Combined diagnostic imaging of uterine carcinosarcoma: A case report

Imaging Features of Carcinosarcoma Arising from Adenofibroma of the Uterus: A Case Report

BACKGROUND

Adenofibroma is a benign tumor composed histologically of epithelial elements and mesenchymal stroma. Carcinosarcoma is a malignant neoplasm that contains elements of carcinoma and sarcoma. Carcinosarcoma arising from adenofibroma of the uterus has never been reported in the literature in English language. Case Presentaion: We report a case of a 56-year-old woman who complained vaginal spotting persisting for several months. We described here for the first time a case of malignant transformation of uterine endometrial adenofibroma into carcinosarcoma that was depicted as a multilocular cystic lesion with enhancing solid portions and stalk-like structure between the myometrium and endometrial mass.

Staging MRI of uterine malignant mixed Müllerian tumors versus endometrial carcinomas with emphasis on dynamic enhancement characteristics

PURPOSE

To determine whether staging pelvic magnetic resonance imaging (MRI) can distinguish malignant mixed Müllerian tumor (MMMT) from EC.

METHODS

Thirty-seven treatment-naïve patients with histologically proven uterine MMMT and 42 treatment-naïve patients with EC, treated at our institution, were included in our retrospective study. Staging pelvic MRI scans were reviewed for tumor size, prolapse through cervical os, and other features. Time-intensity curves for tumor and surrounding myometrium regions of interest were generated, and positive enhancement integral (PEI), maximum slope of increase (MSI), and signal enhancement ratio (SER) were measured. The Fisher's exact test or Wilcoxon rank-sum test was used to compare characteristics between disease groups. Multivariate and univariate logistic regression models were used to distinguish MMMT from EC. Receiver operating characteristic analysis and the area under the curve (AUC) were used to evaluate prediction ability.

RESULTS

MMMTs were larger than ECs with higher rate of tumor prolapse and more heterogeneous tumor enhancement compared to ECs. During the late phase of contrast enhancement, 100% of ECs, but only 84% of MMMTs, had lower signal intensity than the myometrium. Threshold PEI ratio ≥ 0.67 predict MMMT with 76% sensitivity, 84%, specificity and 0.83 AUC. Threshold SER ≤ 125 predict MMMT with 90% sensitivity, 50% specificity, and 0.72 AUC.

CONCLUSION

MMMTs may show more frequent tumor prolapse, more heterogeneous enhancement, delayed iso- or hyper-enhancement, higher PEI ratios, and lower tumor SERs compared with EC. MRI can be used as a biomarker to distinguish MMMT from EC based on the enhancement pattern.

Malignant mixed Müllerian tumors of the uterus: sonographic spectrum

OBJECTIVE

To describe the sonographic findings for malignant mixed Müllerian tumors (MMMTs) of the uterus with particular emphasis on their features on saline contrast sonohysterography (SCSH) and color Doppler sonography, and to determine how they relate to pathological findings.

METHODS

The SCSH and color Doppler findings in 29 histologically proven cases of uterine MMMT were reviewed retrospectively and their relationship to gross and histological findings were investigated.

RESULTS

Of the 29 uterine tumors, 16 were located only in the corpus, nine only in the fundus and four in both the corpus and fundus. Mean tumor size was 5.4 cm. The most common appearance was a polypoid mass projecting into the endometrial cavity, found in 23 cases. Twenty-eight tumors had an irregular surface, which was papillary in 20 cases and lobulated in eight. Most appeared heterogeneously isoechoic (n = 16) or hypoechoic (n = 12), occasionally with a trabecular appearance, and they often had clefts or fissure-like cystic areas (n = 10), necrosis (n = 4) or hemorrhagic areas (n = 7). Myometrial invasion was present in 27 cases and dilatation of the endometrial cavity was seen in 11. Color Doppler sonography showed moderate to marked vascularity in 20 out of the 24 cases in which it was performed, with a mean resistance index of 0.41, and appeared as feeding (n = 15) or randomly dispersed (n = 9) vessels.

CONCLUSIONS

Uterine MMMTs have distinct sonographic features that are related to pathological findings. Knowledge of the sonographic appearance of MMMTs may facilitate diagnosis.

