Tejal Amin

A prospective comparison of the diagnostic accuracies of ultrasound and magnetic resonance imaging in preoperative staging of endometrial cancer

To compare the diagnostic accuracies of ultrasound and magnetic resonance imaging (MRI) for deep (≥50%) myometrial invasion (DMI) and cervical stromal invasion (CSI) in women with endometrial cancer. This was a prospective study at a gynecology clinic for women with postmenopausal bleeding. Between October 2015-October 2018, consecutive women with suspected endometrial cancer based on ultrasound subjective pattern recognition were simultaneously assessed for DMI and CSI on ultrasound. Subsequently, they also underwent preoperative MRI. We compared the diagnostic accuracies of ultrasound and MRI in predicting DMI and CSI with the final histology as the gold standard. We included 51 women. The prevalence of DMI and CSI were 22/51 (43%) and 7/51 (14%), respectively. The majority of malignancies were of endometrioid histological subtype (38/51, 75%) and FIGO stage 1 or 2 (40/51, 78%). Ultrasound diagnosed more cases of DMI compared to MRI (19/22 vs. 17/22), however, the difference was not statistically significant. The sensitivities and specificities of ultrasound and MRI for DMI were 86% vs. 77% and 66% vs. 76%, respectively. For CSI, ultrasound and MRI correctly diagnosed the same number of cases (5/7, 71%); their respective false-positive rates were low, 0/44 (0%) and 1/44 (2%). Ultrasound and MRI had a moderate agreement for DMI (ƙ=0.49; 95% confidence interval [CI]=0.26-0.73), whereas the agreement for CSI was substantial (ƙ=0.69; 95% CI=0.36-1.00). Endometrial cancer can be simultaneously diagnosed and staged at women's initial ultrasound assessment. The accuracies of ultrasound for DMI and CSI are comparable to MRI. ISRCTN Identifier: ISRCTN24363390.

Efficacy of transrectal ultrasound in assessing endometrium of postmenopausal women with axial uterus

ABSTRACTObjectiveTo evaluate the acceptance and efficacy of transrectal ultrasound (TRS) in assessing the endometrium in postmenopausal women with an axial uterus.MethodsThis was a prospective cross‐sectional study conducted between October 2015 and October 2018 of consecutive postmenopausal women with an axial uterus on transvaginal ultrasound (TVS). Women with a known diagnosis of gynecological malignancy were excluded. TRS was offered immediately after TVS without prior bowel preparation. A single operator determined subjectively whether the endometrium was visualized satisfactorily on TVS and TRS. In women with postmenopausal bleeding (PMB), endometrial thickness (ET) was measured and endometrial morphology was categorized as atrophic, uniformly thickened, benign endometrial polyp or endometrial cancer, based on subjective pattern recognition. All women with PMB and a non‐atrophic endometrium underwent outpatient endometrial biopsy, hysteroscopy or hysterectomy. The success rate of TRS in assessing satisfactorily the endometrium was compared with that of TVS. In patients with PMB, ET measurements and subjective diagnosis of endometrial cancer on TVS vs TRS were compared.ResultsOf the 1553 women who underwent TVS examination, 103 (6.6%) had an axial uterus, of whom 76 (73.8%) presented with PMB. TRS was accepted by 66/103 (64.1%) women with an axial uterus. TRS assessed satisfactorily a significantly higher proportion of endometria compared with TVS (90.9% vs 62.1%; χ2 = 14.1, P < 0.001). In 50 women with PMB and an axial uterus who underwent both TVS and TRS, TVS failed to visualize the endometrium satisfactorily in 15 (30.0%) women, whilst TRS provided satisfactory images in all cases. Among the 35 women with PMB and a satisfactory endometrial assessment on TVS and TRS, measurements of ET on TRS were significantly lower compared to those on TVS (median difference, −1.2 (interquartile range, −3.0 to −0.4) mm). The overall agreement of TVS and TRS on the presence or absence of endometrial cancer using subjective pattern recognition was 30/35 (85.7%; 95% CI, 74.1–97.3%). While all seven cases of histologically confirmed endometrial cancer were diagnosed correctly on TRS, four were misdiagnosed on TVS as benign polyps or uniformly thickened endometrium.ConclusionsTRS is an acceptable and effective way to assess the endometrium in postmenopausal women with an axial uterus. Among women presenting additionally with PMB, TRS is associated with a higher proportion of satisfactory endometrial assessments and fewer misdiagnoses of endometrial cancer by subjective pattern recognition compared with TVS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: prospective inter‐rater agreement and reliability study

ABSTRACTObjectivesTo assess the inter‐rater agreement and reliability of using subjective pattern recognition for diagnosing endometrial cancer (EC) on ultrasound in women with postmenopausal bleeding (PMB).MethodsThis was a prospective cross‐sectional study conducted at a gynecological rapid‐access clinic, between October 2016 and December 2017, in which consecutive women with PMB and endometrial thickness of ≥ 4.5 mm on transvaginal ultrasound examination were included. Women on hormone replacement therapy or tamoxifen and those with a history of primary gynecological malignancy were excluded. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women as having uniformly thickened endometrium, benign endometrial polyp or EC, using subjective pattern recognition. Inter‐rater reliability of ultrasound diagnosis was assessed using Cohen's kappa (κ) statistic. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy.ResultsForty women were included in the study, with a median age of 61 (interquartile range (IQR), 57–69) years and a median endometrial thickness of 11.0 (IQR, 6.2–20.3) mm. Final histological analysis confirmed 16 (40%) women with EC, 16 (40%) with benign endometrial polyp, four (10%) with atrophic endometrium, three (8%) with proliferative endometrium and one (3%) with endometrial hyperplasia. Inter‐rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, benign endometrial polyp and EC was 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; inter‐rater reliability was good (κ = 0.69; 95% CI, 0.49–0.88). When the ultrasound diagnoses were grouped as either cancer or no cancer, inter‐rater agreement was 85% and inter‐rater reliability was good (κ = 0.78; 95% CI, 0.61–0.95). Rater A correctly identified 14/16 cases of EC and Rater B identified 15/16. EC was misdiagnosed as benign polyps on ultrasound in two women by Rater A and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 90%, respectively.ConclusionsOur results show good inter‐rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, benign endometrial polyp and EC on ultrasound in women with PMB. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.