1. Case Presentation

Uterine carcinosarcoma (UCS), previously known as malignant mixed Mullerian tumor, is a very rare tumor of the female reproductive tract, composed of both high-grade sarcomatous and carcinomatous elements [1]. In the United States its incidence is 1-4 per 100,000 women, is more frequently find in black women and the median age at diagnosis is between 62-67 years old [1]. Risk factors for developing UCS include advanced age, obesity, nulliparity, exogenous estrogen use, pelvic radiation, and tamoxifen [2]. Due to its aggressive nature, up to 60% have an extrauterine disease at presentation [3]. A pelvic ultrasound is the first-line imaging study. The typical appearance is a heterogeneous solid intrauterine mass with an irregular shape, hypoechoic and septated cystic echotexture, an ill-defined boundary, possible expansion of the endometrial canal, and abundant blood flow signals [4, 5]. UCS has a worse prognosis compared to other high-risk uterine endometrial cancers, with reported five-year disease-specific survival rates of 59% for stage I/II disease, 22% for stage III disease, and 9% for stage IV disease, regardless of therapy [2].

This image concerns a 58-year-old P1G1 woman with postmenopausal uterine bleeding and pelvic pain over the past 2 months. Ultrasound assessment, with endovaginal (Figure 1) and abdominal probes, revealed an enlarged uterus reaching the supraumbilical level and bearing a solid tumor with multiple cystic areas and a color Doppler score 4. The Pipelle sampling confirmed the diagnosis of carcinosarcoma in this patient who died two days later.

Figure 1: Ultrasound assessment, with endovaginal.

Transvaginal ultrasonography is appropriate for an initial evaluation of postmenopausal bleeding. Endometrial thickness of 4 mm, or less, has a greater than 99% negative predictive value for endometrial cancer [6]. The ultrasound is not accurate to distinguish carcinosarcomas from other endometrial malignancies since the features of high-grade endometrial cancer also include heterogeneous echogenicity, high Color Doppler score, multifocal vessel pattern, and irregular myometrial-endometrial junction [6]. However, symptoms and clinical signs, along with the recognition of suspected ultrasound features presented here, should trigger prompt medical assistance to improve patient survival.

References

1. Ravishankar P, Smith DA, Avril S, et al. Uterine carcinosarcoma: a primer for radiologists. Abdominal Radiology 44 (2019): 2874-2885.
2. Sagebiel TL, Bhosale PR, Patnana M, et al. Uterine Carcinosarcomas. Seminars in Ultrasound, CT and MRI. 40 (2019): 295-301.
3. Denschlag D, Ulrich UA. Uterine carcinosarcomas - Diagnosis and management. Oncology Research and Treatment 41 (2018): 675-679.
4. Zhao F, Xu Y, Zhang H, et al. Ultrasonographic findings of uterine carcinosarcoma. Gynecol Obstet Invest 84 (2019): 277-282.
5. Hosh M, Antar S, Nazzal A, et al. Uterine Sarcoma: Analysis of 13,089 Cases Based on Surveillance, Epidemiology, and End Results Database. Int J Gynecol Cancer 26 (2016).
6. Epstein E, Fischerova D, Valentin L, et al. Ultrasound characteristics of endometrial cancer as defined by International Endometrial Tumor Analysis (IETA) consensus nomenclature: prospective multicenter study. Ultrasound Obstet Gynecol 51 (2018): 818-828.