Validation of ultrasound strategies to assess tumor extension and to predict high-risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)-4 cohort

Ultrasonic prediction model using three-dimensional power doppler for endometrial cancer detection in women with postmenopausal bleeding

Distinguishing benign and malignant endometrial lesions on the basis of endometrial thickness (ET) may lead to a missed diagnosis of endometrial carcinoma (EC) in women with postmenopausal bleeding (PMB) or increased invasive examination and pain in women with benign endometrial lesions. Our research aims to establish an ultrasonic prediction model for differentiating between benign endometrial lesions and EC in women with PMB. PMB women with ET ≥ 5 mm (n = 412) or ET < 5 mm who presented with recurrent vaginal bleeding (n = 57) were enrolled in this prospective observational study. According to the pathological examination results of the endometrium, women with PMB were divided into endometrial atrophy (EA) (n = 231), endometrial polyp (EP) (n = 98), endometrial hyperplasia (EH) (n = 58) and EC (n = 82) groups. Ultrasonic parameters were compared among the four groups. The predictive value of different parameters for differentiation between benign endometrial lesions and EC in women with PMB was determined via receiver operating characteristic (ROC) curves. The best cut-off of ultrasonic parameters analyzed by ROC curves was used to establish prediction model. Women with EC had significantly thicker endometrium and higher endometrial volume (EV), vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) than women with other pathological types of endometrium (P < 0.05). The endometrial VI, FI and VFI of women with EH were significantly higher compared with those in women with EA and EP (P < 0.05). For patients with ET ≥ 5 mm, the best parameter for distinguishing between benign lesions and EC was the FI, with an area under the curve (AUC) of 0.86, a sensitivity of 86.7% and a specificity of 81.4%. In addition, for patients with ET < 5 mm, the best parameter for distinguishing between benign lesions and EC was the VI, with an AUC of 0.92, a sensitivity of 92.1% and a specificity of 72.9%. The ultrasonic prediction model based on the FI and VI had better predictive value for EC in both patients with ET ≥ 5 mm and patients with ET < 5 mm. The ultrasonic parameters differed among the different pathological types of the endometrium in women with PMB. The ultrasonic prediction model based on the endometrial FI and VI was clinically useful for differentiating between benign endometrial lesions and EC, especially in postmenopausal patients with recurrent vaginal bleeding presenting with ET of less than 5 mm.

Ultrasound in endometrial cancer: evaluating the impact of pre-surgical staging

Preoperative staging in endometrial cancer has recently been implied as an important factor in accurately selecting low-risk cases, ultimately avoiding unnecessary lymph node debulking. Transvaginal ultrasound seems promising in clinical staging as it offers the possibility to assess the depth of myometrial infiltration and cervical stromal invasion. This commonly available, non-invasive, and low-cost modality serves as an accurate alternative to MRI, especially in middle- and low-income countries, where MRI may not be promptly available and cost is an important issue. This review aims to summarize the progressive role of clinical implementation of pelvic ultrasonography in the locoregional staging of endometrial carcinoma and to compare its accuracy with other preoperative methods.

Standardized IETA criteria enhance accuracy of junior and intermediate ultrasound radiologists in diagnosing malignant endometrial and intrauterine lesions

OBJECTIVES

To transform the standardized descriptions of the ultrasound characteristics of endometrial and intrauterine lesions devised by the International Endometrial Tumor Analysis (IETA) group into a practical scoring method and to investigate whether application of this method enhances the diagnostic accuracy of ultrasound radiologists with different levels of experience in detecting malignancy compared with subjective assessment.

METHODS

This was a retrospective study of 855 patients with endometrial and/or intrauterine lesions, who were divided into a training (n = 600) and a validation (n = 255) set. Ultrasound radiologists with varying levels of experience (expert, intermediate and junior) evaluated all lesions by subjective assessment and according to IETA rules. Using IETA rules, the experts identified signs of malignancy in the training set, assigned scores for each indicator and validated the scoring method in the validation set. The intermediate-level and junior ultrasound radiologists reassessed the malignancy of the lesions using the IETA scoring method and compared their classifications with those made previously by subjective assessment. Postsurgical pathological evaluation was used as the reference standard.

RESULTS

Using subjective assessment, the experts demonstrated the highest level of diagnostic accuracy, with a sensitivity of 85.0%, specificity of 94.3% and an area under the receiver-operating-characteristics curve (AUC) of 0.897. Applying the IETA scoring method (comprising eight ultrasound characteristics that contributed to the total score) with a threshold of > 25 points for the diagnosis of malignancy achieved a sensitivity of 84.7%, specificity of 94.7% and AUC of 0.9533 in the training set, with similar performance in the validation set, when performed by experts. Using the IETA scoring method, both junior and intermediate ultrasound radiologists showed improvement in sensitivity (from 55.5% to 74.8% and from 70.2% to 77.1%, respectively), specificity (from 88.4% to 91.5% and from 87.4% to 92.2%, respectively) and AUC (from 0.704 to 0.827 and from 0.793 to 0.841, respectively) for diagnosing malignant lesions.

