Leiomyosarcoma differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[2]

Overview

Leiomyosarcoma must be differentiated from other soft tissue tumors, some variants of leimyoma resembles malignant tumor. Other possible differential diagnosis of leimyosarcoma include, epithelioid endometrial stromal sarcoma, alveolar soft part sarcoma, epithelioid angiosarcoma, pleomorphic rhabdomyosarcoma.

Differentiating Leiomyosarcoma from other Diseases

The table below summarizes the findings that differentiate Leiomyosarcoma from other conditions that may cause similar signs and symptoms.

Diseases	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination
							Lab Findings			Imaging			Histology
							Lab 1	Lab 2	Lab 3	Imaging 1	Imaging 2	Imaging 3
Uterine Leiomyosarcoma	Abnormal vaginal bleeding (Postmenopausal or intermenstrual bleeding or bleeding from uterus or vagina) Pressure or pain pelvic or abdomen Vaginal dyscharge Change in bladder or bowel habits Fatigue Fever Malaise Weight loss			Lump protruding from vagina Mass in abdomen or pelvic Tendenrness on palpating pelvic or Abdomen Lymphadenopathy									Grossly, most LMSs are large, solitary, poorly circumscribed masses (average 10 cm) or the largest mass in a fibroid uterus that typically display a fleshy variegated cut surface with areas of hemorrhage or necrosis
Leimyoma (mitotically active type)	Vaginal bleeding Pelvic pain						CBC Suggestive of Anemia			Enlarged uterus with multiple whorled mass lesions, largest of size 8.6×7.1 cm, not extending into the abdomen			Abscence of cytologic atypia Mild nuclear atypia, up to 10-20 mitosis No tumor cell necrosis	Biopsy and histology	-
Hemorrhagic cellular leiomyomas (apoplectic leiomyoma)	Abdominal pain										-	-	On microscopic analysis: Zones of recent hemorrhage within nodules of hypercellular smooth muscle. Coagulative necrosis (red degeneration) Mitotic figure not exceeding 2/10 HPF, mostly located in the perihemorrhagic areas On gross examination: Features of multiple hemorrhagic area Necrosis Cyst formation Softening, or color different than the usual leiomyoma	Biopsy specimen and histology
Endometrial Cancer	Abnormal Vaginal bleeding or post coital bleeding	Pelvic pain	Dysparunia	Vaginal Bleeding	Enlarged uterus	Lymphadenopathy	CBC and Clotting studies to r/o anemia and coagulopathy	Urine or serum Beta HCG to r/o pregnancy	LFT/ CA-125 can also be done	Thickened endometrial line on ultrasound.	Thickened endometrial line on CT	Thickened endometrial line on MRI	In well-differentiated forms, endometrioid adenocarcinoma produces small, round back-to-back glands without intervening stroma with varying degrees of glandular complexity are demonstrated by luminal infolding, budding, papillae (with or without psammoma bodies), and cribriforming. In grade 1 lesions, nuclei of the lining epithelial cells are uniform and oval to cylindrical, with minimal atypia and small discrete nucleoli. The cellular axes are perpendicular to the basement membrane, and stratification may or may not be present. Typically, high-grade tumors (with significant solid components) display an increased amount of nuclear atypia, as demonstrated by pleomorphism, irregular chromatin clumping, and prominent nucleoli	Biopsy under hysteroscopic guidance	-
PEComa	Palpable abdominal masses Abnormal vaginal bleeding Flank pain (kidneys) Dull abdominal pain in right upper quadrant (liver)
Epitheloid angiosarcoma	Painful, enlarging soft tissue masses Long bone fractures Arteriovenous shunting and subsequent high-output cardiac failure symptoms such as dypnea on exertion.												Epithelioid sarcoma is composed of sheets, nodules, and trabeculae of infiltrative epithelioid to spindled cells, with intensely eosinophilic cytoplasm.