“Sonography findings spurring suspicion for a confirmed case of Leiomyosarcoma: A Case Report”

“Sonography findings spurring suspicion for a confirmed case of Leiomyosarcoma: A Case Report” | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report “Sonography findings spurring suspicion for a confirmed case of Leiomyosarcoma: A Case Report” Temiloluwa Adejuyigbe, Anh Vi Burgess, Brandon Nguyen, Brooke Andrews, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5327515/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Differentiating degenerating leiomyomas and malignant leiomyosarcomas is often difficult, given the lack of criteria for imaging findings and difficulty in reliably sampling myometrial neoplasms of the uterus. Case : We present the case of using a transvaginal ultrasound to evaluate for characteristics of leiomyosarcoma prior to further referral of a patient to gynecology oncology for hysterectomy, with final pathology confirming a leiomyosarcoma. Conclusions: Ultrasound findings of uterine masses that include a large mass with heterogeneous tissue, irregular loculated spaces in combination with increased vascularity and symptoms of pelvic pain and abnormal uterine bleeding, as described in this case, can support a suspicion of and further investigation for malignancy. In addition, further evaluation of ultrasound as a modality to evaluate vascularity in atypical uterine masses is supported by this presentation Leiomyosarcoma risk stratification ultrasound uterine mass Background Uterine leiomyosarcoma (LMS) is a rare, malignant smooth muscle neoplasm with an estimated incidence of 0.36 per 100,000 woman–years [ 1 ]. Given that LMS have similar presenting symptoms as benign smooth muscle neoplasms, it is difficult to reliably distinguish them clinically from benign leiomyomas prior to pathologic distinction. Although LMS is rare, it is important to identify LMS because of its poor prognosis. Unfortunately, there are currently no reliable methods for distinguishing malignant smooth muscle tumors from benign tumors prior to surgical removal [ 2 ]. Proper identification of potential LMS is important to adequately determine the optimal approach for surgical therapy for these patients. At this time, many preoperative pelvic sarcomas are imaged using MRI with intravenous contrast; however, no imaging modality has been established as the gold standard as of yet. Objective criteria on MRI are poorly specific for differentiating atypical leiomyomas from malignancy; although progress is being made in identifying qualitative findings on MRIs that may be more suggestive, this process is not validated yet [ 3 , 4 , 5 ]. CT is also unreliable; it is less specific in determining both myometrial masses and pelvic anatomy than MRI [ 6 ]. Histopathologic evaluation with endometrial biopsy has also proved to be non-diagnostic in these cases. Given these challenges, the majority of leiomyosarcomas are diagnosed at time of hysterectomy [ 7 ]. This approach is less than ideal for patients given the possibility of iatrogenic seeding during removal when not performed en-bloc, contributing to already poor outcomes [ 8 ]. Concerns about seeding have led to a large abandonment of uncontained power morcellation that assist in minimally invasive tissue extraction techniques for enlarged fibroid uteri. This effect has had the unintended consequence of increased uptake for laparotomic approach to hysterectomy, with associated increased perioperative complication rates [ 9 ]. Given that ultrasounds are typically more easily accessible and cheaper for patients, establishing ultrasound characteristics that are suspicious for malignancy in the case of myometrial masses is imperative. There is a broad differential diagnosis for leiomyomas and their variants, including adenomyomas, neuroendocrine tumors, and other sarcomas. Thus, further study of ultrasonography and findings to differentiate high-risk versus low-risk myometrial masses is necessary to both improve outcomes from leiomyosarcomas and decrease surgical complications for benign masses. The present case discusses the presentation, subsequent workup using sonography and therapy of a 49-year-old patient with a myometrial mass later confirmed via pathology as leiomyosarcoma. Case Presentation A 49-year-old woman presented to her primary care provider with a chief complaint of lower abdominal pain. She had no significant past personal or family medical history, no history of STIs or abnormal pap smears, and had one previous pregnancy resulting in a cesarean section. Informed consent was obtained for the analysis and writing of this case. She reported multiple months of intermittent right lower quadrant abdominal pain that intensified over time, with