Fertility-sparing surgery in uterine leiomyosarcoma

Uterine sarcomas: A critical review of the literature

This review aims to provide a comprehensive description of surgical approaches for the management of uterine sarcomas. Uterine sarcomas are rare uterine neoplasms. Frequently, diagnosis is made after hysterectomy or myomectomy scheduled for presumed benign leiomyomas. The gold standard for surgical treatment of uterine sarcomas is hysterectomy with bilateral salpingo-oophorectomy. It is possible to adopt a fertility-sparing approach for those patients who wish to maintain their fertility. The role of pelvic lymphadenectomy is controversial; in fact, removal of lymph nodes is only recommended in the case of radiological suspicion of nodal involvement. Use of a morcellator is associated with increased risk of total recurrence, intra-abdominal recurrence and death. Advanced disease management should be customized based on the patient's performance status given the uncertain role of adjuvant chemotherapy. Treatment of advanced or recurrent disease remains a subject of debate, but surgery is the best approach in terms of morbidity and mortality. There are few options for management of these uterine tumours, and further studies are needed to clarify the diagnostic and therapeutic pathways of patients with a first diagnosis of uterine sarcoma and patients with relapse of uterine sarcoma. No specific evidence supports the adoption of adjuvant therapy in uterine-confined disease, and molecular/genomic profiling may be useful to identify patients at risk of recurrence.

Fertility-Sparing Management May Be Considered in Young Women with Uterine Sarcoma

Uterine sarcomas occur very rarely in young women. Hysterectomy, which is a standard treatment, may not be acceptable for those patients, especially nulliparous women. Fertility-sparing management may be an alternative. The aim of the study was to assess fertility-sparing management in patients with uterine sarcoma. Eleven patients were eligible for the study. Histopathologic types of the tumor included: adenosarcoma (n = 3), low-grade endometrial stromal sarcoma (n = 3), low-grade myofibroblastic sarcoma (n = 1), leiomyosarcoma (n = 1), leiomyosarcoma myxoides (n = 1), rhabdomyosarcoma (n = 1), high grade endometrial stromal sarcoma (n = 1). The mean age of the patients at the time of diagnosis was 27.4 years (range: 17–35) and the average follow-up 61 months (range: 12–158). Six patients received adjuvant treatment: megestrol (n = 5) and chemotherapy (n = 1). Recurrence was diagnosed in five cases. Median time to recurrence was 35 months (range: 8–90). Three patients conceived spontaneously following treatment and gave at least one live birth. In total, five full-term pregnancies were recorded and five healthy children were born. Fertility-sparing management may be considered in some patients with uterine sarcoma; however, it may not be appropriate in high-grade endometrial stromal sarcoma. Patients with adenosarcoma may have a low chance of childbearing.

Uterine Sarcomas: How to Navigate an Ever-Growing List of Subtypes

Uterine sarcomas are rare mesenchymal tumors that are aggressive cancers. The rarity of these tumors, and consequently limited prospective data, has made surgical management of uterine sarcomas challenging. One major obstacle in the management of uterine sarcomas is establishing the diagnosis prior to surgery, which is crucial for appropriate intraoperative management. This paper serves to review aspects of surgical management of uterine sarcomas that remain unanswered. Distinguishing common benign myomas from rare uterine sarcomas is important for operative planning and subspecialty care because benign myomas are frequently managed with minimally invasive hysterectomy or myomectomy, whereas the mainstay of management of uterine sarcomas is hysterectomy without specimen fragmentation. Preoperative clinical presentation, serum studies, imaging, and histologic examination all have limitations in establishing a preoperative diagnosis. In addition, patients are often of reproductive age and desire fertility preservation. Although surgery remains the cornerstone for management, high-quality data guiding best practices are sparse. Morcellation should be avoided. Expert pathologic review, imaging to assess for metastatic disease, and consideration of hormone receptor testing are advisable. Recent data have further informed surgical approach and fertility preservation in early-stage disease, but controversy remains. Despite substantial advancement in the medical management of uterine sarcomas, surgical management of uterine sarcomas remain challenging. Larger studies with long-term follow-up are needed to guide fertility preservation surgery options, both local resection and ovarian preservation, further in young women. Development of novel methods to differentiate between benign and malignant uterine masses is needed.

