Evaluation of pretreatment transvaginal ultrasonography in the management of patients with endometrial carcinoma

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.

[Preoperative endovaginal ultrasound in the assessment of myometrial invasion of endometrial adenocarcinoma]

OBJECTIVE

To determine, according to histological tumor grade, the reliability of preoperative endovaginal ultrasound in the detection of myometrial invasion in patients with stage I endometrial cancer.

PATIENTS AND METHODS

Sixty-one patients with stage I endometrial carcinoma were evaluated with preoperative endovaginal ultrasound compared to postoperative results of pathologic examination, in a six-year retrospective study.

RESULTS

Twenty-nine patients had a deep myometrial invasion (stage IC). The mean endometrial thickness was 9.5 mm in stage IA, 17.0 mm in stage IB and 20.0 mm in stage IC disease (P = 0.01). The sensitivity and the specificity of the ultrasound in the assessment of myometrial invasion in grade 1 tumors were 100% and 93.7%, respectively. They fell to 69.2% and 88.9% for high-grade tumors. The global accuracy of ultrasound was 82%.

DISCUSSION AND CONCLUSIONS

The performance of preoperative ultrasound varies according to the literature. The association of morphological and morphometric criteria enables an increase in the sensitivity of the exam. In grade 1 tumors, the preoperative endovaginal ultrasound could help in identifying a group of patients at low risk of lymph node metastasis for which a pelvic lymphadenectomy would be avoidable.

Early detection of endometrial cancer by combined use of vaginal ultrasound and endometrial vacuum sampling

With increasing lifespan and decreased incidence of uterine cervical cancer, the importance of the proper and early diagnosis of endometrial cancer has become a demand to gynecology. The objective of the present study is to evaluate the effectiveness of gynecologic diagnostic tools in detection of endometrial cancer in early stage. The patients (72) involved in the study, after giving their informed consent, were investigated by transvaginal ultrasound and subsequent vacuum endometrial sampling in office settings. Whenever the histology examination of endometrial vacuum sampling showed hyperplasia or carcinoma, it was reassured by sampling with dilatation and curettage. The analysis of sonography and histology results showed that in 4 cases (5.6%) endometrial hyperplasia and in two cases (2.8%) endometrial adenocarcinoma were present. Also analyzed were sensitivity, specificity, positive and negative predictive values for histology results and for sonographic findings. These results show that transvaginal ultrasound is a reliable method for screening for endometrial carcinoma. Moreover, in the case of pathologic endometrial change suspected by ultrasound, the combination of vacuum endometrial sampling with ultrasound examination can yield firm diagnosis in office settings, saving cost and time in early diagnosis of endometrial cancer.

Preoperative selection of patients with low-stage endometrial cancer at high risk of pelvic lymph node metastases

The goal of this study was to determine diagnostic accuracy of preoperative transvaginal sonography (TVS) to assess myometrial infiltration in patients with endometrial cancer and to determine the possibility of preoperatively selecting low-stage endometrial cancer patients at high risk of lymph node metastases. The depth of myometrial infiltration of endometrial cancer was assessed using TVS before or after curettage. Infiltration was classified as superficial if less than half of the myometrium was involved, otherwise it was classified as deep infiltration. Results were compared with the histology results of the definitive specimens. Patients were classified as high risk when they satisfied two of the following three criteria: 60 years of age or older; deep myometrial infiltration; and poorly differentiated or undifferentiated tumor. A total of 93 patients from 11 clinics were analyzed. The mean age was 66.1 years (SD +/- 11.4). The sonography and histology findings were in agreement in 69 of 93 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), of "deep infiltration" by preoperative TVS were 79% (95% CI 0.65-0.93), 72% (95% CI 0.61-0.83), 61% (95% CI 0.46-0.75), and 86% (95% CI 0.76-0.96), respectively. Combining tumor grade and myometrial infiltration in the hysterectomy specimen and age, 30 of 81 patients were classified as high-risk patients. Sensitivity and PPV, specificity, and NPV for preoperative diagnosis of high risk were 80% (95% CI 0.65-0.94) and 88% (95% CI 0.79-0.97), respectively. Preoperative assessment of myometrial tumor infiltration using just TVS is only moderately reliable in endometrial cancer patients. If the results of TVS, however, are combined with the patient's age and the degree of tumor differentiation in curettings, it is possible to preoperatively select endometrial cancer patients with a high risk of pelvic lymph node metastases with sufficient reliability.

Frequency and determinants of lymphadenectomy in endometrial carcinoma: a population-based study from northern Italy

BACKGROUND

The diffusion of pelvic and para-aortic lymphadenectomy for the surgical pathological staging of endometrial carcinoma into clinical practice has been evaluated only with questionnaire surveys of gynecological oncologists. No population-based information is available.

METHODS

In this study of operable endometrial carcinoma cases registered by the population-based Romagna Cancer Registry (northern Italy) between 1987 and 1994, the association of demographic (age, time period, place of birth, place of residence, place of treatment, and marital status) and pathological factors (histological type, tumor grade, myoinvasion, and extension of disease to cervix, serosa, adnexa, and vagina) with the probability of lymphadenectomy was evaluated by multiple logistic regression analysis.

RESULTS

Of the 300 potentially eligible cases, sufficient information was obtained for 276 (92%; median age, 63 years; range, 33-87 years). No case of para-aortic lymphadenectomy was observed. Pelvic lymphadenectomy was performed in 86 (31%) cases. The probability of pelvic lymphadenectomy was related to tumor grade (positive association), place of treatment, and marital status. All other variables, including myoinvasion and extension of disease to the cervix and beyond the uterus, had no effect whatsoever.