dyspareunia, intermittent constipation, and urinary incontinence. She also reported that her periods had become irregular, heavy, painful, and lasting for up to 3 weeks at a time. A CT pelvis authorized by an outside clinic the previous month demonstrated a 9.5 cm cystic structure with peripheral enhancement and calcifications at the uterine fundus, with an unremarkable body and cervix, and no peritoneal carcinomatosis or retroperitoneal lymphadenopathy. At that time, she was referred to our general gynecology clinic for further evaluation. Her initial gynecology visit revealed a 16–18 week mobile uterus with a 10 cm tender mass at the fundus. An endometrial biopsy at this visit showed weakly proliferative endometrium with stromal breakdown. There was no malignancy or hyperplasia noted. Gynecology performed a transvaginal ultrasound (GE Voluson S10, wideband microconvex endocavitary probe 2.9–9.7 MHz, Chicago, USA) that revealed a large heterogeneous mass measuring 9x11 cm from the posterior wall of the uterus involving complete thickness of the myometrial wall (see Leiomyosarcoma Case Report.mov). There were large irregular loculated spaces and increased vascularity within the uterine mass. Evaluation of the ovaries was limited due to mass effect. No free fluid or ascites was noted. Given these concerning ultrasound findings, the patient was referred to gynecologic oncology. Upon referral to gynecologic oncology, she underwent a CT chest which showed no evidence of metastatic disease in the chest; however, she had a nonspecific 4.6 mm mass in the spleen. Additional MRI of the pelvis noted that the endometrial cavity was severely distended with hemorrhagic fluid and thick irregular marginal enhancing tissue concerning for endometrial malignancy. There was significant myometrial thinning, but no serosal invasion or pelvic metastatic disease. The patient underwent a total abdominal hysterectomy with bilateral salpingectomy with frozen section. No adnexal masses or hepatic nodules were noted, with normal appearing ovaries and fallopian tubes. Frozen section returned as spindle cell neoplasm with possible increased mitotic activity. Following the hysterectomy, final pathology results revealed a Stage 1B Uterine Leiomyosarcoma. Based on National Comprehensive Cancer Network Guidelines [ 10 ], no adjuvant treatment was recommended, and she was counseled to undergo surveillance per NCCN guidelines. Following surgery, the patient underwent an MRI pelvis to further evaluate the non-specific splenic mass and this revealed no remarkable findings; she had a follow-up CT four months after surgery with no evidence of disease, with stability noted of the splenic mass. To date, she will continue to have CTs performed every 3–4 months for 2–3 years, and then every 6–12 months following. Discussion and Conclusions Sonography can be highly informative on risk stratification for leiomyosarcomas versus other masses. As seen in the video, intralesional vascularity was easily identified. A 2007 review of sonographic findings for uterine sarcomas found that in patients with leiomyosarcomas, compared to patients with benign leiomyomas, leiomyosarcomas were significantly larger than other masses, were all solitary, and had lesions greater than or equal to 8 cm [ 11 ]. Degenerative cystic changes were observed in half of the cases reviewed, and increased vascularity of lesions was demonstrated in almost 90% of cases [ 11 ]. Further, a 2019 retrospective study that evaluated ultrasonographic findings of 116 patients with uterine sarcomas found that the median size of the largest tumor was 9.1 cm, 77% of sarcomas had inhomogeneous tissue, cystic areas were described in 44%, and moderate or rich vascularization was found in 44% of cases [ 12 ]. In a 2021 review of uterine leiomyosarcomas and ultrasound features, 78% of diagnosed leiomyosarcomas had mild to moderate intralesional vascularity [ 13 ]. Our report is in line with this literature and should encourage the revisitation of further research using sonography to evaluate for leiomyosarcomas, particularly as technology continues to advance rapidly. Ultrasound findings of uterine masses that include a large mass with heterogeneous tissue, irregular loculated spaces in combination with increased vascularity and symptoms of pelvic pain and abnormal uterine bleeding, as described in this case, can support a suspicion of and further investigation for malignancy. In addition, further evaluation of ultrasound as a modality to evaluate vascularity in atypical uterine masses is supported by this presentation. In particular, this patient’s ultrasound findings of severely increased vascularity and irregular loculated spaces with increased color flow spurred a concern for malignancy and immediate referral to gynecologic oncology. Because of this, her primary surgery was completed by the appropriate specialist and had no delays in care with an early stage of detection. Declarations Ethics approval and consent to participate and publish: This case was written in accordance with the standards established by the University of Texas IRB. The patient provided consent to the write-up of this article. Availability of data and materials: Not applicable. Competing interests: The authors have no conflicts of interest to report. This article has not been previously published and is not under consideration at any other journal. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: TA and AVB drafted the case presentation and discussion, and BA, CS, and MYWB provided key discussion points as well as critical oversight. BN compiled the images with commentary. Acknowledgements: The authors would like to thank CommUnity Care and the University of Texas at Austin. References Toro JR, Travis LB, Wu HJ, Zhu K, Fletcher CD, Devesa SS. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978–2001: An analysis of 26,758 cases. Int J Cancer. 2006;119(12):2922–30. 10.1002/ijc.22239 . Tantitamit T, Huang KG, Manopunya M, Yen CF. Outcome and Management of Uterine Leiomyosarcoma Treated Following Surgery for Presumed Benign Disease: Review of Literature. Gynecol Minim Invasive Ther. 2018;7(2):47–55. 10.4103/GMIT.GMIT_10_18 . Cornfeld D, Israel G, Martel M, Weinreb J, Schwartz P, McCarthy S. MRI appearance of mesenchymal tumors of the uterus. Eur J Radiol. 2010;74(1):241–9. 10.1016/j.ejrad.2009.03.005 . Lakhman Y, Veeraraghavan H, Chaim J, et al. Differentiation of Uterine Leiomyosarcoma from Atypical Leiomyoma: Diagnostic Accuracy of Qualitative MR Imaging Features and Feasibility of Texture Analysis. Eur Radiol. 2017;27(7):2903–15. 10.1007/s00330-016-4623-9 . Kaganov H, Ades A, Fraser DS, PREOPERATIVE MAGNETIC RESONANCE IMAGING DIAGNOSTIC FEATURES OF UTERINE. LEIOMYOSARCOMAS: A SYSTEMATIC REVIEW. Int J Technol Assess Health Care. 2018;34(2):172–9. 10.1017/S0266462318000168 . DeMulder D, Ascher SM. Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment? AJR Am J Roentgenol. 2018;211(6):1405–15. 10.2214/AJR.17.19234 . George S, Serrano C, Hensley ML, Ray-Coquard I. Soft Tissue and Uterine Leiomyosarcoma. J Clin Oncol. 2018;36(2):144–50. 10.1200/JCO.2017.75.9845 . George S, Barysauskas C, Serrano C, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer. 2014;120(20):3154–8. 10.1002/cncr.28844 . Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822 [published correction appears in Obstet Gynecol. 2021;138(2):313]. Obstet Gynecol. 2021;137(3):e63-e74. 10.1097/AOG.0000000000004291 National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. Uterine Neoplasms, Version 1.2024. Updated September 20, 2023. https://www.nccn.org/guidelines/category_1 Exacoustos C, Romanini ME, Amadio A, et al. Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma? J Clin Ultrasound. 2007;35(8):449–57. 10.1002/jcu.20386 . Ludovisi M, Moro F, Pasciuto T, et al. Imaging in gynecological disease (15): clinical and ultrasound characteristics of uterine sarcoma. Ultrasound Obstet Gynecol. 2019;54(5):676–87. 10.1002/uog.20270 . Russo C, Camilli S, Martire FG, et al. Ultrasound features of highly vascularized uterine myomas (uterine smooth muscle tumors) and correlation with histopathology. Ultrasound Obstet Gynecol. 2022;60(2):269–76. 10.1002/uog.24855 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Oct, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 24 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5327515","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":370311888,"identity":"d7f5cc89-02dd-4eb7-b715-8697278888c5","order_by":0,"name":"Temiloluwa Adejuyigbe","email":"data:image/png;base64,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","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":true,"prefix":"","firstName":"Temiloluwa","middleName":"","lastName":"Adejuyigbe","suffix":""},{"id":370311889,"identity":"acc72727-ea42-4915-84c6-dadf32f00bd1","order_by":1,"name":"Anh Vi Burgess","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Anh","middleName":"Vi","lastName":"Burgess","suffix":""},{"id":370311891,"identity":"a29ff87a-d308-4ac9-9320-80a1bdd9c2ad","order_by":2,"name":"Brandon Nguyen","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Brandon","middleName":"","lastName":"Nguyen","suffix":""},{"id":370311892,"identity":"b6ae3fef-3e49-4968-a2d4-2aaae8e95294","order_by":3,"name":"Brooke Andrews","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Brooke","middleName":"","lastName":"Andrews","suffix":""},{"id":370311893,"identity":"2fab8249-1142-4050-833d-4eca0b65c528","order_by":4,"name":"Christina