CONCLUSIONS

The IETA scoring method exhibits high diagnostic efficacy for malignant endometrial and intrauterine lesions. This method compensates for the lack of experience among junior and intermediate-level ultrasound radiologists, enhancing their diagnostic skill to a level nearing that of experienced senior ultrasound radiologists. Further research is essential to validate the practicality of implementing this method and to confirm its clinical value. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

A Transvaginal Ultrasound-Based Deep Learning Model for the Noninvasive Diagnosis of Myometrial Invasion in Patients with Endometrial Cancer: Comparison with Radiologists

RATIONALE AND OBJECTIVES

This study aimed to determine the feasibility of using the deep learning (DL) method to determine the degree (whether myometrial invasion [MI] >50%) of MI in patients with endometrial cancer (EC) based on ultrasound (US) images.

MATERIALS AND METHODS

From September 2017 to April 2023, 1289 US images of 604 patients with EC who underwent surgical resection at center 1, center 2 or center 3 were obtained and divided into a training set and an internal validation set. Ninety-five patients from center 4 and center 5 were randomly selected as the external testing set according to the same criteria as those for the primary cohort. This study evaluated three DL models trained on the training set and tested them on the validation and testing sets. The models' performance was analyzed based on accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC), and the performance of the models was subsequently compared with that of 15 radiologists.

RESULTS

In the final clinical diagnosis of MI in patients with EC, EfficientNet-B6 showed the best performance in the testing set in terms of area under the curve (AUC) [0.814, 95% CI (0.746-0.882]; accuracy [0.802, 95% CI (0.733-0.855]; sensitivity [0.623]; specificity [0.879]; positive likelihood ratio (PLR) [6.750]; and negative likelihood ratio (NLR) [0.389]. The diagnostic efficacy of EfficientNet-B6 was significantly better than that of the 15 radiologists, with an average diagnostic accuracy of 0.681, average AUC of 0.678, AUC of the best performance of 0.739, accuracy of 0.716, sensitivity of 0.806, specificity 0.672, PLR2.457, and NLR 0.289.

CONCLUSION

Based on the preoperative US images of patients with EC, the DL model can accurately determine the degree of endometrial MI; the performance of this model is significantly better than that of radiologists, and it can effectively assist in clinical treatment decisions.

Staging by imaging in gynecologic cancer and the role of ultrasound: an update of European joint consensus statements

In recent years the role of diagnostic imaging by pelvic ultrasound in the diagnosis and staging of gynecological cancers has been growing exponentially. Evidence from recent prospective multicenter studies has demonstrated high accuracy for pre-operative locoregional ultrasound staging in gynecological cancers. Therefore, in many leading gynecologic oncology units, ultrasound is implemented next to pelvic MRI as the first-line imaging modality for gynecological cancer. The work herein is a consensus statement on the role of pre-operative imaging by ultrasound and other imaging modalities in gynecological cancer, following European Society guidelines.

Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for the Detection of Myometrial Infiltration in Endometrial Cancer: A Systematic Review and Meta-Analysis

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.

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with low-grade endometrioid endometrial cancer: A systematic review and head-to-head meta-analysis

PURPOSE

We aimed to compare the diagnostic performance of magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS) for detecting myometrial invasion (MI) in patients with low-grade endometrioid endometrial carcinoma.

METHODS

A comprehensive search of MEDLINE (Pubmed), Web of Science, Embase and Scopus (from January 1990 to December 2022) was performed for articles comparing TVS and MRI in the evaluation of myometrial infiltration in low-grade (grade 1 or 2) endometrioid endometrial carcinoma in the same group of patients. We used QUADAS-2 tool for assessing the risk of bias of studies.

RESULTS

We found 104 citations in our extensive research. Four articles were ultimately included in the meta-analysis, after excluding 100 reports. All articles were considered low risk of bias in most of the domains assessed in QUADAS-2. We observed that pooled sensitivity and specificity for detecting deep MI were 65% (95% confidence interval [CI] = 54%-75%) and 85% (95% CI = 79%-89%) for MRI, and 71% (95% CI = 63%-78%) and 76% (95% CI = 67%-83%) for TVS, respectively. No statistical differences were found between both imaging techniques (p > 0.05). We observed low heterogeneity for sensitivity and high for specificity regarding TVS; and moderate for both sensitivity and specificity in case of MRI.

CONCLUSIONS

The diagnostic performance of TVS and MRI for the evaluation of deep MI in women with low-grade endometrioid endometrial cancer is similar. However, further research is needed as the number of studies is scanty.

An implementation of the learning curve cumulative summation test to evaluate a practicum for endometrial cancer ultrasound staging

PURPOSE

The learning curve cumulative summation (LC-CUSUM) test is commonly used as a quantitative assessment of the individual learning process. This study aimed to evaluate the skill acquisition process for performing ultrasound staging of endometrial cancer using the LC-CUSUM test.

METHODS

Sixty-seven ultrasound examinations performed by two operators were evaluated using the LC-CUSUM test according to their rate of success or failure to correctly stage myometrial invasion, serosa involvement, and pelvic and para-aortic lymph node involvement. The reference standard was the pathologic result. After the learning phase, the cumulative summation (CUSUM) test was applied to assess performance maintenance.

