Saline-Infusion Sonography Endometrial Sampling Compared With Endometrial Biopsy in Diagnosing Endometrial Pathology

Combining Ultrasonography and Endometrial Aspiration as a One-Stop Screening for Endometrial Neoplasia

OBJECTIVE

To assess the performance of simultaneous endometrial aspiration and sonohysterography to screen for endometrial cancer or hyperplasia in women aged 50 years or older.

METHODS

We conducted a prospective study from February 2014 to October 2020 at the ultrasound unit of a large urban academic medical center. The study included 1,635 women aged 50 years or older referred for endometrial evaluation, with follow-up through January 2021. Participants underwent saline infusion sonohysterography combined with ultrasound-guided endometrial aspiration. The primary outcome measured was a diagnosis of endometrial cancer or hyperplasia within 1 year from screening. The diagnostic accuracy of the combined evaluation method, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), was assessed.

RESULTS

Of 1,170 women who completed the study protocol, 82 (7.0%) had endometrial cancer and 42 (3.6%) had endometrial hyperplasia. Of all patients who developed cancer during the follow-up period, 85.5% were diagnosed within 1 year after evaluation. The application of simultaneous endometrial aspiration and sonohysterography together demonstrated a sensitivity of 99.1%, specificity of 24.9%, PPV of 11.8%, and NPV of 99.6%. Using a theoretical sequential approach, assuming an endometrial aspiration is performed only in patients determined to be high risk by sonohysterography, demonstrated a sensitivity of 93.4%, specificity of 99.9%, PPV of 99.0%, and NPV of 99.3%.

CONCLUSION

Simultaneous endometrial aspiration and sonohysterography is an effective one-stop outpatient screening tool for detecting endometrial cancer and hyperplasia in women aged 50 years or older. With the integration of two screening modalities into a single procedure, simultaneous endometrial aspiration and sonohysterography may overcome the limitations inherent in each of the currently recommended methods individually, potentially improving patient prognosis and streamlining the diagnostic process.

Diagnostic efficacy of gel infusion sonography in post-menopausal bleeding

Background

Our purpose was to evaluate the diagnostic performance of two-dimensional transvaginal ultrasound (2D-TVUS) and gel infusion sonography (GIS) at offline analysis for endometrial characterization compared with real-time evaluation during scanning.

One hundred fifty women presented with PMB. At TVUS, endometrial thickness was ≥ 4 mm in 122 (81.3%) women and < 4 mm in 28 (18.72%). Among 122 women with endometrial thickness > 4 mm, GIS was successfully performed in 117 (95.9%). Examinations were stored as video clips for later evaluation (offline analysis) by two less experienced radiologists. Endometrial lesions were classified into four categories: no endometrial abnormality, hyperplasia, polyps, and cancer. Diagnostic efficiency of real-time and offline analysis for diagnosis of each category was calculated and compared, and inter-observer agreement for offline analysis was calculated.

Results

All patients underwent hysteroscopy and/or hysterectomy. Histopathological results confirmed no endometrial abnormality in (27.3%, 41/150), endometrial hyperplasia in (12.7%, 19/150), endometrial polyps in (17.3%, 26/150), and endometrial cancer in (42.7%, 64/150).

Overall diagnostic accuracy of real-time imaging was 89.7% (CI 84–91%)). The highest accuracy 92.7% (CI 88–98%) was seen in the diagnosis of cancer, and polyps 91.5% (CI 86–97%). The lowest accuracy 75% (CI 69–82%) was seen in hyperplasia.

Overall diagnostic accuracy of offline analysis was 81%, and it increased to 88% (CI 83–92%) after a restricted analysis of good quality clips. The highest accuracy 90.7% (CI 83–95%) was seen in the diagnosis of polyps, and cancer 90.4% (CI 83–96%). The lowest accuracy 71% (CI 69–75%) was seen in hyperplasia.

At offline analysis, the inter-observer agreement was substantial k = 0.77 (CI 71–84) in the evaluation of four endometrial categories after the exclusion of bad quality videos. It was excellent in exclusion of endometrial abnormalities k = 0.85 (0.78–0.90), substantial in the diagnosis of polyps k = 0.71 (0.69–0.88), cancer k = 0.61 (0.61–0.77), and moderate in the diagnosis of hyperplasia k = 0.41 (0.30–0.41).

Conclusion

Offline 2D analysis with a good image quality has comparable accuracy to a real-time evaluation during scanning in the diagnosis of endometrial lesions. It can increase the accuracy of sonography in ruling out endometrial abnormalities and diagnose non-hyperplastic endometrial pathologies. High NPV and substantial reproducibility can make it an efficient initial screening method in a post-menopausal bleeding.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis

Introduction

In women with abnormal uterine bleeding (AUB), endometrial polyps are a frequent finding, and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women is important.

Aim

To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB.

Material and methods

The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2.

Results

After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively.

