Mesenteric Leiomyosarcoma Mistaken as Subserosal Fibroid: A

Case Report
DOI: 10.17354/cr/2015/129
Mesenteric Leiomyosarcoma Mistaken as Subserosal
Fibroid: A Rare Case Report
Reena Sharma1, Neelam Mahajan2, Anju Vij3, Usha Kumari Chaudhary4, Ajay Sharma5
Senior Resident, Department of Obstetrics & Gynecology, Dr. Rajendera Parsad Medical College, Tanda, Kangra, Himachal Pradesh, India,
Professor, Department of Obstetrics & Gynecology, Dr. Rajendera Parsad Medical College, Tanda, Kangra, Himachal Pradesh, India, 3Associate
Professor, Department of Obstetrics & Gynecology, Dr. Rajendera Parsad Medical College, Tanda, Kangra, Himachal Pradesh, India, 4Senior Resident,
Department of Anesthesia, Dr. Rajendera Parsad Medical College, Tanda, Kangra, Himachal Pradesh, India, 5Senior Resident, Department of
Cardiology, Dr. Rajendera Parsad Medical College, Tanda, Kangra, Himachal Pradesh, India
1
2
Mesenteric leiomyosarcoma is a rare entity. It is usually seen in middle-aged individuals. The tumor usually remains asymptomatic for longer duration
until it acquires a big size. Surgical removal is the main modality of treatment. Common symptoms of the patients are usually pain or distension
abdomen. Pre-operative diagnosis is usually difficult. Ultrasonography and computed tomography scan can help in the diagnosis. In this case, the
tumor was mistaken for subserosal fibroid but intraoperatively turned out a mesenteric mass with retroperitoneal extension. On histopathological
examination, it was a leiomyosarcoma. Reoccurrence can occur. Early diagnosis and wide surgical resection can improve the prognosis of the patient.
Keywords: Abdominal hysterectomy, Mesenteric leiomyosarcoma, Mesenteric tumor, Subserosal fibroid
INTRODUCTION
The leiomyosarcoma is an extremely rare tumor with a
reported incidence of 1:350,000. 1 The leiomyosarcoma
is a malignant mesenchymal tumor that derives from
the smooth muscle lineage.2 The differential diagnosis
includes leiomyosarcoma and other mesenteric tumors
such as gastrointestinal stromal tumors (GIST), malignant
myofibroblastic tumor, solitary fibrous tumor, liposarcoma,
and lymphoma. 3 The ultrasonography or computed
tomography scan of the abdomen can help the diagnosis.
The presence of cystic or necrotic malformation within the
tumor, however, can mislead the diagnosis to a mesenteric
cyst, pancreatic pseudocyst, or uterine tumor.4-6 Treatment
strategies for mesenteric leiomyosarcoma vary. Surgical
excision with a wide margin of normal tissue is most effective
since adjuvant chemotherapy or radiotherapy is unreliable.7
CASE REPORT
We report here a case of a 50-year-old multigravida
postmenopausal female patient presented to the outpatient
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gynecology department with complaints of pain lower
abdomen and mass abdomen since 3 years. The patient was
having an ultrasound report showing a large, predominately
hypoechoic lesion seen arising from the uterine fundus?
Subserosal fibroid, of size 8 cm × 8.8 cm × 9.5 cm, few cystic
changes are also noticed in it. Sign of degenerative changes
seen in (Figure 1). Findings were suggestive of subserosal
fibroid uterus. The patient was postmenopausal since
4 years. The patient was P2L2 with a history of previous
two caesarean sections. Last child birth and tubectomy were
done 28 years ago. On examination, the general physical
examination was within normal limits, vitals were stable.
Chest and the cardiovascular system were normal. On per
abdomen examination, a vertical midline infraumbilical
scar of previous two cesarean sections was present, an
irregular mass arising from the pelvis of size 18-20 weeks,
non-tender, firm to hard in consistency with restricted
mobility. On per speculum examination, cervix and
vagina were healthy. On per vaginal examination, uterus
18-20 weeks size, irregular, firm to hard in consistency,
non-tender with restricted mobility. Probable diagnosis of
fibroid uterus was kept. The patient admitted in gynecology
ward and planned for total abdominal hysterectomy
with bilateral salpingo-oophorectomy. Intra-operatively,
the uterus was grossly healthy of postmenopausal size,
bilateral tubes, and ovaries were grossly normal and
atrophic. There was a mass of size 10 cm × 15 cm size,
irregular in shape, lobulated, restricted mobility, with some
retroperitoneal extension on left side, with gut adhesions,
firm in consistency, and with rich vascular connections
Corresponding Author:
Dr. Reena Sharma, Department of Gynecology, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh, India.
