Three-dimensional hysterosonography for the study of endometrial tumors: comparison with conventional transvaginal sonography, hysterosalpingography, and hysteroscopy

The role of three-dimensional power Doppler hysterosonography (3-DPDS) in distinguishing atypical polypoid adenomyomas (APAs) from other intrauterine tumors: correlation with pathologic findings

OBJECTIVE

This study was undertaken to describe the sonographic characteristics of atypical polypoid adenomyomas (APAs) of the uterus and to determine the value of three-dimensional power Doppler hysterosonography (3-DPDS) in distinguishing APA from other polypoid uterine tumors.

METHODS

Ninety-five women with a mean age of 37 years (range 28-45) with a suspicious polypoid uterine tumor were referred for preoperative evaluation with 3-DPDS. Sonographic criteria used for the diagnosis of APA were based on a system that consisted of morphological characteristics, histological evaluation and power Doppler imaging. Biopsy samples of the intrauterine tumors were obtained via operative hysteroscopy.

RESULTS

Fifteen lesions were histopathologically diagnosed as APAs, 25 as endometrial polyps and 55 as submucous myomas. In the present study, the sensitivity and specificity of 3-DPDSs in discriminating APA from other polypoid tumors was 82.5 and 86.7%, respectively.

CONCLUSIONS

APAs can be accurately distinguished from other polypoid tumors of the uterus with the use of 3-DPDS demonstrating the following characteristics: lobular tumor with inhomogeneous echotexture, echogenicity similar to myometrium, broad base, acoustic shadow and linear vessel arrangement.

Hysteroscopy as a valid tool for endometrial pathology in patients with postmenopausal bleeding or asymptomatic patients with a thickened endometrium: hysteroscopic and histological results

OBJECTIVE

This study compares hysteroscopic and histopathological results in postmenopausal women with abnormal uterine bleeding (AUB) and asymptomatic postmenopausal women with a thickened endometrium.

MATERIALS AND METHODS

This is a retrospective study of 570 cases hysteroscopically examined between January 2008 and July 2012. The patients were followed up at the Istituto Tumori 'Giovanni Paolo II', Bari, Italy.

RESULTS

A total of 320 of the 570 cases were selected. The inclusion criteria were transvaginal ultrasound, hysteroscopy and endometrial biopsy. In the AUB group, if the hysteroscopy results were normal, a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 100, 95, 71 and 100%, respectively, were achieved, while in the asymptomatic group these values were 100, 97, 90 and 100%, respectively. For both the group with polyps and that with myomas, the sensitivity, specificity, PPV and NPV were 100%. For endometrial hyperplasia, hysteroscopy showed a sensitivity, specificity, PPV and NPV of 81, 96, 87 and 93%, respectively, in the AUB group, while in the asymptomatic group, the sensitivity was 60%, the specificity and PPV were 100%, and the NPV was 98%. The sensitivity of hysteroscopy for endometrial cancer was 63%, the specificity 97%, the PPV 77%, and the NPV 95%.

CONCLUSIONS

In postmenopausal women with a thickened endometrium with or without AUB, hysteroscopy allows for an accurate diagnosis in benign endometrial pathology. Hysteroscopy also allows directed biopsies of suspicious lesions, which is useful in malignant endometrial pathology.

Evaluation of endometrium in peri-menopausal abnormal uterine bleeding

Abnormal Uterine Bleeding (AUB) is one of the most common health problems encountered by women. It affects about 20% women of reproductive age, and accounts for almost two thirds of all hysterectomies. Gynaecologists are often unable to identify the cause of abnormal bleeding even after a thorough history and physical examination. Diagnostic evaluations and treatment modalities have been evolving over time. The onus in AUB management is to exclude complex endometrial hyperplasia and endometrial cancer. From D and C + EUA under general anesthesia the shift to more accurate procedures like hysteroscopy and vision directed biopsy was welcome. But the current minimally invasive procedures like sonohysterography, office vacuum aspiration (Pipelle) and the use of office hysteroscopy have revolutionized the management of AUB. We have tried to review the current literature and guidelines for evaluation of endometrium with the twin goals of finding an accurate reason causing the AUB and to rule out endometrial cancer or a potential for the cancer in future. We have also attempted to compare the current procedures and their present perspective vis-à-vis each other. Histological assessment is the final word, but obtaining a sample for histology makes it more accurate, and we have reviewed these techniques to enhance accuracy in diagnosis. Hysteroscopy and directed biopsy is the 'gold standard' approach for most accurate evaluation of endometrium to rule out focal endometrial Ca. Blind endometrial biopsies should no longer be performed as the sole diagnostic strategy in perimenopausal as well as in postmenopausal women with AUB. A single-stop approach, especially in high risk women (Obesity, diabetes, family history of endometrial, ovarian or breast cancer) as well as in women with endometrial hyperplasia of combining the office hysteroscopy, directed biopsy in presence of a focal lesion, and vacuum sampling of endometrium in normal looking endometrium, all without anesthesia is the most minimally invasive and yet accurate approach in current practice.

