Multifocal Ovarian Leiomyosarcoma Presenting With Ambiguous Imaging and Rapid Progression: A Diagnostic Dilemma

Uterine sarcomas are rare, aggressive tumors with high recurrence rates and nonspecific presentations, making preoperative diagnosis difficult. Leiomyosarcoma with ovarian involvement is particularly uncommon and can mimic primary ovarian malignancy. A postmenopausal woman presented with progressive abdominal pain and unsteady gait. Examination revealed abdominal distension and tenderness. Imaging demonstrated a large heterogeneous pelvic mass with pelvic free fluid and bilateral inguinal lymphadenopathy, raising suspicion for ovarian malignancy. Laboratory testing revealed elevated cancer antigen 125 (CA-125). Imaging was inconclusive regarding the primary origin. The patient underwent exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, tumor debulking, and cholecystectomy. Histopathology confirmed multifocal high-grade leiomyosarcoma involving both ovaries, fallopian tube, mesosalpinx, and pelvic sidewall implant, with positive margins. No uterine histological involvement was noted. Surveillance imaging revealed rapid recurrence with peritoneal and nodal metastases. The patient commenced single-agent doxorubicin chemotherapy. This case highlights the diagnostic ambiguity, aggressive course, and need for early multidisciplinary management in leiomyosarcoma.