Exploring the Evolution of Leiomyomatosis Peritonealis Disseminata: A Longitudinal Study on Malignant Transformation and Potential Biomarkers

  • Clinical Medicine & Research
  • November 2025,
  • 23
  • (3)
  • 111-
  • 120;
  • DOI: https://doi.org/10.3121/cmr.2025.1978
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Abstract

Introduction: Leiomyomatosis peritonealis disseminate (LPD) is an entity with uncertain biological behavior, characterized by multiple smooth muscle intra-abdominal and pelvic nodules that may recur after apparently complete resection. LPD has been predominantly described in childbearing age females. Most case reports with short term follow-up describe this as a benign entity. Only isolated case reports indicate the malignant potential of the disease. A comprehensive collation of cases is lacking in literature.

Methods: We present a case of malignant transformation of LPD, confirmed by histology and imaging, occurring over two decades. This patient was originally diagnosed with uterine atypical smooth muscle tumor but developed frank malignancy during follow-up. An increasingly malignant aggressive disease course resulted in ultimate development of liver and lung metastases almost 23 years after original diagnoses, resulting in her demise. A comprehensive literature review was performed, and 213 cases of LPD were described, including the present case. Patients were divided into G1 (reportedly benign), G2 (malignant at presentation), and G3 (malignant transformation).

Results: Compared to G1, G2 at presentation were more likely to be symptomatic (73%/88%), larger sized (4.1/8.4 cm), and older aged (38/44). In G1, G2, and G3, the average age was 38.5, 44.3, and 37.5 years, respectively; while the disease specific survival was 100%, 71%, and 40%, respectively. The mean number of surgeries performed in G1, G2, and G3 was 1.6, 1.8, and 3.8, respectively. Hormone receptors were found in 24.4% of cases. The mean reported follow-up time in G1, G2, and G3, respectively, was 44.9, 13.1, and 70.5 months. This suggests with longer follow-up, even apparently benign tumors may develop malignancy. The transformation time to malignancy in G3 was 77.8 months, which is more than the average reported follow-up in G1 (44.9 months).

Conclusions: LPD is a potentially malignant condition with long latency prior to transformation. Lifelong surveillance should be considered even in cases originally presumed to be benign. Loss of hormone receptor expression may serve as a marker for this transformation. Circulating Tumor DNA (ctDNA) levels may be associated with development of hematogenous metastases and may be a useful biomarker.

Keywords:

Multiple peritoneal leiomyomas were first described in 1952 as benign smooth muscle tumors arising in a patient with a coexisting ovarian granulosa cell tumor.1 This disease entity was given the name of leiomyomatosis peritonealis disseminate (LPD) in 1965.2 Since then, over 200 cases have been reported in the English literature; however, the natural history of the disease has not been well documented. Most reported cases are in premenopausal women with only a short-term follow up. When reported, the symptoms are those of early satiety, abdominal discomfort, and distension. Imaging indicates multiple intraabdominal tumors without obvious invasion, and no hematogenous or lymphatic metastases.

Different etiological theories have been proposed including hormonal imbalance,3-7 differentiation of sub-peritoneal mesenchymal stem cells,3,4,6-9 myofibroblast metaplasia,7 genetic,6,7 iatrogenic causes,5-7 morcellation,4-6,8,9 and epithelial mesenchymal transition.6 However, none of these can satisfactorily explain the biological behavior of tumors.

Here we present a unique case of LPD with a long-term follow-up of over two decades, demonstrating malignant transformation, the potential utility of estrogen receptor (ER)/progesterone receptor (PR) loss, and potential utility of circulating tumor DNA (ctDNA) as biomarkers. In this manuscript, a case of a 44 year old nulliparous female who initially presented with abdominal pain and uterine masses in 1999, which developed into malignancy, over the next two decades is presented. The initial diagnosis was an atypical smooth muscle that progressed to outright leiomyosarcoma (LMS) during the follow-up is reported. The transition from an estrogen receptor (ER) positivity in origin tumor to lack of expression when LMS was diagnosed was observed. She ultimately passed away from hematogenous metastases with corresponding ctDNA elevation. The clinical management is described.

We also created an Excel database of all the reported cases of LPD in the English literature. Data on demographic information, clinical presentation, patient and tumor characteristics, diagnosis, therapeutic interventions, and adjuvant therapies was collated. Descriptive statistics were utilized. The insights gained from the comprehensive literature review are presented.

