Predictors of final histology in patients with endometrial cancer

OBJECTIVE: To assess the usefulness of preoperative tumor grade and intraoperative assessment of gross depth of myometrial invasion as "predictors" of final grade, final depth of myometrial invasion and surgical stage in patients with "low-risk" endometrial cancer. METHODS: We retrospectively compared preoperative histology and intraoperative gross depth of invasion with final pathologic evaluation on hysterectomy specimens. For patients traditionally considered intraoperatively to be "low-risk" for lymph node metastasis (grade 1 or 2 adenocarcinoma with less than 50% myometrial invasion), "predictors" combining preoperative histology and intraoperative gross depth of myometrial invasion were established; that is, a preoperative biopsy of grade 1 adenocarcinoma with an intraoperative gross depth of myometrial invasion of 30% was assigned the predictor IbG1 (Stage Ib, grade 1). These predictors were then compared to final grade and surgical stage. Sensitivity, specificity, and positive predictive value were then calculated. RESULTS: A total of 153 patients had both a preoperative biopsy and intraoperative assessment of gross depth of invasion. Twenty-four patients had the IaG1 predictor; eight had stage IaG1 on final pathologic evaluation (sensitivity, 0.50; specificity, 0.88; positive predictive value, 0.33). Eight patients had the IaG2 predictor; none had stage IaG2 on final pathologic evaluation (sensitivity, 0; specificity, 0.95; positive predictive value, 0). Eighty-nine patients had the IbG1 predictor; forty-six had stage IbG1 on final pathologic evaluation (sensitivity, 0.72; specificity, 0.52; positive predictive value, 0.52). Thirty-two patients had the IbG2 predictor; 11 had stage IbG2 on final pathologic evaluation (sensitivity, 0.46; specificity, 0.84; positive predictive value, 0.34). CONCLUSION: A clinically significant number of patients will have more advanced disease than predicted by preoperative or intraoperative prognostic factors. These predictors should not be relied on in the staging of endometrial cancer.     

Preoperative assessment of myometrial invasion and cervical involvement of endometrial cancer by transvaginal ultrasonography

The aim of the study was to assess the depth of myometrial invasion and cervical involvement by endometrial cancer using preoperative 6.5-MHz, high-frequency transvaginal ultrasonography as compared with postoperative assessment using histopathological examination. The study included 47 patients with histologically proven cancers of the endometrium. All patients underwent transvaginal sonography before surgery. The depth of myometrial invasion was classified as none, inner half of the uterine wall, and outer half of the uterine wall. Cervical spread is recorded as positive or negative. Of 36 (76.6%) patients with proven myometrial invasion, 33 cases (91.66%) were revealed by sonography. Histologically proven cervical invasion that correlated with sonography was shown in 3 patients (75%). In 7 patients (14.9%) ultrasonography could not correctly predict the depth of myometrial invasion. The depth of invasion was underestimated in 4 (8.5%) cases and overestimated in 3 (6.4%) cases. Preoperative assessment of invasion of the uterine wall and cervical spread by transvaginal ultrasonography had an accuracy of 85 and 97.8% if correlated with the definitive histopathological examination. The role of transvaginal ultrasonography in preoperative assessment of the depth of myometrial invasion and cervical involvement in patients with endometrial cancer needs to be studied further before making reliable conclusions.     

Ovarian metastasis in women with clinical stage I endometrial carcinoma

BACKGROUND: The incidence of ovarian metastasis in women with clinical stage I endometrial carcinoma is generally reported to be 5%, leading to the practice of removing the ovaries at surgery even in young patients. METHODS: A retrospective study of 84 patients with clinical stage I endometrial cancer was carried out. Patients were excluded if the pathologic study revealed any evidence of extrauterine, apart from adnexal, spread or if the peritoneal cytology was positive. Patients with serous papillary or clear cell tumor histology were also excluded. RESULTS: Sixty-seven patients fulfilled the inclusion criteria. Only three (4%) patients were found to be in surgical stage IIIA, all three had grade 3 tumors. Of these patients, two had uterine serosal involvement and one had a microscopic tumor implant in a fallopian tube; none had ovarian metastasis. CONCLUSIONS: The risk of ovarian metastasis in women with well to moderately differentiated endometrial cancer, myometrial invasion limited to less than one half of the myometrium, negative peritoneal cytology and no evidence of metastatic lymph node spread is negligible. Young patients with a preoperative histological diagnosis of well to moderately differentiated endometrial carcinoma may be surgically staged, leaving the final decision regarding removal of the ovaries pending a thorough pathological review of the surgical specimens.     

