Leiomyoma Treatment & Management

Updated: Jun 15, 2021
  • Author: Fnu Nutan, MD, FACP; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

Because all leiomyomas are tumors, medical management has a limited role in the resolution or destruction of these lesions. However, pharmacologic intervention may alleviate associated pain.

Several investigators report that calcium channel blockers, particularly nifedipine, relieves pain associated with many cases of piloleiomyomas. As the name implies, drugs in this class inhibit the movement of extracellular calcium ions across the cell membrane into the smooth muscle cell, thereby inhibiting muscular contraction. These data support the theory that muscle contraction is somehow responsible for pain in at least some tumors.

Phenoxybenzamine, an alpha-adrenoceptor blocker, is also reported to be helpful in alleviating pain, [38] including cold-induced pain, in some cases.

Gabapentin has also shown promise in alleviating pain from piloleiomyomas; however, larger randomized trials have not yet been conducted. [39, 40]

Two case reports describe botulinum toxin therapy for relief of pain associated with leiomyoma, although one suggested a possible placebo effect. [41, 42]

Metformin has been suggested, given the association with decreasing cancer incidence in diabetic individuals. It induces oxidative damage and, hence, is proapoptotic and antineoplastic.

Fumarate hydratase‒cancer-specific treatments such as heme oxygenase, englerin A, or those geared towards particular fumarate hydratase transcriptional targets are possible future therapies. [43]

Antineoplastic drugs for use in hereditary leiomyomatosis and renal cell cancer

Retrospective review of the safety of bevacizumab with erlotinib in patients with renal cell carcinoma (RCC) associated with hereditary leiomyomatosis and RCC (HLRCC) showed that the combination therapy was effective with mild toxicity, [44] two reported cases of metastatic RCC associated with HLRCC syndrome responded positively to the combination therapy, [45] and another reported case showed positive long-term response to the therapy. [46] Given the success, bevacizumab with erlotinib could be suggested as a first-line treatment for HLRCC-associated RCC.

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Surgical Care

Surgical excision or ablation may be helpful for some symptomatic individuals. If left alone, most of the cutaneous leiomyomas tend to grow over time. Excision is frequently effective with a solitary leiomyoma, especially when followed by skin graft.

Excision of multiple piloleiomyomas is more cosmetically problematic and less effective than excision of solitary leiomyomas. The recurrence of lesions is more common with multiple piloleiomyomas than with single lesions. After excision, subsequent recurrences have been reported to occur from 6 weeks to more than 15 years. [1] One case report described total excision of multiple leiomyomas followed by immediate artificial skin graft, with successful results. [47] Another case report described a reduction in pain and size of multiple symptomatic leiomyomas with liquid nitrogen cryotherapy.

One report revealed promising results for pain relief with carbon dioxide laser ablation of several symptomatic leiomyomas over a follow-up of as long as 3-9 months. Only local anesthesia was required for this procedure.

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Consultations

There are no guidelines for the management or screening of hereditary leiomyomatosis and renal cell cancer (HLRCC). Female patients with multiple leiomyomas and a history of a family member with multiple leiomyomas should be referred to a gynecologist for evaluation at least once a year, a dermatologist for a full skin examination and potential biopsy biannually, and for annual MRI. [48] Patients also need consultation with a urologist once renal involvement is suspected based on a simple urinalysis. [49] In addition, referral to genetic counseling should be considered when appropriate. [50]

The radiological investigation of choice for surveillance still has not been established. CT scanning of the abdomen is not recommended, owing to radiation exposure. MRI and ultrasonography are indicated, but ultrasonography is not sensitive for isoechoic renal lesions. Some experts suggest wide excision for all tumors that are found. [51]

Women who have multiple cutaneous piloleiomyomas may also have uterine leiomyomas. If the latter are present, the patient most likely has a familial condition termed multiple cutaneous and uterine leiomyomata (MCUL). [15] This is also known as leiomyomatosis cutis et uteri, or Reed syndrome.

A disease variant involving aggressive renal cancer can also occur and is termed HLRCC. [15] Two family kindreds in Finland with uterine leiomyomas had the unusual association of unilateral papillary renal cell carcinoma. Interestingly, seven members of one family had cutaneous nodules. Two of them underwent skin biopsy, which showed multiple cutaneous piloleiomyomas.

Reed syndrome is thought to be inherited as an autosomal dominant trait with incomplete penetrance. As such, not all women in a family are affected, and those who are affected may have only cutaneous, only uterine, or both cutaneous and uterine leiomyomas.

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Prevention

In a study of 1036 randomly selected premenopausal women (age range, 35-49 y), adequate plasma levels of vitamin D (>20 ng/mL) were associated with a reduced risk of uterine leiomyomas. Only 10% of the 620 black women and 50% of the 416 white women in the study had sufficient levels of vitamin D. Compared with women with vitamin D insufficiency, those with sufficient vitamin D had about 32% lower odds of uterine leiomyomas. This relationship was similar for black and white women. There was also an association between daily sun exposure for 1 hour or more and a reduced risk of developing uterine leiomyomas. [52]

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