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Title: Application of two-dimensional (2D) and three-dimensional (3D)ultrasound in preoperative staging of endometrial cancer


Introduction: Endometrial cancer is one of the most frequent malignancies in female patients. Morbidity and mortality rates vary and are heavily dependent on the economic status. The most frequent histological type, known as endometroid adenocarcinoma, represents nearly 80% of cases, and is associated with high estrogen levels. As a well-differentiated malignancy, endometroid cancer presents good prognosis. However, due to the advanced patients’ age and additional medical conditions at the time of diagnosis, the risk of treatment complications is significantly increased. The management of choice is surgery. Clinical staging (anatomical extent of the tumour) at diagnosis and optimal treatment planning are extremely important prognostic factors for patients with endometrial cancer. Final staging is always set after surgery and pathological: evaluation. However preoperative preliminary assessment of the tumour extent is even more significant, for the clinical point of view, to optimize patient treatment. For this purpose, a variety of imaging modalities, especially computed tomography (CT), magnetic resonance imaging (MRI), and also positron emission tomography (PET CT) used in countries with better funding for health care, is applies. In recent years, transvaginal ultrasound (TUS) became comparable and useful technique in preoperative preliminary staging of the disease. Objective ; s: The aim of this study was to evaluate the diagnostic performance of two - dimensional (2D) and three - dimensional (3D) ultrasound in the preoperative staging of endometrial cancer and to propose combined transvaginal and transabdominal ultrasound protocol with three-dimensional modalities applied in order to optimize the diagnosis. Methods: 87 women diagnosed with endometroid adenocarcinoma were enrolled in this study. GE Healthcare Voluson E6 BT12 system with volumetric endocavitary, transabdominal and linear probes was utilized. Before surgery transvaginal and transabdominal ultrasound scans were performed in each patient to assess local extent of the tumour (myometrial and cervical involvement). Following measurements, adopted from the literature or modified by the author, were applied in the myometrial invasion assessment: maximal endometrial thickness and the antero- posterior (AP) uterine diameter ratio in longitudinal uterine section in 2D and -3D imaging (method 1 and 2), the deepest myometrial invasion distance and uterine wall thickness ratio in longitudinal uterine section in 2D and 3D imaging (method 3 and 4), tumour - free distance from serosa (TFD) in 2D and 3D imaging (method 5 and 6), tumour and uterine corpus volume ratio in 3D (method 7). Deep myometrial invasion was defined if the ratio was more than 50% or the TFD less than 10mm. Basing on the own experi ; ence a new technique (method 8), for the myometrial invasion assessment, was introduced in this study. Following criteria characterized author’s method: 1) type of endometrial - myometrial junction, 2) ratio of the deepest myometrial invasion distance and the uterine wall thickness in longitudinal section in 3D, 3) bright edge of the endometrial - myometrial junction which characterizes polypoid type of growth, 4) cervical stromal invasion, 5) Power Doppler assessment of the endometrium. All features were based on the volumetric images depicted by means of multiplanar view enhanced with volume contrast imaging (MPV VCI static). Five criteria were presented in the form of a scoring system. Total number of points equal to or greater than 9 was considered as a threshold for deep myometrial infiltration. Cervical stromal involvement was analysed in 3D volumes containing full information about corpus and uterine cervix. Infiltration was identified if the tumour extends internal os of the cervix and covers cervical stroma. Evaluation of the distal tumour extent consists of serosa and adnexa state assessment, vaginal and parametrial state, lymph node metastasis, urinary bladder, rectum state and distal metastasis. Results: 87 patients were evaluated. The average age of the subjects was 62 years, mean body weight 83 kg, mean body mass index exceeds 30. Before the time of diagnosis, nea ; rly 80% of patients demonstrated vaginal bleeding. Basing on the pathological reports 47 (54%) women were classified as stage IA (none or less than 50% myometrial invasion), 40 (46%) as at least stage IB (equal to or more than 50% myometrial invasion). Myometrial involvement was examined by means of all applied methods, which were compared. Overall accuracy and Cohen's kappa coefficient were calculated. For predicting myometrial involvement the highest overall accuracy and kappa value were found using the method developed by the author (88.5% and 0.77). Overall accuracy for the methods numbered 1 and 2 (endometrial thickness and AP uterine diameter ratio in 2D and 3D) was 75.86% and 78.16% respectively; and Cohen's kappa coefficient 0.5 and 0.56 respectively. High compliance, comparable to the author’s system, also appeared in the method numbered 6 (kappa value - 0.7). Remaining results calculated for the additional methods were much lower than those shown above. For predicting cervical stromal infiltration overall accuracy and kappa were found as 88.5% and 0.62. By excluding 3 cases of microinvasion (unable to detect under ultrasound resolution) accuracy increased to 92% and kappa to 0.71. Only 7 out of 84 patients were incorrectly staged. In the distant tumour extent evaluation, ultrasound scans defined 11 cases as advanced. Compliance between ultrasound and surgical -pathol ; ogic qualification was found in 8 subjects. Pathologists as severe classified eventually 15 women. Accurate assessment of lymph nodes for the presence of metastases involved 80 of the 87 examined women. For predicting lymph node infiltration and for predicting lymph nodes free of invasion accuracies were found as 50% and 94% respectively. Cohen kappa coefficient was 0.33. Conclusions: None of 2D parameters allowed for accurate assessment of the myometrial infiltration depth in cases of endometrial cancer. Volumetric sonography increases ultrasound diagnostic value in the field of local tumour extent evaluation. 2D together with 3D ultrasound based on multifactorial image interpretation is a feasible clinical method in interpretation of the myometrial and cervical involvement. Transvaginal sonographic local staging should be always combined with transabdominal evaluation of the retroperitoneal space and abdominal organs.

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Level of degree:

2 - studia doktoranckie

Degree discipline:

onkologia ; ginekologia

Degree grantor:

Wydział Lekarski


Pityński, Kazimierz

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Last modified:

Mar 15, 2023

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Jun 19, 2015

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ZB-122889 Mar 15, 2023


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