Mistakes and overdiagnosis of soft tissue leiomyoma. skin leiomyoma

A disease called "uterine fibroids" is very common. The emergence of pathology contributes to many adverse factors that women have to face in modern life. Infertility can be a serious complication. Uterine fibroids, fibroids, leiomyomas are varieties of the same tumor that differ from each other in structure, but can lead to equally severe consequences. It is important to detect and eliminate the pathology in a timely manner.

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Features of leiomyoma

Benign tumors of the uterus (fibroids) are formed in its wall. In addition to muscle fibers, there is also a connective tissue base, as well as a network of blood vessels. Depending on the structure of tumors, several types of such pathology are distinguished. For example, fibroma consists of fibrous (connective) tissue, fibromyoma - from a mixture of fibrous and muscular tissue, with the former predominating. Leiomyoma is a tumor, almost entirely consisting of smooth muscle fibers with a small admixture of fibrous tissue, which has a vascular system.

It is a tangle that forms in the thickness of the wall, and then grows towards the uterine cavity or goes beyond it. Leiomyoma occurs mainly in women of reproductive age (20-40 years), as it is an estrogen-dependent tumor. The peculiarity is that in some cases it is able to disappear on its own.

Stages of development and forms of existence

The development of leiomyoma takes place in stages.

At the first stage, its germ is formed. Subsequent cell division leads to the gradual formation of a tumor node.

In the second stage, the increase in leiomyoma continues due to improved nutrition, as the network of blood vessels grows.

The third stage is regression, the reverse development of uterine leiomyoma, which occurs if the estrogen content in the body drops sharply. This happens, for example, with menopause, when a small leiomyoma, formed earlier, resolves on its own after the cessation of the functioning of the ovaries. The same result leads to timely treatment in the formation of a tumor in a young woman. In this case, a small leiomyoma disappears after an artificial decrease in estrogen levels with the help of special preparations.

The tumor can exist in nodular (the most common) and diffuse form. The nodal form is characterized by the formation of one (single type) or several (multiple type) rounded nodes with clear boundaries. With a diffuse form, numerous shapeless thickenings appear, scattered throughout the volume of the organ. This form is extremely rare.

The nodes of a multiple tumor are formed non-simultaneously, have different sizes. Along with leiomyoma nodes, similar tumors of a different type may be present ( fibromyomas, for example).

Types of leiomyoma

The wall of the uterus consists of 3 layers: endometrium (internal, monthly renewing mucous membrane), myometrium (muscular layer) and perimetry (outer serous membrane). Depending on the direction in which the node grows, leiomyomas are divided into the following types:

1. Intramural tumor does not extend beyond the myometrium.
2. Submucosal leiomyoma (submucosal) bulges into the cavity, taking up an increasing volume of it with an increase.
3. Subserous (subperitoneal) grows outside, goes into the abdominal cavity and quite often connects to the body of the uterus with a thin stem.

If the tumor is located close to the peritoneum and has a significant size, it can be detected by palpation of the abdomen.

Reasons for the formation of leiomyoma

The main reason for the development of uterine leiomyoma is hormonal failure. A pathological increase in the concentration of estrogens in the blood occurs in the following cases:

1. The production of the pituitary hormones FSH and LH, which regulate the formation of estrogens and progesterone in the ovaries, is disrupted (the “central” variant of the occurrence of pathology). The cause of violations can be endocrine diseases, head injuries, improper cerebral circulation, mental and nervous disorders.
2. There is a failure of the hormone-forming function of the ovaries due to the occurrence of inflammatory or tumor diseases in them, damage to these organs (“ovarian variant”). The appearance of leiomyoma in this case is facilitated by abortions and operations on the genitals, as well as non-compliance with the rules of hygiene and protection against infection with sexual infections.
3. In the uterine cavity, receptors that respond to the effects of estrogens are damaged (the “uterine” variant). This occurs during curettage or abdominal trauma.

The factor provoking the excessive accumulation of estrogen in the blood is the use of hormonal preparations with a high content of it, a metabolic disorder leading to obesity, a change in the composition of the blood. The cause of improper exchange can be a woman's low physical activity and systematic overeating.

An important role is played by hereditary predisposition to the occurrence of such tumors, as well as the presence of congenital pathologies in the development of the genital organs. The presence of vascular diseases, in which the blood supply to various organs is disrupted, contributes to the occurrence of leiomyoma.

