Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment?

Focal Area of Low T2 Signal on MRI Scans in a Heterogeneous Uterine Leiomyoma Does Not Exclude the Possibility of Malignancy: A Report of Two Cases

Background: Uterine sarcomas are uncommon malignant tumors with a grim prognosis, accounting for less than 1% of all gynecologic malignancies. Radiological series often include a limited number of patients, and diagnostic approaches can vary. While the presence of low T2 signal intensity in leiomyomas on MRI has been proposed as a criterion to exclude sarcoma, exceptions to this rule exist. We present two cases that challenge this notion. Case reports: The first patient was a 48-year-old woman presenting with metrorrhagia. MRI revealed a large intramural leiomyoma characterized by extensive hypointensity on T2-weighted imaging (T2WI) and a small intraleiomyoma focus with intermediate signal intensity. Histopathological examination confirmed leiomyosarcoma. The second patient was a 51-year-old woman presenting with menometrorrhagia. MRI showed a subserosal myoma with zones of T2WI hypointensity interspersed with a region of intermediate signal intensity. Histopathological examination confirmed low-grade endometrial stromal sarcoma. In both cases, diffusion-weighted imaging (DWI) revealed an intratumoral zone of restricted diffusion, with an apparent diffusion coefficient (ADC) value ≤ 0.86 × 10-3 mm2/s. Conclusion: MRI is crucial for distinguishing leiomyomas from sarcomas. We propose combining T2WI and DWI with ADC for this purpose, noting limitations in each sequence's reliability. Suggestive MRI criteria for malignancy in sarcomas are identified, emphasizing the need for comprehensive imaging analysis. In characterizing uterine smooth muscle tumors, particularly when analyzing leiomyoma variants, DWI emerges as the dominant sequence, with T2WI serving as a secondary sequence. ADC values aid in histopathological hypothesis, but caution is warranted due to overlap with benign lesions. This approach may refine preoperative diagnosis and guide therapeutic management.

A Rare Case of Giant Uterine Leiomyomata: A Difficult Diagnosis Accompanied by Surgical Difficulties

Leiomyomas, also known as fibroids, are a group of benign smooth muscle tumors commonly present in premenopausal women. Giant uterine leiomyomas are rare. It is described as giant when it weighs 11.4 kg. This report concerns a 45-year-old, asymptomatic woman of reproductive age who presented for her first gynecological consultation at the clinic of Trikala General Hospital, Greece, for a routine smear and gynecological examination. A large, painless abdominal mass was palpated during the clinical exam, reaching the level of the xiphoid process. Imaging confirmed the clinical diagnosis of a myomatous uterus, and surgical intervention via laparotomy was decided. Intraoperatively, a giant uterine leiomyoma was identified, leading to an abdominal total hysterectomy with bilateral salpingectomy and oophorectomy. A histological examination confirmed the diagnosis. After a five-day hospitalization with an uneventful postoperative recovery, the patient was discharged. This rare case emphasizes the uncommon presentation of a giant uterine leiomyoma in an asymptomatic reproductive-age patient, highlighting the diagnostic and surgical challenges associated with managing such cases.

The value of multiparametric MRI-based habitat imaging for differentiating uterine sarcomas from atypical leiomyomas: a multicentre study

PURPOSE

To explore the feasibility of multiparametric MRI-based habitat imaging for distinguishing uterine sarcoma (US) from atypical leiomyoma (ALM).

METHODS

This retrospective study included the clinical and preoperative MRI data of 69 patients with US and 225 patients with ALM from three hospitals. At both the individual and cohort levels, the K-means and Gaussian mixture model (GMM) algorithms were utilized to perform habitat imaging on MR images, respectively. Specifically, T2-weighted images (T2WI) and contrast-enhanced T1-weighted images (CE-T1WI) were clustered to generate structural habitats, while apparent diffusion coefficient (ADC) maps and CE-T1WI were clustered to create functional habitats. Parameters of each habitat subregion were extracted to construct distinct habitat models. The integrated models were constructed by combining habitat and clinical independent predictors. Model performance was assessed using the area under the curve (AUC).

RESULTS

Abnormal vaginal bleeding, lactate dehydrogenase (LDH), and white blood cell (WBC) counts can serve as clinical independent predictors of US. The GMM-based functional habitat model at the cohort level had the highest mean AUC (0.766) in both the training and validation cohorts, followed by the GMM-based structural habitat model at the cohort level (AUC = 0.760). Within the integrated models, the K-means functional habitat model based on the cohort level achieved the highest mean AUC (0.905) in both the training and validation cohorts.

CONCLUSION

Habitat imaging based on multiparametric MRI has the potential to distinguish US from ALM. The combination of clinical independent predictors with the habitat models can effectively improve the performance.

Li-Fraumeni Syndrome: Imaging Features and Guidelines

Li-Fraumeni syndrome (LFS) is a rare autosomal dominant familial cancer syndrome caused by germline mutations of the tumor protein p53 gene (TP53), which encodes the p53 transcription factor, also known as the "guardian of the genome." The most common types of cancer found in families with LFS include sarcomas, leukemia, breast malignancies, brain tumors, and adrenocortical cancers. Osteosarcoma and rhabdomyosarcoma are the most common sarcomas. Patients with LFS are at increased risk of developing early-onset gastric and colon cancers. They are also at increased risk for several other cancers involving the thyroid, lungs, ovaries, and skin. The lifetime risk of cancer in individuals with LFS is greater than 70% in males and greater than 90% in females. Some patients with LFS develop multiple primary cancers during their lifetime, and guidelines have been established for screening these patients. Whole-body MRI is the preferred modality for annual screening of these patients. The management guidelines for patients with LFS vary, as these individuals are more susceptible to developing radiation-induced cancers-for example, women with LFS and breast cancer are treated with total mastectomy instead of lumpectomy with radiation to the breast. The authors review the role of imaging, imaging guidelines, and imaging features of tumors in the setting of LFS. ©RSNA, 2024 Supplemental material is available for this article.

Risk assessment and prediction of occult uterine sarcoma in patients with presumed uterine fibroids before high-intensity focused ultrasound treatment

OBJECTIVE

To develop a diagnostic model for predicting occult uterine sarcoma in patients with presumed uterine fibroids.

MATERIALS AND METHODS

We retrospectively reviewed 41631 patients with presumed uterine fibroids who presented for HIFU treatment in 13 hospitals between November 2008 and October 2023. Of these patients, 27 with occult uterine sarcoma and 54 with uterine fibroids were enrolled. Univariate analysis and multivariate logistics regression analysis were used to determine the independent risk factors for the diagnosis of occult uterine sarcoma. A prediction model was constructed based on the coefficients of the risk factors.

RESULTS

The multivariate analysis revealed abnormal vaginal bleeding, ill-defined boundary of tumor, hyperintensity on T2WI, and central unenhanced areas as independent risk factors. A scoring system was created to assess for occult uterine sarcoma risk. The score for abnormal vaginal bleeding was 56. The score for ill-defined lesion boundary was 90. The scores for lesions with hypointensity, isointensity signal/heterogeneous signal intensity, and hyperintensity on T2WI were 0, 42, and 93, respectively. The scores for lesions without enhancement on the mass margin, uniform enhancement of tumor, and no enhancement in the center of tumor were 0, 20, and 100, respectively. Patients with a higher total score implied a higher likelihood of a diagnosis of occult uterine sarcoma than that of patients with a lower score. The established model showed good predictive efficacy.

