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Gray-scale and color Doppler ultrasound characteristics of endometrial cancer in relation to stage, grade and tumor size
Abstract
To describe the gray-scale and vascular characteristics of endometrial cancer in relation to stage, grade and size using two-dimensional (2D)/three-dimensional (3D) transvaginal ultrasound.
This was a prospective multicenter study including 144 women with endometrial cancer undergoing transvaginal ultrasound before surgery. The sonographic characteristics assessed were echogenicity, endometrial/myometrial border, fibroids, vascular pattern, color score and tumor/uterus anteroposterior (AP) ratio. Histological assessment of tumor stage, grade, type and growth pattern was performed.
Hyperechoic or isoechoic tumors were more often seen in Stage IA cancer, whereas mixed or hypoechoic tumors were more often found in cancers of Stage IB or greater (P = 0.003). Hyperechogenicity was more common in Grade 1-2 tumors (i.e. well or moderately differentiated) (P = 0.02) and in tumors with a tumor/uterine AP ratio of < 50% (P = 0.002), whereas a non-hyperechoic appearance was more commonly found in Grade 3 tumors (i.e. poorly differentiated) and in tumors with a tumor/uterine AP ratio of ≥ 50%. Multiple global vessels were more often seen in tumors of Stage IB or greater than in Stage IA tumors (P = 0.02), in Grade 3 tumors than in Grade 1 and 2 tumors (P = 0.02) and in tumors with a tumor/uterine AP ratio of ≥ 50% (P < 0.001). A moderate/high color score was significantly more common in tumors of higher stage (P = 0.03) and larger size (P = 0.001).
The sonographic appearance of endometrial cancer is significantly associated with tumor stage, grade and size. More advanced tumors often have a mixed/hypoechoic echogenicity, a higher color score and multiple globally entering vessels, whereas less advanced tumors are more often hyperechoic and have no or a low color score.
... Image resolution is also extremely important in the studies of endometrial lesion vascularity as transvaginal probes of most currently used ultrasound high-end scanners are sensitive enough to detect Doppler signal and blood flow even in very small tumor vessels [17,18]. It might be important, e.g., in cases of distinguishing between adenomyosis and EC [19]. ...
... Conversely, early ECs were more often hyperechoic and had no color or a low color score at power Doppler examination. Despite encouraging results, threedimensional sonography is still not widely used because it requires extensive training and expertise [18]. For instance, Green et al. found that the off-line assessment of myometrial or cervical invasion in women with EC using three-dimensional sonography had lower interrater reliability and lower accuracy than two-dimensional video clip assessment [24]. ...
... It was suggested that the appearance of EC on ultrasound examination was significantly associated with tumor staging and tumor grading [18]. More advanced tumors in this study presented more often with hypoechoic or mixed echogenicity; they were also characterized by higher color score and the presence of multiple and larger intratumoral vessels. ...
Background:
Abnormal uterine bleeding (AUB) represents a common diagnostic challenge, as it might be related to both benign and malignant conditions. Endometrial cancer may not be detected with blind uterine cavity sampling by dilatation and curettage or suction devices. Several scoring systems using different ultrasound image characteristics were recently proposed to estimate the risk of endometrial cancer (EC) in women with AUB.
Aim:
The aim of the present study was to externally validate the predictive value of the recently proposed scoring systems including the Risk of Endometrial Cancer scoring model (REC) for EC risk stratification.
Material and methods:
It was a retrospective cohort study of women with postmenopausal bleeding. From June 2012 to June 2020 we studied a group of 394 women who underwent standard transvaginal ultrasound examination followed by power Doppler intrauterine vascularity assessment. Selected ultrasound features of endometrial lesions were assessed in each patient.
Results:
The median age was 60.3 years (range ± 10.7). The median body mass index (BMI) was 30.4 (range ± 6.0). Histological examination revealed 158 cases of endometrial hyperplasia (EH) and 236 cases of EC. Of the studied ultrasound endometrial features, the highest areas under the curve (AUCs) were found for endometrial thickness (ET) (AUC = 0.76; 95% CI: 0.71-0.81) and for interrupted endomyometrial junction (AUC = 0.70, 95% CI: 0.65-0.75). Selected scoring systems presented moderate to good predictive performance in differentiating EC and EH. The highest AUC was found for REC model (AUC = 0.75, 95% CI: 0.70-0.79) and for the basic model that included ET, Doppler score and interrupted endometrial junction (AUC = 0.77, 95% CI: 0.73-0.82). REC model was more accurate than other scoring systems and selected single features for differentiating benign hyperplasia from EC at early stages, regardless of menopausal status.
Conclusions:
New scoring systems, including the REC model may be used in women with AUB for more efficient differentiation between benign and malignant conditions.
... Tumor echogenicity at preoperative TVU may provide additional information relevant for stage and prognosis in endometrial cancer. Mixed or hypoechoic tumors are reportedly more frequent in patients with deep myometrial invasion and in grade 3 tumors [11], and non-regular endometrial-myometrial border at TVU also predicts deep myometrial invasion [11, 35•]. Doppler parameters characterizing the vascular tumor morphology may also be linked to stage and grade. ...
... Doppler parameters characterizing the vascular tumor morphology may also be linked to stage and grade. High color score and vascularization index (VI) are reportedly more frequent in tumors with deep myometrial invasion and in grade 3 tumors [11,55]. One study proposed cut-offs for the vascularization index for the prediction of deep myometrial invasion and grade 3 tumors of VI >7 and VI >10 %, respectively [55]. ...
... Low tumor Fb (blood flow) and high tumor E (extraction fraction; reflecting capillary leakage) predict reduced recurrence/progression-free survival and are more frequent in non-endometrioid tumors [10]. Interestingly, Fb is also reportedly inversely correlated to the expression of prognostic immunohistochemical markers reflecting microvascular [11], low resistive index, and high peak systolic velocity [12], high VI [55] Disorganized angiogenesis with altered tumoral blood flow VI >7 for DMI and VI >10 for grade 3 tumors [55] MRI ADC value (based on DW MRI) Low ADCmean predicts DMI [8], high ADCq a predicts DMI and LNM [13], and low ADCmin predicts aggressive disease [14] Increased cellularity and intratumor heterogeneity of water movement ADCmean < 0.75 for DMI [8] ADCmin < 0.66 for recurrence [14] Blood flow (based on DCE-MRI) Low tumor blood flow predicts reduced recurrence/ progression-free survival [9•, 10] Tumor hypoxia due to disorganized angiogenesis [ [38] ADC apparent diffusion coefficient (10 −3 mm 2 /s), AP anterioposterior, CC craniocaudal, DCE dynamic contrast enhanced, DMI deep myometrial invasion, DW diffusion weighted, FDG fluorodeoxyglucose, LNM lymph node metastases, MRI magnetic resonance imaging, MTV metabolic tumor volume (mL), NR not reported, PET positron emission tomography, SUV standard uptake value, TFD tumor-free distance to serosa, TLG total lesion glycolysis (g), TV transverse, TVU transvaginal ultrasound, VI vascularization index (%) a ADCq is defined as the difference in ADC between the 25th and the 75th percentile voxel in one lesion [13] b Volume index is defined as products of maximum anterioposterior (AP), transverse (TV), and craniocaudal (CC) diameters (cm) [62] proliferation [9•]. Tumor hypoxia, which is a characteristic feature of various solid tumors and believed to promote tumor progression and resistance to therapy [67,68], may thus play a pivotal role in the pathogenic mechanisms leading to tumor growth and metastatic spread, in endometrial cancer. ...
Although endometrial cancer is surgicopathologically staged, preoperative imaging is recommended for diagnostic work-up to tailor surgery and adjuvant treatment. For preoperative staging, imaging by transvaginal ultrasound (TVU) and/or magnetic resonance imaging (MRI) is valuable to assess local tumor extent, and positron emission tomography-CT (PET-CT) and/or computed tomography (CT) to assess lymph node metastases and distant spread. Preoperative imaging may identify deep myometrial invasion, cervical stromal involvement, pelvic and/or paraaortic lymph node metastases, and distant spread, however, with reported limitations in accuracies and reproducibility. Novel structural and functional imaging techniques offer visualization of microstructural and functional tumor characteristics, reportedly linked to clinical phenotype, thus with a potential for improving risk stratification. In this review, we summarize the reported staging performances of conventional and novel preoperative imaging methods and provide an overview of promising novel imaging methods relevant for endometrial cancer care.
... [3][4] While Trans-Vaginal Sonography (TVS) is the first-line method for the assessment of UCS, as it can detect neoformations of the myometrium, diagnosis can usually be made by the histopathological examination of targeted endometrial biopsies, possibly associated with hysteroscopy. [5][6] Magnetic resonance imaging (MRI) is the best imaging modality for staging. Furthermore, it shows a typical high enhancement with a "spotty" distribution, which may suggest bleeding and is a distinct hallmark of carcinosarcoma. ...
... Furthermore, it shows a typical high enhancement with a "spotty" distribution, which may suggest bleeding and is a distinct hallmark of carcinosarcoma. [6][7] Depending on the histopathologic assessment of the tumor (depth of invasion and presence or absence of metastases) and clinical presentation, 8 the management of UCS requires a multimodality treatment comprised of surgery, systemic therapy, and radiotherapy. The estimated 5-year survival rate ranges from 33 to 39%, but the recurrence rate remains high. ...
... The measurement of endometrial thickness in premenopausal women is not a useful parameter, as I mentioned, due to the important variations that it registers during the menstrual cycle, and cannot be used as an alternative to endometrial biopsy. A study of 200 premenopausal women with abnormal uterine bleeding states the existence of endometrial pathology such as endometrial polyps or submucosal leiomyomas in 20% of women with an endometrial thickness <5 mm (17). In premenopausal asymptomatic women, endometrial evaluation should be based on a combination of factors including the results of cervical cytology with glandular or endometrial cell abnormalities, history of estrogenic excess or anovulation, corroborated with endometrial thickness. ...
... Other studies have also found that tumor size correlated with lymph node metastasis and disease-free survival ine women with endometrial cancer (17). Other authors have reported the association of increased color density on color Doppler examination with increasing stage of the disease and the presence of lymph node metastases, the number of vessels with multifocal origin tending to increase in proportion with the stage of the disease and the infiltrative character, knowing that angiogenesis, measured by microvascular density, has been shown to play a key role in the prognosis of endometrial cancer (18,19) (1). ...
