Preoperative Differential Diagnosis of Uterine Sarcomas: Current Considerations and Challenges

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Abstract

Introduction. Uterine mesenchymal tumors represent a significant proportion of oncogynecological malignancies. Accurate preoperative differential diagnosis is critical for determining optimal patient management strategies, as misdiagnosis frequently leads to non-radical treatment, subsequently reducing survival rates and increasing risks of local recurrence or metastasis. Current challenges in clinical assessment, including the absence of specific diagnostic criteria and low preoperative verification rates, underscore the need for novel diagnostic tools in this field. Aim. To analyze current domestic and international literature on preoperative differential diagnosis of uterine mesenchymal tumors. Materials and Methods. We conducted a systematic literature review using PubMed/MEDLINE, UpToDate, e-Library, Scopus, and professional society resources (ESUR, ACR, ESGO, NCCN) from 2014–2024. Full-text studies and reviews addressing clinical presentation, laboratory findings, and imaging approaches for uterine mesenchymal tumors were included and analyzed. о - Results. This review synthesizes current diagnosticap- - proaches and identifies persistent challenges in uterine mesеenchymal tumor evaluation. Given the lack of validated bio- - markers and complexities in pathological verification, imaging - modalities combined with clinical data emerge as fundamental й for preoperative differentiation and treatment planning. - Conclusion. The morphological heterogeneity of uterine mesenchymal tumors continues to present significant diagnostic challenges, necessitating further research to develop improved diagnostic algorithms and optimize patient management strategies.

About the authors

V. V. Litvinova

Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Health Ministry of Russian Federation

Email: valentina_li@list.ru
ORCID iD: 0000-0001-9437-2005
SPIN-code: 9540-7046
Moscow, the Russian Federation

A. E. Solopova

Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Health Ministry of Russian Federation; Sechenov First Moscow State Medical University (Sechenov University), Health Ministry of Russian Federation

Email: valentina_li@list.ru
ORCID iD: 0000-0003-4768-115X
SPIN-code: 7153-5476
Scopus Author ID: 24460923200
ResearcherId: P-8659-2015
Moscow, the Russian Federation; Moscow, the Russian Federation

G. N. Khabas

Fomin Clinic Michurinsky LLC

Email: valentina_li@list.ru
ORCID iD: 0000-0002-5011-9152
Moscow, the Russian Federation

D. L. Ovodenko

Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Health Ministry of Russian Federation

Email: valentina_li@list.ru
ORCID iD: 0000-0003-0700-8374
SPIN-code: 8242-0188
Moscow, the Russian Federation

