Uterine smooth muscle tumors of uncertain malignant potential: diagnostic challenges and therapeutic dilemmas. Report of 2 cases and review of the literature

Uterine smooth muscle tumor of uncertain malignant potential (STUMP) ABOUT a CASE

INTRODUCTION AND IMPORTANCE

Uterine smooth muscle tumor of uncertain malignant potential (STUMP) is rare tumor, and regarded as sub-classification in uterine smooth muscle tumors between benign and malignant criteria. They represent a heterogeneous group of rare tumors.

PRESENTATION OF CASE

We report a case of a STUMP tumor in a fifty-three-year-old patient who underwent surgery for a hysterectomy.

DISCUSSION

STUMP often presents with nonspecific clinical manifestation the only confirmatory examination is anatomopathological and may be supported by immunohistochemistry, hysterectomy is currently considered the gold standard of treatment.

CONCLUSION

Uterine STUMP tumor represents a therapeutic dilemma. A multidisciplinary approach is mandatory.

Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Comprehensive Multidisciplinary Update

Background and Objectives: The uterine smooth muscle tumors of uncertain malignant potential (STUMP) are tumors with pathological characteristics similar to leiomyosarcoma, but that do not satisfy histological criteria for leiomyoma. These are problematic lesions with intermediate morphologic features; thus, diagnosis and treatment are difficult. This narrative review aims to review data in the literature about STUMPs, particularly focusing on management and therapeutic options and strategies for women who desire to preserve fertility. Material and Methods: authors searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed and Scopus databases, from 2000 to March 2023. Pertinent articles were obtained in full-text format and screened for additional references. Only articles in English language were included. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: The median age was 43 years old. Symptoms are similar to those of leiomyomas, with a mean diameter of 8.0 cm. Total hysterectomy with or without bilateral salpingo-oophorectomy is the standard care for women if fertility desire is satisfied. Myomectomy alone can be considered for young patients. Although these tumors have not a high malignant potential, several studies described recurrence and metastases. Conclusions: STUMPs are complex uterine smooth muscle tumors, with a rare but reasoned clinical-diagnostic management. Considering the high clinical and histological complexity of these tumors, high level of expertise is mandatory.

The Role of Pathogenesis Associated with the Tumor Microclimate in the Differential Diagnosis of Uterine Myocytic Tumors

Myocytic tumors of the uterus present vast morphological heterogeneity, which makes differential diagnosis between the different entities necessary. This study aims to enrich the existing data and highlight new potential therapeutic targets regarding aspects related to the pathogenic process and the tumor microenvironment in order to improve the quality of life of women. We performed a 5-year retrospective study, including particular cases of uterine myocyte tumors. Immunohistochemical analyses of pathogenic pathways (p53, RB1, and PTEN) and tumor microclimate using markers (CD8, PD-L1, and CD105), as well as genetic testing of the PTEN gene, were performed. The data were statistically analyzed using the appropriate parameters. In cases of atypical leiomyoma, a significant association was observed between PTEN deletion and an increased number of PD-L1+ T lymphocytes. For malignant lesions and STUMP, PTEN deletion was associated with the advanced disease stage. Advanced cases were also associated with an increased mean CD8+ T cell count. An increased number of lymphocytes was associated with an increased percentage of RB1+ nuclei. The study corroborated clinical and histogenetic data, highlighting the importance of the differential diagnosis of these tumors to improve the management of patients and increase their quality of life.

MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement

Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.

Five-Year Retrospective Study of Uterine STUMP and Leiomyosarcoma

Taking into account the unpredictable evolution of uterine STUMP and leiomyosarcomas, there are no clearly established therapeutic protocols to date, the only certified treatment being total hysterectomy. We performed a 5-year retrospective study including cases of malignant tumors and those with uncertain malignant potential originating in the smooth muscle tissue of the uterine body. The clinical data, pathological aspects, and the immunohistochemical results were statistically analyzed using SPSS Statistics Version 26. The main associations of the p53 gene were identified with age, atypia, and the occurrence of metastases. The average number of CD8+ T cells correlated with the hormonal status of the patients, the presence of diabetes, and alteration of thyroid function, but also with the severity of the atypia. The therapeutic method was represented by total hysterectomy, and 30% of the patients with leiomyosarcoma also benefited from adjuvant chemotherapy. The average period until death was 25.66 months. The present study showed that the mutant expression of p53 could have a role in assessing the clinical evolution of patients, given the association with exitus and metastasis. In addition, the average number of CD8+ T cells corresponded to severe atypia, indicating the possibility of applying targeted immunotherapies in these cases.

