Cotyledonoid Leiomyoma Clinical Characteristics, Imaging Features, and Review of the Literature

Abstract

Cotyledonoid leiomyoma of the uterus is a rare variant of benign uterine leiomyoma. It has a favorable attitude, despite some ultrasound presentations. A bulky uterus with a heterogeneous mass with irregular margins, high vascularity, and infiltration of the myometrium can induce the suspicion of a malignant mesenchymal tumor and lead to a radical surgical treatment. If present, some imaging features may suggest this rare type of leiomyoma, thus avoiding extensive surgery, especially in young nulliparous women. We report 13 cases of cotyledonoid leiomyoma with clinical characteristics, imaging features, and a literature review.

The Management of the Cotyledonoid Leiomyoma of the Uterus: A Narrative Review of the Literature

“…Presenting symptoms were the same as for typical fibroids, such as the presence of abdominopelvic masses (38 cases, 40.4%), abnormal uterine bleeding (37 cases, 39.4%), abdominopelvic pain (12 cases, 12.8%), or abdominal swelling (3 cases, 3%), but cotyledonoid leiomyoma were also found incidentally (5 cases, 5.3%). Serum CA-125 was reported within normal limits or slightly increased [3]. Tumor size varied widely from 4 to 43 cm, with a median of 12 cm.…”

“…A total of 94 cases with a histologically proven diagnosis of cotyledonoid leiomyoma (70 cases of cotyledonoid dissecting leiomyoma, 74.5%, and 24 of cotyledonoid leiomyoma, 25.5%) were collected, including our 13 cases recorded at the IRCCS Burlo Garofolo of Trieste and the Aviano Regional Cancer Centre [3].…”

“…The gynecologist can come across a heterogeneous irregular large mass with a high vascularization [4,42], no shadowing, and possible indistinct margins within the myometrium [3], described according to MUSA (the Morphological Uterus Sonographic Assessment) terms and definitions [60]. Most of these lesions are isoechoic compared to the myometrium and are surrounded by a capsule, which can be interrupted in the dissecting form.…”

“…The tongues of its tissue can also invade the myometrium by dividing it, giving this type of myoma the term "dissecting" (cotyledonoid dissecting leiomyoma) [2], raising the suspicion of a possible infiltrative pattern, despite its total benignity. Although the diagnosis may be entirely accidental because occasionally it can be mistaken for a typical form of fibroma, in some cases, it takes on extremely atypical features that may lead to the suspicion of malignancy [3]. In particular, specific clinical experiences which showed a large size of the lesion, its intense vascularization and heterogeneity, and its tendency to invade adjacent structures such as the broad ligament, have raised the suspicion of malignancy and have led surgeons to opt for radical surgery [3,4].…”

“…Based on a recently published case report series [3], whilst performing a more extensive study of the literature, this narrative review aims to briefly describe the distinctive aspects of this particular form of fibroid, considering not only imaging studies, but also pathological examination and hormonal and surgical treatments.…”