Leiomyomas Beyond the Uterus: A Case Series of Extrauterine Leiomyomas

Leiomyomas, also called fibroids or myomas, are the most common benign tumors in the female reproductive system (5,6). These smooth muscle growths affect approximately 20-30% of women during their reproductive years, with the highest incidence between ages 30 and 50 (20). By age 50, the lifetime risk of developing uterine leiomyomas approaches 70-80%, making them one of the leading indications for gynecological surgery worldwide (6,7). The majority of leiomyomas arise from the smooth muscle of the uterine myometrium; however, a small subset develops in extrauterine locations. These extrauterine fibroids present unique diagnostic and therapeutic challenges that remain inadequately documented in the medical literature (1,18).

Uterine leiomyomas are well-characterized entities with established clinical patterns, risk factors, and management strategies. Hormonal influences, particularly estrogen and progesterone, play a significant role in their growth (6). These tumors typically proliferate during reproductive years and may regress following menopause (20). The pathophysiology involves clonal proliferation of smooth muscle cells with variable amounts of fibrous connective tissue, resulting in well-circumscribed masses ranging from microscopic seedlings to large tumors weighing several kilograms. Clinically, leiomyomas may be asymptomatic or present with symptoms including abnormal uterine bleeding, pelvic pressure or pain, urinary frequency, constipation, and reproductive complications such as infertility and pregnancy-related issues (6,7,12).

In contrast, extrauterine leiomyomas represent a distinct and poorly understood clinical entity (1,18). These tumors can develop in virtually any anatomical location containing smooth muscle tissue, though certain sites are more frequently reported. Documented locations include the ovary, cervix, vagina, vulva, broad ligament, round ligament, urinary bladder, urethra, and even more distant sites such as the gastrointestinal tract, retroperitoneum, and extremities (1). The term "parasitic leiomyoma" refers to fibroids that have detached from the uterus and established an independent blood supply from adjacent structures. "Benign metastasizing leiomyoma" describes histologically benign-appearing smooth muscle tumors found in distant sites, most commonly the lungs (1). Each variant presents unique pathophysiological considerations and clinical

 

 

 

presentations and implications.

The rarity of extrauterine leiomyomas contributes to diagnostic uncertainty and frequent misdiagnosis (13). Clinicians may not consider these tumors in the differential diagnosis of pelvic or extragenital masses, potentially leading to inappropriate management or delayed diagnosis. The clinical presentation varies widely depending on tumor location, size, and relationship to adjacent structures (8,15). Many extrauterine leiomyomas are discovered incidentally during imaging studies or surgical procedures performed for other indications. Symptomatic cases may present with mass-related symptoms, pain, or organ-specific dysfunction.

 

Ovarian Leiomyomas

Ovarian leiomyomas are exceedingly rare, accounting for less than 1% of all benign ovarian tumors and only 0.5-1% of all ovarian neoplasms (2,16). Since Spiegelberg first reported a case in 1895, fewer than 200 cases have been documented in the English medical literature. The pathogenesis remains uncertain, with several theories proposed regarding their origin. The most widely accepted hypothesis suggests derivation from smooth muscle cells in ovarian vessels, particularly within the ovarian ligament and its vasculature (2). Alternative theories propose origin from smooth muscle in vessel walls within the ovary itself or from embryonic smooth muscle cell remnants. Some investigators suggest that certain ovarian leiomyomas may represent parasitic uterine fibroids that have attached to the ovary and developed an independent blood supply, though this concept remains controversial (16).

Diagnosis of ovarian leiomyoma requires specific criteria originally proposed by Spiegelberg and subsequently modified (2): the tumor must be located within the ovary, connected to the ovary by the utero-ovarian ligament or infundibulopelvic ligament, must demonstrate histological features of leiomyoma with smooth muscle proliferation, and must contain normal ovarian tissue within the tumor wall. These stringent criteria help differentiate primary ovarian leiomyomas from subserosal or broad ligament uterine fibroids, as well as from other ovarian smooth muscle tumors (2,16).

 

 

 

 

Cervical Leiomyomas

Cervical leiomyomas account for approximately 2.6 to 8% of all uterine leiomyomas, depending on the series reported (3). These tumors arise from the smooth muscle of the cervix and can be classified based on their growth pattern as anterior, posterior, lateral, or circumferential. Unlike their uterine counterparts, cervical leiomyomas present unique management challenges due to their proximity to critical structures including the bladder, ureters, rectum, and major pelvic blood vessels (10,19). As they enlarge, cervical fibroids can displace and distort normal pelvic anatomy, potentially compromising urinary and bowel function.

