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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 187-189

Leiomyosarcoma causing obstructive uropathy and acute renal failure


1 Department of Obstetrics and Gynaecology, BirthRight by Rainbow Hospitals, Hyderabad, Telangana, India
2 Department of Radiology, BirthRight by Rainbow Hospitals, Hyderabad, Telangana, India

Date of Submission22-May-2021
Date of Decision17-Oct-2021
Date of Acceptance18-Oct-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Y Radhika
BirthRight by Rainbow Hospitals, Road No. 2, Near Hotel Park Hyatt, Sri Nagar Colony, Kamalapuri Colony, Banjara Hills, Hyderabad 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcsr.jcsr_31_21

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  Abstract 


A 41-year-old nulliparous woman presented to the hospital with lower abdominal pain for 15 days and constipation since 1 week and acute retention of urine for 3 days. Ultrasound revealed enlarged uterus with a large posterior wall fibroid with degenerative changes and bilateral mild hydro ureteronephrosis and MRI pelvis with contrast showed 17 × 10 × 12 cm pelvic mass along the posterior wall of the uterus with cystic degeneration and necrosis minimal haemorrhage with multiple fibrotic strands. Enlarged bilateral external internal, right iliac and lymph nodes noted. Laboratory evaluation revealed an elevated urea 101 mg/dl and creatinine levels 9.4 mg/dL with normal myoglobin levels (39 ng/mL). The patient was haemodynamically stable with serum electrolytes and ABG normal. After taking a nephrologist and urologist opinion and proper counselling for exploratory laparotomy +/- hysterectomy, proceeded with total abdominal hysterectomy. Immediate improvement of renal parameters and reversal of renal failure was noted and

Keywords: Acute renal failure, large degenerating fibroid, leiomyosarcoma, obstructive uropathy


How to cite this article:
Radhika Y, Reddy P, Rewatkar NA. Leiomyosarcoma causing obstructive uropathy and acute renal failure. J Clin Sci Res 2022;11:187-9

How to cite this URL:
Radhika Y, Reddy P, Rewatkar NA. Leiomyosarcoma causing obstructive uropathy and acute renal failure. J Clin Sci Res [serial online] 2022 [cited 2022 Aug 12];11:187-9. Available from: https://www.jcsr.co.in/text.asp?2022/11/3/187/350737




  Introduction Top


Uterine leiomyosarcoma is a very rare uterine malignancy seen in 0.64/100000 women annually.[1],[2] Incidentally only 0.5% of the women who undergo hysterectomies for uterine fibroids are found to have Leiomyosarcoma. We report the occurrence of acute presentation of uterine malignancy with acute kidney injury (AKI).


  Case Report Top


A 41 year old nulliparous women is admitted with presenting complaint of Severe pain abdomen since 15 days associated with constipation on and off since 1 week and urinary retention since 2 days. She underwent myomectomy 6 years back, and was diagnosed to have Adenomyosis since 5 years and took injection leupride 4 doses followed by dienogest for 6 months. In March 2020 as she was undergoing fertility workup, abdominal ultrasonography showed only adenomyoma uterus, and was diagnosed to have ostium secundum atrial septal defect on two-dimensional echocardiography. She also had hypertension but was not on any pharmacological treatment.

Patient was admitted and Foley's catheterisation done but only 10 ml of urine drained. On examination patient is moderately built with BP of 140/100 mm/Hg pulse 88 per minute, respiratory rate 20 per minute. Per abdominal examination revealed a soft to firm mass extending transversely from the lower abdomen upto the umbilicus corresponding to 24 weeks pregnant uterus. The mobility of the mass could not be assessed.

Patient was evaluated thoroughly clinically. Biochemical tests and imaging showed: haemoglobin 9.5 g/dL serum creatinine 9.4 mg/dL serum urea 101 mg/dL, serum lactate dehydrogenase 370 IU/L, serum myoglobin 39 ng/mL; arterial blood gas analysis was normal. Abdominal ultrasonography showed bulky uterus with Heterogenous focal lesion measuring 15 x 12 x 11 cm involving posterior myometrium and right lateral wall likely fibroid with possible malignant transformation and red degeneration. Bilateral mild hydrouretro nephorsis seen on ultrasound likely due to mass effect by large fibroid.

Magnetic resonance imaging (MRI) pelvis with contrast [Figure 1] showed large 17 x 10 x 12 cm pelvic mass along the posterior wall of the uterus with areas of cystic degeneration, necrosis, hemorrhage, multiple fibrotic strands with extension as described. Few enlarged bilateral external and internal iliac lymph nodes were seen. The findings were suggestive of subserosal/broad ligament fibroid with cystic degeneration.
Figure 1: MRI Pelvis with contrast showing large 17 x 10 x 12 cm pelvic mass (asterisk)

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She was counselled for exploratory laparotomy with or without hysterectomy, haemodialysis, and ureteric stenting as per requirement as suggested by the nephrologist and urologist and a “high-risk” consent was obtained.