Case Report

In 1999, a nulliparous female patient, aged 44 years, presented at an outside hospital with abdominal pain and a palpable abdominal mass. She had a previous inguinal hernia repair in 1995 and a left oophorectomy in 1988 for a ruptured ovarian cyst. She was otherwise in good health. The patient was on oral contraceptives. There was no family history of breast, colon, endometrial, or ovarian cancer. She did not use alcohol or tobacco. Initial workup included an abdominal ultrasound, which was suggestive of a mass arising from the uterus. She underwent a laparotomy and myomectomy. Intraoperatively, a 15 cm uterine mass was identified. Pathology was reported as an atypical leiomyoma with fewer than 3 mitotic figures per 10 high power field. The pathology slides from this procedure are not available for review, as the initial procedure took place at the outside facility and were unrecoverable. The operative note did not mention any additional intra-abdominal pathology at the time.

The patient then presented to our hospital with abdominal bloating and distension associated with menses as well as possible rectal bleeding in 2003. Workup included a computed tomography (CT) scan of the abdomen and pelvis (Figure 1A), which demonstrated numerous peritoneal implants, most prevalent in the pelvis. It was elected to undergo repeat laparotomy with cytoreduction. Intraoperatively, the patient underwent total abdominal hysterectomy, right salphingo-oophorectomy, appendectomy, and infracolic omentectomy.

(A) CT abdomen/pelvis 2003. Numerous peritoneal implants, most prevalent in the pelvis with largest tumor measuring 12 cm. (B) CT abdomen/pelvis 2014 demonstrates scattered masses with largest tumor measuring 14cm. (C) CT abdomen/pelvis 2018 demonstrates recurrent tumor growth. Masses palpable on abdominal examination. (D) CT abdomen/pelvis 2019 with multiple soft tissue masses throughout the abdomen, most prominent in the left abdomen. (E) CT abdomen/pelvis 2020 multiple large intraabdominal masses, with the largest in the left abdomen. (F) CT abdomen/pelvis 2022 with recurrent intraabdominal tumors in the left abdomen.
Figure 1.

(A) CT abdomen/pelvis 2003. Numerous peritoneal implants, most prevalent in the pelvis with largest tumor measuring 12 cm. (B) CT abdomen/pelvis 2014 demonstrates scattered masses with largest tumor measuring 14cm. (C) CT abdomen/pelvis 2018 demonstrates recurrent tumor growth. Masses palpable on abdominal examination. (D) CT abdomen/pelvis 2019 with multiple soft tissue masses throughout the abdomen, most prominent in the left abdomen. (E) CT abdomen/pelvis 2020 multiple large intraabdominal masses, with the largest in the left abdomen. (F) CT abdomen/pelvis 2022 with recurrent intraabdominal tumors in the left abdomen.

The largest tumor removed was 12 cm. The pathology report described a benign leiomyoma with atypical smooth muscles cells, no necrosis, and abundant cytoplasm consistent with LPD. The tumor was estrogen receptor (ER) and progesterone receptor (PR) positive.

In 2014, the patient re-presented to clinic with complaints of right lower quadrant fullness and urinary frequency. Repeat CT of the abdomen and pelvis (Figure 1B) demonstrated scattered masses. A complete cytoreduction was again possible with bowel resection. The largest tumor measured 14 cm. The pathology at this time was reported to be a smooth muscle neoplasm, with isolated foci of coagulative necrosis, moderated cytologic atypia consistent with low grade leiomyosarcoma in association with leiomyomatosis disseminata. The LPD tumors were ER/PR positive, while the LMS were ER/PR negative. Systemic therapy was declined by the patient.

The patient presented again in 2018 with an asymptomatic, palpable abdominal mass. The CT scan (Figure 1C) demonstrated regrowth of tumors in the upper and middle abdomen. As she was asymptomatic at the time, she elected to proceed with close observation.

In 2019, she re-presented with fatigue, abdominal discomfort, shortness of breath, and intermittent explosive bowel movements. A CT scan (Figure 1D) demonstrated multiple soft tissue masses throughout the abdomen. A complete cytoreduction was again performed, requiring small bowel resection, colon resection, and cholecystectomy. No frozen section was performed, and the final pathology again described a low to intermediate grade leiomyosarcoma. She continued to decline systemic therapy.

The patient presented again within 6 months with progressive intra-abdominal disease. A CT scan (Figure 1E) showed multiple intra-abdominal masses. After tumor board discussion, she underwent cytoreductive surgery with heated intra-peritoneal chemotherapy (HIPEC) in early 2020. This necessitated further bowel resection. She was without evidence of disease for over 14 months. At the end of 2021, there was radiological evidence of disease without symptoms. In early 2022, she remained asymptomatic, although the lesions almost doubled in dimension (Figure 1F). She subsequently had symptomatic progression and underwent repeat cytoreductive surgery and HIPEC, achieving complete cytoreduction with removal of multiple small and large tumors. The final pathology was consistent with recurrent leiomyosarcoma in all tumors. Next generation sequencing (NGS) was performed. Genomic findings including PTEN loss exon 2-9, CDKN2a/B loss, Fam123B with alteration Y956, IGF1R amplification, MED12 with alteration G44s, and TP53 with alteration K164E were all identified. There were no actionable mutations identified.

