Uterine sarcoma is a malignant tumor that is rare and constitutes from 3 to 5% of all malignant tumors of the uterus. Leiomyosarcoma develops on average at the age of 43–53 years, endometrial stromal sarcoma, carcinosarcoma, and other types of tumors more often occur in postmenopausal women.
Morphological classification of uterine sarcomas:
• endometrial stromal sarcoma;
• mixed homologous Mullerovskaya sarcoma (carcinosarcoma);
• mixed heterologous Mullerian sarcoma (mixed mesodermal sarcoma);
• other uterine sarcomas.
Clinical picture. Clinical manifestations are associated with the location and rate of tumor growth. The uterus quickly grows in size, as it grows, menstrual irregularities join, pain in the pelvis, abundant watery leucorrhoea, sometimes with an unpleasant smell. If uterine sarcoma occurs in myomatous nodes, the clinical manifestations may not differ from those in uterine myoma (submucous, subserous, interstitial).
When a tumor is infected and large areas of necrosis are formed, fever appears, anemia develops and cachexia occurs quickly. It usually takes several months from the first symptoms to see a doctor.
An important diagnostic sign is the growth of postmenopausal fibroids. Clinical and anatomical classification of the uterus sarcomas.
Stage 1 – the tumor is limited to the body of the uterus;
Pa stage – the tumor is limited to endometrium or myometrium;
PB stage – the tumor affects the body and cervix, without leaving the uterus;
Stage III – the tumor extends beyond the uterus, but does not extend beyond the pelvis;
Sha stage – tumor germinates parametrium, metastatic lesion of uterine appendages occurs;
Stage II16 – the tumor affects the parametric tissue, it is possible metastasis to the lymph nodes or vagina;
Stage IV – the tumor grows into adjacent organs, spreads beyond the pelvis, or gives distant metastases.
Diagnosis is based on anamnesis (rapid growth of fibroids, as well as its growth in postmenopausal patients, characteristic complaints of patients).
According to the ultrasound, one can suspect uterine sarcoma on the basis of heterogeneous echogenicity and nodal transformation of the uterus, areas with malnutrition and necrosis in the nodes. Abnormal blood flow appears with a decrease in Doppler sonography TI <0.40.
Aspiration biopsy in leiomyosarcoma is uninformative, but it allows to suspect carcinosarcoma and endometrial sarcoma in 30% of cases. The diagnostic information content of hysteroscopy and separate diagnostic curettage is 80-100%. It is possible to confirm intramuscular sarcoma intraoperatively with morphological examination of the biopsy.
Cremation, or ligation of the uterine arteries, can be performed as an independent method of treatment or as a stage before myomectomy to reduce intraoperative blood loss. Temporary clamping or ligation is performed from transvaginal access; after performing myomectomy, the terminals or ligatures are removed. In laparoscopic access, the intersection of the ascending uterine artery trunk or permanent ligation is usually used. In addition to the reduction of intraoperaonal blood loss, the imposition of ligatures on the ascending trunk of the uterine artery causes a sharp contraction of the myometrium and the release of myomatous nodes into the abdominal cavity. Clementing of uterine arteries slows the growth of fibroids, however, it is impossible to rule out growth recurrence or the possibility of the formation of new zones – the effectiveness of this treatment method for stopping the clinical manifestations of fibroids is 65%.
FUS ablation of fibroids refers to a non-invasive treatment method in which a focused ultrasound remotely coagulates the isolated areas of the fibroids under the control of MRI. The indication for the use of this method of treatment is uterine fibroids with clinical manifestations. The use of FUS ablation is contraindicated for fibroids with a diameter of less than 2 cm and more than 10 cm, multiple uterine fibroids, presence of nodes on the back wall (due to the possibility of unintentional damage to nerve endings and the development of plexitis), cervical and peregrine nodes bone), fibroids due to poor vascularization, the presence of scars on the anterior abdominal wall (risk of burn), metal implants and obesity. The method can be considered effective if the destruction of more than 60% of the total volume of the node. Successful FUZ-ablation of fibroids does not prevent the growth of nodes of other localization in the long-term period. The advantages of the method are its low invasiveness, the absence of anesthesia, the possibility of outpatient use. Limit the use of the method to the need for highly specific operating room equipment and a large range of contraindications.
Forecast. Uterine fibroids are benign tumors with rare malignancy, so the prognosis for life is favorable. However, with the growth of fibroids may require surgical treatment with the exception of menstrual and reproductive functions in young women. Even small myomatous nodes can cause primary and secondary infertility.
Prevention of uterine fibroids is the early detection of the disease in the early stages and conducting pathogenetically substantiated therapy.