J Clin Ultrasound 21:405-408, July/August 1993 zyxwvut 0 1993 by John Wiley zyxwvutsrqp & Sons, Inc. CCC 0091-27511931060405-04 Case zy Report z Uterine Malignancy Predicted by Transvaginal Sonography and Color Flow Doppler Ultrasonography Jonathan Carter, MB, BS, Dip RACOG, FRACOG, Theresa Perrone, MD, Linda F. Carson, MD, Jay Carlson, DO, and Leo B. Twiggs, MD Endometrial stromal sarcoma (ESS), previously termed endolymphatic stromal myosis, is a rare tumor in premenopausal women. This first re- ported case of ESS imaged with transvaginal so- nography (TVS), and color flow Doppler (CFD) ultrasonography demonstrates the importance of performing transvaginal ultrasonography in pa- tients with abnormal uterine bleeding and the usefulness of color flow Doppler in predicting malignancy. CASE REPORT A 45-year-old mother of two presented to her lo- cal physician complaining of menorrhagia, fa- tigue, and malaise. For as long as she could re- member, she had had heavy periods. Her general physical examination was unremarkable except for conjunctival pallor. Pelvic examination re- vealed an enlarged, mobile uterus. A hemoglobin obtained at this visit was 6.4 g% with markers of severe iron deficiency. The presumed diagnosis at this stage was uterine leiomyoma or adenomy- osis. A transvaginal sonogram was performed us- ing an ATL Ultramark 9 ultrasound scanner with a 5-MHz curved array intravaginal probe. An asymmetrically enlarged uterus, measuring 15 cm x 10 cm x 8 cm, was demonstrated. The posterior uterine wall was markedly thickened, but without evidence of a discrete mass, such as a leiomyoma. The endometrium was echoic, and From the Department of Obstetrics and Gynecology, Labora- tory Medicine and Pathology, Women's Cancer Center, Divi- sion of Gynecologic Oncology, University of Minnesota, Min- neapolis, Minnesota. For reprints contact Dr. Jonathan Carter, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Box 395 UMHC, 420 Delaware St. SE, Minneapolis, MN 55455. the uterine cavity was distended by an echoic polypoid lesion that appeared to invade into the myometrium with loss of the subendometrial halo (Figure 1). The uterine vessels were identi- fied by CFD ultrasonography. A spectral analy- sis was performed on the uterine artery and the Pulsatility Index (PI) calculated. The uterine ar- tery PI was 1.0 (Figure 2). CFD was then used to identify vascularity within the polypoid intralu- minal lesion, and within the polypoid lesion or adjacent myometrium. No increased intratu- moral flow was detected within the thickened or normal myometrium. A full staging laparotomy was performed. The uterus was enlarged to the size of a 14-week pregnancy. No other abnormalities were appar- ent. On sectioning the uterus, there was a 6-cm, fleshy, partly hemorrhagic, tan tumor protruding into the uterine cavity from the posterior wall that appeared to be deeply infiltrating the myo- metrium (Figure 3). The tumor was a typical low-grade ESS with a mitotic rate less than 5 per 10 high power fields. It arose from the endome- trium and invaded the myometrium to a depth of 0.78 cm to 0.80 cm. It also extensively invaded vascular spaces in the posterior myometrium. The anterior myometrium was 3 cm thick, and no leiomyoma or other lesion was found. DISCUSSION Low-grade ESS, previously termed endometrial stromatosis or endolymphatic stromal myosis, is the most common variant of the endometrial stromal tumors. Patients tend to be perimeno- pausal, and aged between 42 and 53 years; how- ever, more than half are premenopausal, and young women and adolescents may be affected.' A fleshy tumor is usually found in the uterine cavity, but typically it is overshadowed by the 405