References

  1. Lax S.F. Mesenchymal and mixed uterine tumors: Current overview and practical aspects. Pathologe. 2019; 40(1): 36–45.-DOI: https://dx.doi.org/10.1007/s00292-019-0567-6.
  2. Sparić R., Andjić M., Babović I., et al. Molecular insights in uterine leiomyosarcoma: A systematic review. Int J Mol Sci. 2022; 23(17): 9728.-DOI: https://dx.doi.org/10.3390/ijms23179728.
  3. Stewart E.A., Cookson C.L., Gandolfo R.A., et al. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017; 124(10): 1501–12.-DOI: https://dx.doi.org/10.1111/1471-0528.14640.
  4. Урманчеева А.Ф., Ульрих Е.А. Принципы лечения сарком матки. Практическая онкология. 2008; 9(3): 132-136.-EDN: QCRWIT.-URL: https://www.practical-oncology.ru/articles/261.pdf. [Urmancheeva A.F., Ul’rih E.A. Principles of uterine sarcoma treatment. Prakticheskaja Onkologija = Practical Oncology. 2008; 9(3): 132-136. EDN: QCRWIT.-URL: https://www.practical-oncology.ru/articles/261.pdf (In Rus)].
  5. Ульрих Е.А. Особенности лечения сарком матки. Практическая онкология. 2013; 14(2): 127-134.-EDN: QCRWXT.-URL: https://practical-oncology.ru/articles/110.pdf. [Ul’rih E.A. Treatment of uterine sarcomas. Prakticheskaja Onkologija = Practical Oncology. 2013; 14(2): 127-134.-EDN: QCRWXT.-URL: https://practical-oncology.ru/articles/110.pdf (In Rus)].
  6. Mallmann P. Uterine sarcoma — difficult to diagnose, hard to treat. Oncol Res Treat. 2018; 41(11): 674.-DOI: https://dx.doi.org/10.1159/000494393.
  7. Zouzoulas D., Tsolakidis D., Pavlidi O., et al. Rate of leiomyosarcomas during surgery for uterine fibroids: 8-year experience of a single center. J Clin Med. 2023; 12(24).-DOI: https://dx.doi.org/10.3390/jcm12247555.
  8. Borella F., Mancarella M., Preti M., et al. Uterine smooth muscle tumors: a multicenter, retrospective, comparative study of clinical and ultrasound features. Int J Gynecol Cancer. 2024; 34(2): 244–50.-DOI: https://dx.doi.org/10.1136/ijgc-2023-004880.
  9. Höhn A.K., Brambs C.E., Hiller G.G.R., et al. 2020 WHO classification of female genital tumors. Geburtshilfe Frauenheilkd. 2021; 81(10): 1145–53.-DOI: https://dx.doi.org/10.1055/a-1545-4279.
  10. Richaud C., Jochum F., Journo G., et al. Impact of guideline adherence and expert center referral on the early management and outcomes of uterine sarcoma patients: A retrospective analysis from the French NETSARC network. Eur J Surg Oncol. 2024; 50(2): 107319.-DOI: https://dx.doi.org/10.1016/j.ejso.2023.107319.
  11. Raffone A., Raimondo D., Neola D., et al. Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2024; 165(1): 22–33.-DOI: https://doi.org/10.1002/ijgo.15136.
  12. Sun S., Bonaffini P.A., Nougaret S., et al. How to differentiate uterine leiomyosarcoma from leiomyoma with imaging. Diagn Interv Imaging. 2019; 100(10): 619–34.-DOI: https://dx.doi.org/10.1016/j.diii.2019.07.007.
  13. Kostov S., Kornovski Y., Ivanova V., et al. New aspects of sarcomas of uterine corpus-a brief narrative review. Clin Pract. 2021; 11(4): 878–900.-DOI: https://dx.doi.org/10.3390/clinpract11040103.
  14. U.S. Food and Drug Administration. FDA updated assessment of the use of laparoscopic power morcellators to treat uterine fibroids. Silver Spring. 2017.-URL: https://www.fda.gov/media/109018/download.
  15. U.S. Food and Drug Administration. UPDATED laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication [archived]. Silver Spring. 2014.-URL: https://www.wilsonlaw.com/wp-content/uploads/2014/12/UPDATED-Safety-Communication_Laparoscopic-Power-Morcellation.pdf.
