Uterine sarcomas as a group are uncommon cancers, representing approximately 8% of all uterine malignancies1; of these, 42 to 60% are of the leiomyosarcoma subtype.2 Uterine leiomyosarcomas are aggressive, heterogeneous cancers associated with high rates of progression and recurrence and poor outcome. The rarity of the disease, however, has not hampered research efforts to study its etiology and discover newer interventions.
Uterine leiomyosarcoma is most often discovered by chance when a woman has a hysterectomy performed for fibroids. Usually women present with abnormal vaginal bleeding, palpable pelvic mass, and pelvic pain.
Laparoscopic hysterectomies are increasingly popular because of the morcellated tissue remaining after the short recovery period of patients after total laparoscopic hysterectomy, causing short hospital stays and reducing health care costs. Several studies have reported intra-abdominal pieces.
A 45-year-old P3L3 posthysterectomized patient presented in casualty on January 30, 2017, with complaints of abdominal fullness and discomfort since 2 years, bloating sensation after meals and loss of appetite since 2 months. She was P3L3 with all vaginal deliveries and normal menstrual history previously. She underwent total laparoscopic hysterectomy + bilateral salpingectomy + left oophorectomy for menorrhagia 3 years back and histopathological analysis suggestive of endometrium in proliferative phase, normal myometrium, chronic nonspecific cervicitis, changes of hydrosalpinx in fallopian tube, and simple cyst in the ovary. There was no report of any morcellation done during the last surgery.
On examination vitally, she was stable and a large mass occupying whole of the abdomen with irregular borders and firm consistency was felt.
On admission, ultrasonography was done s/o posthysterectomy status, large solid cystic mass of 22 × 19 × 16 cm arising from pelvis posterior to urinary bladder, extending into lower abdomen above umbilical level. It was compressing posterior wall of urinary bladder laterally extending up to lateral pelvic walls and compressing right ureter with proximal hydroureteronephrosis in right kidney s/o right ovarian mass lesion.
Ca-125 was 40.13, carcinoembryonic antigen 1.3, and alpha-fetoprotein 1.4.
The computed tomographic scan of abdomen and pelvis was done on January 31, 2017 (Fig. 1). A large heterogeneously enhancing solid mass lesion of 17 × 19 × 26 cm with central necrotic areas was seen in pelvis posterosuperior to the urinary bladder, laterally reaching up to both pelvic walls, superiorly extending into abdomen predominantly on left side in umbilical and left lumbar region and displacing bowel loops superiorly and the right lateral aspect.
Anterosuperiorly, mass is seen beneath the anterior abdominal wall. Anteroinferiorly, it was causing mass effect on posterior wall of urinary bladder, posteriorly causing severe compression of the distal sigmoid colon and proximal rectum with suspicious loss of fat planes with the rectum and adjacent fat planes.
The lesion was also causing lateral displacement of bilateral mid and lower ureter right more than left, causing mild hydronephrosis on right side.
The patient underwent staging laparotomy on February 1, 2017 (Fig. 2). Intraoperatively, bilateral double J stenting was done. A large irregular mass 30 × 30 × 20 cm was seen occupying the whole of the abdomen (Fig. 3). Mass was adherent to lateral pelvic walls (Fig. 4), omentum and extending into left inguinal canal and was removed in toto (Figs 5 and 6) and weighed 3.8 kgms (Figs 7 and 8). The bowel was free of tumor.
Right and left hemidiaphragm, liver, splenic flexure, stomach were palpated and appeared free from disease. Pelvic congestion and edema were also seen.
Infracolic omentectomy, appendectomy, and bilateral ureteric dissection were done.
Two units of packed cell volume were transfused and the patient was managed in intensive care unit for 2 days. Postoperatively, the patient recovered well. Histopathological analysis was suggestive of leiomyosarcoma, Fédération Nationale des Centres de Lutte Contre le Cancer grade III with no lymphovascular invasion, attached ovary not involved by tumor, omentum, pelvic peritoneum, and appendix uninvolved by tumor.
The patient was advised radiation and is on regular follow-up with the oncosurgeon.
A recent study showed that there is a small probability of unexpected malignancies incorrectly prescreened patients for laparoscopic hysterectomy procedures. In this study, in 0.25% of the patients having a laparoscopic hysterectomy, an unexpected malignancy was found by histological analysis of the tissue obtained by surgery. About 50% of these unexpected malignancies were found to be a leiomyosarcoma.2
Recently, a case has been reported describing disseminated peritoneal leiomyosarcoma shortly after laparoscopic myomectomy with morcellation.3
The case was reported where a woman had an unexpected leiomyosarcoma 4 years after the removal of the uterus without any macroscopic intra-abdominal metastasis.4
As our case showed, the possibility of leiomyosarcoma should always be considered in case of a suspected tumor in the lower abdomen, even after previous removal of the uterus.