Author Information
Modi A*, Pardeshi S**, Gupta AS***.
(* Junior resident, ** Assistant Professor, *** Professor, Department of Obstetrics & Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
Endometriosis is a common benign gynecological disease in women. Here we are presenting a rare case of broad ligament endometriotic cyst.
Introduction
The broad ligament is a rare site for endometriosis. The most common site for endometriosis is the ovaries which usually present as a chocolate cyst. The prevalence of this disease increases up to 30 % in patients with infertility and up to 45 % in patients with chronic pelvic pain.[1] Depending upon the site of implantation, endometriosis can be either endopelvic or extrapelvic. Extrapelvic endometriosis is rare but it can occur. These sites include gastrointestinal, urinary tracts, the upper and lower respiratory system, the diaphragm, the pleura, the pericardium, and abdominal scars.
Case Report
A 32 year old multigravida, married for 13 years presented in the gynecology OPD with complaint of dysmenorrhea since 4 years. She was infertile for 4 years. She was relatively asymptomatic 4 years back when she started having dysmenorrhea, increasing pain with each cycle. Pain would appear 4-5 days before menses and subsided when menses stopped. Pain was severe in intensity, not relieved by medication. She tried some non allopathic treatment too however she had no symptomatic relief. Previous menstrual cycle was normal of 30 days and painless. On general examination she was moderately built and had mild pallor. On per abdominal examination, abdomen was soft, had no guarding, tenderness, or rigidity. Per speculum examination showed cervical erosion, vagina was otherwise healthy. On per vaginal examination uterus was of normal size deviated to the left with restricted mobility. Right fornix was ill-defined, pulled up and tender
Modi A*, Pardeshi S**, Gupta AS***.
(* Junior resident, ** Assistant Professor, *** Professor, Department of Obstetrics & Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Abstract
Endometriosis is a common benign gynecological disease in women. Here we are presenting a rare case of broad ligament endometriotic cyst.
Introduction
The broad ligament is a rare site for endometriosis. The most common site for endometriosis is the ovaries which usually present as a chocolate cyst. The prevalence of this disease increases up to 30 % in patients with infertility and up to 45 % in patients with chronic pelvic pain.[1] Depending upon the site of implantation, endometriosis can be either endopelvic or extrapelvic. Extrapelvic endometriosis is rare but it can occur. These sites include gastrointestinal, urinary tracts, the upper and lower respiratory system, the diaphragm, the pleura, the pericardium, and abdominal scars.
Case Report
A 32 year old multigravida, married for 13 years presented in the gynecology OPD with complaint of dysmenorrhea since 4 years. She was infertile for 4 years. She was relatively asymptomatic 4 years back when she started having dysmenorrhea, increasing pain with each cycle. Pain would appear 4-5 days before menses and subsided when menses stopped. Pain was severe in intensity, not relieved by medication. She tried some non allopathic treatment too however she had no symptomatic relief. Previous menstrual cycle was normal of 30 days and painless. On general examination she was moderately built and had mild pallor. On per abdominal examination, abdomen was soft, had no guarding, tenderness, or rigidity. Per speculum examination showed cervical erosion, vagina was otherwise healthy. On per vaginal examination uterus was of normal size deviated to the left with restricted mobility. Right fornix was ill-defined, pulled up and tender
She had an ultrasound done that was suggestive of right ovarian chocolate cyst of size 4.1×4.4×3.4 cm, about 31 cc in volume with normal vascularity on color Doppler. Tubular cystic mass of 3.9×1.9 cm was seen in the right adnexa suggestive of a hematosalpinx. Left ovary was normal. Except for Hb of 8.9 gm% all other hematological parameters including LFT’s, RFT’s were normal. PAP smear was inflammatory. A diagnostic hystero-laparoscopy was performed under general anesthesia. Hysteroscopic examination was normal. On laparoscopic examination uterus appeared bulky with restricted mobility. Right sided fallopian tube and ovary could not be visualized. There was an adnexal mass of about 4×4 cms size on the right side. Left fallopian tube and ovary too could not be visualized as a fold of omentum was covering the left adnexa. Posterior uterine wall was densely adherent to the sigmoid colon. Decision for exploratory laparotomy was taken. Intraoperatively uterus could not be delivered out as it was densely adherent to the sigmoid colon and a 5×5 cm right broad ligament cyst was noted (figure 1). The right adnexal anatomy was also distorted, and the right ovary was adhered to the posterior uterine wall and the posterior surface of broad ligament on the right side. Right fallopian tube was dilated and convoluted with agglutination of the fimbrial end.
Prior to excision of the cyst, the cyst was aspirated and endometriotic fluid aspirate was confirmed. Cyst was then dissected from between the leaves of the broad ligament but it ruptured inadvertently punctured. Chocolate colored endometrotic fluid drained out (figure 2). Cyst wall was peeled off and sent for histopathological examination. Base of the cyst cauterized. Right ovary was densely adherent to the posterior uterine wall on its right side and hence could not be separated. Broad ligament was reconstructed.
Prior to excision of the cyst, the cyst was aspirated and endometriotic fluid aspirate was confirmed. Cyst was then dissected from between the leaves of the broad ligament but it ruptured inadvertently punctured. Chocolate colored endometrotic fluid drained out (figure 2). Cyst wall was peeled off and sent for histopathological examination. Base of the cyst cauterized. Right ovary was densely adherent to the posterior uterine wall on its right side and hence could not be separated. Broad ligament was reconstructed.