CONCLUSIONS

Our results demonstrated that the diagnostic prediction model can be used to evaluate the risk of uterine sarcoma in patients with presumed uterine fibroids.

Validating the diagnostic accuracy of an MRI-based scoring system for differentiating benign uterine leiomyomas from leiomyosarcomas

OBJECTIVE

Uterine leiomyomas are the most common benign uterine tumors. They are difficult to distinguish from their malignant counterparts-smooth muscle tumors of unknown malignant potential (STUMP) and leiomyosarcoma. The purpose of this study is to propose and validate the diagnostic accuracy of the MRI-based Oman-Canada Scoring System of Myometrial Masses (OCSSMM) to differentiate uterine leiomyomas from STUMP/leiomyosarcomas.

METHODS

This is a retrospective study performed at two tertiary care centers. All patients with a pathology-proven uterine mass who underwent pre-operative pelvic MRI between January 2010 and January 2020 were included. Using a 1.5T MRI machine, sequences included were axial/coronal/sagittal T2 and T1 weighted imaging, axial diffusion weighted and apparent diffusion coefficient map, and axial or sagittal dynamic contrast-enhanced sequences. A scoring system was designed based on previously published worrisome MRI features for uterine leiomyosarcoma. Each feature was allocated a score from 0 to 2 according to the strength of association with malignancy. Subsequently, the MR images were blindly and independently reviewed by a fellowship-trained radiologist and a clinical fellow/senior resident. Each uterine mass was scored according to their imaging features. The scores were divided into five categories according to the sum of scores. Category III and above was considered positive for leiomyosarcoma/STUMP. Sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

A total of 244 women were included (age range 20-74 years, mean 40). Of these, 218 patients had benign leiomyoma, 13 had STUMP, and 13 had leiomyosarcoma. The sensitivity and specificity of the scoring system were 92.3% and 64.7%, respectively. The negative predictive value was 98.6%. No leiomyosarcoma was missed using this scoring system. The presence of non-cystic T2 hyperintensity or diffusion restriction in a uterine mass were the most sensitive signs of a leiomyosarcoma/STUMP.

CONCLUSION

The proposed multi-parametric MRI scoring system may be useful in differentiating benign uterine leiomyomas from leiomyosarcomas/STUMP.

Uterine Leiomyosarcoma in a 22-Year-Old Young Woman: A Case Report

Leiomyosarcoma is one of the rarest types of gynecological cancer. It is a relatively rare condition that affects young women. The most frequent symptom of this disease is vaginal bleeding. The primary treatment for localized disease is still surgical intervention. It is widely recognized that leiomyosarcoma has a poor prognosis, with reduced survival rates and a high likelihood of early recurrence. This report presents a case of uterine leiomyosarcoma in a 22-year-old female patient. Following a total hysterectomy and bilateral salpingo-oophorectomy, the diagnosis of leiomyosarcoma was confirmed through a histopathological examination of the surgical specimen.

Case report: Spontaneous rupture of leiomyosarcoma uteri 8 months after primary laparoscopic surgery of STUMP

Introduction

Leiomyosarcoma (LMS), together with smooth muscle tumors of uncertain malignant potential (STUMP) and benign leiomyomas, belongs to a heterogeneous group of uterine neoplasms. According to the World Health Organization, tumors originating from uterine smooth muscle fibers are the second most frequent tumors. It is challenging to distinguish between STUMP and LMS because of an overlap of symptoms, lack of a precise definition, and unequivocal information obtained using imaging diagnostic methods. Following myomectomy or hysterectomy with laparoscopic or laparotomy surgery and a definitive histological diagnosis of STUMP, the course of treatment is determined by the need to preserve fertility. In 2014, the U.S. Food and Drug Administration published an alert that unprotected laparoscopic morcellation is correlated with a 3-fold higher likelihood of dissemination of malignant cells and disease progression. Unprotected morcellation was independently associated with a higher risk of disease recurrence after demolition or conservative surgery, with a relative risk of 2.94.

Conclusion

Hematoperitoneum resulting from the spontaneous rupture of a uterine tumor is a rare gynecological emergency, with very few cases reported in the last decade.

A case of low-grade endometrial stromal sarcoma presented as an intramyometrial mass mimicking uterine leiomyoma on MRI

A low-grade endometrial stromal sarcoma (ESS) has a pattern of presenting as an intramyometrial mass and is often misdiagnosed as cellular leiomyoma or degenerative uterine leiomyoma. A low-grade ESS is a malignant tumour that requires total hysterectomy with bilateral salpingo-oophorectomy; while a leiomyoma is a benign tumour and could be acceptable for enucleation. As the treatment strategies differ between a low-grade ESS and leiomyoma, radiologists should be familiar with the characteristic MRI findings of a low-grade ESS. A 51-year-old woman with abnormal uterine bleeding had been observed for 2 years at a previous hospital for a uterine leiomyoma based on MRI findings. A contrast-enhanced MRI demonstrated an intramyometrial mass composed of three components with the hypointense rim on T2-weighted images (T2WI): the first component was a homogeneous solid structure with mild hyperintensity on T2WI with a low apparent diffusion coefficient value; the second component was cystic; the third component was a structure of low signal intensity on T2WI similar to the muscle. Although a degenerative uterine leiomyoma was a differential diagnosis, these MRI findings were suggestive of a low-grade ESS. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and partial omentectomy were performed. The pathological diagnosis was a low-grade ESS. In a low-grade ESS, there are three major patterns of MRI findings: one of these patterns is the less popular but clinically important intramyometrial mass pattern, which can be misdiagnosed as a leiomyoma, and this case conformed to this pattern.

Leiomyoma or sarcoma? MRI performance in the differential diagnosis of sonographically suspicious uterine masses

PURPOSE

To assess the diagnostic performance of MRI in distinguishing between leiomyomas and malignant/potentially malignant mesenchymal neoplasms in patients with rapidly enlarging/sonographically suspicious uterine masses.

METHODS

IRB-approved retrospective study including 88 patients (51 ± 11 years) who underwent MRI for rapidly enlarging/sonographically suspicious uterine mass at our Institution between January 2016 and December 2021, followed by surgery or >12 months follow-up. Qualitative image analysis was independently performed by 2 radiologists and included lesion's margins (sharp/irregular), architecture (homogeneous/inhomogeneous), presence of endometrial infiltration (yes/no), necrotic areas (yes/no), hemorrhagic areas (yes/no), predominant signal intensity on T1-WI, T2-WI, CE T1-WI, DWI, and ADC map. The same radiologists performed quantitative image analysis in consensus, which included lesion's maximum diameter, lesion/myometrium signal intensity ratio on T2-WI and CE T1-weighted images, lesion/endometrium signal intensity ratio on DWI and ADC map and necrosis percentage. Lesions were classified as benign or malignant. Imaging findings were compared with pathology and/or follow-up.

