Background: Leiomyoma is a uterine benign tumor of the smooth muscle, with a high frequency in female population. On the other hand, leiomyosarcoma is a rare uterine malignant tumor of the smooth muscle. The ultrasonographic features of a leiomyosarcoma may not be distinct from those of a leiomyoma; in fact, both may show heterogeneous echogenicity and central necrosis, especially in the case of atypical benign lesions. So, ultrasonography and MRI, because of the non existence of typical ultrasonographic and radiologic features, are unable to predict the preoperative malignancy of a mass, which is why the definite diagnosis of sarcoma is almost always defined postoperatively by definitive histologic examination. For these reasons, with this study we wanted to analyze the possibility of applying elastography at the time of pre-surgical differential diagnosis between leiomyoma and uterine leiomyosarcoma. Elastography is a non invasive ultrasound imaging technique that measures tissue stiffness, through the hardness ratio value. Due to the fact that leiomyosarcoma appears pleomorphic, with hemorrhagic areas and necrosis colliquative and with hemorrhagic cysts within it, making it softer in texture than the surrounding uterine tissue, the elastogram shows a coloration within blue-green range and a lower hardness ratio value than benign masses. In contrast, leiomyoma consists of spindle cells, arranged in bundles, thus giving a stiffer texture to the mass. As a consequence of this, the elastogram shows a staining on the range of red and a higher hardness ratio value. Aim: first target of the study is to obtain, through elastography, an estimated uterine mass stiffness’ value, calculated as hardness ratio. Second target is to score the correlation between the main ultrasonographic features of uterine masses (vascular lacunae, shadow cones and color score), hardness ratio (%) values and the final histologic examination. Materials and methods: the study conducted is a prospective observational study. A specific set of symptomatic and asymptomatic patients with single or multiple uterine neoformations has been considered. Results: During preoperative visits, 37 patients with uterine masses have been enrolled. Out of the full group, 32 people received histopathological diagnoses of uterine leiomyoma, 3 of uterine leiomyosarcoma, and 2 of STUMP. All hardness ratio (%) values in the malignant group were lower than those in the benign group with also statistically significant difference between the median hardness ratios (%) obtained in the benign versus malignant population (P value < 0.0001). In addition, an HR cut-off value of 79.46% was obtained, thus allowing the discrimination of a malignant mass from a benign one with 100% sensitivity. Finally, two different correlation forces have been calculated. In particular, the correlation between vascular lacunae and color score and histologic examination (0.75) turns out to be less strong than the total calculated correlation between histologic and hardness ratio (1.00). The results obtained, underscore the importance of hardness ratio in order to classify with absolute certainty whether a uterine mass is benign or malignant. Conclusions: transvaginal elastosonography appears to be a promising diagnostic tool to differentiate malignant (leiomyosarcoma and STUMP) from benign (leiomyoma) uterine masses complimentarily to transvaginal ultrasound.
Background: Il leiomioma è un tumore benigno della muscolatura liscia del corpo uterino e presenta alta frequenza nella popolazione femminile. Il leiomiosarcoma, invece, è un tumore maligno della muscolatura liscia del corpo uterino, è molto raro e colpisce prevalentemente donne in post-menopausa. Le caratteristiche ecografiche di un leiomiosarcoma possono non essere distinte da quelle di un leiomioma, infatti, entrambi possono mostrare ecogenicità eterogenea e necrosi centrale, soprattutto in caso di lesioni benigne atipiche. Dato che l’ecografia e la risonanza magnetica non sono capaci di predire la malignità pre-operatoria di una massa, a causa dell’inesistenza di aspetti ecografici e radiologici tipici, la diagnosi certa di sarcoma è definita quasi sempre post-operatoriamente con l’esame istologico definitivo. Per tale motivo, con questo studio si è voluta analizzare la possibilità di applicare l’elastosonografia nel momento della diagnosi differenziale pre-chirurgica tra leiomioma e leiomiosarcoma uterino. L'elastosonografia è una tecnica di imaging a ultrasuoni non invasiva che misura la rigidità dei tessuti, attraverso il valore di hardness ratio. Dato che il leiomiosarcoma risulta pleomorfo, con aree emorragiche e di necrosi colliquativa e con cisti emorragiche al suo interno, che lo rendono di consistenza più morbida rispetto al tessuto uterino circostante, l’elastogramma presenta una colorazione sulla gamma del blu-verde e un valore più basso di rigidità rispetto alle masse benigne. Al contrario, il leiomioma è costituito da cellule fusate, disposte in fasci, che conferiscono una consistenza più rigida alla massa, motivo per cui l’elastogramma presenta una colorazione sulla gamma del rosso e un valore maggiore di rigidità. Scopo dello studio: lo studio si propone di ottenere un valore di stima della rigidità, espressa come hardness ratio (%), della massa uterina, attraverso l’utilizzo