Abstract. Background: Based on a clinicopathologic study
conducted at the University of Rostock, Germany, between
1/1997 and 6/2003, the histological records of 1761 patients
who had been hysterectomized were evaluated. 1422 of these
patients were suffering from smooth muscle tumours: 1389
were diagnosed as multiple leiomyomas, 26 as leiomyomas of
uncertain malignant potential and 7 as leiomyosarcomas.
Patients and Methods: The data about the microscopic
findings were obtained by use of both conventional histology
(HE and Giemsa) and immunohistochemistry with markers
for leiomyosarcomas (desmin, actin, sm-actin, myoglobin,
vimentin, MIB1) and evaluated by statistical methods. Three
case reports are also presented: 2 patients with leiomyosarcoma
and 1 patient with an UMP tumour. Results: The statistical
evaluation included the frequencies of the different tumours
subdivided into age groups, their localizations (with 23
distinctions), the associated microscopic findings (with 12
distinctions and most important combinations) and, finally,
the number of tumours per patient and their (grouped) sizes.
The case reports showed the presence of nuclear atypia, a
heightened mitotic index and tumour cell necrosis.
Immunohistochemical methods confirmed the histological
diagnosis of a leiomyosarcoma. Conclusion: In accordance
with earlier studies, more than 95% of the smooth muscle
tumours were leiomyomas. Leiomyosarcomas were rare (<1%
in our study). In 3 out of 7 cases, a leiomyosarcoma had its
origin in a leiomyoma.
Uterine leiomyomas are the most frequent smooth muscle
tumours of the uterus, whereas uterine leiomyosarcomas are
rare. The different types of smooth muscle tumours, their
frequencies and correlations, as well as their localization
and the associated microscopic findings, were the subject of
the present study. Further, two case reports of patients
suffering from leiomyosarcoma and an additional one of a
patient suffering from a leiomyoma of uncertain malignant
potential are presented.
Patients and Methods
The following results are based on a clinicopathologic study
conducted at the University of Rostock, Germany, from January 1,
1997, to June 30, 2003. In this study, the histological records of
1761 patients who had been hysterectomized were evaluated. One
thousand four hundred and twenty-two of these patients were
suffering from smooth muscle tumours: 1389 (97.7%) were
diagnosed as multiple leiomyomas, 26 (1.8%) as leiomyomas of
uncertain malignant potential (UMP tumour) and 7 (0.5%) as
leiomyosarcomas. The data about the microscopic findings were
obtained by use of both conventional histology (hematoxylin-eosin
(HE) stain and Giemsa stain) and immunohistochemistry with
markers for leiomyosarcomas (desmin, actin, sm-actin, myoglobin,
vimentin and MIB1).
Figure 1 illustrates both the absolute and relative values of
the frequency of smooth muscle tumours. Additionally, each
bar in the chart is divided into 7 segments. The length of
each segment represents the frequency (resp. relative
frequency) of the tumours within the age group under
consideration, i.e. up to an age of 30, between 31 and 40, 41
and 50, 51 and 60, 61 and 70, 71 and 80 and older than 80
A total of 1333 (93.7%) smooth muscle tumours were
located in the corpus of the uterus, 14 (1.0%) in the cervix and
42 (3.0%) in the corpus as well as the cervix. Further, we
observed a strong dominance in the age group 41-50
independent of the localization. Some more details are given
Correspondence to: J. Makovitzky, MD, PhD, University of Rostock,
Department of Obstetrics and Gynaecology, Doberaner Str. 142,
18057 Rostock, Germany. e-mail: email@example.com-
Key Words: Leiomyoma, leiomyoblastoma, leiomyoma of uncertain
malignant potential, leiomyosarcoma, immunohistochemistry.
ANTICANCER RESEARCH 25: 1559-1566 (2005)
Smooth Muscle Tumours of the Uterine
Corpus: a Clinicopathologic Study with
J. WALDMANN1, A. STACHS1, H. TERPE2, G. STROPAHL2and J. MAKOVITZKY1
1Department of Obstetrics and Gynaecology and
2Institute of Pathology, University of Rostock, Germany
in Table I. The data of localization of the remaining 33 (2.3%)
tumours are not reported. Finally, in Figure 2, we report on
the localization of the tumours in full detail, i.e. subdivided in
23 localizations (L1-L23).