RESULTS

The processes achieved satisfactory performance in the majority of the cases according to the established definitions. Operator 1 reached adequate performance within the 30th procedure for all the locations considered, while operator 2 performed fewer than 30 ultrasound examinations by the audit time. The CUSUM test confirmed that the target quality was preserved after the learning phase. Moreover, the ultrasound staging for endometrial cancer was highly accurate.

CONCLUSION

Using the LC-CUSUM test made it possible to monitor the achievement and maintenance of a satisfactory performance quantitatively. The LC-CUSUM test could be a valuable instrument to survey diagnostic pathways in gynecological ultrasonography quantitatively.

Accuracy of transvaginal ultrasound versus MRI in the PreOperative Diagnostics of low-grade Endometrial Cancer (PODEC) study: a prospective multicentre study

AIM

To investigate if the diagnostic accuracy of transvaginal ultrasound (TVUS) performed by gynaecologists is sufficient for preoperative assessment of low-grade endometrial cancer (EC) compared to magnetic resonance imaging (MRI).

MATERIALS AND METHODS

MRI and TVUS performed by gynaecologists were assessed at the participating centres. The MRI examinations were interpreted by two radiologists at the tertiary centre. Deep myometrial and cervical stroma invasion were visually assessed and compared to postoperative histopathology.

RESULTS

Two hundred and fifty-nine patients were included. There was a statistically significant difference in specificity assessing deep myometrial invasion between MRI and TVUS (MRI 0.88, TVUS 0.68). There was no difference in sensitivity (MRI 0.73, TVUS 0.68). When assessing cervical stroma infiltration, MRI had a higher specificity (MRI 0.96, TVUS 0.90), but there was no difference in sensitivity (MRI 0.41, TVUS 0.32).

CONCLUSION

MRI has higher specificity than TVUS performed by gynaecologists for assessing deep MI and CSI in low-grade EC, but similar sensitivities. The use of TVUS as a first-line test, rather than MRI, may be supported by this study in centres where access to MRI may be limited.

Radiomics and Molecular Classification in Endometrial Cancer (The ROME Study): A Step Forward to a Simplified Precision Medicine

Molecular/genomic profiling is the most accurate method to assess prognosis of endometrial cancer patients. Radiomic profiling allows for the extraction of mineable high-dimensional data from clinical radiological images, thus providing noteworthy information regarding tumor tissues. Interestingly, the adoption of radiomics shows important results for screening, diagnosis and prognosis, across various radiological systems and oncologic specialties. The central hypothesis of the prospective trial is that combining radiomic features with molecular features might allow for the identification of various classes of risks for endometrial cancer, e.g., predicting unfavorable molecular/genomic profiling. The rationale for the proposed research is that once validated, radiomics applied to ultrasonographic images would be an effective, innovative and inexpensive method for tailoring operative and postoperative treatment modalities in endometrial cancer. Patients with newly diagnosed endometrial cancer will have ultrasonographic evaluation and radiomic analysis of the ultrasonographic images. We will correlate radiomic features with molecular/genomic profiling to classify prognosis.

IETA Ultrasonic Features Combined with GI-RADS Classification System and Tumor Biomarkers for Surveillance of Endometrial Carcinoma: An Innovative Study

Objectives: We were the first to combine IETA ultrasonic features with GI-RADS and tumor biomarkers for the surveillance of endometrial carcinoma. The aim was to evaluate the efficacy of single IETA ultrasonography GI-RADS classification and combined tumor biomarkers in differentiating benign and malignant lesions in the uterine cavity and endometrium. Methods: A total of 497 patients with intrauterine and endometrial lesions who had been treated surgically between January 2017 and December 2021 were enrolled; all of them had undergone ultrasound examinations before surgery. We analyzed the correlation between the terms of ultrasonic signs of the uterine cavity and endometrial lesions defined by the expert consensus of IETA and the benign and malignant lesions and then classified these ultrasonic signs by GI-RADS. In addition, the tumor biomarkers CA125, CA15-3, CA19-9 and HE4 were combined by adjusting the classification. The results of the comprehensive analysis were compared with pathological results to analyze their diagnostic efficacy. Results: (1) The statistic analysis confirmed that there were seven independent predictors of malignant lesions, including thickened endometrium (premenopause ≥ 18.5 mm, postmenopause ≥ 15.5 mm), non-uniform endometrial echogenicity (heterogeneous with irregular cysts), endometrial midline appearance (not defined), the endometrial-myometrial junction (interrupted or not defined), intracavitary fluid (ground glass or "mixed" echogenicity), color score (3~4 points) and vascular pattern (focal origin multiple vessels or multifocal origin multiple vessels). (2) In traditional ultrasound GI-RADS (U-T-GI-RADS), if category 4a was taken as the cut-off value of benign and malignant, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy were 97.2%, 65.2%, 44.0%, 98.8% and 72.2%, respectively, and the area under the ROC curve (AUC) was 0.812. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 88.1%, 92.0%, 75.6%, 96.5% and 91.2%, 0.900, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.5%, 93.2%, 93.4%, 93.4% and 0.868, respectively, when taking category 5 as the cutoff point. In modified ultrasound GI-RADS (U-M-GI-RADS), if 4a was taken as the cut-off value, The diagnostic efficacy was the same as U-T-GI-RADS. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV, diagnostic accuracy and AUC were 88.1%, 92.3%, 76.2%, 96.5%, 91.3% and 0.902, respectively. If 4c was taken as the cutoff point, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.7%, 94.3%, 93.4%, 93.6% and 0.870, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 66.1%, 99.7%, 98.6%, 91.3%, 92.4% and 0.829, respectively, if taking category 5 as the cutoff point. (3) In the comprehensive diagnostic method of U-T-GI-RADS combined tumor biomarkers results, the AUC of class 4a, 4b and 5 as the cutoff value was 0.877, 0.888 and 0.738, respectively. The AUC of class 4a, 4b, 4c and 5 as the cutoff value in the comprehensive diagnostic method of U-M-GI-RADS combined tumor biomarkers results was 0.877, 0.888, 0.851 and 0.725, respectively. There was no significant difference in diagnostic efficiency between the two comprehensive diagnostic methods. Conclusions: In this study, no matter which diagnostic method was used, the best cutoff value for predicting malignant EC was ≥GI-RADS 4b. The GI-RADS classification had good performance in discriminating EC. The tumor biomarkers, CA125, CA19-9, CA15-3 and HE4, could improve the diagnostic efficacy for preoperative endometrial carcinoma assessment.

