Diagnostic Approach to Endometrial Stromal Neoplasms

Clinical Presentation and Diagnostic Challenges

Transvaginal ultrasound (TVUS) is sensitive for detecting structural abnormalities but cannot determine the specific etiology of endometrial thickening or masses, according to the American College of Radiology 1, 2
The presence of leiomyomas and adenomyosis can obscure complete visualization of the endometrium, potentially masking coexistent ESN, as noted by the American College of Radiology 1, 3, 4
Sonohysterography, while excellent at distinguishing polyps from submucosal fibroids (97% accuracy), cannot differentiate benign from malignant endometrial pathology with certainty, as reported by the American College of Radiology 5, 6, 7

MRI can identify malignant uterine pathology with sensitivity up to 79% for endometrial cancer and 100% for leiomyosarcomas, according to the American College of Radiology 5, 7
Diffusion-weighted imaging improves diagnostic accuracy for distinguishing benign from malignant lesions, with abnormal signal and irregularity of the endometrial-myometrial interface being key features, as noted by the American College of Radiology 1, 3
MRI with diffusion-weighted imaging should be considered when ultrasound is inconclusive, as recommended by the American College of Radiology 5, 7

Endometrial sampling or hysteroscopy with biopsy is required when any focal endometrial abnormality is identified on imaging, regardless of whether fibroids are also present, according to the American College of Radiology 5, 6, 8
Postmenopausal women with fibroids and bleeding must have endometrial cancer and uterine sarcoma excluded before any treatment, as recommended by the American College of Radiology 9
Endometrial thickness ≥5 mm in postmenopausal women with bleeding requires tissue sampling, as noted by the American College of Radiology 2

The presence of fibroids on ultrasound does not exclude concurrent endometrial pathology, including ESN, as reported by the American College of Radiology 1, 3
Neither ultrasound nor MRI can definitively distinguish ESN from benign conditions; tissue diagnosis is mandatory, according to the American College of Radiology 5, 6, 7
Morcellation is contraindicated when ESN is suspected, as it can upstage disease and worsen outcomes, as recommended by the American College of Radiology 9