Uterine carcinosarcomas (malignant mixed müllerian tumours): a review with special emphasis on the controversies in management

Uterine carcinosarcomas (MMMT-malignant mixed Müllerian tumours) are highly aggressive, rare, biphasic tumours composed of epithelial and mesenchymal elements believed to arise from a monoclonal origin. While hysterectomy with bilateral salpingo-oophorectomy remains the mainstay treatment, high rates of recurrence and metastases suggest a need for lymphadenectomy and postoperative adjuvant treatment. There are no established consensus guidelines for therapeutic patient management. Though well recognized that it improves locoregional control, the role of radiation in improving overall survival outcomes remains undecided. Although various combinations of chemotherapy have been explored, an optimal therapeutic modality is yet to be determined. As overall survival rates have not improved in thirty years, it is suggested that targeted chemotherapy and/or a multimodality approach may yield better outcomes. This paper provides a summary of the aetiopathogenesis of carcinosarcomas (MMMT) limited to the uterus with special emphasis on the controversies in the management of these patients.

Can MRI predict the diagnosis of endometrial carcinosarcoma?

AIM

To ascertain whether magnetic resonance imaging (MRI) can be used to suggest a diagnosis of endometrial carcinosarcoma.

MATERIALS AND METHODS

A retrospective imaging review was performed of the MRI images of 39 patients with endometrial carcinosarcoma. Anteroposterior and longitudinal dimensions of the uterus and measurement of the endometrial thickness were taken in the sagittal plane. The ratio of antero-posterior measurement to endometrial thickness was calculated. The same measurements were taken on 50 patients with endometrial adenocarcinoma. A two-tailed t-test and receiver operator characteristic analysis were performed on these measurements for both patient groups.

RESULTS

There was a statistically significant difference between the longitudinal (p=0.0084) and anteroposterior (p=0.00036) dimensions of the uterus of the two groups. There was also a statistically significant difference between the ratios of anteroposterior dimension to endometrial thickness (p=0.00018). The optimal cut-off ratio above which the radiologist should be alerted to a potential diagnosis of endometrial carcinosarcoma was shown to be 0.63.

CONCLUSION

MRI can be helpful in suggesting a diagnosis of endometrial carcinosarcoma with the help of some simple measurements.

MRI appearances of uterine malignant mixed müllerian tumors

OBJECTIVE

Uterine malignant mixed müllerian tumors (MMMTs) are rare aggressive tumors with a high incidence of lymphatic, peritoneal, and pulmonary metastases. Preoperative differentiation from endometrial adenocarcinoma would be beneficial because their prognoses differ.

MATERIALS AND METHODS

We retrospectively reviewed MRI examinations of 51 histologically confirmed MMMTs. Tumor size, growth pattern, and imaging characteristics were recorded. Data were compared with MRI appearances of 73 endometrial adenocarcinomas.

RESULTS

On T1-weighted images, MMMTs were predominantly isointense to myometrium (76%) and endometrium (71%), with heterogeneous texture in 33% of cases and hyperintense foci in 27% of cases. On T2-weighted images, 92% of MMMTs were hyperintense to myometrium and either hypointense (55%) or isointense (41%) to endometrium. In 12% of cases, large heterogeneous MMMTs obliterated uterine architecture and were aggressive in appearance, whereas in 88% of cases, the appearances were indistinguishable from those of endometrial adenocarcinoma. Significantly more MMMTs than endometrial adenocarcinomas had cervical invasion (p = 0.008) and nodal enlargement (p = 0.00008). Dynamic contrast-enhanced images (available for 19 of 51 patients) obtained at less than 1 minute after administration of contrast agent showed MMMT enhancement to be hypointense (42%; 5/12 patients) or isointense (33%; 4/12 patients) to myometrium; between 1 and 4 minutes after administration of contrast agent, tumors were hypointense (58%; 7/12 patients); and at more than 4 minutes after administration of contrast agent (n = 18), MMMTs were isointense in 56% of cases. This finding is significantly different from that for endometrial adenocarcinoma, where enhancement is less than that of myometrium in 90% of cases (p = 4 × 10⁻⁸).

CONCLUSION

MMMTs do not have a pathognomonic MRI appearance. However, radiologic suspicion should increase in the presence of large heterogeneous infiltrative tumors or when tumoral enhancement equals or exceeds that of myometrium.

Role of PET or PET/CT in the post-therapy surveillance of uterine sarcoma

OBJECTIVE

To evaluate the clinical accuracy and clinical impact of positron emission tomography (PET) or positron emission tomography/computed tomography (PET/CT) in detecting and treating tumor recurrence in patients with treated uterine sarcoma.

