Tsarna Ermioni, Kontou Lorena, Tsochrinis Alexios, Chavez Nestor, Georgopapadakos Nikolaos
Obstetrics and Gynecology, General Hospital of Nikaia "Agios Panteleimon", Nikaia, Piraeus, GRC.
Cureus. 2020 Nov 20;12(11):e11586. doi: 10.7759/cureus.11586.
Abnormal uterine bleeding (AUB) is a common gynecological complaint in reproductive aged women. In this case report, we present a case of emergency total hysterectomy performed in a hemodynamically unstable patient due to AUB. Based on pelvic ultrasound (US) and CT scan along with the prevalence of uterine smooth muscle tumors, leiomyomatous uterus was the most likely preoperative diagnosis. The histological examination of the surgical specimen revealed a leiomyosarcoma with coagulative necrosis, cellularity, mitotic index greater than 20 mitotic figures per 10 high-power-fields, and local invasion of the myometrium at the tumor's stalk. A positron emission tomography (PET) scan was performed postoperatively. The results revealed multiple hypermetabolic secondary lesions at the lungs bilaterally, liver, vaginal cuff, peritoneal involvement, and a small lesion at the left rectus femoris muscle. Thus, tumor was classified as stage IVB uterine leiomyosarcoma according to the International Federation of Gynecology and Obstetrics (FIGO) staging. The patient was referred to an oncology center for chemotherapy and hormonal therapy. Uterine leiomyosarcomas are the most common uterine sarcomas, but remain a rare entity among uterine smooth muscle tumors. Notably, the US imaging of both leiomyosarcomas and other uterine smooth muscle tumors are practically indistinguishable. Thus, diagnosis is difficult to be established prior to surgical treatment. Overall, prognosis in case of leiomyosarcoma is poor, and tumor stage III/IV, tumor size greater than 10 cm, mitotic index greater than or equal to 20 mitotic figures per 10 high-power-fields, and reactive nuclei for Ki67 more than or equal to 10% are associated with shorter survival period. Reliable risk scores to stratify the risk of malignancy in case of leiomyomatous uterus and guide the timing of surgical treatment are totally lacking, and, thus, hindering earlier diagnosis of leiomyosarcoma and improved prognosis.
异常子宫出血（AUB）是育龄期女性常见的妇科病症。在本病例报告中，我们呈现了一例因AUB对血流动力学不稳定的患者实施紧急全子宫切除术的病例。基于盆腔超声（US）和CT扫描以及子宫平滑肌肿瘤的患病率，术前最可能的诊断是平滑肌瘤性子宫。手术标本的组织学检查显示为平滑肌肉瘤，伴有凝固性坏死、细胞密度、有丝分裂指数大于每10个高倍视野20个有丝分裂象，且肿瘤蒂部肌层有局部浸润。术后进行了正电子发射断层扫描（PET）。结果显示双侧肺部、肝脏、阴道残端、腹膜受累处有多个高代谢继发性病灶，左股直肌有一个小病灶。因此，根据国际妇产科联盟（FIGO）分期，该肿瘤被分类为IVB期子宫平滑肌肉瘤。患者被转诊至肿瘤中心接受化疗和激素治疗。子宫平滑肌肉瘤是最常见的子宫肉瘤，但在子宫平滑肌肿瘤中仍然是一种罕见的病症。值得注意的是，平滑肌肉瘤和其他子宫平滑肌肿瘤的超声成像实际上难以区分。因此，在手术治疗前很难确诊。总体而言，平滑肌肉瘤患者的预后较差，肿瘤分期为III/IV期、肿瘤大小大于10 cm、有丝分裂指数大于或等于每10个高倍视野20个有丝分裂象以及Ki67反应性核大于或等于10%与生存期较短相关。目前完全缺乏可靠的风险评分来对平滑肌瘤性子宫的恶性风险进行分层并指导手术治疗时机，因此阻碍了平滑肌肉瘤的早期诊断和预后改善。