Is it possible to obtain a presurgical Lasmar score for hysteroscopic myomectomy by ultrasound alone?

OBJECTIVE

To determine whether a Lasmar score obtained entirely by the use of two-dimensional (2D) and three-dimensional (3D) ultrasound provides results similar to those obtained using the original hysteroscopic technique.

METHODS

This was a prospective study performed on a series of patients presenting with symptomatic submucous fibroids and scheduled for hysteroscopic myomectomy. Ultrasound Lasmar scores were obtained by a single physician, a specialist in ultrasonography, in the luteal phase of the menstrual cycle. 3D images were evaluated by offline examination using multiplanar analysis. Classical Lasmar scores were obtained by a different physician, a specialist in hysteroscopy, during the follicular phase of the subsequent cycle. Surgery was performed by a third physician in the follicular phase who also reported a Lasmar score, which we considered as the gold standard. The concordance between group classifications (I-III, relating to difficulty of hysteroscopic resection) according to the three methods used to obtain the Lasmar score (ultrasound, classical and surgery) was calculated using Cohen's κ statistic.

RESULTS

Thirty-four women, with a mean age of 43 ± 4.9 years, were enrolled in the study. Thirty-six submucous fibroids were identified by both ultrasound and diagnostic hysteroscopy. The mean diameter of fibroids evaluated was 28 ± 13.2 mm. The concordance between the three methods of classifying patients according to Lasmar score was high: classical vs. surgery, κ = 0.88; ultrasound vs. surgery, κ = 0.93; and classical vs. ultrasound, κ = 0.77.

CONCLUSION

The Lasmar score can be obtained solely by ultrasound examination performed in the luteal phase of the menstrual cycle, avoiding office hysteroscopy without a loss of diagnostic accuracy.

Role of hysteroscopy in the detection of endometrial pathologies in women presenting with postmenopausal bleeding and thickened endometrium

OBJECTIVES

The goal of this study was to define the diagnostic value of hysteroscopy in evaluating uterine cavity compared to endometrial biopsy in women presenting with postmenopausal bleeding and thick endometrial mucosa with particular attention to endometrial hyperplasia and carcinoma.

METHODS

Eighty-three consecutive women presenting with postmenopausal bleeding and endometrial thickness of 5 mm or more measured by transvaginal ultrasound (TVU) were enrolled in a prospective study between May 2008 and July 2010. They underwent diagnostic hysteroscopy and endometrial biopsy. Hysteroscopic data was compared with the final diagnosis established by histological examination.

RESULTS

The women's mean age was 61.2 ± 5.2 years (range 44-80). The most frequent endometrial lesion was endometrial polyps (31.1%). Hyperplastic endometrium was confirmed in 23 (27.8%), only 13 cases were suspected by the hysteroscope. Out of the 14 (16.9%) proven cases of endometrial cancer, only half of the cases were suspected. In benign endometrial lesions, the sensitivity of the hysteroscopic view was 94.7%, specificity was 97.8%, positive (PPV) and negative (NPV) predictive values were 97.3 and 95.7%, respectively. On the other hand, hysteroscopy demonstrated an overall sensitivity, specificity, PPV, and NPV of 56.5, 91.6, 72.2, and 84.6%, respectively, in endometrial hyperplasia, whereas the same parameters for endometrial cancer were 50, 94.2, 63.6, and 90.2%.

CONCLUSION

Hysteroscopy can be used as the first line diagnostic tool for evaluating the benign endometrial lesions, such as endometrial polyp and submucosal myoma, nonetheless hysteroscopy has poor validity for excluding endometrial hyperplasia and cancer in women presenting with the postmenopausal bleeding and thick endometrium.

Current concepts in the pathology and epigenetics of endometrial carcinoma

In the Western world, endometrial carcinoma is the most common malignant tumour of the female genital tract and is the fourth most common cancer in women. Two different clinicopathological subtypes are recognised: the oestrogen-related (type I, endometrioid) and the non-oestrogen related (type II, non-endometrioid). This article reviews the epidemiology, risk factors, genetic alterations during endometrial carcinogenesis, features of tumours and precursors and early detection of the disease. Insights into the epigenetic alterations, with emphasis on DNA methylation during endometrial carcinogenesis, and their diagnostic value are also provided.

Three-dimensional sonohysterography for examination of the uterine cavity in women with abnormal uterine bleeding: Preliminary findings

INTRODUCTION

To compare the diagnostic values of three-dimensional sonohysterography (3DSH), transvaginal ultrasound (TVUS), and 2-dimensional sonohysterography (2DSH) in the work-up of abnormal uterine bleeding (AUB), in particular the ability of each method to identify intracavitary lesions arising from the endometrium or uterine wall.

MATERIALS AND METHODS

24 patients referred for AUB underwent TVUS followed by 2-D and 3-D HS in the same session. Three-dimensional data were acquired with a free-hand technique during maximal distention of the uterus. Within 10 days of the sonographic session, each patient underwent hysteroscopy, which was considered the reference standard. For each of the 3 imaging methods, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy.

