Uterine Leiomyosarcoma Incidentally Diagnosed After Sigmoid Colon Perforation: A Case Report and Review of the Literature Highlighting Individualized Surgical and Oncologic Decision-Making

Introduction: Uterine leiomyosarcoma (uLMS) is a rare, highly aggressive malignancy arising from the smooth muscle tissue of the uterine wall. It typically presents with abnormal vaginal bleeding, pelvic pain, or a pelvic mass. In rare instances, symptoms may result from local invasion or metastasis. We report a case of uLMS initially diagnosed following colonic perforation due to direct tumor invasion, accompanied by a comprehensive narrative review of the literature on the incidental identification of uterine sarcomas during emergency general surgery to further emphasize the diagnostic challenges, treatment approaches, and need for individualized care in these complex cases. Case Presentation: A 45-year-old woman presented to the Emergency Department with acute abdominal pain of several hours’ duration, in the absence of other associated symptoms. An emergency exploratory laparotomy was performed, revealing feculent peritonitis secondary to sigmoid colon rupture, resulting from local invasion by a large uterine mass. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was undertaken, followed by en bloc resection of the sigmoid colon, appendectomy and construction of a terminal colostomy. Her postoperative course was uneventful, and she was discharged on postoperative day eight. Histopathological examination of the specimen revealed a high-grade uterine leiomyosarcoma. Following evaluation by a multidisciplinary oncology board, the patient received adjuvant chemotherapy. Methods and Results: A narrative review of the literature was performed to identify cases of uterine sarcomas incidentally diagnosed during emergency surgery performed by general surgeons. Including the present case, six cases were identified. Most patients presented with acute abdomen mimicking gastrointestinal pathology, with diagnosis established intraoperatively or postoperatively. Definitive surgical management was achieved during the initial emergency procedure in all cases. Conclusion: Although exceptionally rare, uterine sarcoma should be considered in the differential diagnosis of acute abdomen in female patients undergoing emergency surgery. Awareness of this atypical presentation, the appropriate diagnostic approach, real-time intraoperative adaptability, and individualized multidisciplinary management are essential for ensuring appropriate surgical management and optimizing patient care.