Diagnostic Ultrasound - Abdomen and Pelvis

Endometrial Carcinoma
764
Diagnoses: Female Pelvis
○ Atypical hyperplasia
– Confers 25% risk of developing endometrial cancer
– Hyperplasia without atypia → 2% risk
○ Endometrioid subtypes: Unopposed estrogen
stimulation
– Hormone replacement therapy without progestins
– Early menarche and late menopause
– Tamoxifen
– Estrogen-secreting tumors
• Genetics
○ P53 suppressor gene: Nonendometrioid subtypes
– More common in African American women,
associated with poorer outcomes
○ Hereditary nonpolyposis colorectal cancer syndrome
(HNPCC) (Lynch syndrome)
○ PTEN-hamartoma tumor syndrome (Cowden syndrome)
– More common in Caucasian women, associated with
better outcomes
○ Peutz-Jeghers syndrome (PJS)
Staging, Grading, & Classification
• Stage I: Confined to uterus
• Stage II: Spread to involve cervix but not beyond uterus
• Stage III: Spread beyond uterus confined to true pelvis
• Stage IV: Disseminated metastases or bladder/bowel
involvement
Microscopic Features
• Majority are adenocarcinoma, 75% endometrioid type
(associated with estrogen stimulation)
• Serous (papillary serous), clear cell types also occur (not
associated with estrogen stimulation)
○ Older patients, more aggressive behavior
○ Serous type invades lymphovascular spaces →
metastasizes without invasion of deep myometrium
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Abnormal bleeding in 90%
• Other signs/symptoms
○ Endometrial cells on Papanicolaou smear
○ Symptoms related to metastases in advanced disease
• Clinical profile
○ Postmenopausal women with abnormal vaginal bleeding
Demographics
• Age
○ Most common in 50-65-year-old age group
– 75% postmenopausal, 25% premenopausal
• Epidemiology
○ Most common gynecologic malignancy
○ 4th most common cancer in women
○ Western affluent societies, least common in
India/Southeast Asia
Natural History & Prognosis
• Depends on stage at diagnosis
○ Stage I or II: 5-year survival 96%
○ Stage III: 5-year survival 63%
○ Stage IV: 5-year survival 8%
• African American woman tend to have worse outcome than
Caucasian women
○ Mortality rates 1.8x greater
○ Higher stage at diagnosis
○ More aggressive types (papillary serous, clear cell)
Treatment
• Stage dependent
○ Stage I or II: Surgical ± radiation therapy (XRT)
○ Stage III: Combined surgery, XRT
○ Stage IV: Combined surgery, chemotherapy, XRT
• Surgery
○ Hysterectomy, bilateral salpingo-oophorectomy,
lymphadenectomy
○ Surgical staging vital as imaging misses microscopic
disease
DIAGNOSTIC CHECKLIST
Consider
• Endometrial cancer is most serious cause of PMB
○ 10% of women with PMB will have endometrial cancer
○ Other etiologies include hyperplasia, polyps, atrophy, or
fibroids
• TV US is good test to detect EC
○ Use of 5 mm bilayer thickness as threshold for
intervention will detect 96% of EC
○ Safe to use TV US as initial diagnostic test
– Better tolerated than endometrial biopsy
○ Normal endometrium with bilayer thickness < 5 mm
– Negative test for endometrial cancer
– Obviates need for additional testing in patient with
PMB and nondiagnostic office biopsy
Image Interpretation Pearls
• Imaging alone cannot differentiate hyperplasia from
carcinoma
• Cancer may arise within endometrial polyp
SELECTED REFERENCES
1. Kabil Kucur S et al: Role of endometrial power Doppler ultrasound using the
international endometrial tumor analysis group classification in predicting
intrauterine pathology. Arch Gynecol Obstet. 288(3):649-54, 2013
2. Breijer MC et al: Capacity of endometrial thickness measurement to
diagnose endometrial carcinoma in asymptomatic postmenopausal women:
a systematic review and meta-analysis. Ultrasound Obstet Gynecol.
40(6):621-9, 2012
3. Van den Bosch T et al: Pre-sampling ultrasound evaluation and assessment
of the tissue yield during sampling improves the diagnostic reliability of
office endometrial biopsy. J Obstet Gynaecol. 32(2):173-6, 2012
4. Jacobs I et al: Sensitivity of transvaginal ultrasound screening for
endometrial cancer in postmenopausal women: a case-control study within
the UKCTOCS cohort. Lancet Oncol. 12(1):38-48, 2011
5. Menzies R et al: Significance of abnormal sonographic findings in
postmenopausal women with and without bleeding. J Obstet Gynaecol Can.
33(9):944-51, 2011
6. Odeh M et al: Three-dimensional endometrial volume and 3-dimensional
power Doppler analysis in predicting endometrial carcinoma and
hyperplasia. Gynecol Oncol. 106(2):348-53, 2007
7. Barwick TD et al: Imaging of endometrial adenocarcinoma. Clin Radiol.
61(7):545-55, 2006
8. Messiou C et al: MR staging of endometrial carcinoma. Clin Radiol.
61(10):822-32, 2006