RESULTS

Hysteroscopy demonstrated the presence of an intrauterine lesion in 21/24 patients (87.5%). In 3/24 patients hysteroscopy was negative. For TVUS, 2DSH, and 3DSH, sensitivity was 76% (16/21), 90% (19/21), 100% (21/21), respectively; specificity was 100% (3/3), 100% (19/19), 100% (21/21); PPV was 100%, 100%, 100%; NPV was 37%, 60%, 100%; accuracy was 76%, 90%, 100%.

CONCLUSIONS

3DSH is more sensitive that 2DSH or TVUS in the detection of intrauterine lesions. If these preliminary results are confirmed in larger studies, 3DSH could be proposed as a valuable alternative to diagnostic hysteroscopy.

Comparison of 3-dimensional with 2-dimensional saline infusion sonohysterograms for the evaluation of intrauterine abnormalities

OBJECTIVE

To compare 3-dimensional saline infusion sonohysterography (3DSIS) with 2-dimensional sonohysterography (2DSIS) using hysteroscopy and histologic diagnosis as the gold standard.

METHOD

A retrospective analysis of all SIS examination performed between July 1, 2005 and April 30, 2007 in our gynecological sonographic unit. 2DSIS or 3DSIS sonographic techniques were used randomly. Management decisions and operative procedures were done by the referring provider. Patients that had diagnostic hysteroscopy and complete histologic evaluation were included. Concordance between the various assessment methods as well as sensitivity and specificity were compared between 2DSIS and 3DSIS. Student's t test and chi-square test were used for statistical analysis. p < 0.05 was considered statistically significant.

RESULT

Of 804 patients that had SIS, 125 patients met the inclusion criteria. Patient median age was 48 (range 19-82). Also, 77 patients were premenopausal, and 48 patients were postmenopausal. Furthermore, 43 patients had 2DSIS and 82 patients had 3DSIS. 3DSIS was found to correlate with hysteroscopic findings more often than 2DSIS (p < 0.05). A trend for higher specificity of 3DSIS with the different uterine pathologies was seen, but it did not reach statistical significance. No difference in sensitivity of 3DSIS compared with 2DSIS was found for all pathologic diagnoses.

CONCLUSION

3DSIS correlated better with hysteroscopy than 2DSIS. Specificity for histologic diagnosis appears to be higher with 3DSIS compared with 2DSIS but larger-scale studies are needed to confirm this finding.

Two- and three-dimensional saline contrast sonohysterography: interobserver agreement, agreement with hysteroscopy and diagnosis of endometrial malignancy

OBJECTIVES

The aims of our study were to compare the interobserver reproducibility of two-dimensional (2D) and three-dimensional (3D) saline contrast sonohysterography (SCSH) and agreement of these techniques with hysteroscopy, and to determine which SCSH findings best discriminate between benign and malignant endometrium.

METHODS

Consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm underwent 2D and 3D SCSH; the results were videotaped and stored electronically, respectively, for analysis by two independent experienced examiners who were blinded to each other's results. A histological diagnosis was obtained by dilatation and curettage, hysteroscopic resection or hysterectomy. The hysteroscopist was blinded to the ultrasound results and used the same standardized research protocol to describe the uterine cavity as the ultrasound examiners.

RESULTS

Of 170 consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm, 84 (14 with endometrial malignancy) fulfilled our inclusion criteria. Hysteroscopy findings in 54 women (one with endometrial malignancy) were used to determine agreement with SCSH. Interobserver agreement of 2D and 3D SCSH was 95% (80/84) vs. 89% (75/84) with regard to presence of focal lesions, 89% (75/84) vs. 88% (74/84) for presence of focal lesions with irregular surface, 67% (54/81) vs. 63% (51/81) for number of focal lesions, and 77% (46/60) vs. 70% (42/60) for location of focal lesions. The agreement between 2D and 3D SCSH and hysteroscopy was 94% (51/54) vs. 93% (50/54) with regard to presence of focal lesions, 74% (40/54) vs. 76% (41/54) for presence of focal lesions with irregular surface, 63% (34/54) vs. 54% (29/54) for number of focal lesions, and 66% (29/44) vs. 64% (28/44) for location of focal lesions. The SCSH finding that best discriminated between benign and malignant endometrium was the presence of focal lesion(s) with irregular surface (for 2D SCSH: sensitivity 71%, specificity 97%, positive likelihood ratio 25, negative likelihood ratio 0.3; for 3D SCSH: sensitivity 43%, specificity 97%, positive likelihood ratio 15, negative likelihood ratio 0.6).

CONCLUSIONS

3D SCSH does not seem to be superior to 2D SCSH when performed by experienced ultrasound examiners either with regard to reproducibility, agreement with hysteroscopy findings or diagnosis of endometrial malignancy. The presence of focal lesion(s) with irregular surface is the best SCSH variable for discrimination between benign and malignant endometrium.

