Journal List > J Gynecol Oncol > v.30(4) > 1148323

Şahin, Karatas, Coban, Özen, Erdem, Onan, and Ayhan: Uterine smooth muscle tumor of uncertain malignant potential: fertility and clinical outcomes

Abstract

Objective

In this study, we aimed to evaluate the clinicopathological features, obstetric, and oncological outcomes of patients diagnosed with a uterine smooth muscle tumors of uncertain malignant potential (STUMP).

Methods

A dual-institutional, database review was carried out to screen patients with STUMP who were treated with upfront surgery between January 2006 and December 2017. Data including age at the time of diagnosis, recurrence rate, disease-free survival, overall survival, and fertility outcomes were retrospectively analyzed.

Results

Fifty-seven patients with STUMPs were included in the study. The median age at the time of diagnosis was 42 (range, 16 to 75) years. The median follow-up was 57 (range, 16 to 125) months. Eight patients (14%) had recurrence during follow-up. Recurrent STUMPs were seen in seven patients and leiomyosarcoma after 14 months in one patient. Seven patients with a recurrent STUMP survived, while the remaining patient died. Recurrence rates were similar for women who underwent myomectomy and those who underwent hysterectomy. The presence of uterine localization of tumor (subserosal vs intramural-submucosal) statistically significantly affected recurrence rates (odds ratio=5.72; 95% confidence interval=1.349–24.290; p=0.018). Ten of 27 patients who underwent myomectomy for uterine myoma had fertility desire. Seven pregnancies were recorded.

Conclusions

Our study results suggest that fertility-sparing approaches are feasible in patients with STUMP, although recurrence may be seen.

References

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Fig. 1.
A smooth muscle tumors of uncertain malignant potential case with recurrent leiomyosarcoma. A cellular smooth muscle tumor with mild atypia (A) and necrosis of uncertain type (B) (Hematoxylin and eosin stain, ×40).
jgo-30-e54f1.tif
Fig. 2.
Recurrent tumor as leiomyosarcoma with tumor cell necrosis (A) (H&E ×40) and severe atypia (B) (H&E ×200). H&E, hematoxylin and eosin stain.
jgo-30-e54f2.tif
Fig. 3.
An atypical smooth muscle tumor containing bizarre cells with hyperchromatic nuclei. Scattered mitotic figures and karyorrhectic nuclei were also seen (hematoxylin and eosin stain, ×200).
jgo-30-e54f3.tif
Fig. 4.
A smooth muscle tumor with mild atypia (A) and necrosis of infarct-type (B) (hematoxylin and eosin stain, ×100).
jgo-30-e54f4.tif
Fig. 5.
A cellular smooth muscle tumor (A) (H&E ×100) with brisk mitotic activity (B) (H&E ×400). H&E, hematoxylin and eosin stain.
jgo-30-e54f5.tif
Table 1.
Demographic and clinicopathological characteristics of patients (n=57)
Characteristics Values
Age (yr), median 42 (23–69)
Gravida, median 2 (0–6)
Parity, median 2 (0–4)
Tumor size (cm), median 6 (1–26)
Serum CA-125 (U/mL), median 21 (4–65)
 >35 10 (17.5%)
 <35 28 (49.1%)
 Unknown 19 (33.3%)
Smoking habit  
 Yes 14 (24.6%)
 No 39 (68.4%)
 Unknown 4 (7%)
Surgical type  
 TAH 11 (19.3%)
 TAH+BSO 14 (24.6%)
 TAH+USO 4 (7%)
 VH 1 (1.8%)
 Abdominal myomectomy 26 (45.6%)
 Hysteroscopic myomectomy 1 (1.8%)
Uterine localization  
 Intramural 38 (66.7%)
 Subserous 12 (21.1%)
 Submucous 7 (12.3%)
Mitosis  
 0–5 19 (33.3%)
 5–10 32 (56.1%)
 ≥10 6 (10.5%)
Cellularity  
 Moderate 11 (19.3%)
 High 46 (80.7%)
Necrosis  
 Absent 48 (84.2%)
 Multifocal 9 (15.8%)
Atypia  
 Mild 14 (24.6%)
 Mild to moderate 23 (40.4%)
 Moderate 9 (15.8%)
 Moderate to severe 11 (19.3%)
Recurrence rate 8 (14%)
 After hysterectomy 2 (3.5%)
 After myomectomy 6 (10.5%)
Recurrent pathology  
 STUMP 7 (12.3%)
 LMS 1 (1.8%)
Median follow-up (mo), (min-max) 57 (16–125)