Magnetic resonance imaging in stage I endometrial carcinoma

A prospective study was conducted on 50 consecutive patients with stage I endometrial cancer who had primary surgical treatment. The purpose of the study was to assess the value of magnetic resonance imaging (MRI) for accurate staging of early disease and determination of myometrial invasion. Features identified by MRI were correlated with surgical pathology. Preliminary MRI results provided additional valuable information. All but one of 18 patients with histologically proven deep myometrial invasion were predicted preoperatively by MRI. Of 17 patients with detached fragments of malignant tissue in the endocervical curettage (ECC) but with results inconclusive for actual cervical invasion, MRI revealed all three patients with true cervical tissue involvement. Magnetic resonance imaging detected all six patients with gross extrauterine spread and also precisely measured uterine enlargement by myomata. The extent and location of tumor growth in the uterus could be mapped out in the majority of cases. Based on these findings, a pretreatment MRI scan of the pelvis in presumably stage I endometrial carcinoma resulted in an advance in staging in 18% of the patients, and accurately predicted deep myometrial invasion in 94% of the cases. Inclusion of MRI in the routine work-up in stage I endometrial carcinoma should be considered for proper clinical staging, particularly in patients with a positive but nondiagnostic ECC, uterine papillary serous carcinoma, or grade 3 tumor.     

The prognostic significance of positive peritoneal cytology in endometrial cancer

A retrospective analysis of clinical data extracted from hospital records of 145 patients who had had primary surgical treatment for endometrial cancer in Queen Mary Hospital, Hong Kong, from 1987 to 1993 was performed to study the prognostic significance of positive peritoneal cytology. Positive peritoneal cytology was found to be associated with poor prognostic factors such as deep myometrial invasion, high grade tumor, extrauterine spread and lymphovascular permeation. By univariate analysis, all the poor prognostic factors were found to be significant in affecting survival. These included age above 65, nonadenocarcinoma histology, deep myometrial invasion, positive cytology, extrauterine involvement and lymphovascular involvement. By multivariate analysis, only histology and extrauterine involvement remained significant. In patients with positive cytology, 61.1% had extrauterine involvement at initial presentation. Patients who had positive cytology and extrauterine disease had the shortest survival. The survival was independent of cytology result when the tumor was confined to the uterus.     

Intraoperative evaluation of depth of myometrial invasion in stage I endometrial adenocarcinoma

In patients with stage I endometrial adenocarcinoma, the incidence of pelvic and para-aortic lymph node metastasis is related to the grade of the tumor and the depth of myometrial invasion. Although the grade of the tumor may be predicted preoperatively by endometrial sampling, the depth of myometrial invasion cannot be determined until after the uterus has been removed. Although complications have been attributed to lymph node sampling, failure to perform the procedure in patients at risk for nodal metastasis may result in underdiagnosis of extrauterine disease, leading to inadequate therapy. Gross visual examination of the cut surface of the tumor at the time of hysterectomy accurately determined the depth of myometrial invasion in 135 of 148 prospectively studied patients (91%) (P less than .001). The sensitivity of the test was 0.71, the specificity was 0.96, and the positive predictive value was 0.80. Intraoperative assessment of the depth of myometrial invasion is a simple, inexpensive, and useful technique for selecting those patients with stage I endometrial adenocarcinoma who might benefit from selective para-aortic lymphadenectomy.     

Papillary serous adenocarcinoma of the endometrium: a clinicopathologic study of 19 cases.

Survival in 19 patients with papillary serous adenocarcinoma of the endometrium treated at the University of Vermont during the period 1960-1987 was significantly worse than that for 360 patients with other types of endometrial cancer. Deaths were associated with extrauterine spread and deep myometrial invasion detected at the time of surgery. Two patients without myometrial invasion and with extrauterine spread who also died may have developed synchronous peritoneal serous carcinoma.     

