IETA常规超声特征与超声造影对子宫内膜癌病理分期的评估价值

目的联合使用国际子宫内膜肿瘤分析（IETA）经阴道常规超声与超声造影评估子宫内膜癌（EC）患者肌层浸润深度及宫颈有无侵犯,预测EC的病理分期;比较此2种方法的诊断价值。 方法将南方医科大学深圳医院及中山大学附属第七医院2017年1月至2020年12月间83例已手术的EC患者纳入研究,所有患者术前1个月内均行经阴道常规超声及超声造影检查,由2名具有10年以上妇产超声工作经验的超声医师,掌握IETA专家小组拟定的子宫内膜病变共识的具体内容,对所有入组病例的常规超声及超声造影图像进行盲法分析,以病理结果为参考,比较分析常规超声主、客观测量法及超声造影主、客观测量法对EC病理分期的诊断符合率,采用Kappa检验分析超声与病理结果的一致性。同时采用受试者操作特征（ROC）曲线分析超声客观测量方法对EC深肌层浸润及宫颈有无侵犯的诊断效能。 结果本研究发现IETA专家共识总结的子宫内膜厚度、病灶回声、宫腔线的形状、子宫内膜-肌层交界处（结合带）情况、无“亮边”征及子宫内膜病灶血管模式在不同病理分期的EC中,均有较高的特异度及一致性,是预测EC较好的超声指标。超声造影主观评估法（Kappa=0.873,P＜0.001）、超声造影客观测量法（Kappa=0.842,P＜0.001）、IETA常规超声主观评估法（Kappa=0.811,P＜0.001）、IETA常规超声客观测量法（Kappa=0.764,P＜0.001）此4种诊断方法与病理结果一致性均良好,超声造影较常规超声对EC病理分期的诊断符合率有一定程度的提高［主观评估法、客观评估法：（90.36%、87.95%） vs（85.54%、81.93%）］。常规超声或超声造影显示病灶前后径、病灶的体积、病灶与子宫前后径的比值对预测EC深肌层浸润（浸润深度≥1/2）均有较好的诊断效能,ROC曲线下面积（AUC）均≥0.945,常规超声或超声造影显示病灶外缘与浆膜层的最小距离评估法诊断效能较差,AUC仅为0.414、0.462。常规超声或超声造影显示病灶下缘与宫颈外口距离评估法对预测EC有无宫颈侵犯的诊断效能一般,AUC为0.521、0.559。 结论IETA经阴道常规超声声像特征与超声造影对EC的诊断及预测病理分期均具有较好的效果,且对超声术语进行规范化描述,临床上值得推荐使用。超声造影较经阴道常规超声的诊断效能有一定程度提高,能更好地显示病变对周围肌层及宫颈的浸润深度、侵犯范围;超声造影联合经阴道常规超声,可能达到EC早期发现、准确分期、早期治疗的目的。

Diagnostic value of IETA conventional ultrasound imaging characteristics versus contrast-enhanced ultrasound in predicting pathological stage of endometrial carcinoma

ObjectiveTo compare the value of IETA conventional transvaginal ultrasound and contrast-enhanced ultrasound (CEUS) in evaluating the depth of muscular invasion and cervical invasion in patients with endometrial cancer (EC), and in predicting the pathological stage of EC. MethodsA total of 83 EC patients who had been operated on at Shenzhen Hospital of Southern Medical University or the Seventh Affiliated Hospital of Sun Yat-sen University from January 2017 to December 2020 were enrolled in the study. All patients underwent conventional transvaginal ultrasound and CEUS examination within one month before surgery. The conventional ultrasound and CEUS images of all enrolled patients were analyzed by two sonographers with more than 10 years of experience in obstetrics and gynecology ultrasound, both of whom had been familiar with the specific contents of the consensus on endometrial lesions by the IETA expert group prior to the analysis. The diagnostic coincidence rate of conventional ultrasound and CEUS for EC pathological staging was compared by using pathological results as the reference, and the kappa value was used to test the consistency between ultrasound and pathological results. ROC curve was used to analyze the diagnostic efficacy of objective ultrasonic measurement methods for deep muscle invasion and cervical invasion in EC. ResultsThe endometrial thickness, endometrial echogenicity, endometrial midline appearance, endometrial-myometrial junction, absence of "bright edge" sign, and vascular pattern of endometrial lesions concluded by IETA experts had high specificity and consistency in EC with different pathological stages in this study, and they were good ultrasonic indicators for predicting EC. The CEUS subjective assessment (Kappa=0.873, P＜0.001), CEUS objective measurement (Kappa=0.842, P＜0.001), IETA conventional ultrasound subjective assessment (Kappa=0.811, P＜0.001), and IETA conventional ultrasound objective measurement (Kappa=0.764, P＜0.001) were in good agreement with pathological results. The diagnostic coincidence rate of CEUS for EC pathological stages was somewhat improved compared with that of conventional ultrasound. On conventional ultrasound or CEUS, the anterior and posterior diameter of the lesion, the volume of the lesion, and the ratio of the anterior and posterior diameter of the lesion to the uterine anterior and posterior diameter (AP ratio) all had good diagnostic efficacy in predicting deep muscular invasion (invasion depth ≥1/2) in EC, and the areas under the ROC curves (AUCs) were all ≥0.945; the minimum distance between the outer edge of the lesion and the serous layer had poor diagnostic efficiency, with AUCs of only 0.414 and 0.462, respectively; the distance between the lower edge of the lesion and the external cervical opening was not effective in predicting the presence of cervical invasion in EC, with AUCs of 0.521 and 0.559, respectively. ConclusionBoth IETA routine transvaginal ultrasonography and CEUS have high diagnostic efficacy in the prediction of pathological stages of EC. The diagnostic efficiency of CEUS is somewhat improved compared with that of conventional transvaginal ultrasound, and it can better display the depth of lesion invasion to the muscular layer and the scope of cervical invasion. Combining CEUS with routine transvaginal ultrasound may help achieve the goal of early detection, accurate staging, and early treatment of EC.