Case presentation
A 46-year-old Gravida 3 para 3 woman with no medical, allergy, and drug
use history and with a history of abdominal pain, hypermenorrhea, and
pelvic pressure was referred to the gynecology and oncology ward of a
university Hospital a few months ago. In the vaginal exam, there was
bulging in the right side, which completely deviated the cervix to the
left and upward position. On abdominal sonography, the uterus size was
63*42 mm with an endometrial thickness of 9 mm. A heterogeneous
114*99-mm mass in a posterior cul-de-sac, probably with the uterine
origin, was detected. Magnetic Resonance Imaging (MRI) revealed a
well-defined heterogeneous soft-tissue mass from degeneration and
necrosis in the pelvic cavity posterior to the uterus was observed and
separated from the uterus and ovaries. In post-contrast images,
heterogeneous enhancement at the tumor was noticed (Figures 1&2). This
mass lesion posed pressure on the right ureter, causing
hydroureteronephrosis, and was in close contact with the right external
iliac vein (Figure3). She had a surgical history of cesarean section
withpfannenstiel
incision for three times, and her last child was ten years old. The
attempts for ureteral stent placement before surgery had failed; hence,
she was scheduled for surgery. The surgery was performed by the fellows
of oncogynecology under the direct supervision of their attending
surgeon. She underwent an exploratory laparotomy under the general
anesthesia by a midline incision on the suspicion of leiomyoma. A huge
solid retroperitoneal mass (16*12*11 cm) was detected in the right broad
ligament, which was attached to the pelvic floor and seemed to be
separated from the uterus. Surgical excision aimed to resect the tumor
completely. Because of the dense adhesion of the tumor to the ureter and
vessels, the internal iliac vein and ureteral injury were torn during
dissection. The internal iliac vein was repaired by a vascular surgeon.
The intraoperative frozen section analysis suggested smooth muscle tumor
without determining its being benign or malignant. Hysterectomy and
bilateral salpangectomy was performed, and the ovaries were preserved.
An internal ureteral DJ stent was inserted, and the primary ureteral was
repaired by the urologist. After consulting with an anesthesiologist, we
transfused three-unit Pack Cell to the patient during the operation due
to blood loss. The oral diet began one day after surgery, and the
patient was discharged 72 hours after admission. Before surgery, Hb was
10.5, and the patient was discharged with Hb=9.8. Ureteral DJ was
removed six weeks later with no complication. Pathologic examination
revealed grade II / III LMS with the mitotic rate of 12 / 10 HPF,
including atypical forms. Necrosis extent was <50%, and the
margin could not be assessed. The pathologic stage was pT4. The patient
was a candidate for radiation; hence, external beam radiotherapy was
provided for her for 25 sessions.