RESULTS

After surgery (52/88 patients) or follow-up (36/88 patients, 33 ± 20 months), 83/88 (94.3%) lesions were classified as benign and 5/88 (5.7%) as malignant/potentially malignant. Presence of necrotic areas, high necrosis percentage, hyperintensity on DWI and high lesion/endometrium DWI signal intensity ratio were significantly associated with malignant/potentially malignant lesions (p = 0.027, 0.002, 0.008 and 0.015, respectively). The two readers identified malignant/potentially malignant lesions with 95.5% accuracy, 80.0% sensitivity, 96.4% specificity, 57.1 % PPV, 93.3% NPV.

CONCLUSION

MRI has high accuracy in identifying malignant/potentially malignant myometrial masses. In everyday practice, however, MRI positive predictive value is relatively low given the low pre-test malignancy probability.

A differential diagnosis between uterine leiomyoma and leiomyosarcoma using transcriptome analysis

BACKGROUND

The objective of this study was to estimate the accuracy of transcriptome-based classifier in differential diagnosis of uterine leiomyoma and leiomyosarcoma. We manually selected 114 normal uterine tissue and 31 leiomyosarcoma samples from publicly available transcriptome data in UCSC Xena as training/validation sets. We developed pre-processing procedure and gene selection method to sensitively find genes of larger variance in leiomyosarcoma than normal uterine tissues. Through our method, 17 genes were selected to build transcriptome-based classifier. The prediction accuracies of deep feedforward neural network (DNN), support vector machine (SVM), random forest (RF), and gradient boosting (GB) models were examined. We interpret the biological functionality of selected genes via network-based analysis using GeneMANIA. To validate the performance of trained model, we additionally collected 35 clinical samples of leiomyosarcoma and leiomyoma as a test set (18 + 17 as 1st and 2nd test sets).

RESULTS

We discovered genes expressed in a highly variable way in leiomyosarcoma while these genes are expressed in a conserved way in normal uterine samples. These genes were mainly associated with DNA replication. As gene selection and model training were made in leiomyosarcoma and uterine normal tissue, proving discriminant of ability between leiomyosarcoma and leiomyoma is necessary. Thus, further validation of trained model was conducted in newly collected clinical samples of leiomyosarcoma and leiomyoma. The DNN classifier performed sensitivity 0.88, 0.77 (8/9, 7/9) while the specificity 1.0 (8/8, 8/8) in two test data set supporting that the selected genes in conjunction with DNN classifier are well discriminating the difference between leiomyosarcoma and leiomyoma in clinical sample.

CONCLUSION

The transcriptome-based classifier accurately distinguished uterine leiomyosarcoma from leiomyoma. Our method can be helpful in clinical practice through the biopsy of sample in advance of surgery. Identification of leiomyosarcoma let the doctor avoid of laparoscopic surgery, thus it minimizes un-wanted tumor spread.

US, MRI, CT Performance and Interpretation of Uterine Masses

Uterine masses are commonly encountered as incidental findings during cross-sectional imaging or when individuals present with symptoms such as pain and bleeding. The World Health Organization categorizes tumors of the uterine corpus into 5 distinct groups: endometrial epithelial tumors and their precursors, tumor-like growths, mesenchymal uterine tumors, tumors with a combination of epithelial and mesenchymal elements, and various other types of tumors. The primary imaging method for assessing uterine abnormalities is transvaginal ultrasound. However, magnetic resonance imaging (MRI) can be employed to enhance the visualization of soft tissues, enabling a more detailed characterization of uterine masses. This article aims to outline the imaging features of both benign and malignant uterine masses using ultrasound, MRI, and computed tomography.

Sonographic and Magnetic Resonance Characteristics of Gynecological Sarcoma

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.

Fertility-sparing options for cancer patients

Fertility preservation is becoming an integral part of cancer care among women of reproductive age. Despite advances in the treatment of pelvic malignancies, all the currently available treatment approaches, including radiotherapy, chemotherapy, and surgery, place women at high risk for future fertility impairment. With improved long-term survival rates associated with cancer, expanding the reproductive options available is of high priority. Several fertility preservation options are available today for women with gynecologic and non-gynecologic malignancies. Depending on the underlying oncological entity, these can include the following procedures whether alone or in combination: oocyte cryopreservation, embryo cryopreservation, ovarian tissue cryopreservation, ovarian transposition, and trachelectomy. The purpose of this review is to provide the most up-to-date information on the aforementioned fertility-preserving approaches and highlight the current challenges, drawbacks, and areas of research where more data are still very necessary to optimize outcomes in young female oncological patients desiring pregnancy in the future.

Imaging of Vaginal and Vulvar Malignancy

Vaginal and vulvar malignancies are rare gynecologic malignancies but can be associated with high morbidity and mortality if undiagnosed and untreated. Advanced imaging modalities such as MRI enable assessment of the local extent of disease and evaluation for regional or distant spread. Accurate identification and description of the primary lesion and sites of involvement as well as detection and localization of suspicious lymph nodes are critical in guiding appropriate management. Additionally, radiologists should be aware of potential mimickers on imaging and the differential diagnoses for vaginal and vulvar lesions.

MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement

Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.

ACR Appropriateness Criteria® Fibroids

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Computed tomography and magnetic resonance imaging findings in dogs with vaginal leiomyoma and leiomyosarcoma

BACKGROUND

In humans, magnetic resonance imaging (MRI) is preferred over computed tomography (CT) for the assessment of pelvic lesions. Although CT findings of several pelvic tumours have been reported in veterinary medicine, MRI findings are limited.

OBJECTIVES

The purpose of this study was to retrospectively compare the CT and MRI findings in dogs with vaginal leiomyoma and leiomyosarcoma.

METHODS

This retrospective study of five dogs compared the CT and MRI findings of intrapelvic lesions, including vaginal leiomyoma (n = 4) and leiomyosarcoma (n = 1). No invasion of the surrounding tissue was detected on histopathological examination. In this retrospective study, the following parameters of CT and MRI were recorded for each dog: the border between the lesion and the adjacent pelvic organs, including the prostate, rectum or urethra; signal intensity (SI) of the lesion; enhancement pattern; presence of haemorrhage; necrosis or cystic areas and lymphadenopathy. Because SI on MRI is affected by cell density, tumour cell density was analysed using a microscope slide.

RESULTS

In vaginal leiomyoma, the border between the lesion and the surrounding pelvic organ tends to be clearer on MRI than on CT. In vaginal leiomyosarcoma, the border was comparable between MRI and CT. Each lesion showed heterogeneous enhancement on CT and MRI scans. In each lesion, the assessment of haemorrhage, necrosis, cystic areas and lymphadenopathy was comparable between MRI and CT. The SI of the lesion on T2WI of the vaginal leiomyoma and leiomyosarcoma were hyperintense in four cases (4/4; 100%) and mixed intense in one case (1/1; 100%), respectively. The cell density of leiomyosarcoma is higher than that of leiomyomas.

CONCLUSIONS

The SI on T2WI may be useful for differentiating leiomyoma from leiomyosarcoma. MRI may be useful to differentiate vaginal leiomyomas from leiomyosarcomas and evaluate margins.