  16. Hartmann K.E., Fonnesbeck C., Surawicz T., et al. Management of uterine fibroids. Rockville (MD): Agency for Healthcare Research and Quality (US). Comparative Effectiveness Review, No. 195. 2017.-URL: https://www.ncbi.nlm.nih.gov/books/NBK537742/.
  17. Surace A., Baù M.G., Privitera S., et al. Risk of unexpected uterine leiomyosarcoma during laparoscopic procedures: Experience from a single tertiary institute in Italy. Int J Gynaecol Obstet. 2022; 156(2): 236–9.-DOI: https://doi.org/10.1002/ijgo.13701.
  18. Pedra Nobre S., Hensley M.L., So M., et al. The impact of tumor fragmentation in patients with stage I uterine leiomyosarcoma on patterns of recurrence and oncologic outcome. Gynecol Oncol. 2021; 160(1): 99–105.-DOI: https://dx.doi.org/10.1016/j.ygyno.2020.10.020.
  19. Rey Valzacchi G.M., Rosas P., Uzal M., et al. Incidence of leiomyosarcoma at surgery for presumed uterine myomas in different age groups. J Minim Invasive Gynecol. 2020; 27(4):926–9.-DOI: https://dx.doi.org/10.1016/j.jmig.2019.06.013.
  20. Kainsbak J., Hansen E.S., Dueholm M. Literature review of outcomes and prevalence and case report of leiomyosarcomas and non-typical uterine smooth muscle leiomyoma tumors treated with uterine artery embolization. Eur J Obstet Gynecol Reprod Biol. 2015; 191: 130–7.-DOI: https://dx.doi.org/10.1016/j.ejogrb.2015.05.018.
  21. ООО «Российское общество акушеров-гинекологов» (РОАГ). Миома матки: клинические рекомендации (протокол лечения). Минздрав РФ. 2024; 1–46.-URL: https://drive.google.com/file/d/1W57cS9Yq1DoJB8GNLmPny1hpI-pC5bXV/view. [Russian Society of Obstetricians and Gynecologists (ROSG). Uterine fibroids: clinical guidelines (treatment protocol). Ministry of Health of the Russian Federation. 2024; 1–46.-URL: https://drive.google.com/file/d/1W57cS9Yq1DoJB8GNLmPny1hpI-pC5bXV/view (In Rus)].
  22. Qu Y., Chen L., Guo S., et al. Genetic liability to multiple factors and uterine leiomyoma risk: a Mendelian randomization study. Front Endocrinol (Lausanne). 2023; 14: 1133260.-DOI: https://dx.doi.org/10.3389/fendo.2023.1133260.
  23. Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822. Obstet Gynecol. 2021; 137(3): e63–74.-DOI: https://dx.doi.org/10.1097/AOG.0000000000004291.
  24. Song K.-J., Yu X.-N., Lv T., et al. Expression and prognostic value of lactate dehydrogenase-A and -D subunits in human uterine myoma and uterine sarcoma. Medicine (Baltimore). 2018; 97(14): e0268.-DOI: https://dx.doi.org/10.1097/MD.0000000000010268.
  25. Glorie N., Baert T., VAN DEN Bosch T., Coosemans A.N. Circulating protein biomarkers to differentiate uterine sarcomas from leiomyomas. Anticancer Res. 2019; 39(8): 3981–9.-DOI: https://dx.doi.org/10.21873/anticanres.13553.
  26. Di Cello A., Borelli M., Marra M.L., et al. A more accurate method to interpret lactate dehydrogenase (LDH) isoenzymes’ results in patients with uterine masses. Eur J Obstet Gynecol Reprod Biol. 2019; 236: 143–7.-DOI: https://dx.doi.org/10.1016/j.ejogrb.2019.03.017.
  27. Zhang F., Liu Y., Quan Q., et al. Diagnostic value of preoperative CA125, LDH and HE4 for leiomyosarcoma of the female reproductive system. Cancer Manag Res. 2021; 13: 4657–64.-DOI: https://dx.doi.org/10.2147/CMAR.S302223.
  28. Tabatabaei F., Babadi S., Nourigheimasi S., et al. Neutrophil to lymphocyte ratio as an assessment tool to differentiate between uterine sarcoma and myoma: a systematic review and meta-analysis. BMC Cancer. 2024; 24(1): 12.-DOI: https://dx.doi.org/10.1186/s12885-023-11775-5.
  29. Jeong M.J., Park J.H., Hur S.Y., et al. Preoperative neutrophil-to-lymphocyte ratio as a prognostic factor in uterine sarcoma. J Clin Med. 2020; 9(9).-DOI: https://dx.doi.org/10.3390/jcm9092898.