Figure 3 presents the microscopic findings (MF1- MF11)
and their combinations. Further details of the microscopic
findings can be found in Table II. The relative frequencies
given in the columns 2-8 of the Table represent the
conditional distribution of the combinations given the
occurrence of a microscopic finding in the localization
under consideration. The localizations L1–L7 (Figure 2)
were observed with the following relative frequencies: L1=
8.3%, L2= 33.1%, L3= 11.5%, L4= 9.0%, L5= 2.7%, L6
= 14.8%, L7= 14.1%. Thus, 93.5% (and, together with
L18–L21, 93.7%) of the microscopic findings were located in
the corpus. Therefore, we could restrict our attention to the
corpus only. Additionally, including all patients without any
of these microscopic findings, the relative frequencies
changed in an obvious way. This fact, however, had no
influence on the interpretation of our results.
Figure 3 and Table II show that more than one
microscopic finding can occur simultaneously. Indeed, we
observed up to eight microscopic findings at a
localization. However, there was only one (in 689 cases or
48.5%) and the number h(x) of cases decreased with an
increase of the number (x) of microscopic findings (i.e.
h(2) = 237 (16.7%), h(3) = 69 (4.9%), h(4) = 32 (2.3%),
h(5) = 14 (1.0%), h(6) = 6 (0.4%), h(7) = 1 (0.0%), h(8)
= 1 (0.0%). In 373 (26.2%) cases we found none (of these
The data on tumour size (in cm) are grouped in 5
intervals of equal length and an additional one containing
the remaining sizes (Figure 4). In case of more than one
tumour, the size of the largest one was used. In analogy to
Figures 1 and 2, the bars are subdivided into the segments
associated with the age groups under consideration.
In Figure 1 it can be seen that 7 smooth muscle tumours
were diagnosed as leiomyosarcomas. Three out of these 7
leiomyosarcomas had an origin in a leiomyoma.
Case Report 1
Anamnesis. The patient (44 years old) received medical
treatment because of a prolapse of the uterus as well as
uterine leiomyomas. She reported one spontaneous delivery,
one stillbirth, one abortion, one EUP with laparoscopic
salpingectomy, chronic adnexitis, pain and nausea during
menstruation, otherwise normal menstruation. No hormone
replacement therapy was used.
Clinical diagnosis. Anteflexion of the uterus was diagnosed,
size of fist, mobile and coarse. A vaginal hysterectomy was
performed without adnexectomy.
ANTICANCER RESEARCH 25: 1559-1566 (2005)
Figure 1. Frequencies of the smooth muscle tumours.
Table I. Localization of the tumours.
Total1333 14 42
Total (in %) 93.71.03.0
Waldmann et al: Uterine Smooth Muscle Tumours
Figure 2. More detailed localization of the tumours.
Figure 3. Most frequent combinations of the microscopic findings MF1–MF11.
Preparation of the uterus. The size (in cm) of the uterus was
12.5 x 7.0 x 5.5cm. A yellow-coloured leiomyoma was visible
which was 2.5 cm in diameter and had penetrated the
Histology. The tumour was fibrogenic and of moderate
cellularity, with partly elongated, moderately polymorphic
nuclei and perinuclear vacuoles. The mitotic index was 3 per
10 high-power fields (HPF). In some parts, stronger atypism
of nuclei with formation of giant tumour cells was observed.
Immunohistochemistry. The tumour tissue showed a modest
reaction to the marker sm-actin and a very positive one to
desmin. Using the proliferative marker MIB1, the rate of
proliferation was less than 1% in cancer cells and especially
the giant cells were negative.
Diagnosis. A diagnosis of pleomorphic leiomyoma of the
uterus with symblastic giant cells, was made.
Case Report 2
Anamnesis. A 42-year-old patient was admitted to the hospital
because of spasmodic pain of the lower abdomen, which had
occurred for a week, and night sweats. A computed
tomography of the abdomen and a coloscopy had already
been carried out. The level of CA 125 was high. Her history
included two spontaneous deliveries, hypermenorrhoea, but
no hormone replacement therapy.
Clinical diagnosis. An uneven, nodular and immobile
tumour was detected during palpation, which was mostly
indolent and filled the whole of the lower abdomen up to
two fingers above the navel. Sonography showed the tumour
to have several lumps and it gave a mainly solid echo.