The clinical presentation of cervical leiomyomas differs from typical uterine fibroids. Patients may experience urinary symptoms including frequency, urgency, retention, or hydronephrosis secondary to ureteral compression (19). Large posterior cervical fibroids may cause bowel symptoms such as constipation or tenesmus. Dyspareunia and vaginal discharge are also commonly reported (3). On examination, cervical leiomyomas typically present as firm, smooth masses that may be difficult to distinguish from the cervix itself, particularly with large tumors. The uterine corpus may be displaced superiorly and may be difficult to palpate separately

Case 1: Ovarian Leiomyoma

A 42-year-old woman, para 2 with 2 living children, presented with complaints of abdominal distension and pain for 6 months. Her menstrual history was unremarkable. Per abdominal examination revealed a large, firm, mobile abdominal mass extending from the pelvis to the umbilicus. Ultrasonography demonstrated a large solid mass measuring approximately 16×12 cm arising from the left adnexa, separate from the uterus. Magnetic resonance imaging (MRI) confirmed a well-defined heterogeneous mass with features suggestive of a solid ovarian neoplasm.

Laboratory investigations including tumor markers (carcinoembryonic antigen [CEA- 0.89], cancer antigen 125 [CA-125-32.1]) were within normal limits. Following comprehensive counseling regarding diagnosis, treatment options, and potential complications, the patient provided informed consent for surgical management. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Intraoperative findings revealed a large, well-encapsulated mass arising from the left ovary, measuring 16×12 cm (Fig.2). The uterus and right adnexa appeared normal. The tumor was successfully excised without complications.

Histopathological examination confirmed the diagnosis of ovarian leiomyoma. Microscopic examination revealed interlacing bundles of smooth muscle cells with elongated, blunt-ended nuclei and eosinophilic cytoplasm (Fig.6). No nuclear atypia, mitotic activity, or necrosis was identified. Normal ovarian tissue was identified within the tumor capsule, fulfilling the diagnostic criteria for primary ovarian leiomyoma. The patient's postoperative course was uncomplicated. She was discharged on postoperative day 5 and remained asymptomatic at 6-month follow-up.

 

Case 2: Cervical Leiomyoma

A 48-year-old woman, Para 2 with 2 living children, presented with complaints of lower abdominal pain, urinary frequency, and occasional vaginal spotting for 3 months. She had attained menopause 2 years prior.

 

On bimanual examination, a firm, non-tender mass was palpated in the lower pelvis, appearing to arise from the cervix. The uterine corpus could not be clearly distinguished from the cervical mass. mass arising from the cervix,  with the uterine corpus displaced superiorly. MRI demonstrated a well-defined mass arising from the posterior cervix, with displacement of the bladder anteriorly and rectum posteriorly (Fig.3). The ureters appeared normal with no evidence of hydronephrosis. Based on clinical and

 

 

imaging findings, a diagnosis of cervical leiomyoma was suspected.

After informed consent, the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Intraoperatively, a 6×6 cm firm mass was identified arising from the posterior cervix. Careful dissection was performed to preserve the ureters and major blood vessels. The surgery was completed without complications. Histopathological examination confirmed cervical leiomyoma with typical features of smooth muscle proliferation and no malignant features (Fig.7). The patient recovered well postoperatively and was asymptomatic at 3-month

follow-up.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case 3: Anterior Vaginal Wall Leiomyoma

A 35-year-old woman para 1, living child 1, presented with complaints of vaginal discomfort and a sensation of vaginal fullness for 4 months. She also reported mild dyspareunia. Menstrual history was unremarkable. On speculum examination, a firm, smooth, well-circumscribed mass was visible in the

anterior vaginal wall, approximately 3 cm from the introitus. The overlying vaginal mucosa appeared normal. On bimanual examination, a 5×4 cm firm, mobile mass was palpated in the anterior vaginal wall, distinct from the cervix and uterus.

Ultrasonography confirmed a well-defined hypoechoic mass within the anterior vaginal wall measuring 5×4 cm. MRI demonstrated a homogeneous mass with signal characteristics consistent with smooth muscle tissue.  No connection to the uterus or cervix was identified. Following counseling and informed consent, the patient underwent local excision of the vaginal mass under regional anesthesia.

A transverse incision was made in the vaginal mucosa overlying the mass. The tumor was carefully dissected from surrounding tissues and completely excised. The vaginal mucosa was closed with absorbable sutures. Histopathological examination revealed typical features of leiomyoma with fascicles of smooth muscle cells showing no atypia or malignant features (Fig.5). The patient's postoperative recovery was uneventful. At 6-month follow-up, the surgical site was well-healed, and the patient reported complete resolution of symptoms with normal sexual function.