Abnormal uterine bleeding is probably the most frequent gynecological issue that leads women to a consult with a subsequent ultrasound. Transvaginal ultrasonographic evaluation represents the most sensitive method of endometrial evaluation, being more adequate than the transabdominal approach, especially when differentiating the benign lesions from the malignant ones. Transvaginal ultrasound is extremely useful in measurement, morphology and vascularization examination of the uterine cavity, especially the endometrium. We present 10 endometrial issues in which transvaginal ultrasound has proven its utility in the paraclinical evaluation of the patient: endometrial cycle phase, endometrial thickness, endomyometrial junction, endometrial vacuum line, cystic endometrium, endometrial vascularization, endometrial polyp, intracavitary development of leiomyomas, thick endometrium and endometrial cancer.
... Previous studies used fewer parameters including ET, heterogeneous echogenicity, and multivessel vascular pattern 16,21 reported lower accuracy. 22 An interrupted EMJ 23 and endometrial surface irregularity at GIS 24 are good predictors for endometrial cancer. ...
... However, the absence of endometrial cancer in this group of patients proved the effectiveness of this management strategy in these populations. Tumor vascularity is dependent on tumor characteristics 21,38 and the sample of cancer cases. Accuracy of cancer diagnosis is dependent on diagnostic signs with subjective nature (endometrial focal lesion with an irregular surface, irregular EMJ, an interrupted EMJ), and variable accuracy could be expected. ...
Objective
(a) To comparatively evaluate the performance of grayscale ultrasound features, power Doppler (PD) blood flow characteristics, and gel infusion sonography (GIS) in diagnosing endometrial cancer during real-time examination, (b) to compare the performance of real-time diagnosis of endometrial cancer by experienced observers with offline analysis by blinded observers using similar sonographic criteria during review of cine loop clips.
Methods
152 females with post-menopausal bleeding (PMB) had ET ≥ 4 mm at first-line ultrasound were included. Two experienced radiologists evaluated endometrial patterns at real-time evaluation (grayscale ultrasound, PD, and GIS), then examinations were stored as video clips for later evaluation by two less-experienced radiologists. The reference standard was hysteroscopy (HY) and/or hysterectomy with the histopathological examination. The area under (AUC) the receiver operating characteristic (ROC) curve was calculated to assess the diagnostic performance for the prediction of endometrial cancer.
Results
Among 152 females with ET ≥ 4 mm at first line TVUS, 88 (57.9%) patients had endometrial cancer on final pathologic analysis. Real-time ultrasound criteria (ET ≥ 5 mm with the presence of irregular branching endometrial blood vessels or multiple vessels crossing EM or areas with densely packed color-splash vessels with non-intact or interrupted EMJ at the grayscale ultrasound and/or GIS) correctly diagnosed 95% of endometrial cancers with 92% diagnostic efficiency. There is comparable accuracy of real-time evaluation (96%) and offline analysis (92%) after the exclusion of poor quality videos from the analysis. The diagnostic criteria showed good to an excellent agreement between real-time ultrasound and offline analysis.
Conclusion
When real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility.
Advances in knowledge
when real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility.
... [6] Nowadays preoperative evaluations using advanced imaging techniques have become more common, but little has been done on the best imaging technique for routine use and preoperative evaluations of endometrial carcinoma. The accuracy of transvaginal ultrasound has been reported in different studies [7] and some results are comparable to MRI. [8] Many studies have shown that findings, such as intra-tissue color flow, indicate the likelihood of malignancy of the tissue if elevated along with a decrease in blood flow resistance. [9] Concerning endometrial tissue in spite of the many theoretical differences, some studies advocate that transvaginal Doppler ultrasound can distinguish endometrial malignancies. ...
... Grading of endometrial carcinoma was performed as follows. [7] Grade 1: Well-differentiated endometrial carcinoma Grade 2: Moderately differentiated endometrial carcinoma Grade 3: Poorly differentiated endometrial carcinoma (undesirable histologic type, penetration to more than half myometrial depth, penetration into the cervix) ...
Introduction:
Given the role of angiogenesis in tumor growth, the evaluation of tissue vascularization by Doppler ultrasound has been thought to be useful in the prediction of malignant endometrial changes. The aim of this study was to evaluate the efficacy of transvaginal color Doppler ultrasound (TV-CDU) findings in the differentiation between endometrial hyperplasia and endometrial carcinoma and its relation with pathologic findings.
Methods:
This observational study included 48 women with either endometrial hyperplasia (n = 10) or endometrial carcinoma (n = 38) that had been diagnosed by endometrial biopsy. The intratumoral blood flow characteristics including resistance (RI), pulsatility (PI) and peak systolic velocity (PSV) index were analyzed using TV-CDU before surgery. Endometrial thickness and myometrial invasion also was assessed in all patients using gray-scale ultrasound. Then the relationship between these ultrasound findings and histologic results was evaluated with EC.
Results:
RI, PI, and PSV indices in endometrial carcinoma were significantly higher than endometrial hyperplasia (P < 0.0001). There was also a significant difference between the mean endometrial thickness between the two groups of endometrial hyperplasia and endometrial carcinoma (P < 0.0001). Intratumoral blood flow index were higher in high grade tumors than in low grade tumors (P < 0.05).
Conclusion:
TV-CDU may be useful to show a difference the difference in tumor angiogenesis between endometrial hyperplasia and endometrial carcinoma and therefore be used in differentiation of endometrial hyperplasia and carcinoma. Evaluation of intratumoral blood flow using RI, PI, and PSV indices in patients with endometrial carcinoma may be helpful distinguishing between low-grade and high-grade tumors as well as preoperative tumor invasion before surgery.
... For DMI assessment, a transvaginal or transrectal ultrasound performed by an expert or a pelvic magnetic resonance imaging (MRI) is recommended [4][5][6][7]. The most recent meta-analysis comparing 2D-TVS (transvaginal ultrasound) to MRI was published in 2017 and concluded that MRI showed similar specificity and superior sensitivity compared to TVS in detecting DMI in women with EC, but the difference was not statistically significant [8]. ...
Simple Summary
The optimal imaging method for deep myometrial infiltration assessment in endometrial cancer is uncertain. We aimed to compare transvaginal ultrasound and magnetic resonance imaging in the preoperative assessment of deep myometrial infiltration. Our study indicates that transvaginal ultrasound provides diagnostic performance comparable to magnetic resonance imaging. However, magnetic resonance imaging showed significantly better specificity in low-grade endometrial cancer. Further studies are needed for the evaluation of myometrial infiltration, especially concerning patients with fertility-sparing wishes.
Abstract
In endometrial cancer (EC), deep myometrial invasion (DMI) is a prognostic factor that can be evaluated by various imaging methods; however, the best method of choice is uncertain. We aimed to compare the diagnostic performance of two-dimensional transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the preoperative detection of DMI in patients with EC. Pubmed, Embase and Cochrane Library were systematically searched in May 2023. We included original articles that compared TVS to MRI on the same cohort of patients, with final histopathological confirmation of DMI as reference standard. Several subgroup analyses were performed. Eighteen studies comprising 1548 patients were included. Pooled sensitivity and specificity were 76.6% (95% confidence interval (CI), 70.9–81.4%) and 87.4% (95% CI, 80.6–92%) for TVS. The corresponding values for MRI were 81.1% (95% CI, 74.9–85.9%) and 83.8% (95% CI, 79.2–87.5%). No significant difference was observed (sensitivity: p = 0.116, specificity: p = 0.707). A non-significant difference between TVS and MRI was observed when no-myometrium infiltration vs. myometrium infiltration was considered. However, when only low-grade EC patients were evaluated, the specificity of MRI was significantly better (p = 0.044). Both TVS and MRI demonstrated comparable sensitivity and specificity. Further studies are needed to assess the presence of myometrium infiltration in patients with fertility-sparing wishes.
... Trans-vaginal ultrasound, with color Doppler/power Doppler study of endometrial vascularization. 15,16 Hysteroscopy (assessment of endometrial tissue with targeted biopsies). 17 MRI, which can detect gross myometrial invasion or extension of tumor to the cervical stroma and the presence of lymphnodal involvement, local and distant metastatic disease at diagnosis. ...
... The evaluation of quantitative parameters (RI, PSV, severity of vascularization) and qualitative parameters (type of echogenicity) due to their high utility is a valuable part of preoperative evaluation. Low opacities (RI < 0.4) and increased flow velocity (PSV) show a correlation with deep infiltration (uMI > 50%), high grade (G2-3), cervical infiltration, and LVSI involvement, indicating a high risk of lymph node metastasis and recurrence [38][39][40]. ...
Simple Summary
This paper delves into the issue of metastatic endometrial cancer (EC), which significantly impacts treatment success and overall survival rates. The study explores various factors contributing to metastasis, including the molecular profile of EC, hormone activity (like estrogen and prolactin), and pro-inflammatory adipocytokines. It also investigates how altered microRNA expression affects gene regulation linked to the dissemination of the cancer. The paper highlights the importance of imaging techniques, particularly transvaginal ultrasound with tumor-free distance (uTFD), in detecting metastases. Additionally, it discusses how diagnostic and therapeutic methods can influence the spread of EC, with hysteroscopy potentially increasing risk in advanced stages and laparoscopic hysterectomy being safer if performed with care. This research could improve our understanding of EC and guide better diagnostic and treatment strategies.
Abstract
The presence of metastatic endometrial cancer (EC) is a key problem in treatment failure associated with reduced overall survival rates. The most common metastatic location is the pelvic lymph nodes, and the least common is the brain. The presence of metastasis depends on many factors, including the molecular profile of cancer (according to the TCGA—Genome Atlas), the activity of certain hormones (estrogen, prolactin), and pro-inflammatory adipocytokines. Additionally, an altered expression of microRNAs affecting the regulation of numerous genes is also related to the spread of cancer. This paper also discusses the value of imaging methods in detecting metastases; the primary role is attributed to the standard transvaginal USG with the tumor-free distance (uTFD) option. The influence of diagnostic and therapeutic methods on EC spread is also described. Hysteroscopy, according to the analysis discussed above, may increase the risk of metastases through a fluid medium, mainly performed in advanced stages of EC. According to another analysis, laparoscopic hysterectomy performed with particular attention to avoiding risky procedures (trocar flushing, tissue traumatization, preserving a margin of normal tissue) was not found to increase the risk of EC dissemination.
... This is of particular importance in cases qualified for fertility-preserving procedures. A multicenter prospective study conducted by Epstein et al. [38] in 2007-2009 identified sono-morphological and Doppler features characteristic of low-grade endometrial cancer and also cases with a high risk of recurrence. These results were confirmed by Fischerov et al. in another prospective study [39]. ...