Occult leiomyosarcoma simulating malignant ovarian tumor: A case report

INTRODUCTION AND IMPORTANCE

Leiomyosarcoma (LMS) is a malignant tumor of the uterine smooth muscle. It is highly aggressive and accounts for 1 % of all uterine malignancies. Symptoms often include a rapidly growing mass, with an average course of illness ranging from six to eight months. Leiomyosarcomas are rare in younger individuals.

CASE PRESENTATION

A 31-year-old nulliparous woman was diagnosed with a suspected malignant ovarian tumor. A unilateral salpingo-oophorectomy and surgical staging were planned to preserve the patient's fertility. However, the large solid mass was found to be arising from the uterus during surgery. In light of the preference for fertility preservation, a myomectomy was performed, with subsequent pathology results showing a malignant leiomyosarcoma. Following counseling and discussion with the patient and her spouse, follow-up surgery was performed to ensure a free surgical margin.

CLINICAL DISCUSSION

Leiomyosarcomas at a young age is very rare, and early diagnosis is quite a challenge, especially when the tumor characteristics are not atypical. Thus, surgical evaluation and staging are paramount.

CONCLUSION

Surgical diagnosis of any mass with a history of rapid enlargement and characteristics of malignancy is very important, especially when anatomical landmarks are distorted due to the enlarged mass.

Advances in the Preoperative Identification of Uterine Sarcoma

Simple Summary

As a lethal malignant tumor, uterine sarcomas lack specific diagnostic criteria due to their similar presentation with uterine fibroids, clinicians are prone to make the wrong diagnosis or adopt incorrect treatment methods, which leads to rapid tumor progression and increased metastatic propensity. In recent years, with the improvement of medical level and awareness of uterine sarcoma, more and more studies have proposed new methods for preoperative differentiation of uterine sarcoma and uterine fibroids. This review outlines the up-to-date knowledge about preoperative differentiation of uterine sarcoma and uterine fibroids, including laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies, and provides recommendations for future research.

Abstract

Uterine sarcomas are rare malignant tumors of the uterus with a high degree of malignancy. Their clinical manifestations, imaging examination findings, and laboratory test results overlap with those of uterine fibroids. No reliable diagnostic criteria can distinguish uterine sarcomas from other uterine tumors, and the final diagnosis is usually only made after surgery based on histopathological evaluation. Conservative or minimally invasive treatment of patients with uterine sarcomas misdiagnosed preoperatively as uterine fibroids will shorten patient survival. Herein, we will summarize recent advances in the preoperative diagnosis of uterine sarcomas, including epidemiology and clinical manifestations, laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies.

Uterine fibroid-like tumors: spectrum of MR imaging findings and their differential diagnosis

Uterine leiomyoma, also known as uterine fibroid, is the most common gynecological tumor, affecting almost 80% of women at some point during their lives. In the same time, other fibroid-like tumors have similar clinical presentations and about 0.5% of resected tumors of which were presumed benign fibroids in the preoperative diagnosis revealed as malignant sarcomas in the final histopathological examination. Amid the emergence of nonsurgical or minimally invasive procedures for symptomatic benign uterine fibroids, such as uterine artery embolization, high-intensity-focused ultrasound, or laparoscopic myomectomy, the preoperative diagnosis of uterine tumors through imaging becomes all the more relevant. Preoperative tissue sampling is challenging because of the variable location of the myometrial mass; thus, the preoperative evaluation of size and location is increasingly performed through magnetic resonance imaging. Features in images might also be useful for examining the full spectrum of such growths, from benign fibroids to neoplasms of uncertain behavior and malignant sarcomas. Benign fibroids include usual-type leiomyomas, myomas with degeneration, and mitotically active leiomyomas. Neoplasms of uncertain behavior include smooth muscle tumors of uncertain malignant potential, leiomyomas with bizarre nuclei, and cellular leiomyomas. Malignant sarcomas comprise leiomyosarcomas, endometrial stromal sarcomas, adenosarcomas, and carcinosarcomas. The purpose of this article is to review the spectrum of MRI findings of uterine fibroid-like tumors, from benign variants, uncertain behavior to malignant sarcomas, and update the advanced imaging modalities, including diffusion-weighted imaging, positron emission tomography/computed tomography, combining texture analysis and radiomics, to tackle this important issue.

Uterine Fibroid Embolization in a Series of Women Older Than 50 Years: An Observational Study

Objective: Women older than 50 years, and in particular postmenopausal, are not usually considered candidate for uterine artery embolization (UAE). We reviewed the outcome of UAE in a series of women older than 50 years, who presented with different symptoms of uterus enlargement.

Population: Women referred to the radiologist from gynecologists in the United Kingdom with minimal age over 50 years.

Methods: This is a retrospective observational study. The clinical criteria are women older than 50 years with symptoms related to large fibroids affecting their quality of life, who underwent UAE over a 4-year period at Royal Surrey Foundation Trust Hospital and London Clinic between 2012 and 2016. We retrieved the information from the patients' hospital notes and respective images, including magnetic resonance and ultrasound of the pelvis, and from questionnaires and telephone reviews.

Main Outcome Measures: We measured the reduction of uterine size, complications, and overall satisfaction of patients.

Results: The overall reduction of uterine size 8 weeks following UAE was between 50% and 64% in 12 out of 23 patients. Thirty-five percent of patients (8/23) experienced a reduction of over 65% of overall uterine volume. Only on 2 occasions, the reduction was below 50%. We asked the patients if they would recommend this operation. Twenty out of 23 would recommend it. Improvement of symptoms was measured with a scale between 0 and 5. Twelve out of 23 had total resolution of symptoms—no change in 1 case. One patient underwent a hysterectomy as symptoms persisted.

Conclusions: In our series of women older than 50 years, UAE was an effective alternative to surgery, with reduction in fibroid size and improvement of symptoms.

MR Imaging of uterine sarcomas: a comprehensive review with radiologic-pathologic correlation

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 findings of a uterine tumour should raise suspicion for malignancy (including irregular contour, intra-tumoral necrosis/hemorrhage and low ADC values), some particular features may suggest their specific histological subtype such as the gross lymphovascular invasion associated with endometrial stromal sarcomas, the "bag of worms" appearance of the low-grade endometrial stromal sarcoma and the "lattice-like" aspect of adenosarcomas which results from the mixed composition of solid and multiseptated cystic components. Knowledge of the different histological uterine sarcoma subtypes, their specific MRI features and comprehension of their pathological background allows for a more confident diagnosis and may indicate the correct histological subtype.

