Diagnostic Accuracy of Ultrasound in the Diagnosis of Uterine Leiomyomas and Sarcomas

Myxoid leiomyosarcoma of the uterus in a woman of childbearing age: A case report

Myxoid leiomyosarcoma of the uterus (MLMS) is an extremely rare malignancy characterized by a poor prognosis. The present report describes a rare case of MLMS in a woman of childbearing age. The patient was a 33-year-old woman who presented with lower abdominal pain and was initially diagnosed with uterine myoma by preoperative B-mode ultrasound and magnetic resonance imaging. However, intraoperative pathological biopsy indicated the presence of a malignant tumor. The patient underwent total uterine and bilateral salpingectomy, along with pelvic lymph node biopsy, which confirmed the diagnosis of MLMS postoperatively. In a subsequent surgical procedure, the bilateral ovaries, omentum and appendix were also resected. The patient then received chemotherapy with gemcitabine and docetaxel and remains in good health, with no signs of recurrence. The present case report underscores the importance of early diagnosis and personalized treatment strategies for MLMS, particularly regarding their implications for fertility and survival outcomes in young women.

Assessing the Clinical Characteristics and the Role of Imaging Modalities in Uterine Sarcoma: A Single-Center Retrospective Study From Vietnam

BACKGROUND

This study aims to describe the clinical and imaging characteristics of uterine sarcomas and the role of imaging modalities in assessing them.

MATERIALS AND METHODS

This retrospective study enrolled all patients diagnosed with uterine sarcoma at Tu Du Hospital, Vietnam between January 2020 and December 2023. The findings of ultrasound (US) and magnetic resonance imaging (MRI) were compared to histology as the reference.

RESULTS

Among 78 patients, 46.2% of cases were menopause. Abnormal vaginal bleeding was the most common symptom. Three common types of uterine sarcoma were leiomyosarcoma (50.0%), low-grade endometrial stromal sarcoma (23.1%), and carcinosarcoma (19.2%). Some imaging features of uterine sarcomas were found including nontypical lesion of fibroid (89.7%), solitary mass (84.6%), inhomogeneous structure (76.9%), invisible endometrium (67.9%), moderate-rich vascularization on Doppler signal (57.7%), irregular border of tumor (48.7%), classification of FIGO 0 (44.9%), cystic area within tumor (42.3%), acoustic shadowing (34.6%), "cooked" appearance (9.0%), and calcification image in tumor (6.4%). The sensitivity of standard US, consultant US, and MRI was 56.4%, 88.4%, and 87.5%, respectively.

CONCLUSIONS

Besides clinical presentations, uterine sarcomas present some specific features on US. Consultant US and MRI could be added to standard US to increase the accuracy and help in surgical decision making where applicable.

The expression of autophagy-related gene CXCL12 in endometriosis associated ovarian cancer and pan-cancer analysis

Background

Endometriosis-associated ovarian cancer (EAOC), an aggressive form of malignant ovarian neoplasm with origins in endometriosis (EM), has risen to prominence recently. Despite extensive investigation, the precise pathophysiology remains elusive.This article explores new autophagy-related DEG genes between EM and EAOC, and investigates CXCL12's expression and prognostic relevance across pan-cancer.

Methods

From Gene Expression Omnibus (GEO), we retrieved gene sequencing data to uncover DEGs. We carried out enrichment analysis, PPI network construction and explored CXCL12's multi-database expression and prognostic significance employing the analytical tools of ONCOMINE, PrognoScan, GEPIA, and Kaplan-Meier Plotter. Subsequently, assessing the relationship between CXCL12 expression and immune presence in cancer utilizing GEPIA and TIMER. Lastly, CXCL12, IL17, STAT3, and FOXP3 protein expressions were determined through immunohistochemistry analysis in EAOC, EM, and normal endometrial tissues.

Results

Two DEGs were discovered and enrichment analysis indicated virus-cytokine/receptor interactions, chemokine signaling, and cytokine-cytokine receptor interplay as pivotal in EAOC. Notably, cancerous tissues exhibited reduced CXCL12 levels compared with non-malignant tissues across cancers. CXCL12, IL17, STAT3, Th17/Treg ratio, and FOXP3 expressions were also lower in EAOC than EM and normal tissues. Additionally, CXCL12 expression was related to stage, survival, immune subtype, and molecular classification across cancers.

