IMAJ • VOL 12 • MAy 2010 case cOmmunicatiOns mucosal small Bowel metastasis from uterine leiomyosarcoma Offir Ben-Ishay MD1, Pavel Shmulevsky MD1, Eran Brauner MD1, Euvgeny Vladowsy MD2 and Yoram Kluger MD FACS1 1 Department of General Surgery B and 2Institute of Pathology, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel motherapy is well established, but there is tant metastases were evident at that time. KeY wOrds: uterine leiomyosarcoma, mucosal no consensus regarding the optimal man- Histopathology examination showed small bowel metastases, abnormal agement of these patients. Metastases are spindle cell leiomyosarcoma with areas [18F]-2-fluoro-deoxy-D-glucose uptake common and recurrence rates are high, of myxoid and pleomorphic cells with IMAJ 2010; 12: 309–310 possibly due to the presence of microme- a mitotic index of 10–15 mitotic figures tastases at the time of diagnosis. per 10 high power fields. At the same We present here a patient who was time chest computed tomography scan diagnosed with leiomyosarcoma of the revealed a lesion suspected to be a metas- u enchymal neoplasm composed terine leiomyosarcoma is a mes- uterus presenting with distant meta- tasis in the lower lobe of the left lung. static spread in a rare location. This was confirmed by PET-CT and a of smooth muscle. It is the most com- segmental lobar metastasectomy was mon uterine pure mesenchymal tumor, performed. Histopathology revealed a although it represents only 5% of uterine Patient descriPtiOn metastatic lesion of the primary uterine malignancies . It affects 0.4/100,000 A 60 year old woman was admitted to leiomyosarcoma. A local recurrence at women a year . Owing to the aggres- hospital in March 2009 for exploratory the same site was found and resected sive nature of this tumor, women with laparotomy due to abnormal uptake on at the end of the same year. In 2007, a uterine sarcomas have a poor prognosis positron emission tomography with right upper lobe metastasis was discov- with an overall survival of 50% at 2 years, radiolabeled [18F]-2-fluoro-deoxy-D- ered by routine follow-up PET-CT scan. even when diagnosed early . Surgical glucose scan, revealing the presence of Consequently, another segmental lobar resection is the treatment of choice and a small lesion suspected to be a meta- metastasectomy was performed. may be curative for lesions confined to the static leiomyosarcoma in the left lower In 2008, a routine PET-CT showed uterus. The role of radiotherapy and che- abdominal quadrant. increased FDG uptake in the left lobe of Her medical history was remarkable the thyroid suspected to be a metastatic for recurrent metastatic uterine leiomyo- lesion. The patient underwent a partial [a] Abnormal focal FDG uptake in left lower quadrant presumed sarcoma that was repeatedly treated thyroidectomy and again histopathol- to be metastatic lesion by (transaxial) PET-CT with wide local excisions. In 1993 at the ogy revealed a metastatic lesion of leio- age of 44 and still premenopausal, the myosarcoma. patient was diagnosed with symptom- In March 2009 a follow-up PET-CT atic uterine myomas. Due to her morbid scan showed increased FDG uptake in obesity and three prior cesarean sec- the left lower abdominal quadrant sus- tions, follow-up only was prescribed. pected to be a small metastatic lesion In 2005, at the age of 56, she was [Figure A]. At laparotomy no peritoneal, admitted for evaluation of abdominal hepatic, retroperitoneal or intestinal sero- pain. Diagnostic workup revealed a large sal spread was found. Thorough manual pelvic mass causing partial small bowel examination of the small bowel revealed obstruction. On surgical exploration a a small (3 cm) intraluminal polypoid large (24 cm) pelvic mass originating mass at mid-jejunum. Segmental small from the uterus was revealed. A total bowel resection was performed and the abdominal hysterectomy and bilateral PET-CT = positron emission tomography- salpingo-oopherectomy was performed. computed tomography Neither enlarged lymph nodes nor dis- FDG = [18F]-2-fluoro-deoxy-D-glucose 309 case cOmmunicatiOns IMAJ • VOL 12 • MAy 2010 for 25% of uterine mesenchymal patients who present with abnormal [B] Leiomyosarcoma, infiltrating mucosa of small intestine tumors, endometrial stromal sarcomas FDG uptake in the abdominal cavity hematoxylin and eosin, x50 for 15% and mixed mullerian tumors and carefully searched for during explo- for 50% of the tumors, the latter being ration. Even though leiomyosarcoma is referred to as metaplastic carcinoma an aggressive and lethal tumor, it can (carcinosarcoma) . Sarcomas most be treated with routine follow-up and commonly invade and spread locally, aggressive intervention for metastatic but may have an aggressive growth spread if and when it occurs. pattern with lymphatic and hemato- genous spread. Micrometastases are correspondence: dr. O. Ben-ishay often present at the time of diagnosis. Dept. of General Surgery B, Rambam Health Care The most common sites for metastatic Campus, Haifa 31096, Israel spread are the peritoneal cavity and the Phone: (972-4) 856-2231 email: firstname.lastname@example.org omentum (30–50%), lung (30–40%) and liver (10%) . Metastases to the references heart, pericardium, skin, stomach and 1. Denschlag D, Masoud I, Stanimir G, Gilbert L. pancreas have also been described. Prognostic factors and outcome in women with patient recovered uneventfully. The his- Metastases to the gastrointestinal uterine sarcoma. Eur J Surg Oncol 2007; 33(1): 91-5. 2. Brown L. Pathology of uterine malignancies. De- topathology report confirmed that the tract from extra-abdominal sites are un- partment of Histopathology, Leicester Royal mass was a metastatic lesion of spindle common. Malignant melanoma and car- Infirmary, Leicester, UK, Clinical Oncology (2008) cell leiomyosarcoma with pleomorphic cinoma of the breast and lung are the 20: 433e447 doi:10.1016/j.clon.2008.04.005 3. Melone GA, D'Elia A, Brogna C, Salvati M. areas of uterine origin [Figure B]. most common malignancies spreading Uterine leiomyosarcoma metastatic to the brain: to the gastrointestinal tract. case report. Tumori 2008; 94(6): 856-60. Small bowel mucosal metastases 4. Mawrin C, Kirches E, Dietzmann K, Weis S. cOmment from uterine leiomyosarcomas are ex- Uterine leiomyosarcoma metastatic to the brain stem. Arch Gynecol Obstet 2002; 266(2): 119-21. Uterine sarcomas are rare tumors that tremely rare. To the best of our knowl- 5. Gerst PH, Levy J, Swaminathan K, Kshettry account for 5% of all uterine malignan- edge, only one prior case was reported in V, Albu E. Metastatic leiomyosarcoma of the cies. Mean age at presentation is 55 the English-language literature . This uterus: unusual presentation of a case with late endobronchial and small bowel metastases. years . Leiomyosarcomas account rare occurrence should be suspected in Gynecol Oncol 1993; 49(2): 271-5.