Adhesiolysis between sigmoid colon and posterior surface of the uterus was attempted; however in view of excessive bleeding during dissection and significant risk of injury to the sigmoid colon further dissection was abandoned. Abdomen was irrigated and then closed in layers. She tolerated the procedure well. Post operatively she was administered injection luprolide 3.75mg monthly for 3 months. Histopathology report of the cyst wall was confirmed an endometriotic cyst.
Figure 1. Babcock forceps has held the round ligament. Arrow points to the broad ligament endometrioma.
Figure 2. Aspiration of the endometrioma.
Discussion
Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. Its prevalence is 5 % with peak age between 25 to 35 years. As endometriosis is an estrogen dependent condition, it mainly affects female of reproductive age group.[2] The most common site is the ovaries followed by fossa ovarica, uterosacral ligaments, and pouch of Douglas.
In our case the endometriosis collection was between the leaves of the right broad ligament. We postulate that the right ovary which had dense adhesions to the posterior surface of the right broad ligament was the site of an endometrioma which must have ruptured through the posterior leaf of the right broad ligament and an endometriotic collection.
Etiology and pathogenesis of endometriosis is still unclear. The mechanism most widely accepted for the peritoneal endometriotic lesions is via retrograde menstruation. Menstrual debris are found in peritoneal fluid in perimenstrual period in 90 % of women with patent fallopian tubes. Development of pelvis endometriosis depends on the balance between retrograde flow of menses and their clearance by the immune mechanism.[3] Patients with mullerian anomaly and active endometrium causing hematometra have increased incidence of endometriosis.[4] Another theory is celomic hyperplasia suggested by Grunewald in 1942 which can explain endometriosis in amenorrheic women and extrapelvic site endometriosis like pleural cavity, diaphragm, brain and others. According to this theory, mesothelial cells under the influence of steroid hormones or exogenous factors differentiate into functional endometrial cells.[5] Cytokine imbalance in the form of increased pro-inflammatory mediators such as TNF alpha, IL 4 & 6 and decreased production of INF gamma leads to defective cytotoxicity by T cell and NK cell. It may be the reasons for local proliferation of ectopic endometrial tissue.[6] Endometriosis can be diagnosed by laparoscopy and biopsy of lesions.[2] Blood diagnostic test such as CA 125 cannot be used for diagnosis because of lack of sensitivity and specificity.[7] Combined oral contraceptive pills can be used empirically for pain relief as it decreases menstrual flow and causes decidualization of ectopic endometrium. It reduces cell proliferation and causes apoptosis.[8] Progesterone administered as depot medroxy progesterone acetate (DMPA) or norethisterone acetate (NETA) also cause pseudo pregnancy state, decidualization and atrophy of the endometrial implants. It also decreases matrix metallo-proteinase that is required for implantation and growth of the endometrial implant. LNG IUD is also effective for pain relief in patient who does not want to conceive. It decreases menstrual flow and reduces future recurrence.[9] GnRH agonists bind to pituitary receptors resulting in a shutdown of pituitary hormone secretion which in turn down regulates the ovarian production of estrogen. This down-regulation is constant and results in a hypoestrogenic state much like menopause.[10] Combined use of laparoscopy surgery and GnRH analogous decreases recurrence rate compared to surgery used alone.
References
References
- Mehedintu C, Plotogea MN, Ionescu S, Antonovici M. Endometriosis still a challenge. Journal of medicine and life. 2014;7(3):349-57.
- Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014 May;10(5):261-75.
- Olive DL, Henderson DY. Endometriosis and mullerian anomalies. Obstet Gynecol. 1987;69(3 Pt 1):412-5.
- Halme J, Hammond MG, Hulka JF, Raj SG, Talbert LM. Retrograde menstruation in healthy women and in patients with endometriosis. Obstet Gynecol. 1984 Aug;64(2):151-4.
- Gruenwald P. Origin of endometriosis form the mesenchyme of the celomic walls. Am J Obstet Gynecol. 1942; 44(3):470-474.
- Szyllo K, Tchorzewski H, Banasik M, Glowacka E, Lewkowicz P, Kamer-Bartosinska A. The involvement of T lymphocytes in the pathogenesis of endometriotic tissues overgrowth in women with endometriosis. Mediators Inflamm. 2003; 12(3): 131–138.
- Agic A, Djalali S, Wolfler MM, Halis G, Diedrich K, Hornung D. Combination of CCR1 mRNA, MCP1, and CA125 measurements in peripheral blood as a diagnostic test for endometriosis. Reproductive Sciences. 2008;15(9):906-911.
- Meresman GF, Auge L, Baranao RI, Lombardi E, Tesone M, Sueldo C. Oral contraceptives suppress cell proliferation and enhance apoptosis of eutopic endometrial tissue from patients with endometriosis. Fertil Steril.2002;77(6):1141–7.
- Petta CA, Ferriani RA, Abrao MS, Hassan D, E Silva RJC, Podgaec S et al. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod. 2005;20(7):1993–8.
- Wilson AC, Meethal SV, Bowen RL, Atwood CS. Leuprolide acetate: a drug of diverse clinical applications. J Expert Opinion on Investigational Drugs. 2007;16(11):1851-1863.
Citation
Modi A, Pardeshi S, Gupta AS. A Case Report Of Broad Ligament Endometriotic Cyst. JPGO 2019. Vol 6 No. 6. Available from: https://www.jpgo.org/2019/07/a-case-report-of-broad-ligament.html
Modi A, Pardeshi S, Gupta AS. A Case Report Of Broad Ligament Endometriotic Cyst. JPGO 2019. Vol 6 No. 6. Available from: https://www.jpgo.org/2019/07/a-case-report-of-broad-ligament.html