Video: Causes of fibroids, how to prevent its development

Symptoms of leiomyoma

Uterine leiomyoma can develop asymptomatically until it reaches a size of 2-3 cm. The growth of neoplasms leads to pain due to tissue stretching, impaired uterine contractility.

There are menstrual irregularities. Menstruation becomes long and plentiful. Not knowing the reason, the woman begins to take hemostatic and pain medications. This helps to alleviate the unpleasant manifestations, and the visit to the doctor is postponed. The regularity of the cycle is gradually disturbed, blood loss increases.

There are signs of a disorder in the functioning of the bladder (cramps, frequent urination) and indigestion. This is due to the compressive effect of the tumor on other organs of the small pelvis.

Due to the increase in the size of the nodes in a woman, the stomach begins to grow, like in a pregnant woman. It is customary to estimate the size of leiomyoma both in centimeters and in "obstetric weeks". The size of the abdomen with an increase in the tumor corresponds to its size at a certain week of pregnancy.

Note: Enlargement of the abdomen due to the growth of fibroids is sometimes mistaken for a sign of pregnancy. Even the presence of menstruation does not bother, since bloody discharge occurs during this period.

What are the possible complications

The severity of complications depends on the size and location of the leiomyoma. Tumors are found most often after an increase in the size of the nodes up to 5-6 cm or more.

Depending on the type of tumor

Submucosal uterine leiomyoma is the most common and tangible cause of complications such as:

1. Menstrual disorders, manifested by prolonged heavy bleeding, not only during menstruation, but also between them.
2. Infertility. The tumor interferes with the normal formation of the endometrium, which makes it impossible to retain the embryo in the uterus, as well as the formation of a normal placenta. It can block the cervix or fallopian tubes.
3. Birth of leiomyoma. Under the action of contractions of the uterine muscles, a large fibroid, located near the neck and having a thin base, may fall into the vaginal area.
4. Damage to the vessels of the tumor, leading to dangerous uterine bleeding, the occurrence of an "acute abdomen" and anemia.

Subserous. Disorders of menstrual function do not appear. But the complications can be no less severe. Twisting the thin stem of such a tumor leads to necrosis of its tissues. Decomposition of a dead tumor in the abdominal cavity causes peritonitis.

The pressure of the nodes on the neighboring organs of the small pelvis leads to disruption of their work, squeezing of blood vessels, inflammation, severe pain in the abdomen, nausea, and vomiting. Such tumors are more difficult to detect, often they are learned about only when complications appear.

Intramural. With an increase in the tumor, the state of the vascular network and the structure of the muscle layer are disturbed. This leads to a decrease in uterine contractility, as a result of which the removal of menstrual blood takes longer than usual. Perhaps the occurrence of stagnation of blood in the cavity of the body, the appearance of endometritis and endometriosis.

Dull constant pain in the abdomen is a characteristic sign of the presence of such a tumor.

Leiomyoma during pregnancy

With the formation of large submucosal nodes in a woman, the onset of pregnancy is difficult due to a violation of the structure of the uterine mucosa. An excess of estrogens, which provokes the appearance of a tumor, leads to the appearance of anovulatory cycles, in which the egg does not mature, conception is impossible. The fixation of the embryo in the wall of the uterus is prevented not only by the immaturity of the endometrium, but also by the increased contractility of the uterus during the formation of submucosal fibroids.

If the nodes are small, then pregnancy is possible, but the growing tumor prevents the growth of the fetus, impairs its blood supply and nutrition. Childbirth can begin a few weeks before the due date, severe bleeding may occur.

After a neoplasm such as uterine leiomyoma is detected in a pregnant woman, its development is carefully monitored. If it increases so much that it interferes with the growth of the fetus, it is removed (most often after the 16th week of pregnancy). Childbirth is carried out ahead of time using a caesarean section.

Leiomyoma with menopause

In women older than 50 years, such a tumor cannot normally form. And even vice versa, a pre-existing node often resolves on its own. However, when endocrine diseases occur, uterine tumors still appear, and the risk of their degeneration into cancer increases significantly, especially in the presence of a diffuse type tumor.

A warning: A woman should immediately contact a gynecologist if she has bleeding from the genitals during the postmenopausal period. Sometimes it's vital.

Diagnosis and treatment

When prescribing treatment, the benignness of the neoplasm, the number, size and location of the nodes, as well as the severity of the symptoms, are specified.

