Can MRI predict the diagnosis of endometrial carcinosarcoma?

Evaluation of Uterine Carcinosarcoma and Uterine Endometrial Carcinoma Using Magnetic Resonance Imaging Findings and Texture Features

Aim  This study aimed to evaluate the diagnostic feasibility of magnetic resonance imaging (MRI) findings and texture features (TFs) for differentiating uterine endometrial carcinoma from uterine carcinosarcoma. Methods This retrospective study included 102 patients who were histopathologically diagnosed after surgery with uterine endometrial carcinoma (n=68) or uterine carcinosarcoma (n=34) between January 2008 and December 2021. We assessed conventional MRI findings and measurements (cMRFMs) and TFs on T2-weighted images (T2WI) and apparent diffusion coefficient (ADC) map, as well as their combinations, in differentiating between uterine endometrial carcinoma and uterine carcinosarcoma. The least absolute shrinkage and selection operator (LASSO) was used to select three features with the highest absolute value of the LASSO regression coefficient for each model and construct a discriminative model. Binary logistic regression analysis was used to analyze the disease models and conduct receiver operating characteristic analyses on the cMRFMs, T2WI-TFs, ADC-TFs, and their combined model to compare the two diseases. Results A total of four models were constructed from each of the three selected features. The area under the curve (AUC) of the discriminative model using these features was 0.772, 0.878, 0.748, and 0.915 for the cMRFMs, T2WI-TFs, ADC-TFs, and a combined model of cMRFMs and TFs, respectively. The combined model showed a higher AUC than the other models, with a high diagnostic performance (AUC=0.915). Conclusion A combined model using cMRFMs and TFs might be helpful for the differential diagnosis of uterine endometrial carcinoma and uterine carcinosarcoma.

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.

Dynamic contrast-enhanced MR and PET/CT findings of uterine sarcomatoid carcinoma: a case report

Background

Sarcomatoid carcinoma (SC) is a malignant tumour composed of spindle cells. The incidence of SC is low, especially in the uterus. The imaging features of uterine sarcomatoid carcinoma (USC) are rarely reported. We report a case of USC and discuss the dynamic contrast-enhanced MR (DCE-MR) and PET/CT findings.

Case presentation

A 69-year-old woman presented to the Department of Gynaecology with vaginal bleeding. Ultrasound examination discovered a heterogeneous mass in the cervix. Then, MRI examination of the pelvis was performed. On T2-weighted images, the uterus was replaced by an ill defined and diffuse lesion with inhomogeneous intensity. On T1-weighted images, the lesion appeared with signal hypointensity and was heterogeneously enhanced with contrast material. Additionally, enlarged lymph nodes were found in the pelvic cavity. PET/CT demonstrated high uptake in the region of the uterus and pelvic lymph nodes, which was consistent with MRI findings. The radiologists diagnosed the patient with malignant uterine lesions. The patient underwent hysterectomy and bilateral adnexectomy with pelvic lymph node dissection. Then, systemic radiotherapy and chemotherapy were performed. USC with lymph node metastasis was diagnosed with the help of immuno-histochemical analysis. There was no treatment related complication and no evidence of tumour recurrence at the postoperative 6-month follow-up.

Conclusion

MRI and PET/CT features are sufficient to indicate the malignant nature of a USC, but they are not pathognomonic.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Uterine carcinosarcoma: a primer for radiologists

OBJECTIVE

To provide a modern overview for radiologists of the unique radiological, pathological, and clinical features of uterine carcinosarcoma (UCS).

RESULTS

UCS is a unique gynecological malignancy that continues to present diagnostic and therapeutic challenges to the field of oncology. The classification and clinical understanding of this malignancy have evolved in recent years, yielding a modern conceptualization of a neoplastic entity that has been well studied but incompletely understood. As UCS causes a significant proportion of deaths secondary to uterine cancer, developing a familiarity with the imaging and clinical features of this entity is critical. In addition to summarizing the modern understanding of this tumor variant, an overview of the common imaging features of UCS will be presented. The role of radiological staging, imaging findings on presentation and follow-up imaging, and modern treatment paradigms will be discussed. Lastly, the current treatment paradigms and surveillance recommendations for UCS will be summarized.

CONCLUSION

Knowledge of the modern understanding of uterine carcinosarcoma, including its relevant imaging and clinical features, is critical for radiologists.