At this time ctDNA became commercially available and was undetectable on first evaluation in June 2022, corresponding to no radiological evidence of hematogenous disease, though peritoneal recurrence was noted (Figure 2). She declined to consider systemic therapy and continued to receive complementary and alternative medicine.

CT with IV Contrast: (A) July 2022 without evidence of liver metastasis; (B) November 2022 with new liver mass measuring 4.5 cm; (C) May 2023 with liver mass measuring 9.6 x 9.8 x 14.6 cm. (D) Patient’s ctDNA findings: Undetectable in June 2022, corresponding to no radiological findings. Minimally elevated ctDNA noted in 11/2/2022, corresponding to a newly present liver mass. ctDNA significantly increased by March 2023, consistent with significantly enlarged liver mass on CT in May 2023.
Figure 2.

CT with IV Contrast: (A) July 2022 without evidence of liver metastasis; (B) November 2022 with new liver mass measuring 4.5 cm; (C) May 2023 with liver mass measuring 9.6 x 9.8 x 14.6 cm. (D) Patient’s ctDNA findings: Undetectable in June 2022, corresponding to no radiological findings. Minimally elevated ctDNA noted in 11/2/2022, corresponding to a newly present liver mass. ctDNA significantly increased by March 2023, consistent with significantly enlarged liver mass on CT in May 2023.

Unfortunately, she had clinical and radiological progression. In November 2022, elevated ctDNA was noted along with asymptomatic hematogenous liver metastases (Figure 2). She continued to decline systemic therapy and developed symptomatic progressive liver and lung disease along with significantly elevated ctDNA. She ultimately passed away 24 years after her original diagnoses.

Review of Literature

A comprehensive review of the English literature was performed. The search terms utilized were “Leiomyomatosis Peritonealis Disseminata”, “malignant LPD”, “Malignant Leiomyomatosis Peritonealis Disseminata”, and “Transformed Leiomyomatosis Peritonealis Disseminata”. We identified 149 articles covering 212 cases of LPD, with 23 cases being malignant. The search date range was from 1955 to 2021.

The patients were divided into group 1 (G1 - thought to be benign), group 2 (G2 - malignant at presentation) and Group 3 (G3 - transformed into malignancy from initial benign presentation during follow up). These will be referred to G1, G2, and G3, respectively, in the rest of the manuscript. The current case is reported as “+1” in the table. Data were then pulled from these articles and entered into an excel database (CD, EA). The summarized data from this table can be found in Table 1.

View this table:
Table 1.

Leiomyomatosis peritonealis disseminate (LPD) literature review (1952-2021)

There were 189 (G1), 14 (G2), and 9+1 (G3). Most cases occurred in females, with only seven reported in males. Significantly higher percentage were in males, 3 (42.9%). The median (and mean) age at presentation for (G1) is 36.5 / 37.4 years, and those with malignancy (G2+G3) is 41 / 51 years. The median (and mean) age of the patients was 37 / 38.5 years in G1, 41.5 / 44.3 years in G2, and 27 / 37.5 years in G3. The mean / median length of follow-up reported was 44.9 / 23 months for G1, 13.1 / 11.5 months for G2, and 70.5 / 36 months for G3. Of the G1, 128 (67.7%) were either currently or previously pregnant. This Number was 2 (14.2%) of G2 and 5 (50%) of G3. History of endometriosis was reported in 10.6% (G1), 14.2% (G2) and 10% (G3). Almost all patients in this series had symptoms at presentation with pain being the most common (61.6%), followed by bleeding (17.6%) and weight loss (2.5%) mass sensation (54.1%). In G1, 82% of patients were managed with laparotomy, whereas 90% of G3 initially had laparoscopic surgery. All in G2 were managed with laparotomy. Of G1, 10% had intra operative tumor morcellation, and unfortunately 7% in G2 also had morcellation. As there is only a relatively short-term follow up in G1 patients reported, it is unclear if this affected the outcome negatively. There was no significant difference in the range of tumor sizes between the groups (0.015 - 40 in G1, 0.1 - 40 in G2, 0.6 - 15.5 in G3). The hormone receptor status (estrogen [ER] and progesterone [PR]), was only reported in 62.9% of the entire cohort: 34.4% were in G1, 2.5% in G2, and 1% in G3 had receptor expression.