3D Ultrasound in Gynecology and Reproductive Medicine

With advances occurring in medicine on a daily basis, it was only a matter of time before essential gynecological investigations, such as ultrasound, were modified. Many clinicians remain unconvinced by its reputed advantages and 3D ultrasound is not without disadvantages. These mainly relate to the cost implications and training requirements. 3D ultrasound imaging is still at a relatively early stage in terms of its role as a day-to-day imaging modality in gynecology and reproductive medicine. 3D imaging has several obvious benefits that relate to an improved spatial orientation and the demonstration of multiplanar views, of which the coronal plane is particularly useful. It offers a more objective and reproducible measurement of volume and vascularity of the region of interest, and an improved assessment of normal and pathological pelvic organs through further postprocessing modalities, including tomographic ultrasound imaging and various rendering modalities. It also has the benefit of offering reduced scanning time, the option of teleconsultation and storage of images for re-evaluation. However, other than its application in the assessment and differentiation of uterine anomalies, there is very little evidence demonstrating that 3D ultrasound results in a clinically relevant benefit or negates the need for further investigation. Future work should ensure that 3D ultrasound is compared with conventional imaging in randomized trials where the observer is blind to the outcome, only after which will we truly be able to evaluate its role in an evidence-based manner.

Saline infusion sonohysterography and the risk of malignant extrauterine spread in endometrial cancer

The aim of this study was to evaluate the incidence of tumor cell dissemination after saline infusion sonohysterography (SIS) in patients with endometrial cancer (EC). A retrospective study was conducted on 173 patients with EC in whom one of the following methods were performed: dilation and curettage (D&C, n = 120) and D&C followed by SIS (n = 53). No selection or randomization of patients was applied to both groups. The presence of positive peritoneal cytology, as well as adnexal or abdominal metastases was considered the endpoint of this analysis. Positive peritoneal cytology was present in one patient (0.8%) after D&C and in one patient (1.9%) after D&C followed by SIS (chi(2) = 0.030; p > 0.05). Adnexal metastases were present in nine (7.5%) patients after D&C and in three (5.7%) patients after D&C followed by SIS (chi(2) = 0.013; p > 0.05). Metastases to abdominal cavity were found in three (2.5%) patients after D&C and in two (3.8%) patients after D&C followed by SIS (chi(2) = 0.001; p > 0.05). Upstaged because of positive cytology, adnexal or abdominal metastases were 13 patients (10.8%) after D&C and six patients (11.3%) after D&C followed by SIS (chi(2) = 0.029; p > 0.05). These data show that SIS does not increase the risk of malignant cell dissemination in patients with EC.

Three-dimensional hysterosonography versus hysteroscopy for the detection of intracavitary uterine abnormalities

OBJECTIVE

To compare 3-dimentional hysterosonography (3-DHS) and diagnostic hysteroscopy for the evaluation of intrauterine lesions.

METHODS

In this prospective study 124 women with suspected intrauterine abnormality on 2-D ultrasonography or on hysterosalpingography were scheduled to undergo hysteroscopy, 3-DHS, and 3-D power Doppler (3-DPD) examination. However, 3-DHS could not be performed in 3 of the women because of cervical stenosis. The sensitivity and specificity of 3-DHS and 3-DPD were compared with those of hysteroscopy.

RESULTS

Of the 121 women found to have an intracavitary abnormality, 20 had polyps, 11 had myomas, 2 had Müllerian duct anomalies, and 6 had synechiae on hysteroscopy. There was agreement between hysteroscopy and 3-DHS in 19 of the polyp cases, 11 of the myoma cases, 2 of the Müllerian anomaly cases, and 4 of the synechiae cases. Examination with 3-DHS and 3-DPD reached a sensitivity of 91.9% and specificity of 98.8%, with a positive predictive value of 97.1% and a negative predictive value of 96.5%, respectively.

CONCLUSIONS

Examination with 3-DHS and 3-DPD both allows for accurate assessment of intrauterine abnormalities.

Reproducibility of the measurement of submucous fibroid protrusion into the uterine cavity using three-dimensional saline contrast sonohysterography

OBJECTIVE

To determine the intraobserver and interobserver reproducibility of measurement of the percentage of protrusion of submucous fibroids into the uterine cavity using three-dimensional saline contrast sonohysterography (3D-SCSH).

METHODS

Women diagnosed with submucous uterine fibroids on B-mode two-dimensional (2D) ultrasound scan were invited to join the study and 3D-SCSH was carried out. 3D volume datasets were stored digitally and were examined later using the technique of planar reformatted sections. The reproducibilities of the measurement of fibroid diameter and protrusion ratio into the uterine cavity (ratio of the size of the segment of the fibroid protruding into the cavity to the total diameter of the fibroid) were examined by two independent observers who were unaware of the initial 2D scan findings. Interobserver reproducibility was assessed by calculating the difference between measurements taken by the two operators (limits of agreement) and interclass correlation coefficient. Intraobserver repeatability was assessed by calculating the difference between two measurements for each variable (limits of agreement) and further expressed as an intraclass correlation coefficient.

