Uterine carcinosarcoma due to foreign body (migrated intrauterine device): an extremely rare etiology of gynecological neoplasm

Abstract

Introduction

Uterine carcinosarcomas are extremely rare gynecological neoplasms. The coexistence of intraabdominal foreign bodies, such as migrated IUDs, and uterine neoplasms, particularly carcinosarcomas, represents a significant clinical challenge and infrequent association. Chronic inflammation associated with foreign bodies can act as a cofactor in carcinogenesis and explain the appearance of these tumors.

Case presentation

A 65-year-old woman with a history of cesarean section, presented to the emergency department with a 5-day complaint of abdominal pain, nausea and constipation. An abdominal CT scan was performed, revealing a left parauterine mass containing a migrated intrauterine device (Lippes’s loop) with a transition zone in the sigmoid colon. The patient was taken to exploratory laparotomy, where a subtotal hysterectomy and left salpingo-oophorectomy were performed. Pathology report showed uterine carcinosarcoma.

Discussion

This case exemplifies a rare clinical presentation of uterine neoplasm secondary to the presence of a foreign body (Lippes’s loop), debuting with bowel obstruction.

Conclusion

Uterine neoplasm secondary to foreign bodies are very rare clinical entities, and its pathophysiological mechanisms have not been fully understood. Particularly, uterine carcinosarcomas are a subgroup of these malignancies with a more aggressive behavior and poor oncological prognosis. Early diagnosis and prompt surgical management are the cornerstones of management.

Introduction

Uterine carcinosarcomas are malignant mixed neoplasms that combine histological carcinoma and sarcoma features. They are classified within malignant mixed Müllerian tumors and are known for their clinical aggressiveness and high recurrence rate [1]. They represent less than 5% of all uterine cancers, with a global incidence of approximately 1.7 cases per 100,000 women/year, commonly presenting in postmenopausal women over 60 years of age [2]. The most common symptoms include postmenopausal vaginal bleeding – which is present in over 70% cases – pelvic pain, and gastrointestinal symptoms, including secondary bowel obstruction due to direct invasion or compression by tumor masses [3]. In this case report, we discuss a patient with a uterine carcinosarcoma that emerged from a migrated intrauterine device (IUD), leading to an acute bowel obstruction that was managed surgically with an exploratory laparotomy, adhesion release, subtotal hysterectomy and left salpingo-oophorectomy. Our patient had a full recovery and was discharged without complications, later receiving adjuvant oncological treatment.

Methods

This work was completed in line with the SCARE criteria.

Case presentation

A 65-year-old woman with history of a previous cesarean section presented to the emergency department with a 5-day complaint of abdominal pain, nausea and constipation, with absence of flatus and stool. Fourty years before, the patient had an intrauterine device (Lippes’s loop) placement. This device was never found by ultrasound. She persisted with abnormal uterine bleeding, so another intrauterine hormonal device (Kyleena), was placed by her gynecologist. Upon admission to the emergency department, a plain abdominal X-ray showed graded air-fluid levels with minimum distal gas, clearly compatible with intestinal obstruction (Fig. 1). The x-ray also showed the Lippes´s and the Kyleena device projected in the pelvis (Fig. 1).

Fig. 1.

Plain abdominal x-ray upon admission

Medical management was initiated with intravenous fluids and nasogastric tube placement. An abdominal double-contrast CT scan revealed a left parauterine mass containing a migrated intrauterine device (Lippes’s loop) in the peritoneal cavity, with a transition zone at the level of the ileum with significant retrograde small bowel dilation (Fig. 2A-C). The mass was in contact with the sigmoid colon and the bladder, but no pneumoperitoneum or other abnormal findings were visualized.

Fig. 2.

