Intravenous Leiomyomatosis
A 32-year-old woman was admitted with complaints of abdominal swelling and pain since 6 months. Pain abdomen was intermittent and confined to lower abdomen. She also had feeling of incomplete voiding of urine with overflow and stress incontinence since 3 months. Menstrual cycles were normal and there was no menorrhagia. She has one living child and underwent tubectomy 6 years ago. Abdominal examination revealed irregular, nontender uterine mass of 24 weeks pregnant size. Pelvic ultrasound showed bulky uterus measuring 9×6.8×4.3 cm, with multiple hypoechoic lesions in anterior and posterior myometrium, the largest one measuring 11×8.8×7 cm. Computed tomography (CT) scan was not done due to unavailability of the facility in the rural set-up as well as the unaffordability of the patient. As the mass was very big and the patient was symptomatic and had already completed her family, the decision of total abdominal hysterectomy was taken. Abdomen was opened by midline vertical incision. During surgery, multiple large subserosal, intramural, and submucosal fibroids ranging from 5×4 cm to 20×30 cm were seen. During surgical removal, the tumor showed worm-like projections into the pelvic veins []. A presumptive diagnosis of intravenous leiomyomatosis was made. Ovaries appeared healthy and were retained. There were no technical difficulties in removing the uterus. The tumor was very vascular; it started bleeding profusely from the cut margins. Bilateral hypogastric artery ligation was done which reduced uterine blood supply and enabled easy removal of the uterus. Hemostasis was well achieved. The tumor weighed 6.7 kg. The postoperative course was uneventful and she has been in good health for 16 months after the operation. Microscopic examination demonstrated the tumor cells invaginating the vascular tree with no evidence of atypia.