Salazar","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"","lastName":"Salazar","suffix":""},{"id":370311895,"identity":"dfc57d57-e924-4347-9ffa-0b965cc69208","order_by":5,"name":"Marian Yvette WIlliams-Brown","email":"","orcid":"","institution":"The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Marian","middleName":"Yvette","lastName":"WIlliams-Brown","suffix":""}],"badges":[],"createdAt":"2024-10-24 16:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5327515/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5327515/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68364832,"identity":"88ced5d4-6b42-4892-8ca2-bbe93275d89e","added_by":"auto","created_at":"2024-11-06 13:03:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":208837,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5327515/v1/97002b78-883d-4316-bb70-d586bf498592.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Sonography findings spurring suspicion for a confirmed case of Leiomyosarcoma: A Case Report”","fulltext":[{"header":"Background","content":"\u003cp\u003eUterine leiomyosarcoma (LMS) is a rare, malignant smooth muscle neoplasm with an estimated incidence of 0.36 per 100,000 woman\u0026ndash;years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Given that LMS have similar presenting symptoms as benign smooth muscle neoplasms, it is difficult to reliably distinguish them clinically from benign leiomyomas prior to pathologic distinction. Although LMS is rare, it is important to identify LMS because of its poor prognosis. Unfortunately, there are currently no reliable methods for distinguishing malignant smooth muscle tumors from benign tumors prior to surgical removal [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Proper identification of potential LMS is important to adequately determine the optimal approach for surgical therapy for these patients.\u003c/p\u003e \u003cp\u003eAt this time, many preoperative pelvic sarcomas are imaged using MRI with intravenous contrast; however, no imaging modality has been established as the gold standard as of yet. Objective criteria on MRI are poorly specific for differentiating atypical leiomyomas from malignancy; although progress is being made in identifying qualitative findings on MRIs that may be more suggestive, this process is not validated yet [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. CT is also unreliable; it is less specific in determining both myometrial masses and pelvic anatomy than MRI [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Histopathologic evaluation with endometrial biopsy has also proved to be non-diagnostic in these cases. Given these challenges, the majority of leiomyosarcomas are diagnosed at time of hysterectomy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This approach is less than ideal for patients given the possibility of iatrogenic seeding during removal when not performed en-bloc, contributing to already poor outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Concerns about seeding have led to a large abandonment of uncontained power morcellation that assist in minimally invasive tissue extraction techniques for enlarged fibroid uteri. This effect has had the unintended consequence of increased uptake for laparotomic approach to hysterectomy, with associated increased perioperative complication rates [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven that ultrasounds are typically more easily accessible and cheaper for patients, establishing ultrasound characteristics that are suspicious for malignancy in the case of myometrial masses is imperative. There is a broad differential diagnosis for leiomyomas and their variants, including adenomyomas, neuroendocrine tumors, and other sarcomas.\u003c/p\u003e \u003cp\u003eThus, further study of ultrasonography and findings to differentiate high-risk versus low-risk myometrial masses is necessary to both improve outcomes from leiomyosarcomas and decrease surgical complications for benign masses. The present case discusses the presentation, subsequent workup using sonography and therapy of a 49-year-old patient with a myometrial mass later confirmed via pathology as leiomyosarcoma.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 49-year-old woman presented to her primary care provider with a chief complaint of lower abdominal pain. She had no significant past personal or family medical history, no history of STIs or abnormal pap smears, and had one previous pregnancy resulting in a cesarean section. Informed consent was obtained for the analysis and writing of this case.