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Endometrium and its pathologies
- 1. Endometrium & its pathologies Presented by : Dr Alma Swathi Dsouza Moderator: Dr Supreetha Hegde 1
- 2. ⊳ age ⊳ menstrual history ⊳ hormone replacement & tamoxifen. ⊳ Both benign and malignant conditions affect the endometrium. ⊳ Benign conditions must be distinguished from malignant & premalignant conditions. ⊳ M/C used -pelvic USG with TAS and TVS techniques. ⊳ HSG & MRI 2
- 4. 4 Normal appearance ● Thin, echogenic line. ● 1/4th of neonates --fluid collection in endometrium
- 5. 5 Pathological appearance ● Hydrocolpos- distension of vagina ● Hydrometrocolpos-dilatation of uterus + vagina ● Ovarian cysts
- 7. 7 Normal endometrium ● USG 1st line ● 2 layers ● Mid sag TVS image- best measurement ● Immediately ---menses ET : 1-4 mm
- 8. 8 Menstruation ● Thin echogenic line ● 1-4 mm Proliferative phase ● Day 6-14 ● Thicker --5-7mm ● More echogenic compared to myometrium ● (glands, blood vessels and stroma) Late proliferative/periovulat ory ● Multi layered appearance ● Echogenic basal layer ● Hypoechoic inner functional layer ● Thin echogenic median Layer ● 11 mm Secretory ● 7-16mm ● More echogenic (stromal edema, glands distended with mucus and glycogen) Mid secretory Max thickness
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- 13. 13 Normal appearance ● Thin, homogenous & echogenic double-layer thickness of less than 5 mm without focal thickening excludes significant disease and is consistent with atrophy
- 14. ET thickest prior to progestin exposure and thinnest after progestin phase 14 Cyclic estrogen & progestin therapy ET Vary upto 3mm Unopposed estrogen ET >8mm consider biopsy Progesterone + estrogen therapy Scan at the beginning or end to check change in ET
- 15. Postmenopausal bleeding Causes: ● endometrial atrophy ● endometrial polyps ● submucosal fibroids ● endometrial hyperplasia endometrial carcinoma ● estrogen withdrawal 15
- 19. 19
- 21. Endometrial Adenocarcinoma ● M/C gynecologic malignancy ● in developing countries, it is the 2nd M/C abnormal uterine bleeding (intermenstrual or postmenopausal) in more than 80% of cases. ● EC is more common during the 6th and 7th decades 21
- 22. Endometrial Adenocarcinoma ● US signs of endometrial carcinoma include heterogeneity and irregular endometrial thickening ● These signs are nonspecific ● Biopsy ● More specific sign is irregularity of endometrium- myometrium border. ● Intrauterine fluid collections - raise concern for endometrial carcinoma. 22
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- 30. Intrauterine fluid collections ● tiny amount of fluid within the postmenopausal endometrial canal may be considered normal ● associated with both endometrial & cervical cancers ● obstructing tumor must be excluded ● premenopausal patients, fluid collections are M/C associated with menstruation, early IUP, or the pseudogestational sac in an ectopic pregnancy 30
- 32. 32
- 34. IUDS 34
- 35. IETA In an attempt to standardise the ultrasound examination of the endometrium and the uterine cavity, the International Endometrial Tumor Analysis (IETA) group ● how to perform an ultrasound examination of the endometrium and of the uterine cavity ● terms and definitions to be used to report the ultrasound findings 35
- 36. ● The ultrasound examination should start with the acquisition of a proper midsagittal section of the uterus ● If 3D acquisition is not available, the endometrial thickness should NOT be measured (it should be reported as ‘not measurable’, together with a short explanation of the reason why) ● Fluid instillation sonography will usually highlight the endometrium enabling a reliable endometrial measurement. ● The endometrium is measured in midsagittal section where the endometrium is considered to be at its thickest 36
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- 44. 44
- 45. Conclusion There are many different imaging appearances of the normal and abnormal endometrium. Although US is almost always the first modality used in the radiologic work-up of endometrial disease, the use of multiple imaging modalities is common. Whether using US, MR imaging, sonohysterography, or hysterosalpingography, radiologists must understand that the appearance of the endometrium is dynamic. They must take into account the patient’s age, stage in the menstrual cycle, and pregnancy status and whether she has undergone hormonal replacement therapy or tamoxifen therapy. 45
- 46. Thank you
Notas del editor
- Female gynaecologic conditions arising from the endometrium are common and depend on a woman's age, her menstrual history, and the use of medications such as hormone replacement and tamoxifen. Both benign and malignant conditions affect the endometrium. Benign conditions must be distinguished from malignant and premalignant conditions. The most commonly used imaging modality for evaluating the endometrium is pelvic ultrasound with transabdominal and transvaginal techniques. Additional imaging methods include hysterosonography and magnetic resonance imaging