Incorporation of Tumor-Free Distance and Other Alternative Ultrasound Biomarkers into a Myometrial Invasion-Based Model Better Predicts Lymph Node Metastasis in Endometrial Cancer: Evidence and Future Prospects

Myometrial invasion (MI) is a parameter currently used in transvaginal ultrasound (TVS) in endometrial cancer (EC) to determine local staging; however, without molecular diagnostics, it is insufficient for the selection of high-risk cases, i.e., those with a high risk of lymph node metastases (LNM). The study’s objective was to answer the question of which TVS markers, or their combination, reflecting the molecular changes in EC, can improve the prediction of LNM. Methods: The TVS examination was performed on 116 consecutive EC patients included in this prospective study. The results from the final histopathology were a reference standard. Univariate and multivariate logistic models of analyzed TVS biomarkers (tumor [T] size, T area [AREA], T volume [SPE-VOL], MI, T-free distance to serosa [TFD], endo-myometrial irregularity, [EMIR], cervical stromal involvement, CSI) were evaluated to assess the relative accuracy of the possible LNM predictors., Spline functions were applied to avoid a potential bias in assuming linear relations between LNM and continuous predictors. Calculations were made in R using libraries splines, glmulti, and pROC. Results: LNM was found in 20 out of the 116 (17%) patients. In univariate analysis, only uMI, EMIR, uCSI and uTFD were significant predictors of LNM. The accuracy was 0.707 (AUC 0.684, 95% CI 0.568−0.801) for uMI (p < 0.01), 0.672 (AUC 0.664, 95% CI 0.547−0.781) for EMIR (p < 0.01), 0.776 (AUC 0.647, 95% CI 0.529−0.765) for uCSI (p < 0.01), and 0.638 (AUC 0.683, 95% CI 0.563−0.803) for uTFD (p < 0.05). The cut-off value for uTFD was 5.2 mm. However, AREA and VOL revealed a significant relationship by nonlinear analysis as well. Among all possible multivariate models, the one comprising interactions of splines of uTFD with uMI and splines of SPE-VOL with uCSI showed the most usefulness. Accuracy was 0.802 (AUC 0.791, 95% CI 0.673−0.91) Conclusions: A combination of uTFD for patients with uMI > 50%, and SPE-VOL for patients with uCSI, allows for the most accurate prediction of LNM in EC, rather than uMI alone.

Is preoperative ultrasound tumor size a prognostic factor in endometrial carcinoma patients?

Objective

We aimed to assess the prognostic value of preoperative ultrasound tumor size in EC through a single center, observational, retrospective, cohort study.

Methods

Medical records and electronic clinical databases were searched for all consecutive patients with EC, preoperative ultrasound scans available to ad hoc estimate tumor size, and a follow-up of at least 2-year, at our Institution from January 2010 to June 2018. Patients were divided into two groups based on different dimensional cut-offs for the maximum tumor diameter: 2, 3 and 4 cm. Differences in overall survival (OS), disease specific survival (DSS) and progression-free survival (PFS) were assessed among the groups by using the Kaplan-Meier estimator and the log-rank test.

Results

108 patients were included in the study. OS, DSS and PFS did not significantly differ between the groups based on the different tumor diameter cut-offs. No significant differences were found among the groups sub-stratified by age, BMI, FIGO stage, FIGO grade, lymphovascular space invasion status, myometrial invasion, lymph nodal involvement, histotype, and adjuvant treatment.

Conclusions

Preoperative ultrasound tumor size does not appear as a prognostic factor in EC women.

A prospective comparison of the diagnostic accuracies of ultrasound and magnetic resonance imaging in preoperative staging of endometrial cancer

OBJECTIVE

To compare the diagnostic accuracies of ultrasound and magnetic resonance imaging (MRI) for deep (≥50%) myometrial invasion (DMI) and cervical stromal invasion (CSI) in women with endometrial cancer.

