MR imaging findings of unusual leiomyoma and malignant uterine myometrial tumors: what the radiologist should know

Uterine sarcomas account for less than 1% of gynecological malignancies and 2–5% of all uterine malignancies. Such sarcomas mainly include leiomyosarcoma (LMS) and endometrial stromal sarcoma (ESS). Additionally, inflammatory myofibroblastic tumor (IMT) and endometrial carcinoma arising in adenomyosis can occur as uterine myometrial tumors. Their differentiation from leiomyoma (LM), particularly degenerated LM and the malignant tumors, is challenging, but preoperative diagnosis is very important for the patient’s management. We demonstrate the useful and compulsory findings to differentiate between uterine myometrial malignant tumors and degenerated LM with an unusual appearance. Similar content being viewed by others

Oliva E, Zaloudek CJ, Soslow RA. Mesenchymal tumors of the uterus. In: Kurman RJ, Ronnett BM, Ellenson L, editors. Blaustein’s pathology of the female tract. New York: Springer; 2019. p. 535–647. Paul PG, Rengaraj V, Das T, Garg R, Thomas M, Khurd AS. Uterine sarcomas in patients undergoing surgery for presumed leiomyomas: 10 years’ experience. J Minim Invasive Gynecol. 2016;23:384–9. Lakhman Y, Veeraraghavan H, Chaim J, Feier D, Goldman DA, Moskowitz CS, et al. Differentiation of uterine leiomyosarcoma from atypical leiomyoma: diagnostic accuracy of qualitative mr imaging features and feasibility of texture analysis. Eur Radiol. 2017;27:2903–15. Ando T, Kato H, Furui T, Morishige KI, Goshima S, Matsuo M. Uterine smooth muscle tumours with hyperintense area on T1 weighted images: differentiation between leiomyosarcomas and leiomyomas. Br J Radiol. 2018;91:20170767. Lin G, Yang LY, Huang YT, Ng KK, Ng SH, Ueng SH, et al. Comparison of the diagnostic accuracy of contrast-enhanced MRI and diffusion-weighted MRI in the differentiation between uterine leiomyosarcoma /smooth muscle tumor with uncertain malignant potential and benign leiomyoma. J Magn Reson Imaging. 2016;43:333–42. Tamai K, Koyama T, Saga T, Morisawa N, Fujimoto K, Mikami Y, et al. The utility of diffusion-weighted MR imaging for differentiating uterine sarcomas from benign leiomyomas. Eur Radiol. 2008;18:723–30. Takeuchi M, Matsuzaki K, Nishitani H. Hyperintense uterine myometrial masses on T2-weighted magnetic resonance imaging: differentiation with diffusion-weighted magnetic resonance imaging. J Comput Assist Tomogr. 2009;33:834–7. Namimoto T, Yamashita Y, Awai K, Nakaura T, Yanaga Y, Hirai T, et al. Combined use of T2-weighted and diffusion-weighted 3-T MR imaging for differentiating uterine sarcomas from benign leiomyomas. Eur Radiol. 2009;19:2756–64. Tasaki A, Asatani MO, Umezu H, Kashima K, Enomoto T, Yoshimura N, et al. Differential diagnosis of uterine smooth muscle tumors using diffusion-weighted imaging: correlations with the apparent diffusion coefficient and cell density. Abdom Imaging. 2015;40:1742–52. Sato K, Yuasa N, Fujita M, Fukushima Y. Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma. Am J Obstet Gynecol. 2014;210(368):e1-8. Ochiai R, Fujii S, Kudo A, Mukuda N, Murakami A, Fukunaga T, et al. A case of uterine leiomyosarcoma mimicking red degeneration. Rinshouhoushasen. 2019;64:1549–54 ((in Japanese)). Koyama T, Togashi K, Konishi I, Kobayashi H, Ueda H, Kataoka ML, et al. MR imaging of endometrial stromal sarcoma: correlation with pathologic findings. AJR Am J Roentgenol. 1999;173:767–72. Furukawa R, Akahane M, Yamada H, Kiryu S, Sato J, Komatsu S, et al. Endometrial stromal sarcoma located in the myometrium with a low-intensity rim on T2-weighted images: report of three cases and literature review. J Magn Reson Imaging. 2010;31:975–9. Fujii S, Nosaka K, Mukuda N, Fukunaga T, Sato S, Ogawa T. MR Imaging of an intramural adenosarcoma with pathologic correlation. Magn Reson Med Sci. 2018;17:1–2. Huang YL, Ueng SH, Chen K, Huang YT, Lu HY, Ng KK, et al. Utility of diffusion-weighted and contrast-enhanced magnetic resonance imaging in diagnosing and differentiating between high- and low-grade uterine endometrial stromal sarcoma. Cancer Imaging. 2019;19:63. Kim TH, Kim JW, Kim SY, Kim SH, Cho JY. What MRI features suspect malignant pure mesenchymal uterine tumors rather than uterine leiomyoma with cystic degeneration? J Gynecol Oncol. 2018;29:e26. Li HM, Liu J, Qiang JW, Gu WY, Zhang GF, Ma FH. Endometrial stromal sarcoma of the uterus: magnetic resonance imaging findings including apparent diffusion coefficient value and its correlation with Ki-67 Expression. Int J Gynecol Cancer. 