Survey

If a wall thickening and an increase in the size of the uterus are detected, an examination with ultrasound (transvaginal and abdominal), an x-ray of the uterus using a contrast solution (hysterosalpingography) is prescribed. Inspection of the organ cavity is also performed using an optical device (hysteroscopy is performed). If necessary, a tissue sample is taken from the tumor (biopsy using the laparoscopy method), which makes it possible to exclude oncology and clarify the structure of the fibroid. Additionally, MRI and CT scans, a blood test for hormone levels can be prescribed.

Treatment

The treatment uses both conservative and surgical methods. When choosing a technique, the size and location of the uterine leiomyoma nodes, as well as the age of the patient and her desire to preserve the functionality of the reproductive organs, are taken into account.

Conservative therapy it is used in the case when the size of the tumor is not more than 12 obstetric weeks, there are no dangerous symptoms of complications. The indication for such treatment is the woman's intention to have children later.

The level of estrogen in the body is reduced. In this case, oral contraceptives (COCs) are used, which help regulate the cycle, normalizing the ratio of female sex hormones.

To eliminate the consequences of hyperestrogenism, progestin preparations (duphaston, utrogestan, pregnin) are prescribed, which suppress the effect of estrogen on uterine tissues. A decrease in estrogen production is also achieved with the help of drugs that suppress the production of pituitary hormones that stimulate the formation of estrogen in the ovaries (zoladex).

To accelerate the process of tumor regression, physiotherapeutic procedures (therapeutic baths, electrophoresis, and others) are prescribed.

Surgery. Indications for its implementation are the large size of the nodes (more than 3 cm in diameter), the existence of a long stem, a noticeable increase in the tumor, a decrease in the free volume of the uterus, the presence of severe bleeding and anemia. A contraindication will be the presence of inflammatory and infectious diseases in a woman, as well as vascular pathologies and blood diseases.

To remove the tumor, the most commonly used method is laparoscopy - an operation to eliminate the neoplasm through punctures in the abdomen. A more traumatic method is laparotomy - removal of the tumor through an incision above the pubis. It is used in the presence of large fibroids. In some cases, the tumor is removed (myomectomy) through the vagina.

The most sparing methods are UAE (blocking of tumor blood vessels), ultrasonic ablation. With extensive damage to the uterus, its partial or complete removal is performed.

Video: Treatment of uterine fibroids with UAE

Leiomyoma (leiomyoma; from leios - smooth + myos - muscle) - a benign tumor formed from smooth muscle tissue, found in organs where there are smooth muscle cells (esophagus, stomach, small intestine, etc.). Skin leiomyoma was first described by Virchow in 1854 in a 32-year-old man on the chest skin. In 1884, Babes identified angioleiomyomas as a separate group. The connection of the tumor with the muscle that lifts the hair was established. Characteristic is the soreness of the tumor in the cold, the appearance of "goose bumps" when it is irritated. In the study, multiple nerve endings were found in the foci of skin leiomyoma, which explains the pain.

There are 3 types of skin leiomyomas: multiple, dartoid and solitary angioleiomyomas.

Cases of familial lesions of skin leiomyoma are described. The leading symptom is pain crises associated with mechanical irritation, hypothermia, accompanied by a drop in blood pressure, blanching, and vomiting. On examination, there is a node of dense elastic consistency, with a diameter of 5 mm to 3 cm. The skin is not changed. Sometimes cyanosis is determined above the node, rarely - peeling. Leiomyoma of the skin begins with a slowly growing single nodule, and only then do new tumor elements appear. Differential diagnosis is carried out with fibromas, angiomas, nevi. Treatment - electroexcision.

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Skin leiomyoma (synonym: angioleiomyoma) is a benign tumor of smooth muscles.

There are three varieties of this tumor: leiomyoma, which develops from the muscle that lifts the hair; dartoid (genital), emanating from the smooth muscles of the scrotum, female external genital organs or muscles that squeeze the nipple of the mammary glands; angioleiomyoma, which develops from the muscle elements of small vessels of the skin.

Leiomyomas arising from the levator pilaris muscle are small, firm, reddish, reddish-brown, or normal-skin-colored, nodular or plaque-like lesions arranged in groups or linearly, more commonly on the extremities. Usually painful. Solitary leiomyoma has the same appearance, but the elements are much larger.

Causes and pathogenesis of skin leiomyoma. According to histogenesis, 3 types of skin leiomyomas are currently distinguished, characterized by clinical and histomorphological features characteristic of each of them.

