Long-Term Survival in a Patient With Abdominal Sarcomatosis From Uterine Leiomyosarcoma: Role of Repeated Laparoscopic Surgery in Treatment and Follow-Up

How to differentiate uterine leiomyosarcoma from leiomyoma with imaging

Uterine leiomyomas, the most frequent benign myomatous tumors of the uterus, often cannot be distinguished from malignant uterine leiomyosarcomas using clinical criteria. Furthermore, imaging differentiation between both entities is frequently challenging due to their potential overlapping features. Because a suspected leiomyoma is often managed conservatively or with minimally invasive treatments, the misdiagnosis of leiomyosarcoma for a benign leiomyoma could potentially result in significant treatment delays, therefore increasing morbidity and mortality. In this review, we provide an overview of the differences between leiomyoma and leiomyosarcoma, mainly focusing on imaging characteristics, but also briefly touching upon their demographic, histopathological and clinical differences. The main indications and limitations of available cross-sectional imaging techniques are discussed, including ultrasound, computed tomography, magnetic resonance imaging (MRI) and positron emission tomography/computed tomography. A particular emphasis is placed on the review of specific MRI features that may allow distinction between leiomyomas and leiomyosarcomas according to the most recent evidence in the literature. The potential contribution of texture analysis is also discussed. In order to help guide-imaging diagnosis, we provide an MRI-based diagnostic algorithm which takes into account morphological and functional features, both individually and in combination, in an attempt to optimize radiologic differentiation of leiomyomas from leiomyosarcomas.

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

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

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The patient underwent myomectomy for occult STUMP 3 years before.

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

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STUMPs require a close surveillance especially after conservative surgery.

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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.