Conclusions

Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Comparison of saline infusion sonography (SIS) versus SIS-guided endometrial sampling in the diagnosis of endometrial pathology

PURPOSE

To compare saline infusion sonography (SIS) to tissue obtained from SIS-guided endometrial sampling (SISES) to determine sensitivity and specificity for benign and malignant conditions of the endometrium.

METHODS

Added value of SISES after SIS was evaluated over 5 years. SIS and SISES techniques have been previously described. Women with abnormal uterine bleeding and endometrial findings underwent SIS. Criteria for SISES included atypical polypoid mass, focal irregularity or global endometrial thickening, nondiagnostic SIS, discordance between SIS and endometrial biopsy, or request from the primary team. Final surgical pathology was compared with SIS and SISES.

RESULTS

One-hundred twenty-three SIS patients had SISES. SIS alone had a sensitivity of 100%, specificity of 42%, positive predictive value of 16%, and negative predictive value of 100%. A total of 120 patients had final clinical or surgical outcomes. Specificity was greatly improved with addition of SISES (95.5%, p < 0.001). Combination of SIS with SISES detected all 12 premalignant and malignant endometrial lesions. Three cases had small foci of hyperplasia (n = 2) or atypia (n = 1) in polyps on final surgical pathology, which were not prospectively identified on SISES.

CONCLUSIONS

SISES significantly improves the specificity in the diagnosis of endometrial lesions. False-negative findings of SISES in polyps in postmenopausal women with bleeding suggest the need for surgical removal in this setting. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:416-422, 2016.

The yield of endometrial aspiration in women with various risk factors and bleeding abnormalities

Background

Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology.

Methods

Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results.

Results

The charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution.

Conclusions

The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.

Simultaneous endometrial aspiration and sonohysterography for the evaluation of endometrial pathology in women aged 50 years and older

OBJECTIVE

To evaluate the performance of simultaneous endometrial aspiration at the time of sonohysterography for screening postmenopausal women at risk for endometrial cancer.

METHODS

A retrospective cohort study of women older than 50 years who underwent saline-infusion sonohysterography for the evaluation of their endometrium. On completion of imaging, the remaining intracavitary saline and endometrial tissue were aspirated through the saline-infusion sonohysterography catheter and submitted for pathologic evaluation. Based on the clinical, pathologic, and ultrasonographic results, the patients underwent surgical treatment with hysteroscopy, hysterectomy, or clinical observation. Follow-up results and outcomes were collected using electronic medical records. Sensitivity, specificity, and predictive values of saline-infusion sonohysterography, endometrial aspiration, and combined approaches for endometrial aspiration and sonohysterography were assessed.

RESULTS

Six hundred three patients underwent endometrial aspiration at the time of sonohysterography. Endometrial tissue was present in 567 (94.0%) and outcome data were available for 540 (89.5%). In 194 (35.9%) patients, final pathology was obtained by surgical intervention. The remaining 346 (64.1%) patients were monitored for at least 6 months. Thirty patients (5.6%) had cancer or endometrial hyperplasia. A sequential model, in which endometrial aspiration was done only for positive saline-infusion sonohysterography findings, yielded sensitivity of 86.7% (95% confidence interval [CI] 69-96%) and specificity of 100% (95% CI 99-100%) for detecting endometrial hyperplasia or cancer (area under the curve 0.93). Considering proliferative endometrium as abnormal endometrial aspiration reduced specificity to 88.3% (95% CI 85-91%, P<.01) without significant increase in sensitivity (100%, 95% CI 88-100%, P=.13).

CONCLUSION

The high sensitivity and specificity of the sequential endometrial aspiration at the time of sonohysterography make this approach a useful and reliable screening algorithm for detecting endometrial cancer or hyperplasia in postmenopausal women at risk. Endometrial aspiration at the time of sonohysterography should be considered as an initial one-stop endometrial evaluation in this population.

Detection of intracavitary uterine pathology using offline analysis of three-dimensional ultrasound volumes: interobserver agreement and diagnostic accuracy

OBJECTIVE

To estimate the diagnostic accuracy and interobserver agreement in predicting intracavitary uterine pathology at offline analysis of three-dimensional (3D) ultrasound volumes of the uterus.

METHODS

3D volumes (unenhanced ultrasound and gel infusion sonography with and without power Doppler, i.e. four volumes per patient) of 75 women presenting with abnormal uterine bleeding at a 'bleeding clinic' were assessed offline by six examiners. The sonologists were asked to provide a tentative diagnosis. A histological diagnosis was obtained by hysteroscopy with biopsy or operative hysteroscopy. Proliferative, secretory or atrophic endometrium was classified as 'normal' histology; endometrial polyps, intracavitary myomas, endometrial hyperplasia and endometrial cancer were classified as 'abnormal' histology. The diagnostic accuracy of the six sonologists with regard to normal/abnormal histology and interobserver agreement were estimated.