Role of surgery in gynaecological sarcomas

Gynaecological sarcomas account for 3-4% of all gynaecological malignancies and have a poorer prognosis compared to gynaecological carcinomas. Pivotal treatment for early-stage uterine sarcoma is represented by total hysterectomy. Whereas oophorectomy provides survival advantage in endometrial stromal sarcoma is still controversial. When the disease is confined to the uterus, systematic pelvic and para-aortic lymphadenectomy is not recommended. Removal of enlarged lymph-nodes is indicated in case of disseminated or recurrent disease, where debulking surgery is considered the standard of care. Fertility sparing surgery for uterine leiomyosarcoma is not supported by strong evidence, whilst available data on fertility sparing treatment for endometrial stromal sarcoma are more promising. For ovarian sarcomas, in the absence of specific data, it is reasonable to adapt recommendations existing for uterine sarcomas, also regarding the role of lymphadenectomy in both early and advanced stage disease. Specific recommendations on cervical sarcomas' surgery are lacking. Existing data on surgical approach vary from radical hysterectomy to fertility-preserving surgery in the form of trachelectomy or wide local excision, however no definite conclusions can be drafted on the recommended surgical approach. For vulval sarcomas, complete surgical excision with at least 2 cm of free margin is considered to be the primary treatment which is associated with good prognosis. The aim of this review is to provide highest quality evidence to guide gynaecologic oncologists throughout surgical management of gynaecological sarcomas.

Outcome and Management of Uterine Leiomyosarcoma Treated Following Surgery for Presumed Benign Disease: Review of Literature

Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer, usually diagnosed incidentally at the time of myomectomy or hysterectomy. There have been concerns for several years about the fact that the inadvertent disruption of occult uLMS may have a negative impact on patient outcome. This study reviews the outcome and management of patients with a diagnosis of uLMS after surgery for presumed benign disease. We conducted a literature search in which 47 published English-language articles were obtained for evaluation. A total of 23 studies with outcomes data were included. It is evidenced that patients who underwent surgery with tumor disruption resulted in poorer outcomes compared with en bloc tumor, especially by power morcellation. The power morcellation was associated with an increased risk of recurrence, shorten time to recurrence, and upstage after re-exploration. Early re-exploration and surgical staging are appreciated for better prognosis and may alter postoperative treatment. We also updated on the incidence and preoperative evaluation to assess the risk of patient and give an effective counseling.

Incidental leiomyosarcoma found at the time of cesarean hysterectomy for morbidly adherent placenta

Background

Incidental leiomyosarcoma (LMS) is a rare diagnosis in pregnancy or in the puerperium. To our knowledge, this is the first case reported in the literature of incidental LMS after cesarean hysterectomy for morbidly adherent placenta.

Case

We present a case of a cesarean hysterectomy performed for a suspected morbidly adherent placenta in a patient with three prior cesarean deliveries, an anterior placenta previa and a fundal fibroid. Subsequent pathology identified a LMS on final specimen. The patient declined bilateral oophorectomy and removal of her remaining cervix. No chemotherapy or radiation was given for her presumed stage IB disease.

Conclusion

An incidental finding of a LMS is infrequent; the risk of recurrence is > 50% even if the sarcoma is removed in its entirety.

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Occult uterine sarcomas may be found even during cesarean hysterectomy.

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Imaging should be performed when a leiomyosarcoma is diagnosed postoperatively.

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Recurrence risk can be > 50% even if a leiomyosarcoma is confined to the uterus.

