OBJECTIVE: The aim of this study was to analyze the clinical and reproductive outcomes of patients treated with myomectomy who were histologically diagnosed with uterine smooth muscle tumor of uncertain malignant potential (STUMP). METHODS: Patients who were diagnosed with STUMP and underwent a myomectomy at our institution between October 2003 and October 2019 were identified. Variables of interest obtained from the institution's database included patient age, relevant medical history, pre-operative appearance of the tumor on ultrasound, parameters of the surgical procedure, histopathological analysis of the tumor, post-operative clinical course, and course of follow-up, including reinterventions and fertility outcomes. RESULTS: There were a total of 46 patients that fulfilled the criteria of STUMP. The median patient age was 36 years (range, 18-48 years) and the mean follow-up was 47.6 months (range, 7-149 months). Thirty-four patients underwent primary laparoscopic procedures. Power morcellation was used for specimen extraction in 19 cases (55.9% of laparoscopic procedures). Endobag retrieval was used in nine patients and six procedures were converted to an open approach due to the suspicious peri-operative appearance of the tumor. Five patients underwent elective laparotomy due to the size and/or number of tumors; three patients had vaginal myomectomy; two patients had the tumor removed during planned cesarean section; and two underwent hysteroscopic resection.There were 13 reinterventions (five myomectomies and eight hysterectomies) with benign histology in 11 cases and STUMP histology in two cases (4.3% of all patients). We did not observe any recurrence as leiomyosarcoma or other uterine malignancy. We did not observe any deaths related to the diagnosis. Twenty-two pregnancies were recorded among 17 women, which resulted in 18 uncomplicated deliveries (17 by cesarean section and one vaginal), two missed abortions, and two pregnancy terminations. CONCLUSIONS: Our study found that uterus-saving procedures and fertility-preservation strategies in women with STUMP are feasible, safe, and seem to be associated with a low risk of malignant recurrence, even while maintaining the mini-invasive laparoscopic approach.

Department of Obstetrics and Gynecology 1st Faculty of Medicine Charles University General University Hospital Prague Czech Republic

Department of Pathology 1st Faculty of Medicine Charles University General University Hospital Prague Czech Republic

Zobrazit více v PubMed

Zimmermann A, Bernuit D, Gerlinger C, et al. . Prevalence, symptoms, and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health 2012;12:6. 10.1186/1472-6874-12-6 PubMed DOI PMC

Eurostat . Fertility statistics. 2017. Available: http://ec.europa.eu/eurostat/statistics-explained/index.php/Fertility_statistics#Further_Eurostat_information [Accessed 12 Jan 2018].

Olive DL, Lindheim SR, Pritts EA. Non-surgical management of leiomyomas: impact on fertility. Curr Opin Obstet Gynecol 2004:239–43. 10.1097/00001703-200406000-00006 PubMed DOI

Mara M, Kubinova K, Maskova J, et al. . Uterine artery embolization versus laparoscopic uterine artery occlusion: the outcomes of a prospective, nonrandomized clinical trial. Cardiovasc Intervent Radiol 2012;35:1041–52. 10.1007/s00270-012-0388-y PubMed DOI

Bell SW, Kempson RL, Hendrickson MR. Problematic uterine smooth muscle neoplasms. Clinicopathological study of 213 cases. Am J Surg Pathol 1994;18:535–58. PubMed

Guntupalli SR, Ramirez PT, Anderson ML. Uterine smooth muscle tumor of uncertain malignant potential: a retrospective analysis. Gynecol Oncol 2009;113:324–6. 10.1016/j.ygyno.2009.02.020 PubMed DOI PMC

Oliva E, Carcangiu ML, Carinelli SG. Tumors of the uterine corpus: mesenchymal tumors: smooth muscle tumor of uncertain malignant potential. In: Kurman RJ, Carcangiu ML, Herrington CS, et al.., eds. World health organization classification of tumors of female reproductive organs. Lyon: IARC Press, 2014: 138–9.

Şahin H, Karatas F, Coban G, et al. . Uterine smooth muscle tumor of uncertain malignant potential: fertility and clinical outcomes. J Gynecol Oncol 2019. 10.3802/jgo.2019.30.e54 PubMed DOI PMC

Timmerman D, Planchamp F, Bourne T, et al. . ESGO/ISUOG/IOTA/ESGE consensus statement on pre-operative diagnosis of ovarian tumors. Int J Gynecol Cancer 2021:961–82. 10.1136/ijgc-2021-002565 PubMed DOI PMC

Van den BT, Dueholm M, Leone FPG, et al. . Terms, definitions, and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol 2015;46:284–98. 10.1002/uog.14806 PubMed DOI

Ludovisi M, Moro F, Pasciuto T, et al. . Imaging of gynecological disease: clinical and ultrasound characteristics of uterine sarcomas. Ultrasound Obstet Gynecol 2019;54:676–87. PubMed

Bonneau C, Thomassin-Naggara I, Dechoux S, et al. . Value of ultrasonography and magnetic resonance imaging for the characterization of uterine mesenchymal tumors. Acta Obstet Gynecol Scand 2014;93:261–8. 10.1111/aogs.12325 PubMed DOI

