Low grade endometrial stromal sarcoma presenting as infected polyp

A 60 yr old post menopausal woman came to Gynaecology OPD with complaints of Bleeding per vagina of 1month duration and H/o of intermittent low grade fever of 4 days. She was changing 4– 5 pads per day, associated with clots, not associated with dysmenorrhoea ,no white discharge , no burning micturition , no retention of urine or no recent loss of weight. She had loss of appetite for the past 10 days. She attained menopause 4 years back. She was anemic and emaciated. Per abdomen there is a mass of 14 weeks size, in lower abdomen , firm, uniformly enlarged, lower border could not be made out. On speculum examination a large necrotic fungating mass covered with slough & purulent foul smelling discharge occupying whole of vagina was found. Finger could be passed around the mass and assumed that the mass could be arising from the body of uterus. Cervix felt separately from growth. On Per rectal examination PV findings were confirmed, rectal mucosa is free. A provisional diagnosis of Infected Polyp was made with suspicion of malignancy. Usually any mass arising from uterus or cervix at this age clinically gives a suspicion of malignancy. Fibroid polyp may arise from body of the uterus or from the cervix. Sub mucous fibroid extrudes into uterine cavity. During this process a broad pedicle forms when it is attached to fundus of uterus. She was admitted in the hospital for confirmation of diagnosis, investigations and further management. Surgical profile was done and found to be anemic which was corrected by three blood transfusions and infection by systemic antibiotics. Retention of urine was treated by continuous bladder drainage. Findings of Ultrasonography and MRI suggested that the mass is benign. Intra operatively also there was no suspicion of malignancy in staging Laparotomy as there were no secondary lesions in Ileo- ceacal junction, liver, under diaphragm and Para-aortic lymphnodes , no free fluid and adnexae were normal. H.P.E report only showed Low grade Endometrial stromal sarcoma. Pathologist advised Immuno – Histochemical studies which was in favour of Endometrial stromal sarcoma. The main reason for presentation of this case is to emphasize on staging laparotomy, when ever a case with such a large polyp with sloughing and infection presents to out- patient department with high index of suspicion of malignancy. Early diagnosis of secondaries has to be kept in mind. To emphasize the need of oncoprotein immunohistochemical staining studies to differentiate Leio-myo sacroma, Endometrial stromal sarcoma, Vascular tumor.