METHODS

This was a prospective study at a gynecology clinic for women with postmenopausal bleeding. Between October 2015-October 2018, consecutive women with suspected endometrial cancer based on ultrasound subjective pattern recognition were simultaneously assessed for DMI and CSI on ultrasound. Subsequently, they also underwent preoperative MRI. We compared the diagnostic accuracies of ultrasound and MRI in predicting DMI and CSI with the final histology as the gold standard.

RESULTS

We included 51 women. The prevalence of DMI and CSI were 22/51 (43%) and 7/51 (14%), respectively. The majority of malignancies were of endometrioid histological subtype (38/51, 75%) and FIGO stage 1 or 2 (40/51, 78%). Ultrasound diagnosed more cases of DMI compared to MRI (19/22 vs. 17/22), however, the difference was not statistically significant. The sensitivities and specificities of ultrasound and MRI for DMI were 86% vs. 77% and 66% vs. 76%, respectively. For CSI, ultrasound and MRI correctly diagnosed the same number of cases (5/7, 71%); their respective false-positive rates were low, 0/44 (0%) and 1/44 (2%). Ultrasound and MRI had a moderate agreement for DMI (ƙ=0.49; 95% confidence interval [CI]=0.26-0.73), whereas the agreement for CSI was substantial (ƙ=0.69; 95% CI=0.36-1.00).

CONCLUSION

Endometrial cancer can be simultaneously diagnosed and staged at women's initial ultrasound assessment. The accuracies of ultrasound for DMI and CSI are comparable to MRI.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN24363390.

Transvaginal Ultrasound Versus Magnetic Resonance Imaging for Assessing Myometrial Infiltration in Endometrioid Low Grade Endometrial Cancer: A Prospective Study

OBJECTIVE

To compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for assessing myometrial infiltration (MI) in patients with low grade endometrioid endometrial cancer.

METHODS

Observational prospective study performed at a single tertiary care center from 2016 to 2020, comprising 156 consecutive patients diagnosed by endometrial sampling as having an endometrioid grade 1/grade 2 endometrial cancer. TVS and MRI were performed prior to surgical staging for assessing MI, which was estimated using subjective examiner's impression and Karlsson's method for both TVS and MRI. During surgery, intraoperative assessment of MI was also performed. Definitive pathological study considered as reference standard. Diagnostic accuracy for ultrasound, MRI, and intraoperative biopsy was estimated and compared.

RESULTS

Sensitivity and specificity of TVS for detecting deep MI were 75 and 73.5% for subjective impression and 65 and 70% for Karlsson method, respectively (P = .54). Sensitivity and specificity of MRI for detecting deep MI were 80 and 87% for subjective impression and 70 and 71.3% for Karlsson method. MRI subjective impression showed a significant better specificity than MRI Karlsson method (P = .03). MRI showed better specificity than TVS when subjective impression was considered (P <.05), but not for Karlsson method. Sensitivity and specificity of intraoperative were 75 and 97%, respectively. Intraoperative biopsy showed better specificity than ultrasound and MRI either using examiner's impression or Karlsson method (P <.05).

CONCLUSIONS

MRI revealed a significant higher specificity than TVS when assessing deep myometrial infiltration. However, the intraoperative biopsy offers a significant better diagnostic accuracy than preoperative imaging techniques.

Fusion imaging in preoperative assessment of extent of disease in patients with advanced ovarian cancer: feasibility and agreement with laparoscopic findings

OBJECTIVES

Fusion imaging is an emerging technique that combines real-time ultrasound examination with images acquired previously using other modalities, such as computed tomography (CT), magnetic resonance imaging and positron emission tomography. The primary aim of this study was to evaluate the feasibility of fusion imaging in patients with suspicion of ovarian or peritoneal cancer. Secondary aims were: to compare the agreement of findings on fusion imaging, CT alone and ultrasound imaging alone with laparoscopic findings, in the assessment of extent of intra-abdominal disease; and to evaluate the time required for the fusion imaging technique.

METHODS

Patients with clinical and/or radiographic suspicion of advanced ovarian or peritoneal cancer who were candidates for surgery were enrolled prospectively between December 2019 and September 2020. All patients underwent a CT scan and ultrasound and fusion imaging to evaluate the presence or absence of the following abdominal-cancer features according to the laparoscopy-based scoring model (predictive index value (PIV)): supracolic omental disease, visceral carcinomatosis on the liver, lesser omental carcinomatosis and/or visceral carcinomatosis on the lesser curvature of the stomach and/or spleen, involvement of the paracolic gutter(s) and/or anterior abdominal wall, involvement of the diaphragm and visceral carcinomatosis on the small and/or large bowel (regardless of rectosigmoid involvement). The feasibility of the fusion examination in these patients was evaluated. Agreement of each imaging method (ultrasound, CT and fusion imaging) with laparoscopy (considered as reference standard) was calculated using Cohen's kappa coefficient.