RESULTS

Thirty-three 3D ultrasound volumes were examined. There was a good agreement between the observers in classifying the fibroids as greater or less than 50% confined to the myometrium (Cohen's kappa 0.81). There was no bias in measurements for both variables either between observers or with repeated measurements by each observer. For fibroid diameter and protrusion ratio the inter- and intraclass correlation coefficients were high (0.984-0.995), with narrow limits of agreement.

CONCLUSION

3D-SCSH is a reproducible method for the quantification of the percentage of a submucous fibroid protruding into the uterine cavity.

Endometrial volume and vascularity measurements by transvaginal 3-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: an interobserver reproducibility study

OBJECTIVE

The purpose of this study was to evaluate interobserver reproducibility of endometrial volume and vascular indices of the endometrium and subendometrial area estimated by 3-dimensional power Doppler angiography (3D-PDA) using the Virtual Organ Computer-Aided Analysis program, determining the influence of the endometrial growth etiology on measurements.

METHODS

Forty women underwent 3D-PDA ultrasonography. Group A comprised 25 women scanned on the day after controlled ovarian stimulation with human chorionic gonadotropin. Group B comprised 15 patients who had uterine bleeding and questionable endometrial thickening. (Histologic evaluation revealed 10 endometrial cancers and 5 endometrial hyperplasias.) A single observer examined all patients and acquired all volume data sets. Forty volume data sets were then analyzed with the Virtual Organ Computer-Aided Analysis program by 2 different observers. Endometrial volume and vascularity indices (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]) of the endometrium and subendometrium were manually calculated in the coronal plane with a 9 degrees rotation step. An intraclass correlation coefficient (ICC) was used to assess interobserver reliability.

RESULTS

Endometrial volume was more reproducible in group A (ICC = 0.98) than in group B (ICC = 0.58) (P < .05). Endometrial and subendometrial VI, FI, and VFI also presented good reproducibility with ICC greater than 0.84. The ICC was not statistically different for endometrial and subendometrial VI, FI, and VFI according to patient group, although subendometrial VFI was less reproducible in group B (ICC = 0.53) than in group A (ICC = 0.88).

CONCLUSIONS

Endometrial volume and endometrial and subendometrial 3D power Doppler indices have acceptable reproducibility. The interobserver reproducibility in tumoral endometrium was more similar than in stimulated endometrium. Our results indicate that 3D-PDA is a reliable method to evaluate physiologic and pathologic endometrial changes.

The clinical value of 3-dimensional saline infusion sonography in addition to 2-dimensional saline infusion sonography in women with abnormal uterine bleeding: work in progress

OBJECTIVE

To evaluate the clinical relevance of 3-dimensional saline infusion sonography (3D-SIS) in addition to conventional SIS in women with abnormal uterine bleeding suspected of having intrauterine abnormalities.

METHODS

All women suspected of having intrauterine abnormalities were eligible. Before 3D-SIS, conventional SIS was performed. The results of these techniques were compared with the "combined method reference standard" (hysteroscopy, endometrial sampling, and clinical follow-up in cases with normal SIS findings). Diagnostic characteristics (with 95% confidence intervals [CIs]) of 3D-SIS and SIS were calculated as well as their respective accuracy in evaluating the histologic nature, the intrauterine extension, and the location of intrauterine abnormalities. Moreover, the reliability (kappa value) and clinical relevance of 3D-SIS were assessed.

RESULTS

A total of 49 women were included, and 4 women were excluded. The positive predictive values of 3D-SIS and SIS were, respectively, 1.00 and 0.86 (95% CI, 0.72-0.99; P = .15), and the diagnostic accuracy values were 0.98 (95% CI, 0.94-1.0) and 0.91 (95% CI, 0.83-0.99; P = .08). Saline infusion sonography and 3D-SIS were equally accurate in evaluating the histologic nature, intrauterine extent, and location of intrauterine abnormalities (respective kappa values: 0.85 versus 0.93; P = .88; 0.83 versus 0.83; and 0.77 versus 0.80; P = .81). The reliability of 3D-SIS was good: intraobserver and interobserver agreement (kappa) were 0.78 and 0.72. Three women (6.7%) had the benefit of additional 3D-SIS: in these women, SIS wrongly led to a diagnosis of intrauterine abnormalities (P = .08).

CONCLUSIONS

Three-dimensional saline infusion sonography is valid and reliable in women suspected of having intrauterine abnormalities and may indeed have relevant clinical value in addition to conventional SIS.

Cancer of the endometrium: current aspects of diagnostics and treatment

Background

Endometrial cancer represents a tumor entity with a great variation in its incidence throughout the world (range 1 to 25). This suggests enormous possibilities of cancer prevention due to the fact that the incidence is very much endocrine-related, chiefly with obesity, and thus most frequent in the developed world. As far as treatment is concerned, it is generally accepted that surgery represents the first choice of treatment. However, several recommendations seem reasonable especially with lymphadenectomy, even though they are not based on evidence. All high-risk cases are generally recommended for radiotherapy.

Methods

A literature search of the Medline was carried out for all articles on endometrial carcinoma related to diagnosis and treatment. The articles were systematically reviewed and were categorized into incidence, etiology, precancerosis, early diagnosis, classification, staging, prevention, and treatment. The article is organized into several similar subheadings.