BGCS uterine cancer guidelines: Recommendations for practice

The British Gynaecological Cancer Society has issued the first Endometrial (Uterine) Cancer guidelines as recommendation for practice for the UK.

Risk, risk reduction and management of occult malignancy diagnosed after uterine morcellation: a commentary

Minimally invasive surgical techniques compared with laparotomy offer the advantages of less intraoperative blood loss, shorter hospitalization, fewer wound complications and faster return to baseline activity for both hysterectomy and myomectomy. While morcellation allows for the laparoscopic removal of large specimens, it may result in intraperitoneal dissemination of benign disease or upstaging of occult malignancy leading to compromised survival. There has been heightened scrutiny over appropriate patient selection and preoperative assessment in light of recent warnings against power morcellation issued by the US FDA. This commentary therefore summarizes the magnitude of such risks associated with uterine morcellation, current national regulatory statements and potential merits of risk-reducing approaches such as contained morcellation. The importance of patient counseling is underscored.

Uterine leiomyosarcoma manifesting as a tricuspid valve mass

Uterine leiomyosarcoma is a rare malignancy and carries a poorer prognosis when compared to endometrial carcinoma. It has been observed to metastasize to all the major organs. It presents with symptoms of abdominal distension, vaginal bleeding and may pass unnoticed until an advanced stage in patients with leiomyomas. Surgery is a viable option in patients with disease limited to the uterus, but metastasis to the heart may require surgery to prevent acute and catastrophic complications. The case described here involves metastasis to the tricuspid valve, which caused severe tricuspid regurgitation in the setting of acute pulmonary embolism. Surgical resection restored cardiac function and stabilized the patient. This case illustrates a rare site of metastasis of leiomyosarcoma which required immediate intervention and resulted in a favorable outcome.

Uterine sarcomas: then and now

OBJECTIVE

The purpose of this article is to provide an updated review of uterine sarcomas. The traditionally described neoplasms are reviewed as well as several recently characterized entities in terms of their imaging and clinical aspects. We attempt to provide a longitudinal imaging overview, from initial presentation to follow-up. Imaging features are also described of response to traditional therapeutic agents and newer targeted agents.

CONCLUSION

A greater understanding of the pathogenesis has improved our ability to image and treat uterine sarcomas, both at initial staging and on follow-up. Targeted therapy is assuming an increasingly important role in the management of these lesions. It is imperative for radiologists to be aware of response characteristics and potential complications of these agents as well as conventional chemotherapeutic agents.

Staging of uterine sarcomas

Uterine sarcomas comprise leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, undifferentiated endometrial sarcoma, and their variants. Carcinosarcoma is historically classified as sarcoma, but it is now regarded as a metaplastic carcinoma. Uterine sarcomas are rare, and are traditionally staged in the same way as endometrial carcinoma. Because of their different clinical and biological behaviours, the International Federation of Gynecology and Obstetrics introduced a new staging system in 2009 for leiomyosarcoma, endometrial stromal sarcoma and adenosarcoma, and carcinosarcoma, respectively. Following an extensive literature review no good evidence was found to support the modification of the staging system. This is mainly because of the rarity of the sarcomas and the heterogeneity of the reports, the different diagnostic criteria and treatments changing over the decades the retrospective nature and small sample size in most studies, and the lack of uniform pathological review even in large studies. Currently, evidence is still lacking about the use of preoperative imaging for staging purpose, and uterine sarcomas remain to be surgically staged. Total hysterectomy is the cornerstone for both staging and treatment. Newer evidence shows that routine lymphadenectomy and bilateral salpingo-oophorectomy may not be necessary, unless in the presence of extra-uterine spread, suspicious ovaries or lymph nodes, and certain poor histological types, such as undifferentiated endometrial sarcoma and adenosarcoma with sarcomatous overgrowth. More research and data collection are definitely needed in order to verify and further revise the current staging systems.