Acute abdomen with a parasitic smooth muscle tumor of uncertain malignant potential (STUMP) in pregnancy; a unique case report

INTRODUCTION AND IMPORTANCE

Diagnosis of a smooth muscle tumor of uncertain malignant potential (STUMP) during pregnancy is rare. Furthermore; the investigation of an intra-abdominal mass during pregnancy is clinically challenging due to anatomical changes and additional considerations of the developing fetus and radiation exposure. The unusual nature and diagnostic dilemma of such a case warrants a case report to serve as an educational prompt to clinicians who may encounter pregnant patients with undifferentiated intra-abdominal masses and/or suspecting of STUMP.

CASE PRESENTATION

We report a rare case of a parasitic STUMP diagnosed during pregnancy. The patient presented with a new umbilical hernia and deranged liver function tests (LFT's) during her third trimester. MRI reported a large mass in the left mid flank with intra-abdominal varices extending into the umbilical hernia. She went on to develop an acute abdomen requiring laparotomy where a parasitic fibroid adherent to the omentum was excised and a preterm infant was delivered via caesarean section. Histology was difficult due to pregnancy related changes but ultimately confirmed a diagnosis of STUMP.

CLINICAL DISCUSSION

STUMP in pregnancy is rare and diagnosis is further complicated by histological challenges due to pregnancy related changes. Postoperative diagnosis is challenging due to lack of universally accepted diagnostic criteria and Uncertainty regarding prognostic factors makes management and follow-up of patients with STUMP challenging. Studies have shown that younger patients are more likely to demonstrate recurrence.

CONCLUSION

Investigation and management of intra-abdominal masses in pregnancy is challenging. It requires timely multi-disciplinary team (MDT) input. Additional complications and considerations relate to the preterm fetus. Knowledge and understanding of these difficulties will better equip clinicians working with such patients to formulate a structured and well informed approach to the pregnant patient with a new intra-abdominal mass. Diagnosis of STUMP during pregnancy may be challenging for the pathologist and require further exert opinion.

Management of a giant uterine smooth muscle tumor of uncertain malignant potential in a 32-year-old woman: case report and review of the literature

Uterine smooth muscle tumors of uncertain malignant potential (STUMP) represent a group of rare uterine smooth muscle tumors not diagnosed unequivocally as benign or malignant. To data, diagnostic criteria, malignant potential, surgical management, and follow-up of these neoplasms remain controversial. Considering that STUMP and leiomyoma are not significantly different in terms of clinical presentation and preoperative sonographic characteristics, it might be difficult to distinguish between the two affections prior to pathological confirmation at surgery. All cases should be managed by multidisciplinary tumor teams and patients' follow-up should comprise consultation with a gynecologic oncologist and a close surveillance because of the possibility of recurrence or metastasis. We present the case of a 32-year-old nulliparous woman admitted to our gynecology clinic. She was asymptomatic and only complained an increase in abdominal volume started during the past 6 months. A transabdominal and transvaginal pelvic ultrasound revealed a large heterogeneous tumor mass measuring 190×163 mm, color score 2, expanded in the left iliac fossa, suspected for benign uterine myoma. Subsequent magnetic resonance imaging confirmed a large pelvic-abdominal tumor located near the left posterior-lateral uterine wall with areas of necrosis, suggestive of subserosal leiomyoma with cystic degeneration. The patient underwent a median longitudinal laparotomy for excision of the pelvic mass. The patient was normally discharged five days after surgery in good health conditions. The final histological examination was compatible with STUMP. At present, the patient has had no relapses or metastases and she is undergoing follow-up.

