Which uterine myomatous masses must be removed?

Sir,

Leiomyoma is the most common tumor of uterus and female pelvis. Leiomyosarcoma almost always arise de novo and almost it doesn’t results from sarcomatous transformation of a leiomyoma. One of the most controversial concepts on the subject of uterine smooth muscle tumors is smooth muscle tumor of uncertain malignant potential (STUMP), a term first used by Kempson in 1973.[1] These are a group of heterogeneous and uncommon uterine smooth muscle tumors which fulfill some but not all the diagnostic criteria for leiomyosarcoma. This makes them unclassifiable by currently available criteria as unequivocally benign or malignant.[1] In these tumors, it is simply impossible with current tools to predict the behavior with certainty and this makes their management difficult.[2] What makes the management more complicated is the difficulty in counselling patients with regards to the likely clinical behavior. However, data from literature suggest a low risk of recurrence and a generally good clinical outcome.[23] Since recurrence of STUMP has been reported to be regional and resectable, surgical resection has been recommended as the primary modality for the treatment of recurrence.[2] Recurrence rates have been similar for patients who underwent myomectomy and those who underwent hysterectomy.[4] Moreover, leiomyosarcomatous transformation likelihood is low and there is no evidence that adjuvant treatments improve long-term outcomes. As a result, most authors have recommended expectant management of STUMP in the form of close clinical observation in all patients.[2]

Herein, we briefly report a case of 29 years nulligravid woman presented in 2011 with a two years history of menometrorrhagia and pelvic pain. Ultra sonography revealed a pedunculated subserosal myomatous mass measuring 65 × 50 × 50 mm as well as three small intramural myomatous masses with the greatest diameter of 17 mm. The patient underwent myomectomy. On pathologic examination, one of the small intramural masses was found to be STUMP. Since the gynaecologists frequently decide not to remove small myomatous masses during myomectomy procedure, the question is which myomatous masses should be considered for surgical removal. She recovered completely without complication. The problem becomes more challenging when considering the fact that the preoperative diagnosis of STUMP is usually leiomyoma[2] This question is open to more discussions and suggestions by experts in this field.