• Type I - multiple leiomyomas that develop from smooth, erect hairs, or diagonal muscles.
• Type II - dartoid (genital) solitary leiomyomas that develop from the tunica dartos of the scrotum and smooth muscles of the pectoral nipples.
• Type III - angioleiomyoma salts, developing from the muscular walls of the trailing arteries and smooth muscle elements of the walls of small vessels.

Some scientists believe that leiomyoma is more of a malformation than a neoplasm. There are single descriptions of familial leiomyoma, which allows us to consider this disease as genetically determined.

Skin leiomyoma symptoms. Leiomyoma of the skin is common in men. The element of the lesion is a hemispherical dense nodule of a round or oval shape, ranging in size from a pinhead to lentils, large beans and more, stagnant red, brownish, bluish-reddish in color. A characteristic feature of skin leiomyomas is their sharp soreness under the influence of mechanical irritation (rubbing with clothes, scratching, pressure or touch) and cooling. The pain syndrome is caused by the pressure of nerve cells by leiomyoma. Unbearable pain is often accompanied by dilated pupils, lowering blood pressure, blanching of the skin. Leiomyomas usually have a multiple character and are localized on the face, neck, trunk and extremities, more often they tend to group.

Histopathology. Leiomyoma consists of intertwining bundles of smooth muscle fibers separated by connective tissue layers. The cells have hyperchromic nuclei, the number of vessels is reduced, and the number of nerve fibers is increased.

Pathomorphology. The tumor node of this type of leiomyoma is clearly delimited from the surrounding dermis and consists of intertwining thick bundles of smooth muscle fibers, between which there are narrow layers of connective tissue. When stained according to the Van Gieson method, the muscle bundles are stained yellow, and the connective tissue is stained red. A tumor that develops from diagonal mice, without clear boundaries, has a similar structure, but the bundles of muscle fibers are somewhat thinner and lie more loosely. Between the muscle bundles in the sparse connective tissue are capillary-type vessels, sometimes with focal lymphohistiocytic infiltrates. Edema and dystrophic changes may be observed.

Dartoid leiomyoma is a solitary, painless, brownish-red nodule about 2 cm in diameter. Histologically, it differs little from leiomyoma that develops from the muscle that lifts the hair.

Angioleiomyoma is usually solitary, slightly raised above the skin surface, covered with unchanged or reddish-bluish skin, painful on palpation. In a limited area, several elements may occur, localized more often on the limbs, mainly near the joints.

Pathomorphology. Angioleiomyoma differs from other types of leiomyomas in that it consists of a dense interweaving of bundles of thin and short fibers, located randomly in places, in places in the form of concentric structures or eddies. The tumor tissue contains many cells with elongated nuclei that are intensely stained with hematoxylin and eosin. Among these elements, many vessels are found with an indistinct muscular membrane, which directly passes into the tumor tissue, and therefore the vessels look like slits located between bundles of muscle fibers. Depending on the nature of the predominant vascular structures, four main types of angioleiomyoma structure can be distinguished. The most common angioleiomyomas are of the arterial type, then venous and mixed, as well as poorly differentiated angioleiomyomas, in which a few vessels are determined, mainly with slit-like lumens. In some angioleiomyomas, one can see similarities with Barre-Masson's glomus angiomas. They are characterized by the presence of "epithelioid" cells that make up the bulk of the tumor. In later periods, various secondary changes can be detected in angioleiomyomas in the form of a sharp expansion of blood vessels, proliferation of connective tissue, leading to sclerosis, hemorrhage, followed by the formation of hemosiderin.

Histogenesis. Electron microscopy shows that leiomyomas from the muscles that raise the hair, consist of bundles of normal-looking muscle cells. They have a centrally located nucleus surrounded by the endoplasmic reticulum and mitochondria, and along the periphery - a large number of myofilament bundles. Each muscle cell is surrounded by a basement membrane. Among them, nerve fibers are found in a state of twisting and disintegration of the myelin layer, apparently as a result of their compression by muscle cells. Some authors explain the soreness of these tumors by such changes in nerve fibers, while others believe that soreness is the result of muscle contractions. A.K. Apatenko (1977), studying the histogenesis of angioleiomyomas, showed that the source of the development of this type of tumor is the trailing arteries, as evidenced by the characteristic structure of the vessels (the presence of a longitudinal muscle layer, epithelioid cells, stellate lumens) and soreness.

Leiomyosarcoma is rare. It can occur at any age, including in the first months of life. It is located in the deep layers of the skin, reaching large sizes, sometimes protrudes significantly above the surface of the skin, occasionally ulcerates. More often located on the lower extremities, then on the head and neck. The tumor is usually solitary, but multiple tumors also occur.