The surgical oncologist was called and the incision was extended upwards to the umbilicus as a inverted T-shaped incision and proceeded with hysterectomy At surgery, haemorrhagic peritoneal fluid present. Uterus enlarged 14-16 weeks size with a large posterior fibroid. 20 x 20 cms of flaky degenerative tissue removed piece meal. Part of the tissue adherent to the recto-sigmoid so careful dissection was done and separated and proceeded with hysterectomy by the standard procedure. The bilateral tubes and ovaries could not be visualised separately and blood loss about 500 mL, 2 units of packed red blood cells were transfused intra-operatively. Abdominal wall closed in layers with intra-peritoneal drain placement. Specimen sent for histopathological examination.

Macroscopic examination [Figure 2] showed multiple, irregular, grey white to grey brown and haemorrhagic tissue bits altogether measuring 31.2 x 22.5 x 4.5 cm. Serial section across are grey white to grey brown, glistening, soft and gelatinous. Sections from the tumour showed a spindle cell proliferation with cells arranged in interlacing bundles and fascicles. The cells show moderate nuclear atypia with indistinct cytoplasm, ovoid nuclei and inconspicuous nucleoli. Mitoses are numerous, about 25/10 high power field in mitotically active areas. Large areas of coagulative necrosis are seen. Sections from fibroid like lesion shows an adenomyoma corresponding to leiomyosarcoma [Figure 3]. Immunohistochemistry would be required for grading of the tumour. This could not be done for logistic reasons.
Figure 2: Gross specimen photograph showing fleshy tumour with areas of necrosis, suggestive of leiomyosarcoma

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Figure 3: Photomicrograph showing highly cellular spindle cell tumour, in bundles (Haematoxylin and eosin, X100) (a); spindle cells with nuclear pleomorphism (Haematoxylin and eosin, X400) (b)

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Patient was extubated after 24 hrs. Immediate postoperative period and post-surgery the urine output and renal parameters gradually improved. Serum creatinine came down to 1.7 mg/dL on day 6. Post-operative period was uneventful, and she did not have any fistula in the post-operative period. The patient was advised to consult radiation oncologist for further management. She did not come back to us and was lost to follow-up.


  Discussion Top


Leiomyosarcoma is a very aggressive tumour with very poor prognosis.[1],[2] It usually occurs in post menopausal women, and can present with various symptoms such as abnormal vaginal bleeding, abdominal and pelvic pain and a palpable pelvic mass and sometimes it can be diagnosed only during surgery or in histopathological examination.

Imaging studies such as ultrasonography and magnetic resonance imaging (MRI) are not always accurate hence a combination of these is more important. Treatment of leiomyosarcoma is hysterectomy with or without bilateral salpingo-oophorectomy.[1],[2] The most common mode of spread is haematogenous with lymphatic spread being rare <3% hence lymph node dissection is not a must.[3]

Recurrence are seen in lungs and upper abdomen and the survival depends upon the stage of the disease at diagnosis.[4],[5],[6] Uterine fibroids are associated with obstructive renal failure as they can cause compression of the ureters leading to acute urinary retention and post renal nephropathy but soft tissue leiomyosarcoma causing obstruction leading to renal failure is very rare. Although several features on USG and MRI can raise suspicion of Uterine sarcoma, there are no pathognomonic features on an imaging techniques.[4],[5],[6]

Our case reiterates the clinical axiom that in women presenting with AKI, obstructive uropathy due to uterine, pelvic masses constitutes an uncommon but, important differential diagnosis. In our case haemodialysis and ureteric stenting were planned but was not done and the diagnosis of leiomyosarcoma being a very rare case causing renal failure due to obstructive uropathy and having a very poor prognosis, made us report the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Corcoran S, Hogan AM, Nemeth T, Bennani F, Sullivan FJ, Khan W, Barry K. Isolated cutaneous metastasis of uterine leiomyosarcoma: Case report and review of literature. Diagn Pathol 2012;7:85.  Back to cited text no. 1
    
2.
D'Angelo E, Prat J. Uterine sarcomas: A review. Gynecol Oncol 2010;116:131-9.  Back to cited text no. 2
    
3.
Sivakumari S, Rajaraman R, Subbiah S. Uterine Sarcoma: The Indian Scenario. Indian J Surg Oncol 2015;6:232-6.  Back to cited text no. 3
    
4.
Juhasz-Böss I, Gabriel L, Bohle RM, Horn LC, Solomayer EF, Breitbach GP. Uterine Leiomyosarcoma. Oncol Res Treat 2018;41:680-6.  Back to cited text no. 4
    
5.
Roberts ME, Aynardi JT, Chu CS. Uterine leiomyosarcoma: A review of the literature and update on management options. Gynecol Oncol 2018;151:562-72.  Back to cited text no. 5
    
6.
Vellanki VS, Rao M, Sunkavalli CB, Chinamotu RN, Kaja S. A rare case of uterine leiomyosarcoma: A case report. J Med Case Rep 2010;4:222.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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