Endometrial adenocarcinoma: therapeutic impact of preoperative histopathologic examination of endometrial tissue

Adenocarcinoma of the endometrium is diagnosed by the histologic evaluation of endometrial tissue. In stage I disease, five-year survival depends upon a number of prognostic factors. Histologic grade and type of carcinoma are most important. The need for pelvic and para-aortic lymphadenectomy is often based on the preoperative histologic grade and type of tumor. The purpose of this study was: 1) to compare preoperative histology of endometrial carcinoma to that found at hysterectomy, 2) to determine if preoperative histology can accurately predict depth of myometrial invasion or extra-uterine spread, 3) to determine whether para-aortic lymphadenectomy could be deleted based only on the preoperative finding of well differentiated carcinoma. In 19 (28%) of the 68 patients studied, the histologic grade or pattern at hysterectomy was different from that found preoperatively. In seven (13%) of the 52 "good prognosis" patients with grades 1 and 2 preoperative histology, hysterectomy revealed a more serious histologic type. Three of the seven (43%) had extrauterine spread. In the 16 "poor prognosis" patients with preoperative grade 3 or papillary serous/clear cell carcinoma, 14 (88%) had a similar histologic pattern at hysterectomy. Three of these patients had metastatic disease. Depth of myometrial invasion could not be predicted by preoperative histology even though the data suggested that extrauterine spread could. Clinical stage I endometrial carcinoma, grade 1 or 2, should not be treated without para-aortic nodal sampling based only on a supposedly favorable preoperative histologic pattern. Confirmed para-aortic nodal disease will alter the fields of post-operative radiation therapy should that become necessary. In these patients, however, pelvic lymphadenectomy is not justified.2 +     

Endometrial carcinoma: the relevance of cervical cytology

In patients with endometrial carcinoma, preoperative identification of poor prognostic factors is helpful in planning therapy. Extended surgical staging, including pelvic and periaortic node dissection, is indicated in patients with deep myometrial invasion or high-grade tumor, or when other risk factors for extrauterine spread are present. In this study, cervical cytology was reviewed in 86 patients with endometrial carcinoma, all of whom underwent surgical staging, to correlate the cytologic results with surgical and pathologic findings. Cervical cytology was normal in 20 patients (23%), whereas suspicious or malignant endometrial cells were present in 23 and 43 cases (27 and 50%), respectively. Suspicious or malignant cervical cytology was associated with deeper myometrial invasion (P = .011), higher postoperative tumor grade (P = .006), positive peritoneal washings (P = .012), and more advanced stage by International Federation of Gynecology and Obstetrics criteria (P = .024). When compared with patients with normal cervical cytology, those who had malignant endometrial cells had over twice the risk of deep myometrial invasion (67 versus 30%), twice the risk of grade 2 or 3 tumor (60 versus 30%), and three times the risk of positive peritoneal washings (33 versus 10%). Seventy-four percent of patients with malignant cervical cytology were stage IC or more. In contrast, 70% of patients with normal cervical cytology were stage IA or IB. Patients with endometrial carcinoma who have malignant endometrial cells detected by cervical cytology are at increased risk of having a deeply invasive, high-grade, advanced-stage tumor, and therefore are more likely to require extended surgical staging.     

Clinical utility of magnetic resonance imaging and the preoperative identification of low risk endometrial cancer

BACKGROUND: Magnetic resonance imaging (MRI) is reported to offer the best imaging of local disease in endometrial cancer. We audited MRI scans to identify their clinical utility, particularly in the preoperative identification of 'low risk' endometrial cancer (grade one or two endometrioid tumours confined to the inner half of the myometrium). AIM: To correlate histological and MRI findings and to establish our ability to preoperatively identify women with 'low risk' tumours. STUDY DESIGN: A retrospective audit of MRI scans in women with a new diagnosis of endometrial cancer from July 1998 to November 2002. Radiology and pathology reports and surgical staging data were extracted. Independently a team of radiologists reviewed MRI films and the findings were compared to pathology. RESULTS: Thirty-nine patients were included. Only 10% of original reports contained all the clinically relevant information. On review, the sensitivity for the detection of myometrial invasion was 90%, specificity 71%, positive predictive value (PPV) 93% and negative predictive value (NPV) 63%. For the detection of deep invasion, sensitivity was 56%, specificity 77%, PPV 64% and NPV 71%. All women with grade one or two tumours having no invasion or grade one having superficial invasion detected on MRI had pathological 'low risk' disease. CONCLUSIONS: Magnetic resonance imaging scans as reported offered limited clinical benefit. Attention needs to be given to MRI sequencing and reporting protocols. If the review results can be confirmed by prospective studies, MRI offers significant clinical utility in the identification of low risk patients and their surgical treatment planning.     