New Aspects of Sarcomas of Uterine Corpus-A Brief Narrative Review

Sarcomas of the uterine corpus are rare malignant neoplasms, which are further classified into mesenchymal tumors, and mixed (epithelial plus mesenchymal) tumors. The main issues concerning these neoplasms are the small number of clinical trials, insufficient data from evidence-based medicine, insignificant interest from the pharmaceutical industry, all of which close a vicious circle. The low frequency of these malignancies implies insufficient experience in the diagnosis, hence incomplete surgical and complex treatment. Additionally, the rarity of these sarcomas makes it very difficult to develop clinical practice guidelines. Preoperative diagnosis, neoadjuvant and adjuvant chemoradiation, target and hormone therapies still raise many controversies. Disagreements about the role and type of surgical treatment are also often observed in medical literature. There are still insufficient data about the role of pelvic lymph node dissection and fertility-sparing surgery. Pathologists’ experience is of paramount importance for an accurate diagnosis. Additionally, genetics examinations become part of diagnosis in some sarcomas of the uterine corpus. Some gene mutations observed in uterine sarcomas are associated with different outcomes. Therefore, a development of molecular classification of uterine sarcomas should be considered in the future. In this review, we focus on the epidemiology, pathogenesis, pathology, diagnosis and treatment of the following sarcomas of the uterine corpus: leiomyosarcoma, low- and high-grade endometrial stromal sarcomas, undifferentiated sarcoma and adenosarcoma. Uterine carcinosarcomas are excluded as they represent an epithelial tumor rather than a true sarcoma.

Utility of magnetic resonance imaging for differentiating malignant mesenchymal tumors of the uterus from T2-weighted hyperintense leiomyomas

PURPOSE

To generate a new discrimination method to distinguish between malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma based on magnetic resonance imaging findings and clinical features.

MATERIALS AND METHODS

Data from 32 tumors of 32 patients with malignant mesenchymal tumors of the uterus and from 34 tumors of 30 patients with T2-weighted hyperintense leiomyoma were analyzed. Clinical parameters, qualitative magnetic resonance imaging features, including computed diffusion-weighted imaging, and quantitative characteristics of magnetic resonance imaging of these two tumor types were compared. Predictive values for malignant mesenchymal tumors of the uterus were calculated using variant discriminant analysis.

RESULTS

The T1 bright area on qualitative assessment and mean apparent diffusion coefficient value on quantitative assessment yielded the most independent magnetic resonance imaging differentiators of malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma. The classification accuracy of the variant discriminant analysis based on three selected findings, i.e., a T1 bright area, computed diffusion-weighted imaging with a b-value of 2000s/mm² (cDWI₂₀₀₀), and T2-hypointense bands, was 84.8% (56/66), indicating high accuracy.

CONCLUSIONS

Variant discriminant analysis using the T1 bright area, cDWI₂₀₀₀, and T2-hypointense bands yielded high accuracy for differentiating between malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma.

Fertility-sparing management of a suspicion of leiomyosarcoma: avoiding hysterectomy by performing transcervical myoma biopsy

OBJECTIVE

To describe the fertility-sparing management of an atypical uterine myoma.

DESIGN

Step-by-step video explanation of transcervical biopsy using transabdominal ultrasound guidance, highlighting tips and tricks. Patient consent was obtained before the publication of the case.

SETTING

University hospital.

PATIENT(S)

A 32-year-old nulliparous woman with a history of dysmenorrhea was found to have an atypical myoma FIGO 6, with suspicion of leiomyosarcoma on magnetic resonance imaging.

INTERVENTION(S)

A transcervical biopsy of an atypical myoma was done under transabdominal ultrasound guidance. A myomectomy by a minimally invasive approach was performed without morcellation.

MAIN OUTCOME MEASURE(S)

Feasibility of transcervical biopsy and correlation with definitive anatomopathological diagnosis.

RESULT(S)

The patient was under general anesthesia. A hysteroscopy confirmed the normal appearance of the uterine cavity with no direct access to the myoma. Four core biopsies were performed with a 16-gauge needle transcervically under ultrasound guidance. The preliminary diagnosis of cellular leiomyoma allowed a fertility-sparing surgery. Myomectomy and surgical treatment of endometriosis were performed secondarily. This patient had a successful recovery, and the diagnosis of benign cellular leiomyoma was confirmed on the surgical specimen.

CONCLUSION(S)

The current video highlights the safety and feasibility of transcervical ultrasound-guided core biopsy in patients with atypical uterine fibroids.

Leiomyosarcoma of the Uterus: A Rare Diagnosis

Uterine leiomyosarcoma is a rare malignant tumor that accounts for almost 2-5% of all uterine malignancies. It has the highest prevalence during pre and perimenopause. Further, it clinically resembles benign conditions like leiomyoma, and the diagnosis is confirmed with the histologic findings of the mass. Here, we present the case of a 70-year-old female who presented with lower abdominal pain for two years. Exploratory laparotomy with hysterectomy was performed, and the diagnosis of leiomyosarcoma was confirmed after histological examination of the resected tumor.

Uterine fibroid vascularization: from morphological evidence to clinical implications

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.

Growth of surgically confirmed leiomyomas in postmenopausal women: analysis of the influencing factors

OBJECTIVES

The aim of this study was to examine the growth of uterine leiomyomas in postmenopausal women and evaluate the influencing factors associated with fibroid growth.

METHODS

We retrospectively analyzed the medical records of postmenopausal women with fibroids between 2015 and 2020. All women received at least 2 transvaginal ultrasound examinations within a 6-month interval. All fibroids were verified via surgery. The postoperative pathology of all tumors was uterine fibroid. We calculated the fibroid volume using the ellipsoid volume formula and evaluated the growth rate of fibroids within 6 months simultaneously. Univariable analysis and a linear mixed-effects model were used to assess the factors influencing fibroid growth.

RESULTS

A total of 102 postmenopausal women with a total of 132 fibroids were assessed. The median growth rate of surgically confirmed fibroids in postmenopausal women was 12.9% every 6 months (from -61.4% to 184.1%). Obesity was associated with fibroid growth (P < 0.05). Notably, the estimated growth rates of fibroids in obese and overweight women were 26.6% (95% confidence interval [CI]: 2.3-50.9) and 15.9% (95% CI: 0.4-31.4) higher than those in women of normal weight, respectively. The growth of fibroids varied by the initial tumor size (P < 0.05). The estimated growth rate of larger fibroids (≥5.0 cm diameter) was reduced 30.0% (95% CI: -52.4 to -7.5) compared with that of small fibroids (<3.0 cm diameter).

CONCLUSIONS

Uterine fibroids continually grow in some postmenopausal women. Obesity and small fibroids (<3.0 cm diameter) may contribute to higher growth rates of fibroids.

Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check!

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET¹T²ER Check! to help identify key features more suggestive of a uterine sarcoma.

New imaging modalities to distinguish rare uterine mesenchymal cancers from benign uterine lesions

PURPOSE OF REVIEW

Uterine sarcomas are rare and are often challenging to differentiate on imaging from benign mimics, such as leiomyoma. As functional MRI techniques have improved and new adjuncts, such as machine learning and texture analysis, are now being investigated, it is helpful to be aware of the current literature on imaging features that may sometimes allow for preoperative distinction.

RECENT FINDINGS

MRI, with both conventional and functional imaging, is the modality of choice for evaluating uterine mesenchymal tumors, especially in differentiating uterine leiomyosarcoma from leiomyoma through validated diagnostic algorithms. MRI is sometimes helpful in differentiating high-grade stromal sarcoma from low-grade stromal sarcoma or differentiating endometrial stromal sarcoma from endometrial carcinoma. However, imaging remains nonspecific for evaluating rarer neoplasms, such as uterine tumor resembling ovarian sex cord tumor or perivascular epithelioid cell tumor, primarily because of the small number and power of relevant studies.

