character-
ized  by  presence  of  innumerable  smooth  muscle  nodules 
throughout the peritoneal cavity. It occurs mostly in women of 
reproductive age group who have uterine leiomyomas.(1)
We  present  a  case  where  leiomyomatosis  peritonealis  dis-
seminata in a perimenopausal woman occurred involving the 
pelvic peritoneum extensively without a trace of leiomyoma in 
uterus and cervix.
Case Report:
A 47 years  old woman P3+0 attended the gynecology  outpa-
tient’s department of our hospital with dull aching pain of the 
abdomen since four months. Her menstrual history revealed no 
abnormality.  The pain had no relation  to  menstruation.  She 
complained of a loss in weight and appetite for the last four 
months. The loss in weight was not associated with a rise in 
temperature. There was no alteration of bowel habit. Her last 
childbirth was sixteen years ago. She never used any oral con-
traceptive pills in her lifetime.
On examination, she was found to be moderately anemic, BP 
– 130/80 mm of Hg. Abdominal and bimanual examination re-
vealed  a  firm  nontender  immobile  mass  in  the  pouch  of 
Douglas  separate from the uterus.  The mass appeared to be 
fixed to the pelvic wall. Respiratory and cardiovascular system 
revealed no abnormality.
Investigations  revealed  Hemoglobin  –  7gm%,  TC  WBC  – 
8600/mm3 with  68%  neutrophils,  random  plasma  glucose 
-112mg%, serum creatinine – 0.8mg%. Chest X ray was nor-
mal.  CA-125  was  325IU/ml.  Ultrasonography  when  per-
formed, showed a hypodense mass 83mm×66mm in the pouch 
of Douglas that appeared to arise from the left ovary. A small 
amount of ascites was present too. In view of the short history 
and the clinical and investigation findings, malignant ovarian 
tumor was diagnosed and laparotomy suggested after transfu-
sion of two units of blood.
Laparotomy revealed a normal sized uterus with slightly cystic 
ovaries  bilaterally.  A  lobulated  highly  vascular  mass  with 
variegated consistency was seen in the left broad ligament and 
parametrium. Nodules were seen in the uterovesical pouch and 
lateral pelvic wall too, none more than 2cm in diameter.1 liter 
of mucoid ascitic fluid was drained and total abdominal hys-
terectomy done with bilateral salpingoophorectomy after  the 
left ureter was dissected free to prevent its injury (Fig 1). Nine 
nodules  were dissected out  from the uterovesical  pouch and 
lateral pelvic  wall (Fig 2). Exploration of the abdomen was 
performed along with infracolic omentectomy as part of a sta-
ging procedure. Neither revealed any deposit.
Fig 1:  Hysterectomy specimen, with a large leiomyoma that 
invaded into the broad ligament; uterus being cut open, reveals 
no leiomyoma
1
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Online Journal of Health and Allied Sciences
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Published Quarterly :  Mangalore, South India : ISSN 0972-5997
Volume 9, Issue 2; Apr-Jun 2010
Fig 2:  Post hysterectomy vaginal vault being lifted with the 
Alles tissue forceps reveals two leiomyomas in the uterovesic-
al pouch of peritoneum and a few arising from the lateral pel-
vic wall
Histopathology showed interlacing fascicles of benign smooth 
muscle cells with no evidence of malignancy in either of the 
nodules dissected. Serial sectioning of uterus failed to demon-
strate a single leiomyoma.
Other than copious mucoid fluid discharge from the laparo-
tomy wound, that continued till fifth postoperative day and ne-
cessitated daily change of dressing, the patient made good re-
covery. She was discharged with the advice of follow up every 
four months. One year and three months since her surgery, she 
