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. 2025 Mar 13;17(3):e80507.
doi: 10.7759/cureus.80507. eCollection 2025 Mar.

Clinical Features and Imaging Findings of Low-Grade Endometrial Stromal Sarcoma: A Retrospective Case Series-Based Analysis

Yumiko Miyazaki  1 , Kenji Takata  2 , Tasuku Wakabayashi  2 , Toshimichi Onuma  1 , Hideaki Tsuyoshi  1 , Akiko Shinagawa  1 , Makoto Orisaka  1 , Yoshio Yoshida  1
Affiliations

Clinical Features and Imaging Findings of Low-Grade Endometrial Stromal Sarcoma: A Retrospective Case Series-Based Analysis

Yumiko Miyazaki et al. Cureus. .

Abstract

Objective: This case series presents six cases of low-grade endometrial stromal sarcoma (LGESS) and discusses their magnetic resonance imaging (MRI) findings in light of recent advancements in LGESS diagnosis.

Methods: Data from six cases of LGESS treated at Fukui University Hospital between June 2007 and October 2024 were retrospectively analyzed. The clinical behavior, histopathological features, therapeutic approaches, and survival outcomes were evaluated. MRI images were assessed by two radiologists over multiple parameters that were considered specific to the LGESS.

Results: Among the six patients with LGESS, four patients had tumors located within the myometrium, whereas two patients had tumors located in the submucosal layer. All cases were classified as International Federation of Gynecology and Obstetrics Stage Ⅰ, and no recurrence was observed during follow-up. On MRI, all six tumors exhibited high signal intensity on T2-weighted images (T2WI), compared to the myometrium, and high signal intensity on diffusion-weighted images (DWI), compared to the endometrium. In four of the five evaluable cases, the mean apparent diffusion coefficient (ADC) value was 0.86 × 10⁻³ mm²/s (range: 0.81-0.99).

Conclusion: Both clinically and based on imaging findings, distinguishing between LGESS and rare leiomyoma variants is challenging. MRI findings, including high signal intensity on T2WI and DWI as well as low ADC values, may prove valuable in differentiating these two entities.

Keywords: apparent diffusion coefficient (adc); diffusion-weighted imaging (dwi); endometrial stromal sarcoma; leiomyoma uteri; magnetic resonance imaging.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Microscopic features of low-grade endometrial stromal sarcoma
(A) Neoplastic cells exhibiting uniform oval-to-spindle-shaped nuclei and morphologically resembling the stroma of the endometrium in the proliferative phase. (B–D) Immunohistochemical analysis demonstrates positive staining for estrogen receptor (B), progesterone receptor (C), and CD10 (D). Scale bar: 100 μm
Figure 2
Figure 2. Fifty-two-year-old woman with LGESS (case 6)
A mass was found in the uterine wall showing isointensity on T1WI (A) and heterogeneous hyperintensity with hypointense bands (arrows) on T2WI (B). Diffusion-weighted imaging (DWI) (C) and apparent diffusion coefficient (ADC) map (D) showing hyperintense and hypointense masses, respectively (arrows). Sagittal contrast-enhanced T1WI with fat suppression (E) showed a heterogeneous enhanced mass. T1WI: T1-weighted imaging; T2WI: T2-weighted imaging; LGESS: low-grade endometrial stromal sarcoma
Figure 3
Figure 3. Magnetic resonance imaging findings in LGESS in representative cases
A submucosal lesion is evident on sagittal T2WI (A) and protrudes into the vaginal canal (arrows); notably, an intramass band-like structure with low signal intensity (arrows) was observed (case 3). Sagittal T2WI (B) reveals an oval, well-defined, heterogeneously hyperintense myometrial mass with cystic areas (arrows; case 1). On axial T2WI (C), a T2 high-signal mass surrounded by a low-signal rim (arrows) exhibits nodular invasive growth (arrows; case 2). T2WI: T2-weighted imaging; LGESS: low-grade endometrial stromal sarcoma
Figure 4
Figure 4. Forty-five-year-old woman with LGESS (case 5)
A mass was located in the uterine posterior wall (arrow), showing isointensity on T1WI (A) and hyperintensity on T2WI (B). This mass showed high signal intensity upon diffusion-weighted MRI (C) with a low ADC value (arrows) (D). LGESS: low-grade endometrial stromal sarcoma; T1WI: T1-weighted imaging; T2WI: T2-weighted imaging; MRI: magnetic resonance imaging; ADC: apparent diffusion coefficient
Figure 5
Figure 5. Evaluation of average ADC values by two readers
(A) The average ADC values for each case from the two readers were analyzed using a t-test, with p < 0.05 considered indicative of a significant difference. Except for case 4, no significant differences were observed in the average ADC values between the two readers. (B) No significant difference was detected between case 4 and the other cases (cases 2, 3, 5, and 6). R: reader: ADC: apparent diffusion coefficient
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