Müllerian mixed tumors: CT characteristics with clinical and pathologic observations

Lipoleiomyosarcoma with pleomorphic liposarcoma of the uterus: Computed tomography findings with pathological correlation. A case report and review of literature

Uterine lipoleiomyosarcomas (L-LMS) are rare malignant tumors with only few cases descripted in literature. As well, liposarcomas (LPS) arising from uterine corpus are extremely rare since fat tissue is commonly poor or absent in uterus. We report a case of L-LMS of the uterine corpus with an associated component of pleomorphic LPS. As for other female pelvic malignancies, these neoplasms are more common in postmenopausal women and clinical findings are nonspecific. Most frequent signs and symptoms are metrorrhagia and abdominal pain often associated with pelvic distension/mass. We describe diagnostic and therapeutic steps of our patient from acceptation to conclusive diagnosis. In this case, contrast-enhanced computed tomography (CECT) depicted pivotal diagnostic findings and showed a clear distinction between different tumor components. Therefore, our goal with this essay is to stress the role of CECT imaging for diagnosis of these rare neoplasms. We also perform a review of current literature about liposarcomas of the uterine corpus.

Clinical and multiparametric MRI features for differentiating uterine carcinosarcoma from endometrioid adenocarcinoma

INTRODUCTION

The purpose of our study was to differentiate uterine carcinosarcoma (UCS) from endometrioid adenocarcinoma (EAC) by the multiparametric magnetic resonance imaging (MRI) features.

METHODS

We retrospectively evaluated clinical and MRI findings in 17 patients with UCS and 34 patients with EAC proven by histologically. The following clinical and pathological features were evaluated: post- or pre-menopausal, clinical presentation, invasion depth, FIGO stage, lymphaticmetastasis. The following MRI features were evaluated: tumor dimension, cystic degeneration or necrosis, hemorrhage, signal intensity (SI) on T2-weighted images (T2WI), relative SI of lesion to myometrium on T2WI, T1WI, DWI, ADCmax, ADCmin, ADCmean (RSI-T2, RSI-T1, RSI-DWI, RSI-ADCmax, RSI-ADCmin, RSI-ADCmean), ADCmax, ADCmin, ADCmean, the maximum, minimum and mean relative enhancement (RE) of lesion to myometrium on the arterial and venous phases (REAmax, REAmin, REAmean, REVmax, REVmin, REVmean). Receiver operating characteristic (ROC) analysis and the area under the curve (AUC) were used to evaluate prediction ability.

RESULTS

The mean age of UCS was higher than EAC. UCS occurred more often in the postmenopausal patients. UCS and EAC did not significantly differ in depth of myometrial invasion, FIGO stage and lymphatic metastasis. The anterior-posterior and transverse dimensions were significantly larger in UCS than EAC. Cystic degeneration or necrosis and hemorrhage were more likely occurred in UCS. The SI of tumor on T2WI was more heterogeneous in UCS. The RSI-T2, ADCmax, ADCmean, RSI-ADCmax and RSI-ADCmean of UCS were significantly higher than EAC. The REAmax, REAmin, REAmean, REVmax, REVmin and REVmean of UCS were all higher than EAC. The AUCs were 0.72, 0.71, 0.86, 0.96, 0.89, 0.84, 0.73, 0.97, 0.88, 0.94, 0.91, 0.69 and 0.80 for the anterior-posterior dimension, transverse dimension, RSI-T2, ADCmax, ADCmean, RSI-ADCmax, RSI-ADCmean, REAmax, REAmin, REAmean, REVmax, REVmin and REVmean, respectively. The AUC was 0.997 of the combined of ADCmax, REAmax and REVmax. Our study showed that ADCmax threshold value of 789.05 (10-3mm2/s) can differentiate UCS from EAC with 100% sensitivity, 76.5% specificity, and 0.76 AUC, REAmax threshold value of 0.45 can differentiate UCS from EAC with 88.2% sensitivity, 100% specificity, and 0.88 AUC.

CONCLUSION

Multiparametric MRI features may be utilized as a biomarker to distinguish UCS from EAC.

Metachronous small bowel metastasis from a mixed Müllerian mesodermal tumour

A mixed Müllerian mesodermal tumour (MMMT) is a rare aggressive carcinosarcoma. Metastatic progression is uncommon, and occurs via haematological, lymphatic and intraperitoneal spread. Although the latter is seen most frequently, the small intestine seems to be relatively preserved from disease progression with only one reported case of synchronous involvement. We report a case of metachronous MMMT involvement of the small bowel presenting with subacute obstruction that was successfully resected at operation.

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.

Radiologic Evaluation of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

Primary malignant mixed mullerian tumor of the uterus: findings on sonography, CT, and gadolinium-enhanced MRI

OBJECTIVE

The purpose of our study was to evaluate the sonographic, contrast-enhanced CT, and gadolinium-enhanced MRI findings of primary malignant mixed müllerian tumors (MMMTs) of the uterus.

CONCLUSION

Uterine MMMT most commonly presents as an intracavitary mass with coexistent dilatation of the endometrial canal. Tumors tend to appear hyperechoic on sonography, heterogeneously hypodense and ill defined on contrast-enhanced CT, and heterogeneously hyperintense on T2-weighted MR images with signal abnormalities indicating subacute hemorrhage on T1-weighted MR images. Myometrial invasion is common and has a predilection for the uterine fundus.