CT and MRI of Uterine Sarcomas and Their Mimickers

CT and MRI of Uterine Sarcomas and Their Mimickers

Sung Eun Rha¹, Jae Young Byun¹, Seung Eun Jung¹, Soo Lim Lee¹, Song Mee Cho¹, Seong Su Hwang¹, Hae Giu Lee¹, Sung-Eun Namkoong² and Jae Mun Lee¹

¹ Department of Radiology, College of Medicine, The Catholic University of Korea, 505, Banpo-Dong, Seocho-Ku, Seoul 137-040, South Korea.
² Department of Obstetrics and Gynecology, Kangnam St. Mary's Hospital, Seoul 137-040, South Korea.

View larger version (139K):

[in a new window]

Fig. 1. —67-year-old woman with malignant mixed müllerian tumor. Sagittal T2-weighted (TR/TE, 2,000/80) spin-echo image shows markedly distended endometrial cavity (E) with peripheral polypoid masses. Patient had history of pelvic irradiation for cervix carcinoma 12 years previously. These characteristic imaging features are probably caused by stenosis of cervical canal resulting from previous pelvic irradiation.

View larger version (146K):

[in a new window]

Fig. 2A. —73-year-old woman with malignant mixed müllerian tumor. Sagittal T2-weighted spin-echo image (TR/TE, 2,000/80) shows polypoid endometrial mass (M) distending uterine cavity. Bulky peritoneal mass (arrows) is also present in cul-de-sac, suggesting peritoneal metastasis.

View larger version (146K):

[in a new window]

Fig. 2B. —73-year-old woman with malignant mixed müllerian tumor. Sagittal gadolinium-enhanced fat-suppressed T1-weighted spin-echo image (583/11) shows irregular central nonenhancing necrotic portion of peritoneal mass (arrows). Almost all of these tumors occur after menopause, at median age of 62 years. Most frequent presenting symptom is bleeding. M = endometrial mass.

View larger version (144K):

[in a new window]

Fig. 3. —62-year-old woman with malignant mixed müllerian tumor. Contrast-enhanced CT scan shows markedly enlarged uterus totally replaced by mass and focal disruption of uterine margin (arrowheads). Note inhomogeneous contrast enhancement and calcification. Lobulated peritoneal mass (arrows) is noted anterior to main mass. Ascites (f) is also seen. Intraperitoneal metastases are more common than hematogenous metastases in malignant mixed müllerian tumors. Peritoneum is usually involved in more than half of cases extending beyond uterus. Extent of tumor at time of diagnosis is most important prognostic factor.

View larger version (154K):

[in a new window]

Fig. 4. —73-year-old woman with uterine leiomyosarcoma. Sagittal gadolinium-enhanced T1-weighted spin-echo image (TR/TE, 200/20) shows massive uterine enlargement (arrows) with irregular central zones of low signal intensity, suggesting extensive tumor necrosis (N). Uterine leiomyosarcoma should be suspected if rapid uterine enlargement occurs, especially in post-menopausal women. Because most leiomyosarcomas are located in myometrium, endometrial biopsy is not as useful as in other sarcomas, but it may establish diagnosis in as many as one third of patients in whom lesion is submucosal.

View larger version (141K):

[in a new window]

Fig. 5. —40-year-old woman with low-grade endometrial stromal sarcoma. Contrast-enhanced CT scan shows relatively well-defined low-density myometrial mass (arrows) that cannot be differentiated from intramural myoma on this scan. Usual preoperative diagnosis of low-grade endometrial stromal sarcoma is leiomyoma with unusual degree of bleeding. On CT scans, some cases of low-grade endometrial stromal sarcoma cannot be clearly differentiated from myoma. However, on MRI, endometrial stromal sarcoma usually has infiltrative margin and shows high-signal intensity on T2-weighted images. B = bladder.

View larger version (127K):

[in a new window]

Fig. 6A. —42-year-old woman with low-grade endometrial stromal sarcoma. Axial fat-saturated T2-weighted spin-echo image (TR/TE, 2,000/80) shows large relatively well-marginated hyperintense mass (solid arrows) in left lateral wall of uterus. Endometrial cavity is not distended (open arrows).

View larger version (172K):

[in a new window]

Fig. 6B. —42-year-old woman with low-grade endometrial stromal sarcoma. Axial gadolinium-enhanced T1-weighted image (417/11) shows multiple internal septalike enhanced areas in mass (arrows), which was located predominantly in myometrium on pathologic examination. Presence of bands of low signal intensity in areas of myometrial involvement of low-grade endometrial stromal sarcoma on T2-weighted images may be important imaging finding for low-grade endometrial stromal sarcoma. Pathologically, this imaging finding is considered to be preserved myometrial bundles separated by tumor cells.

View larger version (145K):

[in a new window]

Fig. 7A. —58-year-old woman with high-grade endometrial stromal sarcoma. B = bladder, C = ovarian cyst. Sagittal T1-weighted gradient-echo FLASH image (TR/TE, 162.3/4.8; flip angle, 80°) shows enlarged uterus with large homogeneous low-signal-intensity mass located mainly in endometrial cavity.