Conclusions

In conclusion, our study implicates CXCL12 and altered Th17/Treg balance in progression from EM to EAOC. CXCL12 emerges as a predictive marker for cancer progression across various tumors and is associated with inflammatory response.

The influence of uterine leiomyomatosis on the onset of psoriasis: a nationwide population-based study of 2.5 million Korean females

BACKGROUND

Uterine leiomyomatosis and psoriasis are prevalent conditions and shared pathophysiological factors indicate a potential association. However, a direct correlation has not been established. We investigated the relationship between uterine leiomyomatosis and the risk of new-onset psoriasis in Korean females of reproductive age.

METHODS

This nationwide population-based study used data from the Korean National Health Insurance System database. Data from 2,755,790 Korean females 20-39 years of age who underwent health check-ups from 2009 to 2012 were analyzed. Monitoring began at the initial national health assessment within the time frame and continued until either the diagnosis of emerging psoriasis or until December 2018.

RESULTS

Among 2,503,769 females included, 1.96% were diagnosed with psoriasis and 0.72% with uterine leiomyomatosis. The incidence ratio for new-onset psoriasis was higher in uterine leiomyomatosis patients (3.13 per 1,000) than in subjects without uterine leiomyomatosis (2.72 per 1,000). The hazard ratio for psoriasis occurrence was 1.18 (1.07-1.31) in uterine leiomyomatosis patients, 1.22 (1.08-1.37) in subjects who did not undergo myomectomy, and 1.12 (0.94-1.33) in patients who underwent myomectomy.

CONCLUSIONS

Uterine leiomyomatosis patients, especially those not undergoing myomectomy, showed an increased risk of psoriasis. Lifestyle modifications and surgical intervention for uterine leiomyomatosis may also be beneficial for psoriasis occurrence.

First Case Report of Uterine Leiomyosarcoma Diagnosed After Transcervical Fibroid Ablation

Background: Uterine fibroids are benign monoclonal neoplasms of the myometrium, representing the most common female pelvic neoplasms globally. Treatments may be invasive, such as hysterectomy and myomectomy, non-invasive, such as medical therapy or focused ultrasound, or minimally invasive, such as transcervical radiofrequency ablation (TFA). To date, more than 12,000 women have been treated worldwide using TFA with the Sonata® System. Case Presentation: We present the first case report of TFA on a presumptive fibroid that was initially reclassified as a STUMP (smooth muscle tumor of uncertain malignant potential) and, after additional surgical treatment, leiomyosarcoma. Conclusion: This case highlights that, while uterine sarcoma is rare, inadvertent treatment may still result due to a lack of reliable diagnostic modalities. Nonetheless, TFA with the Sonata System represents a minimally invasive option that might not alter the prognosis of an undiagnosed uterine sarcoma as this treatment is not intraperitoneal and does not resect/morcellate tissue.

Challenges Associated with Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP) Management-A Case Report with Comprehensive Literature Review

Background: Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP) is a poorly studied neoplasm that does not fulfill the definition of either leiomyoma or leiomyosarcoma. STUMP symptoms are indistinguishable from those of benign lesions; it has no specific biochemical markers or ultrasound presentations. The management of this type of tumor is particularly challenging due to significant heterogeneity in its behavior and the lack of clear guidelines; moreover, the lesion may recur after excision. Case Report: We report on a case of a 42-year-old patient diagnosed with a STUMP. The preliminary diagnosis was a submucous leiomyoma, which was removed hysteroscopically due to menorrhagia resulting in anemia. The histopathological examination of the resected myoma pointed to the diagnosis of STUMP. The hysterectomy was performed as the patient had completed her reproductive plans. There were no complications. The patient is currently recurrence-free after a 9-month follow-up. Discussion and Conclusions: The care of a patient diagnosed with STUMP requires a personalized approach and the cooperation of various medical disciplines, including molecular diagnostics, imaging techniques, and minimally invasive surgery. Management of STUMP must consider the patient's plans for childbearing. All cases of tumors with "uncertain malignant potential" are a challenge in the context of patient-physician communication.