Current Status of Magnetic Resonance Imaging in Patients with Malignant Uterine Neoplasms: A Review

In this study, we summarize the clinical role of magnetic resonance imaging (MRI) in the diagnosis of patients with malignant uterine neoplasms, including leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, uterine carcinosarcoma, and endometrial cancer, with emphasis on the challenges and disadvantages. MRI plays an essential role in patients with uterine malignancy, for the purpose of tumor detection, primary staging, and treatment planning. MRI has advanced in scope beyond the visualization of the many aspects of anatomical structures, including diffusion-weighted imaging, dynamic contrast enhancement-MRI, and magnetic resonance spectroscopy. Emerging technologies coupled with the use of artificial intelligence in MRI are expected to lead to progressive improvement in case management of malignant uterine neoplasms.

Diagnostic accuracy of 3.0T diffusion-weighted MRI for patients with uterine carcinosarcoma: Assessment of tumor extent and lymphatic metastasis

BACKGROUND

Assessment of tumor extent and lymphatic metastasis of uterine carcinosarcomas is important for treatment planning.

PURPOSE/HYPOTHESIS

To evaluate the diagnostic accuracy of 3.0T diffusion-weighted (DW) MRI for patients with uterine carcinosarcoma, in assessment of tumor extent and lymphatic metastasis.

STUDY TYPE

Retrospective diagnostic accuracy study.

POPULATION

A consecutive cohort of 68 patients with pathologically proved carcinosarcoma between January 2006 and July 2014.

FIELD STRENGTH/SEQUENCE

3T DW MRI.

ASSESSMENT

Maximal tumor and uterus size, presence of deep myometrial invasion, cervical invasion, adnexal invasion, lymphadenopathy, and the apparent diffusion coefficient (ADC) values of each tumor were used. Histopathology was the gold standard.

STATISTICAL TESTS

Diagnostic accuracy. Logistic regression.

RESULTS

In all, 38 patients entered the final analysis, with median age of 58 years (range, 35-79 years). The sensitivity and specificity in detecting deep myometrial invasion, cervical stromal invasion, adnexal invasion, as well as pelvic and para-aortic lymph node metastases were 65% and 72%, 91% and 85%, 50% and 100%, 33% and 89%, and 33% and 100%, respectively. The largest tumor diameters predicted deep myometrium invasion (anteroposterior direction, P = 0.004) and cervical stroma invasion (craniocaudal direction, P = 0.008). Tumor ADCmin significantly predicted the lymphovascular permeation (P = 0.025; odds ratio = 0.96).

DATA CONCLUSION

Preoperative DW MRI is useful to assess deep myometrial or cervical stromal invasion in uterine carcinosarcoma, yet the diagnostic performance for detecting adnexal invasion and lymphatic metastasis requires further improvement.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018.

A predictive diagnostic model using multiparametric MRI for differentiating uterine carcinosarcoma from carcinoma of the uterine corpus

PURPOSE

To construct a diagnostic model for differentiating carcinosarcoma from carcinoma of the uterus.

MATERIALS AND METHODS

Twenty-six patients with carcinosarcomas and 26 with uterine corpus carcinomas constituted a derivation cohort. The following nine MRI features of the tumors were evaluated: inhomogeneity, predominant signal intensity, presence of hyper- and hypointense areas, conspicuity of tumor margin, cervical canal extension on T2WI, presence of hyperintense areas on T1WI, contrast defect area volume percentage, and degree of enhancement. Two predictive models-with and without contrast-were constructed using multivariate logistic regression analysis. Fifteen other patients with carcinosarcomas and 30 patients with carcinomas constituted a validation cohort. The sensitivity and specificity of each model for the validation cohort were calculated.

RESULTS

Inhomogeneity, predominant signal intensity on T2WI, and presence of hyperintense areas on T1WI were significant predictors in the unenhanced-MRI-based model. Presence of hyperintensity on T1WI, contrast defect area volume percentage, and degree of enhancement were significant predictors in the enhanced-MRI-based model. The sensitivity/specificity of unenhanced MRI were 87/73 and 87/70% according to reviewer 1 and 2, respectively. The sensitivity/specificity of the enhanced-MRI-based model were 87/70% according to both reviewers.

CONCLUSIONS

Our diagnostic models can differentiate carcinosarcoma from carcinoma of the uterus with high sensitivity and moderate specificity.

Carcinosarcoma of the uterus: MRI findings including diffusion-weighted imaging and MR spectroscopy

BACKGROUND

Recently carcinosarcoma has become regarded as a subset of endometrial carcinoma. Because the clinical course of carcinosarcoma is aggressive with poor prognosis, it should be differentiated from endometrial carcinomas for the appropriate surgical management and adjuvant therapy.