LMS, leiomyosarcoma; STUMP, uterine smooth muscle tumors of uncertain malignant potential; TAH+BSO, Total abdominal hysterectomy+bilateral salpingo-oophorectomy; TAH+USO, total abdominal hysterectomy+unilateral salpingo-oophorectomy; TAH, total abdominal hysterectomy; VH, vaginal hysterectomy.

Table 2.
Differences between myomectomy and hysterectomy groups (n=57)
Characteristics Myomectomy (n=27) Hysterectomy (n=30) p-value
Age (yr) 37 (23–52) 46.5 (38–69) <0.001
Gravida 0 (0–4) 3 (1–6) <0.001
Parity 0 (0–3) 2 (1–4) <0.001
Tumor size (cm) 8 (3–25) 5 (1–26) 0.036
Median follow-up (mo) 58 (16–125) 50.5 (20–114) 0.253
Serum CA-125 (U/mL) 22.5 (6–65) 20 (4–60) 0.769
Recurrence rates, No. (%) 6 (22.2%) 2 (6.6%) 0.091

Data shown are median (minimum–maximum) not otherwise specified.

Table 3.
Clinical and pathological characteristics and outcome of patients with recurrence disease (n=8)
Patients s Age (yr) Parity Tumor size (cm) Initial surgery Recurrence location Recurrence treatment Recurrence pathology Outcome
1 35 3 16 Myomectomy Uterus TAH STUMP ANED
2 47 0 5 Myomectomy Uterus TAH+BSO STUMP ANED
3 38 0 9 Myomectomy Uterus Myomectomy STUMP ANED
4 45 2 13 TAH+BSO Pelvic RP mass Mass excision STUMP ANED
5 35 0 2 Hysteroscopic myomectomy Uterus Hysteroscopic myomectomy STUMP ANED
6 52 0 20 Myomectomy Pelvic+ upper abdominal mass Debulking+ chemotherapy LMS DOD
7 30 1 4 Myomectomy Uterus TAH STUMP ANED
8 39 2 11 TAH+USO Pelvic RP mass Mass excision STUMP ANED

STUMP, uterine smooth muscle tumors of uncertain malignant potential; TAH+BSO, total abdominal hysterectomy+bilateral salpingo-oophorectomy; TAH+USO, total abdominal hysterectomy+unilateral salpingo-oophorectomy; ANED, alive with no evidence of disease; RP, retroperitoneal; CT, chemotherapy; DOD, dead of disease; LMS, leiomyosarcoma.