SUMMARY

Through advances in MRI techniques and novel investigational imaging adjuncts, such as machine learning and texture analysis, imaging differentiation of malignant from benign uterine mesenchymal tumors has improved and could help reduce morbidity relating to misdiagnosis or diagnostic delays.

Uterine leiomyoma is associated with the risk of developing endometriosis: A nationwide cohort study involving 156,195 women

Objective

Evidence for an association between uterine leiomyoma and increased risk of endometriosis is limited by small sample sizes and short follow-up periods. We assessed this association in a large nationwide sample with 14 years of data.

Design

Data were sourced from Taiwan’s Longitudinal Health Insurance Database 2000 (LHID2000).

Materials and methods

We identified 31,239 women aged ≥20 years diagnosed with uterine leiomyoma (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] code 218) between Jan 1, 2000 and Dec 31, 2012, who were matched with 124,956 controls (1:4) by 5-year age groups and year of diagnosis. Follow-up was from the date of LHID2000 entry to the first occurrence of endometriosis, loss to follow-up, insurance termination, or until December 31, 2013, whichever was earlier.

Results

In Cox regression analysis, the adjusted hazard ratio (aHR) for endometriosis in women with uterine leiomyoma was 6.44 (95% CI, 6.18, 6.72) compared with controls. The risk of endometriosis was significantly increased in women with uterine leiomyoma and comorbidities of tube-ovarian infection (aHR 2.86; 95% CI, 1.28, 6.36), endometritis (1.14; 1.06, 1.24), infertility (1.26; 1.16, 1.37), or allergic diseases (1.11; 1.05, 1.17). Having both uterine leiomyoma and endometritis significantly increased the risk of endometriosis (aHR 6.73; 95% CI, 6.07, 7.45) versus having only uterine leiomyoma (6.61; 6.33, 6.91) or endometritis (1.49; 1.31, 1.69). Similarly, having both uterine leiomyoma and infertility significantly increased the risk of endometriosis (aHR 6.95; 95% CI, 6.21, 7.78) versus having only uterine leiomyoma (6.66; 6.38, 6.96) or infertility (1.78; 1.57, 2.02).

Conclusions

A diagnosis of uterine leiomyoma appears to increase the risk of endometriosis. Patients presenting with uterine fibroids should be encouraged to give informed consent for possible simultaneous surgical treatment of endometriosis.

MRI features and clinical outcomes of unexpected uterine sarcomas in patients who underwent high-intensity focused ultrasound ablation for presumed uterine fibroids

OBJECTIVE

To investigate the MRI features and clinical outcomes of unexpected uterine sarcomas in patients after high-intensity focused ultrasound (HIFU) ablation for presumed uterine fibroids.

MATERIALS AND METHODS

15,759 consecutive patients who came for HIFU treatment, from November 2008 to September 2019, for presumed uterine fibroids were retrospectively reviewed. All the patients had completed a pre-HIFU MRI. All MRI images were independently analyzed and interpreted by two radiologists in every center.

RESULTS

According to the T2WI MRI features of hyperintensity, accompanied by irregular margins, necrosis or cystic degeneration, multi-lobulated lesion with internal septation, 46 patients were suspected to be uterine sarcomas before HIFU. Eleven patients were histologically diagnosed as uterine sarcomas after laparotomy. Among the 15713 patients who received HIFU treatment for presumed uterine fibroids, 8 patients were found to have occult recurrence during the follow-up period, and 6 were confirmed histologically as uterine sarcomas after laparotomy. The incidence rate of uterine sarcomas was 0.108% (17/15759). Among them, 12 cases were low-grade endometrial stromal sarcoma (LG-ESS) and 5 cases were uterine leiomyosarcoma (LMS). No histological dissemination of the sarcoma was detected in patients with unexpected uterine sarcomas.

CONCLUSION

Although some MRI features of uterine sarcomas and uterine fibroids overlapped, MRI is valuable in distinguishing between uterine fibroids and uterine sarcomas. HIFU does not seem to cause histological dissemination of the sarcoma, but follow-up visits should be strictly adhered to in order to detect unexpected uterine sarcomas at an early stage and to treat them in a timely manner.

MRI findings in-between leiomyoma and leiomyosarcoma: a Rad-Path correlation of degenerated leiomyomas and variants

Leiomyomas are the most common benign tumors of the uterus. On the opposite side, leiomyosarcomas are rare malignant uterine tumors that account for a significant proportion of uterine cancer deaths. Especially when large and degenerated, leiomyomas and leiomyoma variants can have overlapping imaging characteristics with those of leiomyosarcomas. Although not always possible, it is paramount to be able to differentiate between leiomyomas and leiomyosarcomas on imaging, as the therapeutic management can differ. This pictorial review aims to familiarize radiologists with imaging features of leiomyomas and various types of leiomyoma degeneration and variants, together with their pathology correlates.

Benign Uterine Disease: The Added Role of Imaging

Benign uterine diseases are very common gynecologic conditions that affect women mostly in reproductive age. Ultrasound examination is the first-line imaging technique, but MRI is more accurate for diagnosis, characterization, and patient management. In this review, we especially highlight the added value of MRI in the diagnosis of benign uterine disease, discuss their imaging characteristics, and describe the therapeutic options and the added value of MRI in the treatment planning.

Preoperative Blood Inflammatory Markers for the Differentiation of Uterine Leiomyosarcoma from Leiomyoma

Purpose

Preoperative diagnosis of uterine leiomyosarcoma (LMS) is challenging because the disease can mimic benign leiomyoma (LM). The objective of the present study was to investigate the role of preoperative clinical characteristics and hematologic parameters to differentiate uterine LMS and LM.

Methods

Preoperative clinical and laboratory variables were reviewed retrospectively in patients with LMS or LM, and the significances of intergroup differences were assessed. Receiver operating characteristic (ROC) curves were used to determine optimal cut-off values for each variable. Logistic regression analysis was applied to identify variables predicting the presence of LMS.

Results

The preoperative clinical and laboratory variables of 336 patients with uterine tumor were analyzed. Seventy-nine patients had LMS and 257 had LM. A significant difference was observed between LMS and LM in terms of the median value of age at diagnosis, menopausal status, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP), lactate dehydrogenase (LDH), and neutrophil-to-lymphocyte ratio (NLR) (all P < 0.001). Multivariate analyses showed that menopausal status (odds ratio [OR] = 3.40, P= 0.002), WBC count (OR = 2.09, P = 0.012), ANC (OR = 3.17, P < 0.001), CRP (OR = 21.74, P < 0.001), LDH (OR = 10.77, P < 0.001), and NLR (OR = 2.58, P = 0.001) predicted the presence of LMS.

Conclusion

Our results suggest that in older or postmenopausal patients, high WBC count, ANC, CRP, LDH, and NLR could be useful biomarkers for the differentiation of LMS and LM, which indicate that serum markers might be useful, cost-effective, and broadly available diagnostic markers for uterine LMS.

