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High-grade endometrial stromal sarcoma (HG-ESS) in a 78-year-old woman presenting 8 years after cervical carcinoma of the uterus (IIB) treated with chemotherapy and radiation therapy. Axial (a) and sagittal (b) T2WI; axial DWI with b value = 1000 s/mm2 (c) and ADC map (d); sagittal contrast-enhanced T1WI with fat suppression (e) show a large uterine mass with an intracavitary component and extensive infiltration of the myometrium, cervix and vagina ( →) with invasion of the parametria and mesorectum (*). Tumour demonstrates high SI on T2 WI sequences, with thin scattered bands of low T2 SI ( >), restricted diffusion (with high SI on DWI and low ADC values), and heterogeneous contrast-enhancement. Also note bilateral external iliac lymph node metastasis (⌂)
Source publication
The aim of this article is to summarize the MRI features of each sarcoma subtype and to correlate them with its pathological findings. Literature review through PubMed/Medline database to identify relevant articles on uterine sarcomas, with a special emphasis on their MRI findings and pathological features. While several, more generalistic, MRI fin...
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Background:
Uterine sarcomas are rare and aggressive gynaecologic malignancies, characterized by a relatively high recurrence rate and poor prognosis. The aim of this study was to investigate the clinicopathological features and explore the prognostic factors of these malignancies.
Methods:
This was a single-institution, retrospective study. We...
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Objectives:
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Objective
Uterine sarcomas are a rare and heterogeneous group of malignancies that include different histological sub-types. The aim of this study was to identify and evaluate the impact of the different prognostic factors on overall survival and disease-free survival of patients with uterine sarcoma.
Methods
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Citations
... If symptoms suggesting uterine leiomyosarcoma or ESS are observed, transvaginal ultrasonography and partial cervical dilatation and curettage or histopathology of an endometrial biopsy specimen is usually performed. However, limitations in the detection sensitivity of those clinical examinations make an accurate diagnosis difficult [25]. In the clinic, ESS or uterine leiomyosarcoma might, therefore, more often be incidentally detected by histopathologic examination of specimens obtained from hysterectomy or enucleation. ...
The benign tumor uterine leiomyoma (UL) develops from the smooth muscle tissue that constitutes the uterus, whereas malignant tumor uterine sarcoma develops from either the smooth muscle tissue or stroma and is different from UL and endometrial cancer. Uterine sarcoma is broadly classified into three types: uterine leiomyosarcoma, endometrial stromal sarcoma (ESS), and carcinosarcoma. Although uterine leiomyosarcoma and ESS are both classified as uterine sarcoma, they significantly differ in terms of their sites of occurrence, symptoms, and treatment methods. Uterine leiomyosarcoma develops from the muscle tissue constituting the wall of the uterus and accounts for approximately 70% of all uterine sarcoma cases. In contrast, ESS develops from the stromal tissue beneath the endometrium and accounts for approximately 25% of all uterine sarcoma cases. ESS is classified as either low grade (LG) or high grade (HG). This case report aimed to highlight the importance of histopathologic examinations based on surgical specimens. Herein, we reported the case of a 45-year-old woman suspected of having submucosal leiomyoma of the uterus based on imaging results. Transvaginal ultrasonography and endometrial biopsy or partial dilation and curettage were performed. Contrast-enhanced magnetic resonance imaging (MRI) revealed a 32-mm mass projecting from the posterior wall of the uterus into the uterine cavity. T2-weighted imaging revealed a low signal within the mass; thus, submucosal UL was suspected. Histopathologic examination of surgical specimens obtained from a patient suspected of having submucosal UL after contrast-enhanced MRI indicated that the patient had ESS. Despite the remarkable advancements in medical imaging technology, the accuracy of contrast-enhanced MRI for detecting uterine mesenchymal tumors is limited. Therefore, histopathologic diagnosis based on surgical specimens should be performed when medical grounds for diagnosing a benign tumor on contrast-enhanced MRI are lacking.