2017;27:1877–87. Fujii S, Kaneda S, Tsukamoto K, Kakite S, Kanasaki Y, Matsusue E, et al. Diffusion-weighted imaging of uterine endometrial stromal sarcoma: a report of 2 cases. J Comput Assist Tomogr. 2010;34:377–9. Takahashi A, Kurosawa M, Uemura M, Kitazawa J, Hayashi Y. Anaplastic lymphoma kinase-negative uterine inflammatory myofibroblastic tumor containing the ETV6-NTRK3 fusion gene: a case report. J Int Med Res. 2018;46:3498–503. Mohammad N, Haimes JD, Mishkin S, Kudlow BA, Leong MY, Chew SH, et al. ALK is a specific diagnostic marker for inflammatory myofibroblastic tumor of the uterus. Am J Surg Pathol. 2018;42:1353–9. Parra-Herran C, Lee CH, Bennett JA, Rebban JT. Inflammatory myofibroblastic tumour WHO classification of tumours Editorial Board WHO classification of tumours of female reproductive organs. Lyon: International Agency for Research on Cancer; 2020. Horger M, Pfannenberg C, Bitzer M, Wehrmann M, Claussen CD. Synchronous gastrointestinal and musculoskeletal manifestations of different subtypes of inflammatory myofibroblastic tumor: CT MRI and pathological features. Eur Radiol. 2005;15:1713–6. Koshiyama M, Suzuki A, Ozawa M, Fujita K, Sakakibara A, Kawamura M, et al. Adenocarcinomas arising from uterine adenomyosis: a report of four cases. Int J Gynecol Pathol. 2002;21:239–45. Colman HI, Rosenthal AH. Carcinoma developing in areas of adenomyosis. Obstet Gynecol. 1959;14:342–8. Tamai K, Togashi K, Ito T, Morisawa N, Fujiwara T, Koyama T. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. 2005;25:21–40. Hachiya K, Kato H, Kawaguchi S, Kojima T, Nishikawa Y, Fujiwara S, et al. Red degeneration of a uterine fibroid following the administration of gonadotropin releasing hormone agonists. J Obstet Gynaecol. 2016;36:1018–9. Kawakami S, Togashi K, Konishi I, Kimura I, Fukuoka M, Mori T, et al. Red degeneration of uterine leiomyoma: MR appearance. J Comput Assist Tomogr. 1994;18:925–8. Nakai G, Yamada T, Hamada T, Atsukawa N, Tanaka Y, Yamamoto K, et al. Pathological findings of uterine tumors preoperatively diagnosed as red degeneration of leiomyoma by MRI. Abdom Radiol (NY). 2017;42:1825–31. Ueda H, Togashi K, Konishi I, Kataoka ML, Koyama T, Fujiwara T, et al. Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics. 1999;19:131–45. Akbulut M, Gündoğan M, Yörükoğlu A. Clinical and pathological features of lipoleiomyoma of the uterine corpus: a review of 76 cases. Balkan Med J. 2014;31:224–9. Kitajima K, Kaji Y, Imanaka K, Sugihara R, Sugimura K. MRI findings of uterine lipoleiomyoma correlated with pathologic findings. AJR Am J Roentgenol. 2007;189:W100–4. Ono H, Kanematsu M, Kato H, Toyoki H, Hayasaki Y, Furui T, et al. MR imaging findings of uterine pyomyoma: radiologic-pathologic correlation. Abdom Imaging. 2014;39:797–801. Haimes AB, Zimmerman RD, Morgello S, Weingarten K, Becker RD, Jennis R, et al. MR imaging of brain abscesses. AJR Am J Roentgenol. 1989;152:1073–85. Yamashita Y, Torashima M, Takahashi M, Tanaka N, Katabuchi H, Miyazaki K, et al. Hyperintense uterine leiomyoma at T2-weighted MR imaging: differentiation with dynamic enhanced MR imaging and clinical implications. Radiology. 1993;189:721–5. Thomassin-Naggara I, Dechoux S, Bonneau C, Morel A, Rouzier R, Carette MF, et al. How to differentiate benign from malignant myometrial tumours using MR imaging. Eur Radiol. 2013;23:2306–14. Abdel Wahab C, Jannot AS, Bonaffini PA, Bourillon C, Cornou C, Lefrère-Belda MA, et al. Diagnostic algorithm to differentiate benign atypical leiomyomas from malignant uterine sarcomas with diffusion-weighted MRI. Radiology. 2020;297:361–71.

We thank Hiroaki Komatsu, Shinya Sato, Tetsuro Oishi, for their help in the tumor board, as well as Kanae Nosaka for her assistance with the pathological diagnosis and advices. Funding None. Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest None. Ethical statement This article does not contain any studies with human participants or animals performed by any of the authors. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. About this article Cite this article Fujii, S., Mukuda, N., Ochiai, R. et al. MR imaging findings of unusual leiomyoma and malignant uterine myometrial tumors: what the radiologist should know. Jpn J Radiol 39, 527–539 (2021). https://doi.org/10.1007/s11604-021-01096-7 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s11604-021-01096-7