Endometrial cancer: the potential role of cervical cytology in current surgical staging

OBJECTIVE: To evaluate cervical cytology, tumor grade from endometrial sampling, and myometrial invasion with the risk of nodal spread in endometrial cancer. METHODS: Cervical cytology was obtained in 300 patients with endometrial cancer before surgical staging, which included lymphadenectomy. Tumor grade and histology from endometrial sampling were compared with final pathology, and the risk of nodal spread in relation to cervical cytology, tumor grade, and myometrial invasion was assessed using chi(2) and logistic regression analysis. RESULTS: Endometrial cells on cervical cytology, deep myometrial invasion, and high-grade tumor were associated with 91%, 87%, and 83% of the cases with nodal spread, respectively. In patients with grade 1 tumor on biopsy, final pathology revealed grade 2 in 21%, and grade 3 in 2%. In patients with normal cervical cytology, no nodal metastases occurred with grade 1 tumor on biopsy, and no aortic metastases occurred, regardless of grade. Cervical cytology and tumor grade contributed independently to the likelihood of nodal metastases. CONCLUSION: All patients with endometrial cancer should undergo lymphadenectomy until a reliable system is found to identify those with negligible (less than 1%) risk of nodal spread. The risk of lymph node spread in those with normal cervical cytology is low (2%). Further study of those with normal cervical cytology is needed to determine if lymphadenectomy can be omitted with grade 1 tumor on biopsy, or whether aortic lymphadenectomy is necessary regardless of grade.     

Evaluation of the sensitivity, specificity, positive and negative predictive values of preoperative magnetic resonance imaging for staging endometrial cancer. A prospective study of 100 cases at the Dorset Cancer Centre

OBJECTIVES: The objectives were to evaluate the sensitivity and specificity of preoperative magnetic resonance imaging (MRI) in predicting myometrial invasion and disease stage in cases of endometrial carcinoma. STUDY DESIGN: Prospective analytic study in 100 sequential cases of endometrial carcinoma referred to the Dorset Cancer Centre between January 1999 and July 2004. The study included 100 women with histologically proven endometrial malignancy, the mean age of the studied population being 68.6 years +/-2S.D. The preoperative MRI findings were compared with final surgical and histological staging; the latter was taken as the gold standard. The main outcome measures were the sensitivity and specificity of preoperative MRI for staging endometrial cancer. RESULTS: A total of 100 consecutive cases of endometrial cancer were analysed, of which 62 cases were classified as stage Ia/Ib (early disease) by histology. MRI accurately predicted the degree of invasion in 54 cases and overestimated in 8, giving a sensitivity of 87% and specificity of 90%. In stage Ic disease the sensitivity and specificity of MRI were 56 and 86%, respectively. However, MRI showed significantly reduced sensitivity for predicting stage II endometrial cancer at 19% but was found to be both sensitive and specific for predicting advanced endometrial cancer (stages III and IV); the sensitivity and specificity were 100 and 99%, respectively. CONCLUSIONS: The accuracy of MRI scanning in predicting early and advanced endometrial disease is very good, but there is reduced accuracy with stage Ic and stage II disease. MRI is a valuable imaging modality in the preoperative assessment of cases of endometrial cancer.     