  30. Suh D.S., Song Y.J., Roh H.-J., et al. Preoperative blood inflammatory markers for the differentiation of uterine leiomyosarcoma from leiomyoma. Cancer Manag Res. 2021; 13: 5001–11.-DOI: https://dx.doi.org/10.2147/CMAR.S314219.
  31. Cho H., Kim K., Kim Y.-B., No J.H. Differential diagnosis between uterine sarcoma and leiomyoma using preoperative clinical characteristics. J Obstet Gynaecol Res. 2016; 42(3): 313–8.-DOI: https://dx.doi.org/10.1111/jog.12915.
  32. Van den Bosch T., Dueholm M., Leone F.P.G., et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol. 2015; 46(3): 284–98.-DOI: https://dx.doi.org/10.1002/uog.14806.
  33. Cabezas N., López-Picazo A., Diaz P., et al. How frequently benign uterine myomas appear suspicious for sarcoma as assessed by transvaginal ultrasound? Diagnostics (Basel, Switzerland). 2023; 13(3).-DOI: https://dx.doi.org/10.3390/diagnostics13030501.
  34. Wojtowicz K., Góra T., Guzik P., et al. Uterine myomas and sarcomas — clinical and ultrasound characteristics and differential diagnosis using pulsed and color doppler techniques. J Ultrason. 2022; 22(89): 100–8.-DOI: https://dx.doi.org/10.15557/JoU.2022.0017.
  35. Russo C., Camilli S., Martire F.G., 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.-DOI: https://dx.doi.org/10.1002/uog.24855.
  36. Köhler G., Vollmer M., Nath N., et al. Benign uterine mass-discrimination from leiomyosarcoma by a preoperative risk score: a multicenter cohort study. Arch Gynecol Obstet. 2019; 300(6): 1719–27.-DOI: https://dx.doi.org/10.1007/s00404-019-05344-0.
  37. 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.-DOI: https://dx.doi.org/10.1002/uog.20270.
  38. Li D., Yin N., Du G., et al. A real-world study on diagnosis and treatment of uterine sarcoma in Western China. Int J Biol Sci. 2020; 16(3): 388–95.-DOI: https://dx.doi.org/10.7150/ijbs.39773.
  39. Najibi S., Gilani M.M., Zamani F., et al. Comparison of the diagnostic accuracy of contrast-enhanced/DWI MRI and ultrasonography in the differentiation between benign and malignant myometrial tumors. Ann Med Surg. 2021; 70: 102813.-DOI: https://dx.doi.org/10.1016/j.amsu.2021.102813.
  40. Barral M., Placé V., Dautry R., et al. Magnetic resonance imaging features of uterine sarcoma and mimickers. Abdom Radiol (New York). 2017; 42(6): 1762–72.-DOI: https://dx.doi.org/10.1007/s00261-017-1076-9.
  41. Silberzweig J.E., Powell D.K., Matsumoto A.H., Spies J.B. Management of uterine fibroids: A focus on uterine-sparing interventional techniques. Radiology. 2016; 280(3): 675–92.-DOI: https://dx.doi.org/10.1148/radiol.2016141693.
  42. Kubik-Huch R.A., Weston M., Nougaret S., et al. European Society of Urogenital Radiology (ESUR) guidelines: MR imaging of leiomyomas. Eur Radiol. 2018; 28(8): 3125–37.-DOI: https://dx.doi.org/10.1007/s00330-017-5157-5.
  43. 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.-DOI: https://dx.doi.org/10.1007/s00330-016-4623-9.
  44. Bura V., Pintican R.M., David R.E., et al. MRI findings in-between leiomyoma and leiomyosarcoma: a Rad-Path correlation of degenerated leiomyomas and variants. Br J Radiol. 2021; 94(1125): 20210283.-DOI: https://dx.doi.org/10.1259/bjr.20210283.
  45. 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. 2021; 39(6): 527–39.-DOI: https://dx.doi.org/10.1007/s11604-021-01096-7.
  46. Ando T., Kato H., Furui T., et al. Uterine smooth muscle tumours with hyperintense area on T 1 weighted images: differentiation between leiomyosarcomas and leiomyomas. Br J Radiol. 2018; 91(1084).-DOI: https://dx.doi.org/10.1259/bjr.20170767.