Adjuvant therapy was administered in 28 (14.8%) of G1. Most common therapy in this group was hormonal (13%). For unclear reasons, two patients had chemotherapy, and one had radiation in this group. Almost all these patients receiving adjuvant therapy in G2/G3 had either chemotherapy (64.3%/40%) or hormonal therapy (14.3%/50%). The mean number of surgeries in each group was 1.6 (G1), 1.8 (G2), and 3.8 (G3). The mean follow-up duration reported in the G1 (44.9 months) was significantly shorter than G3 (70.5 months) and G2 (12.1 months). The shortest reported follow up in G2 could be reflective of limited survival in this group. The patients dying of disease at last reported follow up was 0% (G1), 35.8% (G2) and 50% (G3).

Discussion

LPD is a rare disease with uncertain biological outcomes. Only isolated case reports and very few case series have been reported in English literature.2,4,10-28 In this manuscript, we have added a case to the wealth of published literature on the subject. This is the first attempt at a comprehensive collation of available published data on this topic, gleaning useful insights into the potential management of this disease entity.

Even though LPD has been thought to be benign in the published literature, the current case demonstrates a significant lag time between initial diagnosis and development of outright malignancy.16 Our case followed a single patient’s progression from benign to outright malignancy over two decades and illustrates the need for long-term follow up.

While the largest category of patients (G1) was thought to constitute a benign process, the mean reported follow-up period was 25.6 months, shorter when compared to G3 (44.9 vs. 70.5 months). It is possible that had patients in G1 been followed long enough the disease process would have eventually transformed into malignancy.

Currently, there are two main hypotheses of the pathogenesis of LPD. The first hypothesis is that it is caused by a hormonal imbalance.3,4,8,9,29 This hypothesis is supported by most of the reported patients being female (96.7%), premenopausal (88.7% under the age of 50), the presence of estrogen and progesterone receptors, and the use of hormonal therapy to treat LPD.29-32 However, the findings of no significant effect of pregnancy, endometriosis, or contraceptive use between the different groups weakens this hypothesis.

As reported in our patient, the loss of estrogen and progesterone hormone receptors may suggest a malignant transformation of the LPD lesions. While a positive ER/PR status was found in 24.4% of case reports, to the best of our knowledge, the current case represents the first documented case of a loss of ER/PR associated with a malignant transformation. Initial specimens were all atypical leiomyoma positive for ER/PR. In specimens received in 2014, it was found that the LPD samples remained ER/PR positive, while the transformed malignancy was found to be ER/PR negative. In 2019, all specimens were found to be the LMS lacking ER/PR. Ideally, NGS analysis of the original atypical smooth muscle tumor would have provided a more direct comparison to the leiomyosarcoma; however, these slides were unavailable Instead we compared the tumors regarding ER/PR expression, noting a loss of hormone receptor expression in the transformed tumor. PR activity has been reported to be uniformly present in LPD nodules from both premenopausal and postmenopausal women, supporting the contention that hormones influence the development of LPD.33 The loss of hormone receptors, such as estrogen and progesterone receptors, can indicate a shift towards a more aggressive phenotype. Ye and Chen34 reported a case of LPD with low-grade malignant change, where the lesions strongly expressed these receptors, suggesting hormonal dependency. the loss of these receptors may reduce the effectiveness of hormonal therapies such as gonadotropin-releasing hormone agonists, which are often used to manage LPD.

LPD has been reported after morcellation of tumors thought to be benign.3-5,35,36 While morcellation may provide the benefit of removing larger tumors during laparoscopic procedures, it does increase the risk of diffuse peritoneal disease and seeding cancer cells within the peritoneal cavity. While no patients in G3 underwent morcellation, only one patient in G2 underwent morcellation during a laparoscopic subtotal hysterectomy and bilateral salpingectomy 10 years prior to the diagnosis of LPD with cellular leiomyoma and sarcoma degeneration.3 Additionally, 10.1% of patients in G1 underwent morcellation, but without long term follow-up in these patients, we are unable to show how morcellation negatively affects these outcomes.4,5,28,36-41 Given the uncertainty of morcellations effects on outcomes, these findings contribute data that supports moving away from the use of morcellation in gynecological procedures.

