Fertility-sparing approach for uterine smooth muscle tumors of uncertain malignant potential

Uterine smooth muscle tumors of uncertain malignant potential (STUMP) are a category of tumors that present diagnostic/therapeutic challenges since they cannot be assigned to either a benign or a malignant entity. Hysterectomy is the mainstay of treatment of STUMP. However, in most cases, STUMPs represent an incidental diagnosis following myomectomy. The optimal management of young women having an incidental diagnosis of STUMP following myomectomy is unclear. Only a few experiences are reported. This review focuses on the fertility-sparing treatment of STUMPs.

This is a systematic review of studies comparing outcomes of patients undergoing hysterectomy and myomectomy. For this review, we included studies reporting outcomes of patients with STUMPs undergoing myomectomy. Studies reporting data only on radical treatment for STUMPs or focusing on conservative management of other uterine malignancies (including leiomyosarcoma) were excluded.

Pooled data of 327 patients (from 9 retrospective studies) were evaluated. Overall, the study included 159 (48.6%) and 168 (51.4%) patients who had myomectomy and hysterectomy, respectively. No differences in recurrence rates were observed after myomectomy and hysterectomy (13.2% vs 9.5%, OR 0.69, 95% CI 0.35 to 1.38, p = .30), after a median follow-up of 44 and 48 months, respectively. Patients treated with myomectomy were more likely to develop STUMP recurrences than patients treated with hysterectomy (11.9% vs 4.1%, OR 2.38, 95% CI 1.04 to 5.44, p = .046). Among 103 patients desiring to conceive, 40 (38.8%) patients achieved at least 1 pregnancy. Pregnancy was not associated with an increased risk of recurrence.

These cumulative data suggest that myomectomy might be considered a safe and effective alternative for women who wish to preserve their childbearing potential. Centralization, pathology review based on clinic-pathologic and molecular integration, and multidisciplinary discussion in referral centers are of paramount importance. Multicenter prospective registries are needed.