Transvaginal ultrasonography with and without saline infusion in assessment of myometrial invasion of endometrial cancer

Comparison of the diagnostic accuracy of contrast-enhanced/DWI MRI and ultrasonography in the differentiation between benign and malignant myometrial tumors

Background

Various modalities including ultrasonography and magnetic resonance imaging (MRI) have been developed as imaging technique for screening malignant myometrial tumors, but a few studies assessed the diagnostic value of these two techniques in differentiation of benign from malignant myometrial tumors that had been the main purpose of this study.

Materials and methods

This cross-sectional study was performed on 63 women underwent surgery for intrauterine masses that were initially assessed using MRI and ultrasound before surgery at a tertiary hospital in Tehran from 2016 to 2020. Their MRI was reviewed by a reputable radiologist in the field. The findings of histopathological assessment were considered as the gold diagnostic standard.

Results

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI to detect sarcoma were revealed to be 94.6%, 92.3%, 94.6%, 92.3%, and 93.7% respectively. Ultrasonography had not preferable applicability to differentiate sarcoma from benign tumors with sensitivity, specificity, PPV, NPV and accuracy of 35.1%, 88.4%, 81.2%, 48.9%, and 57.1% respectively. The diagnostic performance of both modalities was not affected by baseline clinical conditions including pain, abnormal uterine bleeding and menopausal status.

Conclusion

MRI but not ultrasonography can effectively differentiate benign from malignant myometrial tumors.

•

Pretreatment Diagnosis of malignant myometrial tumors may be challenging.

•

MRI with DWI can be considered as a diagnostic tool in leiomyosarcoma.

•

Pretreatment distinction between benign and malignant myometrial tumors is necessary.

Transvaginal Saline Contrast Sonohystography to Investigate Postmenopausal Bleeding: A Systematic Review

Transvaginal ultrasound (TVUS) is the initial investigation of choice for postmenopausal bleeding (PMB), followed by diagnostic hysteroscopy and endometrial sampling if abnormalities are detected. Saline contrast sonohysterography (SCSH) - injection of saline through the cervix into the uterine cavity prior to TVUS - allowed increased diagnostic accuracy in women with PMB in several small, heterogeneous studies.

The objectives of the current study were to evaluate the diagnostic accuracy of SCSH in women with PMB, comparing findings with surgical and pathological reports, highlight the necessity of SCSH in guiding clinical decision-making, and establish if there is an increase/decrease in the number of hysteroscopies performed for PMB and, hence, the adherence of clinicians to imaging referral guidelines.

The search strategy included formulating search terms identifying all synonyms of SCSH and postmenopause. The databases searched were MEDLINE, Embase, and the Cochrane Library.

Only studies comparing SCSH to an alternative method were selected. The studies were screened and data analysis performed using content analysis. Data reduction was performed through systematic coding and the generation of themes

We identified 18 studies, comprising 974 women, using SCSH to evaluate the endometrial cavity in women with PMB; most support SCSH improving diagnostic accuracy through delineating intracavitary structures.

In effect, SCSH could be a first-line investigative modality to assess the uterine cavity once a larger, well-designed study has been conducted to clarify its specificity, sensitivity, and positive predictive value (PPV). Owing to its relatively non-invasive nature and potentially high diagnostic accuracy, SCSH could allow for more accurate decisions regarding the need for further investigation and subsequent management.

Tweetable abstract

"Saline contrast sonohysterography improves the diagnostic accuracy of the endometrium in postmenopausal bleeding."

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.

The Diagnostic Accuracy of Ultrasound in Assessment of Myometrial Invasion in Endometrial Cancer: Subjective Assessment versus Objective Techniques

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.

Transvaginal ultrasound for preoperative assessment of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of deep myometrial infiltration in patients with endometrial cancer, comparing subjective and objective methods.