Diagnostic interpretation of non-contrast qualitative MR imaging features for characterisation of uterine leiomyosarcoma

OBJECTIVE

To assess the value of non-contrast MRI features for characterisation of uterine leiomyosarcoma (LMS) and differentiation from atypical benign leiomyomas.

METHODS

This study included 57 atypical leiomyomas and 16 LMS which were referred pre-operatively for management review to the specialist gynaeoncology multidisciplinary team meeting. Non-contrast MRIs were retrospectively reviewed by five independent readers (three senior, two junior) and a 5-level Likert score (1-low/5-high) was assigned to each mass for likelihood of LMS. Evaluation of qualitative and quantitative MRI features was done using uni- and multivariable regression analysis. Inter-reader reliability for the assessment of MRI features was calculated by using Cohen's κ values.

RESULTS

In the univariate analysis, interruption of the endometrial interface and irregular tumour shape had the highest odds ratios (ORs) (64.00, p < 0.001 and 12.00, p = 0.002, respectively) for prediction of LMS. Likert score of the mass was significant in prediction (OR, 3.14; p < 0.001) with excellent reliability between readers (ICC 0.86; 95% CI, 0.76-0.92). The post-menopausal status, interruption of endometrial interface and thickened endometrial stripe were the most predictive independent variables in multivariable estimation of the risk of leiomyosarcoma with an accuracy of 0.88 (95%CI, 0.78-0.94).

CONCLUSION

At any level of expertise as a radiologist reader, the loss of the normal endometrial stripe (either thickened or not seen) in a post-menopausal patient with a myometrial mass was highly likely to be LMS.

ADVANCES IN KNOWLEDGE

This study demonstrates the potential utility of non-contrast MRI features in characterisation of LMS over atypical leiomyomas, and therefore influence on optimal management of these cases.

Uterine Fibroid in a 16-Year-Old Adolescent Managed with a Fertility-Sparing Approach: A Case Report and Review of the Literature

BACKGROUND

Uterine fibroids are the most common benign tumor of the uterus in adult women. However, it is exceedingly rare in adolescents.

CASE

A 16-year-old girl presented with severe anemia and abnormal uterine bleeding. MRI of the pelvis demonstrated a 9-cm mass within the uterus concerning for leiomyoma or leiomyosarcoma. A fertility preserving myomectomy led to the final diagnosis of a benign uterine fibroid.

SUMMARY AND CONCLUSION

Despite the rare incidence of leiomyomas in adolescents, it is imperative that it is included in the differential diagnosis when young women present with abnormal uterine bleeding. A less common diagnosis to consider is leiomyosarcoma; however, this is histologically diagnosed. Thus, a fertility-preserving myomectomy permits for a diagnostic opportunity to rule out a potential malignancy.

Multiparametric MR evaluation of uterine leiomyosarcoma and STUMP versus leiomyoma in symptomatic women planned for high frequency focussed ultrasound: accuracy of imaging parameters and interobserver agreement for identification of malignancy

OBJECTIVE

To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential.

METHODS

Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites.

RESULTS

32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003-0.0004) or irregular (p = 0.003-0.004) lesion margin, T2 hyperintensity >50% (p = 0.001-0.004), and peripheral CE (p = 0.02-0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63-80% of LM. Agreement was greatest for margin characteristics (κ = 0.73-0.81).

CONCLUSION

Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability.

ADVANCES IN KNOWLEDGE

Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.

Magnetic resonance imaging findings of a myxoid leiomyosarcoma of the uterus: A case report and literature review

Uterine myxoid leiomyosarcomas (MLMSs) are extremely rare. Here, we report a rare case of uterine MLMS with unique and bizarre magnetic resonance imaging (MRI) findings on diffusion-weighted images (DWIs) and dynamic contrast-enhanced (DCE) MRI scans. A 67-year-old woman presented with a uterine MLMS that had a multilocular cystic mass with a septum and solid components. The tumour demonstrated marked hyperintensity on T2-weighted images in a myxoid stroma with gradual partial contrast enhancement and diffusion restriction, which could be a characteristic feature suggestive of a myxoid malignant smooth muscle tumour of the uterus rather than a uterine leiomyoma with myxoid degeneration.

The Risk of Uterine Malignancy in a Population Being Evaluated for Uterine Fibroid Embolization

OBJECTIVE

The aim of the study was to determine the frequency of uterine malignancy in patients evaluated for uterine fibroid embolization (UFE) and the role of magnetic resonance imaging in triage.

METHODS

Records and imaging studies of 864 UFE consult patients were reviewed for MRI findings suggestive of fibroid malignancy. Pathology was obtained for cases with suspicious baseline MRI's, and the most atypical mass was reanalyzed by an experienced radiologist, blinded to the pathological findings.

RESULTS

Twenty one of 864 patients had baseline MRI findings concerning for malignancy at consultation and 17 had complete records. Re-evaluation suggested that 5 were malignant. Three were confirmed malignant (0.35%). One malignancy among the 843 without suspicious baseline MRI findings was missed at consultation.

CONCLUSIONS

In our UFE population, uterine malignancy is rare (4/864, 0.46%), and MRI detected the majority, 3 (75%) of 4 before UFE. The observed prevalence of any malignancy was 0.35%, congruent with current Federal Drug Administration estimates.

Which imaging method is better for the differentiation of adenomyosis and uterine fibroids?

OBJECTIVE

The paper compares shear wave elastography (SWE), strain elastography (SE) and magnetic resonance imaging apparent diffusion coefficient (MRI ADC) values, to evaluate their efficacy for differentiating between adenomyosis (AM) and uterine fibroids (UF).

METHODS

Patients who were scheduled for hysterectomy for AM or UFs, with a preliminary diagnosis, were additionally evaluated before surgery by transabdominal and transvaginal ultrasound elastography. SE of patients were evaluated by transvaginal ultrasound, and SWE of patients and control subjects were evaluated by transabdominal ultrasound. Then, the patients with a definitive histopathological diagnosis as AM or UFs were evaluated retrospectively and compared to the control group without myometrial pathology. In addition, MRI images of patients with UFs and AM were examined for ADC values.

RESULTS

The results of 98 patients in the UF group, 37 patients in the AM group, and 40 volunteers with a healthy myometrium in the control group were compared. There were no statistically significant differences in age and body mass index between the groups (P > 0.05). Uterine size was significantly higher in the UF and AM group than the control group (P < 0.001). A statistically significant difference was found between strain ratio (mean), strain ratio (max), and ADC values between the UF and AM groups (P < 0.001 for all three). There was a statistically significant difference in elastography scores distribution between the groups (P < 0.001). There was a statistically significant difference between the UF and control (P < 0.001) and between the UF and AM (P < 0.001) groups in terms of SWE (kilopascal (kPa)) averages (P < 0.001). We found that none of these discrimination methods were statistically superior to each other in differentiating the UFs from the AM.

CONCLUSION

In the differentiation of myometrial pathologies in gynecological imaging, both SE and SWE are cheaper, provide faster results, are non-invasive and easy to apply, and hence are as promising as the more expensive MRI ADC. Our study is the first to use both modalities of elastography and MRI ADC values together, compare these methods with each other and confirm the results pathologically.