- endometrium generally appears as a thin, echogenic line Approximately one-fourth of neonates will have fluid collections within the endometrial cavity Normal pediatric endometrium. in a 2-year-old girl demonstrates a thin endometrium
- The most common pelvic masses in neonates include hydrocolpos, hydrometrocolpos, and ovarian cysts. Hydrocolpos is characterized by distention of the vagina Hydrometrocolpos is characterized by dilatation of both the uterus and vagina with serous fluid and possibly urine if there is a urogenital sinus The endometrium is intrinsically normal, but the endometrial cavity is distended with fluid. Both hydrocolpos and hydrometrocolpos result from vaginal or cervical stenosis, hypoplasia, or agenesis US demonstrates a cystic midline mass with internal echoes representing mucoid material and cellular debris On the other hand, hematocolpos and hematometrocolpos in adolescent girls are generally associated with an imperforate hymen without an increase in associated congenital anomalies. US demonstrates an echogenic, tubular, cystic midline mass with internal echoes representing fluid and debris Hematometrocolpos in a 12-year-old girl with abdominal pain. Sagittal US image demonstrates a markedly distended vagina (straight arrow) and uterine cavity (curved arrow).
- The best way to measure the endometrial thickness is on a midsagittal transvaginal image. The normal endometrium is composed of 2 layers and the combined thickness of the 2 layers depends on where a woman is in her menstrual cycle.
- In this stage, the endometrium may measure up to 11 mm in thickness. The layered appearance usually disappears 48 hours after ovulation.
- Immediately following menses, the endometrium is a thin echogenic line measuring 1-4 mm (Figure 1). normal endometrium in periovulatory phase. There is a trilaminar appearance. Central functional layer of endometrium is relatively hypoechoic. 3 echogenic lines formed by the 2 basal layers of hyperechoic endometrium and the collapsed endometrial cavity
- normal endometrium in the secretory phase. endometrium measures 15 mm Endometrium is echogenic due to mucus and glycogen in the endometrial cells. ) A 51-year-old woman with postmenopausal bleeding. Transvaginal sagittal ultrasound (US) shows atrophic endometrium that measures 2 mm (arrowheads; typically less than 5 mm). The myometrium is heterogeneously echogenic in the fundus due to calcified arcuate arteries (asterisk).
- The MR imaging appearance of normal endometrium is best demonstrated on T2-weighted images because the uterus has homogeneous intermediate signal intensity with T1-weighted sequences. T2-weighted images delineate the uterine zonal anatomy. The normal endometrium is of uniformly high signal intensity, and the inner myometrium, or junctional zone, is of uniformly low signal intensity Normal premenopausal endometrium. T2- weighted MR image shows the normal endometrium (straight arrow) and junctional zone (curved arrow).
- The postmenopausal examination should take into consideration patient’s clinical history (eg, vaginal bleeding) and whether she has undergone hormonal replacement therapy. The normal postmenopausal endometrium should appear thin, homogeneous, and echogenic. In general, a double-layer thickness of less than 5 mm without focal thickening excludes significant disease and is consistent with atrophy Homogeneous, smooth endometria measuring 5 mm or less are considered within the normal range with or without hormonal replacement therapy
- The endometrium in a patient undergoing hormonal replacement therapy may vary up to 3 mm if cyclic estrogen and progestin therapy is being used (22). The endometrium will appear thickest prior to progestin exposure and thinnest after the progestin phase. Imaging should be performed at the beginning or end of a cycle of treatment, when the endometrium will be at its thinnest and any pathologic thickening will be most prominent. A patient undergoing unopposed estrogen therapy with endometrial thickening exceeding 8 mm should be considered for biopsy, whereas patients receiving progesterone in addition to estrogen can be rescanned at the beginning or end of the following cycle to determine if there has been a change in endometrial thickness
- Imaging should take place immediately after bleeding has stopped, when the endometrium is presumed to be thinnest and any disease entity will be most prominent. Endometrial thickness less than 4 –5 mm at transvaginal US generally excludes cancer
- Postmenopausal endometrial atrophy. (15) Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid. (16) T2-weighted MR image demonstrates an atrophic postmenopausal endometrium (arrows). Any thickness greater than 5 mm in the setting of postmenopausal bleeding or any endometrial heterogeneity or focal thickening seen at transvaginal US should be investigated further with sonohysterography, biopsy, or hysteroscopy.
