Secondary peritoneal leiomyomatosis after uterine leiomyoma intervention: multi-institutional clinical and radiologic experience

PURPOSE: To assess the clinical and imaging features of secondary peritoneal leiomyomatosis (SPL) in women with a history of uterine leiomyoma intervention. METHODS: Multi-institutional review identified 31 women with peritoneal leiomyomatosis, including 28 cases of SPL related to prior uterine leiomyoma intervention (mean age at index CT, 42.7 ± 10.6 years). Patient demographics, surgical history, imaging (US/CT/MR/PET), and pathology were reviewed. Retrospective imaging review of the peritoneal findings was performed by board-certified abdominal radiologists. RESULTS: Of the 28 female patients with SPL, 12 underwent prior myomectomy and 16 underwent prior hysterectomy for primary uterine leiomyoma treatment. In 17 cases, power morcellator use during the procedure was confirmed. SPL was diagnosed an average 7.2 ± 4.5 years after primary fibroid surgery, with 78.6% (22/28) being symptomatic. Mean size of the largest peritoneal-based lesion on index CT was 8.0 ± 5.6 cm, with the number of lesions ranging from 1 to too numerous to count (TNTC) (mean, 4.1 ± 3.8 lesions, excluding 2 TNTC cases). Typical US/CT/MR findings included multiple rounded/lobulated, enhancing peritoneal-based nodules/masses with imaging characteristics similar to uterine leiomyomata. 24 patients underwent tumor resection/debulking surgery, and one patient underwent CT-guided biopsy. Available pathology results included benign leiomyomas (n = 22) and leiomyosarcoma (n = 3). Five patients went on to develop additional documented SPL recurrence following initial resection an average 6.5 years later (range, 0.7-16.0 years). CONCLUSION: This study highlights a rare, mostly benign and symptomatic, complication following surgical intervention of intrauterine leiomyomas. Despite the literature focus on morcellator-related peritoneal leiomyosarcoma dissemination, only a small minority of our cases proved to be malignant.