View larger version (153K):

[in a new window]

Fig. 7B. —58-year-old woman with high-grade endometrial stromal sarcoma. B = bladder, C = ovarian cyst. Sagittal T2-weighted turbo spin-echo image (3,900/99) shows inhomogeneous increased signal intensity of mass (arrowheads). Note focal invasion of deep myometrium (arrow).

View larger version (159K):

[in a new window]

Fig. 7C. —58-year-old woman with high-grade endometrial stromal sarcoma. B = bladder, C = ovarian cyst. Gadolinium-enhanced T1-weighted image (162.3/4.8) shows inhomogeneous contrast enhancement of mass. Gross specimen (not shown) showed lobulated mass resembling fish flesh with hemorrhage and necrosis.

View larger version (129K):

[in a new window]

Fig. 8A. —High-grade endometrial stromal sarcoma in 20-year-old woman who had profuse vaginal bleeding. (Reprinted with permission from [9]) Axial T2 -weighted turbo spin-echo image (TR/TE, 3,900/99) shows bulky lobulated intracavitary mass (arrows). Tumor invasion of entire thickness of myometrium at right-sided fundus (arrowhead) is well visualized.

View larger version (157K):

[in a new window]

Fig. 8B. —High-grade endometrial stromal sarcoma in 20-year-old woman who had profuse vaginal bleeding. (Reprinted with permission from [9]) Axial contrast-enhanced T1-weighted image (450/13) shows inhomogeneous contrast enhancement of uterine mass (straight arrows) that extends through entire thickness of myometrium (arrowhead). Endometrial cavity is mildly widened (curved arrow). Diagnosis can be confirmed by endometrial biopsy.

View larger version (161K):

[in a new window]

Fig. 9. —65-year-old woman with advanced endometrial carcinoma. Sagittal T2-weighted turbo spin-echo image (TR/TE, 3,900/99) shows enlarged uterus and diffuse tumor involving entire endometrial surface. Hydrometra (E) is also present. Large amount of ascites (A) and peritoneal metastases (arrows) are also seen. Advanced endometrial carcinoma cannot be clearly differentiated from malignant mixed müllerian tumor on images. However, in practice, most patients with endometrial carcinomas have tumors that are confined to endometrium or that only superficially invade myometrium, and most malignant mixed müllerian tumors or endometrial stromal sarcomas tend to be massive with deep myometrial invasion on initial presentation.

View larger version (142K):

[in a new window]

Fig. 10A. —48-year-old woman with uterine lymphoma. Contrast-enhanced CT scan shows diffuse enlargement of uterus and several small low-attenuation nodules.

View larger version (109K):

[in a new window]

Fig. 10B. —48-year-old woman with uterine lymphoma. Contrast-enhanced CT scan obtained at level above A shows multiple small, nodular low-density lesions in both kidneys, suggesting multinodular form of renal lymphoma. Although imaging findings of lymphoma involving uterus are nonspecific, diffuse uterine enlargement, somewhat lobular contour, and relatively homogeneous attenuation with multiple lymphadenopathy, can suggest lymphoma involvement of uterus.

View larger version (129K):

[in a new window]

Fig. 11A. —37-year-old woman with IV leiomyomatosis. Axial T2-weighted image (TR/TE, 2000/80) shows lobulated high-signal-intensity mass in right side of uterine body and another mass with same features in right adnexa.

View larger version (148K):

[in a new window]

Fig. 11B. —37-year-old woman with IV leiomyomatosis. Axial T2-weighted image (2,000/80) caudal to A shows that parametrial mass extends out from uterine mass. Pathology confirmed diagnosis of IV leiomyomatosis. IV leiomyomatosis is characterized by growth of histologically benign smooth muscle initially into venous channels within broad ligament and then into uterine and iliac veins. This IV growth takes form of visible, wormlike projections extending out from a myomatous uterus into parametria toward pelvic sidewalls. IV extension of endometrial stromal sarcoma must be considered in differential diagnosis.

View larger version (138K):

[in a new window]

Fig. 12. —35-year-old woman with focal adenomyosis. Sagittal T2-weighted turbo spin-echo image (TR/TE, 3,900/99) shows ill-defined circumscribed area of low signal intensity in posterior wall of uterine body. Multiple punctate foci of high signal intensity (arrowheads) that are thought to represent hemorrhagic endometrial nests are scattered throughout mass. These foci were also seen on T1-weighted images (not shown). In contrast to adenomyosis, endometrial stromal sarcoma exhibits high signal intensity on T2-weighted images.

View larger version (135K):

[in a new window]

Fig. 13A. —42-year-old woman who has intramural leiomyoma with myxoid and cellular degeneration. Sagittal T2-weighted turbo spin-echo image (TR/TE, 3,900/99) shows well-defined intramural mass (arrows) with high signal intensity peripherally and irregular isointensity of signal in myometrium centrally.

View larger version (134K):

[in a new window]

Fig. 13B. —42-year-old woman who has intramural leiomyoma with myxoid and cellular degeneration. Gadolinium-enhanced T1-weighted image shows poor enhancement of periphery of mass and homogeneous enhancement of central portion of mass (arrows). Pathologically, mass was identified as intramural leiomyoma, its central portion showed cellular degeneration, and its periphery showed myxoid degeneration. Degenerated myoma may mimic imaging findings of uterine sarcomas.

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

Technorati What's this?