Uterine leiomyosarcomas are rare, aggressive tumors
with a high mortality rate. Survival depends on disease
stage. These tumors usually occur in postmenopausal
women, making them rare in pregnancy. There are seven
reports of leiomyosarcoma in pregnancy in the literature.
All cases were found incidentally, and none presented as
a spontaneously aborting mass.
A 38-year-old white woman, gravida 13, para 12, was de-
livered vaginally of a term infant at a community hospital.
Despite the patient’s complaints of uterine cramping, the
patient and infant were discharged home on postpartum
day 1. At home, the patient passed a mass measuring 14 ϫ
8 ϫ 6 cm per vaginum. Serial sectioning revealed nuclear
atypia and tumor cell necrosis with >16 mitotic figures
per 10 high-power fields (Fig 1). No villi were found.
These findings were consistent with leiomyosarcoma.
The patient was referred to the Gynecologic Oncology
Division at the Columbia Presbyterian Medical Center.
Preoperative workup included magnetic resonance imag-
ing and chest radiography, which were negative. Labora-
tory evaluation was significant for a hematocrit of 26%
and a mean corpuscular volume of 85 fL, consistent with
the puerperal state. The patient was counseled regarding
treatment options. A total abdominal hysterectomy with
selective lymph node sampling was performed. Intraop-
eratively, there were no gross metastases. She recovered
well and went home on postoperative day 3.
On pathologic examination, the myometrium con-
tained thrombosed blood vessels consistent with a re-
cently gravid uterus. On the posterior endometrial wall,
there was a friable lesion measuring 3 ϫ 2 cm, which
grossly involved the myometrium and extended to 1.2 cm
from the serosal surface. No mitoses, coagulative necro-
sis, or villi were identified. However, severe nuclear atypia
and increased cellularity was present (Fig 2). The lymph
nodes were negative. Taken in context with the original
tumor, these changes were thought to represent residual
The patient was counseled about adjuvant treatment.
She opted for alternative therapy of an unknown nature.
At 8-months’ follow-up, she is disease free.
The histologic criteria used to diagnose leiomyosarco-
mas are somewhat controversial. According to some, the
mitotic index is of paramount importance in determin-
ing whether a uterine smooth muscle tumor is malignant.
According to others, combining histologic features, in-
cluding increased cellularity, nuclear atypia, and tumor
necrosis, in spite of intermediate mitotic index, more ac-
curately predicts the diagnosis. In fact, tumor cell necro-
sis alone appears to be a significant predicting factor.
pregnancy, the diagnosis is difficult because hormonal ef-
fects can mimic sarcomatous changes in uterine tissue by
increasing mitotic activity. By using the combination of
atypia, tumor necrosis, and mitotic index, pathologists at
three independent reference laboratories confirmed the
diagnosis of high-grade leiomyosarcoma in our postpar-
The management of leiomyosarcoma in the puer-
perium is the same as for postmenopausal women.
Total abdominal hysterectomy and bilateral salpingo-
oophorectomy are the standard of care. However, bilat-
eral salpingo-oophorectomy does not improve the prog-
nosis and is optional.
Conservative therapy in women desiring fertility re-
mains controversial. Selected cases have been managed
with myomectomy. Strict follow-up with imaging is neces-
From the Department of Obstetrics and Gynecology, New York Presbyter-
ian Hospital, Columbia Presbyterian Medical Center.
Received for publication December 14, 2001; revised March 18, 2002;
accepted May 15, 2002.
Reprints not available from the authors.
© 2002, Mosby, Inc. All rights reserved.
0002-9378/2002 $35.00 + 0 6/1/126647
Completely aborted uterine leiomyosarcoma in the puerperium
Jane Cleary-Goldman, MD, Alexandra Cole, MD, Fang Qian, MD, and Ephraim Resnik, MD
New York, NY
A patient passed a large tissue mass at home on postpartum day 1. Pathologic examination demonstrated
leiomyosarcoma. A total abdominal hysterectomy was performed, which demonstrated residual disease. All
tissue passed in the puerperium should be evaluated to ensure that significant pathologic conditions are not
overlooked. Conservative management of leiomyosarcomas is controversial. (Am J Obstet Gynecol
Key words: Pregnancy, leiomyosarcoma, spontaneously aborted tumor