CONCLUSIONS

The most likely interpretations of results include poor acceptance of current surgical pathological staging criteria and insufficient use of standard diagnostic techniques for preoperative and intraoperative assessment of myoinvasion and extrauterine spread.

Radiologic staging in patients with endometrial cancer: a meta-analysis

PURPOSE

To apply a meta-analysis to compare the utility of computed tomography (CT), ultrasonography (US), and magnetic resonance (MR) imaging in staging endometrial cancer.

MATERIALS AND METHODS

Data were obtained from a MEDLINE literature search and from manual reviews of article bibliographies. Articles were selected that included results in patients with proved endometrial cancer and imaging-histopathologic correlation and that presented data that allowed calculation of contingency tables. Data for the imaging evaluation of myometrial and cervical invasion were abstracted independently by two authors. Data on year of publication, International Federation of Gynecology and Obstetrics (FIGO) stage distribution, and methodologic quality were also collected. A subgroup analysis was performed to compare contrast medium-enhanced MR imaging with nonenhanced MR imaging, US, and CT.

RESULTS

Six studies met the inclusion criteria for CT; 16, for US; and 25, for MR imaging. Summary receiver operating characteristic analysis showed no significant differences in the overall performance of CT, US, and MR imaging. In the assessment of myometrial invasion, however, contrast-enhanced MR imaging performed significantly better than did nonenhanced MR imaging or US (P < .002) and demonstrated a trend toward better results, as compared with CT. The lack of data on the assessment of cervical invasion at CT or US prevented meta-analytic comparison with data obtained at MR imaging. Results were not influenced by year of publication, FIGO stage distribution, or methodologic quality.

CONCLUSION

Although US, CT, or MR imaging can be used in the pretreatment evaluation of endometrial cancer, contrast-enhanced MR imaging offers "one-stop" examination with the highest efficacy.

Transvaginal sonography and hysteroscopy in women with postmenopausal bleeding

OBJECTIVE

To make a prospective comparison between endometrial thickness determined by transvaginal sonography (TVS) and hysteroscopic findings in women with postmenopausal bleeding with histologic findings obtained by dilatation and curettage (D&C).

METHODS

Eighty-one patients who had not received hormonal replacement therapy were scanned by transvaginal probe, and double-layer endometrial thickness was measured 1 day before hysterectomy and D&C.

RESULTS

The histologic diagnosis was atrophy in 12 cases, irregular proliferative changes in 21, endometrial polyps in 16 hyperplasia in 16 and endometrial carcinoma in 16. TVS detected 46 of 48 pathologic conditions, including all cases of endometrial carcinoma if the endometrial thickness (both layers) was > or = 5 mm (sensitivity 95.8%, specificity 4.5%). Hysteroscopy also detected the endometrial pathology in 46 of 48 cases but with a higher specificity (sensitivity 95.3%, specificity 93.9%).

CONCLUSION

TVS and hysteroscopy are complementary diagnostic methods and could be accurately used to discriminate normal and pathologic conditions in patients with postmenopausal bleeding.

Transvaginal ultrasonography for identifying endometrial pathology in postmenopausal women

The objective of this study was to evaluate the usefulness of transvaginal ultrasonography in postmenopausal women with a clinical indication for a dilatation and curettage (D&C). Of the 167 postmenopausal women included in the study, 88% were referred for a D&C because of vaginal bleeding and 12% of the women had other clinical indications such as myomas, gynecological pain or suspected gynecological tumors. Hormone replacement therapy (HRT) was used by 37% of the women. The women were examined with transvaginal ultrasonography before the D&C. The endometrial thickness and texture were used as indicators of endometrial abnormalities. The ultrasonographical findings were related to the histological diagnosis obtained from the D&C. Histologically, 31% of the women had an atrophic endometrium and the corresponding ultrasonographically mean endometrial thickness was 4.6 mm (range 0-14 mm). Endometrial cancer was histologically found in 10% of the women and the endometrial thickness of the malignant endometrium, measured by ultrasonography, was 13.9 mm (range 6-31 mm). All the malignancies were found in the group of women with vaginal bleeding, but only one was in the group of women on HRT. Histologically, endometrial hyperplasia was found in 6.5% of the women and endometrial polyps in 8.5% after the D&Cs. In these postmenopausal women it was demonstrated that if the endometrium was < 6 mm thick, no endometrial cancer was found at histopathological investigation. By using a cut-off point of 6 mm of ultrasonographically measured endometrial thickness for identification of endometrial pathology in our study, at least 50% of the D&Cs could be spared.

Preoperative sonographic evaluation of patients with endometrial carcinoma

OBJECTIVE

The aim of the study was to evaluate the possibilities of endovaginal ultrasound in the preoperative clinical assessment of patients with endometrial carcinoma.

METHOD

Sixty-four postmenopausal women with a diagnosis of endometrial carcinoma after dilatation and curettage were scanned before operation with a 7.5-MHz endovaginal probe.

RESULTS

The location of the process and depth of myometrial invasion were estimated correctly in the vast majority of patients. Spread beyond the uterus and distance from the serosa could not be estimated precisely.

CONCLUSION

Preoperative evaluation and staging of endometrial carcinoma are possible and useful for gynecologists, as they provide information on tumor location, depth of myometrial invasion, and involvement, if present, of the lower uterine segment or cervix.

Seeking early medical attention after vaginal bleeding will not assure mild disease in postmenopausal endometrial carcinoma

We compared the length of time between the onset of vaginal bleeding and (1) initial visit to a physician and (2) hysterectomy in patients with endometrial carcinoma (mild vs advanced disease). There was no difference in these times. We conclude that patients with advanced endometrial carcinoma do not delay seeking medical attention when compared with patients with mild disease.