Clinical and Histopathological Predictors of Recurrence in Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Multicenter Retrospective Cohort Study of Tertiary Centers

BACKGROUND

The term uterine smooth muscle tumor of uncertain malignant potential (STUMP) indicates a rare, equivocal entity between benign leiomyomas and leiomyosarcomas. In the present study, we evaluated a comprehensive range of clinical, surgical, and pathological features in a large multicenter series of patients with STUMP to identify risk factors for recurrence.

METHODS

This is a retrospective study performed by collecting consecutive cases diagnosed between January 2000 and December 2020 in five tertiary centers. Associations between STUMP recurrence and clinicopathological characteristics as well as surgical treatment modality were investigated.

RESULTS

Eighty-seven patients affected by STUMP were considered. Of them, 18 cases (20.7%) recurred: 11 as leiomyosarcoma (LMS) and 7 as STUMP. The mean time to recurrence was 79 months. We found that fragmentation/morcellation, epithelioid features, high mitotic count, Ki-67 value > 20%, progesterone receptor (PR) < 83%, and p16 diffuse expression were associated with higher risk of recurrence and shorter recurrence-free survival (RFS). Furthermore, morcellation/fragmentation and mitotic count remained independent risk factors for recurrence and shorter RFS after multivariate analysis, while the presence of epithelioid features was an independent risk factor for recurrence only.

CONCLUSIONS

Our results suggest that morcellation is associated with risk of recurrence and shorter RFS, thus it should be avoided if a STUMP is suspected preoperatively. Epithelioid features, high proliferation activity, low PR expression, and diffuse p16 expression are also unfavorable prognostic factors, so patients presenting these features should be closely followed up.

Recurrence of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Systematic Review of the Literature

Background: This study aimed to systematically review the existing literature on uterine smooth muscle tumor of uncertain malignant potential (STUMP) to provide information about characteristics and outcomes of patients and the risk factors for recurrence over a period of 60 years (1960−2021). Methods: According to PRISMA guidelines, we searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed (all fields) and Scopus (Title/Abstract/Keywords) databases (accessed on 1 January 2022). Relevant articles were obtained in full-text format and screened for additional references. The only filter used was the English language. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: Thirty-four studies, including 189 cases, were included. The median age was 43 years, and in 21.5% of cases there was a recurrence of the disease. Bivariate analysis showed a significant association between use of morcellation without bag and risk of recurrence (p = 0.001). Unprotected morcellation during demolitive or conservative surgery was independently associated with a higher risk of disease recurrence with a relative risk of 2.94 (p < 0.001). A significant progressive decrease in the recurrence rate was observed over time (r = −0.671, p = 0.008). The percentage of patients who underwent surgery followed by in-bag protected morcellation significantly increased after the publication of the U.S. Food and Drug Administration alert about the risk linked to this procedure (p = 0.01). Conclusions: Unprotected morcellation of the lesion is associated with the relapse of the disease. However, this clinical condition showed a drastic decrease over time. This could likely be due to the increased awareness by surgeons of the importance of customizing surgical treatment.

Rare Case of Smooth Muscle Tumor of Uncertain Malignant Potential - Clinical Case