Simple Summary
Endometrial cancer is a gynecological neoplasm characterized by a constant increase in incidence in highly developed countries. Due to the tendency towards late motherhood in these regions of the world, it is starting to affect more and more young women as well, often those who have not realized their maternity plans. At the same time, we note a very intensive development of research related to endometrial cancer, both in terms of diagnostics and new therapies. Therefore, nowadays, is there a sparing treatment option for young women?
Abstract
Endometrial cancer (EC) rarely develops in young women. Most cases are associated with known risk factors: BMI > 30, history of Polycystic Ovary Syndrome (PCOs), and race differentiation. The molecular EC classification based on The Cancer Genome Atlas Research Network divides these heterogeneous cancers into four types: Polymerase Epsilon Mutation (POLE), Microsatellite Instability (MSI), Copy Number Low (CNL), and Copy Number High (CNH). This division was introduced to allow for early assessment of neoplastic changes and clinical management, including targeted therapies. The basic technique for imaging endometrium changes is transvaginal sonography. Hysteroscopy is the standard for obtaining endometrial material for histological evaluation. The MRI result permits assessment of the extent of EC cancer infiltration. In young women who want to preserve fertility, apart from surgery, conservative management is often implemented after strict selection based on clinical and pathological data. This pharmacological treatment involves the administration of progestogens MPA (medroxyprogesterone acetate) and MA (megestrol acetate). The use of metformin may increase the effectiveness of such treatment. An alternative option is to apply progestogens locally—via the levonorgestrel-releasing intrauterine device. In addition to pharmacological treatment, hysteroscopic resection may be used—part of the uterine muscle adjacent to the pathologically changed endometrium may also undergo resection. An alternative is the administration of estrogen receptor modulators (e.g., SERMs) or aromatase inhibitors, or GnRH agonists.
... Stage 1A tumor exhibit no or low vascularization and are usually hyperechoic; on the other hand, tumors stage IB or greater may display high color scores, multiple globally entering vessels, and mixed or hypoechogenicity. 69 However, the role of Doppler US in diagnosis of endometrial cancer is still controversial and requires further assessment. 67,70 In postmenopausal women, a thin endometrium (<5 mm) tends to signify the absence of endometrial cancer. ...
Imaging plays a crucial role in the diagnosis, staging, and follow-up of endometrial cancer. Endometrial cancer is staged surgically using the International Federation of Gynecology and Obstetrics (FIGO) staging system. Preoperative imaging can complement surgical staging but is not yet considered a required component in the current FIGO staging system. Preoperative imaging can help identify some tumor characteristics and tumor spread, both locally and distally. More accurate assessment of endometrial cancers optimizes management and treatment plan, including degree of surgical intervention. In this article, we review the epidemiology, FIGO staging system, and the importance of imaging in the staging of endometrial cancer.
... The results broadly confirm our current knowledge on endometrial ultrasound 7,9,[28][29][30][31][32][33][34][35][36][37][38][39] . Alcázar and Galvan 38 evaluated power-Doppler features in 91 postmenopausal women with abnormal bleeding. ...
Objective:
To describe the ultrasound features of different endometrial and other intracavitary pathologies in pre- and postmenopausal women presenting with abnormal uterine bleeding using the International Endometrial Tumor Analysis (IETA) terminology.
Methods:
Prospective observational multicenter study of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced ultrasonography with color Doppler was performed in all cases and fluid instillation sonography in 1857. Endometrial sampling was performed according to each center's local protocol. In 2216 women, endometrial histology was available, and these were defined as the study population. The histological endpoints were cancer, atypical endometrial hyperplasia, endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, and intracavitary leiomyoma. For fluid instillation sonography the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint we report typical ultrasound features using the IETA terminology.
Results:
Median (range) age was 49 years (19-92), median parity 2 (0-10) and median body mass index 24.9 (16.0-72.1). Of the study population 38% (n=843) were postmenopausal. Endometrial polyps were diagnosed in 751 women (33.9%), intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None of 66 women with endometrium < 3mm (0%; 95% CI 0.0-5.5%) had endometrial cancer (or atypical hyperplasia/endometrioid intraepithelial neoplasia, EIN). Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 endometria with a three-layer pattern (1.1%; 95% CI 0.4-3.1%), and in three of 459 endometria with a linear endometrial midline (0.7%; 95% CI 0.2-1.9%) and in five of 337 cases with a single vessel without branching on unenhanced ultrasound (1.5%; 95% CI 0.6-3.4).
Conclusions:
The paper describes the typical ultrasound features of endometrial cancer, polyps, endometrial hyperplasia and endometrial atrophy using IETA terminology. Some easy to assess IETA-features (i.e. endometrial thickness < 3mm, triple layer pattern, linear midline and single vessel without branching) make endometrial cancer unlikely. This article is protected by copyright. All rights reserved.
... Once a lymph node is visualized in the setting of a patient with a pelvic malignancy, there are a number of potentially useful features to determine if it is involved with tumor or not. However, the sensitivity and specificity of these features are modest [20,21,22,23]. ...
... Well or moderately differentiated (grades I-II) tumors are hyperechoic, compared to grade III, and more widespread lesions that are hypoechoic or heterogeneous. 10 Though irregular endometrial surface is another diagnostic criterion for the diagnosis of the endometrial malignancy (Fig. 39), this can be best appreciated by sonohysterography. However, if malignancy is suspected either clinically or on the ultrasound, sonohysterography is not preferred for the risk of its peritoneal spread and seeding. ...
... With the help of the endovaginal ultrasound with pulsed Doppler it is identified, highly accurately, the presence of the endometrial adenocarcinoma, which determines the decrease of the number of falsepositive results (14). ...
Aim:
Our study had as a major objective the highlighting of more objective criteria in establishing the morphological diagnosis and the evaluation of prognosis elements in endometrial hyperplasia and endometrial carcinoma, representing a specific pathology for the premenopausal and postmenopausal women. Endometrial adenocarcinoma is a malignant tumor, rare in women under 40 years of age, but the incidence increases after menopause, gradually reaching a maximum between 70-79 years.
Material and methods:
The study included 291 patients with endometrial adenocarcinoma. The patients were admitted in 2005-2010 to "Cuza-Voda" Obstetrics and Gynecology Hospital in Iasi. The study group was diagnosed and investigated on the basis of the clinical examination and the specialized complementary explorations. The histopathological diagnosis was obtained by the processing of the hysterectomy specimen.
Results:
The results of the study that we conducted highlight the fact that nearly half of the patients diagnosed with endometrial adenocarcinoma were 50-59 years old. In 78.01% cases the uterus was of normal size, between 4-6cm, in 10.31% cases was increased over 6 cm and 11.68% it was of small size, less than 4 cm.
Conclusions:
The study recommends surveillance of cases with endometrial hyperplasia especially if are associated with incriminated risk factors in the etiology of carcinoma of the uterus.
... The presence of stromal tumor invasion of the uterine cervix was also determined using the approach described by Epstein et al. 10 This methodology included the objective findings of the distance from the external cervical os to the lower margin of tumor (Dist-OCO) and the subjective findings of the dynamic sonographic technique to demonstrate tumor extension into the cervical stroma. A negative "sliding test" (absence of vascularity when moved) enables possible demonstration of vascularity directly to the tumor. ...
The goal of this study was to compare the sonographic assessment of endometrial cancer diagnosis and staging using three-dimensional transvaginal sonography with the staging that was ultimately found at surgery. Three-dimensional transvaginal sonography was performed for 20 consecutive cases of presumptive endometrial cancer using power Doppler angiography, virtual organ computer-aided analysis, and volume contrast imaging. These results were compared with the surgical staging found for those identified cases. The sonographic findings predicted the correct minimum endometrial cancer staging in 100% of the 20 cases that were examined and correlated to surgical outcomes. The successful prediction of endometrial cancer staging demonstrated by others was replicated in the organization of this case series. The findings compared favorably with other imaging modalities used for this purpose. This study assists in demonstrating the value of using presurgical three-dimensional sonography to plan for the optimal surgical excision and overall treatment of endometrial cancer.
... But the same success has not been supported in all studies. They thought that vascular findings depend on tumor char- acteristics and the sample size of the studies [14,15] . And some studies suggest that power Doppler examinations do not improve the diagnostic efficiency of malignancies [16] . ...
... In our study, subjective evaluation was confirmed as the most reliable method to assess myometrial invasion. The possible reason for the superiority of subjective assessment of myometrial invasion is that it can take more features into account other than size and proportion, including dynamic tests (e.g., sliding sign of tumor against uterine wall or in endocervical canal) or vascular pattern [42]. Furthermore, every objective model requires a subjective identification of endometrial tumor and determination of its borders. ...
The aim of this study was to assess the diagnostic accuracy of subjective ultrasound evaluation of myometrial invasion of endometrial cancer and to compare its accuracy to objective methods. All consecutive patients with histologically proven endometrial cancer, who underwent ultrasound evaluation followed by surgical staging between January 2009 and December 2011, were prospectively enrolled. Myometrial invasion was evaluated by subjective assessment using ultrasound (<50% or ≥50%) and calculated as deepest invasion/normal myometrium ratio (Gordon’s ratio) and as tumor/uterine anteroposterior diameter ratio (Karlsson’s ratio). Histological assessment from hysterectomy was considered the gold standard. Altogether 210 patients were prospectively included. Subjective assessment and two objective ratios were found to be statistically significant predictors of the myometrial invasion (AUC = 0.65, p value < 0.001). Subjective assessment was confirmed as the most reliable method to assess myometrial invasion (79.3% sensitivity, 73.2% specificity, and 75.7% overall accuracy). Deepest invasion/normal myometrium (Gordon’s) ratio (cut-off 0.5) reached 69.6% sensitivity, 65.9% specificity, and 67.3% overall accuracy. Tumor/uterine anteroposterior diameter (Karlsson’s) ratio with the same cut-off reached 56.3% sensitivity, 76.4% specificity, and 68.1% overall accuracy. The subjective ultrasound evaluation of myometrial invasion performed better than objective methods in nearly all measures but showed statistically significantly better outcomes only in case of sensitivity.
... In the group of 105 patients sonohysteroscopy failed to detect endometrial polyps in 30 cases [18], SIS may also lead to erroneous diagnosis of blood clots as endometrial polyps [20]. Many authors do not regard sonohysterography results as sufficient evidence to confirm or exclude endometrial abnormalities [4,6,12,[21][22][23][24]. ...
Objectives:
The aim of this study was to assess the usefulness of sonohysterography with feeding artery visualization using transvaginal sonography to diagnose endometrial polyps.