RESULTS

Fifty-two patients were enrolled into the study. Fusion imaging was feasible in 51 (98%) of these patients (in one patient, it was not possible for technical reasons). Two patients were excluded because laparoscopy was not performed, leaving 49 women in the final analysis. Kappa values for CT, ultrasound and fusion imaging, using laparoscopy as the reference standard, in assessing the PIV parameters were, respectively: 0.781, 0.845 and 0.896 for the great omentum; 0.329, 0.608 and 0.847 for the liver surface; 0.472, 0.549 and 0.756 for the lesser omentum and/or stomach and/or spleen; 0.385, 0.588 and 0.795 for the paracolic gutter(s) and/or anterior abdominal wall; 0.385, 0.497 and 0.657 for the diaphragm; and 0.336, 0.410 and 0.469 for the bowel. The median time needed to perform the fusion examination was 20 (range, 10-40) min.

CONCLUSION

Fusion of CT images and real-time ultrasound imaging is feasible in patients with suspicion of ovarian or peritoneal cancer and improves the agreement with surgical findings when compared with ultrasound or CT scan alone. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Combination IETA Ultrasonographic Characteristics Simple Scoring Method With Tumor Biomarkers Effectively Improves the Differentiation Ability of Benign and Malignant Lesions in Endometrium and Uterine Cavity

Objectives

To evaluate International Endometrial Tumor Analysis (IETA) ultrasonographic characteristics simple scoring method and tumor biomarkers for the diagnosis of uterine cavity and endometrial lesions.

Methods

We classified and scored the normalized description of IETA ultrasonic characteristics, according to IETA expert consensus literature, previous IETA-related research articles, and the previous research experience of this project group. We conducted a retrospective analysis of the ultrasound images of 594 patients enrolled from January 2017 to June 2020, scored them item by item, and finally calculated the total score of each case. Meanwhile, we combined the results of seven tumor biomarkers. The objective was to evaluate the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve of IETA ultrasonographic characteristics simple scoring method and tumor biomarkers for benign and malignant uterine cavity or endometrial lesions. The diagnostic efficiency between the combined method and the single method was compared.

Results

A total of 594 cases were confirmed by postoperative pathology or surgery records, including 475 benign lesions and 119 malignant lesions. In the simple ultrasound scoring method, the average score of benign lesions was 3.879 ± 1.279 and that of malignant lesions was 9.676 ± 4.491. If ≥6.5 points was taken as the cutoff value for the judgment of malignant lesions, the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve (AUC) were 76.5%, 96.0%, 92.1%, and 0.935, respectively. The difference in tumor antigen 19-9 (CA19-9) and human epididymal protein 4 (HE4) between benign and malignant lesions was statistically significant (all p ≤ 0.01). The other five tumor biomarkers (CA125, CA15-3, SCC-Ag, AFP, and CEA) showed no statistically significant difference in benign and malignant lesions. If the value of CA19-9 ≥13.96 U/ml was taken as cutoff value, the sensitivity, specificity, and coincidence rate of the diagnosis of endometrial benign and malignant lesions were 54.8%, 74.7%, and 70.7%, respectively, and the AUC was 0.620. If the value of HE4 ≥ 39.075 pmol/L was taken as cutoff point, the sensitivity, specificity, coincidence rate, and AUC were 77.4%, 67.9%, 69.8%, and 0.796, respectively. The sensitivity was increased to 97.6% and the AUC was 0.939 when IETA ultrasound characteristics simple scoring method combined CA19-9 and HE4 in parallel test.

Conclusions

In IETA ultrasound characteristics simple scoring method, with ≥6.5 points as the cutoff value, it could quickly and accurately assess the benign and malignant in uterine cavity and endometrial lesions, with high diagnostic value. The diagnostic efficacy of seven tumor biomarkers was all mediocre. Combining with these two methods, the comprehensive diagnosis could improve sensitivity and accuracy and reduce the risk of missed diagnosis.

Diagnostic performance of transvaginal ultrasound and magnetic resonance imaging for preoperative evaluation of low-grade endometrioid endometrial carcinoma: prospective comparative study

OBJECTIVE

To compare the diagnostic performance of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the prediction of deep myometrial invasion (DMI) and cervical stromal invasion (CSI) in patients with low-grade (Grade 1 or 2) endometrioid endometrial cancer (EEC).

METHODS

This was a prospective study including all patients with low-grade EEC diagnosed between October 2013 and July 2018 at the Vall d'Hebron Hospital in Barcelona, Spain. Preoperative staging was performed using TVS and MRI, followed by surgical staging. Final histology was considered as the reference standard. Sensitivity, specificity, likelihood ratios and diagnostic accuracy were calculated for both imaging techniques in the prediction of DMI and CSI, and the agreement index was calculated for both techniques. The STARD 2015 guidelines were followed.

RESULTS

A total of 131 patients with low-grade EEC were included consecutively. Sensitivity was higher for TVS than for MRI both for the prediction of DMI (69% (95% CI, 53-82%) vs 51% (95% CI, 36-66%), respectively) and CSI (43% (95% CI, 27-61%) vs 24% (95% CI, 12-41%), respectively). Specificity was similar for TVS and MRI in the prediction of DMI (87% (95% CI, 78-93%) vs 91% (95% CI, 82-96%)) and equal in the prediction of CSI (97% (95% CI, 91-99%) for both). The agreement index between TVS and MRI was 0.84 (95% CI, 0.76-0.90) for DMI and 0.92 (95% CI, 0.85-0.96) for CSI.

