<b>Uterine Diagnostic Error</b>

<b>Abstracts of Medical Journal Articles</b>

compiled by doctordee 



Am J Obstet Gynecol 1990 Apr;162(4):968-74; discussion 974-6
<b>Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas.</b> Leibsohn S, d'Ablaing G, Mishell DR Jr, Schlaerth JB. Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Women's Hospital, Los Angeles 90033.

The incidence of leiomyosarcoma in uterine leiomyomas is estimated to be between 0.13 to 0.29%. However, the exact incidence of leiomyosarcoma in uteri removed with a preoperative diagnosis of benign uterine leiomyomas has not been previously reported. Between 1983 and 1988, a total of 1432 patients in Women's Hospital, a self-referred indigent population, had a hysterectomy planned because of abnormal uterine bleeding or abdominal pain associated with the presence of uterine leiomyomas, or because of a pelvic mass thought to be uterine leiomyoma of sufficient size or character to warrant surgical exploration. The ages of these women ranged from 36 to 62 years and the presence of leiomyosarcoma in the hysterectomy specimens increased steadily from the fourth to seventh decades of age (0.2%, 0.9%, 1.4%, and 1.7%, respectively). Preoperative histologic examination of the endometrium was performed in eight patients. Three of the eight patients had a preoperative tissue diagnosis of leiomyosarcoma that was clinically confined to the uterus. After the hysterectomy in the 1429 patients with presumed benign disease, histologic diagnosis of leiomyosarcoma was made in seven (0.49%). There was no evidence of malignancy in the endometrial sampling of any of these seven patients and the diagnosis was suspected intraoperatively in only three. Preoperative uterine size ranged from 8 to 20 weeks' gestational size and postoperative uterine weight ranged from 120 to 1100 gm. Seven of the 10 patients had symptoms of abnormal uterine bleeding. Between the ages of 40 and 60 years, 1% (8 of 817) of women with presumed uterine leiomyomas producing symptoms that necessitated hysterectomy in this series had leiomyosarcoma diagnosis postoperatively. Such treatments as gonadotropin-releasing hormone agonists, endometrial ablation, myomectomy by hysteroscopy or laparotomy instead of hysterectomy in such women could delay the diagnosis and definitive treatment of leiomyosarcoma. 



Cancer 1978 May;41(5):1902-10 <b>A reassessment of uterine neoplasms originally diagnosed as leiomyosarcomas.</b> Hart WR, Billman JK Jr. 

Twenty-eight uterine tumors originally diagnosed as leiomyosarcomas were histologically reclassified without prior knowledge of follow-up or clinical data. Thirteen (46%) neoplasms were reinterpreted as cellular or pleomorphic leiomyomas. They had sparse mitotic activity with three or fewer mitotic figures per 10 high power microscopic fields (MF/10 HPF). None recurred or metastasized, and all patients were alive from 6.3 to 23 years after operation (median of 14.2 years). In 15 cases the diagnosis of leiomyosarcoma (LMS) was confirmed. All showed hypercellularity, nuclear atypism and high mitotic activity. Mitosis counts ranged from 6 to more than 50 MF/10 HPF with 93% of LMS having at least 15 MF/10 HPF. These patients all died of LMS after post-operative intervals of 3 months to 7.5 years (median survival of 13 months). No consistent correlation was found between length of survival and the patient's menopausal status or histologic grade of LMS. The degree of mitotic activity is the single most reliable diagnostic criterion of malignant potential, albeit not the only one. Surgery alone is ineffective treatment for LMS and combination therapy with radiation therapy and/or chemotherapy should be considered. 
&&url PMID: 647634 