RESULTS

Intracavitary pathology was diagnosed at histology in 39% of patients. Agreement between the ultrasound diagnosis and the histological diagnosis (normal vs abnormal) ranged from 67 to 83% for the six sonologists. In 45% of cases all six examiners agreed with regard to the presence/absence of intracavitary pathology. The percentage agreement between any two examiners ranged from 65 to 91% (Cohen's κ, 0.31-0.81). The Schouten κ for all six examiners was 0.51 (95% CI, 0.40-0.62), while the highest Schouten κ for any three examiners was 0.69.

CONCLUSION

When analyzing stored 3D ultrasound volumes, agreement between sonologists with regard to classifying the endometrium/uterine cavity as normal or abnormal as well as the diagnostic accuracy varied substantially. Possible actions to improve interobserver agreement and diagnostic accuracy include optimization of image quality and the use of a consistent technique for analyzing the 3D volumes.

Office diagnosis and management of abnormal uterine bleeding

Abnormal uterine bleeding is one of the most common presenting complaints encountered in a gynecologist's office or primary care setting. The availability of diagnostic tools, such as ultrasound, endometrial sampling, and diagnostic hysteroscopy has made it possible to promptly diagnose and treat an increasing number of menstrual disorders in an office setting. The incorporation of newer medical therapies: antifibrinolytic drugs, shorter hormone-free interval oral contraceptive pills, and levonorgestrel inserts along with office minimally invasive treatments operative hysteroscopy and endometrial ablations have proven to be powerful therapeutic arsenals to provide short-term relief of abnormal uterine bleeding, and potentially, avoiding or delaying the hysterectomy.

Saline infusion sonohysterography versus hysteroscopy for uterine cavity evaluation

BACKGROUND AND OBJECTIVES

The most frequent procedures performed on women with abnormal uterine bleeding are 2D and 3D ultrasound. The most common accepted approach for the management of abnormal uterine bleeding is 2D TV scan followed by therapeutic hysteroscopy. The purpose of this prospective study was to assess whether 3D saline infusion sonohysterography (3D SIS) could replace diagnostic hysteroscopy (DH) for the diagnosis of endometrial pathology, in patients with abnormal uterine bleeding.

DESIGN AND SETTING

A prospective study in the ultrasound department of the Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia from January 2008 to February 2010.

PATIENTS AND METHODS

0One hundred and one patients with abnormal uterine bleeding, suspected to have endometrial abnormality by 2D and 3D transvaginal scan, were prospectively studied. Of these, 55 patients had undergone both 3D SIS and DH, followed by verification of results with histopathology.

RESULTS

Upon comparison of 3D SIS and DH individually with histopathology, specificity and sensitivity for 3D SIS were 67% and 100%, respectively, and for hysteroscopy 67% and 98%, respectively. In addition, the positive predictive value and negative predictive value were 98% and 100%, respectively, for 3D SIS, while for DH they were 98% and 67%, respectively.

CONCLUSION

3D SIS is a safe alternative to hysteroscopy. However, larger randomized controlled trials should be conducted to ascertain the validity and reliability of this advantageous, less-invasive procedure, for women with abnormal uterine bleeding, who require evaluation of the endometrial cavity.

Comparação entre ultrassonografia transvaginal e histerossonografia na avaliação de pacientes com sangramento uterino anormal

OBJETIVO: Avaliar a eficácia da ultrassonografia transvaginal (USTV) e da histerossonografia (HSG) e compará-las na avaliação de alterações endometriais em portadoras de sangramento uterino anormal. MATERIAIS E MÉTODOS: Estudo transversal com 30 pacientes, idade entre 29 e 71 anos, 21 delas (70%) na pré-menopausa e 9 (30%) na pós-menopausa. Utilizou-se solução salina a 0,9% para contraste na HSG. Foi considerado o achado histeroscópico e/ou histopatológico como método padrão. Utilizou-se o teste de MacNemar para comparação dos testes diagnósticos. RESULTADOS: A histeroscopia diagnosticou 18 casos (60%) de alterações intracavitárias, sendo 10 pólipos (33,3%). A USTV apresentou sensibilidade e especificidade de 83,3% e a HSG mostrou sensibilidade de 94,4% e especificidade de 91,6%. O teste de MacNemar evidenciou sensibilidade (p = 0,500) e especificidade (p = 1,000) semelhantes entre a USTV e a HSG para detecção de alterações endometriais. No diagnóstico de pólipo, a HSG apresentou maior sensibilidade (90,9% × 27,3%; p = 0,016), com especificidade semelhante (89,5% × 94,7%; p = 1,000). CONCLUSÃO: A HSG e a USTV apresentam boas taxas de predição para doenças endometriais em pacientes com sangramento uterino anormal. A HSG apresenta sensibilidade e especificidade semelhantes às da USTV na detecção dessas doenças, porém apresenta sensibilidade maior para pólipos.