CONCLUSIONS

The diagnostic performance of TVS is similar to that of MRI for the prediction of DMI and CSI in low-grade EEC, and TVS can play a role as a first-line imaging technique in the preoperative evaluation of low-grade EEC. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group

In centers with access to high-end ultrasound machines and expert sonologists, ultrasound is used to detect metastases in regional lymph nodes from melanoma, breast cancer and vulvar cancer. There is, as yet, no international consensus on ultrasound assessment of lymph nodes in any disease or medical condition. The lack of standardized ultrasound nomenclature to describe lymph nodes makes it difficult to compare results from different ultrasound studies and to find reliable ultrasound features for distinguishing non-infiltrated lymph nodes from lymph nodes infiltrated by cancer or lymphoma cells. The Vulvar International Tumor Analysis (VITA) collaborative group consists of gynecologists, gynecologic oncologists and radiologists with expertise in gynecologic cancer, particularly in the ultrasound staging and treatment of vulvar cancer. The work herein is a consensus opinion on terms, definitions and measurements which may be used to describe inguinal lymph nodes on grayscale and color/power Doppler ultrasound. The proposed nomenclature need not be limited to the description of inguinal lymph nodes as part of vulvar cancer staging; it can be used to describe peripheral lymph nodes in general, as well as non-peripheral (i.e. parietal or visceral) lymph nodes if these can be visualized clearly. The association between the ultrasound features described here and histopathological diagnosis has not yet been established. VITA terms and definitions lay the foundations for prospective studies aiming to identify ultrasound features typical of metastases and other pathology in lymph nodes and studies to elucidate the role of ultrasound in staging of vulvar and other malignancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Preoperative prediction of high-risk endometrial cancer by expert and non-expert transvaginal ultrasonography, magnetic resonance imaging, and endometrial histology

OBJECTIVE

To identify women with high-risk endometrial cancers using expert and non-expert transvaginal ultrasonography (TVS) and MRI.

STUDY DESIGN

Myometrial involvement was prospectively evaluated in patients with atypical hyperplasia or endometrial cancer on ultrasound by non-experts at first visit (non-expert-TVS: n = 266) and experts (expert-TVS: n = 188) at second visit. MRI (n = 175) was performed when high-risk cancer was suspected on non-expert-TVS. Preoperatively, high-risk cancer was defined as myometrial involvement ≥50 %, or preoperative unfavorable tumor histology (grade 3 endometrioid, non-endometrioid tumors, or tumor in cervical biopsies) obtained by endometrial sampling or hysteroscopic biopsies. Preoperative evaluations were compared with final histopathology obtained at surgery, high-risk cancer being defined as unfavorable tumor histology or patients with FIGO stage ≥1b.

RESULTS

Preoperative unfavorable tumor histology was seen in 64 women and correctly identified 63 of 128 high-risk cancers. Preoperative diagnosis of unfavorable tumor histology or myometrial involvement ≥50 %, i.e. judged high-risk, had an area under the curve (AUC), sensitivity, and specificity of 79.5 %, 93.8 %, 65.2 % on non-expert-TVS; 85.5 %, 84.4 %, 86.5 % on expert-TVS, and 85.4 %, 89.6 %, 81.2 % on MRI. AUC values were not significantly different between MRI and expert-TVS, but lower on non-expert-TVS (p < 0.02). However, sensitivity was highest on non-expert-TVS, where a low cutpoint for myometrial involvement was used (included potentially deep and difficult evaluations) in contrast to an exact cutpoint of myometrial involvement ≥50 % used on expert-TVS and MRI. The highest AUC, 88.6 %, was seen when MRI was performed in patients with myometrial involvement ≥50 %, determined on non-expert TVS. Sensitivity was reduced to 85.9 %, while specificity increased to 91.3 %. Thus, MRI was needed for risk classification in only 104 (39 %) patients.

CONCLUSION

Diagnostically, expert-TVS and MRI were comparable and superior to non-expert-TVS. However, non-expert-TVS classified all patients with unclear myometrial involvement ≥50 %, and thereby only misdiagnosed 6.2 % of high-risk cases. Non-expert-TVS combined with MRI when myometrial involvement was ≥50 % on non-expert-TVS was a simple and effective method comparable with expert imaging to identify low- and high-risk cancer and select patients for SLND. Addition of MRI to the diagnostic regimen was needed in only 39 % of our patients.

Risk Assessment of Endometrial Hyperplasia or Endometrial Cancer with Simplified Ultrasound-Based Scoring Systems

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.

Immunohistochemical Markers in Endometrial Cancer

In 2018, 382,069 new cases of uterine cancer were registered worldwide and 89,929 deaths from this cancer were reported [...].