J Reprod Med 1992 Dec;37(12):980-2
<b>Incidental finding of endolymphatic stromal myosis during luteinizing hormone releasing hormone agonist therapy for suspected benign uterine myomata. A case report.</b>
Smith S, Cooper M, Schinfeld JS. Department of Obstetrics and Gynecology, Temple University School of Medicine, Abington Memorial Hospital, PA 19001.
A 39-year-old woman with an enlarging myomatous uterus underwent a three-month course of luteinizing hormonereleasing hormone (LHRH) agonist treatment. Despite a 50% reduction in uterine size, pathologic examination after uncomplicated hysterectomy revealed a low-grade endometrial stromal sarcoma. As the use of LHRH agonists for myoma reduction increases, delay in the diagnosis of sarcomatous disease will become more widespread. With current available diagnostic modalities, differentiation between sarcomatous and myomatous growth within the uterus is difficult. The possibility of delay in the diagnosis of unsuspected sarcoma when using LHRH agonists is an inherent and apparently unavoidable complication in some cases. 
&&url PMID: 1287209 


Zhonghua Fu Chan Ke Za Zhi 1992 Jul;27(4):206-8, 249
<b>[Diagnostic errors in dysfunctional uterine bleeding. Analysis of 24 cases].</b> [Article in Chinese]
Long L. Capital institute of Medicine, Xuanwu Hospital, Beijing.


This paper reports 24 cases of genital organic diseases which were misdiagnosed as dysfunctional uterine bleeding during 1984-1990. These include small submucous uterine myoma 5 cases, Granulosa cell tumor of ovary 2 cases, leiomyosarcoma of uterus 1 case, ectopic pregnancy 7 cases, carcinoma of endometrium 4 cases, abortion 3 cases, choriocarcinoma 2 cases, altogether there were 9 patients with malignant tumors in the series. The author point out that it is possible to reduce the misdiagnosis rate by emphasizing history, diagnostic curettage, ultrasonography, hysteroscopy and blood hCG determination.
&&url PMID: 1291214 


Zhonghua Zhong Liu Za Zhi 1990 Nov;12(6):441-3
<b>[Bizarre leiomyoma of the uterus--a clinicopathological analysis of 21 cases].</b> [Article in Chinese]
Zhao ZS. Hangzhou Hospital of Traditional Chinese Medicine.


Twenty-one patients with bizarre leiomyoma of uterus treated in the Obstetrics and Gynecology Hospital, Zhejiang Medical College from 1968 to 1988 are reported. These accounted for 1% of patients with uterine myogenic tumors in the same period. All were multipara. Their age ranged from 25 to 59 years with an average of 41.3 years. Of these 21 cases, 7 had taken oral contraceptives, 3 had had IUD, 8 had undergone tubosterilization and 3 had concurrent pregnancy. Twelve cases were diagnosed as bizarre leiomyoma of uterus by pathology and 9 as leiomyoma with sarcoma-like changes in limited areas or leiomyosarcoma. Among these 21 cases, 9 had limited focal bizarre leiomyoma and 12 pseudosarcomatoid tumor. The bizarre leiomyoma of uterus is of benign nature. Its treatment is similar to that of the common leiomyoma. Its occurrence might be related to the primary leiomyoma of uterus under constant influence of high level sex hormone or being of bizarre cell type at the very beginning. The differentiation between the bizarre leiomyoma of uterus and leiomyosarcoma is discussed.
&&url PMID: 2076641 


Am J Obstet Gynecol 1988 Oct;159(4):826-7
Comment in: Am J Obstet Gynecol. 1990 Jan;162(1):293
<b>Diagnosis of a tumor with an unusual presentation in the pelvis.</b>
Sloan D. Department of Obstetrics and Gynecology, New York Medical College, Lenox Hill Hospital, NY.