Tinelli A, Malvasi A, Hurst BS, et al. . Surgical management of neurovascular bundle in uterine fibroid pseudocapsule. JSLS 2012;16:119–29. 10.4293/108680812X13291597716302 PubMed DOI PMC

Luketic L, Shirreff L, Kives S, et al. . Does ulipristal acetate affect surgical experience at laparoscopic myomectomy? J Minim Invasive Gynecol 2017;24:797–802. 10.1016/j.jmig.2017.02.025 PubMed DOI

Mara M, Boudova B, Lisa Z, et al. . Laparoscopic myomectomy after or without pre-treatment with ulipristal acetate. Minim Invasive Ther Allied Technol 2021;30:55–62. 10.1080/13645706.2019.1674337 PubMed DOI

Levitz J. Fibroid surgery puts doctor fighting cancer diagnosis in spotlight. During routine procedure doctors find rare cancer, which procedure may have spread. 2013. Available: www.wsj.com/articles/fibroid-surgery-puts-doctor-fighting-cancer-diagnosis-in-spotlight-1387457121 [Accessed 6 Jun 2021].

Cotrino I, Carosso A, Macchi C, et al. . Ultrasound and clinical characteristics of uterine smooth muscle tumors with uncertain malignant potential. Eur J Obstet Gynecol Reprod Biol 2020;251:167–72. 10.1016/j.ejogrb.2020.05.040 PubMed DOI

Ho K-C, Dean Fang Y-H, Lin G, et al. . Presurgical identification of uterine smooth muscle malignancies using the characteristic FDG uptake pattern on PET scans. Contrast Media Mol Imaging 2018;2018:1–10. 10.1155/2018/7890241 PubMed DOI PMC

Suzuki Y, Wada S, Nakajima A, et al. . Magnetic resonance imaging grading system for preoperative diagnosis of leiomyomas and uterine smooth muscle tumors. J Minim Invasive Gynecol 2018;25:507–13. 10.1016/j.jmig.2017.08.660 PubMed DOI

Glaser LM, Friedman J, Tsai S, et al. . Laparoscopic myomectomy and morcellation: a review of techniques, outcomes, and practice guidelines. Best Pract Res Clin Obstet Gynecol 2018;46:99–112. 10.1016/j.bpobgyn.2017.09.012 PubMed DOI

Donnez O, Jadoul P, Squifflet J, et al. . A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116:492–500. 10.1111/j.1471-0528.2008.01966.x PubMed DOI

Van der Meulen JF, Pijnenborg JMA, Boomsma CM, et al. . Parasitic myoma after laparoscopic morcellation: a systematic review of the literature. BJOG 2016;123:69–75. 10.1111/1471-0528.13541 PubMed DOI

Pritts EA, Vanness DJ, Berek JS, et al. . The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecol Surg 2015;12:165–77. 10.1007/s10397-015-0894-4 PubMed DOI PMC

Odejinmi F, Aref-Adib M, Liou N, et al. . Rethinking the issue of power morcellation of uterine fibroids: is morcellation the real problem or is this another symptom of disparity in healthcare provision? In Vivo 2019;33:1393–401. 10.21873/invivo.11616 PubMed DOI PMC

Food and Drug Administration (FDA). 2020. Available: www.fda.gov/medical-devices/safety-communications/update-fda-recommends-performing-contained-morcellation-women-when-laparoscopic-power-morcellation

Sandberg EM, van den Haak L, Bosse T, et al. . Disseminated leiomyoma cells can be identified following conventional myomectomy. BJOG 2016;123:2183–7. 10.1111/1471-0528.14265 PubMed DOI

Toubia T, Moulder JK, Schiff LD, et al. . Peritoneal washings after power morcellation in laparoscopic myomectomy: a pilot study. J Minim Invasive Gynecol 2016;23:578–81. 10.1016/j.jmig.2016.02.001 PubMed DOI

Takeda A, Tsuge S, Shibata M, et al. . Identification of leiomyoma cell sheets in peritoneal washings retrieved by an intraoperative red blood cell salvage device during laparoscopic-assisted myomectomy with in-bag manual tissue extraction: a pilot study. J Minim Invasive Gynecol 2018;25:1266–73. 10.1016/j.jmig.2018.03.026 PubMed DOI

Yu SP, Lee BB, Han MN, et al. . Irrigation after laparoscopic power morcellation and the dispersal of leiomyoma cells: a pilot study. J Minim Invasive Gynecol 2018;25:632–7. 10.1016/j.jmig.2018.01.027 PubMed DOI

Seidman MA, Oduyebo T, Muto MG, et al. . Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One 2012;7:e50058. 10.1371/journal.pone.0050058 PubMed DOI PMC

Gupta M, Laury AL, Nucci MR, et al. . Predictors of adverse outcome in uterine smooth muscle tumours of uncertain malignant potential (STUMP): a clinicopathological analysis of 22 cases with a proposal for the inclusion of additional histological parameters. Histopathology 2018;73:284–98. 10.1111/his.13515 PubMed DOI

D’Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010;116:131–9. 10.1016/j.ygyno.2009.09.023 PubMed DOI

Ip PPC, Cheung ANY, Clement PB. Uterine smooth muscle tumors of uncertain malignant potential (STUMP). Am J Surg Pathol 2009;33:992–1005. 10.1097/pas.0b013e3181a02d1c PubMed DOI