Dynamic contrast-enhanced ultrasound improves diagnostic performance in endometrial cancer staging

OBJECTIVES

To compare the sensitivity and specificity of conventional two-dimensional transvaginal ultrasound/power Doppler (2D-TVU/PD) alone and 2D-TVU/PD combined with dynamic contrast-enhanced ultrasound (DCE-US) in diagnosing deep myometrial invasion (MI) and cervical stromal involvement (CSI) in women with endometrial cancer (EC), and to assess the association of DCE-US semiquantitative and qualitative variables with International Federation of Gynecology and Obstetrics (FIGO) Stage ≥ IB and 'high-risk' cancer.

METHODS

This was a prospective study of 101 consecutive women with biopsy-confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, a tertiary referral center. All consenting women underwent DCE-US using a 1.5-2.5-mL intravenous bolus of SonoVue contrast agent, as well as conventional 2D-TVU/PD examination. DCE-US videoclips were analyzed with regard to filling (global or focal), wash-in (prior, simultaneous or after) and wash-out (global or focal) patterns of the contrast agent in the tumor compared with the surrounding tissue, as well as semiquantitative DCE-US parameters (wash-in slope, time-to-peak, peak intensity and area under the time-intensity curve (TIC)) obtained from a TIC. The study cohort was compared with a control cohort of women with EC examined at our center according to the International Endometrial Tumor Analysis protocol using 2D-TVU/PD only, matched at a ratio of 3:1 for FIGO stage and grade. The sensitivity and specificity of 2D-TVU/PD alone in the control cohort and in combination with DCE-US in the study cohort in the diagnosis of deep MI, CSI and high-risk cancer (defined as FIGO Stage ≥ IB and/or Grade 3 endometrioid and/or non-endometrioid histology) were compared, using pathological evaluation after hysterectomy as the 'gold standard'.

RESULTS

After exclusions, 93 women were included in the study cohort and were matched to 279 women in the control cohort. The prevalence of FIGO Stage IA, Grade 1-2 EC was 52% in both cohorts. The sensitivity of 2D-TVU/PD with DCE-US in the study cohort was higher than that of 2D-TVU/PD alone in the control cohort in diagnosing both deep MI (0.74 vs 0.62; P = 0.036) and CSI (0.75 vs 0.51; P < 0.001), whereas the specificity was not significantly different (0.87 vs 0.85 and 0.96 vs 0.95, respectively). Compared with 2D-TVU/PD alone, the specificity of 2D-TVU/PD with DCE-US was higher in detecting high-risk cancer (0.94 vs 0.85; P = 0.024) but the sensitivity did not differ (0.73 vs 0.71). High-risk cancer and FIGO Stage ≥ IB were characterized by a 'focal' filling pattern, with a 'prior' wash-in pattern and a 'focal' wash-out pattern on subjective assessment of DCE-US videoclips. All semiquantitative DCE-US parameters were significantly predictive of FIGO Stage ≥ IB but not of high-risk cancer, despite a clear trend.

CONCLUSIONS

Compared with 2D-TVU/PD alone, combining 2D-TVU/PD with DCE-US can significantly improve the detection of deep MI and CSI in women with EC, without increasing the false-positive rate. It can also improve the correct classification of high-risk disease, mainly by increasing specificity, thereby possibly reducing the number of unnecessarily extensive surgeries by almost 10%. Semiquantitative DCE-US parameters, as well as a 'focal' filling pattern, endometrial wash-in prior to the myometrium and a 'focal' wash-out pattern, are all associated with more advanced disease. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Nonpuerperal Uterine Inversion: What the Gynaecologists Need to Know?

Introduction

Nonpuerperal uterine inversion (NPUI) is a rare clinical problem with diagnostic and surgical challenges. The objective of our study was to review the literature on NPUI and describe causative pathologies, diagnosis, and different surgical options available for treatment.

Materials and Methods

A comprehensive literature review was carried out on MEDLINE and Google Scholar databases to look for NPUI using the term “non-puerperal uterine inversion,” and further went through the cross-references of the published articles. Data are published case reports from 1911 to September 2018. Of the 153 published cases, 133 reports had adequate details of surgery for analysis. These reports were analyzed, concerning the clinical presentation, methods of diagnosis, and surgical treatment.

Results

Mean age of the women was 46.3 years (standard deviation: 18, N = 153). Leiomyoma remained the commonest (56.2%) aetiology. While malignancies contributed to 32.02% of cases, 9.2% were idiopathic. High degree of clinical suspicion and identification of unique features on ultrasonography and magnetic resonance imaging enable prompt diagnosis. In cases of uncertainty, laparoscopy or biopsy of the mass was used to confirm the diagnosis. Hysterectomy or repositioning and repair of the uterus are the only treatment options available. The surgical methods implemented were analyzed in three aspects: route of surgical access, method of repositioning, and final surgical procedure undertaken. The majority (48.8%) had only abdominal access, while 27.1% had both abdominal and vaginal access. Haultain procedure was the most useful procedure for reposition (18.0%) of the uterus. The majority (39.7%) required abdominal hysterectomy with or without debulking of the tumour abdominally, while 15.0% had uterine repair after repositioning. We reviewed the different surgical techniques and described and proposed a treatment algorithm.

Conclusions

Fibroids were the commonest cause for NPUI. Malignancies accounted for one-third of cases. A combined abdominal and vaginal approach, followed by hysterectomy or repair after repositioning, seems to be better for nonmalignant cases.