- Endometrial polyps are a common cause of postmenopausal bleeding and are most frequently seen in patients receiving tamoxifen. Polyps are best seen at sonohysterography and appear as echogenic, smooth, intracavitary masses outlined by fluid The polyp may be broad-based and sessile or pedunculated The point of attachment should not disrupt the endometrial lining. Polyps may also be seen at hysterosalpingography as pedunculated filling defects within the uterine cavity T2-weighted MR imaging as low signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium Color Doppler US may be used to image vessels within the stalk. Fibroids or foci of endometrial hyperplasia or carcinoma can mimic a sessile polyp, and foci of atypical hyperplasia are sometimes found within polyps Endometrial polyp. Sonohysterogram reveals a small polyp attached by a stalk to the endometrium (black arrow). An echogenic focus in the endometrial cavity (white arrow) represents injected air. On hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).
- They are commonly identified at US as hypoechoic solid masses, but they may be heterogeneous or hyperechoic, depending on the degree of degeneration and calcification. Fibroids tend not to interrupt the endometrium unless they are submucosal in location. Submucosal fibroids may distort the uterine cavity with varying degrees of intracavitary extension and are best visualized at sonohysterography Submucosal fibroid. (a) Transvaginal US image reveals a uterine mass (arrows) with posterior acoustic shadowing. (b) Sonohysterogram reveals that the mass is submucosal in location, a finding that is consistent with an echogenic fibroid.
- At hysterosalpingography, submucosal fibroids are seen as filling defects with enlargement or deformity of the uterine cavity (Fig 21). At T1- weighted MR imaging, fibroids appear iso- to hypointense relative to the myometrium, whereas at T2-weighted imaging they appear homogeneously hypointense or heterogeneously hyperintense when degeneration is present
- Endometrial hyperplasia is an abnormal proliferation of endometrial stroma and glands All types of endometrial hyperplasia (cystic, adenomatous, atypical) can cause diffusely smooth or, less commonly, focal hyperechoic endometrial thickening Endometrial hyperplasia is considered whenever the endometrium appears to exceed 10 mm in thickness, especially in menopausal patients Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia (cursors). This finding was confirmed at biopsy
- Adenocarcinoma.—Endometrial adenocarcinoma is the most common invasive gynecologic malignancy, US signs of endometrial carcinoma include heterogeneity and irregular endometrial thickening These signs are nonspecific and can be seen in endometrial hyperplasia as well as polyps, leading to biopsy of almost any irregularity in the setting of postmenopausal bleeding. A more specific US sign is irregularity of the endometrium-myometrium border, a finding that indicates invasive disease. A small amount of fluid in the endometrial canal is likely related to benign cervical stenosis and does not require further evaluation. An intrauterine fluid collection in a postmenopausal patient, although possibly related to cervical stenosis, should raise concern for endometrial (or cervical) carcinoma. EC spreads by direct infiltration or via lymphatic, transtubal peritoneal seeding or hematogenous routes. Locally, EC initially invades the myometrium and then the endocervix. After transserosal spread, direct invasion of the parametrium, bladder, or bowel may occu
- Stage I reflects ECs that are confined to the uterine corpus. It is further divided into stages IA and IB. Stage IA reflects tumors that are confined to the inner endometrium and invade less than 50% of the myometrial thickness. Stage IB represents tumors with more than 50% of myometrial thickness invasion. Stage III represents tumor with local or regional spread beyond the uterus, but not outside the true pelvis. It is further divided into stage IIIA which includes tumors that invade the uterine serosa and/or adnexa, stage IIIB which includes tumors that extend into the parametrium and/or with vaginal involvement, and stage IIIC which includes tumors with spread to pelvic or para-aortic lymph nodes. Stage IIIC is further divided into stage IIIC1 when the tumor presents with pelvic lymph node involvement and stage IIIC2 when there is para-aortic lymph node involvement (with or without pelvic nodes). Stage IV represents tumors that are locally advanced or have distant metastases. It is further divided into stage IVA that includes tumors with extension to the bladder or bowel mucosa and stage IVB consisting of tumors that have distant metastases.
- endometrial thickness threshold of 5 mm, in postmenopausal women, is used to define abnormal endometrial thickening endometrial cancer. demonstrate a thickened and heterogeneous endometrium measuring 2.0 cm (arrows).