Pathomorphology. With a longer and less malignant course, the structure of the tumor resembles that of benign leiomyoma, differing from it in a noticeable proliferation of spindle-shaped elements and the presence of areas of polymorphism of the nuclei. In a more malignant variant, a large number of anaplastic hyperchromic nuclei are found in the tumor, located in places in groups, forming multinuclear symplasts, many unevenly scattered mitoses, as well as infiltrating growth into the underlying tissues.

Differential diagnosis should be made with fibromas, angiomas, fibrosarcomas, epitheliomas, skin leiomyosarcomas, neurofibromas and other tumors.

Treatment of skin leiomyoma. Surgical or laser excision, cryotherapy, intravenous or intramuscular injections of prospidin, per course - 1-2.5 g. With multiple foci, a calcium antagonist, nifedipine, has a good effect.

The first description and histological study of this tumor belongs to Virchow (1854). Further work by Besnier and Babes (1873-1884) led to the isolation of vascular leiomyoma as a special form of the disease and the creation of a classification of skin leiomyomas.

Currently, according to histogenesis, three types of leiomyomas are distinguished, each of which has characteristic clinical and histomorphological features.

Multiple leiomyomas develop from the diagonal or levator hair muscles. Clinically characterized by the presence of small (3-10 mm) tumor-like elements of a round or elongated shape - dense, raised above the skin nodules with a smooth shiny surface, pink, red-brown, bluish-red color, slightly or moderately painful on palpation. The nodules are usually multiple, located on the limbs (the most common localization), face, trunk, sometimes linearly or strictly unilaterally (in the pathogenesis of the disease, the involvement of the peripheral nervous system is not excluded). A characteristic feature of leiomyomas from the muscles that raise the hair is increased pain under the influence of mechanical irritation, cooling, stress. In these cases, and sometimes spontaneously, attacks of pain can be observed, accompanied by a pronounced vegetative reaction - a decrease in blood pressure, pallor, a feeling of fear, etc.

The disease usually manifests itself in 15-30 years. Men get sick twice as often as women; familial cases have been described.

The course and prognosis are relatively favorable - the nodules that appear slowly, increase in size and number over the years, show a tendency to group, sometimes undergo spontaneous involution. Secondary changes are uncharacteristic, malignancy is practically not observed. At the same time, multiple leiomyomas present a serious problem both for the patient (pain, pronounced functional disorders and cosmetic defects) and for the doctor (the recurrence rate for surgical treatment reaches 50%).

Genital leiomyomas are much less common. They are localized more often on the scrotum and labia majora, less often on the nipples. They appear as dense single nodular tumors of red-brown color, up to 3 cm in size, surrounded by a zone of hyperemia. Less painful than multiple leiomyomas, but also react with worm-like contractions to cold and mechanical irritation.

Angioleiomyomas develop from the muscular walls of the trailing arteries and smooth muscle elements of the walls of small skin vessels. More often they are solitary, less often - diffusely widespread or locally multiple formations in the form of dense nodules of the color of normal skin or a bluish-reddish color, slightly rising above the surface of the skin. The nodules are moderately painful on palpation, becoming more sensitive when the ambient temperature drops.

Multiple angioleiomyomas are usually localized on the extremities, with leiomyomas developing from small vessels more often affecting the skin of the upper extremities, and leiomyomas developing from the trailing arteries - the skin of the lower extremities with a favorite localization in the joints of the lower leg and foot.

Mostly women aged 30-50 years and older are ill. The disease may be hereditary.

Morphologically, angioleiomyomas of arterial, venous, mixed type, as well as poorly differentiated forms of the tumor are distinguished. Angioleiomyomas of the arterial type are the most common.

The clinical diagnosis of leiomyomas can be both relatively simple (in typical cases) and extremely complex. In all cases, histological confirmation of the diagnosis is necessary.

Differential diagnosis. Angioleiomyoma should be differentiated from levator hair muscle leiomyoma, cavernous hemangioma. Leiomyoma from the muscles that raise the hair should be differentiated from angioleiomyoma, syringoma, fibroma, neurofibroma, Kaposi's sarcoma. Genital leiomyomas are differentiated from angioendotheliomas, fibrosarcoma.

Radical treatment - surgical excision within healthy tissues, electroexcision, cryotherapy. With multiple leiomyoma, intravenous and intramuscular injections of prospidin, calcium antagonists (nifedipine) are recommended to eliminate the pain syndrome.

leiomyoma