术前诊刮后病理分级和术中肉眼判断肌层浸润深度预测临床Ⅰ期子宫内膜样腺癌高危因素的准确性评价

目的 评价术前诊刮后病理分级和术中肉眼判断肌层浸润深度预测临床Ⅰ期子宫内膜样腺癌高危因素[即术前诊刮后病理分级为G,和(或)术中肉眼判断肌层浸润深度≥1/2]的准确性.方法 收集1999年1月-2008年12月在浙江大学医学院附属妇产科医院接受手术治疗的687例临床Ⅰ期子宫内膜样腺癌患者的临床病理资料,对术前和术中预测存在高危因素者实施腹膜后淋巴结切除术.以手术切除的子宫标本的病理诊断为"金标准",评价术前和术中预测高危因素的准确性,并分析其影响因素.结果 术前和术中预测临床Ⅰ期子宫内膜样腺癌存在高危因素需行腹膜后淋巴结切除术的敏感度为70.4%,特异度为80.2%,准确率为77.6%,假阴性率为12.0%,假阳性率为43.0%,阳性预测值为57.0%,阴性预测值为88.0%.单因素分析显示,临床Ⅰ期子宫内膜样腺癌患者的年龄、绝经与否、病灶大小、宫颈受累与否、淋巴结转移与否及子宫外转移与否明显影响术前和术中预测高危因素的准确性(P＜0.05);多因素分析显示,患者的年龄、病灶大小、淋巴结转移与否及子宫外转移与否足影响术前和术中预测高危因素的准确性的独立因素(P＜0.05).结论 术前诊刮后病理分级和术中肉眼判断肌层浸润深度预测临床Ⅰ期子宫内膜样腺癌需行腹膜后淋巴结切除术的町靠性较高;但预测其不需行淋巴结切除术的假阴性率较高,需结合患者的年龄、病灶大小及是否疑有淋巴结或子宫外转移综合判断.     

术中快速冰冻病理检查诊断子宫内膜癌的价值探讨

目的:评价术中快速冰冻病理检查在评估子宫内膜癌是否行分期手术中的临床价值。方法:回顾性分析2009年1月至2011年6月在上海市长宁区妇幼保健院收治的69例术前诊断性刮宫诊断为子宫内膜癌患者的临床资料,以术后石蜡病理检查结果为标准,比较患者术中快速冰冻病理检查结果在判断肿瘤分级和肌层浸润方面与其的符合率。结果:①69例子宫内膜样腺癌患者,术中快速冰冻病理检查肿瘤分级G1的符合率为54.8%(23/42),G2为90.0%(9/10),G3为100.0%(2/2),经McNemar-Bowker检验,差异有高度统计学意义(χ2=30.22,P=0.000)。②病变组织在肌层浸润方面,Ⅰ级(内膜层)符合率为25.8%(8/31),Ⅱ级(浅肌层)符合率为91.4%(32/35),Ⅲ级(深肌层)符合率为100.0%(3/3),经McNemar-Bowker检验,差异有高度统计学意义(χ2=22.18,P=0.000)。结论:肿瘤分级越差、肿瘤浸润肌层越深,其冰冻病理诊断符合率越高。术中快速冰冻病理检查结果和术后石蜡病理检查结果存在一定偏差,但这种偏差多发生在高分化或浅浸润的患者,依靠术中快速冰冻病理检查来决定子宫内膜癌患者是否行分期手术仍具有一定的意义。     

Significance of preoperative diagnosis of endometrial carcinoma by angio-CT

Angio computed tomography (CT) was performed in 87 previously untreated patients with endometrial carcinoma to study its clinical usefulness. All the patients subsequently underwent surgery and the angio CT findings were correlated with the surgical and pathologic findings. The results were as follows: 1. The tumor appeared as areas of low density in comparison with the surrounding myometrium after intraarterial infusion of contrast medium. 2. Angio CT proved to be useful in determining the depth of myometrial invasion. The myometrial invasion measured from the serosal surface in millimeters was assessed on angio CT. The CT findings were correlated well with pathologic findings. 3. Patients with intact myometrium greater than 10mm from the serosal surface assessed by angio CT had no nodal metastases. Angio CT provides a better display of cross-sectional uterine pathology than CT after intravenous infusion of contrast medium. The depth of myometrial invasion measured from the serosa on angio CT seems to be a useful prognostic factor in patients with endometrial carcinoma.     