Material and methods:
We conducted an observational study of 60 perimenopausal patients referred to the Department of Fetal Medicine and Gynaecology, Medical University of Lodz with abnormal uterine bleeding or suspicion of endometrial pathology based on sonography scan. In all 60 patients transvaginal sonography scan showed a possibility of an endometrial polyp. Of these, 46 underwent saline infusion sonohysterography with sonography visualization of a feeding artery. Pathological examination was performed on material collected during hysteroscopy.
Results:
Sonography detection of endometrial polyp based on feeding artery visualization had a 40% sensitivity, whereas sonohysterographic polyp detection had a sensitivity of 75% and a specificity of 100%. The positive and negative predictive values of saline infusion sonohysterography in diagnosing endometrial polyps were estimated at 75% and 72% (95% CI: 52-86%), respectively. The combination of sonohysterography and feeding artery imaging in transvaginal sonography was 84% sensitive and 95% specific in detecting endometrial polyps. The positive and negative predictive values were: PPV = 96% and NPV = 89%.
Conclusion:
Saline infusion sonohysterography with feeding artery visualization may become a standard method in the diagnostics of endometrial polyps in perimenopausal women.
... Different endometrial pathologies may manifest diverse ultrasound features [1][2][3][4][5][6] . Mathematical models that include grayscale and color Doppler ultrasound variables (e.g. ...
Objectives:
To estimate intra- and inter-rater agreement and reliability with regard to describing ultrasound images of the endometrium using the International Endometrial Tumor Analysis (IETA) terminology.
Methods:
Four expert and four non-expert raters assessed video clips of transvaginal ultrasound examinations of the endometrium from 99 women with postmenopausal bleeding and sonographic endometrial thickness ≥4.5 mm and no fluid in the uterine cavity. The following features were rated: endometrial echogenicity (nine categories), endometrial midline (four categories), bright edge (yes, no), endometrial-myometrial junction (four categories), color score (1 to 4), vascular pattern (seven categories), irregularly branching vessels (yes, no), color splashes (yes, no). The color content of the endometrial scan was estimated using a visual analogue scale (VAS) graded from 0 to 100. The clips were assessed twice > 2 months apart. The raters were blinded to their own results and to those of the others.
Results:
Inter-rater differences in the prevalence of most IETA variables were substantial, and some variable categories were rare. Specific agreement was poor for variables with many categories. For binary variables, specific agreement was better for absence than presence of a category. For variables with more than two outcome categories specific agreement was best for undefined endometrial midline (93% and 96% for expert and non-expert raters), regular endometrial-myometrial junction (72% and 70%), and three-layer endometrial pattern (67% and 56%). The most reliable gray scale ultrasound variable was uniform versus non-uniform echogenicity (multirater Kappa, κ, 0.55 and 0.52 for expert and non-expert raters), the least reliable were appearance of the endometrial-myometrial junction (κ 0.25 and 0.16) and the nine-category endometrial echogenicity variable (κ 0.29 and 0.28). The most reliable color Doppler variable was color score (mean weighted κ 0.77 and 0.69). Intra- and inter-rater agreement and reliability were similar for experts and non-experts.
Conclusions:
Agreement and reliability when using IETA terminology was limited. This may have implications when assessing the association between a particular ultrasound feature and a specific histological diagnosis, because lack of reproducibility reduces the relationship of a feature with the outcome. Future studies should investigate if using fewer variable categories or offering practical training could improve agreement and reliability.
... • The echo texture of endometrial cancer may often be heterogenic [108]. Moreover, the endoemyometrial junction may be interrupted [109]. In postmenopausal women, JZ is a thin hypoechoic line that is often indistinct. ...
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Vascular pattern recognition using color Doppler imaging is important in the diagnosis of benign and malignant conditions of the uterus involving myometrium, endometrium, and uterine cavity. Color imaging facilitates the detection of myometrial lesions (differential diagnosis between a fibroid, adenomyosis, and uterine sarcoma), intracavitary lesions (differential diagnosis between an endometrial polyp, an intracavitary fibroid, or endometrial cancer), or retained products of conception. Sufficient knowledge of Doppler machine settings is necessary to optimize color imaging and hence diagnostic accuracy.
It is important to distinguish uterine lesions from other lesions occurring in the pelvic cavity for the
proper management. The primary radiological evaluation of uterine lesions is performed using transvaginal
ultrasonography, and if the lesion is too large or shows atypical benign imaging findings, magnetic
resonance imaging should be performed. Analyzing radiological findings of uterine lesions
through a pattern recognition approach can help establish the accurate diagnosis and treatment plan.
In this pictorial assay, we describe imaging characteristics of various lesions arising from the uterus
and evaluate them based on the pattern recognition approach.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Ultrasonography is a cornerstone in the evaluation of gynecologic disease. This authoritative new book looks at the techniques of ultrasonography in both office and hospital settings, offering guidance on the optimal use of equipment and covering the full range of benign and malignant gynecologic disease as well as infertility. Ultrasonography in Gynecology offers extensive coverage of the diagnostic potential of ultrasound in gynecologic disease, from the moment the patient walks into the physician's office. All the different approaches in the ultrasonographic evaluation of disease – including 3D ultrasonography, 3D sonohysterography, Doppler imaging and pelvic floor imaging – are extensively covered, with color images throughout. Written and edited by leaders in the field of ultrasonography who have actively participated in national and international teaching courses, Ultrasonography in Gynecology is a must for all gynecologists dealing with infertility, endometriosis, uterine fibroids, gynecologic cancers, and many more gynecologic conditions.
Endometrial cancer is a common malignancy in women worldwide, with myometrial invasion (MI) being an important prognostic factor, usually assessed via imaging techniques. The aim of this review is to compare the diagnostic accuracy of 3D transvaginal ultrasound (3D-TVUS), a relatively new imaging modality, to that of 2D transvaginal ultrasound (2D-TVUS) and MRI in the prediction of deep myometrial invasion. Relevant articles were sought on MEDLINE/PubMed, Scopus, Web of Science and Wiley Online Library databases. Articles were included if they were primary studies comparing 3D-TVUS to 2D-TVUS and/or MRI in adult endometrial cancer patients, with histopathological confirmation of MI as a reference standard. Ultimately, 7 studies were included, with 714 participants, 242 with deep MI and a mean age of approximately 60 years. 3D-TVUS, 2D-TVUS, MRI and 3D-TVUS-MRI co-evaluation had a pooled sensitivity of 80.4%, 77.6%, 80.7% and 94.6% respectively and a specificity range of 82.8%, 81.6%, 87% and 69.1% respectively. Overall, no statistically significant differences were found in sensitivity and specificity among 3D-TVUS and the other methods, except for a significant increase in sensitivity (p = 0.038) when combined with MRI. This shows that 3D-TVUS is comparable to MRI as far as diagnostic accuracy is concerned, however remains cheaper, less time-consuming and more tolerable, while offering some advantages over 2D-TVUS as well. Therefore 3D-TVUS application in MI assessment seems promising, although more research is required to further assess this finding and ascertain 3D-TVUS's place in endometrial cancer MI assessment.
Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.
Uterine corpus and cervical cancers are showing, in the last decades, increasing incidence and mortality in industrialized and developing countries, respectively; on the other hand, innovative therapeutic strategies are emerging for the management of advanced gynecological malignancies. Risk factors and predisposing conditions are widely and continually studied; thus, prevention, through lifestyle correction and/or validated screening tests, could represent a promising tool to diagnose earlier and reduce mortality of uterine cancers. Herein, management of endometrial and cervical tumors from diagnosis to commonly applied standards of care and experimental frontiers are depicted so as to profile gynecological cancers in personalized medicine era.
Objective:
To compare the sensitivity and specificity of conventional two-dimensional transvaginal ultrasound/power Doppler (2D-TVU/PD) alone to 2D-TVU/PD combined with dynamic contrast-enhanced ultrasound (DCE-US) in diagnosing deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer (EC) and to correlate DCE-US and 2D-TVU/PD quantitative and qualitative variables to FIGO stage ≥IB and to 'high' risk cancer (stage ≥IB and/or grade 3 endometrioid and/or non-endometrioid histology).
Methods:
A prospective study including 101 consecutive women with biopsy-confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, Stockholm, Sweden, a tertiary referral center. All consenting women underwent DCE-US (using a 1.5-2.5 ml intravenous bolus of Sonovue® contrast agent) and conventional 2D-TVU/PD examination. DCE-US video clips were analyzed with regard to filling pattern, wash-in pattern and wash-out pattern and semi-quantitative DCE-US parameters (wash-in slope, time-to-peak, peak intensity and area-under-the-time-intensity-curve) obtained from a time-intensity curve. The study cohort was compared to a control cohort examined with 2D-TVU/PD only, matched 3:1 on FIGO stage and grade, using cases from our center examined according to the IETA (International Endometrial Tumor Analysis) protocol. Pathological evaluation after hysterectomy served as 'gold standard'.
Results:
After exclusions, 93 women remained in the study cohort and matched to 279 women in the control cohort. The prevalence of stage IA, grade 1-2 were 51% in both cohorts. The sensitivity was higher in the study cohort than in the control cohort in diagnosing both deep MI and CSI (MI: 0.74 vs. 0.62, p=0.036, CSI: 0.75 vs. 0.51, p<0.001) whereas specificity was not significantly different (MI: 0.87 vs. 0.85, CSI: 0.96 vs. 0.95). Specificity was higher in detecting 'high' risk cancer in the study cohort (0.94 vs. 0.85, p=0.024) but sensitivity did not differ. 'High' risk cancer and FIGO stage ≥IB was characterized by a 'focal' filling pattern, with wash-in 'prior' and a 'focal' wash-out pattern on subjective assessment of DCE-US. All quantitative DCE-US parameters were significantly predictive of FIGO stage ≥IB, but not to 'high' risk cancer despite a clear trend.
Conclusion:
Combining DCE-US with 2D-TVU/PD can significantly improve the detection of deep MI and CSI without increasing the false positive rate compared to using 2D-TVU alone. It can also improve the correct classification of high-risk disease mainly by increasing the specificity and thereby possibly avoid unnecessary surgeries by almost ten percent. Quantitative DCE-US parameters, as well as a 'focal' filling pattern, endometrial wash-in 'prior' to the myometrium and a 'focal' wash-out pattern, all correlate to more advanced disease. This article is protected by copyright. All rights reserved.
Objective: The aim of this study was to evaluate the position of uterine artery resistance index and endometrial thickness findings in the estimation of endometrial malignancy in vaginal color Doppler ultrasonography in the first examination of patients with postmenopausal bleeding.
Material and methods: Transvaginal color Doppler ultrasonography was performed for the determination of endometrial thickness and resistance index of both uterine arteries in 50 patients who presented with postmenopausal bleeding before endometrial sampling. Patients were divided into two groups as benign and malignant according to their pathology results. Both groups were compared in terms of age and ultrasonography findings.