\u003c/p\u003e \u003cp\u003eShe reported multiple months of intermittent right lower quadrant abdominal pain that intensified over time, with dyspareunia, intermittent constipation, and urinary incontinence. She also reported that her periods had become irregular, heavy, painful, and lasting for up to 3 weeks at a time. A CT pelvis authorized by an outside clinic the previous month demonstrated a 9.5 cm cystic structure with peripheral enhancement and calcifications at the uterine fundus, with an unremarkable body and cervix, and no peritoneal carcinomatosis or retroperitoneal lymphadenopathy. At that time, she was referred to our general gynecology clinic for further evaluation.\u003c/p\u003e \u003cp\u003eHer initial gynecology visit revealed a 16–18 week mobile uterus with a 10 cm tender mass at the fundus. An endometrial biopsy at this visit showed weakly proliferative endometrium with stromal breakdown. There was no malignancy or hyperplasia noted.\u003c/p\u003e \u003cp\u003eGynecology performed a transvaginal ultrasound (GE Voluson S10, wideband microconvex endocavitary probe 2.9–9.7 MHz, Chicago, USA) that revealed a large heterogeneous mass measuring 9x11 cm from the posterior wall of the uterus involving complete thickness of the myometrial wall (see Leiomyosarcoma Case Report.mov). There were large irregular loculated spaces and increased vascularity within the uterine mass. Evaluation of the ovaries was limited due to mass effect. No free fluid or ascites was noted. Given these concerning ultrasound findings, the patient was referred to gynecologic oncology.\u003c/p\u003e \u003cp\u003eUpon referral to gynecologic oncology, she underwent a CT chest which showed no evidence of metastatic disease in the chest; however, she had a nonspecific 4.6 mm mass in the spleen. Additional MRI of the pelvis noted that the endometrial cavity was severely distended with hemorrhagic fluid and thick irregular marginal enhancing tissue concerning for endometrial malignancy. There was significant myometrial thinning, but no serosal invasion or pelvic metastatic disease.\u003c/p\u003e \u003cp\u003eThe patient underwent a total abdominal hysterectomy with bilateral salpingectomy with frozen section. No adnexal masses or hepatic nodules were noted, with normal appearing ovaries and fallopian tubes. Frozen section returned as spindle cell neoplasm with possible increased mitotic activity.\u003c/p\u003e \u003cp\u003eFollowing the hysterectomy, final pathology results revealed a Stage 1B Uterine Leiomyosarcoma. Based on National Comprehensive Cancer Network Guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], no adjuvant treatment was recommended, and she was counseled to undergo surveillance per NCCN guidelines. Following surgery, the patient underwent an MRI pelvis to further evaluate the non-specific splenic mass and this revealed no remarkable findings; she had a follow-up CT four months after surgery with no evidence of disease, with stability noted of the splenic mass. To date, she will continue to have CTs performed every 3–4 months for 2–3 years, and then every 6–12 months following.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eSonography can be highly informative on risk stratification for leiomyosarcomas versus other masses. As seen in the video, intralesional vascularity was easily identified. A 2007 review of sonographic findings for uterine sarcomas found that in patients with leiomyosarcomas, compared to patients with benign leiomyomas, leiomyosarcomas were significantly larger than other masses, were all solitary, and had lesions greater than or equal to 8 cm [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Degenerative cystic changes were observed in half of the cases reviewed, and increased vascularity of lesions was demonstrated in almost 90% of cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Further, a 2019 retrospective study that evaluated ultrasonographic findings of 116 patients with uterine sarcomas found that the median size of the largest tumor was 9.1 cm, 77% of sarcomas had inhomogeneous tissue, cystic areas were described in 44%, and moderate or rich vascularization was found in 44% of cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In a 2021 review of uterine leiomyosarcomas and ultrasound features, 78% of diagnosed leiomyosarcomas had mild to moderate intralesional vascularity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our report is in line with this literature and should encourage the revisitation of further research using sonography to evaluate for leiomyosarcomas, particularly as technology continues to advance rapidly.