Unexpected Uterine Leiomyosarcoma During Laparoscopic Hysterectomy

Background: Uterine leiomyosarcomas (LMS) have been the subject of much discussion because of cases in which suspected benign leiomyomas have been power morcellated and subsequently have proven to be LMS. Some of these cases have received public attention and have led to the U.S. Food and Drug Administration (FDA) issuing a warning against uncontained power morcellation. Case: A 45-year-old woman had a symptomatic uterine fibroid with heavy menstrual bleeding, and incontinence caused by pressure from the fibroid. She had previously received 6 months of treatment with Esmya((R)) (Gedeon Richter, Budapest, Hungary; ulipristal acetate; UPA), and her symptoms were reduced. However, subsequently in September 2015, she was then admitted to the gynecologic department of a hospital because she had increased pain. A high level of C-reactive protein was found, and necrosis of the fibroid was assumed to be the reason. She decided in December 2015 to opt for a laparoscopic hysterectomy at the hospital because of her increasing pain and pressure symptoms caused by her fibroid and a lack of conviction that the pharmaceutical treatment was sufficient. During a preoperative examination, ultrasound showed a 106 x 73 mm fibroid with no abnormal blood flow or lacuna of fluid inside the fibroid; thus, there was no suspicion of any malignancy preoperatively. Results: The weight of the morcellated uterus was 575 g. A postoperative positron emission tomography scan also showed 4 metastatic processes in her lungs. Conclusions: In this case, the UPA treatment actually led to a delay in the diagnosis, with a larger or even metastatic tumor as a consequence. This is the first case in the literature for which LMS were treated with UPA and contained morcellation.