Introduction: Smooth muscle tumor of uncertain malignant potential (STUMP) still represents a medical and surgical challenge, being rare and hard to diagnose. Normally STUMP consists in a multitude of uterine tumors that do not meet the current histologic criteria for a specific malignant or benign tumor. Clinical, imagistic and laboratory investigations seem to only raise the presumptive diagnosis in these cases, the diagnosis being confirmed during histological examination of the post hysterectomy/myomectomy specimen. Case report: We present the case of a 50-year-old female patient who was examined for the first time for pelvic pain and sensation of increased pressure in the lower abdomen in June 2020. A gynecology consultation was performed, during which a large uterine mass was felt on vaginal digital examination combined with pelvic palpation. Further pelvic ultrasound examination revealed a voluminous tumor of the left ovary. Then, a magnetic resonance imaging was performed, which showed a large pelvi-abdominal tumor of probable ovarian origin with a mixt tissue type and cystic structure, the presence of pathological abdominal and pelvic lymph nodes, ascites with a suspicion of peritoneal carcinomatosis. The patient was referred to a tertiary center and the multidisciplinary team recommended surgical treatment. A total hysterectomy with bilateral oophorectomy and stadial lymphadenectomy was performed. After surgery, the patient had a favorable evolution and was discharged five days after the intervention in a good health condition. Macroscopic and histological examinations of the biopsy pieces showed morphological aspects of uterine smooth muscles tumors with uncertain malignancy potential/STUMP and multiple uterine leiomyomas. Discussion:Due to the rarity of these tumors, the scientific literature needs to be constantly updated in order to help physicians to correctly identify and treat this pathology. It is highly recommended to identify tumors with a high malignancy potential, so that the follow up will be sufficient to discover and treat recurrences before they become life-threatening. Conclusion:Smooth muscle tumor of uncertain malignant potential remains a difficult diagnosis due to uncertainty between malignancy and benign features. Treatment approaches are difficult in these cases and must always be in accordance with the patients' desire to maintain their reproductive functions and fertility. Recurrence of STUMP has been reported, therefore a close follow up of these patients must always be performed.

Clinical and reproductive outcomes of uterine smooth muscle tumor of uncertain malignant potential: a single-center retrospective study

OBJECTIVE

To evaluate the clinical outcomes, histopathological features, and obstetric and oncological outcomes of uterine smooth muscle tumor of uncertain malignant potential (STUMP).

METHODS

We conducted a single-center, database review of patients with STUMP between January 2001 and December 2015. We investigated the clinical, operative, histopathologic, recurrence, and fertility outcomes of the included cases.

RESULTS

Nineteen patients with STUMP were studied. Three were reclassified as sarcoma after slide review, and 16 patients were finally included in the study. The mean age was 45 years. Ki-67 expression was ≥10% in 25.0% of cases and 30% in the only recurrent case. Recurrence occurred 52 months after a diagnosis of STUMP in a 56-year-old female patient who underwent hysterectomy. Two of six patients who underwent myomectomy had fertility requirements, and both successfully delivered babies without recurrence. Recurrence was not related to mitosis, degree of atypia, or necrosis. There was also no relationship between type of surgery or surgical approach and recurrence.

CONCLUSIONS

Patients with STUMP warrant a pathological review process in centers with experience. Fertility-preservation is worth attempting, but young patients must be followed-up closely. Ki-67 might be a valuable marker predicting recurrence.

Incidence of occult uterine sarcoma and other unexpected pathologies in patients having surgery for presumed myomas: A retrospective observational study

OBJECTIVE

To determine the incidence of occult uterine sarcomas and other unexpected pathologies in patients undergoing hysterectomies or myomectomies with a pre-operative diagnosis of uterine leiomyomas.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary hospital in Santiago, Chile.

POPULATION

921 women who underwent surgery for presumed myomas. Database analysis of surgical and pathological notes, from January 2007 to December 2017 with a preoperative diagnosis of uterine leiomyoma.

MAIN OUTCOME MEASURES

number of patients with uterine sarcoma confirmed on histology.

RESULTS

During this period, a total of 921 gynecological surgeries were performed for benign uterine fibroids of which 787 were hysterectomies and 134 were myomectomies. We found four cases of malignant neoplasms (0,43 %). Two were uterine leiomyosarcoma (LMS), one mixed epithelial and mesenchymal tumor, and one case of incidental cervical cancer. This gives an LMS incidence of 1 in 460 and 1 in 921 of mixed epithelial and mesenchymal tumor. There were seven cases of unexpected benign pathology. This included six atypical myomas and one leiomyoblastoma epithelioid myoma. If we combine the malignant and benign cases, we would have an incidence of 1.2 % of unexpected pathology.

CONCLUSION

In our series of patients undergoing myomectomies or hysterectomies for presumed myomas the incidence of LMS was 1 in 460. The incidence of any unexpected pathology including benign ones in presumed myomas was 1 in 83 (six atypical myomas, one leiomyoblastoma epithelioid myoma, two LMS, one mixed epithelial and mesenchymal tumor, one incidental cervical cancer).