\u003c/p\u003e\u003cp\u003eUltrasound findings of uterine masses that include a large mass with heterogeneous tissue, irregular loculated spaces in combination with increased vascularity and symptoms of pelvic pain and abnormal uterine bleeding, as described in this case, can support a suspicion of and further investigation for malignancy. In addition, further evaluation of ultrasound as a modality to evaluate vascularity in atypical uterine masses is supported by this presentation. In particular, this patient’s ultrasound findings of severely increased vascularity and irregular loculated spaces with increased color flow spurred a concern for malignancy and immediate referral to gynecologic oncology. Because of this, her primary surgery was completed by the appropriate specialist and had no delays in care with an early stage of detection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate and publish: This case was written in accordance with the standards established by the University of Texas IRB. The patient provided consent to the write-up of this article.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Not applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no conflicts of interest to report. This article has not been previously published and is not under consideration at any other journal.\u003c/p\u003e\n\u003cp\u003eFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: TA \u0026nbsp;and AVB drafted the case presentation and discussion, and BA, CS, and MYWB \u0026nbsp;provided key discussion points as well as critical oversight. BN compiled the images with commentary.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to thank CommUnity Care and the University of Texas at Austin.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eToro JR, Travis LB, Wu HJ, Zhu K, Fletcher CD, Devesa SS. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978\u0026ndash;2001: An analysis of 26,758 cases. Int J Cancer. 2006;119(12):2922\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.22239\u003c/span\u003e\u003cspan address=\"10.1002/ijc.22239\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTantitamit T, Huang KG, Manopunya M, Yen CF. Outcome and Management of Uterine Leiomyosarcoma Treated Following Surgery for Presumed Benign Disease: Review of Literature. Gynecol Minim Invasive Ther. 2018;7(2):47\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/GMIT.GMIT_10_18\u003c/span\u003e\u003cspan address=\"10.4103/GMIT.GMIT_10_18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornfeld D, Israel G, Martel M, Weinreb J, Schwartz P, McCarthy S. MRI appearance of mesenchymal tumors of the uterus. 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Ultrasound Obstet Gynecol. 2022;60(2):269\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/uog.24855\u003c/span\u003e\u003cspan address=\"10.1002/uog.24855\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Leiomyosarcoma, risk stratification, ultrasound, uterine mass","lastPublishedDoi":"10.21203/rs.3.rs-5327515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5327515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Differentiating degenerating leiomyomas and malignant leiomyosarcomas is often difficult, given the lack of criteria for imaging findings and difficulty in reliably sampling myometrial neoplasms of the uterus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase\u003c/strong\u003e: We present the case of using a transvaginal ultrasound to evaluate for characteristics of leiomyosarcoma prior to further referral of a patient to gynecology oncology for hysterectomy, with final pathology confirming a leiomyosarcoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eUltrasound findings of uterine masses that include a large mass with heterogeneous tissue, irregular loculated spaces in combination with increased vascularity and symptoms of pelvic pain and abnormal uterine bleeding, as described in this case, can support a suspicion of and further investigation for malignancy. In addition, further evaluation of ultrasound as a modality to evaluate vascularity in atypical uterine masses is supported by this presentation\u003c/p\u003e","manuscriptTitle":"“Sonography findings spurring suspicion for a confirmed case of Leiomyosarcoma: A Case Report”","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 13:02:59","doi":"10.21203/rs.3.rs-5327515/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-25T08:56:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-25T07:41:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-25T07:38:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2024-10-24T16:41:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c08c2768-2633-4700-ac0a-c9592144b224","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-12-19T07:11:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-06 13:02:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5327515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5327515","identity":"rs-5327515","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}