Color Doppler ultrasonographic findings in low and high grade endometrial stromal sarcomas

Endometrial stromal sarcoma: An aggressive uterine malignancy

Endometrial stromal sarcoma (ESS) is an aggressive uterine sarcoma. We report a case of a large endometrial stromal sarcoma in a 42 year nulliparous woman with chronic kidney disease presenting with acute urinary retention and irregular per vaginal bleeding. Ultrasound and Doppler imaging revealed a heterogeneous mass in the endometrial cavity with internal vascularity. Magnetic resonance imaging (MRI) revealed a large lobulated mass in the endometrial cavity extending into the vagina, causing local mass effect. Multiple linear hypointense bands on magnetic resonance T2 weighted (T2wt) images were characteristic of ESS. MRI is a very useful imaging modality in characterizing the lesion and also for the staging. It is necessary to distinguish these tumors from benign as well as other uterine malignancies for better management. We also review relevant literature discussing imaging findings of ESS.

Sonographic findings of uterine endometrial stromal sarcoma

Objective

The study was performed to present the sonographic findings of uterine endometrial stromal sarcoma (ESS).

Materials and Methods

We conducted a retrospective review of sonographic findings of 10 cases that were diagnosed as uterine ESS. The patients' ages ranged from 25 to 51 years (mean age: 36.1 years). The reviews focused on the location, margin, size, number and echotexture of the lesions. Hysterectomy (n = 9) and myomectomy (n = 1) were performed and a pathologic diagnosis was obtained in all cases.

Results

The masses were located in the uterine wall (n = 6), or they presented as a polypoid mass protruding into the endometrial cavity from the myometrium (n = 3) or as a central cavity mass (n = 1). The lesion margins were smooth (n = 5), ill defined (n = 2), or smooth with partially nodular extensions (n = 3). The maximal mass length was 38 mm to 160 mm with a mean mass length of 83.5 mm. There were single lesions in eight cases and multiple lesions in two cases. The lesion echotextures were hypoechoic solid (n = 3), heterogeneously intermediate echoic (n = 5), diffuse myometrial thickening with heterogeneous echogenicity (n = 1) and septated cystic (n = 1).

Conclusion

Endometrial stromal sarcoma presents with four patterns of its sonographic appearance; a polypoid mass with nodular myometrial extension, an intramural mass with an ill defined margin and heterogeneous echogenicity, an ill defined large central cavity mass or, diffuse myometrial thickening.

A case of endometrial stromal sarcoma with curvilinear calcification

BACKGROUND

Although many histopathological, clinical, and imaging findings of ESS have been described, intense calcifications have not been reported previously.

CASE

A 54-year-old female was admitted with vaginal bleeding and abdominal pain. Gynecologic examination revealed a huge, firm pelvic mass extending up to the epigastrium. Transabdominal ultrasonography and computed tomography demonstrated a well-demarcated uterine mass containing heterogeneous solid and cystic areas and a centric curvilinear calcification. Histopathological diagnosis was established as undifferentiated high-grade endometrial stromal sarcoma.

CONCLUSION

Endometrial stromal sarcomas should be considered in the differential diagnosis of uterine masses containing curvilinear calcifications.

Uterine sarcomas versus leiomyomas: gray-scale and Doppler sonographic findings

PURPOSE

The aim of the study was to evaluate the contribution of gray-scale sonography and Doppler flow studies in differentiating between uterine sarcomas of different histologic types and leiomyomas.

PATIENTS AND METHODS

The study included 111 patients, divided retrospectively into 2 groups: 98 patients with leiomyomas and 13 with postoperative diagnosis of uterine sarcoma. This latter group was further divided into a group of 6 patients with uterine leiomyosarcoma and 7 with malignant mixed mesodermal tumor. The gray-scale sonograms and Doppler parameters in the 3 groups were compared.

RESULTS

The patients with leiomyomas were younger than those with sarcomas (52 years +/- 11 versus 65 years +/- 15, p < 0.05). No differences were noted between the 3 groups regarding gravidity, parity, symptoms upon admission, or findings during physical examination. The sonographic appearances of the leiomyomas were similar to those of the leiomyosarcomas, but in 6/7 cases, they were different from those of the malignant mixed mesodermal tumors. There was a significant difference between the mean resistance index in arterioles of the leiomyomas (0.59 +/- 0.01) and that of the malignant mixed mesodermal tumors (0.41 +/- 0.06) (P < 0.001) but not between those of the leiomyomas and the leiomyosarcomas (0.49 +/- 0.18).