METHODS

Results of 36 patients who underwent PET or PET/CT in post-therapy surveillance of uterine sarcoma were retrospectively assessed. Histopathologic confirmation or clinical/radiological outcome at least 6 months after PET or PET/CT was standard of reference.

RESULTS

The 36 patients underwent 48 PET or PET/CT scans as part of post-therapy surveillance. Thirty scans (8 PET and 22 PET/CT) were performed due to suspicion of disease recurrence on CT, whereas 18 scans (4 PET and 14 PET/CT) were performed as part of routine post-therapy surveillance in asymptomatic patients. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of PET or PET/CT were 92.9%, 100%, 94.4%, 100% and 80%, respectively, in patients with suspected recurrence and 87.5%, 95.5%, 93.3%, 87.5% and 95.5%, respectively, in asymptomatic patients. PET or PET/CT influenced the management of 12 patients (33.3%), by initiation of previously unplanned treatment in 8 patients and by avoidance of previously planned treatment in 4 patients.

CONCLUSION

PET or PET/CT was highly effective in discriminating true recurrence in patients with suspected recurrence and was highly sensitive in detecting recurrence in asymptomatic patients. It had impacts on clinical decision making in a high proportion of patients.

18F-fluorodeoxyglucose positron emission tomography in uterine carcinosarcoma

PURPOSE

Uterine carcinosarcomas clinically confined to the uterus usually harbor occult metastases. We conducted a pilot study to evaluate the value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in uterine carcinosarcoma.

METHODS

Patients with histologically confirmed uterine carcinosarcoma were enrolled. Abdominal and pelvic magnetic resonance imaging (MRI)/whole-body computed tomography (CT) scan, and whole-body (18)F-FDG PET or PET/CT were undertaken for primary staging, evaluating response, and restaging/post-therapy surveillance. The clinical impact of (18)F-FDG PET was determined on a scan basis.

RESULTS

A total of 19 patients were recruited and 31 (18)F-FDG PET scans (including 8 scans performed on a PET/CT scanner) were performed. Positive impacts of scans were found in 36.8% (7/19) for primary staging, 66.7% (2/3) for monitoring response, and 11.1% (1/9) for restaging/post-therapy surveillance. PET excluded falsely inoperable disease defined by MRI in two patients. Aggressive treatment applying to three patients with PET-defined resectable stage IVB disease seemed futile. Two patients died of disease shortly after salvage therapy restaged by PET. With PET monitoring, one stage IVB patient treated by targeted therapy only was alive with good performance. Using PET did not lead to improvement of overall survival of this series compared with the historical control (n = 35) (P = 0.779).

CONCLUSIONS

The preliminary results suggest that (18)F-FDG PET is beneficial in excluding falsely inoperable disease for curative therapy and in making a decision on palliation for better quality of life instead of aggressive treatment under the guidance of PET. PET seems to have limited value in post-therapy surveillance or restaging after failure.

Positron emission tomography scanning in gynecologic and breast cancers

PURPOSE OF REVIEW

Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose represents a noninvasive functional imaging modality that is based on metabolic characteristics of malignant tumors. The recent findings of this technique in breast cancer, cervical cancer, ovarian cancer, and other gynecologic malignancies are discussed.

RECENT FINDINGS

In breast cancer, positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose is more accurate than conventional methods for the staging of distant metastases, enables early assessment of treatment response in patients undergoing primary chemotherapy. The diagnostic accuracy for axillary lymph node staging depends on the tumor load of the lymph nodes. The sensitivity of this technique in detecting primary breast cancer is limited in small breast lesions and invasive lobular cancer. In cervical cancer it is the most accurate noninvasive method for lymph node staging and it can accurately depict recurrent ovarian cancer in patients with elevated CA125 levels. False negative findings in well differentiated adenocarcinoma and borderline lesions as well as false positive findings in benign conditions limit the role of positron emission tomography scanning for the differential diagnosis of adnex tumors.

SUMMARY

Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose reveals unique information about tumor metabolism in gynecologic malignancies and breast cancer. This technique is complementary to morphological imaging for primary diagnosis, staging and re-staging. It may become the method of choice for the early assessment of treatment response in breast cancer and the detection of recurrent disease in ovarian cancer. This method, however, cannot replace invasive procedures if microscopic disease is of clinical relevance.