Optimal management of uterine leiomyosarcoma

Uterine leiomyosarcomas (LMSs) are rare tumors, comprising 1.3% of all uterine cancers. Primary therapy for localized disease entails complete surgical resection. The majority of patients recur within 2 years of primary therapy as these tumors tend to undergo early hematogenous spread. A randomized, controlled trial showed no improvement in the overall or disease-free survival with adjuvant radiotherapy, compared with observation, following resection of early-stage uterine LMS. A Phase II study of adjuvant chemotherapy following complete surgical resection of uterine LMS reported promising results. However, in the absence of Phase III randomized data demonstrating improved outcomes, the role of post-resection chemotherapy for early-stage disease remains experimental. For metastatic or unresectable LMS, systemic chemotherapy forms the mainstay of treatment. First-line treatment options include gemcitabine-docetaxel or doxorubicin with or without ifosfamide. Novel targeted therapies are under investigation in an attempt to devise more effective treatment strategies.

The management of patients with uterine sarcoma: a debated clinical challenge

Uterine sarcomas include a heterogeneous group of rare tumours that usually have an aggressive clinical behaviour and a poor prognosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard surgical treatment. Pelvic and/or para-aortic lymphadenectomy is indicated for carcinosarcoma, but not for leiomyosarcoma and undifferentiated endometrial sarcoma. Some recent data on low numbers of patients with low-grade endometrial stromal sarcoma appear to show an incidence of nodal involvement higher than previously expected, thus suggesting a role for lymphadenectomy in this malignancy. Carcinosarcoma also requires a comprehensive surgical peritoneal staging. Postoperative treatment of uterine sarcomas has been long debated. Adjuvant pelvic radiotherapy appears to improve local control without any significant impact on overall survival. There is little evidence in the literature supporting the use of adjuvant chemotherapy in any gynaecological sarcomas except for carcinosarcomas. However, uterine sarcomas have a high tendency to develop distant recurrences, and recent data on adjuvant chemotherapy in soft tissue sarcomas are promising. As for the drugs to be used, it is worth noting that in a Swiss study, the combination of ifosfamide (IFO) and doxorubicin (DOX) obtained similar response rates in advanced gynaecological sarcomas and in advanced soft tissue sarcomas of other sites. In our decision-making scheme for early-stage disease, patients with leiomyosarcoma or undifferentiated endometrial sarcoma should receive adjuvant doxorubicin/epidoxorubicin (EPIDX)+ifosfamide, and those with carcinosarcoma should be treated with adjuvant cisplatin (CDDP)-based chemotherapy. The same drug regimens are used for the treatment of advanced disease. Sequential pelvic radiotherapy following chemotherapy could be delivered to selected cases. Recurrent disease often requires the integration of different therapeutic modalities, but no curative option is currently available with the possible exception of surgery for lung metastases and hormone therapy with or without debulking surgery for recurrent low-grade endometrial stromal sarcoma. Patients should be encouraged to enter clinical trials designed to identify new active drugs for these malignancies.

Uterine myomas: management

OBJECTIVE

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

DESIGN

Literature review of 198 articles pertaining to uterine myomas.

RESULT(S)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

CONCLUSION(S)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

Surgical conservation of both ovaries in an adolescent with uterine müllerian adenosarcoma: a case report

Fertility-sparing and minimally invasive surgeries are advancing everyday in gynecologic oncology. However, data on conservation of ovaries in uterine müllerian adenosarcoma are limited due to its very rare incidence in reproductive-aged females. Conservation of both ovaries along with adjuvant chemotherapy was performed in a 14-year-old girl with uterine adenosarcoma. After 30 months, she had no evidence of disease. Therefore, surgical conservation of ovaries might be a solution for fertility sparing in uterine müllerian adenosarcoma.