Ascitis was found in the lower abdomen as well as
subhepatically. A laparotomy as well as a hysterectomy were
performed together with adnexectomy on both sides,
removal of the pelvic and para-aortal lymph nodes and
biopsy of the omentum.
ANTICANCER RESEARCH 25: 1559-1566 (2005)
Table II. Relative frequencies (in %) of the microscopic findings given L1–L7.
MF1, MF9, MF10
MF1, MF8, MF9
MF1, MF3, MF10
MF1, MF2, MF3
Total 100100100 100100 100 100
Preparation of the uterus. The size of the uterus was 16 x 15
x 7.5 cm. Several tumours were seen in the uterine cavity,
the right fallopian tube and the serosa, reaching up to 11.5
cm in diameter. The sectional areas of the tumours were
greyish-yellow, necrotic as well as bloody.
Histology. Fully grown leiomyoblasts, several short spindle
cells with scarce myofibriles and a distinctive nuclear and
cellular polymorphism with polyploidy were found in the
tumours. The index of mitosis per 10 HPF was significantly
increased. Corresponding to the macroscopic findings,
necrosis and haemorrhages were visible.
Immunohistochemistry. The tumour tissue reacted positively
to sm-actin, desmin and vimentin. The rate of proliferation
was significantly increased (MIB1 over 70%).
Diagnosis. A diagnosis of leiomyosarcoma of the uterus
having its origin in leiomyomatosis was made. Widespread
metastases were present in both of the adnexes, in the
peritoneum, in the greater and lesser omentum, as well as
in the para-aortic lymph nodes.
Case Report 3
Anamnesis. The 52-year-old patient received medical
treatment because of pain in the lower abdomen of four
weeks’ duration, along with an increase of girth and pain
radiating to both the right leg and spine. The general
gynaecological anamnesis was negative. Her further history
was 1 spontaneous delivery, menopause since the previous
year, but no hormone replacement therapy.
Clinical findings. Palpation showed a tumour, which was
tender to pressure, clearly defined and reaching up to the
navel. Sonography showed a heterogeneous tumour 15 cm in
diameter. It was mostly liquid, but contained areas of clear
echoes parietally as well. The uterine cavity could not be
defined. An explorative laparotomy was subsequently
conducted, which revealed a soft, magnified uterus with
multiple leiomyomas, reaching up above the navel.
Consequently, a hysterectomy was performed along with
adnexectomy on both sides.
Preparation of the uterus. The uterus was 21x16x15 cm. A
cyst, 12.5 cm in diameter and filled with a liquid rich in
cholesterol, was located in the sectional area. It was necrotic
at the paries, focally covered by fibrin and blood. Several
leiomyomas, reaching up to 2.5 cm in diameter, were
additionally found beneath the serous membrane in some
areas of the paries.
Histology. The outside of the tumour was composed of highly
cellular but still mostly isomorphic smooth muscle tissue. Nuclei
of different sizes and mitoses appeared in some isolated cases.
Pleomorphic tumour tissue with bizarre nuclei was located close
to the tumour’s edge. Plurinuclear giant cells were frequently
found. The cystically degenerated area appeared towards the
centre. Necroses with granulocytotic reaction appeared there as
well, but also with foamy cellular mesenchymal reaction with
occurrence of multinucleated giant cells. The mitotic index was
increased (9-14 per 10 HPF) (Figure 6).
Immunohistochemistry. The tumour tissue, in areas of high
cellularity reacted positive to desmin, myoglobin (Figure 7),
sm-actin and actin (Figure 8). The pleomorphic, giant
cellular part reacted positively for actin, while other markers
were scarce or absent. Both the reactive foam cells, as well
as the reactive multinucleated giant cells, reacted in a
positive way to vimentin, CD 68 and lysozyme. Positive
nuclei could be found in the pleomorphic parts of the
tumour with MIB1.
Diagnosis. A diagnosis of undifferentiated leiomyosarcoma
of the uterus (partly still differentiated into spindle cells,
partly undifferentiated into pleomorphic giant cells) with
central cystic degeneration, having its origin in one of
several leiomyomas, was made.
In accordance with earlier studies (1, 2), more than 95%
Waldmann et al: Uterine Smooth Muscle Tumours
Figure 4. Histogram of grouped tumour sizes.