Results: Of 50 patients with postmenopausal hemorrhage, 44 (88%) had benign 6 (12%) malignant endometrial sampling. When the benign and malignant groups were compared in terms of endometrial thickness, a significant difference was found between the two groups (p <0.05). When the two groups were evaluated in terms of uterine artery resistance indexes, a significantly lower resistance was observed in the malignant group (p <0.05).
Conclusion: Conservative treatment may be an option in patients with postmenopausal bleeding with transvaginal Doppler ultrasound 10 mm below endometrial thickness and> 0.79 uterine artery resistance index.
Objectives
To derive and validate a practical scoring system for identification of endometrial cancer (EC) or atypical hyperplasia (AH) using transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) in women with postmenopausal bleeding (PMB).
Study design
Endometrial pattern was correlated with endometrial pathology in consecutive women with PMB in both a derivation study (N = 164) and a validation study (N = 711). Logistic regression was used to derive and validate two scoring systems (A and B) for prediction of EC/AH: scoring system A was Doppler score + interrupted endo-myometrial junction (IEJ) (2 points); and scoring system B was Doppler score + IEJ (1 point) + Irregular Endometrial Outline (IESO) by GIS (1 point); the Doppler score was based on the presence of more than one single or double vessel (1 point) + multiple vessels (1 point) + large vessels (1 point).
Outcome measures
Diagnostic performance and calibration curves for identification of EC/AH.
Results
Both scoring systems had good observer agreement.
Validation data
Scoring was most effective with endometrial thickness (ET) ≥ 8 mm. Both scoring systems were well calibrated and performed satisfactorily in women with ET ≥ 8 mm. The sensitivity and specificity of a score of ≥ 2 points in system A were 92% and 84%; the respective values were 89% and 88% in system B.
Conclusions
Scoring was highly efficient in identifying EC/AH. Four risk groups of EC/AH may guide the management of women with PMB: very low (ET < 4 mm), low (ET 4–7.9 mm), intermediate (ET ≥ 8 mm and score < 2 points) and high risk (ET ≥ 8 mm and score ≥ 2 points).
Study objective:
To evaluate the Risk of Endometrial Cancer (REC) scoring system for the prediction of high and low probability of endometrial cancer (EC) in women with postmenopausal bleeding (PMB).
Design:
Prospective study (Canadian Task Force classification II-1).
Setting:
Academic hospital.
Patients:
Nine hundred and fifty consecutive patients with PMB underwent transvaginal ultrasonography (TVS) and REC scoring between November 2013 and December 2015.
Interventions:
Obstetrics and gynecology residents, supervised by trained physicians, scored endometrial patterns according to the previously established REC scoring system. The reference standard was endometrial samples, endometrial thickness (ET; 4-4.9 mm), operative hysteroscopy, or hysterectomy (ET ≥5 mm), and one-year follow-up in all patients presenting with ET <4 mm. Diagnostic performance for prediction of probability of malignancy was assessed using the REC scoring system.
Measurements and main results:
The area under the receiver operating characteristic (ROC) curve (AUC) of the TVS REC score system was 97% (range: 95-98) for prediction of malignancy. In 656 patients with ET ≥4 mm, REC scoring effectively predicted high probability of malignancy: sensitivity (95% confidence interval): 92% (range: 87%-95%); specificity: 94% (range: 91%-96%). An REC score of 0 was present in 206 (32%) patients with ET ≥4 mm and was associated with a low negative likelihood ratio of 0.026 for EC. Only 7 patients with EC/atypical hyperplasia were seen among these 206 patients.
Conclusion:
The REC scoring system identified or ruled out most ECs, clearly demonstrating that more specific image analysis at first-line TVS can accelerate the diagnosis of EC in patients with PMB and may allow for improved selection of second-line strategies in patients with ET ≥4 mm.
Objectives:
To describe the sonographic features of endometrial cancer in relation to stage, grade, and histological type using the International Endometrial Tumor Analysis (IETA) terminology.
Methods:
Prospective multicenter study on 1714 women with endometrial cancer undergoing a standardized transvaginal grayscale and Doppler ultrasound examination by an experienced ultrasound examiner using a high-end ultrasound system. Clinical and sonographic data were entered into a web-based protocol. We assessed how strongly sonographic characteristics, according to IETA, were associated to outcome at hysterectomy, i.e. tumor stage, grade, and histological type.
Results:
After excluding 176 women (no or delayed hysterectomy, final diagnosis other than endometrial cancer, or incomplete data), 1538 women were included in our statistical analysis. Median age was 65 years (range 27-98), and median BMI 28.4 (range 16-67), 1378 (89.7%) women were postmenopausal, and 1296 (84.2%) reported abnormal vaginal bleeding. Grayscale and color Doppler features varied according to grade and stage. High-risk tumors (stage 1A, grade 3 or non-endometrioid or ≥ stage 1B) were less likely to have regular endometrial myometrial border (difference of -23%, 95% CI -27 to -18%), whilst they were larger (mean endometrial thickness; difference of +9 mm, 95% CI +8 to +11 mm), more frequently had non-uniform echogenicity (difference of +10%, 95% CI +5 to +15%), a multiple, multifocal vessel pattern (difference of +21%, 95% CI +16 to +26%), and a moderate or high color score (difference of +22%, 95% CI +18 to +27%), than low-risk tumors.
Conclusion:
Grayscale and color Doppler ultrasound features are associated with grade and stage, and differ between high and low risk endometrial cancer.
This chapter focuses on the endometrium and its pathologies. The first section deals with standard definitions and terminology for studying the endometrium primarily based on the recent IETA recommendations. This is followed by a discussion on the normal appearances of the endometrium, asseen in women of various age groups and through various phases of the menstrual cycle.
The common pathologies of the endometrium are discussed next. They include endometrial polyps, endometrial hyperplasia, endometrial carcinoma, Asherman’s syndrome, subendometrial fibrosis, endometritis and intracavitary fluid.
The chapter has more than 70 images of cases with confirmed pathology of various conditions. Most of these are composite images showing multiple images highlighting various ultrasound features of a given pathology. The endometrium is relatively more challenging to study, as compared to the adnexa or myometrium, because tissue is minimal and the endometrial walls are in opposition. In addition, if the patient has a high BMI or the uterus is mid-positioned (axial), as is often the case, visualisation is suboptimal. The chapter focuses on the most recent understanding of subtle findings that help in diagnosis of various endometrial pathologies.
Objective
The aim of this study is to prospectively evaluate and compare the accuracy of high-frequency TVS and of two type of MRI (dynamic contrast-enhanced MRI or diffusion-weighted MRI), in association with HE4 in preoperative endometrial cancer (EC) staging. Study designStarting from January 2012 to February 2015, all patients with EC at prior endometrial biopsy, referred to the Division of Gynaecologic Oncology of the University Campus Bio-Medico of Rome, were prospectively included in the study. All of them underwent complete surgical staging hysterectomy and bilateral oophorectomy, pelvic and lumboaortic lymphadenectomy, according to 2011 NCCN guidelines. The day before surgery, patients underwent to transvaginal ultrasonography (TVS), HE4 serum dosage, and using a computer-based random procedure, to dynamic contrast-enhanced MRI (Group A) or to diffusion-weighted MRI (Group B), to assess myometrial invasion and cervical involvement. ResultsStarting from January 2012 to February 2015, a total of 79 patients were considered for the analysis and randomly divided into Group A (n = 38) and Group B (n = 41). Regarding myometrial invasion, MRI and TVS resulted comparable in terms of preoperative detection. Concerning the cervical infiltration, the association between TVS and HE4 is characterized by a better preoperative diagnostic validity (TVS + HE4 96.3 vs. 91 % for MRI and 85 % for the TVS). Conclusion
Our results, even the low number of enrolled patients, are promising and may lead to a greater efficiency and lower health care costs in identifying those women who require radical surgery and pelvic lymphadenectomy and should be addressed, in specialized centers.
Aims:
To assess intra-endometrial lesions according to five two-dimensional sonographic parameters for predicting malignancy.
Material and methods:
This is a retrospective analysis of stored digital images from consecutive pathological reports of patients with benign endometrial polyps and stage 1 endometrial carcinoma. Five sonographic parameters were evaluated: heterogeneous or complex echogenicity of the lesion, presence of a 'bright edge sign,' regular endometrial-myometrial junction, the presence of a normal endometrium adjacent to the lesion, and detection of small intralesional cysts. The sensitivity, specificity, PPV, and NPV of these parameters were calculated, as well as combinations of pairs of parameters.
Results:
Seventy-nine patients were eligible for the current study, 26 with benign endometrial polyps and 53 with stage 1 endometrial carcinoma. The sonographic appearance of numerous small intralesional cysts (cystic formation) was highly related to benign polyp; the presence of a lesion with heterogeneous echogenicity had sensitivity and specificity for malignancy of 63.5 and 88.5%, respectively.
Conclusions:
We have shown that asymptomatic endometrial lesions, which are homogenous, have bright edges, and small intralesional cysts are likely to be benign Determining these parameters during sonographic evaluation can assist in identifying patients who will benefit from a follow-up strategy instead of an unnecessary surgical intervention.
Ovarian neoplasms of metastatic origin account for up to 20 % of all cases of ovarian malignant tumors and present a special challenge to accurate diagnosis with regard to their nature and origin. This chapter outlines the basic guidelines for a multifaceted approach to their diagnosis and summarizes extensive ultrasound observation into general principles that are helpful in correctly assessing the metastatic nature of these tumors as well as in finding the possible primary site. Using these combined methods, the diagnostic accuracy could reach 90 %.
This chapter describes the application of optical imaging techniques to biological tissue, to yield both qualitative and quantitative metrics of morphological and functional information. An in-depth narrative proffers reasoning for the diagnostic and prognostic value of such techniques via comparable descriptions of its invasive predecessors. Optical sectioning techniques of both the scattering and absorption based variety are described. The inherent need for non-invasive imaging modalities in modern medicine is discussed, in addition to the advantageous applications of their use and current limitations affecting performance.
In this study we compare transvaginal sonography with MR imaging for use in detecting the depth of myometrial involvement by endometrial carcinoma.