Non-puerperal inversion of the uterus caused by leiomyosarcoma: a case report and clinical management

Uterine inversion is a rare complication of the postpartum period, but it is an even rarer complication of the non-puerperal period. A 49-year-old nulliparous woman was admitted to the hospital with the following complaints: abnormal vaginal bleeding, pain, anuria and a mass protruding from the vulva. The mass was removed by twisting and a laparotomy was required for massive bleeding due to the inversion. The diagnosis of complete inversion was made during the laparotomy. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the pathological examination revealed a leiomyosarcoma. Uterine inversion in the non-puerperal period is an extremely rare event and it should be kept in mind that the cause of the inversion may be a malignant disease, like leiomyosarcoma.

Uterine sarcomas

A wide variety of sarcomas occur in the uterus but two subtypes - leiomyosarcoma and endometrial stromal sarcoma - account for a majority of those more routinely encountered. Using the 2003 World Health Organization classification, this review focuses on six uterine sarcomas: endometrial stromal sarcoma, undifferentiated endometrial sarcoma, leiomyosarcoma, rhabomyosarcoma, angiosarcoma and liposarcoma. The epidemiological, clinical, pathological and molecular features are presented along with therapeutic approaches. Familiarity with molecular aspects of these tumors and application of novel technologies in their assessment should be encouraged as they may provide alternate therapies resulting in improved survival for the patient. Clinical information necessary for accurate diagnosis of these lesions is emphasised. A multidisciplinary approach to management of patients with uterine sarcomas is essential for optimal management.

Reproduction beyond cancer: A message of hope for young women

OBJECTIVE

Aggressive chemotherapy and radiotherapy or radical oncological surgery in young women with cancer has greatly enhanced these patients' life expectancy, but these treatments often cause infertility or premature ovarian failure due to a massive destruction of the ovarian reserve. The objective of this review is to discuss the effect of the various cancer treatments on fertility and present the various fertility sparing operations and fertility preservation strategies.

METHOD

An extensive survey of the most up-to-date literature was performed.

RESULTS

This review discusses the impact of current cancer treatment on fertility potential and the various surgical and assisted-reproduction innovations available today for the most common cancers in young women. Although the ability to retain reproductive potential is becoming a major quality-of-life factor in an increasing number of young female cancer survivors, they are still being poorly counseled with regard to the negative impact of the treatment on their fertility and on their options for fertility preservation.

CONCLUSION

As the emerging discipline of fertility preservation is steadily attracting increasing interest, developments in the near future promise to be very exciting. However, in everyday routine work, better interdisciplinary cooperation between gynecological and pediatric oncologists, surgeons, immunologists, and endocrinologists is necessary so that individualized options for fertility preservation can be offered in advance of surgical procedures or cancer treatments.

Malignant Transformation of Myomas: Myth or Reality?

The possibility that a fibroid may actually be a smooth muscle tumor of uncertain malignant potential or a leiomyosarcoma often dictates the clinical management of rapidly growing fibroids. This article provides a clinicopathologic background regarding uterine leiomyosarcomas and answers common questions that obstetricians and gynecologists have about the management of rapidly growing fibroids and leiomyosarcoma. The clinician must be aware that the infrequent occurrence of uterine leiomyosarcomas makes it difficult to establish absolutely firm recommendations for the diagnosis and management of this disease, particularly with regard to fertility preservation. Nevertheless, this article addresses major issues that a clinician might face in the evaluation of a smooth muscle tumor of the uterus that clinically may be malignant.

Prognostic factors and impact of adjuvant chemotherapy for uterine leiomyosarcoma

OBJECTIVE

The aim of this study was to investigate prognostic factors and impact of adjuvant therapy for uterine leiomyosarcoma (LMS).

METHODS

All cases with uterine LMS were retrieved from medical registry (1984 through 2003) of Chang Gung Memorial Hospital. After excluding cases with initial surgery at outside the hospital, missing chart, and wrong pathologic diagnosis, 51 patients (41 for stage I, 7 for stage III, and 3 for stage IV) met the study criteria. Approximate stratified analysis and Cox proportional hazards model were used to adjust confounding factors.