Giant uterine mass with uterine smooth muscle tumor of uncertain malignant potential: A case report

•

STUMP is a rare disease histologically, and giant STUMP is extremely rare.

•

To our knowledge, present case represents the largest STUMP reported.

•

After successful surgery, the patient is alive without evidence of recurrence.

Background

Uterine smooth muscle tumor of uncertain malignant potential (STUMP) is a rare tumor belonging to a group of smooth muscle tumors that possess both benign and malignant features, complicating the diagnosis.

Case report.

We present the case of a 41-year-old primiparous woman who complained of heavy menstrual bleeding and severe pressure symptoms in the lower abdomen for 3 months. Magnetic resonance imaging revealed a large intramural myoma measuring 35 × 25 cm in the lower uterine corpus. A laparotomy including total hysterectomy was performed. Grossly, the uterine mass measured 38.5 × 35.4 × 20.4 cm in the largest diameter and weighed 18.3 kg. Pathological analysis revealed a uterine mass diagnosed as a smooth muscle tumor of uncertain malignant potential. The patient was normally discharged 7 days after surgery and decided to follow up without further treatment. At the time of this report, the patient had been followed up as an outpatient for 18 months without recurrence.

Conclusion

Giant uterine STUMP is extremely rare and difficult to diagnose on physical examination and imaging findings alone. It is important to consider the possibility of an underlying malignancy when performing a preoperative examination and to perform frozen biopsy if malignancy is suspected. During follow-up, patients should undergo consultation with a gynecologic oncologist and should be surveilled closely because of the possibility of recurrence or metastasis.

Uterine smooth muscle tumours of uncertain malignant potential: single-centre experience and review of the literature

Introduction

Uterine smooth muscle tumours of uncertain malignant potential (STUMPs) are a rare histologically heterogeneous group of uterine smooth muscle tumours (SMTs). Their malignant potential and clinical differentiation between leiomyoma and leiomyosarcoma remain uncertain prior to surgical removal.

Aim of the study

To investigate the patients and tumour characteristics of patients with STUMPs and to propose algorithms for optimal diagnosis, treatment, and follow-up management.

Material and methods

This was a single-centre retrospective cohort study of all patients who underwent surgery for a preoperative diagnosis of uterine myoma at the University Hospital “Dr. Georgi Stranski”, Pleven, Bulgaria during a period of 33 months (from January 2013 until October 2015). Data were obtained from the medical history records. We performed descriptive analysis to characterise the patient population (e.g. demographics, age, contraceptive use, and complaints that led to the diagnosis) and the tumour characteristics. Last data were obtained prior May 2019.

Results

A total of 320 medical records were retrospectively evaluated. The preoperative diagnosis of myoma was confirmed in 279 of the cases (89.4%). In 27 (8.3%) cases the final histological result was completely different. In 14 (2.3%) a histological postoperative diagnosis of STUMP was identified. All 14 STUMP lesions were intramural with a median size of 7.5 cm (range 3.5 to 15 cm). The median age at diagnosis of STUMP was 45.4 years (range 36 to 52 years), and 92.9% (n = 13) of the patients were premenopausal. Ultrasound data of a rapidly growing myoma were a reason for diagnosis in only three patients (25%), whereas 92.9% of the patients (n = 13) presented with heavy menstrual bleeding with or without anaemia. After surgery, none of the patients with STUMP experienced a relapse of the disease within the median follow-up time of 48 months (R = 40-78).

Conclusions

STUMP tumours are rare tumours, predominantly diagnosed in premenopausal women. They define a group of patients with very good long-term prognosis. Therefore, longer follow-up is needed to allow for conclusions on recurrence rate and survival.

Ultrasound and clinical characteristics of uterine smooth muscle tumors of uncertain malignant potential (STUMPs)

OBJECTIVE(S)

Smooth muscle tumors of uncertain malignant potential are rare uterine neoplasms. Their identification through imaging is still limited due to the few available descriptions in the scientific literature. The objective of this paper is to provide clinical and ultrasound features that could support an early identification of these neoplasms.

