Prognostic Implication of Primary Treatment of Uterine Low-grade Endometrial Stromal Sarcoma: a Case Series
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CASE REPORT
Prognostic Implication of Primary Treatment of Uterine Low-grade Endometrial Stromal Sarcoma: a Case Series S. Suchetha 1
&
J. Sivaranjith 2 & P. Rema 1 & Shaji Thomas 2
Received: 21 January 2020 / Accepted: 7 May 2020 # Indian Association of Surgical Oncology 2020
Introduction Uterine sarcomas constitute 1% of female genital malignancies and 3 to 7% of genital tract cancers. Endometrial sarcomas (ESS) are of two types: low-grade ESS (LG-ESS) and high-grade ESS. Usual presentation is abnormal uterine bleeding, dysmenorrhea or pelvic pain. Twenty-five percent of patients will be asymptomatic. Some patients will be diagnosed in pathology report of myomectomy specimen. Power morcellation during laparoscopic myomectomy can cause inadvertent dissemination of the tumour which will upstage the disease. Stage of tumour is an independent predictor of prognosis. Stages I and II have overall survival of 90% which falls down to 50% for stages III and IV. Not much data is available regarding prognosis and various surgical approaches. Hysterectomy with bilateral salpingo-oophorectomy remains the main stay of treatment. Some patients may need adjuvant therapy as progestational agents, aromatase inhibitor or radiation therapy.
Case 1 A 24-year-old parous lady underwent laparoscopic myomectomy with specimen retrieval by morcellation at a peripheral hospital. Two weeks later she was presented to our institution with history of profuse bleeding per vagina. Clinical examination revealed bulky uterus with a pelvic mass in the pouch of Douglas. She was further evaluated with contrast-enhanced
CT scan of the abdomen and pelvis which showed a pelvic mass and multiple hypodensities in subhepatic area, paracolic gutter and omentum and along surface of bowel. The provisional diagnosis was organised hematoma or peritoneal deposits. Pathology slides were reviewed and confirmed LGESS. In view of continuing recurrent bleeding per vaginum and the CT finding suspicious of intraperitoneal hematoma/ multiple deposits, an emergency exploratory laparotomy was done. There was a large tumour deposit in the pouch of Douglas infiltrating uterus and sigmoid colon. There were multiple tumour deposits over omentum, small bowel serosa and bladder serosa. Complete excision of the tumour was done by hysterectomy, bilateral salpingo-oophorectomy, omentectomy, excision of all deposits anterior resection, ileal resection and anastomosis. Diversion proximal ileostomy was done to protect two-bowel resection anastomosis. Postoperative period was uneventful and discharged from hospital on 7th postoperative day. Final histopathology report confirmed disseminated LG-ESS; ER, PR-diffuse strong positive, treated with adjuvant hormonal therapy. Diversion stoma was reversed after 2 months. There was a small tumour deposit present in the mesocolon during stoma reversal. It was excised, and histologically suggestive of tumour recurrence. This shows the aggressive nature of the low-grade tumour probably due to peritoneal dissemination. The patient is continu
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