Abstract

Uterine sarcomas are a rare heterogeneous group of tumours accounting for approximately 1% of all female genital tract malignancies and 8% of all uterine malignancies, a notably higher proportion than previous estimates of 2 - 3% [1]. This increased incidence may be explained by improved diagnostics, accompanied by a true increase of incidence in the ageing population [1]. We present a case of uterine sarcoma in a 49-year-old woman, mother of three, who presented initially with menorrhagia. Her examination under anaesthesia (EUA), hysteroscopy, and dilatation and curettage (D and C) revealed no significant abnormalities. The endometrium looked unremarkable and a Mirena coil was inserted. She continued to have persistent symptoms and a pelvic ultrasound scan revealed a 5 cm fibroid.

Ten months later, the patient presented again with heavy bleeding per vagina. An urgent pelvic ultrasound showed a significant increase in the fibroid size, now measuring 10.3 x 11.3 x 10 cm. No other pelvic or abdominal abnormalities were noted, with the Mirena coil remaining in situ. The patient agreed to start LHRHa injections for symptomatic management, however this had little impact and she presented again three months later, still in significant pain. Her abdomen was distended with a large pelvi-abdominal mass reaching the level of the umbilicus. She was considered for an urgent laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). Laparotomy revealed an enlarged uterus reaching the umbilical level, with multiple metastatic lesions covering the uterine surface, bowel, and omentum. The planned surgical intervention was abandoned, and multiple biopsies were taken. CT-TAP was performed and revealed distant widespread metastases. Palliative treatment was decided after discussion with the multidisciplinary team (MDT), patient, and immediate family.

Keywords: Uterine Sarcoma; Endometrial Stromal Sarcoma; ESS; Leiomyoma; Fibroid; Laparotomy; Bleeding

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