Broad Ligament Fibroid Mimicking as Ovarian Tumor on Ultrasonography and Computed Tomography Scan
A 40-year-old nulliparous lady, married for 23 years, came with a 6-month history of abdominal discomfort. She had no history of bowel or bladder complaints, weight loss, anorexia, or fever. Previous menstrual cycles were regular. On examination, the patient was afebrile, pulse 76/min, and blood pressure 130/80 mmHg. Abdominal examination revealed a mass of 24-26 weeks size gravid uterus, which appeared to be arising from the pelvis. On palpation, mass was of found to vary in consistency, non-tender, transversely mobile with irregular margins. The lower pole could be reached partially. On speculum examination, cervix could not be visualized, and no abnormal discharge was seen. On vaginal examination, the mass was felt in the pouch of Douglas pushing the cervix anteriorly. Forniceal fullness was present and it was non-tender. Routine blood analysis was within normal limits. Serum Human chorionic gonadotropin values were <0.10 milli international units per liter. Serum CA-125 (cancer antigen 125) value was 28 milli international units per liter. On ultrasonography, a well-defined, mixed echogenic lesion measuring 22 cm × 12.2 cm × 18.6 cm was seen in the midline posterior to bladder pushing the uterus anterolaterally toward the left side [], extending cranially up to mid-abdomen with multiple internal cystic changes []. There was moderate to gross internal vascularity. Minimal fluid with internal echoes was noted in the endometrial cavity. There were two fibroids measuring 1.5 cm × 1.5 cm and 3 cm × 3 cm in the anterior and left lateral wall respectively. The right ovary was not seen as separate from the mass. Left ovary was normal. There was mild hydroureteronephrosis in the right kidney likely due to ureteric obstruction by the right adnexal mass. Diagnosis of right ovarian neoplasm was made. On contrast-enhanced computed tomographic (CECT) scan of abdomen and pelvis, a large mixed density abdomino-pelvic lesion was seen in the pouch of Douglas with thick internal septations and solid components []. The septations and solid components showed significant enhancement on postcontrast images []. The CECT appearance was typical of cystic ovarian neoplasm. Final diagnosis based on the CECT scan of abdomen and pelvis was right ovarian neoplasm.\nWith a provisional diagnosis of malignant ovarian tumor, the patient was taken up for an exploratory laparotomy. Intra-operatively, an abdomino-pelvic mass of size approximately 24 cm × 18 cm × 8 cm was seen with variable consistency and increased vascularity, arising from the right side of the uterus pushing the ureter laterally. Right fallopian tube, ovarian ligament, and round ligament stretched over the mass. Right ovary was normal. Left tube and ovary were normal. The mass was loosely adherent to the small bowel loops. Two fibroids in the fundus of uterus measuring 2 cm × 2 cm and 3 cm × 2 cm and 5-6 seedling fibroids were noted per-operatively. As the tumor was distorting the pelvic anatomy, careful dissection was done to prevent ureteric injuries. Excision of tumor with total hysterectomy and bilateral salpingo-oophorectomy was done. Post-operative course was uneventful.\nThe surgically resected specimen included a large nodular cystic mass measuring 25 cm × 25 cm × 8 cm adjacent to the uterus in the right broad ligament with bilateral normal ovaries []. On histopathological examination, the cut section of the mass showed solid fleshy areas and cystic areas filled with hemorrhage. The uterus revealed two large and multiple small intramural fibroids. The largest one measured 4 cm × 5 cm and smallest 0.5 cm in diameter. Right fallopian tube was stretched and measured 14 cm and right ovary was 3.5 cm × 1.5 cm × 0.5 cm. Cut section of ovary showed cyst filled with serous fluid. Cyst measured 2 cm in diameter. The ligamentous membranous attachment to the lesion seen on the right side was noted to be the broad ligament. Left fallopian tube was 3.5 cm. The mass in the broad ligament stained with hematoxylin and eosin showed the endo-myometrium was composed of round to oval glands lined by columnar epithelium set in a compact stroma. Section studied from the larger parametrial mass showed a benign tumor with interlacing bundles of smooth muscle cells, scattered thick-walled blood vessels, and evidence of cystic, myxoid and hyaline degeneration []. Cervix showed a mild-to-moderate sub-epithelial lymphocytic infiltrate. There was no evidence of dysplasia or malignancy in the cut sections of the cervix. The final histopathological report was:\nProliferative phase endometrium Leiomyoma: Intramural and parametrial (mass arising adjacent to the uterus) Chronic cervicitis Bilateral adnexa with no significant pathology