Conclusions

In spite of the overall good prognosis during the early stages of the disease, the survival is poor in advanced stages or recurrences. Diagnostic measures are very well able to detect asymptomatic recurrences. These only seem justified if patients' chances are likely to improve, otherwise such measures increases costs as well as decrease the patients' quality of life. To date neither current nor improved concepts of endocrine treatment or chemotherapy have been able to substantially increase patients' chances of survival. Therefore, newer concepts into the use of antibodies e.g. trastuzumab in HER2-overexpressing tumors and the newer endocrine compounds will need to be investigated. Furthermore, it would seem highly desirable if future studies were to identify valid criteria for an individualized management, thereby maximizing the benefits and minimizing the risks.

Managing women with post-menopausal bleeding

Transvaginal ultrasound examination can reliably distinguish women with post-menopausal bleeding (PMB) who are at low risk of endometrial pathology (endometrial thickness < or =4 mm) from those who are at high risk (endometrium > or =5 mm) and can rule out focally growing lesions in the uterine cavity using saline infusion into the cavity as a negative contrast agent (hydrosonography). The 5 mm cut-off is applicable irrespective of the use of hormone replacement therapy. It is justified to refrain from endometrial sampling in women with PMB and an endometrial thickness of < or =4 mm because the risk of endometrial cancer in these women is low (0.1-1.0%). However, it is not known whether these women need follow-up. About 80% of women with PMB and an endometrium of > or =5 mm have focally growing pathological lesions in the uterine cavity. These should be removed by operative hysteroscopy because dilatation and curettage (D and C) will fail to diagnose and remove a large proportion of these lesions. However, D and C is a reliable diagnostic method for women without focal lesions in the uterine cavity. It is not known whether simple outpatient sampling devices (e.g. Pipelle) are as reliable as D and C in women without focal lesions. A measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer. The reliability of ultrasound evaluation of endometrial morphology and/or vascularization for risk estimation of endometrial malignancy remains to be determined.

Saline infusion sonohysterography: technique, indications, and imaging findings

OBJECTIVE

To review the technique, indications, and common imaging findings regarding saline infusion sonohysterography.

METHODS

The literature on saline infusion sonohysterography was reviewed. Pertinent images from our institution are presented to illustrate common imaging findings.

RESULTS

From the literature review, we summarize the various clinical scenarios in which saline infusion sonohysterography is useful and give examples from our clinical practice.

CONCLUSIONS

Saline infusion sonohysterography is a useful procedure for evaluation of endometrial and subendometrial abnormalities.

Three-dimensional ultrasonography in gynecology: technical aspects and clinical applications

OBJECTIVE

The aim of this work was to review the technical aspects and clinical applications of three-dimensional ultrasonography in gynecologic imaging.

METHODS

With the use of a computerized database (MEDLINE), articles on three-dimensional ultrasonography were reviewed. Other pertinent references were obtained from the references cited in these articles. In addition, we reviewed our own clinical experience over the past 7 years.

RESULTS

Numerous applications of three-dimensional ultrasonography have been reported, including imaging of the uterus, the endometrial cavity, adnexa, and the pelvic floor and color and power Doppler applications. The accuracy of volume calculations and the networking opportunities with three-dimensional ultrasonography have also been reported. Technical problems and limitations of this technique are summarized.

CONCLUSIONS

Three-dimensional ultrasonography has proved to be a useful imaging tool for clinical problem solving in gynecology, especially in imaging the uterus and uterine cavity.

A prospective study to evaluate the efficacy of two- and three-dimensional sonohysterography in women with intrauterine lesions

OBJECTIVE

To measure the accuracy of three-dimensional (3D) sonohysterography in detecting intrauterine lesions.

DESIGN

Prospective study.

SETTING

Teaching hospital.

PATIENT(S)

Two hundred nine infertile patients suspected to have an intrauterine lesion on 2D ultrasound or hysterosalpingography.

INTERVENTION(S)

Three-dimensional ultrasound, 2D and 3D sonohysterography (SHG). Ninety-two of the patients had a lesion distorting the endometrium on the 3D SHG, and those were referred for hysteroscopy.

MAIN OUTCOME MEASURE(S)

Sensitivity and specificity of 2D, 3D ultrasound, and 2D SHG compared to 3D SHG.

RESULT(S)

Of the 92 patients with a lesion, 48 had polyps, 35 submucous/intramural myomas, 3 both polyps and myomas, 4 müllerian anomalies, 1 thick endometrium, and 1 synechiae. Compared with the 3D SHG results, the sensitivity and specificity were 97% and 11% for the 2D transvaginal ultrasound, 87% and 45% for the 3D ultrasound, and 98% and 100% for the 2D SHG. In the group of 59 patients who had hysteroscopy, the sensitivity of the 2D SHG and 3D SHG were 98% and 100%, with a positive predictive value of 95% and 92%, respectively.

