Giant Uterine Leiomyosarcoma with Ascitic Cytology Positive: A Case Report on Diagnostic and Surgical Challenges in a Low-Resource Setting

Introduction: Uterine leiomyosarcoma (uLMS) is a rare, aggressive smooth-muscle malignancy that constitutes only a small fraction of uterine cancers but contributes significantly to morbidity and mortality. Preoperative distinction from benign fibroids remains challenging, particularly in low-resource settings. This report aims to describe a case of giant uterine leiomyosarcoma with peritoneal dissemination and highlight the diagnostic and surgical challenges encountered in a resource-limited environment. Case Presentation: A 45-year-old multiparous woman from rural Somalia presented with a five-year history of progressive abdominal distension and irregular vaginal bleeding. Imaging revealed a massive heterogeneous uterine mass with central necrosis and ascitic fluid. Following preoperative stabilization, total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Intraoperatively, a large vascular uterine tumor was observed occupying the abdominal cavity and adherent to the omentum and peritoneum. Histopathology confirmed high-grade uterine leiomyosarcoma with extensive myometrial invasion and peritoneal dissemination, evidenced by malignant cells in the ascitic fluid. The postoperative recovery was uneventful, and the patient was referred for adjuvant oncology evaluation. Long-term follow-up was limited due to financial and logistic constraints. Conclusion: This case illustrates the clinical, diagnostic, and management difficulties of uterine leiomyosarcoma in resource-limited settings. Strengthening gynecologic oncology services, affordable access to imaging and pathology, and early recognition of suspicious uterine masses are essential for improving outcomes and advancing women's health equity in developing regions.