 

Fig 7: Histopathological Images of Cervical Leiomyoma

 

Histopathological examination reveals leiomyomas characterized by intersecting fascicles of uniform spindle-shaped smooth muscle cells with eosinophilic cytoplasm and elongated nuclei. The tumors demonstrate typical features including whorled architecture, interlacing bundles, and well-circumscribed borders without cellular atypia. Various magnifications show the characteristic fascicular growth pattern, scattered vascular channels, and in submucosal locations, overlying epithelium (hematoxylin and eosin [H&E] stain) (1).

 

Gross specimens showing bisected leiomyomas with firm, whorled cut surfaces. Large leiomyoma gross specimen demonstrating characteristic whorled appearance on cut section, typical of smooth muscle tumors with interlacing fascicular architecture.

 

Surgical management represents the definitive treatment for symptomatic extrauterine leiomyomas (10). The surgical approach must be individualized based on tumor location, size, patient age, fertility desires, and presence of concurrent pathology. For ovarian leiomyomas, options include oophorectomy, salpingo-oophorectomy, or fertility-sparing tumor enucleation in younger women desiring future childbearing (16). In our case, given the patient's age and completed childbearing, total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.

 

Cervical leiomyomas present unique surgical challenges (10,19). Small cervical fibroids may be amenable to myomectomy; however, larger tumors often necessitate hysterectomy due to distortion of cervical anatomy and proximity to vital structures (10). The risk of ureteral injury during dissection of large cervical fibroids is substantial, requiring careful identification and preservation of the ureters throughout the procedure (19).

 

In selected cases, preoperative ureteral stenting may be considered to facilitate identification and reduce injury risk.

 

Vaginal leiomyomas are generally amenable to local excision with excellent outcomes (4,14,17). The surgical technique involves incision of the vaginal mucosa overlying the tumor, careful dissection to separate the mass from surrounding tissues, complete excision, and meticulous closure of the vaginal wall (17). Preservation of vaginal length and function is an important consideration, particularly in younger, sexually active women (4). In our case, complete excision was achieved with preservation of normal vaginal anatomy and function.

 

The outcomes of surgical management for extrauterine leiomyomas are generally excellent when appropriate surgical technique is employed (10,14,17). Recurrence is rare following complete excision. Long-term complications are uncommon. In our series, all three patients had uncomplicated postoperative courses with complete symptom resolution and high satisfaction at follow-up. These outcomes are consistent with published literature on extrauterine leiomyomas (1,4,10,17).

 

The role of minimally invasive surgical approaches for extrauterine leiomyomas continues to evolve. Laparoscopic management of ovarian leiomyomas has been reported with favorable outcomes in selected cases. Vaginal approach for accessible anterior and posterior vaginal wall leiomyomas offers the advantages of avoiding abdominal incisions and potentially shorter recovery times (14,17). However, the decision regarding surgical approach must consider factors including tumor size, location, surgeon expertise, and available resources.

 

Several important learning points emerge from this case series. First, extrauterine leiomyomas, though rare, should be included in the differential diagnosis of pelvic masses, particularly solid masses with imaging characteristics suggesting smooth muscle origin (1,8,15). Second, comprehensive imaging evaluation, particularly with MRI, is invaluable for preoperative planning and counseling (15). Third, histopathological confirmation is essential as clinical and imaging features alone cannot reliably distinguish benign leiomyomas from malignant smooth muscle tumors or other entities (9,13). Fourth, surgical management—individualized based on tumor characteristics, location, patient factors, and fertility

 

desires—offers excellent outcomes with minimal morbidity when performed by experienced surgeons (10).

This case series contributes to the limited literature on extrauterine leiomyomas and emphasizes the importance of considering these rare entities in the differential diagnosis of pelvic masses (1,18). The successful management of diverse presentations—ovarian, cervical, and vaginal leiomyomas—demonstrates the importance of individualized surgical management tailored to tumor characteristics, anatomical location, patient age, fertility desires, and associated medical conditions. Continued documentation and sharing of such cases through case series and registries will enhance our collective understanding and improve outcomes for patients with these uncommon tumors.

ACKNOWLEDGEMENTS

The authors express their gratitude to the Department of Obstetrics and Gynaecology, Chettinad Hospital and Research Institute, for providing facilities and support for this study; the Department of Pathology for expertise in histopathological examination; the Department of Radiodiagnosis for imaging evaluation; the Department of Urology for collaborative input in patient management; the Department of Vascular Surgery for perioperative anticoagulation guidance; the Department of General Surgery for assistance with adhesiolysis; the anesthesiology team for perioperative care; the nursing staff and operation theater personnel; the medical records department; and most importantly, the patients who consented to documentation of their cases for academic purposes.

Sources of Support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts Of Interest: The authors declare no conflicts of interest related to this work.

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