Phone: +91-9418452012. E-mail: dreenajay@gmail.com
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Sharma, et al.: Mesenteric Leiomyosarcoma Mistaken as Subserosal Fibroid
with mesentery and ovarian vessels (Figure 2). General
surgeons were called intra-operatively; found that it was
a big mesenteric mass present intra-peritoneal extending
from the left side of the pelvis through left infundibulopelvic
ligament with retroperitoneal extension. Mass excised
after ligating the various vascular connections and
opening the retroperitoneum. Left ureter preserved. Intraabdominal drain kept. Specimen sent for histopathological
examination. Post-operatively patient not all allowed
orally for 48 h. The rest of the post-operative period was
uneventful and patient discharged on 5th post-operative
day. On follow-up, histopathological examination revealed
that it was a mesenteric leiomyosarcoma (Figures 3 and 4).
DISCUSSION
The mesentery presents a common site of metastasis
of gastrointestinal malignancies. However, primary
tumors originating between the leaves of the mesentery
are quite uncommon, with the lymphoma being the
most common. Other primary mesenteric malignancies
include leiomyosarcomas, liposarcomas, fibrosarcomas,
malignant teratomas, or hemangiopericytomas. 8,9
Leiomyosarcomas present the most mesenchymatous
malignant tumor of the mesentery. These tumors are today
referred to as GIST, and share common immunohistologic
patterns including C-kit (CD117), CD34, or actin. 10
Mesenteric tumor is considered to arise from mesodermal
elements of the mesenteric blood vessels, fibrous tissue,
and nerves. 11,12 Common symptoms of these tumors
are a palpable mass, abdominal distension, and pain.13
However, most of these tumors tend to be asymptomatic
and grow to a large size by the time of diagnosis, since
the mobility and elasticity of the mesentery allow tumor
to occupy a large intra-peritoneal space without causing
any obstructive symptoms. 14 Lee noted that surgeons
should attempt to improve the survival rate by radical
removal of all smooth muscle tumors, including the
removal of at least 4 inches of healthy tissue on all
sides of tumor, plus the corresponding mesentery. 15
Figure 1: Ultrasound report showing a large, predominately hypoechoic lesion
seen arising from the uterine fundus? Subserosal fibroid, of size 8 cm × 8.8 cm ×
9.5 cm, few cystic changes are also noticed in it, sign of degenerative changes in it
Figure 3: Histopathological picture of leiomyosarcoma showing smooth muscle
bundles with vascularized connective tissue in between (H and E stain)
Figure 2: Intra-operative picture of mesenteric mass turned out to be a mesenteric
leiomyosarcoma after histopathological examination
Figure 4: Tumor consists of spindle cells with high cellularity and hyperchromatic
nuclei (H and E stain)
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Sharma, et al.: Mesenteric Leiomyosarcoma Mistaken as Subserosal Fibroid
Pathologically, leiomyosarcoma exhibits high mitotic
activity. Survival is influenced by the histological grade
of mesenteric leiomyosarcomas, based on cellular
differentiation, cellularity of the tumor, anaplasia, and
number of mitosis per high power field. Ranchod and
Kampson showed frequency of mitoses to be the most
useful indicator of malignant potential.16 The tumor tends
to local reoccurrences of diffuse peritoneal and hepatic
metastasis.17 Hence, post-operative follow-up is must.
CONCLUSION
Primary mesenteric leiomyosarcomas are very rare tumors.
Treatment is surgical resection of the tumor. Diagnosis
is confirmed by histopathological examination. Early
diagnosis and wide surgical resection can improve the
survival of the patient.
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How to cite this article: Sharma R, Mahajan N, Vij A, Chaudhary UK,
Sharma A. Mesenteric Leiomyosarcoma Mistaken as Subserosal Fibroid:
A Rare Case Report. IJSS Case Reports & Reviews 2015;2(4):8-10.
Source of Support: Nil, Conflict of Interest: None declared.
IJSS Case Reports & Reviews | September 2015 | Vol 2 | Issue 4