... On MRI, endometrial stromal sarcomas may be seen as an invasive endometrial mass often extending to the myometrium, and may be a clearly delimited or diffusely infiltrating lesion. 5 On T2-weighted imaging, bands of low signal intensity, corresponding to preserved bundles of myometrium, may be seen within areas of myometrial involvement. 5 Another MRI finding is tumor extension along the vessels or ligaments. ...
... 5 On T2-weighted imaging, bands of low signal intensity, corresponding to preserved bundles of myometrium, may be seen within areas of myometrial involvement. 5 Another MRI finding is tumor extension along the vessels or ligaments. 5 Dr Kim: What would be the imaging study of choice when planning a fertility-sparing treatment? ...
... 5 Another MRI finding is tumor extension along the vessels or ligaments. 5 Dr Kim: What would be the imaging study of choice when planning a fertility-sparing treatment? Once the diagnosis is confirmed, the imaging evaluation is essential to rule out locoregional extension and for considering the possibility of fertility-preserving treatment.5 ...
... It allows quantitative measurements in the form of the apparent diffusion coefficient (ADC) values. In tumors with a high nuclear-to-cytoplasm ratio, the diffusion is limited, which is expressed by lower ADC values [10,[30][31][32]. ...
... Across the studies not differentiating sarcoma between subtypes [33][34][35]37,38], the following features, listed in Table 4, were found multiple times: sarcomas showed heterogeneous and intermediate to high signal intensities on T2WI. These findings are consistent with the presence of intratumoral hemorrhage and necrosis [32]. Intratumoral hemorrhage and necrosis, as well as cystic degeneration, are also explicitly noted as features. ...
... The features noted above for sarcoma in general are also verified in these studies on LMS specifically: irregular borders, heterogeneous, high signal intensity on T2WI, cystic, hemorrhagic, and necrotic changes especially central necrosis presenting as central non-enhancement, as well as hyperintensity on DWI and low values for ADC. These findings are consistent with the current literature [4,32]. Another feature mentioned in two studies [8,41] is the "T2 dark" area. ...
Introduction:
Gynecological sarcomas are rare malignant tumors with an incidence of 1.5-3/100,000 and are 3-9% of all malignant uterine tumors. The preoperative differentiation between sarcoma and myoma becomes increasingly important with the development of minimally invasive treatments for myomas, as this means undertreatment for sarcoma. There are currently no reliable laboratory tests or imaging-characteristics to detect sarcomas. The objective of this article is to gain an overview of sarcoma US/MRI characteristics and assess their accuracy for preoperative diagnosis.
Methods:
A systematic literature review was performed and 12 studies on ultrasound and 21 studies on MRI were included.
Results:
For the ultrasound, these key features were gathered: solid tumor > 8 cm, unsharp borders, heterogeneous echogenicity, no acoustic shadowing, rich vascularization, and cystic changes within. For the MRI, these key features were gathered: irregular borders; heterogeneous; high signal on T2WI intensity; and hemorrhagic and necrotic changes, with central non-enhancement, hyperintensity on DWI, and low values for ADC.
Conclusions:
These features are supported by the current literature. In retrospective analyses, the ultrasound did not show a sufficient accuracy for diagnosing sarcoma preoperatively and could also not differentiate between the different subtypes. The MRI showed mixed results: various studies achieved high sensitivities in their analysis, when combining multiple characteristics. Overall, these findings need further verification in prospective studies with larger study populations.
... Patients are often treated for presumed uterine leiomyomas and diagnosed incidentally on hysterectomy specimen analysis [10,11]. Although magnetic resonance imaging (MRI) has a developing role in the assessment of these malignancies [12], it is unlikely to become a universal preoperative evaluation method because of its high price. The initial evaluation of all our patients was performed using pelvic ultrasound (US). ...
Background:
Uterine sarcomas are rare and aggressive gynaecologic malignancies, characterized by a relatively high recurrence rate and poor prognosis. The aim of this study was to investigate the clinicopathological features and explore the prognostic factors of these malignancies.
Methods:
This was a single-institution, retrospective study. We reviewed the medical records of 155 patients with pathologically confirmed uterine sarcomas including uterine leiomyosarcoma (ULMS), low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS), undifferentiated uterine sarcoma (UUS) and adenosarcoma (AS) between 2006 and 2022. A total of 112 patients who underwent surgery between January 2006 and April 2019 were included in the survival analysis. The current study recorded the clinicopathological, treatment and outcome data to determine clinical characteristics and survival.