Clinical signs and diagnosis of fibroids from adolescence to menopause

The aim of this review was to provide an updated assessment of the present diagnostic tools and clinical symptoms and signs to evaluate uterine fibroids (UFs) on the basis of current guidelines, recent scientific evidence, and a PubMed and Google Scholar search for peer-reviewed original and review articles related to clinical signs and diagnosis of UFs. Approximately 50%-75% of UFs are considered nonclinically relevant. When present, the most common symptoms are abnormal uterine bleeding, pelvic pain and/or bulk symptoms, and reproductive failure. Transvaginal ultrasound is recommended as the initial diagnostic modality because of its accessibility and high sensitivity, although magnetic resonance imaging appears to be the most accurate diagnostic tool to date in certain cases. Other emerging techniques, such as saline infusion sonohysterography, elastography, and contrast-enhanced ultrasonography, may contribute to improving diagnostic accuracy in selected cases. Moreover, artificial intelligence has begun to demonstrate its ability as a complementary tool to improve the efficiency of UF diagnosis. Therefore, it is critical to standardize descriptions of transvaginal ultrasound images according to updated classifications and to individualize the use of the different complementary diagnostic tools available to achieve precise uterine mapping that can lead to targeted therapeutic approaches according to the clinical context of each patient.

Ultrasound features using MUSA terms and definitions in uterine sarcoma and leiomyoma: cohort study

OBJECTIVES

Timely and accurate preoperative diagnosis of uterine sarcoma will increase patient survival. The primary aim of this study was to describe the ultrasound features of uterine sarcoma compared with those of uterine leiomyoma based on the terms and definitions of the Morphological Uterus Sonographic Assessment (MUSA) group. A secondary aim was to assess the interobserver agreement for reporting on ultrasound features according to MUSA terminology.

METHODS

This was a retrospective cohort study of patients with uterine sarcoma or uterine leiomyoma treated in a single tertiary center during the periods 1997-2019 and 2016-2019, respectively. Demographic characteristics, presenting symptoms and surgical outcomes were extracted from patients' files. Ultrasound images were re-evaluated independently by two sonologists using MUSA terms and definitions. Descriptive statistics were calculated and interobserver agreement was assessed using Cohen's κ (with squared weights) or intraclass correlation coefficient, as appropriate.

RESULTS

A total of 107 patients were included, of whom 16 had a uterine sarcoma and 91 had a uterine leiomyoma. Abnormal uterine bleeding was the most frequent presenting symptom (69/107 (64%)). Compared with leiomyoma cases, patients with uterine sarcoma were older (median age, 65 (interquartile range (IQR), 60-70) years vs 48 (IQR, 43-52) years) and more likely to be postmenopausal (13/16 (81%) vs 15/91 (16%)). In the uterine sarcoma cohort, leiomyosarcoma was the most frequent histological type (6/16 (38%)), followed by adenosarcoma (4/16 (25%)). On ultrasound evaluation, according to Observers 1 and 2, the tumor border was irregular in most sarcomas (11/16 (69%) and 13/16 (81%) cases, respectively), but regular in most leiomyomas (65/91 (71%) and 82/91 (90%) cases, respectively). Lesion echogenicity was classified as non-uniform in 68/91 (75%) and 51/91 (56%) leiomyomas by Observers 1 and 2, respectively, and 15/16 (94%) uterine sarcomas by both observers. More than 60% of the uterine sarcomas showed acoustic shadows (11/16 (69%) and 10/16 (63%) cases by Observers 1 and 2, respectively), whereas calcifications were reported in a small minority (0/16 (0%) and 2/16 (13%) cases by Observers 1 and 2, respectively). In uterine sarcomas, intralesional vascularity was reported as moderate to abundant in 13/16 (81%) cases by Observer 1 and 15/16 (94%) cases by Observer 2, while circumferential vascularity was scored as moderate to abundant in 6/16 (38%) by both observers. Interobserver agreement for the presence of cystic areas, calcifications, acoustic shadow, central necrosis, color score (overall, intralesional and circumferential) and maximum diameter of the lesion was moderate. The agreement for shape of lesion, tumor border and echogenicity was fair.

CONCLUSIONS

A postmenopausal patient presenting with abnormal uterine bleeding and a new or growing mesenchymal mass with irregular tumor borders, moderate-to-abundant intralesional vascularity, cystic areas and an absence of calcifications on ultrasonography is at a higher risk of having a uterine sarcoma. Interobserver agreement for most MUSA terms and definitions is moderate. Future studies should validate the abovementioned clinical and ultrasound findings on uterine mesenchymal tumors in a prospective multicenter fashion. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.