Usefulness of the 'cosmos pattern' for differentiating between cervical gastric-type mucin-positive lesions and other benign cervical cystic lesions in magnetic resonance images

Age-related changes in the radiologic findings of lobular endocervical glandular hyperplasia: a multicenter study

PURPOSE

To investigate the age-related changes in magnetic resonance imaging (MRI) findings of lobular endocervical glandular hyperplasia (LEGH) during long-term follow-up.

MATERIALS AND METHODS

This multicenter study included 91 patients who underwent preoperative MRI and had a histopathological diagnosis of LEGH, atypical LEGH, or adenocarcinoma in situ (AIS) with LEGH after surgical resection. Thirty patients underwent follow-up MRIs at intervals of more than 3 months. According to the age and menopausal status, patients were categorized into four groups: group A, 31-40 years; group B, 41-50 years (premenopausal); group C, more than 50 years (premenopausal); group D, postmenopausal. Differences in the MRI findings (size and morphological pattern) were compared among the four groups.

RESULTS

The lesion volume was the largest in group C and smallest in group D, showing a statistically significant difference (p < 0.05). The typical cosmos pattern was seen in 60.0% of group A, 62.2% of group B, 75.0% of group C, and 29.2% of group D. The cosmos pattern was significantly less frequent in postmenopausal patients compared to premenopausal patients (p < 0.05). During follow-up, five of 12 individuals in group A exhibited the typical cosmos pattern. Among the seven individuals who did not initially show the cosmos pattern, two later developed the typical cosmos pattern. No changes in the lesion pattern were observed in participants in their 40 s up to the premenopausal 50 s. From the premenopausal 50 s to the postmenopausal period, the cosmos pattern changed to a microcystic pattern in one case of atypical LEGH.

CONCLUSIONS

LEGH increases in volume with age until menopause, along with an increasing frequency of the typical cosmos pattern in MRI. However, after menopause, both the volume of the lesion and frequency of the typical cosmos pattern decrease.

Novel ultrasound features and diagnostic clues of gastric-type endocervical adenocarcinoma: a case series

Background

Gastric-type endocervical adenocarcinoma (G-EAC) is a rare and aggressive subtype of cervical cancer which is not associated with human papillomavirus (HPV) infection but has poor prognosis because of its high invasiveness and resistance to chemoradiotherapy. The early and accurate diagnosis of G-EAC is challenging owing to its nonspecific symptoms and relatively normal cytological and histological manifestations.

Methods

The present study retrospectively analyzed the demographic and clinical characteristics, and cervical medical imaging features of 10 patients diagnosed with G-EAC at our institution during a five-year period. Postoperative cervical pathological features were examined, and followed-up information was collected. Novel ultrasonographic features of G-EAC were also summarized.

Results

The patients aged 24-70 years (mean: 49.6 ± 11.6). Their clinical presentations included vaginal discharge (60%), irregular vaginal bleeding (40%), and contact bleeding (30%). Nine patients were HPV negative. Ultrasound examination revealed that there were two, three, two, and two cases of types I (multicystic), II (cystic-solid), III (solid), and IV (nearly normal cervix) G-EAC, respectively. There were four CA199 + and two CA125 + cases. Pathology examination confirmed two cases of synchronous mucinous metaplasia and neoplasia of the female genital tract and one case of Peutz-Jeghers syndrome and multiple gastrointestinal polyps. Ultrasonography for cystic lesions revealed a "cosmos sign". Two patients with types I and II G-EAC exhibited vesicular echoes involving the lower uterine segment. In four cases, vesicular echoes were observed within the myometrium. This case series highlights the heterogeneous manifestations, complex imaging patterns, and multifaceted pathology of G-EACs.

Conclusions

Ultrasonography can facilitate the early diagnosis of G-EAC for relatively specific features, such as "cosmos signs" and "vesicular implantation signs." The latter refers to ultrasound manifestations of multicystic or cystic-solid lesions of the cervix accompanied by vesicular lesion in the lower uterine segment and/or vesicular implantation in the myometrium.

Analysis of the differences between HPV-independent and HPV-related cervical adenocarcinoma

Background

No prognostic evaluation criteria have been established for either human papillomavirus (HPV)-related cervical adenocarcinoma (HPV-CA) or HPV-independent cervical adenocarcinoma (HPV-Ind-CA). We aimed to compare and analyze the clinicopathological features and survival prognosis of patients with HPV-related and HPV-independent cervical adenocarcinoma to facilitate clinical diagnosis, treatment and survival prognosis of patients with cervical adenocarcinoma.

