Uterine leiomyoma is the most common benign pelvic neoplasm in women.[1] In light of the considerable negative publicity received with tissue morcellation and subsequent spread of undiagnosed gynaecological malignancy, it has become increasingly important for clinicians to confidently determine the likelihood of malignant pathology preoperatively. [2,3] Currently, there is no single definitive investigation available pre-operatively to differentiate a benign uterine leiomyoma from a malignant uterine neoplasm.[3]
This is a case of a 36-year -old nulliparous female who presented to emergency with a 3 day history of worsening abdominal pain. She reported a similar episode of pain 1 year ago, which led to a pelvic ultrasound demonstrating a large 13 x 9 x 8cm pedunculated fibroid arising from the uterus. The pain improved spontaneously and she did not have any further follow up. Clinical examination revealed a large firm mass up to the xiphisternum with tenderness over the mass. Bimanual examination revealed a fullness in the vaginal fornix with a grossly deviated normal appearing cervix. A pelvic ultrasound reveals a 21 x 17 x 11cm complex mass arising from the left pelvis with areas of cystic degeneration and internal vascularity which was atypical for an uncomplicated leiomyoma. The differential diagnosis included a rapidly growing pedunculated fibroid and or an ovarian fibroma. Subsequent germ cell tumour markers and Ca 125 were unremarkable. An MRI revealed a 23x19x9cm mass from the posterior wall of uterus with a 2.5cm area of restricted diffusion and features compatible with areas of cystic/necrotic changes where leiomyosarcoma was a diagnosis of exclusion. After a multidisciplinary discussion with the Gynaecological Oncology team and the patient, who was very keen to preserve fertility where possible, she underwent a midline laparotomy and myomectomy within 8 days of presentation where the operative findings were consistent with a 30cm pedunculated posterior cervical fibroid.
This case highlights the challenges that are faced by Gynaecologists in assessing the risk of leiomyosarcoma in an otherwise low risk individual where consideration needs to be made towards fertility needs and different options of surgical management. A review of the existing literature will be conducted to determine an optimal management of a woman with a fibroid uterus. The significance of risk factors will be examined, as well as the reliability and sensitivity of diagnostic preoperative modalities including imaging, such as pelvic ultrasound and MRI, and serum markers such as LDH in differentiating benign versus malignant disease.