dell’elastosonografia e di valutare il grado di correlazione delle principali caratteristiche ecografiche delle masse uterine (lacune vascolari, coni d’ombra e color score) e dei valori di hardness ratio (%) con l’esame istologico definitivo. Materiali e metodi: lo studio condotto è uno studio osservazionale prospettico. Sono state incluse pazienti sintomatiche e asintomatiche in follow up con neoformazione singola o multipla. Risultati: durante le visite pre-operatorie abbiamo arruolato 37 pazienti con massa uterina, dove 32 hanno ricevuto diagnosi istopatologica di leiomioma uterino, 3 di leiomiosarcoma uterino e 2 di STUMP. Tutti i valori di hardness ratio (%) ottenuti nel gruppo maligno sono stati riscontrati essere inferiori a quelli del gruppo benigno, con anche differenza statisticamente significativa tra la mediana di hardness ratio (%) ottenuta nella popolazione benigna e in quella maligna (P value < 0,0001). Inoltre, grazie al valore cut-off di HR di 79,46%, risulta possibile discriminare una massa maligna da una benigna con sensibilità 100%. Infine, la correlazione tra lacune vascolari e color score ed esame istologico (0.75) risulta essere meno forte rispetto alla correlazione totale presente tra istologico e hardness ratio (1.00), a sottolineare come attraverso la misurazione dell’hardness ratio risulti possibile classificare con assoluta certezza una massa uterina in base alla sua benignità o malignità. Conclusioni: l'elastosonografia risulta essere uno strumento diagnostico promettente, da utilizzare in maniera complementare all'ecografia transvaginale a ultrasuoni per differenziare le masse uterine maligne (leiomiosarcoma e STUMP) da quelle benigne (leiomioma).
Elaborazione e ottimizzazione di uno score predittivo del rischio di malignità di una massa uterina basato sull'Elastosonografia: studio pilota
PALAZZI, GIULIA
2023/2024
Abstract
Background: Leiomyoma is a uterine benign tumor of the smooth muscle, with a high frequency in female population. On the other hand, leiomyosarcoma is a rare uterine malignant tumor of the smooth muscle. The ultrasonographic features of a leiomyosarcoma may not be distinct from those of a leiomyoma; in fact, both may show heterogeneous echogenicity and central necrosis, especially in the case of atypical benign lesions. So, ultrasonography and MRI, because of the non existence of typical ultrasonographic and radiologic features, are unable to predict the preoperative malignancy of a mass, which is why the definite diagnosis of sarcoma is almost always defined postoperatively by definitive histologic examination. For these reasons, with this study we wanted to analyze the possibility of applying elastography at the time of pre-surgical differential diagnosis between leiomyoma and uterine leiomyosarcoma. Elastography is a non invasive ultrasound imaging technique that measures tissue stiffness, through the hardness ratio value. Due to the fact that leiomyosarcoma appears pleomorphic, with hemorrhagic areas and necrosis colliquative and with hemorrhagic cysts within it, making it softer in texture than the surrounding uterine tissue, the elastogram shows a coloration within blue-green range and a lower hardness ratio value than benign masses. In contrast, leiomyoma consists of spindle cells, arranged in bundles, thus giving a stiffer texture to the mass. As a consequence of this, the elastogram shows a staining on the range of red and a higher hardness ratio value. Aim: first target of the study is to obtain, through elastography, an estimated uterine mass stiffness’ value, calculated as hardness ratio. Second target is to score the correlation between the main ultrasonographic features of uterine masses (vascular lacunae, shadow cones and color score), hardness ratio (%) values and the final histologic examination. Materials and methods: the study conducted is a prospective observational study. A specific set of symptomatic and asymptomatic patients with single or multiple uterine neoformations has been considered. Results: During preoperative visits, 37 patients with uterine masses have been enrolled. Out of the full group, 32 people received histopathological diagnoses of uterine leiomyoma, 3 of uterine leiomyosarcoma, and 2 of STUMP. All hardness ratio (%) values in the malignant group were lower than those in the benign group with also statistically significant difference between the median hardness ratios (%) obtained in the benign versus malignant population (P value < 0.0001). In addition, an HR cut-off value of 79.46% was obtained, thus allowing the discrimination of a malignant mass from a benign one with 100% sensitivity. Finally, two different correlation forces have been calculated. In particular, the correlation between vascular lacunae and color score and histologic examination (0.75) turns out to be less strong than the total calculated correlation between histologic and hardness ratio (1.00). The results obtained, underscore the importance of hardness ratio in order to classify with absolute certainty whether a uterine mass is benign or malignant. Conclusions: transvaginal elastosonography appears to be a promising diagnostic tool to differentiate malignant (leiomyosarcoma and STUMP) from benign (leiomyoma) uterine masses complimentarily to transvaginal ultrasound.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/65811