Currently, there is limited evidence on the use of radiation, chemotherapy, and hormonal therapy in patients with LPD. From the review of literature, we found that in G1, G2, and G3, 0.5%, 0.0%, and 10% underwent radiation; 1.1%, 64.3%, and 40.0% chemotherapy; and 13.2%, 14.3%, and 50% underwent hormonal therapy. To the best of our knowledge, radiation has only been used in two cases of LPD.42,43 A patient in G1 who underwent both radiation and chemotherapy due to the presumed diagnosis of disseminated malignancy was found to have benign LPD during autopsy findings and may have died due to systemic effects of the therapy.43 Chemotherapy was utilized mostly in G2. While there are no specific chemotherapy guidelines for LPD, doxorubicin is the most reported chemotherapy agent used (26.7% of all chemotherapy agents used).42,44-46 Hormonal therapy is the most used pharmacologic therapy for LPD (62.3% of all patients undergoing systemic therapy).11-14,16,18,23,29-31,42,44,46-66 As previously mentioned, this is due to the potential etiology of LPD stemming from hormonal imbalance. The most common hormonal agents used include gonadotrophin-releasing hormone analogs (32.4% of all hormonal therapy) and estrogen antagonists (18.9% of all hormonal therapies).

The use of NGS in patients with LPD has not been well documented. Its use has previously been limited to providing more evidence to underlying phenotype of LPD.67 The current case is the first case, to the best of our knowledge, that used NGS to determine any further actionable mutations after malignant transformation of initially benign LPD was diagnosed. While the NGS results in this case did not reveal immediately actionable targets, they contribute to the limited data on the molecular landscape of LPD and its malignant transformation. NGS analysis highlights key genetic differences between LPD and uterine leiomyosarcoma (uLMS). LPD shows mutations in CDK4, NBN, DAXX, and MYC, suggesting a possible transition toward malignancy while maintaining hormonal dependency.67 In contrast, uLMS exhibits a higher mutation burden with alterations in TP53, ATRX, PTEN, and MED12, alongside extensive copy number variations and gene fusions, reflecting its aggressive nature and loss of hormone receptors.68,69 These finding stress the need for careful monitoring, as receptor loss in LPD may signal progression toward a uLMS-like phenotype.

While HIPEC is not a standard treatment for LPD, there are emerging case reports of its use, particularly in cases where malignancy is suspected or confirmed.70 The use of HIPEC in our patient appeared to have beneficial effects, as it increased the disease-free interval from 6 months following her 2019 surgery to over 14 months following her surgery in 2020. Additionally, the symptoms free interval following surgeries increased from 6 months to over 18 months following the 2020 surgery. The patient’s decision to decline adjuvant therapy limits the conclusions that can be drawn about the efficacy of HIPEC. However, the prolonged disease-free interval following HIPEC is an interesting observation that warrants further investigation in future studies

This is the first case report documenting the potential utility of ctDNA in long term follow-up of LPD patients. ctDNA has shown clinical utility in colon and breast cancer.71,72 We utilized tumor informed platform for measuring the tumor DNA burden. It is of note the levels were undetectable corresponding to lack of radiological evidence of hematogenous metastases. The ctDNA became elevated with development of liver metastases. The levels continued to increase as the hematogenous metastatic burden increased. It is possible ctDNA could potentially be used as a biomarker to guide initiation, duration, type, and intensity of systemic therapy in future.

Conclusions

Leiomyomatosis peritonealis disseminata is a rare disease. All patients diagnosed with LPD, whether symptomatic or not, should be considered for long term follow-up due to potential malignant transformation. Our comprehensive review of 213 LPD cases revealed a higher rate of malignant transformation than previously appreciated, highlighting the need for long-term surveillance. This case report demonstrates the longest follow-up in a single institution that documents the progression of a benign process to malignancy. Additionally, the loss of ER/PR expression, as comprehensively documented for the first time in this case, may serve to be a marker for emergence of aggressive clones. The role of HIPEC surgery in LPD has yet to be established. ctDNA may prove to be a useful addition in guiding systemic therapy in patients with hematogenous metastases. Establishing an international collaborative registry may be helpful in collecting and collating data about this rare disease, management, and outcomes.

Footnotes

  • Disclosures: The authors have no financial support or conflicts of interest related to this work.

  • Received November 11, 2024.
  • Revision received June 16, 2025.
  • Accepted June 26, 2025.

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Clinical Medicine & Research

Vol. 23, Issue 3

1 Nov 2025

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    Exploring the Evolution of Leiomyomatosis Peritonealis Disseminata: A Longitudinal Study on Malignant Transformation and Potential Biomarkers
    • Clinical Medicine & Research
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    • DOI: 10.3121/cmr.2025.1978
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Keywords

ctDNA, ER/PR, Leiomyosarcoma, Leiomyomatosis peritonealis disseminate, LMS, LPD