Beeldvorming van het endometrium Dirk Timmerman UZ KU

Beeldvorming van het endometrium Dirk Timmerman UZ KU Leuven VVOG Het Endometrium 4 december 2009

Abnormaal bloedverlies Echografie? n Endometriumdikte n Bijkomende informatie: Morfologie u Hydrosonografie (SIS) u Kleuren Doppler u Ambulante hysteroscopie

Cyclic changes Proliferative endometrium Early secretory endometrium Late secretory endometrium Histology Ultrasound (T Van den Bosch)

TVS en endometriumdikte: Is dit alles wat we nodig hebben?

PMB: Endometriumdikte n Prevalentie van endo ca: 11% n < 5 mm 15 endo ca/ 1113 (1. 4%) n > 5 mm 248 endo ca/ 1247 (20%) (Meta-analysis by Timmerman &Vergote 1997 : 20 studies)

Endometrial thickness at TVS? Only a normal and thin endometrial line is informative

Morfologie van fibromen (F. Netter)

Fibromen n n Concentrisch, rond Scherp afgelijnd Hyper-, of hypoechogeen Dikwijls calcificaties

Fibroom Poliep

Limitations of hydrosonography n n n Cost? Double compared to TVS alone Time to perform? Extra 5 minutes Side effects: Ø infection: very rare Ø spilling of malignant cells? Yes. Patient discomfort? Minimal Does it change management? Sometimes

Kleuren Doppler… …zien we meer?

Fibroom

Poliep

Can ultrasound with colour Doppler imaging replace second stage tests? (such as SIS and office hysteroscopy) D. Timmerman, J. Verguts, M. Konstantinovic, Ph. Moerman, D. Van Schoubroeck, S. Van Huffel, J. Deprest (Ultrasound Obstet Gynecol 2003; 22: 166 -71)

Study design n Test: typical pedicle artery n Outcome: presence of endometrial polyp (or other pathology) based on results of hysterectomy, hysteroscopy and/or endometrial histology (within 1 yr)

3099 patients no ‘gold’ standard n = 2230 ‘gold’ standard n = 869 polyp n = 182 pedicle : 139 no polyp n = 687 pedicle : 32 Sensitivity: 76. 4 % PPV: no polyp? ? 81. 3 % Specificity: 95. 3 % NPV: 93. 8%

false positives = pedicle without polyp n 32 patients with pedicle u 12 submucous fibroid u 3 endometrial carcinoma u 4 simple hyperplasia u 1 complex hyperplasia u 2 trophoblast tissue 8 normal endometrium u 2 atrophic endometrium u classified as ‘focal pathology’ ‘true’ false positives

Results of “pedicle artery” n PPV 81. 0 % polyp 94. 2 % focal pathology n Sensitivity less than 76 %

Endometrial cancer

Endometrial carcinoma: MRI features T 2: slightly hyperintense n dynamic Gd enhanced T 1 u differentiates tumor from necrosis or residual secretion in the endometrial cavity u tumor has intermediate signal intensity compared to the extremely well enhanced myometrium n

MRI staging of endometrial carcinoma n Stage IV: extension outside the true pelvis u IVa: invasion of adjacent organs (bladder, rectum) • intramural areas of contrast uptake in these organs • disappearance of the interposed fatty layer u IVb: presence of distant metastases

Endo ca: Ultrasound? High resolution n Easily accessible n Volume measurements n Sonohysterography (SIS) n Color Doppler (intratumoral and uterine arteries) n

Endo Ca: MRI Angling the axial plane to the true cross section of the uterus n Very good imaging of uterus n Less operator dependent n

Staging of endo ca: US, CT or MR? n Meta-analysis of 47 studies u US: 16 studies Overall AUC 0. 86 u CT: 6 studies Overall AUC 0. 80 u MR: 25 studies Overall AUC 0. 87 n ROC analysis: no significant differences in overall performance (myometrial invasion, cervical invasion, extrauterine disease, and lymph node metastasis) (Kinkel et al. Radiology 1999; 212: 711 -8)

Myometrial invasion: US, CT or MR? n n Meta-analysis of 47 studies u US: 16 studies AUC 0. 85 u CT: 6 studies AUC 0. 79 u MR: 25 studies AUC 0. 86 t Nonenhanced MR AUC 0. 83 t Contrast-enhanced MR AUC 0. 91 Contrast-enhanced MR: best results for assessment of myometrial invasion (Kinkel et al. Radiology 1999; 212: 711 -8)

Disadvantages of MR Not possible in case of extreme obesity / claustrophobia n Contrast allergies n Cost n Limited availability (waiting list, regional hospital) n Some distance between the sections (very small lesions can be missed) n