RESULTS

The median follow-up for survivors was 47 months. Five-year overall survival and recurrence-free survival (RFS) rates were 67.4% and 59.2% for the whole series. Multivariate Cox regression analyses selected age (>50 versus < or =50 years: relative risk [RR], 11.07 [95% CI 1.53-80.34]), tumor size (>11 versus < or =11 cm: RR, 11.63 [95% CI 2.14-63.12]), stage (III and IV versus I: RR, 21.24 [95% CI 2.20-204.98]), and adjuvant chemotherapy (yes versus no: RR, 0.08 [95% CI 0.01-0.81]) as significant predictors of death. Besides, surgical stage (P = 0.021), tumor size (P = 0.005), and adjuvant chemotherapy (P = 0.011) were significantly correlated with RFS. After approximate stratification, the use of adjuvant chemotherapy also significantly decreased RR of death.

CONCLUSIONS

This is the first report to demonstrate benefit of adjuvant chemotherapy for LMS despite the limitation of sample size and its retrospective nature. Prospective multicenter trials are necessary to clarify the role of chemotherapy, selecting criteria, and optimal chemotherapy regimen for uterine LMS.

Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy

STUDY OBJECTIVE

To emphasize the need for histologic evaluation of intrauterine lesions. Six cases of unexpected mesenchymal uterine tumors were diagnosed following pathologic review of specimens obtained during hysteroscopy to evaluate intrauterine lesions.

DESIGN

Retrospective chart review (Canadian Task Force classification II-3).

SETTING

Large tertiary care medical center.

PATIENTS

Four postmenopausal and two perimenopausal women with uterine mesenchymal tumors.

INTERVENTION

Hysteroscopy and staging laparotomy.

MEASUREMENTS AND MAIN RESULTS

Mean age of the patients was 57.5 +/- 19.5 years (mean +/- 2SD). Four women (67%) were postmenopausal. Three patients had abnormal uterine bleeding, one had a cervical mass, and the other two were asymptomatic and referred for evaluation of thick endometrium detected by routine ultrasound, which had been preformed as part of their annual check-up. In all cases, the initial hysteroscopic diagnosis was endometrial polyp or submucous myoma. Following the pathologic review, all six women underwent complete staging laparotomy. In two women, there was no residual disease in the surgical specimen. None of the patients had extrauterine spread of the disease. At mean follow-up of 21.5 +/- 9.7 months (mean +/- 2SD), all women were asymptomatic.

CONCLUSIONS

Intrauterine lesions erroneously considered to be benign endometrial polyps or myomas can turn out to be malignant mesenchymal uterine tumors. Hysteroscopic evaluation and biopsy might offer early diagnosis and treatment to these patients.

[Surgery for uterine sarcoma: review of the literature and recommendations for the standard surgical procedure]

Hysterectomy and bilateral salpingo-oophorectomy is the gold standard for the surgical procedure of uterine sarcoma in case of tumor limited to the uterine corpus. Omentectomy and lymphadenectomy should be performed in carcinosarcoma. In others histologic subtypes, lymphadenectomy should be performed only in patients with enlarged nodes discovered at the time of the surgical procedure. Surgical resection should be ideally performed without uterine parcelling out and so using a laparotomy in order to avoid this risk.

Leiomyosarcoma of the uterus: a clinicopathologic study of 21 cases

BACKGROUND

The purpose of the present study was to identify the prognostic factors of and to determine the most appropriate mode of treatment for uterine leiomyosarcoma.

METHODS

We reviewed the hospital records, including surgical notes and pathologic reports, of 21 patients with uterine leiomyosarcoma treated at Chang Gung Memorial Hospital, Kaohsiung, Taiwan, between 1987 and 1997. Univariate analysis was performed using the log-rank test. Cox regression was used to identify independent prognostic factors.