Forty-two consecutive patients with stage I endometrial carcinoma had transvaginal sonography and MR imaging at 0.5 T. All the patients had a hysterectomy within 1-10 days after the imaging studies. The results of histologic examination of the surgical specimen were considered the gold standard of the study. We compared transvaginal sonography and MR imaging for use in assessing myometrial invasion by endometrial carcinoma by means of the staging classification of the International Federation of Gynecology and Obstetrics: stage Ia (tumor limited to endometrium), stage Ib (invasion of less than half the myometrium), stage Ic (invasion of more than half the myometrium). The overdiagnoses and the underdiagnoses for both techniques were calculated. We also evaluated the sensitivity and specificity of the two techniques for assessing the presence of myometrial invasion (stage Ib + stage Ic) and the presence of deep myometrial invasion (stage Ic). The diagnostic indexes evaluated and the differences between them were analyzed by using McNemar's test and 95% confidence intervals. The staging diagnoses based on MR imaging and sonographic findings were compared with staging diagnoses based on histologic examination, and a score was assigned to each diagnosis: these scores were then evaluated with Wilcoxon's signed rank test for paired data.
Histologic examination showed that six of the 42 patients had tumor confined to the endometrium (stage Ia), 14 had involvement of the inner half of the myometrium (stage Ib), and 22 had involvement of the outer half of the myometrium (stage Ic). The staging was concordant between the two imaging techniques in 32 cases (concordance, 76%). Among the 10 discordant cases, diagnosis was correct in six cases for MR and four cases for sonography. Overall staging based on sonography was correct with respect to histologic staging in 29 cases (69%; 95% confidence interval, 52-81%). Five tumors (12%) were underdiagnosed and eight (19%) were overdiagnosed. Staging based on MR findings was correct with respect to histologic staging in 31 cases (74%; 95% confidence interval, 58-85%). Five tumors (12%) were underdiagnosed, and six (14%) were overdiagnosed.
In our experience, there is no difference in the staging diagnoses of transvaginal sonography and MR imaging. Also, concordance with histologic staging diagnoses and sensitivity and specificity indexes did not show statistical differences between the two techniques, although these last results have to be considered with caution because of the low power of the statistical tests.
To determine if gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and endometrial vascular morphology as assessed by color Doppler ultrasonography can discriminate between benign and malignant endometrium in women with postmenopausal bleeding.
In a prospective study 95 consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm as measured by transvaginal ultrasound were included. Gray-scale and color Doppler ultrasound examination of the endometrium was performed. The ultrasound examiner characterized the morphology of the endometrium before and during saline infusion and assessed the endometrial vascular tree using a predetermined classification protocol without suggesting a diagnosis. A histopathological diagnosis was obtained by operative hysteroscopy, dilatation and curettage or hysterectomy.
There were no statistically significant differences in ultrasound findings between benign and malignant endometria of uterine cavities without fluid. Heterogeneous echogenicity, irregular surface, and both heterogeneous echogenicity and irregular surface of a focal lesion (or of the endometrium in the absence of focal lesions) in a uterine cavity filled with fluid (spontaneous or infused) were significantly more common in malignant than in benign endometrium. The sensitivity, false positive rate, positive and negative likelihood ratios of these findings were as follows: heterogeneous echogenicity, 80%, 29%, 2.74, 0.28, P = 0.003; irregular surface, 89%, 33%, 2.70, 0.17, P = 0.002; and both, 78%, 12%, 6.59, 0.25, P < 0.001. Two or more vessels were found in 67% (8/12) of the malignant endometria vs. 51% (40/79) of the benign endometria (non-significant difference). Vascular branching tended to be more common in malignant endometria (10/11; 91%) than in benign endometria (39/61; 64%), P = 0.09.
Heterogeneous echogenicity and an irregular surface of a focal lesion or of the endometrium in a fluid-filled uterine cavity are useful ultrasound criteria for predicting endometrial malignancy. Assessment of vascular morphology using color Doppler ultrasound is of limited--if any--value for discrimination between benign and malignant endometrium.
The aims of this study were to compare the diagnostic performance of sonohysterography (SH) with that of magnetic resonance imaging (MRI) in estimation of myometrial invasion and to evaluate the influence of SH on peritoneal cytologic results for patients with endometrial cancer.
Seventy-four patients with endometrial cancer were included. Sonohysterography and MRI were performed before surgery. All patients had complete staging procedures, including peritoneal cytologic analyses. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for SH and MRI.
The concordance rates of myometrial invasion for SH and MRI were 82.4% and 81.1%, respectively. The sensitivity, specificity, PPV, and NPV for identification of deep myometrial invasion were 64.7%, 87.7%, 61.1%, and 89.3% on SH and 70.6%, 84.2%, 57.1%, and 90.6% on MRI. Two patients (2.7%) were found to have positive results for malignant cells on peritoneal cytologic analyses.
Sonohysterography appears to be a useful preoperative method for predicting myometrial invasion, comparable to MRI.
The IETA (International Endometrial Tumor Analysis group) statement is a consensus statement on terms, definitions and measurements that may be used to describe the sonographic features of the endometrium and uterine cavity on gray-scale sonography, color flow imaging and sonohysterography. The relationship between the ultrasound features described and the presence or absence of pathology is not known. However, the IETA terms and definitions may form the basis for prospective studies to predict the risk of different endometrial pathologies based on their ultrasound appearance.
The purpose of this study was to evaluate the role of 3-dimensional power Doppler angiography (3D-PDA) to discriminate between benign and malignant endometrial disease in women with postmenopausal bleeding and thickened endometrium.
Ninety-nine postmenopausal women (median age, 63.1 years; range, 48-84 years) with uterine bleeding and a thickened endometrium (>or= 5 mm) at baseline transvaginal sonography were assessed by 3D-PDA before endometrial biopsy. Endometrial volume, vascularity index (VI), flow index, and vascularity-flow index were calculated with the virtual organ computer-aided analysis method.
Histologic diagnoses were endometrial cancer (44 cases), hyperplasia (13 cases), polyp (23 cases), cystic atrophy (14 cases), and submucous myoma (5 cases). Endometrial volume, VI, and vascularity-flow index were significantly higher in malignant vs benign conditions. Receiver operating characteristic analysis revealed that VI was the best parameter for the prediction of endometrial cancer.
The findings show that 3D-PDA may be useful for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium at baseline sonography.
Myometrial invasion greater than 33% negatively affects the prognosis of endometrial carcinoma. Since the endometrium is readily differentiated from myometrium via high-resolution transvaginal sonography (TVS), this prospective study was undertaken to evaluate the efficacy of TVS in determining the depth of myometrial invasion in women with endometrial adenocarcinoma. Eighteen subjects underwent TVS utilizing 5.0- and 7.5-MHz probes by a single examiner blinded to stage and grade of adenocarcinoma. Predicted TVS ratios were categorized as less than 33% or greater than or equal to 33% and compared to actual histologic invasion. Ultrasound predicted that TVS ratios greater than or equal to 33% are significantly associated with deep (greater than 33%) histologic invasion (P less than 0.01, Fisher's test). When histologic invasion was greater than or equal to 33%, TVS was 100% accurate with no false negatives. The two cases in which TVS ratios erroneously indicated invasion greater than or equal to 33% contained adenomyosis and leiomyomas. TVS is a highly accurate and convenient method for preoperatively evaluating myometrial invasion. Potentially this evaluation could influence the selection of therapy for poor-surgical-risk candidates or direct appropriate referral of patients with deeper invasion to a gynecologic oncologist.
This retrospective study reviewed the records of 375 patients with clinical stage I adenocarcinoma of the endometrium. After criteria for exclusion were applied, 223 patients were analyzed further. Results from office and operating room curettage were compared with findings at hysterectomy. Twenty percent of cases showed an increase in grade at hysterectomy after office curettage; 15% showed upgrading after operating room curettage, a nonsignificant difference. We conclude that the techniques have equivalent accuracy in the determination of tumor grade. However, despite their well-documented reliability in tumor detection, a 15-20% upgrade suggests that frozen section confirmation of grade and depth of invasion in the hysterectomy specimen may be necessary if further surgical staging is not already planned.
To characterize endometrial polyps, hyperplasia, and carcinoma with endovaginal ultrasound in postmenopausal women.
Seventy-three postmenopausal women with abnormally thick endometria on endovaginal sonograms were retrospectively identified. The endometrial appearance was characterized as hyperechoic, containing cystic spaces, or heterogeneous. The final study group consisted of 68 women, in whom the pathologic and sonographic findings were correlated.
Thirty sonograms showed hyperechoic endometria in women with hyperplasia (n = 8), polyps (n = 4), polyps and hyperplasia (n = 2), or atrophy, proliferative change, mild atypia, or normal endometria (n = 16); 27 sonograms showed cystic spaces in women with polyps (n = 21), carcinoma (n = 1), polyps and hyperplasia (n = 2), or atrophy (n = 3); and 11 sonograms showed heterogeneous endometria in women with endometrial carcinoma (n = 7), atrophy (n = 2), proliferative endometrium (n = 1), or secretory endometrium (n = 1). Cystic spaces were predictive of polyps (P = 1.19 x 10(-10)).
Endovaginal sonography may be useful for differentiation of endometrial polyps, hyperplasia, and carcinoma.
In recent years, the incidence of carcinoma of the endometrium has shown an upward trend, such that it is currently the most frequently encountered malignant tumor of the female genital tract. An accurate preoperative diagnosis of the extent and spread of such carcinomas is of crucial importance for the selection of a therapeutic approach appropriate to the stage and infiltration of each particular tumor.
In a prospective study of 80 patients with a carcinoma of the endometrium, performed at the Department of Obstetrics and Gynecology of the University of Mainz, we compared the preoperative findings of transvaginal sonography with the postoperative histological results with respect to the following parameters: endometrial thickness, demarcation of the boundary of the endometrium, myometrial infiltration depth and staging.
In all of these patients, sonography revealed a distinct increase in the thickness of the endometrium. In all cases, the structure of the endometrium was found to be heterogeneous, with an irregular and poorly delineated boundary. Assessments of the depth of tumor infiltration and the tumor staging obtained by transvaginal sonography were found to correlate with the histological findings in 85% and 87.5% of the cases, respectively. Thus, in cases of endometrial carcinoma, transvaginal sonography has an essential role to play in devising an individualized operative treatment program that takes into account the extent, spread and stage of the tumor. Copyright © 1995 International Society of Ultrasound in Obstetrics and Gynecology
To evaluate the diagnostic accuracy of preoperative transvaginal sonography (TVS) in the detection of deep myometrial invasion in endometrial cancer cases classified by the grade of disease, and in comparison to frozen section analysis in grade 1 cases.
In a prospective study, 91 patients with confirmed endometrial carcinoma underwent preoperative TVS for evaluation of myoinvasion. Sonographic results were categorized as superficial (less than or equal to 1/2 myometrial depth) and deep invasion (greater than 1/2 myometrial depth). TAH-BSO followed by retroperitoneal lymph node sampling were performed in all patients with grade 2-3 tumors. In patients with grade 1 disease, the surgical specimen was intraoperatively evaluated by frozen section, and lymph node sampling was carried out if deep invasion was determined. The preoperative sonographic findings and the frozen section results were compared to the final histopathology report of myoinvasion.