CONCLUSION(S)

Three-dimensional sonohysterography allows precise recognition and localization of lesions. If 2D and 3D SHG are normal, invasive diagnostic procedures such as hysteroscopy could be avoided.

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis

Our aim was to determine the diagnostic accuracy of endometrial thickness measurement by pelvic ultrasonography for predicting endometrial carcinoma and disease (hyperplasia and/or carcinoma) during an investigation of postmenopausal bleeding. We performed a systematic quantitative review of the available published literature, which consisted of online searching the MEDLINE and EMBASE databases (1966-2000) coupled with scanning of bibliography of known primary and review articles. The selection of studies, assessment of study quality, and extraction of data were performed in duplicate under masked conditions. Included in the analyses were 57 studies with 9031 patients. Accuracy data were summarized using likelihood ratios for various cut-off levels of abnormal endometrial thickness. The commonest cut-offs were 4 mm (9 studies) and 5 mm (21 studies), measuring both endometrial layers. None of the nine studies using the < or = 4 mm cut-off level were of good quality. Only four studies (out of the 21) used the < or = 5 mm cut-off level, which employed the best-quality criteria. Using the pooled estimates from these four studies only, a positive test result raised the probability of carcinoma from 14.0% (95% CI 13.3-14.7) to 31.3% (95% CI 26.1-36.3), while a negative test reduced it to 2.5% (95% CI 0.9-6.4). In conclusion, ultrasound measurement of endometrial thickness alone, using the best-quality studies cannot be used to accurately rule. However, a negative result at < or = 5 mm cut-off level measuring both endometrial layers in the presence of endometrial pathology rules out endometrial pathology with good certainty.

Ultrasonic assessment of the postmenopausal uterus

OBJECTIVES

To assess the role of different forms of ultrasound in the evaluation of peri- and postmenopausal uterus.

METHODS

B-mode ultrasound, colour and pulsed Doppler sonography, three-dimensional ultrasound and three-dimensional power Doppler sonography are non-invasive tools used repeatedly for assessing morphology and vascularity of the uterus and uterine lesions in peri- and postmenopausal patients.

RESULTS

The application of transvaginal colour Doppler to the peri- and postmenopausal patients for the screening for endometrial and myometrial malignancy may be a viable option if combined with ovarian screening in the same scan. In this way the capital costs would be shared and oncological preventive medicine for postmenopausal women could be initiated. Three-dimensional and power Doppler ultrasound offers improved visualisation of uterine lesions, displays an entire volume, offers accurate volume estimation and enables retrospective review of stored data. Interactive rotation of power Doppler rendered images provides improved visualisation of the uterine vasculature.

CONCLUSIONS

Further technological development of the ultrasound imaging techniques could result in reduction of both the potential risks and economic cost of the invasive diagnostic procedures in postmenopausal patients such as dilatation and curettage operations. Same techniques can be used for early detection of endometrial malignancy in asymptomatic postmenopausal women as well as for prediction of the depth of myometrial invasion.

Clinical implications of sonographic detection of uterine anomalies for reproductive outcome

The purpose of this review article was to analyze the literature on the prevalence, diagnosis and treatment of the congenital uterine anomalies and to discuss current dilemmas on their influence on reproductive outcome. Congenital uterine anomalies are commonly associated with repeated pregnancy failure, in particular an increased risk of first- and second-trimester miscarriages and preterm delivery. Recent reports on two-dimensional and three-dimensional transvaginal ultrasound and saline contrast sonohysterography appear promising for diagnosis and classification of congenital uterine anomalies. The ability to visualize both the uterine cavity and the fundal uterine contour on a three-dimensional scan facilitates the diagnosis of uterine anomalies and enables differentiation between septate and bicornuate uteri. Color Doppler ultrasound allows visualization of intraseptal vascularity and may help in distinguishing the avascular from the vascular septum. Less connective tissue in the septum may result in poor decidualization and placentation, while an increased amount of muscle tissue in the septum can cause miscarriage by the production of local uncoordinated myometrial contractility. Hysteroscopic septum excision is an effective procedure which improves live-birth rates. Because of its simplicity, minimal invasiveness, low morbidity and low cost, a more liberal approach to the treatment of uterine anomalies is being advocated.

Cost-effectiveness of saline-assisted hysterosonography and office hysteroscopy in the evaluation of postmenopausal bleeding: a decision analysis

RATIONALE AND OBJECTIVES

The authors performed this study to evaluate whether hysterosonography (HSG) is a more cost-effective initial diagnostic examination than office hysteroscopy in the evaluation of postmenopausal bleeding (PMB).

MATERIALS AND METHODS

A computer model simulated the diagnosis and treatment of PMB in otherwise healthy women. The hypothetical patient who had one episode of PMB precipitating a clinic visit would undergo either HSG or office hysteroscopy as the initial examination. Algorithms were designed such that a finite number of false-negative and false-positive findings would be expected, and clinical decision making would rely on the reported results. Performance characteristics for diagnostic tests and other clinical probabilities were taken from the literature. Costs were based on actual 1997 Medicare reimbursements. The primary clinical outcome considered was the correct diagnosis of any anatomic abnormality that was amenable to definitive treatment. The primary cost outcome considered was the cost per abnormality detected. Sensitivity analysis was performed to examine the effect of varying performance characteristics for diagnostic techniques.

