The preoperative diagnosis of leiomyosarcoma may be possible. Diagnosis with total serum lactate dehydrogenase (LDH) and LDH isoenzyme 3 measurements along with gadolinium-enhanced diethylenetriamine penta-acetic acid (Gd-DTPA) dynamic MRI was reported to be highly accurate (65). MRI images are taken during the arterial phase, between 40 and 60 seconds after infusion of gadolinium. Sarcomas have increased vascularity and show increased enhancement with gadolinium, while degenerating fibroids have decreased perfusion and exhibit decreased enhancement. Using LDH measurements and Gd-DTPA, a study of 87 women with uterine fibroids, 10 women with leiomyosarcomas, and 130 women with degenerating fibroids reported 100% specificity, 100% positive predictive value, 100% negative predictive value, and 100% diagnostic accuracy for leiomyosarcoma (Fig. 15.3).
The presence of submucous fibroids decreases fertility rates and removing them increases fertility rates. Subserosal fibroids do not affect fertility rates but removing them does increase fertility. Intramural fibroids may slightly decrease fertility, but removal does not increase fertility (66). A meta-analysis of the effect of fibroids on fertility and the effect of myomectomy on fertility found that submucous fibroids that distort the uterine cavity appear to decrease fertility, with ongoing pregnancy/live birth rates decreased by about 70% (relative risk [RR] 0.32; 95% confidence interval [CI], 0.12–0.85) (66). Resection of submucous fibroids slightly increased fertility relative to infertile controls without fibroids (ongoing pregnancy/live birth rate, RR 1.13; 95% CI, 0.96–1.33).
Analysis of studies that routinely used hysteroscopy to confirm clear nondistortion of the cavity by intramural fibroids found ongoing pregnancy/live birth rates were not significantly different compared to controls (RR 0.73; 95% CI, 0.38–1.40) (66). Importantly, removal of intramural or subserosal fibroids did not improve ongoing pregnancy/live birth rates (RR 1.67; 95% CI, 0.75–3.72).
Myomectomy may involve operative and anesthetic risks, risks of infection or postoperative adhesions, a slight risk of uterine rupture during pregnancy, an increased likelihood that a cesarean section will be recommended for delivery, and the expense of surgery and time for recovery. Therefore, until intramural fibroids are shown to decrease and myomectomy to increase fertility rates, surgery should be undertaken with reluctance (66). Randomized studies are needed to clarify the relative risks and benefits of surgical intervention.