METHODS

An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. The eligibility criterion was use of TVS for preoperative assessment of myometrial infiltration by subjective evaluation and/or objective measurements. Objective measurements included, specifically, the approaches of Gordon (ratio of the distance between endometrium-myometrium interface and maximum tumor depth to the total myometrial thickness) and Karlsson (endometrial tumor thickness/anteroposterior uterine diameter ratio), in women with endometrial cancer, using the surgical pathological data as a reference standard. Study quality was assessed using the QUADAS-2 tool.

RESULTS

Our extended search identified a total of 184 citations, among which we examined the full text of 24 articles. Overall pooled sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of TVS for detecting deep myometrial infiltration were 82% (95% CI, 76-87%), 81% (95% CI, 76-85%), 4.3 (95% CI, 3.6-5.3) and 0.22 (95% CI, 0.16-0.30), respectively. We did not observe differences among the three methods in terms of diagnostic performance. Significant heterogeneity was found for sensitivity and specificity of all three methods (I(2) range, 60.6-95.0). The main limitation was that very few studies compared different approaches in the same set of patients.

CONCLUSION

Diagnostic performance of TVS for detecting deep myometrial infiltration in women with endometrial cancer is moderate.

Imaging in endometrial carcinoma

Endometrial carcinoma (EC) is the most common gynecologic malignancy in the United States. Prognosis depends on patient age, histological grade, depth of myometrial invasion and/or cervical invasion, and the presence of lymph node metastases. Although EC is staged surgically according to the International Federation of Gynecology and Obstetrics (FIGO) system, preoperative imaging can assist in optimal treatment planning. Several imaging techniques such as transvaginal ultrasonography (TVUS), computed tomography (CT), and magnetic resonance imaging (MRI) have been used as diagnostic tools for preoperative staging of EC. Recently, positron emission tomography (PET), PET/CT, and PET/MRI have also been used in staging these patients. In this article, we review the value of imaging in diagnosis, staging, treatment planning, and detection of recurrent disease in patients with EC.

Three-dimensional ultrasound with volume contrast imaging for preoperative assessment of myometrial invasion and cervical involvement in women with endometrial cancer

OBJECTIVES

To evaluate the accuracy of transvaginal three-dimensional ultrasound with volume contrast imaging (VCI) for preoperative assessment of depth of myometrial invasion and cervical involvement in women with endometrial cancer.

METHODS

Transvaginal volume acquisition of the uterus was performed in 60 consecutive patients with histological diagnosis of endometrial cancer who were scheduled for primary surgical treatment. Depth of myometrial invasion and presence or absence of cervical involvement were assessed using VCI in multiplanar display mode. Results were compared to final postoperative histopathological findings. Patients with histological high-risk cell types, including Grade 3 endometrioid adenocarcinoma, clear cell carcinoma, papillary serous carcinoma and carcinosarcoma, were excluded.

RESULTS

Forty patients were included in the analysis. The accuracy of VCI in assessing single-stage myometrial invasion (superficial or deep) was 92.5%. In the prediction of deep myometrial invasion, sensitivity, specificity, PPV and NPV of VCI were 100%, 89.7%, 78.6% and 100%, respectively. The accuracy of VCI in assessing cervical involvement was 90.0%. Sensitivity, specificity, PPV and NPV of VCI in predicting the presence of cervical involvement were 100%, 86.2%, 73.3% and 100%, respectively.

CONCLUSION

Transvaginal VCI is an uncomplicated method that is able to predict with reasonable accuracy the depth of myometrial invasion and cervical involvement in women with endometrial cancer.

Diabetes revealed: multisystem danger

OBJECTIVE

The purpose of this article is to review the role of diagnostic imaging in the evaluation of women with diabetes.

CONCLUSION

Diabetic patients present a challenging population for the performance of various imaging studies and special considerations need to be made to obtain adequate studies. Imaging plays a significant role in assessing the multisystem morbidity of diabetes. Furthermore, diabetes in women may have some unique features and consequences and imaging studies can aid in the correct management of these patients.