Multiparametric magnetic resonance imaging of endometrial polypoid lesions

Endometrial polypoid lesions encompass various conditions from physiologic changes to benign or malignant disease. Differentiating between the various causes of endometrial polypoid lesions remains difficult by transvaginal sonography. Magnetic resonance imaging (MRI) can provide valuable information regarding endometrial polypoid lesions in situations where it is difficult to obtain histologic samples. Multiparametric MRI including T2-weighted images, T1-weighted fat-saturation contrast-enhanced images, and diffusion-weighted images may be helpful for differentiating the various endometrial polypoid lesions and establishing specific diagnoses and appropriate treatment.

Laparoscopic Myomectomy - Converting to Laparotomy for a Suspicious Intraoperative Appearance with Subsequent Benign Histology - a Pre- and Intra-Operative Dilemma

Background

Although the most common uterine tumour is leiomyoma, the differential diagnoses also include the rarer adenomyoma and leiomyosarcoma. A lack of clear reliable clinical and radiological features makes the triage of uterine masses to the appropriate surgical procedure difficult. In the case of suspicious appearance of a presumed leiomyoma, an open surgical approach is recommended and morcellation is avoided.

Case

We present a case of a woman undergoing an elective laparoscopic myomectomy for a fibroid that appeared benign on ultrasound but had suspicious features intraoperatively. The operation was converted to a laparotomy to avoid the risk of morcellation-related seeding in the event that the histology was malignant. The histology was subsequently a benign exophytic adenomyoma.

Conclusion

The assessment of the nature of fibroids can be difficult both pre- and intraoperatively, and the need for difficult decision making to convert to open surgery during a laparoscopic myomectomy but with subsequent benign histology should be part of patient counselling.

Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa' italiana di Ginecologia E Ostetricia)

BACKGROUND

Uterine sarcomas are very rare tumours with different histotypes, molecular features and clinical outcomes; therefore, it is difficult to carry out prospective clinical trials, and this often results in heterogeneous management of patients in the clinical practice.

AIM

We planned to set up an Italian consensus conference on these diseases in order to provide recommendations on treatments and quality of care in our country.

RESULTS

Early-stage uterine sarcomas are managed by hysterectomy + bilateral salpingo-oophorectomy according to menopausal status and histology; lymphadenectomy is not indicated in patients without bulky nodes, and morcellation must be avoided. The postoperative management is represented by observation, even though chemotherapy can be considered in some high-risk patients. In early-stage low-grade endometrial stromal sarcoma and adenosarcomas without sarcomatous overgrowth, hormonal adjuvant treatment can be offered based on hormone receptor expression. In selected cases, external beam radiotherapy ± brachytherapy can be considered to increase local control only. Patients with advanced disease involving the abdomen can be offered primary chemotherapy (or hormonal therapy in the case of low-grade endometrial stromal sarcoma and adenosarcoma without sarcomatous overgrowth), even if potentially resectable in the absence of residual disease in order to test the chemosensitivity (or hormonosensitivity); debulking surgery can be considered in patients with clinical and radiological response. Chemotherapy is based on anthracyclines ± ifosfamide or dacarbazine. Palliative radiotherapy can be offered for symptom control, and stereotactic radiotherapy can be used for up to five isolated metastatic lesions.

CONCLUSIONS

Treatment of uterine sarcoma should be centralised at referral centres and managed in a multidisciplinary setting.

Diagnostic Algorithm to Differentiate Benign Atypical Leiomyomas from Malignant Uterine Sarcomas with Diffusion-weighted MRI

Background Improving the differentiation of uterine sarcomas from atypical leiomyomas remains a clinical challenge and is needed to avoid inappropriate surgery. Purpose To develop a diagnostic algorithm including diffusion-weighted MRI criteria to differentiate malignant uterine sarcomas from benign atypical leiomyomas. Materials and Methods This case-control retrospective study identified women with an atypical uterine mass at MRI between January 2000 and April 2017, with surgery or MRI follow-up after 1 year or longer. A diagnostic algorithm including T2-weighted MRI and diffusion-weighted imaging (DWI) signal and apparent diffusion coefficient (ADC) values was developed to predict for sarcoma. The training set consisted of 51 sarcomas and 105 leiomyomas. Two external validation sets were used to evaluate interreader reproducibility (16 sarcomas; 26 leiomyomas) and impact of reader experience (29 sarcomas; 30 leiomyomas). Wilson confidence intervals (CIs) were calculated for sensitivity and specificity. Results Evaluated were 156 women (median age, 50 years; interquartile range, 44-63 years). Predictive MRI criteria for malignancy were enlarged lymph nodes or peritoneal implants, high DWI signal greater than that in endometrium, and ADC less than or equal to 0.905 × 10^-3 mm²/sec. Conversely, a global or focal area of low T2 signal intensity and a low or an intermediate DWI signal less than that in endometrium or lymph nodes allowed readers to confidently diagnose as benign a uterine mass demonstrating one or more of these signs (P < .001) in 100% cases in all three data sets. The sensitivities and specificities of the algorithm for diagnosis of malignancy were 98% (50 of 51 masses; 95% CI: 90%, 100%) and 94% (99 of 105 masses; 95% CI: 88%, 98%) in the training set; 88% (14 of 16 masses; 95% CI: 64%, 97%) and 100% (26 of 26 masses; 95% CI: 87%, 100%) in the validation set; and 83% (24 of 29 masses; 95% CI: 65%, 92%) and 97% (29 of 30 masses; 95% CI: 83%, 99%) for the less experienced reader, respectively. Conclusion A diagnostic algorithm with predictive features including lymphadenopathy, high diffusion-weighted imaging signal with reference to endometrium, and low apparent diffusion coefficient enabled differentiation of malignant sarcomas from atypical leiomyomas, and it may assist inexperienced readers. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Méndez in this issue.

A Mayer-Rokitansky-Kuster-Hauser patient with leiomyoma and dysplasia of neovagina: a case report

Background

Most patients with congenital uterus and vaginal aplasia (i.e., Mayer–Rokitansky–Kuster–Hauser [MRKH] syndrome) have rudimentary pelvic uterine structures that contain smooth muscle. Although leiomyomas and dysplasia of vaginal mucosa are relatively common in the general population, they are rare in MRKH patients. Data on the vulnerability of neovaginas to HPV-associated dysplasia are limited.

Case presentation

A rare case of an MRKH patient with two gynaecological conditions detected during long-term gynaecological follow-up is presented. At the age of 21, the patient was treated for HPV-associated neovaginal dysplasia. At the age of 47, a pelvic leiomyoma was detected with transvaginal ultrasound and confirmed with magnetic resonance imaging.

Conclusion

A Pap smear or human papillomavirus testing is indicated in sexually active MRKH women. Uterine rudiments contain smooth muscle, which facilitates the development of oestrogen-dependent diseases, such as leiomyomas and adenomyosis. Although magnetic resonance imaging is recommended in cases of a pelvic mass, easily attainable and cost-efficient transvaginal ultrasound offers high diagnostic accuracy in patients with a surgically created neovagina and is suitable for the patients’ follow-up. Guidelines for the gynaecological follow-up of MRKH patients are warranted.