STUDY DESIGN

We retrospectively evaluated preoperative sonographic data of patients receiving a histopathological diagnosis of smooth muscle tumors of uncertain malignant potential between 2014 and 2019 at the S. Anna Hospital (Turin, Italy), a tertiary gynecological center. Tumors were characterized on the basis of ultrasound images using terms and definitions according to the morphological uterus sonographic assessment group.

RESULTS

A total of fourteen patients with smooth muscle tumors of uncertain malignant potential (20 lesions, including 18 pure and 2 with associated leiomyosarcoma) were identified. The median age was 47 years (range 28-77) and nine (64%) patients were of reproductive age. Six patients (43%) were asymptomatic, two (14%) presented with abdominal pain, two (14 %) with menorrhagia and four (29%) with both symptoms. Two (14%) patients developed local recurrences as uterine smooth muscle tumor of uncertain malignant potential and leiomyosarcoma, respectively. At ultrasound imaging, nine (69%) smooth muscle tumors of uncertain malignant potential were poorly or moderately vascularized and nine (82%) showed both circumferential and intra-lesional flows. Only three (15%) showed shadowing. The outlines were well-defined in seventeen cases (85%) and most (90%) showed isoechoic or mixed echogenicity with microcystic anechoic areas in fourteen (70%) of cases.

CONCLUSION(S)

Sonographic features of smooth muscle tumors of uncertain malignant potential may vary and a pathognomonic description has not been recognized. However, the identification of single or multiple lesions with specific ultrasound features should raise the suspicion of tumors of uncertain malignant potential. These features include isoechogenicity or mixed echogenicity, regular borders, presence of internal microcystic and anechoic areas, circumferential and intralesional vascularization ranging from minimal to high and absence of shadowing.

Uterine smooth muscle tumors of unknown malignant potential: A challenging question

Uterine smooth muscle tumors of unknown malignant potential [STUMP]s are neoplasms with pathological features that preclude an equivocal diagnosis of leiomyosarcoma, but that do not fulfill the criteria for leiomyoma or its variants, and raise concerns that the tumors may behave in a malign fashion. Total hysterectomy with or without bilateral salpingo-oophorectomy is the standard treatment if fertility is completed, whereas myomectomy alone can be taken into consideration in young patients who desire to preserve childbearing potential. A careful surveillance every 6 months for 5 years and then yearly is strongly warranted. Patients with STUMP can relapse as either STUMP or leiomyosarcoma in approximately 11-13% of the cases, and their 5-year overall survival ranges from 92 to 100%. The present paper reviews the clinicopathological features of uterine STUMPs with a particular focus on most commonly accepted histopathological criteria for the diagnosis and on biological behaviour of these controversial neoplasms.

Uterine smooth muscle tumor of uncertain malignant potential: fertility and clinical outcomes

Objective

In this study, we aimed to evaluate the clinicopathological features, obstetric, and oncological outcomes of patients diagnosed with a uterine smooth muscle tumors of uncertain malignant potential (STUMP).

Methods

A dual-institutional, database review was carried out to screen patients with STUMP who were treated with upfront surgery between January 2006 and December 2017. Data including age at the time of diagnosis, recurrence rate, disease-free survival, overall survival, and fertility outcomes were retrospectively analyzed.

Results

Fifty-seven patients with STUMPs were included in the study. The median age at the time of diagnosis was 42 (range, 16 to 75) years. The median follow-up was 57 (range, 16 to 125) months. Eight patients (14%) had recurrence during follow-up. Recurrent STUMPs were seen in seven patients and leiomyosarcoma after 14 months in one patient. Seven patients with a recurrent STUMP survived, while the remaining patient died. Recurrence rates were similar for women who underwent myomectomy and those who underwent hysterectomy. The presence of uterine localization of tumor (subserosal vs intramural-submucosal) statistically significantly affected recurrence rates (odds ratio=5.72; 95% confidence interval=1.349–24.290; p=0.018). Ten of 27 patients who underwent myomectomy for uterine myoma had fertility desire. Seven pregnancies were recorded.

Conclusions

Our study results suggest that fertility-sparing approaches are feasible in patients with STUMP, although recurrence may be seen.