Abdominal CT scan showing a parauterine mass containing the Lippes´s loop in the (A) axial, (B) coronal and (C) sagittal planes. Small bowel is dilated and the transition zone es marked in the axial plane in circle (A)

Considering the evidence of mechanical bowel obstruction, prompt surgical management was decided. A midline laparotomy incision was performed, and upon inspection we found a 5.5 × 8 cm multilobulated left parauterine mass contacting the abdominal wall, firmly adhered to the bladder and sigmoid colon (Fig. 3), and with a mucoid content. The mass had multiple adhesions to the distal ileum and its mesentery in a 20 cm segment located 270 cm from the ligament of Treitz, which were liberated with blunt dissection. There was also a small amount of peritoneal reaction fluid towards the pelvis. Subsequently, we continued dissection to free the anterolateral aspect of the sigmoid colon and the posterior bladder wall from the mass. The colonic wall was adhered to the tumor, but no vascular involvement or perforation was seen. There was no need for bowel resection.

Fig. 3.

A Left parauterine mass as visualized upon entry to the abdomen. B. The mass was adhered to the sigmoid colon (shown in circle)

After managing to surround the mass circumferentially we released the left uterine horn in a severely hypotrophic uterus. When we completed dissection, we identified a uterine perforation at this level, through which the contraceptive device (Lippes’s loop) had migrated into the abdominal cavity. The device was embedded within the parauterine mass with adjacent inflammatory changes and the perforation described previously (Fig. 4). This particularly was identified as the mechanical cause of bowel obstruction.

Fig. 4.

Uterine perforation (shown with dissection)

With these findings, a subtotal hysterectomy and left salpingo-oophorectomy were performed. Uterine ligaments on both the right and left sides were released, with subsequent ligation of the uterine artery and vein at the cardinal ligament with the ultrasonic energy device Ligasure Impact™ (Covidien, Minnesota, USA). Section of the uterine body was performed with electrocoagulation. The en block surgical resection was completed (Fig. 5), and the uterine stump was closed with continuous hemostatic absorbable suture using a Parker-Kerr technique. Within the uterine cavity we identified the second contraceptive device (Kyleena). Nasogastric tube was removed on the first postoperative day and oral feeding started on the second day. After completing a 72-hour work up the patient was discharged with no immediate postoperative complications.

Fig. 5.

A En bloc surgical resection, including uterus fundus and body, left salpingo-oophorectomy and parauterine mass. B Lippes’s loop among the parauterine mass

In the postoperative follow-up the pathology report was reviewed, showing a uterine carcinosarcoma with lymphovascular and perineural invasion, made up of 90% high-grade serous carcinoma and 10% high-grade sarcoma.

Regarding immunohistochemical markers, staining showed HER-2 negative and positive hormone receptors, without heterologous elements. The main histopathological findings in this case are shown in Fig. 6. With this report, according to the NCCN guidelines, the patient was staged as a pEIIIA (T3aN0M0) tumor due to involvement of serosa and left adnexa [4].

Fig. 6.

Histopathological findings after studying the surgical specimen with H&E stain. This section shows the biphasic tumour with malignant glandular component (arrow), and the mixed mesenchymal component (circle)

The patient was later evaluated by gynecologic oncology and clinical oncology, who considered she required optimal management with adjuvant chemotherapy with cisplatin and radiotherapy, which are in course nowadays.

Discussion

Uterine carcinoma, particularly in its form as uterine carcinosarcoma, is an extremely infrequent gynecological neoplasm with a very low incidence [1]. As mentioned before, these are malignant mixed neoplasms that combine carcinoma and sarcoma features, which gives them greater aggressiveness and local tumor progression rate [1]. Uterine carcinosarcomas are associated with mutations in key genes such as TP53, PTEN, and PIK3CA, which contribute to the deregulation of cell control mechanisms [5].

These genetic alterations explain the aggressive clinical behavior, metastatic capacity, and resistance to conventional treatments [5]. Diagnosis of uterine sarcomas is primary through imaging to show local advancement and outrule distant disease.

CT and MRI are diagnostic imaging modalities of choice to identify location and extent of tumor invasion, as well as planning for surgical resection [6]. Definitive diagnosis is achieved through histopathological revision, confirming the classic features mentioned before [6]. The five-year survival rates in this type of cancer are 25–30% [6].

