The patient was lost follow up after the initial work-up. Two years later, she presented with worsening abdominal distension, anorexia and weight loss. After repeat work-up, she underwent surgery.

Procedure: Total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy, bilateral parametrium removal and umbilical hernia repair.

TAH & BSO: Leiomyosarcoma. Size: 16 cm.  Coagulative necrosis present. Mitotic rate= 7/10 HPF. Moderate nuclear atypia with focal severe nuclear atypia. Endometrium: Proliferative endometrium. Cervix: Mild chronic nonspecific inflammation. Fallopian tubes: Para tubal cyst with no other significant changes. Left ovary: Benign follicular cyst with no other significant pathology. Right ovary: No significant pathology.

Peritoneum & omentum: Chronic inflammation with hemosiderin deposition and reactive mesothelial hyperplasia. No evidence of malignancy seen.

Ascitic fluid analysis: Negative for malignant cells.