A 47-year-old multiparous woman was first seen with signs and symptoms of sudden, copious vaginal bleeding. The pelvic examination revealed a classic-appearing aborting leiomyoma. Subsequent operation and histologic examination, however, revealed a rare pelvic tumor. The diagnostic evidence and management are outlined.
&&url PMID: 3177529 



South Med J 1988 May;81(5):651-2
<b>Calcified uterine leiomyoma simulating metastatic disease on bone scan.</b>
Rohrer DG, Williamson BR, Teates CD. Department of Radiology, University of Virginia Medical Center, Charlottesville 22908.
We have reported a case in which focal uptake in a uterine fibroid simulated a sacral metastasis on bone scanning. CT suggested the correct diagnosis. However, a repeat bone scan using single photon emission computerized tomography (SPECT) was definitive in correctly localizing the abnormality. This method should be used when more precise localization is required than can routinely be obtained. 
&&url PMID: 2835820 


Geburtshilfe Frauenheilkd 1975 Dec;35(12):919-28
<b>[Uterine myoma in geriatric surgical cases (author's transl)]. [Article in German]</b>
Jaluvka V.
The following is a report on 189 cases involving surgical treatment of uterine myoma in women who were at least 60 years old. The cases were collected from 18 gynecological departments in West-Berlin over a 10-year period (1960-1969). 66 of these patients (38,1%) have never been pregnant, 17 (9,8%) had only abortions, while 90 (52,1%) had given birth to one or more children. In only 89 women (47,0%) the pre-operative diagnosis had been uterine myoma. The number of correct diagnosis prior to surgery decreased with increasing age of the patients. 47 patients had been completely asymptomatic; an additional 20 had shown no gynecological symptoms. Total hysterectomy including removal of the tubes and ovaries, which we consider the preferential method of treatment, was done in 105 cases (55,5%). Other surgical procedures were performed in 84 instances (44,5%). 8 registered deaths equal a post-operative mortality rate of 4,2%. Analysis of our cases contradicts the hypothesis regarding postmenopausal involution of uterine myoma. Removal of the uterus for myoma should not be considered a typical geriatric gynecological operation. In many instances it could have been performed at an earlier date; in some cases it even could have been avoided if all diagnostic procedures presently available had been utilized. 
&&url PMID: 1213256 


Thorac Cardiovasc Surg 1994 Dec;42(6):361-3
<b>Intravenous leiomyomatosis extending into the right ventricle: one-stage radical excision during hypothermic circulatory arrest.</b>
Okamoto H, Itoh T, Morita S, Matsuura A, Yasuura K.
Division of Thoracic and Cardiovascular Surgery, Yokkaichi Municipal Hospital, Japan.


A case of intravenous leiomyomatosis with extension into the right ventricle is described. A tumor in the inferior vena cava was detected 5 years after a hysterectomy had been performed for a myomatous uterus, but was misdiagnosed as an intracaval thrombus. Three years later this tumor was discovered after it had enlarged and intruded into the right ventricle. The correct diagnosis was made after a complete evaluation. The patient underwent surgery employing simultaneous sternotomy and laparotomy. Radical excision was achieved using cardiopulmonary bypass with hypothermic circulatory arrest. The diagnostic and surgical approaches are reviewed and discussed.
Publication Types: Review Review of reported cases 
&&url PMID: 7534959 



Acta Obstet Gynecol Scand 1993 Jul;72(5):374-6
<b>Prehysterectomy curettage in women with uterine fibromyomata is not worthwhile.</b>
Moller LM, Berget A.
Department of Obstetrics and Gynecology, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.


OBJECTIVE: To study the value of prehysterectomy curettage in women referred on the suggestion of uterine fibroids. DESIGN: A retrospective study. SETTING: Gentofte Hospital, University of Copenhagen. SUBJECTS: Four hundred and eleven patients with a curettage prior to hysterectomy on suspicion of uterine fibroids. MAIN OUTCOME MEASURE: Histological accuracy, frequency of (pre)malignancies and clinical consequences due to routine curettage. RESULTS: Curettage disclosed two cases of endometrial cancer and four cases of CIN. It missed two cases of CIN and one case of endometrial cancer in a postmenopausal women. In no case did the final histology disclose diseases that had not been taken care of during the laparotomy. CONCLUSION: Curettage in women with a preoperative diagnosis of uterine fibromyomata is not worthwhile. 
&&url PMID: 8392269 