Methods

Clinical data were collected from 47 patients with HPV-Ind-CA (HPV-Ind-CA group) and 285 patients with HPV-CA (HPV-CA group), who were diagnosed at the Oncology Hospital affiliated with Xinjiang Medical University between October 2012 and July 2023. A retrospective analysis was performed to compare the clinical characteristics (including age, ethnicity, fundamental diseases, initial symptoms, gynecological examination findings such as contact bleeding, menstrual history with regard to menopausal status, history of pregnancy and abortion, coexisting benign uterine lesions, etc.), tumor markers (CEA, CA125, CA199), HPV-infection(HPVI), treatment regimens (surgery, radiotherapy and chemotherapy), and pathological results (specific pathological subtype, maximum lesion diameter, degree of tumor differentiation, International Federation of Gynecology and Obstetrics [FIGO] stage) between the two groups. All patients were followed up until July 30, 2023 and differences in therapeutic efficacy (complete response, stable disease, progressive disease) and survival outcomes (progression-free survival [PFS] and overall survival [OS]) were compared between the two patient groups following treatment.

Results

The proportions of patients in the HPV-Ind-CA and HPV-CA groups were 14.2% and 85.8%, respectively. Most patients presented with irregular vaginal bleeding, and a significant number experienced contact bleeding. The patients in the HPV-Ind-CA group were older (≥50 years), had a lower degree of differentiation, a later FIGO stage (> I stage), higher CA125 levels, and constituted a greater number of postmenopausal patients (P < 0.05) than those in the HPV-CA group. The median PFS and OS in the HPV-Ind-CA group were 12 ± 25.5 and 21 ± 25.1 months, respectively; the 3-year OS and PFS rates were 70.21%, and 59.57%, respectively. In contrast, the median PFS in the HPV-CA group was significantly longer at 26 ± 32.3 months, with a corresponding median OS of 35 ± 31.9 months; their respective 3-year OS and PFS rates were 80.70% and 73.68%. The HPV-Ind-CA group demonstrated significantly shorter PFS and OS than the HPV-CA group (P < 0.05). In the HPV-Ind-CA cohort, low cervical adenocarcinoma differentiation (HR=152.673, 95% CI: 1.777-13117.314, P=0.027) and high CA199 levels (HR=104.888, 95%CI: 2.420-4546.373, P=0.016) were independent prognostic factors for OS. Conversely, in the HPV-CA cohort, the FIGO stage (> stage I), absence of HPVI, and high CA125 levels were independent prognostic factors influencing both OS and PFS outcomes; additionally, older age ≥ 50 years and high CA199 levels were independent risk factors for OS and PFS, respectively. Thus, greater than stage I FIGO stage and high CA125 and CA199 levels were identified as independent prognostic factors for PFS and OS in cervical adenocarcinoma. Furthermore, the absence of HPVI and older age of ≥50 years also constituted as independent risk factors for OS in this patient population.

Conclusions

Compared with HPV-CA, HPV-Ind-CA is associated with inferior clinicopathological characteristics and survival outcomes. For patients who are HPV-negative and have elevated levels of CA125 and CA199, with a FIGO stage of I or higher, it is advisable to contemplate an intensified treatment protocol. This approach aims to enhance the opportunity for curative surgical resection when the patient's physical condition permits it, thereby improving the overall prognosis.

Multiple Nabothian Cysts and Tunnel Clusters Clinically Mimicking Lobular Endocervical Glandular Hyperplasia: A Case Report

This report describes a 48-year-old woman who presented with multiple cystic lesions in the uterine cervix. Magnetic resonance imaging (MRI) showed multiple large and small cysts in the uterine cervix, which raised lobular endocervical glandular hyperplasia (LEGH) as a differential diagnosis, because a cosmotic and microcystic pattern characteristic of LEGH might be suggested. However, pathological examination of the conization specimen revealed the simultaneous occurrence of superficial and deep Nabothian cysts (NCs) and tunnel clusters (TCs), without evidence of LEGH. LEGH is a potential precursor lesion to gastric-type adenocarcinoma (GAC) and should be distinguished from NCs and TCs, which do not typically require follow-up. This case highlights the challenges in the clinicoradiological differentiation between benign cervical lesions and LEGH. Clinicians and pathologists should be aware of the possibility of coexisting NCs and TCs mimicking LEGH in imaging studies.

Problems of magnetic resonance diagnosis for gastric-type mucin-positive cervical lesions of the uterus and its solutions using artificial intelligence

PURPOSE

To reveal problems of magnetic resonance imaging (MRI) for diagnosing gastric-type mucin-positive (GMPLs) and gastric-type mucin-negative (GMNLs) cervical lesions.