  47. Abdel Wahab C., Jannot A.-S., Bonaffini P.A., et al. Diagnostic algorithm to differentiate benign atypical leiomyomas from malignant uterine sarcomas with diffusion-weighted MRI. Radiology. 2020; 297(2): 361–71.-DOI: https://dx.doi.org/10.1148/radiol.2020191658.
  48. Li H.M., Liu J., Qiang J.W., Zhang H., et al. Diffusion-weighted imaging for differentiating uterine leiomyosarcoma from degenerated leiomyoma. J Comput Assist Tomogr. 2017; 41(4): 599–606.-DOI: https://dx.doi.org/10.1097/RCT.0000000000000565.
  49. Kim H., Rha S.E., Shin Y.R., et al. Differentiating uterine sarcoma from atypical leiomyoma on preoperative magnetic resonance imaging using logistic regression classifier: Added value of diffusion-weighted imaging-based quantitative parameters. Korean J Radiol. 2024; 25(1): 43–54.-DOI: https://dx.doi.org/10.3348/kjr.2023.0760.
  50. Bi Q., Xiao Z., Lv F., et al. Utility of clinical parameters and multiparametric MRI as predictive factors for differentiating uterine sarcoma from atypical leiomyoma. Acad Radiol. 2018; 25(8): 993–1002.-DOI: https://dx.doi.org/10.1016/j.acra.2018.01.002.
  51. Hindman N., Kang S., Fournier L., et al. MRI evaluation of uterine masses for risk of leiomyosarcoma: A consensus statement. Radiology. 2023; 306(2): e211658.-DOI: https://dx.doi.org/10.1148/radiol.211658.
  52. Malek M., Rahmani M., Seyyed Ebrahimi S.M., et al. Investigating the diagnostic value of quantitative parameters based on T2-weighted and contrast-enhanced MRI with psoas muscle and outer myometrium as internal references for differentiating uterine sarcomas from leiomyomas at 3T MRI. Cancer Imaging. 2019; 19(1): 20.-DOI: https://dx.doi.org/10.1186/s40644-019-0206-8.
  53. Lin G., Yang L.-Y., Huang Y.-T., 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(2): 333–42.-DOI: https://dx.doi.org/10.1002/jmri.24998.
  54. Nakai G., Yamada T., Hamada T., et al. Pathological findings of uterine tumors preoperatively diagnosed as red degeneration of leiomyoma by MRI. Abdom Radiol (New York). 2017; 42(7): 1825–31.-DOI: https://dx.doi.org/10.1007/s00261-017-1126-3.
  55. Li H.M., Liu J., Qiang J.W., et al. 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(9): 1877–87.-DOI: https://dx.doi.org/10.1097/IGC.0000000000001114.
  56. Ricci S., Stone R.L., Fader A.N. Uterine leiomyosarcoma: Epidemiology, contemporary treatment strategies and the impact of uterine morcellation. Gynecol Oncol. 2017; 145(1): 208–16.-DOI: https://dx.doi.org/10.1016/j.ygyno.2017.02.019.
  57. Peters A., Sadecky A.M., Winger D.G., et al. Characterization and preoperative risk analysis of leiomyosarcomas at a high-volume tertiary care center. Int J Gynecol Cancer. 2017; 27(6): 1183–90.-DOI: https://dx.doi.org/10.1097/IGC.0000000000000940.
  58. Stukan M., Rutkowski P., Smadja J., Bonvalot S. Ultrasound-guided trans-uterine cavity core needle biopsy of uterine myometrial tumors to differentiate sarcoma from a benign lesion-description of the method and review of the literature. Diagnostics (Basel, Switzerland). 2022; 12(6). -DOI: https://dx.doi.org/10.3390/diagnostics12061348.
  59. Van Houdt W.J., Schrijver A.M., Cohen-Hallaleh R.B., et al. Needle tract seeding following core biopsies in retroperitoneal sarcoma. Eur J Surg Oncol. 2017; 43(9):1740–5.-DOI: https://dx.doi.org/10.1016/j.ejso.2017.06.009.
  60. Gronchi A., Miah A.B., Dei Tos A.P., et al. Soft tissue and visceral sarcomas: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up☆. Ann Oncol Off J Eur Soc Med Oncol. 2021; 32(11): 1348–65.-DOI: https://dx.doi.org/10.1016/j.annonc.2021.07.006.

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