68-year-old lady presented with post-menopausal bleeding for 1 month.
- Grossly thickened endometrium with tiny cystic spaces (Fig. 1).
- Few areas of abnormal vascularity seen within.
- Endometrium is grossly thickened (thickness measures 4.8 cm) (Fig. 2)
Multiple small T2 hyperintense cystic areas are seen along the right half of the thickened endometrium. (Fig. 3)
- An ill-defined T1 iso-to hyperintense/ T2 hetero-intense solid appearing lesion with diffusion restriction seen in the left half of the thickened endometrium. (Fig. 4 and 5)
- On dynamic post contrast images, the lesion shows heterogenous enhancement.
- Myometrium appears intact (Fig. 6)
- Cervical stroma and endocervical canal appear normal.
- Endometrial biopsy performed 3 days after the MRI Pelvis demonstrates high grade malignant tumor (differentials include endometrial carcinoma, serous carcinoma, malignant mixed Mullerian tumor) Gross Hysterectomy specimen with differential tissue components as seen on MRI. (Fig. 7)
Malignant mixed Mullerian tumors (MMMT) of the uterus.
- Uterine carcinosarcoma (UCS), also known as malignant mixed Müllerian tumor(MMMT), is a rare mixed epithelial and mesenchymal tumor of the female reproductive tract composed of both high-grade sarcomatous and carcinomatous elements.
- It is comprising only 1-2% of uterine cancers and 3-5% of all uterine malignancies.
- They are the most common variety of mixed epithelial and non-epithelial endometrial tumors, with a clinically aggressive course.
- Three theories proposed to ascertain this tumor’s histogenesis include that MMMTs may be 1) collision tumors, 2) combination tumors, or 3) composition tumors.
- UCS most commonly arises from the uterus but, in rare cases, may originate from the fallopian tube, cervix, or peritoneum.
- UCS is surgically staged in accordance with the 2017 International Federation of Gynecology and Obstetrics (FIGO) Tumor, Node, Metastasis (TNM) classification system.
- Endometrial carcinomas are typically diagnosed at endometrial biopsy or dilatation and curettage.
- MRI is reserved to evaluate the extent of disease.
- MRI is the most accurate imaging technique for the preoperative assessment of endometrial cancer because of its superb soft tissue contrast resolution.
- The routine use of dynamic IV contrast enhancement is necessary for state of-the-art MR evaluation of endometrial carcinoma.
Literature image demonstrating polypoidal mass in uterine cavity with areas of hemorrhage and necrosis consistent with mixed malignant Mullerian tumor.
- Sala E, Wakely S, Senior E et-al. MRI of malignant neoplasms of the uterine corpus and cervix. AJR Am J Roentgenol. 2007;188 (6): 1577-87. doi:10.2214/AJR.06.1196 – Pubmed citation
- Teo SY, Babagbemi KT, Peters HE et-al. Primary malignant mixed mullerian tumor of the uterus: findings on sonography, CT, and gadolinium-enhanced MRI. AJR Am J Roentgenol. 2008;191 (1): 278-83. doi:10.2214/AJR.07.3281 – Pubmed citation
- OSR Journal Of Pharmacy (e)-ISSN: 2250-3013, (p)-ISSN: 2319-4219 Www.Iosrphr. Org Volume 3, Issue 9 (October2013), Pp 49-52
Case contributed by:
Radiology resident- Columbia Asia Radiology Group.
Senior Consultant Radiologist
Columbia Asia Radiology Group