A clinicopathologic review and obstetric outcome of uterine smooth muscle tumor of uncertain malignant potential (STUMP) in a single institution

OBJECTIVES

The present study aimed to analyze the clinicopathologic features and treatment of uSTUMP in a single institution. In addition, we described the obstetric outcomes after uterine-preserving surgery for uSTUMP.

METHODS AND MATERIALS

A retrospective chart review was performed of patients diagnosed with uSTUMP between January 2000 and February 2018 at the Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center. We obtained data on the patients' demographics, treatment, therapeutic results, time to recurrence, disease-free and overall survival, and subsequent obstetric outcomes. The central pathology reviews were carried out by two pathologists specializing in gynecologic oncology.

RESULT

A total of 19 patients diagnosed with uSTUMP were identified and included in the study. The mean age at diagnosis was 41 years (range 28-49 years). Frozen sections were performed in 11 patients including five patients during surgery. Nine of the 19 patients (47.4%) were treated by hysterectomy and 10 patients were initially treated by myomectomy. The mean follow-up period was 47 months (range 6-209 months). Two patients (10.5%; 2/19) experienced recurrence. Although not defined as recurrence in the present study criteria, one patient had a secondary diagnosis of atypical leiomyoma one year after the initial diagnosis of uSTUMP. Seven patients requested uterine-preserving treatment, five of whom wanted to become pregnant. Three of them (3/5; 60%) successfully delivered live birth to full term by Cesarean section without complications such as abortion, preterm delivery or uterine rupture, and tumor recurrence.

CONCLUSIONS

The present study describes the clinicopathologic data of uSTUMP patients. Our results suggest a uSTUMP recurrence of 10.5%, comparable to previous reports. Although there is a possibility of malignant recurrence, fertility-preserving management is worth attempting because of relatively low affected age with careful close follow-up.

Abdominal leiomyosarcomatosis after surgery with external morcellation for occult smooth muscle tumors of uncertain malignant potential: A case report

•

We present a rare case of abdominal sarcomatosis from uterine leiomyosarcoma.

•

The patient underwent myomectomy for occult STUMP 3 years before.

•

Risk of relapse, dissemination and malignant transformation of STUMP is uncertain.

•

STUMPs require a close surveillance especially after conservative surgery.

•

Laparoscopy may allow timely diagnosis and treatment of STUMP recurrence.

Introduction

Although rare, cases of abdominal sarcomatosis (AS) after laparotomy/laparoscopic interventions for uterine smooth muscle tumors of uncertain malignant potential (STUMP) have been reported.

Presentation of case

We describe a rare case of diffuse abdominal sarcomatosis in a patient that some year earlier had undergone myomectomy for a suspected uterine myoma, which was histologically proven to be a STUMP. Once the patient was admitted at our Department, she underwent a diagnostic laparoscopy that confirmed a condition of peritoneal sarcomatosis disseminated through the entire abdomen, and then a laparotomic total hysterectomy, bilateral salpingo-oophorectomy, and total omentectomy, achieving a complete cytoreduction. Histological examination showed high-grade uterine leyomiosarcoma (LMS). Since there is no evidence of any clinical benefit of adjuvant treatment, given the risk of disease recurrence, we decided, with the patient’s agreement, to conduct close follow-up with a Positron Emission Tomography (PET)/Computed Tomography (CT) scan every 3 months and diagnostic laparoscopy every 6 months, even in the absence of PET/CT positivity. After 2 years PET/CT showed a relapse of LMS in the perigastric region and, therefore the patient underwent a diagnostic/operative laparoscopy with complete removal of the neoplastic recurrence. To date, the patient is disease-free.

Discussion and conclusion

STUMPs should be submitted to a frequent surveillance for their risk of recurrence, dissemination and transformation into LMS, even many years after the first diagnosis. A follow-up including surgical re-exploration with laparoscopy and PET/CT imaging may allow early detection and timely treatment of the relapse with good long-term outcome, as demonstrated by our case.

Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: Clinicopathologic-Sonographic Characteristics, Follow-Up and Recurrence

Background

Uterine smooth muscle tumor of uncertain malignant potential (STUMP) is rare tumor, and regarded as sub-classification in uterine smooth muscle tumors between benign and malignant criteria. In this study, we evaluated characteristics of cases with STUMP diagnosis in a 10-year period.