METHODS

We selected 172 patients suspected to have lobular endocervical glandular hyperplasia; their pelvic MR images were categorised into the training (n = 132) and validation (n = 40) groups. The images of the validation group were read twice by three pairs of six readers to reveal the accuracy, area under the curve (AUC), and intraclass correlation coefficient (ICC). The readers evaluated three images (sagittal T2-weighted image [T2WI], axial T2WI, and axial T1-weighted image [T1WI]) in every patient. The pre-trained convolutional neural network (pCNN) was used to differentiate between GMPLs and GMNLs and perform four-fold cross-validation using cases in the training group. The accuracy and AUC were obtained using the MR images in the validation group. For each case, three images (sagittal T2WI and axial T2WI/T1WI) were entered into the CNN. Calculations were performed twice independently. ICC (2,1) between first- and second-time CNN was evaluated, and these results were compared with those of readers.

RESULTS

The highest accuracy of readers was 77.50%. The highest ICC (1,1) between a pair of readers was 0.750. All ICC (2,1) values were <0.7, indicating poor agreement; the highest accuracy of CNN was 82.50%. The AUC did not differ significantly between the CNN and readers. The ICC (2,1) of CNN was 0.965.

CONCLUSIONS

Variation in the inter-reader or intra-reader accuracy in MRI diagnosis limits differentiation between GMPL and GMNL. CNN is nearly as accurate as readers but improves the reproducibility of diagnosis.

Preoperative diagnosis of cervical cystic lesions using magnetic resonance imaging: a retrospective study

BACKGROUND

We conducted this study to clarify the magnetic resonance imaging (MRI) characteristics of lobular endocervical glandular hyperplasia (LEGH) and Nabothian cysts.

METHODS

This study included 48 patients who underwent hysterectomy at our institution between 2016 and 2020 for suspected LEGH. Histopathological studies confirmed the presence of 25 Nabothian cysts and 23 cases of LEGH. We retrospectively analyzed five characteristic MRI findings: (1) located at the upper cervical canal, (2) positioned within the cervical stroma, (3) not circumscribing the cervical canal, (4) low- to iso-intensity on T1-weighted images (T1WI), and (5) "cosmos" or "microcystic" pattern. We compared the diagnostic accuracy of these findings for LEGH and Nabothian cysts using sensitivity, specificity, and predictive values. Combinations of findings were also calculated.

RESULTS

The characteristics "cosmos" or "microcystic" pattern, lesion not circumscribing the cervical canal, and low/iso-intensity on T1WI had a sensitivity and specificity greater than 50%. The sensitivity was 73.9% and specificity 84.0% when a combination of "cosmos" or "microcystic" pattern and lesion not circumscribing the cervical canal was present.

CONCLUSION

The coexistence of a "cosmos" or "microcystic" pattern and not circumscribing the cervical canal was the most characteristic finding that distinguished LEGH from Nabothian cysts. When neither of these findings is present, Nabothian cyst can be suspected.

Imaging approaches for the diagnosis of genetic diseases affecting the female reproductive organs and beyond

This review aims to provide an overview of neoplastic lesions associated with genetic diseases affecting the female reproductive organs. It seeks to enhance our understanding of the radiological aspects in diagnosing genetic diseases including hereditary breast and ovarian cancer syndromes, Lynch syndrome, Peutz-Jeghers syndrome, nevoid basal cell carcinoma syndrome, and Swyer syndrome, and explores the patterns and mechanisms of inheritance that require elucidation. Additionally, we discuss the imaging characteristics of lesions occurring in other regions due to the same genetic diseases.

Preoperative multimodal ultrasonic imaging in a case of Peutz-Jeghers syndrome complicated by atypical lobular endocervical glandular hyperplasia: a case report and literature review

BACKGROUND

Peutz-Jeghers syndrome (PJS), an autosomal dominant multiple cancerous disorder, is clinically characterized by mucocutaneous macules and multiple gastrointestinal hamartomatous polyps. Gastric-type endocervical adenocarcinoma (G-EAC), a special subtype of cervical adenocarcinoma with non-specific symptoms and signs, is known to occur in approximately 11% of female patients with PJS.

CASE PRESENTATION

Here, we report a case of PJS in a 24-year-old female with multiple mucocutaneous black macules who complained of vaginal discharge and menorrhagia. Moreover, we first described the multimodal ultrasonographical manifestations of PJS-correlated G-EAC. The three-dimensional reconstructed view of G-EAC on 3D realisticVue exhibited a distinctive "cosmos pattern" resembling features on magnetic resonance imaging, and the contrast-enhanced ultrasound displayed a "quick-up and slow-down" pattern of the solid components inside the mixed cervical echoes. We reported the multimodal ultrasonographical characteristics of a case of PJS-related G-EAC, as well as reviewed PJS-related literature and medical imaging features and clinical characteristics of G-EAC to provide insight into the feasibility and potential of utilizing multimodal ultrasonography for the diagnosis of G-EAC.

CONCLUSIONS

Multimodal ultrasound can visualize morphological features, solid components inside, and blood supplies of the G-EAC lesion and distinguish the G-EAC lesion from normal adjacent tissues. This facilitates preoperative diagnosis and staging of PJS-related G-EAC, thereby aiding subsequent health and reproductive management for patients with PJS.