CONCLUSIONS

Doppler flow studies may assist in differentiating between leiomyomas and malignant mixed mesodermal tumors but not between leiomyomas and leiomyosarcomas.

CA 125 measurement and ultrasonography in borderline tumors of the ovary

OBJECTIVES

Our goal was to perform an analysis of ultrasonographic characteristics and CA 125 levels in ovarian tumors of borderline malignancy.

STUDY DESIGN

We performed a retrospective analysis of CA 125 levels and ultrasonographic parameters in 91 patients with borderline tumors.

RESULTS

Serous tumors of borderline malignancy were associated with elevated CA 125 levels in 75% of patients before surgery (mean, 156 IU/mL) compared with 30% of mucinous tumors (mean, 28 IU/mL; P =.004). CA 125 was elevated in 35% of stage IA serous tumors (mean, 67 IU/mL) compared with 89% of tumors with spread beyond the ovary (mean, 259 IU/mL; P =.001). Mucinous tumors tended to be bigger (13.1 +/- 7 cm) on ultrasonography than serous tumors (9.3 +/- 6.2 cm, P =.016). Mucinous tumors were multilocular in half the patients and contained papillations in 40% of the patients. Serous tumors were multilocular in 30% of the patients but presented with solid or papillary patterns in 78% of the patients (P =.001). A resistance index of <0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13% of patients, ultrasonographic characteristics were compatible with a simple cyst only, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87%, that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93% of patients, 2 were abnormal in 69% of patients, and all 3 were abnormal in 21% of patients.

CONCLUSIONS

A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts.

Imaging techniques for fibroid detection

Ultrasound imaging techniques, both transabdominal and transvaginal, are the most accurate and widely used imaging modalities in the detection and characterization of uterine leiomyomas. The diagnosis of these tumours may be enhanced using ultrasound-guided uterine biopsy and hysterosonography. Magnetic resonance imaging provides accurate imaging information, but its cost and lack of significant superiority over ultrasound have hitherto limited its use. Computerized tomography, plain X-ray, and hysterosalpingography have little to offer in the assessment of fibroids.

Decay constant of Doppler flow waveform as a possible indicator of ovarian malignancy

The objectives of this study were to analyze the decay constant (tau) of the Doppler flow waveform in ovarian tumors; to determine if differences in this constant can discriminate between malignant and benign ovarian tumors; and to compare the decay constant to the known resistive index (RI), in order to determine its potential prognostic application. Patients with ovarian masses (46) were evaluated in a retrospective study; 13 had malignant tumors, 7 showed tumors with low malignant potential (LMP), 11 had benign masses, 4 had secondary ovarian metastases and 11 had functional ovarian masses. Doppler flow waves measured in the ovary before operation were analyzed from archival videotapes. The RI was calculated preoperatively, and the decay constant of the flow waveform was analyzed retrospectively. We approximated the decaying portion of the flow waveform from the systolic peak to the diastolic level to an exponential curve. Then, the decay constant associated with the flow signal was compared for different types of ovarian pathology. Ovaries with malignancies showed significantly higher mean values for the decay constant (89.7; 95% confidence interval 60.0-119.3) than those with benign tumors (41.8; 25.7-57.9) (p < 0.007), where tau is provided in pixels (in this study each pixel equals approximately 11.4 ms). The mean RI value for malignant tumors was 0.44 +/- 0.12 whereas, in benign tumors, it was 0.622 +/- 0.11. For the benign tumors, both tau and RI did not differ significantly from the measured indices in LMP tumors, metastases and functional ovarian findings. In addition, when the cutoff value of tau was set at 48, 92.3% of all malignancies were identifiable using only tau. This preliminary study indicates that the decay constant of the Doppler flow waveform is able to discriminate between malignant and benign masses and may, thus, provide substantial assistance as an additional parameter in the diagnosis of malignant ovarian tumors in postmenopausal patients.