LETTER
Hippokratia 2019, 23(2): 96
Tsakiridis I1,2, Evaggelinos D2, Mamopoulos A1,2
1Third Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, 2Department of Obstetrics and Gynecology, Interbalkan Medical Center, Thessaloniki, Greece
Keywords: Young woman, fibroid uterus, myomectomy, Smooth muscle tumors of uncertain malignant potential, STUMP
Corresponding author: Tsakiridis Ioannis, Third Department of Obstetrics and Gynecology, Hippokratio General Hospital, 49 Konstantinoupoleos str., 54642, Thessaloniki, tel: +302313312120, fax: +302310992950, e-mail: igtsakir@auth.gr
Dear Editor,
Smooth muscle tumors of uncertain malignant potential (STUMPs) represent a distinct category of neoplasms between benign and malignant, with unknown prevalence1.
A 19-year-old nulliparous woman was referred due to pelvic pain, heavy menstrual bleeding, and increased frequency of micturition. She reported a history of progressively worsening menorrhagias over the last two years, despite the use of a combined oral contraceptive pill during the previous six months. She reported menarche at 13 years of age, no sexual activity, and did not smoke.
On physical examination, the body mass index of the patient was 23 kg/m2, her vital signs were normal, the abdomen soft without rebound tenderness, but a large mass was palpated at the lower abdomen up to two cm below the umbilicus. Blood testing showed a hemoglobin level of 9.5 g/dL, low serum ferritin of 9 μg/L, normal liver, and renal function. Transabdominal ultrasonography revealed a large uterus with many spherical masses (largest diameter four cm) resembling fibroids, mostly intramural, normal ovaries, and absence of ascites. Magnetic resonance imaging of the lower abdomen and pelvis confirmed a large uterus with many masses suggestive of fibroids with areas of necrosis and degeneration.
Following counseling, the patient received gonadotropin-releasing hormone (GnRH) agonist (triptorelin 3.75 mg, subcutaneous injection every four weeks) for six months. Upon treatment completion, laparotomy and myomectomy was decided, as no differences were observed in the size of the fibroids, and the heavy menstrual periods recurred. Surgery revealed a large uterus with several fibroid-like masses; overall, 12 masses were excised. The estimated blood loss was less than 300 mL and she was discharged from the hospital three days later.
The histology reported all 12 specimens as STUMPs. The tumors had diffuse moderate atypia, low mitotic index (two to seven mitotic figures per 10 high-power fields), and no tumor cell necrosis. A multidisciplinary team reviewed the case and offered the patient six-month follow-up clinical reviews and recommended hysterectomy when fertility was no longer desired.
The clinical signs of uterine STUMPs include pelvic pain, abnormal uterine bleeding, anemia, pelvic mass, and pressure sensation2, while there is controversy on the appropriate management. Moreover, the patient’s age, desired fertility, specific pathological properties, size, and location of the tumors and recurrence should be considered before offering the appropriate treatment. The patients need follow-up every six months for five years; in a reported series, 19 % of STUMPs recurred3 the effectiveness of adjuvant therapy with progesterone, GnRH analogs, or chemotherapy is yet to be determined2.
To conclude, we presented a unique case of a young woman with 12 STUMPs. Our case highlights the need for accurate diagnosis of these tumors in order to prevent the progression to malignancy, which is estimated at about 11-13 %1.
Conflict of interest
The authors declare no conflict of interest.
References
1. Gadducci A, Zannoni GF. Uterine smooth muscle tumors of unknown malignant potential: A challenging question. Gynecol Oncol. 2019; 154: 631-637.
2. Ip PP, Tse KY, Tam KF. Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy. Adv Anat Pathol. 2010; 17: 91-112.
3. Basaran D, Usubutun A, Salman MC, Narin MA, Boyraz G, Turkmen O, et al. The Clinicopathological Study of 21 Cases With Uterine Smooth Muscle Tumors of Uncertain Malignant Potential: Centralized Review Can Purify the Diagnosis. Int J Gynecol Cancer. 2018; 28: 233-240.