Results:
The most common histopathological type was ULMS (63/155, 40.64%), followed by LG-ESS (56/155, 36.13%) and HG-ESS (16/155, 10.32%). The mean age at diagnosis of all patients was 49.27±48.50 years and 32.90% (51/155) of patients were postmenopausal. Fifteen patients underwent fast-frozen sectioning, 63(54.78%) were diagnosed with malignancy, 29(25.22%) were highly suspected of malignancy that needed further clarification and 23(14.84%) were diagnosed with benign disease. A total of 124(80%) patients underwent total hysterectomy (TH) and salpingo-oophorectomy. Multivariate analyses showed that histological type and tumour size were independent prognostic factors both for overall survival (OS) (p<0.001 and P=0.017, respectively) and progression-free survival (PFS) (p<0.001 and P=0.018, respectively). Tumour stage was only significantly associated with PFS (P=0.002). Elevated preoperative NLR, PLR and postmenopausal status were significantly correlated with shorter PFS and OS in univariate analysis, but no statistically significant difference was found in multivariate analysis.
Conclusions:
In patients with uterine sarcoma, in comparison to LMS and LG-ESS, UUS and HG-ESS tend to present as more aggressive tumour with poorer outcomes. Furthermore, larger tumour (>7.5 cm) were an important predictor of shorter PFS and OS.
... Degenerated and variant uterine fibroids with intermediate/ high signal intensity on T2-weighted imaging can mimic leiomyosarcoma of the myometrium [77]. In fact, unsuspected leiomyosarcoma is identified on pathologic evaluation of surgical specimens of presumed benign fibroids in 1 of every 300-5000 cases [78]. ...
... In fact, unsuspected leiomyosarcoma is identified on pathologic evaluation of surgical specimens of presumed benign fibroids in 1 of every 300-5000 cases [78]. In addition, endometrial stromal sarcoma and undifferentiated uterine sarcoma, which usually demonstrate intracavitary growth, can occasionally demonstrate an intramural growth pattern that mimicks the appearances of degenerated/variant uterine fibroids [77]. ...
Uterine fibroids are the most common gynecologic neoplasm. Although non-degenerated fibroids are easily identifiable on imaging, degenerated fibroids, fibroid variants, and fibroids with unusual growth patterns can constitute a diagnostic dilemma. Identification of these abnormal morphologic features can alter the diagnosis of presumed uterine fibroids and hence change management plans. This article reviews the typical and atypical radiologic imaging features of uterine fibroids, with an emphasis on the pitfalls, mimics, and radiologically identifiable features that can alter clinical management plans.
Graphical abstract
Introduction
Purpose to investigate the added value of ADC histogram parameters combined with the MRI features to differentiate among the uterine sarcomas (US), endometrial carcinomas (EC) and endometrial polyps (EP).
Materials and methods
The differences of MRI features of 31 cases of US, 51 cases of EC and 27 cases of EP were retrospectively analyzed. The binary logistic regression model was adopted to evaluate the discriminating value of variables. ADC histograms of all lesions were reconstructed and measured, the sensitivity and specificity were calculated, and the diagnostic efficacy was evaluated by AUC value.
Results
Binary logistic regression showed that low intensity area on T2WI and presence of cystic degeneration for the characterization between US and EC, the maximum tumor diameter and the muscular invasion for the characterization between US and EP were the most valuable predictive variables (P < 0.001). The ADCmean, ADCmax, ADCmin, Q10, Q25, Q50, Q75, Q90 of US were all significant higher than that of EC, (P < 0.05). Among of them, the ADCmax had the best diagnostic efficiency (AUC = 0.789), the sensitivity and specificity were 77.4%, 80.4% with the cut-off value of 1.37 (*10− 3mm/s). The ADCmean, ADCmin, Q10, Q25 and Q75 of US were significant lower than that of EP (P < 0.05). Among of them, the ADCmin have the best diagnostic efficiency (AUC = 0.856), the sensitivity and specificity were 61.3%, 96.3% with the cut-off value of 0.81 (*10− 3mm/s).