PURPOSE

To clarify the magnetic resonance imaging (MRI) characteristics of uterine carcinosarcoma including diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) measurement and MR spectroscopy (MRS) with quantitative metabolite evaluation.

MATERIAL AND METHODS

MRI findings of 12 pathologically diagnosed uterine carcinosarcomas obtained on 3T MRI were retrospectively evaluated. The mean and minimum ADCs, and the lipid and choline concentration levels were compared with those of pathologically diagnosed 38 endometrial carcinomas.

RESULTS

The mean and minimum ADCs in carcinosarcomas and endometrial carcinomas were not significantly different. The mean ADC of carcinosarcomas was significantly higher than that of higher grade (G2 and G3) endometrial carcinomas. The choline concentration in carcinosarcomas was significantly lower than that in endometrial carcinomas. High lipid peak was observed in 91% of carcinosarcomas and in 24% of endometrial carcinomas.

CONCLUSION

Large, exophytic heterogeneous endometrial mass containing strongly enhanced areas, which may exhibit "tumor delivery", is a suggestive of carcinosarcoma. Relatively high mean ADC and low choline concentration considering its highly malignant nature due to intra-tumoral heterogeneity with necrosis and epithelial cystic components, and the presence of necrosis-associated high lipid peak may be compatible with carcinosarcoma.

Uterine sarcoma vs adenocarcinoma: can MRI distinguish between them?

OBJECTIVE

To analyze the MRI characteristics of uterine sarcomas (mainly carcinosarcomas) and to compare them with those of adenocarcinomas to define the findings that would be useful for the differential diagnosis.

MATERIALS AND METHODS

We retrospectively reviewed the MRI studies of 13 patients with histologically diagnosed uterine sarcoma. We analyzed tumor size, signal in T2-weighted, unenhanced and gadolinium-enhanced T1-weighted, and diffusion-weighted sequences. We compared the data obtained with those of another series of 30 consecutive cases of adenocarcinomas studied with MRI.

RESULTS

The sarcomas (> 9cm in 77% of cases) were considerably larger than the adenocarcinomas (p<0.001). There were no differences in FIGO staging by MRI or surgery: both tumor types were diagnosed in early stages. The signal intensity in T2-weighted images differed significantly between the two tumor types: all the sarcomas were heterogeneous and predominantly hyperintense with respect to the myometrium in T2-weighted sequences (p<0.001). In postcontrast studies, all the sarcomas showed enhancement greater than or equal to the myometrium; this finding was significantly different from the adenocarcinomas (p<0.001). In diffusion-weighted sequences, we found no significant differences in ADC values in the areas with greatest restriction, but the ADC map was more heterogeneous in the sarcomas.

CONCLUSION

Uterine sarcomas do not have specific characteristics on MRI, but some findings can indicate the diagnosis. In our study, we found significant differences between sarcomas and adenocarcinomas. Sarcomas were larger, had more hyperintense and heterogeneous signal intensity in T2-weighted sequences, and enhanced more than or at least as much as the myometrium.

Magnetic Resonance Imaging of Benign and Malignant Uterine Neoplasms

Benign and malignant uterine masses can be seen in the women. Some of these are asymptomatic and incidentally discovered, whereas others can be symptomatic. With the soft tissue contrast resolution magnetic resonance imaging can render a definitive diagnosis, which can further help streamline patient management. In this article we show magnetic resonance imaging examples of benign and malignant masses of the uterus and their treatment strategies.

Magnetic resonance and diffusion-weighted imaging in categorization of uterine sarcomas: correlation with pathological findings

OBJECTIVES

We investigated the utility of magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) in the categorization of uterine sarcoma (US) and compared them with pathological findings.

METHODS

The baseline and MRI characteristics were recorded and compared across the subtypes of USs.

RESULTS

There were no differences in the conventional or DWI signals among the four subtypes of US, except in the heterogeneity of T2-weighted imaging. A difference in the mean apparent diffusion coefficient value for USs and uterine fibroids differed significantly (P=.019).

CONCLUSIONS

MRI characteristics showed no specific differences between any subtypes of US.

Current concepts in the imaging of uterine sarcoma

Recent advances in genetics and pathology have improved our understanding of diagnosis and staging of uterine sarcomas. The major types of uterine sarcomas include leiomyosarcoma, low-grade endometrial stromal sarcoma, undifferentiated endometrial sarcoma, adenosarcoma and carcinosarcoma. The distinctive biological behavior and poor overall survival of uterine sarcoma create challenges in the management of these tumors. We herein present a comprehensive review of taxonomy, epidemiology, pathology, imaging findings and natural history of a wide spectrum of uterine sarcomas.

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.