Table 4.
Differences between non-recurrence and recurrence groups (n=57)
Characteristics Non-recurrence group (n=49) Recurrence group (n=8) p-value
Age (yr), median 42 (23–69) 38.5 (30–52) 0.418
Gravida, median 2 (0–4) 1 (0–4) 0.228
Parity, median 2 (0–3) 0.5 (0–3) 0.159
Tumor size (cm), median 6 (1–26) 10 (3–20) 0.160
Median follow-up (mo) 56 (25–114) 64 (16–125) 0.512
Serum CA-125 (U/mL), median 20 (4–60) 28 (17–65) 0.167
Smoking, No. (%) 12 (24.5%) 3 (37.5%) 0.531
Type of surgery, No. (%)     0.353
 TAH 11 (22.4%) 0  
 TAH+BSO 13 (26.5%) 1 (12.5%)  
 TAH+USO 3 (6.1%) 1 (12.5%)  
 VH 1 (2%) 0  
 Myomectomy 21 (42.9%) 6 (75%)  
Uterine localization, No. (%)     0.002
 Intramural 37 (75.5%) 1 (12.5%)  
 Subserous 7 (14.3%) 5 (62.5%)  
 Submucous 5 (10.2%) 2 (25%)  
Mitosis, No. (%)     0.399
 0–5 18 (36.7%) 1 (12.5%)  
 5–10 26 (53.1%) 6 (75%)  
 ≥10 5 (10.2%) 1 (12.5%)  
Cellularity     0.659
 Moderate 9 (18.4%) 2 (25%)  
 High 40 (81.6%) 6 (75%)  
 Atypia     0.379
 Mild 11 (22.4%) 3 (37.5%)  
 Mild to moderate 22 (44.9%) 1 (12.5%)  
 Moderate 7 (14.3%) 2 (25%)  
 Moderate to severe 9 (18.4%) 2 (25%)  
Necrosis     0.783
 Absent 41 (84.2%) 7 (87.5%)  
 Multifocal 8 (15.8%) 1 (12.5%)  

TAH+BSO, total abdominal hysterectomy+bilateral salpingo-oophorectomy; TAH+USO, total abdominal hysterectomy+unilateral salpingo-oophorectomy; TAH, total abdominal hysterectomy; VH, vaginal hysterectomy; STUMP, uterine smooth muscle tumors of uncertain malignant potential.

Table 5.
Univariate analysis of recurrence risk factors
Variables p-value Univariate analysis
OR 95% CI
Age (yr) 0.432 0.56 0.133–2.367
 <42      
 ≥42      
Parity 0.184 0.37 0.089–1.591
 <2      
 ≥2      
Tumor size (cm) 0.501 0.60 0.139–2.621
 <6      
 ≥6      
Smoking 0.818 0.83 0.180–3.883
 Yes      
 No      
Surgical type 0.157 0.31 0.063–1.563
 Hysterectomy      
 Myomectomy      
Uterine localization 0.018 5.72 1.349–24.290
 Intramural-submucous      
 Subserous      
Necrosis 0.784 0.73 0.079–6.795
 Absent      
 Multifocal      
Cellularity 0.661 0.67 0.117–3.908
 Moderate      
 High      
Mitosis 0.446 0.24 0.027–2.174
 0–5      
 5–10      
 ≥10      
Necrosis 0.784 0.73 0.079–6.795
 Absent      
 Multifocal      
Atypia 0.468 0.81 0.111–5.987
 Mild      
 Mild to moderate      
 Moderate      
 Moderate to severe      
Table 6.
Clinical and pathological characteristics of patients with obstetrics outcomes (n=7)
Patient Age (yr) Gestational age (wk) Parity Tumor siz (cm) e Initial surgery Recurrence location Recurrence treatment Recurrence pathology Birth type Fertility outcome
1 35 38 3 16 Myomectomy Uterus TAH STUMP C/S 2,800 g, live birth
2 36 35 0 5 Myomectomy C/S 2,200 g, live birth
3 25 39 0 6 Myomectomy C/S 3,450 g, live birth
4 23 39 0 8 Myomectomy C/S 3,150 g, live birth
5 26 39 1 10 Myomectomy C/S 3,600 g, live birth
6 38 38 0 11 Myomectomy C/S 3,100 g, live birth
7 30 38 1 3 Hysteroscopic Uterus TAH STUMP VB 3,200 g, live birth
          Myomectomy          

STUMP, uterine smooth muscle tumors of uncertain malignant potential; TAH, total abdominal hysterectomy; VB, vaginal birth; C/S, cesarean section.

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