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11 March 2015 - Case of the Week #345

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Thanks to Dr. Ankur Sangoi, El Camino Hospital, California (USA), for contributing this case.


     

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Case #345

Clinical history:
A 49 year old woman had a hysterectomy for leiomyomas (fibroids) of the uterus.

Microscopic images:



What is your diagnosis?

Click here for diagnosis and discussion:


Diagnosis: Leiomyoma with vasculitis secondary to Lupron

Discussion:
Since the 1980's, gonadotropin releasing hormone (GnRH) agonists such as Leuprorelin (Lupron®) have been used to treat uterine leiomyoma, leading to shrinkage of the leiomyoma and uterus, which facilitates easier surgical treatment (vaginal instead of abdominal hysterectomy, myomectomy instead of hysterectomy) (Wikipedia: Leuprorelin [Accessed 13 November 2023]). The mechanism is initial GnRH stimulation of pituitary LH and FSH production, followed by decreased production as the pituitary becomes desensitized to GnRH. This leads to reduced estrogen production, associated with reduction in size of the estrogen dependent leiomyoma (Int J Surg Pathol 2003;11:339, Int J Gynecol Pathol 1995;14:235). GnRH agonists are used only temporarily, because their anti-estrogen side effects include menopausal symptoms and bone loss, and upon withdrawal, the leiomyomas rapidly regrow.

Histologically, there is often initially edema and necrosis, followed by hyalinization and lymphocytic infiltrate (B and T cells). In this case, there was a prominent vasculitis. The patient had no history of a prior vasculitis and at follow up 3 years later, there was no evidence of vasculitis.


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