is still doing well.
Discussion:
Smooth muscle cells occur sufficiently frequently in the sub-
coelomic mesenchyme, directly below peritoneal mesothelium 
predominantly in the region of the uterosacral ligaments and 
pelvic side walls.(2) Leiomyomatosis peritonealis disseminata 
is  a  rare  condition  characterized  by  numerous  leiomyomas 
throughout  the peritoneal  cavity arising from the underlying 
smooth  muscle  cells  or  from  metaplasia  of  submesothelial 
cells.(1,3)  This  condition  occurs  typically  in  women  in  the 
third and fourth decades as was in our case. It may be caused 
by high estrogen states caused by pregnancy and oral contra-
ceptive use and usually run a benign course with spontaneous 
regression  following  withdrawal  of  ovarian  hormone  or  oo-
phorectomy.(3,4)
Findings on laparotomy overlaps with the appearances of peri-
toneal carcinomatosis,  malignant mesothelioma and primary  
peritoneal  serous  carcinoma.  It  has  been  suggested  that 
leiomyomatosis peritonealis disseminata should be considered 
as  diagnosis  during  surgery  when  patient  has  coexisting 
leiomyoma  or  diffuse  leiomyomatosis  of  uterus  with  no 
omental caking or ascites.(1,4,5)
Our case is exceptional since not a single uterine leiomyoma 
could be identified even after histopathological examination. 
The presence of ascites and high level of CA 125 was further 
confusing. Hence a radical surgery was undertaken. Although 
a conservative  approach is  recommended for  this  condition, 
the reports of malignant changes (about 10%) (3,6) in recent 
years,  have  tilted  the  balance  more  towards aggressive  sur-
gery. When surgical castration is not possible for age or desire 
for children, a close follow up is recommended.(3)
References:
1. Levy AD, Arnaiz J, Shaw JC, Sobin LH. From the 
archives of  the  AFIP:  primary peritoneal  tumors: 
imaging features  with  pathologic  correlation.  Ra-
diographics. Mar-Apr 2008;583-607. 
2. Fredericks  S,  Russel  P,  Cooper  M,  Varol  N. 
Smooth muscle in the female pelvic peritoneum: a 
clinicopathological  analysis  of  31 women.  Patho-
logy. Feb2005:37(1):14-21. 
3. Borsellino G, Zante P, Ciraldo MC.  Diffuse peri-
toneal leiomyomatosis. A clinical case report. Min-
erva Gynecol. Jan-Feb1997;49(1-2):53-7. 
4. Kruczynski  D,  Merz  E,  Beck  T,  Bahlmann  F, 
Wilkens C, Weber G, Macchiella D, Knapstein PG. 
Minimally invasive therapy of peritoneal leiomyo-
matosis. A case report of diagnostic and therapeut-
ic  problems.  Gerburtshilfe  Frauenheilkd. 
Mar1994;54(3):181-3 
5. Coskun A, Ozdemir O, Vardar MA, Kiran G, Arik-
an  D,  Ersoz  C.  A  case  with  diffuse  uterine 
leiomyomatosis and review of the literature.  Clin 
Exp Obstet Gynecol. 2008;35(3):227-30.
6. Rubin  SC,  Wheeler  JE,  Mikuta  JJ.  Malignant 
leiomyomatosis  peritonealis disseminata.  Obstet  
Gynecol. Jul1986;68(1):126-30
2


A case with diffuse uterine leiomyomatosis and review of the literature. Clin Exp Obstet Gynecol.

Diffuse peritoneal leiomyomatosis. A clinical case report.

From the archives of the AFIP: primary peritoneal tumors: imaging features with pathologic correlation.

Malignant leiomyomatosis peritonealis disseminata. Obstet Gynecol.

Minimally invasive therapy of peritoneal leiomyomatosis. A case report of diagnostic and therapeutic problems. Gerburtshilfe Frauenheilkd.

Smooth muscle in the female pelvic peritoneum: a clinicopathological analysis of 31 women.

An Atypical Case of Pelvic Leiomyomatosis Peritonealis Disseminata

An Atypical Case of Pelvic Leiomyomatosis Peritonealis Disseminata

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