RESULTS

HSG and office hysteroscopy correctly depicted 68.1 and 67.6 anatomic abnormalities per 100 patients, respectively. The average cost per abnormality detected was $7,978 with HSG and $8,400 with office hysteroscopy.

CONCLUSION

HSG depicted more abnormalities at a lower cost per abnormality, which suggests that it should be the preferred initial diagnostic examination in the setting of PMB.

Three-dimensional ultrasound in obstetrics and gynecology

Three-dimensional ultrasound is a new modality finding its way into clinical practice. Most of the major ultrasound vendors are now developing three-dimensional ultrasound capabilities. We expect that although three-dimensional ultrasound will not replace two-dimensional ultrasound, many additional benefits will be identified and its use will continue to grow. The ability to evaluate anatomy and pathology with multiplanar and surface-rendered images provides physicians additional valuable clinical information. Volume data allows for a specific point in space to be evaluated from many different orienta tions by rotating, slicing, and referencing the slice to other orthogonal slices. It also allows for new volume-rendering displays that show depth, curvature, and surface images not available with conventional methods. The current limitations of image resolution, intuitive interfaces for obtaining and displaying optimal images, and technologic limitations for data storage and manipulation (including real-time three-dimensional ultrasound) will surely be overcome in the near future.

Ultrasound imaging in three and four dimensions

Three-dimensional (3D) reconstruction of ultrasound images was first demonstrated nearly 15 years ago, but only now is becoming a clinical reality. In the meantime, methods for 3D reconstruction of CT and MRI images have achieved an advanced state of development, and 3D imaging with these modalities has been applied widely in clinical practice. 3D applications in ultrasound have lagged behind CT and MRI, because ultrasound data is much more difficult to render in 3D, for a variety of technical reasons, than either CT or MRI data. Only in the past few years has the computing power of ultrasound equipment reached a level adequate enough for the complex signal processing tasks needed to render ultrasound data in three dimensions. At this point in time, the clinical application of 3D ultrasound is likely to advance rapidly, as improved 3D rendering technology becomes more widely available. This article is a review of the present status of 3D ultrasound imaging. It begins by comparing the characteristics of CT, MRI, and ultrasound image data that either make these data amenable or not amenable to 3D reconstruction. The article then considers the technical features involved with acquiring an ultrasound 3D data set and the mechanisms for reconstructing the images. Finally, the article reviews the literature that is available regarding clinical application of 3D ultrasound in obstetrics, ultrasound, the abdomen, and blood vessels.

Assessment of endometrial volume by three-dimensional ultrasound prior to embryo transfer: clues to endometrial receptivity

The aim of the present prospective study was to obtain quantitative data on endometrial volume by three-dimensional (3D) ultrasound at the time of embryo transfer in an in-vitro fertilization programme and to assess its value in predicting endometrial receptivity. The cycles (n = 72) were classified according to endometrial volume: group A <2 ml, group B 2-4 ml, and group C >4 ml. Comparisons of the groups showed that pregnancy and implantation rates were significantly lower (P < 0.05) in the group of patients with an endometrial volume <2 ml. Furthermore, no pregnancy was achieved with an endometrial volume <1 ml. It is concluded that endometrial volume by 3D transvaginal ultrasound may become a new objective parameter by which to predict endometrial receptivity.

Surveillance for endometrial cancer in women receiving tamoxifen

Recent studies showing a protective effect of tamoxifen in women at high risk for breast cancer have expanded the indications of the drug. While acting as an estrogen antagonist in the breast, tamoxifen can have estrogenic effects on the endometrium; consensus opinion is that tamoxifen increases the risk for endometrial cancer. Because an increasing number of women are taking tamoxifen, a strategy for gynecologic surveillance is needed. Studies examining the relation between risk for endometrial cancer and tamoxifen use have conflicting results. However, because of an overall interpretation that tamoxifen use slightly increases risk for endometrial cancer, some researchers advocate routine ultrasonography and endometrial biopsy for screening asymptomatic women receiving tamoxifen. This paper reviews the literature on endometrial cancer in women taking tamoxifen and the usefulness of various screening methods in this setting. Risk factors and screening criteria for endometrial cancer in the general population are discussed, and a strategy for surveillance of women taking tamoxifen is proposed. Patients should be screened for signs or symptoms of endometrial abnormality before taking tamoxifen. This evaluation, which should include a careful history, pelvic examination, and Papanicolaou smear, should be repeated annually while the patient is receiving tamoxifen. Although transvaginal ultrasonography is not recommended for routine screening, it is indicated if an adequate pelvic examination cannot be performed or if additional risk factors are present. The likelihood of abnormality is greater for patients who have abnormal bleeding, discharge, abnormal glandular cells on Papanicolaou smear, or an endometrial measurement on ultrasonography of more than 8 mm; these findings should prompt an aggressive evaluation of the endometrium.