One stop bleeding clinic Leuven n 1. 2. 3. 4. Ethical committee approval Patient information leaflet and informed consent Patient questionnaires (pain and discomfort) Ultrasound, colour Doppler, SIS Office hysteroscopy Pipelle biopsy Assessment of optimal algorithm (Ph. D thesis Dr Van den Bosch, 2007)

Hysteroscopie of SIS? - Kostprijs -Hysteroscopie: € 27. 19 -Hydrosonografie: € 27. 19 - Pijn score Van den Bosch et al. Ultrasound Obstet Gynecol 2008; 31: 346 -51

“one stop” bloedingskliniek Ultrasound Color Doppler GIS & NO focal lesion ET > 4 mm & NO focal lesion or ? malignant? Follow-up Pipelle ET £ 4 mm ET > 4 mm & FOCAL LESION (Operative) Hysteroscopy “Uncertain” Hysteroscopy

Adenomyosis uteri Common gynecologic disorder n Heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia n (Rokitansky, 1860)

Adenomyosis: presenting symptoms n Diffusely enlarged uterus with u menorrhagia (40 -50%) u dysmenorrhea (10 -30%) u metrorrhagia (10 -12%) u dyspareunia (typically 1 wk prior menstruation) u dyschezia (typically 1 wk prior menstruation)

Adenomyosis: epidemiology About 1% of female patients n 5 - 70% of hysterectomy specimens (Azziz 1989) n 31% if 3 sections; 61% if 6 sections (Bird 1972) n More often in multiparous women n Fourth – fifth decade of life n

Adenomyosis: morphology Asymmetrical uterine enlargement (or globular appearing uterus) n

Adenomyosis n n n Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Small anechoic cysts

Adenomyosis n n Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Small anechoic cysts Indistinct endometrial-myometrial border

Differential diagnosis Adenomyosis Fibroid n Elliptical n Concentric, round n Poorly defined borders n Sharply defined n Lack of mass effect n Mass effect n No calcifications n Often calcifications n Color Doppler

Adenomyosis: MRI diffuse type versus focal type n may contain foci of hemorrhage n n thickened junctional zone (> 12 mm) n small foci of high SI on T 2 and high / low SI on T 1 (ectopic endometrial tissue)

Author Prevalence Sensitivity (%) Specificity (%) Fedele et al. , 1992 23/405 87 99 Fedele et al. , 1992 22/43 80 74 Ascher et al. , 1994 17/20 53 75 Reinhold et al. , 1995 29/100 86 86 Brosens et al. , 1995 28/56 86 50 Atzori et al. , 1996 13/58 87 96 Reinhold et al. , 1996 29/119 89 89 Koçak et al. , 1998 18/95 89 88 Vercellini et al. , 1998 29/102 83 67 Bromley et al. , 2000 51/ ? 84 84 Atri et al. , 2000 30/102 81 71 Bazot et al. , 2001 40/120 65 97 Bazot et al. , 2002 21/23 81 100 26/106 38 97

Problems with imaging studies Rarely ‘gold standard’ (hysterectomy) n Continuum: very mild or junctional zone only vs. adenomyoma or diffuse disease n Operator-dependent n Different equipment n Use of colour Doppler n

Adenomyosis: MRI n n n n Excellent soft tissue differentiation Less operator dependent Low intensity area on T 2 weighted images Focal widening of junctional zone High cost Limited availability 2 nd stage test; TVS for initial evaluation

Adenomyosis: TVS vs MRI Sensitivity Specificity TVS 59 68 MRI 64 88 TVS & MRI 73 75 22/106 patients for hysterectomy. (Dueholm et al, Fertil Steril 9 -2001, 76: 588 -94)

Adenomyosis: other diagnostic modalities X-ray Hysterosalpingography: multiple small (1 -4 mm) spicules with saccular endings (‘lollipop-like) extending from endometrium into the myometrium. Low sensitivity and specificity. n

Adenomyosis: other diagnostic modalities Percutaneous or laparoscopic biopsy n Wood et al 1993 (Med J Aust) Percutaneous biopsy in 10 patients Useful and safe procedure n Brosens et al 1995 (Fertil Steril) (in vitro) High specificity, very low sensitivity n

Morphology of flow n Fibroid: circular flow n Polyp: pedicle Endometrial cancer: multiple irregular vessels in junctional area n Adenomyosis: no clear changes in normal flow pattern n

Abnormal bleeding History, clin. exam, PAP, TVS +Doppler (SIS only if indicated) Exclusion of adnexal pathology Focal pathology No focal pathology Thick endometrium Hysteroscopic resection (polyp / myoma) Biopsy Thin endometrium DUB Medic. R/ Surgery