Methods

We retrospectively evaluated medical records of patients with histopathological STUMP diagnosis in Istanbul Training and Research Hospital, a tertiary center. We analyzed preoperative demographic, clinical features and postoperative follow-up. Preoperative sonographic data were re-evaluated.

Results

The mean age was 42 years. One patient was postmenopausal, and five patients were premenopausal. All of them had a complaint of meno-metrorrhagia. We re-evaluated preoperative sonographic images of patients, and defined 83.3% as well-defined margins, 66.7% hyperechoic, 100% heterogeneous, 66.7% non-cystic, 50% calcification and 66.7% acoustic shadowing. Pathologic features showed mean number of mitosis 8, mild atypia 66.7%, and necrosis 33.3%. In a 24-year-old unmarried female patient with myomectomy, we detected recurrance of tumor in sonographic and MRI studies after 11 months, and confirmed the diagnosis via tru-cut biopsy. There was no relevance between sonographic findings and atypia, necrosis and mitosis. The recurrence was not in relationship with mitosis, degree of atypia and necrosis. We found no relevance between tumor diameter and mitosis, atypia, necrosis and recurrence.

Conclusions

STUMP is classified as an intermediate form, histopathologically so calling it benign or malignant for sure is not possible. Singulary, solidity, hyperechogenicity, heterogenecity and features of acoustic shadowing and margins can guide us to preoperative sonographic diagnosis. Recurrence/metastasis after many years from operation can be seen, and those patients should be followed long term.

May Sonic Hedgehog proteins be markers for malignancy in uterine smooth muscle tumors?

Several studies have demonstrated that the Sonic Hedgehog signaling pathway (SHH) plays an important role in tumorigenesis and cellular differentiation. We analyzed the protein expression of SHH pathway components and evaluated whether their profile could be useful for the diagnosis, prognosis, or prediction of the risk of malignancy for uterine smooth muscle tumors (USMTs). A total of 176 samples (20 myometrium, 119 variants of leiomyoma, and 37 leiomyosarcoma) were evaluated for the protein expression of the SHH signaling components, HHIP1 (SHH inhibitor), and BMP4 (SHH target) by immunohistochemistry. Western blot analysis was performed to verify the specificity of the antibodies. We grouped leiomyoma samples into conventional leiomyomas and unusual leiomyomas that comprise atypical, cellular, mitotically active leiomyomas and uterine smooth muscle tumors of uncertain malignant potential. Immunohistochemical analysis showed that SMO, SUFU, GLI1, GLI3, and BMP4 expression gradually increased depending on to the histologic tissue type. The protein expression of SMO, SUFU, and GLI1 was increased in unusual leiomyoma and leiomyosarcoma samples compared to normal myometrium. The inhibitor HHIP1 showed higher expression in myometrium, whereas only negative or basal expression of SMO, SUFU, GLI1, and GLI3 was detected in these samples. Strong expression of SHH was associated with poorer overall survival. Our data suggest that the expression of SHH proteins can be useful for evaluating the potential risk of malignancy for USMTs. Moreover, GLI1 and SMO may serve as future therapeutic targets for women with USMTs.

Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared With Abdominal Hysterectomy for Presumed Myomas

STUDY OBJECTIVE

Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH.

DESIGN

Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III).

SETTING

U.S. hospitals.

PATIENTS

Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata.

INTERVENTIONS

We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature.

MEASUREMENTS AND MAIN RESULTS

Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained.

CONCLUSION

When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.

Successful pregnancy following myomectomy for uterine smooth muscle tumor of uncertain malignant potential: A case report and review of the literature

•

STUMPs are rare smooth muscle tumors with an overall favorable prognosis.

•

Pregnancy is possible after diagnosis of STUMP treated with myomectomy

•

Management of patients desiring fertility with STUMPs requires a multidisciplinary approach.

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis

OBJECTIVE

The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death.

STUDY DESIGN

A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death.

RESULTS

The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years).

CONCLUSION

The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made.