Surgical staging for patients presenting with grade 1 endometrial carcinoma

OBJECTIVE: To examine the impact of surgical staging of patients presenting with grade 1 endometrial cancer. METHODS: The charts of all patients who presented for surgery for endometrial cancer between March 1997 and July 2003 were analyzed for demographic data, final tumor histology, grade, stage, and complications. RESULTS: A total of 349 patients underwent surgical management for endometrial cancer. Preoperatively, 181 (52%) were identified with grade 1 disease, with a mean age of 61 years (range 27-89). Surgical staging (pelvic +/- para-aortic lymphadenectomy) was performed in 82% of cases and was omitted only in cases when disease was apparently confined to the endometrium and surgical risk was high. In staged patients, 3.2% had severe surgical complications. There were 2 perioperative mortalities (1 pulmonary emboli and 1 myocardial infarct). In comparison of pre- and postoperative histology, 19% of patients were upgraded, with 15% grade 2, 0.5% grade 3, 2.5% serous or clear cell, and 1% mixed mesodermal tumor. Lymph node metastases were found in 3.9% of patients presenting with grade 1 endometrial cancer, and 10.5% had extrauterine spread (> IIb). High-risk uterine features, including myometrial invasion more than 1/2, grade 3 lesions, high-risk histologic variants, and/or cervical involvement, were found in 26% of the patients. No patients with stage Ia-IIb endometrioid cancer received adjuvant teletherapy or chemotherapy. Four patients with low-risk uterine features were found to have extrauterine disease. Twelve percent of patients received adjuvant therapy, and 17% avoided teletherapy and/or chemotherapy based on surgical staging. CONCLUSION: Surgical staging in patients presenting with grade 1 endometrial cancer significantly impacted postoperative treatment decisions in 29% of patients. Omitting lymphadenectomy in patients presenting with grade 1 endometrial cancer may lead to inappropriate postoperative management.     

Prediction of myometrial invasion in patients with endometrial carcinoma: comparison of magnetic resonance imaging, transvaginal ultrasonography, and gross visual inspection

This study evaluated the accuracy of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVUS) in preoperative detection of myometrial invasion by endometrial cancer. We also evaluated the results of gross visual inspection (GVI) of surgical specimens compared with histopathological diagnosis. One hundred and seventy-seven women underwent preoperative pelvic MRI, TVUS, and intraoperative GVI. Myometrial tumor invasion was evaluated histologically and classified as absent (depth a), superficial (depth b: < or = 50% invasion), or deep (depth c: > 50% invasion). The accuracy of MRI, TVUS, and GVI were 64.0, 66.9, and 63.8%, respectively. The positive predictive values of of each modality for depth a were 52.6, 51.4, and 52.2%, respectively. The accuracy of each in detecting deep myometrial invasion (depth c) were 84.0, 86.9, 83.1%. Although evaluation of depth a was limited with all modalities, MRI and TVUS were shown to be reliable for preoperative evaluation of deep myometrial invasion. The high accuracy of these three methods suggests that they are useful either interchangeably or in combination.     

The value of transvaginal sonography in the preoperative assessment of myometrial invasion in high and low grade endometrial cancer and in comparison to frozen section in grade 1 disease

OBJECTIVE: To evaluate the diagnostic accuracy of preoperative transvaginal sonography (TVS) in the detection of deep myometrial invasion in endometrial cancer cases classified by the grade of disease, and in comparison to frozen section analysis in grade 1 cases. METHODS: In a prospective study, 91 patients with confirmed endometrial carcinoma underwent preoperative TVS for evaluation of myoinvasion. Sonographic results were categorized as superficial (less than or equal to 1/2 myometrial depth) and deep invasion (greater than 1/2 myometrial depth). TAH-BSO followed by retroperitoneal lymph node sampling were performed in all patients with grade 2-3 tumors. In patients with grade 1 disease, the surgical specimen was intraoperatively evaluated by frozen section, and lymph node sampling was carried out if deep invasion was determined. The preoperative sonographic findings and the frozen section results were compared to the final histopathology report of myoinvasion. RESULTS: In 77 of the 91 (84.6%) patients, the sonographic assessment of the depth of myoinvasion was in accord with the final histopathologic findings. TVS demonstrated a sensitivity of 87.8% and a specificity of 82.7% in detecting deep invasion in the entire study group (grade 1-3), with positive and negative predictive values (PPV, NPV) of 74.3% and 92.3%, respectively. TVS in grade 1 cases (n=47) showed a sensitivity of 77.7%, a specificity of 79%, PPV of 46.6% and NPV of 93.7%. TVS in cases with grade 2-3 tumors (n=44) showed a sensitivity of 90%, specificity of 91.6%, PPV of 90% and NPV of 91.6%. Thus, the accuracy of TVS in grade 2-3 cases was superior to that achieved in grade 1 cases (91% vs 78.7%; p=.002). The myometrial invasion was assessed by frozen section in 41 out of 47 patients with grade 1 disease and demonstrated a sensitivity of 85.7%, a specificity of 100%, PPV of 100% and NPV of 97.1%. The specificity (100%) and accuracy (97.5%) of the frozen section were found to be superior compared to that of the TVS (79% and 78.7%) in detecting deep invasion in grade 1 cases (p=.008, p=.005, respectively). No statistically significant difference was found between the sensitivity of either technique. CONCLUSIONS: TVS appeared to be a more accurate method for preoperative assessment of myoinvasion in grade 2-3 endometrial cancer patients compared to grade 1 patients. In grade 1 cases, this method achieved lower accuracy in detecting deep invasion compared to the frozen section analysis. Based on these data, the value of preoperative TVS results as the sole criterion in the decision to perform extensive surgical procedures in grade 1 endometrial cancer is questionable and warrants further evaluation.     