Due to its mixed epithelial and mesenchymal components, the pathophysiological mechanisms of uterine carcinosarcomas have not been yet clearly dilucidated. Particularly, the coexistence of an intraabdominal foreign body as causes of this type of neoplasm, such as a migrated IUD, represents a significant clinical challenge and an extremely rare association [7]. It has been hypothesized that the presence of a foreign body in the endometrial cavity enhances oxidative and nitrative stress and also liberates genotoxic mediators that can enhance carcinogenesis and increase risk of uterine neoplasms [7]. Likewise, the presence of foreign bodies – in addition to other factors such as obesity, aging, and diabetes – can elevate cytokine levels, promote the release of growth factors and eventually lead to DNA damage that can explain an increased cancer risk [7].

In the other hand, IUDs are one of the most widely used contraceptive methods worldwide due to their high efficacy and safety. However, migration of the IUD from the uterine cavity into the abdomen is a rare complication, with a reported incidence of 0.1–0.3 cases per 1,000 insertions [8]. It´s also important to highlight that there is no indication of inserting a second IUD with a history of retained or missing IUD, because this is related with abnormal uterine anatomy or hormonal alterations [9].

There are two main mechanisms through which perforations due to IUDs con occur. Primary perforation may occur during insertion, especially when performed postpartum or in the presence of uterine anatomical abnormalities [8]; secondary perforation, occurs when an IUD gradually migrates due to uterine contractions or mechanical pressure, weakening the uterine walls over time [10]. Once the IUD perforates the uterine wall, it can migrate into the abdominal cavity. This process can lead to local inflammation, formation of pelvic adhesions, and risk of intestinal perforations and complications such as obstruction [10].

After conducting an exhaustive literature review, we found a similar case reported in the literature. This case, published in 2012 in a French magazine, describes an 83-year-old patient with history of pelvic surgery and diagnosis of uterine carcinosarcoma due to a foreign body described as a calcified compress [11].

Another case, published in 2015, describes a 73-year-old patient with a cervical mass mimicking a cervical tumor with presence of a vaginal foreign body (plastic bottle cap) [12]. Although the final histopathology result did not report any malignancy, the case depicts how a foreign body can trigger an inflammatory response which may eventually lead to dysplastic cellular changes and subsequently malignant neoplasia. There are no other similar cases reported in literature that link directly the presence of a foreign body in uterine cavity with this type of malignant neoplasms.

Conclusion

Uterine carcinosarcomas are very uncommon gynecological tumors with aggressive local behavior, poor prognosis and short long-term survival. Its high recurrence and local progression limit effective therapeutic options. The gold standard for management include radical hysterectomy to achieve appropriate oncological negative margins, as well as concomitant adjuvant chemoradiotherapy.

Although some articles have described the association between the presence of foreign bodies and the development of uterine neoplasms, this causal relationship is extremely rare and represents a challenge for both the diagnosis and management of this pathology. Intestinal obstruction is part of the common spectrum of complications related to uterine cancer and contributes significantly to the morbidity associated with the disease.

Authors’ contributions

Jorge Luis Turizo Farias: Study conception and design, drafting of manuscript, critical revision of manuscript. Lina María Platero Borda: Analysis and interpretation of data and drafting of manuscript. Camila Andrea Sánchez Castañeda: Analysis and interpretation of data and drafting of manuscript-Juan Carlos Vallejo-Soto: Analysis and interpretation of data, drafting of manuscript, critical revision of manuscript. Jose Luis Rojas-Oviedo: Theoretical advice and analysis, drafting of manuscript, critical revision of manuscript. All authors approved the definitive version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data used in the present study is available upon request to the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical compliance with the Helsinki Declaration, current legislation on research Res. 008430 − 1993 and Res. 2378 − 2008 (Colombia) and the International Committee of Medical Journal Editors (ICMJE) were ensured under our Ethics and Research Institutional Committee (IRB) approval, prior signing of informed consent by the patient. The protocol for this article was previously approved by the Ethics Committee of Investigation in Human Beings (CEISH) of our institution (Hospital Universitario Mayor – Méderi), with reference number CEISH-2025007 on February 25, 2025.

Consent for publication

The patient subject of this report previously signed the written informed consent form in the presence of two witnesses, authorizing the anonymous use of all the information from her medical history (including personal and clinical details) and corresponding images in any publications with scientific or academic interest.

Competing interests

The authors declare no competing interests.