Conclusion
The ADC histogram has the added value to the MRI features in the differential diagnosis among of US, EC and EP.
Soft-tissue sarcomas of the genitourinary tract are an uncommon group of different malignant mesenchymal malignancies with diverse radiologic appearances, histopathologic findings, and biological behaviors. Genitourinary tract soft-tissue sarcomas are rare neoplasms with varied pathologic and clinical features. While some of these tumors may be aggressive high-grade malignancies, others are low grade with a relatively better prognosis. Given that the grade and extent of the disease are important prognostic factors in these tumors, timely diagnosis is crucial. Unfortunately, most imaging features of these malignancies are not pathognomonic, and various histologic subtypes do not manifest with typical classic imaging features. Therefore, reliable differentiation of the various histologic tumor types is not always possible based solely on the radiologic manifestations. Imaging findings need to be considered in the context of clinical history in corroboration with radiologic-pathologic correlation. The authors discuss the specific imaging and pathologic characteristics of various genitourinary tract soft-tissue sarcomas, emphasizing diagnostic difficulties and differential diagnoses.
Purpose
To evaluate the magnetic resonance imaging (MRI) features that may help distinguish leiomyosarcomas from atypical leiomyomas (those presenting hyperintensity on T2-W images equal or superior to 50% compared to the myometrium).
Materials and methods
The authors conducted a retrospective single-centre study that included a total of 57 women diagnosed with smooth muscle tumour of the uterus, who were evaluated with pelvic MRI, between January 2009 and March 2020. All cases had a histologically proven diagnosis (31 Atypical Leiomyomas—ALM; 26 Leiomyosarcomas—LMS). The MRI features evaluated in this study included: age at presentation, dimension, contours, intra-tumoral haemorrhagic areas, T2-WI heterogeneity, T2-WI dark areas, flow voids, cyst areas, necrosis, restriction on diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) values, signal intensity and heterogeneity after contrast administration in T1-WI, presence and location of unenhanced areas. The association between the MRI characteristics and the histological subtype was evaluated using Chi-Square and ANOVA tests.
Results
The MRI parameters that showed a statistically significance correlation with malignant histology and thus most strongly associated with LMS were found to be: irregular contours (p < 0.001), intra-tumoral haemorrhagic areas (p = 0.028), T2-WI dark areas (p = 0.016), high signal intensity after contrast administration (p = 0.005), necrosis (p = 0.001), central location for unenhanced areas (p = 0.026), and ADC value lower than 0.88 × 10⁻³ mm²/s (p = 0.002).
Conclusion
With our work, we demonstrate the presence of seven MRI features that are statistically significant in differentiating between LMS and ALM.
Uterine adenosarcoma is a rare gynecological malignancy with no specific symptoms, and the optimal management is still inconclusive. Herein we present a case of uterine adenosarcoma in a 38-year-old woman with a good prognosis and review of literatures. The patient presented with abnormal vaginal bleeding with no special medical history. Sonographic scan revealed a heterogeneous echoic mass in the cavity, indicating a polypus or a submucous myoma. The pathology based on the specimen after the hysteroscopic tumor excision suggested diagnosis of uterine adenosarcoma. Subsequently, the patient received pelvic MRI scan before surgery. MRI identified a patchy lesion at the cervix-lower endometrial cavity with low signal in T1WI and a mixed high T2 signal in T2WI, with no sign of metastasis. Then total abdominal hysterectomy with bilateral salpingo-oopherectomy plus pelvic lymph node dissection was performed and 6 cycles of chemotherapy were administered. The patient remains disease-free on follow-up to date, more than 15 months after chemotherapy.
Uterine sarcomas are a group of rare uterine tumors comprised of multiple subtypes with different histologic characteristics, prognoses, and imaging appearances. Identification of uterine sarcomas and their differentiation from benign uterine disease on imaging is of critical importance for treatment planning to guide appropriate management and optimize patient outcomes. Herein, we review the spectrum of uterine sarcomas with a focus on the classification of primary sarcoma subtypes and presenting the typical MR imaging appearances.
