Ovarian Leiomyosarcoma as Incidentaloma during Postbariatric Abdominoplasty Surgical Procedure

A 58-year-old woman was referred to our unit with suspicion of a laparocele and abdominal dermatochalasis to undergo abdominoplasty and hernia correction. In the patient’s medical history, an appendectomy, a natural childbirth, and a bariatric surgery procedure (Fig. 1 ) were documented. The patient had a history of hypercholesterolemia, psoriasis, and hypertension complicating a long-term class III obesity (weight 115 kg and body mass index 52.5 kg/m 2 ). Numerous attempts at weight loss through dietary means had proven unsuccessful; indeed, the patient underwent a videolaparoscopic sleeve gastrectomy procedure. Preoperative appearance of the patient; previously, the patient underwent sleeve gastrectomy that led to a decrease in body mass index from 58 to 34. During our preoperative examination, a CT scan of the abdomen revealed a hypodense formation in the mesogastrium (Fig. 2 ), an enlarged uterus, and a mass in the right iliac fossa. The patient also exhibited a paraumbilical hernia, consistent with her history, palpable at physical examination. CT scan showing a 26.9 × 18 cm abdominal and pelvic mass. The decision was made to perform umbilical hernia repair surgery, in cooperation with a general surgeon; subtotal omental excision; and en-bloc excision of the uterine and ovarian structures. The umbilical hernia sac was isolated and removed; moreover, a subtotal omental excision was performed to expose a voluminous mass probably originating from the left ovary, which was capsulated and easily cleaved (Fig. 3 ). An en-bloc excision of the cystic mass, uterus, and adnexa bilaterally was then performed. After removal of the mass, it was deemed sufficient to perform a suture of the rectus abdominal muscles. An abdominoplasty bisiliac incision and undermining of the adipo-cuteneous flap up to xyphoid-costal arch was initially performed to reduce the surgical impact. Indeed, the patient experienced severe anemia during the procedure; therefore, it seemed imperative to minimize the amount of tissue excised. Intraoperative findings of an ovarian cystic mass after omental incision. The excised specimens, including the hernia sac, umbilical scar, and the utero-ovarian mass, were sent for histological examination: the weight accounted for 5.8 kg. Histological investigation revealed a high-grade utero-ovarian leiomyosarcoma with epithelioid aspects. Atrophic endometriosis lacking atypia and a fibro-glandular body polyp were retrieved. Histology classification staged the tumor as pt2a FIGO IIA [ppt2b (34 × 29 cm], G3 FNCLCC; AML +, desmin +, caldesmone +, ER+, PgR+, MNF116+ in epithelioid component, AE1/AE3+, CD10+ plurifocal, INI1 preserved. A postoperative CT scan reported neither suspicious adenopathy nor suspicious nodular lesions. Postoperatively, the patient received adjuvant chemotherapy with gemcitabine and dacarbazine for six cycles. Follow-up imaging at 6 months showed a reduction in the size of the nodular formation, indicating a positive response to chemotherapy. No significant lymphadenopathy was observed, and the inguinal lymph nodes remained unchanged. At the 6-month follow-up, the patient presented normo-trophic abdominal scar, along with good aesthetic and morpho-functional outcomes (Fig. 4 ). Postoperative findings at 6 months follow-up showing normal trophism and appearance of the abdominal scar.

Radiology studies frequently reveal incidentalomas; eight of them (pituitary, thyroid, pulmonary, hepatic, pancreatic, adrenal, renal, and ovarian) have initial care guidelines provided. 4 When discovered, the best course of action depends on the therapeutic setting and the requests of an informed patient. Consensus guidelines containing images of low- and high-risk cysts and management suggestions have been issued by the Society of Radiologists in Ultrasound. Even though CT scan would not be the ideal first-stage imaging test to characterize ovarian masses, it is still the examination undergone by most women. 3 Some studies depict high accuracy of CT scan in characterization of adnexal malignant masses. 7 In our case, due to the dimension of the mass, an ultrasound would not have been sufficient; thus, we opted for a CT scan to highlight the known umbilical hernia. Leiomyosarcoma incidence rises with age and reaches its peak in the seventh decade. 4 Several exogenous agents have been investigated as potential risk factors, but only Epstein-Barr virus infection, in the context of severe immunosuppression, has been linked to leiomyosarcomas. Like other soft tissue sarcomas, leiomyosarcomas show nonspecific symptoms frequently brought on by displacement of tissues rather than invasion at particular anatomic sites. 6 Despite a great mass volume, our patient did not report abdominal symptoms or present anamnestic findings suggesting a higher risk of POMS. The standard of care for all patients with localized soft tissue sarcomas is surgery. A thorough excision with broad negative margins, with or without adjuvant therapy, has shown the most efficacy. 8 In this report, total hysterectomy and bilateral salpingo-oophorectomy was performed, followed by sarcoma-oriented chemotherapy due to the stage of the tumor (IIA). We decided not to perform a total lymphadenectomy, as its benefits are yet to be fully determined, and recent studies, although promising, do not have statistical relevance to be applicable in the daily practice. 9 , 10 Nevertheless, the result turned out satisfactory with no signs of secondary tumor shown at 6-month follow-up.

This case highlights the complexity of managing a 58-year-old woman with an abdominal incidentaloma characterized as utero-ovarian leiomyosarcoma. Prompt surgical intervention plus adjuvant chemotherapy resulted in a favorable outcome. Regular clinical evaluation in multidisciplinary settings is crucial to ensure comprehensive care for patients with such rare pathologies.

The authors have no financial interest to declare in relation to the content of this article.