In 77 of the 91 (84.6%) patients, the sonographic assessment of the depth of myoinvasion was in accord with the final histopathologic findings. TVS demonstrated a sensitivity of 87.8% and a specificity of 82.7% in detecting deep invasion in the entire study group (grade 1-3), with positive and negative predictive values (PPV, NPV) of 74.3% and 92.3%, respectively. TVS in grade 1 cases (n=47) showed a sensitivity of 77.7%, a specificity of 79%, PPV of 46.6% and NPV of 93.7%. TVS in cases with grade 2-3 tumors (n=44) showed a sensitivity of 90%, specificity of 91.6%, PPV of 90% and NPV of 91.6%. Thus, the accuracy of TVS in grade 2-3 cases was superior to that achieved in grade 1 cases (91% vs 78.7%; p=.002). The myometrial invasion was assessed by frozen section in 41 out of 47 patients with grade 1 disease and demonstrated a sensitivity of 85.7%, a specificity of 100%, PPV of 100% and NPV of 97.1%. The specificity (100%) and accuracy (97.5%) of the frozen section were found to be superior compared to that of the TVS (79% and 78.7%) in detecting deep invasion in grade 1 cases (p=.008, p=.005, respectively). No statistically significant difference was found between the sensitivity of either technique.
TVS appeared to be a more accurate method for preoperative assessment of myoinvasion in grade 2-3 endometrial cancer patients compared to grade 1 patients. In grade 1 cases, this method achieved lower accuracy in detecting deep invasion compared to the frozen section analysis. Based on these data, the value of preoperative TVS results as the sole criterion in the decision to perform extensive surgical procedures in grade 1 endometrial cancer is questionable and warrants further evaluation.
The aim of the study was to assess the depth of myometrial invasion by endometrial cancer using preoperative 5-9 MHz, high frequency transvaginal ultrasonography as compared with postoperative assessment using histopathologic examination. The study included 120 patients with histologically proven cancers of the endometrium. All patients underwent transvaginal sonography before surgery. The depth of myometrial invasion was classified as none, inner half of uterine wall, and outer half of uterine wall. Of 106 (88.3%) patients with proven myometrial invasion, 98 cases (92.5%) were revealed by sonography. In 109 cases (90.8%) invasion was believed to be present on transvaginal sonography. Histologically proven invasion that correlated with sonography was shown in 88 patients (73.3%). In 32 patients (26.7%) ultrasonography could not correctly predict the depth of myometrial invasion. The depth of invasion was underestimated in 10 (8.3%) cases and overestimated in 22 (18.3%) cases. Preoperative assessment of invasion of the uterine wall by transvaginal ultrasonography had an accuracy of 73% if correlated with the definitive histopathologic examination. The role of high frequency transvaginal ultrasonography in preoperative assessment of the depth of myometrial invasion in patients with endometrial cancer is limited.
The purpose of this study was to assess the utility of transvaginal ultrasonography in the evaluation of endometrial morphology in addition to the standard criterion of endometrial thickness for selecting patients for endometrial sampling.
Two hundred and seven consecutive cases of postmenopausal bleeding were evaluated by transvaginal ultrasound. Endometrial thickness was measured as the maximum anteroposterior thickness of the endometrium including both the anterior and posterior layers, in the sagittal long axis view. The morphology of the endometrium was studied and categorized as homogeneous, focally increased echogenecity, diffusely increased echogenecity or diffusely inhomogeneous. Patients were followed up for clinical course and endometrial histopathology.
Textural inhomogeneity was observed in all the three cases of endometrial cancers with endometrial thickness of less than 6 mm, and, in ten out of 11 cases of a more than 6 mm thick endometrium. On the other hand the endometrial texture was homogeneous in all cases of endometrial atrophy/tissue inadequate for diagnosis, with thickness of less than 6 mm.
This study adds the dimension of abnormal echogenecity of the endometrium to the currently followed criterion of endometrial thickness with a view to enhance accuracy, both for a better prediction of atrophy and a higher prediction for endometrial cancer. Expectant management can be offered to patients with a homogeneous endometrium which is 6 mm thick or less. Aggressive evaluation for a malignancy must be made if there is a focal increased echogenecity or a diffuse increased echogenecity even in a thin endometrium.
the problem became more apparent to us during the planning stage of an international, multicenter study to characterize adnexal masses by ultrasonographic criteria using the histologic and surgical classification of each mass as the reference procedure. A detailed review of the literature had revealed considerable variation in the diagnostic accuracy of test procedures 2 . There had also been much discussion and more recently a report that the use of diagnostic algorithms derived from the retrospective analysis of data in a particular center 3‐5 does not produce such good results when used prospectively in another center 6 . The possibility arose that both findings might be explained, at least in part, by differences in the interpretation and use of terms and definitions of the diagnostic end-points. Consequently, a new initiative was started to address the problem, which of necessity involved the participation of researchers from different centers; the participants comprise the International Ovarian Tumor Analysis (IOTA) group (see list below). The steering committee for the study held special meetings to discuss the problems of standardization and to formulate terms and procedures to derive morphologic end-points by Bmode imaging and end-points of vascularity and blood flow by color Doppler imaging. The recommendations of the steering committee were distributed to each participating center and subsequently refined after meeting with the principal investigators. The following consensus opinion is being used in the multicenter study and in our routine practices. We hope that the outcome of our deliberations will stimulate further debate, which will eventually lead to internationally agreed terms and definitions within our speciality.
The aim was to study the effectiveness of subjective color Doppler evaluation and spectral Doppler parameters in preoperative characterization of endometrial carcinomas.
Seventy-six patients with endometrial carcinoma were preoperatively analyzed by color Doppler ultrasound in order to subjectively evaluate the amount of intratumoral blood flow (color score) and to analyze the lowest resistance index (RI), the highest peak systolic velocity (PV), and the highest time averaged maximum velocity (TAMVX). These parameters were analyzed according to clinico-pathological characteristics.
In 13 patients no intratumoral arterial vessels were detected by color Doppler examination. No lymph node metastases were found in this group of patients. Positive nodes were found in 24% of patients with detectable arterial vessels, although the difference did not reach the statistical significance. No differences were found in spectral Doppler parameters (RI, PV, TAMVX) according to tumor characteristics or nodal involvement. A higher percentage of cases with a color score of 3 was found in stage >I than in stage I patients (69 vs 42%, P < 0.05), and in patients with myometrial invasion greater than 50% than in those with less than 50% invasion (72 vs 38%; P = 0.05).
Nodal metastases were found in 24% of patients with detectable vessels at color Doppler examination. Subjective analysis of vessel density correlated >50%, myometrial invasion, but spectral Doppler analysis was not predictive of surgical stage, tumor grade, myometrial invasion, or lymph node metastases. These results do not support the use of preoperative intratumoral blood flow analysis as a clinical test in evaluating tumor characteristics or in predicting lymph node metastases.
Endovaginal ultrasound was used in 30 women to characterize endometrial carcinoma with respect to myometrial invasion according to FIGO recommendations for surgical staging of endometrial cancer. The ultrasound data were correlated to macroscopic findings of the uterine specimen and to histopathology.
Using endovaginal ultrasound, the sensitivity of detecting myometrial invasion of > 50% was 15/19 or 79%. However, the positive predictive value was 100%, in all cases when ultrasound suggested myometrial invasion of > 50%. This was confirmed on histopathological examination of the tumor specimen. Cervical tumor extension was correctly diagnosed in all six women in which it was present. Endovaginal ultrasound seems to be a reliable method of assessing tumor invasion and engagement of the cervix. This non-invasive method could be included as an important tool in the establishment of individualized treatment programs in women with endometrial carcinoma. Copyright © 1992 International Society of Ultrasound in Obstetrics and Gynecology
To evaluate the role of transvaginal power Doppler sonography to discriminate between benign and malignant endometrial conditions in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.
Ninety-one postmenopausal women (median age, 58 years; range, 47-83 years) presenting with uterine bleeding and a thickened endometrium (> or = 5-mm double-layer endometrial thickness) on transvaginal sonography were included in this prospective study. Endometrial blood flow distribution was assessed in all patients by power Doppler immediately after B-mode transvaginal sonography. Three different vascular patterns were defined: Pattern A: multiple-vessel pattern, Pattern B: single-vessel pattern and Pattern C: scattered-vessel pattern. Histological diagnoses were obtained in all cases. No patient taking tamoxifen citrate or receiving hormone replacement therapy was included.
Histological diagnoses were as follows: endometrial cancer: 33 (36%), endometrial polyp: 37 (41%), endometrial hyperplasia: 14 (15%), endometrial cystic atrophy: 7 (8%). Blood flow was found in 97%, 92%, 79% and 85% of cases of carcinoma, polyp, hyperplasia and endometrial cystic atrophy, respectively. A total of 81.3% of vascularized endometrial cancers showed Pattern A, 97.1% of vascularized polyps exhibited Pattern B and 72.7% of vascularized hyperplasias showed Pattern C. Sensitivity and specificity for endometrial cancer were 78.8% and 100%. For endometrial polyp these respective values were 89.2% and 87% and for hyperplasia they were 57.1% and 88.3%.
Transvaginal power Doppler blood flow mapping is useful to differentiate benign from malignant endometrial pathology in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.
To determine if power Doppler ultrasound examination of the endometrium can contribute to a correct diagnosis of endometrial malignancy in women with postmenopausal bleeding and endometrium > or = 5 mm.
Eighty-three women with postmenopausal bleeding and endometrium > or = 5 mm underwent gray-scale and power Doppler ultrasound examination using predetermined, standardized settings. Suspicion of endometrial malignancy at gray-scale ultrasound examination (endometrial morphology) was noted, and the color content of the endometrium at power Doppler examination was estimated subjectively (endometrial color score). Computer analysis of the most vascularized area of the endometrium was done off-line in a standardized manner. Stepwise multivariate logistic regression analysis was carried out to determine which subjective and objective ultrasound and power Doppler variables satisfied the criteria to be included in a model to calculate the probability of endometrial malignancy.
