Abstract:
Uterine sarcomas are rare mesenchymal tumors of the uterus which can mimic more benign phenomena such as fibroids. Compared with endometrial carcinomas, which occur more commonly, uterine sarcomas tend to behave more aggressively and are associated with a poorer prognosis. Characteristics such as tumor localization, irregular or nodular margins, rapid growth, and necrosis can help to differentiate these sarcomas from leiomyomas as well as endometrial carcinoma. We discuss a case of uterine sarcoma that had been initially diagnosed as benign Nabothian cysts.
Our patient was a 74 year-old Hispanic female with a past medical history of hypertension, and GERD who presented to our hospital in April 2025 with anorexia, intractable vomiting, and anasarca. She had recently been diagnosed with advanced uterine sarcoma at another medical center where a Port-A-Cath had been placed. Additionally, she had been given chemotherapy two months prior to this hospitalization. CT Abdomen during this admission showed a large 21 x 14 x 22 cm uterine fundal mass with metastasis, noting a 5.4 x 4.3 cm soft tissue mass in the left lower pelvis with a 3.0 x 4.0 cm soft tissue mass seen anterior and to the left of the large uterine mass. This CT also demonstrated fractures of the T12 vertebra, ascites, and bilateral pleural effusions. Of note, CT Abdomen a year prior to this presentation in April 2024 had noted low-density changes within the lower uterus and cervix representing possible Nabothian cyst, with the radiologist recommending a pelvic ultrasound for further assessment. On subsequent transvaginal ultrasound imaging that same month, another radiologist only noted the existence of multiple cervical Nabothian cysts with no other abnormal or malignant findings of the uterus.
In initial labs, the patient was noted to have severe acute renal injury. Due to the patient's aforementioned clinical status, she was not deemed a candidate for further chemotherapy as per oncology. Following this, she was admitted to the critical care unit, where her health continued to decline. After discussion of the patient’s poor prognosis, her family agreed to inpatient hospice, and she passed away shortly after comfort care measures were implemented. Given the rapid course of the patient’s malignancy and clinical deterioration, this raised the likelihood of a missed diagnosis, as imaging findings a year prior had only reported uterine Nabothian cysts. This in turn impacted the potential for earlier detection of the uterine sarcoma and could have contributed to this patient’s unfortunate clinical course.
The timely diagnosis of the uterine sarcoma could have been affected by the cervical location of multiple seeming cyst-like formations, which then resulted in the interpretation of the likely malignancy on initial imaging as the more benign Nabothian cysts by two different radiologists. The uterine sarcoma had not presented with overt or classic telltale signs on initial imaging. This discussion brings to light how cancers with unorthodox presentations deviating from their textbook depictions can at times evade earlier detection and have an unfortunate impact on patient treatment and prognosis.
