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Introduction Detection of gynecological cancers preoperatively is imperative for practitioners for optimal patient management and outcome. This study aimed to estimate the incidence of unexpected malignancy (UM) in patients who underwent hysterectomy or myomectomy for presumed benign indications and to detect the predictive factors of UM. Methods A retrospective analytical study that included patients who underwent hysterectomy or myomectomy for benign indications from January 1st, 2016, to December 31st, 2020, was conducted at the Department of Obstetrics and Gynecology at Salmaniya Medical Complex, Bahrain. The main outcome was the overall incidence of UM and the incidence of each malignancy. Characteristics of UM were compared with benign pathologies. Fisher's exact and Pearson's chi-square tests were used to compare categorical variables and the Mann-Whitney U test or student's t-test for continuous variables. Binary logistic regression was used to identify the predictors of occurrence of UM. Confidence interval (CI) was set at 95%. A probability value (p-value) less than 0.05 was considered statistically significant. Results Out of 513 patients who underwent hysterectomy or myomectomy, 379 (73.9%) fulfilled the inclusion criteria, 314 (82.8%) hysterectomies and 65 (17.2%) myomectomies. The overall incidence of UM was 1.3% (n=5/379), 1.3% (n=4/314) among hysterectomies and 1.5% (n=1/65) among myomectomies. Three (0.8%) pre-malignant pathologies were identified: one (0.26%) smooth muscle tumor of unknown malignant potential, leiomyoma with bizarre nuclei, and mucinous borderline tumor of endocervical type of ovary each. The types of UM were sarcomas in three (0.26%) patients (two (0.5%) leiomyosarcoma and one (0.26%) endometrial stromal sarcoma) and endometrial adenocarcinoma and ovarian cancer in one (0.26%) patient each. No significant difference was found between the characteristics of UM and benign pathologies. Conclusion Although this study demonstrated a low incidence of UM among both hysterectomies and myomectomies, the age at the diagnosis of our patients with UM was as young as 34 years of age, and sarcomas were the most common type of UM. Disconcertingly, none of the studied independent variables had significantly predicted the occurrence of UM.
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Disseminated peritoneal leiomyomatosis (DPL) is a benign metastasis of leiomyoma mimicking metastasis of malignancy. It usually affects premenopausal women. Malignant transformation is a rare clinical scenario of DPL. However, its etiology is unknown with unusual growth patterns, either of which makes the diagnosis difficult. It was postulated that the pathophysiology of DPL is metaplasia of mesothelial cells under the effect of hormonal stimulation. Hence, we reported the case of a 62-year-old woman with a history of left breast cancer, who presented with DPL and metastasis to the lung with malignant transformation after two years of starting prophylactic tamoxifen therapy. The influence of tamoxifen use on the development of DPL is not fully understood; this is a rare case that highlights a possible association between tamoxifen and the malignancy transformation of DPL. Hence, it may help raise awareness among clinicians dealing with women using tamoxifen or other hormonal therapy, and the risk of DPL development with potential malignant transformation in such patients.