Endometrial thickness, vascularity index (vascularized area/endometrial area), and use of hormone replacement therapy (HRT) satisfied the criteria to be included in the model used to calculate the 'objective probability of endometrial malignancy'. Endometrial morphology, endometrial color score and HRT use satisfied the criteria to be included in the model to calculate the 'subjective probability of malignancy'. Endometrial thickness > or = 10.5 mm had a sensitivity with regard to endometrial cancer of 0.88 and a specificity of 0.61. At a fixed sensitivity of 0.88, the specificity of the 'objective probability of malignancy' (0.81) was superior to all other ultrasound and power Doppler variables (P = 0.001-0.02). The 'objective probability of malignancy' detected more malignancies at endometrium 5-15 mm than endometrial morphology (5/7 vs. 1/7, i.e. 0.71 vs. 0.14; P = 0.125) with a similar specificity (49/57 vs. 51/57, i.e. 0.86 vs. 0.89).
Power Doppler ultrasound can contribute to a correct diagnosis of endometrial malignancy, especially if the endometrium measures 5-15 mm. The use of regression models including power Doppler results to estimate the risk of endometrial cancer deserves further development.
To determine the location and intensity of angiogenesis as well as selected flow parameters by transvaginal color Doppler (TVCD) and to evaluate the relation of myometrial invasion, histological grading, lymph nodes, and omental and adnexal metastasis on blood flow characteristics in endometrial cancer.
Transvaginal colour Doppler and pulsed Doppler ultrasound were performed on 90 women with endometrial cancer. The degree of invasion as well as adnexal, omental, and pelvic lymph node metastasis was evaluated. Location of the blood vessels (peripheral, central, mixed) and vascular density as well as selected Doppler blood flow indices: PSV, RI of neoplastic infiltration was assessed.
The median age of the 90 women was 63.3 +/- 12.3 years (range 32 to 86 years); of these 92.2% were postmenopausal. Cancer concerned only the endometrium (E), with superficial (S) and deep infiltration (D) established in 14.4%, 45.6% and 40%, respectively. The histological maturity was as follows: G1 - 17.6%, G2 - 66.7%, G3 - 16.6% of cases. Adnexal, omental and lymph node metastasis was found in 12.2%, 3.3% and 16.6%, respectively. Abnormal low impedance and high velocity flow (mean RI 0.38 +/- 0.09, PSV 20.45 +/- 9.6 cm/sec) were found in 88.9% of cases. In types E, S, D in 61.5%, 92.7% and 94.4%, respectively (p = 0.003). Differences in RI and PSV between groups with high and low vascular density were statistically significant (p = 0.005 and 0.001, respectively). In all cases peripheral and mixed vascularity were found more frequently (p < 0.05). A positive significant correlation between vascular density increase and surgicopathological stage of cancer was found more frequently (p < 0.005). There were significant differences in vascular density, Doppler blood flow indices and vascular location in each type of histological malignancy (p < 0.05). No significant differences in each flow parameter in hematogenous-adnexal/omental metastatic and non metastatic cases were found, whereas pelvic lymph node involvement and vascular density were shown to be statistically significant (p < 0.02). There were significant differences in vascular density in lymph-node positive cases whereas the remaining flow parameters did not differ.
These results suggest that TVCD evaluation of endometrial cancer is a reliable method for assessing endometrial angiogenesis. Our results indicate that blood flow rates correspond with increased angiogenesis in endometrial cancers, and might potentially be used as a good prediction factor for tumor progression and metastasis in affected women. Preoperative ultrasound examination should be seen as an important tool in the establishment of individualized treatment programs for women with endometrial cancer.
Objectives:
Preoperative knowledge of the depth of myometrial infiltration is important in patients with endometrial carcinoma. This study aimed at assessing the value of histopathological parameters obtained from an endometrial biopsy (Pipelle de Cornier; results available preoperatively) and ultrasound measurements obtained after transvaginal sonography with color Doppler imaging in the preoperative prediction of the depth of myometrial invasion, as determined by the final histopathological examination of the hysterectomy specimen (the gold standard).
Methods:
We first collected ultrasound and histopathological data from 97 consecutive women with endometrial carcinoma and divided them into two groups according to surgical stage (Stages Ia and Ib vs. Stages Ic and higher). The areas (AUC) under the receiver-operating characteristics curves of the subjective assessment of depth of invasion by an experienced gynecologist and of the individual ultrasound parameters were calculated. Subsequently, we used these variables to train a logistic regression model and least squares support vector machines (LS-SVM) with linear and RBF (radial basis function) kernels. Finally, these models were validated prospectively on data from 76 new patients in order to make a preoperative prediction of the depth of invasion.
Results:
Of all ultrasound parameters, the ratio of the endometrial and uterine volumes had the largest AUC (78%), while that of the subjective assessment was 79%. The AUCs of the blood flow indices were low (range, 51-64%). Stepwise logistic regression selected the degree of differentiation, the number of fibroids, the endometrial thickness and the volume of the tumor. Compared with the AUC of the subjective assessment (72%), prospective evaluation of the mathematical models resulted in a higher AUC for the LS-SVM model with an RBF kernel (77%), but this difference was not significant.
Conclusions:
Single morphological parameters do not improve the predictive power when compared with the subjective assessment of depth of myometrial invasion of endometrial cancer, and blood flow indices do not contribute to the prediction of stage. In this study an LS-SVM model with an RBF kernel gave the best prediction; while this might be more reliable than subjective assessment, confirmation by larger prospective studies is required.
Objectives:
To determine which endometrial morphology characteristics as assessed by gray-scale ultrasound and which endometrial vessel characteristics as assessed by power Doppler ultrasound are useful for discriminating between benign and malignant endometrium in women with postmenopausal bleeding (PMB) and sonographic endometrial thickness >or= 4.5 mm and to develop logistic regression models to calculate the individual risk of endometrial malignancy in women with PMB, endometrial thickness >or= 4.5 mm, good visibility of the endometrium and detectable Doppler signals in the endometrium.
Methods:
Of 223 consecutive patients with PMB and sonographic endometrial thickness >or= 4.5 mm, 120 fulfilled our inclusion criteria. They underwent transvaginal gray-scale and power Doppler ultrasound examination, which was videotaped for later analysis by two examiners with more than 15 years' experience in gynecological ultrasonography. They independently assessed endometrial morphology and vascularity using predetermined criteria. Their agreed-upon description was compared with the histological diagnosis. Univariate and multivariate logistic regression analyses were used. The best diagnostic test was defined as the one with the largest area under the receiver-operating characteristics curve (AUC).
Results:
Thirty (25%) endometria were malignant. Inter-observer agreement for the description of endometrial morphology and vascularity was moderate to good (Kappa 0.49-0.78). The best ultrasound variables to predict malignancy were heterogeneous endometrial echogenicity (AUC 0.83), endometrial thickness (AUC 0.80), and irregular branching of endometrial blood vessels (AUC 0.77). A logistic regression model including endometrial thickness and heterogeneous endometrial echogenicity had an AUC of 0.91. Its mathematically best risk cut-off yielded a positive likelihood ratio of 4.4, and a negative likelihood ratio of 0.1. Adding Doppler information to the model improved diagnostic performance marginally (AUC 0.92).
Conclusions:
In selected high-risk women with PMB and an endometrial thickness of >or= 4.5 mm, calculation of the individual risk of endometrial malignancy using regression models including gray-scale and Doppler characteristics can be used to tailor management. These models would need to be tested prospectively before introduction into clinical practice.
The purpose of this study was to determine factors responsible for the increasing number of deaths from corpus cancer over three time periods.
Data were collected from the Surveillance, Epidemiology and End Results database from 1988-2001. Kaplan-Meier and Cox proportional hazards regression analyses were performed.
Of 48,510 women with corpus cancer, there was an increase in the proportion of patients dying from advanced cancers (52.1% to 56.0% to 68.8%; P < .001), grade 3 disease (47.5% to 53.3% to 60.6%; P < .001), serous tumors (14.3% to 18.4% to 16.6%; P < .001), and sarcomas (19.1% to 20.4% to 27.2%; P < .001) over time. On multivariate analysis, older age, African American race, lack of primary staging procedures, advanced-stage, high-grade, and non-endometrioid histology were independent prognostic factors for worse survival.
Our data suggest that the increase in mortality in women with corpus cancer over the last 14 years may be related to an increased rate of advanced-stage cancers and high-risk histologies.
Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Incidence and death rates are age-standardized to the 2000 US standard million population. A total of 1,437,180 new cancer cases and 565,650 deaths from cancer are projected to occur in the United States in 2008. Notable trends in cancer incidence and mortality include stabilization of incidence rates for all cancer sites combined in men from 1995 through 2004 and in women from 1999 through 2004 and a continued decrease in the cancer death rate since 1990 in men and since 1991 in women. Overall cancer death rates in 2004 compared with 1990 in men and 1991 in women decreased by 18.4% and 10.5%, respectively, resulting in the avoidance of over a half million deaths from cancer during this time interval. This report also examines cancer incidence, mortality, and survival by site, sex, race/ethnicity, education, geographic area, and calendar year, as well as the proportionate contribution of selected sites to the overall trends. Although much progress has been made in reducing mortality rates, stabilizing incidence rates, and improving survival, cancer still accounts for more deaths than heart disease in persons under age 85 years. Further progress can be accelerated by supporting new discoveries and by applying existing cancer control knowledge across all segments of the population.
To compare the accuracy of transvaginal sonography (TVS) and magnetic resonance imaging (MRI) in the preoperative staging of endometrial carcinoma.
This was a prospective study in which 74 women consecutively diagnosed with endometrial carcinoma were examined using TVS by physicians trained in gynecological sonography and MRI by radiologists with a special interest in gynecology. All patients underwent surgical-pathological staging after removal of the uterus, adnexa and pelvic lymph nodes. Sensitivity, specificity, and positive and negative predictive values were calculated for each imaging modality with regard to detection of neoplastic invasion of the outer half of the myometrium and cervical involvement.
TVS and MRI performed equally well in the preoperative staging of endometrial cancer, with no statistically significant differences between the two techniques. The sensitivity, specificity, positive and negative predictive values, and overall diagnostic accuracy for TVS in the evaluation of myometrial infiltration were 84%, 83%, 79%, 88% and 84%, respectively. Respective values for MRI were 84%, 81%, 77%, 87% and 82%. The corresponding statistics for detection of cervical involvement were 93%, 92%, 72%, 98% and 92% for TVS; and 79%, 87%, 58%, 95% and 85% for MRI.
When carried out by expert practitioners, TVS shows good accuracy in the local staging of endometrial carcinoma. Because of its high costs, MRI should be offered only to those in whom TVS produces images of poor quality.
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Valueofsonohysterography inpreoperativeassessment of myometrial invasion for patients with endometrial cancer power Doppler Lopez R, Zan-Copyright 2011 ISUOG
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Trends in demographic and clinical characteristics in women diagnosed with corpus cancer and their potential impact on the increasing number of deaths
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