RESULTS

The mean follow-up time was 30 months, and the 5-year disease-free survival rate was 55%. Evaluating the correlation between clinicopathologic parameters and survival, early stage (p = 0.0002), tumor cells without necrosis (p = 0.0026), low-grade tumor (p = 0.015), absence of vascular space involvement (p = 0.006), and tumor without atypia (p = 0.016) were associated with good prognosis. However, in a multivariate analysis using the Cox model, only advanced stage (p = 0.032) and tumor necrosis (p = 0.032) were found to be independent poor prognostic factors. The 5-year disease-free survival was only 21% in patients with the presence of any one or both of these two factors. Five of 11 patients in this group had received aggressive adjuvant therapy after surgery, and none of them survived more than 19 months.

CONCLUSIONS

We found that patients with advanced stage or presence of tumor necrosis had an extremely poor prognosis. Adjuvant therapy seemed to play a limited role, and provided no survival benefit. Treatment for these patients should be palliative until effective therapeutic modalities prove otherwise.

Myxoid leiomyosarcoma of the uterus with subsequent pregnancy and delivery

BACKGROUND

Myxoid leiomyosarcoma of the uterus is an extremely rare neoplasm. In young women with this disease, fertility should be considered in the treatment protocol.

CASE

A 20-year-old woman presented with a huge pelvic mass originating from the uterine wall and showing a histopathology of myxoid leiomyosarcoma. Five and one-half years after laparotomy, the recurrent tumor was found and removed. Two years after the second operation, she became pregnant, and delivered a healthy baby by cesarean section. Multiple recurrent masses were evident and removed at cesarean section. She is alive and well without evidence of recurrence 1 year after delivery.

CONCLUSION

The best treatment for this tumor is not established. In young women with a desire to bear children, the management is more controversial.

Sonography of Uterine Leiomyosarcoma

A case of leiomyosarcoma (LMS) is presented. LMS is a potentially rapidly growing malignant uterine tumor that is thought to be indistinguishable from leiomyoma by ultrasound criteria. The authors present a case that shows extremely rapid rate of growth of an LMS and demonstrates its sonographic appearance.

Pregnancy following uterine fibroid embolization

OBJECTIVE

This paper seeks to evaluate the ability to deliver term pregnancies following uterine fibroid embolization, and to identify impediments to pregnancy in the embolization procedure.

STUDY DESIGN

Four physicians performed embolization procedures at various facilities. Patients were asked if fertility was an issue prior to embolization. We measured follicle-stimulating hormone levels before and after embolization. Clinical follow-up, six months following embolization was obtained by interview. Patients were questioned regarding attempts to conceive, menstrual history, and subsequent pregnancy.

MAIN OUTCOME MEASURES

Complications were calculated upon the entire patient population, whether or not fertility was identified as a goal. Fertility risks from embolization were identified. We measured radiation exposure in a random consecutive group of 50 women undergoing embolization. All patients who conceived were asked the details of the pregnancy.

RESULTS

Four hundred women underwent uterine fibroid embolization between 1996 and 1999. One hundred and thirty nine patients stated a desire for fertility after embolization. Of these, 52 were <40 years old. Seventeen pregnancies have been reported in 14 women. Five spontaneous abortions were observed. Ten women have had normal term deliveries and two women are currently pregnant. No perfusion problems, either during the pregnancy or labor, were reported. The average radiation dosage calculated for 50 women undergoing embolization was 14 rads. Four women under 45 years old suffered premature menopause (10/1000). Two women underwent hysterectomy as a complication of embolization (5/1000).

CONCLUSION

The risks of infertility following embolization, premature menopause, and hysterectomy are small, as is the radiation exposure during embolization. These risks compare favorably with those associated with myomectomy. Fertility rates appear similar to patients undergoing myomectomy. No problems, either during pregnancy or delivery, have been observed after embolization. The course of pregnancy and delivery was normal after embolization with no maternal or fetal complications reported. These findings confirm results from other centers. Desire for future pregnancy is not a contraindication to fibroid embolization.