Decoding uterine leiomyosarcoma: is ultrasound diagnosis still a daunting challenge?

Introduction: This narrative review, based on the current literature, aims to evaluate whether or not preoperative ultrasound can effectively distinguish between uterine leiomyosarcomas (ULMS) and leiomyomas (ULM). Evidence acquisition: By using PubMed, Scopus and WOS, an extensive literature search was conducted to identify ultrasound characteristics that specifically differentiate uterine ULMS from ULM. Evidence synthesis: This review analyzed several ultrasound features to distinguish ULMS from ULM, including the maximum diameter of myometrial growth, the number of lesions (solitary/multiple), tissue echogenicity (homogeneous/heterogeneous), growth borders (regular/irregular), the presence of cystic regions, shadow presence, subjective color grading, and the vascular pattern of the myometrial lesion (circumferential/intralesional). Our findings suggest that in postmenopausal patients with abnormal uterine bleeding and a new or enlarging mesenchymal mass, ULMS should be suspected. Features such as irregular tumor margins, moderate-to-abundant intralesional blood flow, cystic regions, and lack of calcifications indicate a higher risk of ULMS. Conclusions: Benign and malignant myometrial lesions should be disclosed by algorithms including ultrasound combined with clinical presentations and, if necessary, magnetic resonance imaging. This means that further prospective studies should be conducted to consolidate our findings.