Case Report: A rare case of gastric-type adenocarcinoma of stumps of duplicated cervices in a 49-year-old woman: A case with hidden focus confused us a lot

Gastric-type endocervical adenocarcinoma (G-EAC) is a rare special type of cervical mucinous adenocarcinomas, and it is reported the incidence is unrelated to human papilloma virus infection. We report a rare case of G-EAC in stumps of duplicated cervices in a 49-year-old female patient. The woman complained of post-coital bleeding. She had a didelphic uterus with a duplex cervix, and had undergone subtotal hysterectomy 16 years ago. Gynecological examination revealed a normal-appearing right cervix, but the non-dominant side of the left cervix, which was buried and covered by the side wall of the left vagina, was difficult to view. After exposing, the left side cervix presented a mature appearance which was smaller than a normal cervix. Her serum carbohydrate antigen-19-9 levels was 112.59 U/ml. The right cervix's cytology was normal, whereas the left cervix had unusual glandular epithelial cells. HPV testing on both cervical smears was negative. Adenocarcinoma was identified at 3, 6, 12 o'clock at the right cervix in a colposcopy-directed punch biopsy, while no abnormality was found in the biopsy of the left cervix, nor in the curettage of the double cervices. Pelvic magnetic resonance imaging (MRI) revealed two cervical canals, with a 1.9cm×1.6cm mass inside the left cervix, and the left wall of the right cervix may be involved by the tumor of the left cervix. After much deliberation, we considered that the patient had adenocarcinoma of the left cervix stage IB1. Then, the patient underwent radical cervical resection with bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy. Her final histopathology indicated G-EAC of the duplicated cervices. After surgery, she received concurrent chemoradiation. Currently, 29 months after the final chemotherapy was administered, the patient remains healthy. Because G-EAC with duplicated cervices is an uncommon cunning tumor with a bad prognosis, early identification and therapy are recommended to enhance the prognosis. The comprehensive evaluation of symptoms and gynecological examination with cervical cytology, colposcopy-directed punch biopsy, endocervical curettage and MRI examine together may assist in determining an accurate preoperative diagnosis.

Biology and management of lobular endocervical glandular hyperplasia

AIM

Lobular endocervical glandular hyperplasia (LEGH) is a multicystic proliferative disorder of the uterine cervix. The aim of this review was to clarify the current understanding of this unique tumor.

METHOD

This article reviews the chronological progress of research regarding clinico-pathological and genetic aspects of LEGH and related cervical cystic diseases such as Nabothian cyst and adenocarcinoma of gastric type (GAS), using the literature and data from our institute. We also describe clinical management including preoperative diagnosis and adequate surgical/expectant treatment based on the biological features.

RESULTS

Recent studies revealed several unique aspects of LEGH, that is, (i) production of gastric mucin, (ii) symptomatic and histological similarity with minimal deviation adenocarcinoma (MDA), and (iii) frequent association with GAS, including MDA. These findings indicated that LEGH is a gastric metaplasia, as well as pre-cancerous neoplasia. For the preoperative diagnosis of LEGH, the combination of "cosmos" sign on magnetic resonance imaging, detection of gastric mucin, and lack of nuclear atypia on cytology is important. Cone biopsy is effective for pathological diagnosis. Simple hysterectomy is indicated as surgical treatment for LEGH; however, meticulous follow-up is also an option, especially for young patients, because the rate of malignant transformation was reported to be 1%-2%. For LEGH patients who selected follow-up, a worsening cytology and increase in lesion size were important signs of malignant change of LEGH for safe follow-up.

CONCLUSION

Proper understanding of the characteristics of LEGH is important for adequate management.

Case Report: Gastric-Type Endocervical Adenocarcinoma Mimicking Submucosal Myoma Under Hysteroscopy

Gastric-type endocervical adenocarcinoma (GAS) is considered a distinct and clinically important entity because it is unrelated to human papillomavirus infection and has aggressive behavior and worse clinical outcomes than the usual type of endocervical adenocarcinoma (ECA). The preoperative diagnosis of GAS is often difficult because of its nonspecific clinical manifestations and special lesion location. We report the case of a 50-year-old Chinese woman who presented with intermittent left lower abdominal pain for 1 year. Preoperative images showed left hydrosalpinx and a lesion that was mainly located in the lower part of the uterine cavity. We considered the lesion to be a polyp before surgery. During hysteroscopic surgery, we suspected that it may be a submucosal myoma. However, pathology revealed that it was a GAS. GAS may be located in the upper endocervix or even reach the uterine cavity. The appearance is occasionally similar to that of submucosal myoma, resulting in difficult preoperative diagnosis and even misdiagnosis.