The evaluation of endometrial tumors by transvaginal and Doppler ultrasonography

Background Endometrial cancer is the most common malignancy of the female genital tractus which is primarily seen in postmenopausal women. The purpose of this study is to investigate the relation between uterine histopathologic alterations and sonographic findings in women diagnosed with endometrial cancer. Materials and methods A total of 120 women who were histologically diagnosed with endometrial cancer and who admitted to Gynecologic Oncology Department in the study center were eligible. The subjects were evaluated by Doppler ultrasonography (USG) coupled with a vaginal probe before surgery. After surgical staging was performed in all participants, the preoperative sonographic findings were compared with histopathologic information yielded from surgical specimens. Results The mean age of the study population was 53.1 years. About 85% of the subjects were postmenopausal. The mean endometrial thickness measured by transvaginal USG was found to be 25.6 ± 13.4 mm (range 6–88 mm). The diagnostic accuracy, sensitivity, specificity, positive and negative predictive values of transvaginal USG was, respectively, 69, 66, 72, 60 and 75%. In 37 (30.8%) patients, transvaginal USG could not correctly predict the depth of myometrial invasion. Myometrial invasion was underestimated in 17 cases (14.2%) and overestimated in 20 cases (16.7%). There was a significant negative correlation between the tumor grade and uterine artery blood flow. Conclusions The results of the present study determine that transvaginal USG has moderate sensitivity and moderate-to-high specificity which limit its use. However, endometrial thickness, myometrial invasion and resistance index values determined by Doppler USG can indicate the tumor grade allowing individualized treatment to be planned for endometrial tumors.     

Accuracy of preoperative tumor grade and intraoperative gross examination of myometrial invasion in patients with endometrial cancer

BACKGROUND AND AIMS: Preoperative prediction of metastases to the regional lymph nodes in women with endometrioid endometrial cancer is a challenge. According to the Danish Gynaecological Cancer Society guidelines, a pelvic lymphadenectomy is warranted in all poorly differentiated tumors and all stage Ic disease. We have evaluated the accuracy of preoperative tumor grade and intraoperative gross examination of myometrial invasion, in predicting the need for a pelvic lymphadenectomy. METHODS: Preoperative tumor grade and intraoperative gross examination of myometrial invasion were prospectively registered in 72 women with stage I endometrioid endometrial cancer, operated between 1 September 2004 and 18 April 2006. The pre- and intraoperative findings were compared with the final pathology report. RESULTS: The preoperative prediction of grade (well, moderate or poorly differentiated) was correct in 96% (69/72) of the patients. Gross examination of myometrial invasion correctly differentiated between stage Ia, Ib, and Ic disease in 89% (64/72) of the patients. The combination of preoperative tumor grade and intraoperative gross examination of myometrial invasion, led to wrong clinical decisions in 11% (8/72) of the patients. Three 'unnecessary' lymphadenectomies were performed, and 5 patients were primary operated upon without 'warranted' lymphadenectomy. CONCLUSIONS: Our data suggest that preoperative tumor grade and intraoperative gross examination of the uterus provide useful information for pre-and intraoperative planning of pelvic lymphadenectomy. However, wrong decisions were made in 11% of the patients, and more reliable evaluation methods are needed.