- It can be difficult to delineate the tumor margins on ultrasound, especially when it is diffusely infiltrating the myometrium Myometrial invasion is suggested when there is irregularity of the endometrium - myometrium border and disruption of the subendometrial halo (inner layer of myometrium) or the tumor extends asymmetrically into the myometrium A 72-year-old female with endometrial cancer. thickened and heterogeneous endometrium (arrows) with ill-defined anterior border and no clear separation from the myometrium (arrowheads), suggestive of myometrial invasion
- On contrast-enhanced CT, EC appears as a hypoattenuating and hypoenhancing mass in the endometrial cavity [Figure 3]. However, this appearance is nonspecific and the differential diagnosis of a hypoenhancing endometrial mass on CT includes submucosal leiomyomas, endometrial polyps, or cervical stenosis CT's poor soft tissue differentiation limits its use in the local staging of EC. CT is less sensitive and less specific in accurately visualizing myometrial invasion and cervical involvement than MRI. A 66-year-old female with endometrial cancer. (A) Coronal and (B) sagittal reformatted contrast-enhanced computed tomography images of the pelvis show thick hypodense and hypoenhancing endometrium (arrows). (C) T2W MR image showing a thick and heterogeneous endometrium (arrow) in this patient with biopsy-proven diagnosis of endometrial cancer
- MRI is considered the most accurate imaging modality. On MRI, EC is usually seen as a hypo-to-isointense mass on T1-weighted images (T1WI) with an intermediate signal intensity lower than the normal endometrium on T2-weighted images (T2WI). EC enhances less than the myometrium A 64-year-old female with endometrial cancer. (A) T2W image show a hyperintense signal intensity tumor distending the endometrial cavity (arrow). (B) On T1W post-contrast image, the tumor (arrow) is low in signal compared to the enhancing adjacent myometrium. It presents restricted diffusion with high signal on DW images (C) and low signal on ADC map (D) (arrows). (E) It presents with high FDG uptake on FDG-PET/CT (arrow)
- Depth of myometrial invasion is one of the most important prognostic factors[27] The depth of myometrial invasion is optimally depicted with T2-weighted sequences. T2W image showing high signal intensity fluid in endometrial cavity (black arrow) with intact low signal intensity junctional zone (white arrows). (B) T1W post-contrast image shows no evidence of myometrial invasion or cervical involvement indicating stage IA disease
- Dynamic contrast-enhanced MR imaging improves the accuracy of the assessment of the depth of myometrial invasion. EC enhances less than normal myometrium after administration of intravenous gadolinium Sagittal T2W MR image, (B) T1W post-contrast image, (C) DW image, and (D) ADC map image show a large and irregular endometrial mass (white arrows) which disrupts the cervical stroma (black arrowheads), but does not extend beyond the uterus indicating stage II disease. Note normal posterior cervical lip (white arrowheads)
- Although a tiny amount of fluid within the postmenopausal endometrial canal may be considered normal (44), any significant fluid collection is abnormal and requires careful evaluation of the uterus and adnexal structures for associated findings. Intrauterine fluid collections are associated with both endometrial and cervical cancers (45– 47). An obstructing tumor must be excluded even when cervical stenosis has been identified clinically. In premenopausal patients, fluid collections are most commonly associated with menstruation, early IUP, or the pseudogestational sac in an ectopic pregnancy. In prepubertal patients, fluid in the endometrial canal may be related to hematometrocolpos. Other benign causes of obstruction leading to intrauterine fluid production include polyps, infection, and submucosal fibroids. The fluid may range in appearance from hypoechoic to hyperechoic depending on whether it is composed of serum, mucin, or blood.
- Tamoxifen causes the endometrium to appear thickened, irregular, and cystic at US The punctate cystic spaces may be secondary to reactivation of adenomyosis within the inner myometrium or to obstructed glands in the endometrium due to the drug’s weak estrogenic effects Two MR imaging patterns associated with tamoxifen have been described. The first pattern manifests as homogeneous high signal intensity on T2-weighted images, The second pattern manifests as heterogeneous signal intensity on T2-weighted images Endometrial thickening associated with tamoxifen therapy. (a) US image reveals marked endometrial thickening (arrowheads) associated with subendometrial cysts (arrows) resulting from tamoxifen therapy.
- Endometrial thickening associated with tamoxifen therapy. T2-weighted MR image shows a thickened endometrium (straight arrows) with focal areas of decreased signal intensity (curved arrow) associated with polyps resulting from tamoxifen therapy.
- Endometrial adhesions are posttraumatic or postsurgical in nature and can cause Asherman syndrome, which includes infertility, recurrent pregnancy loss, and amenorrhea. Sonohysterography may demonstrate synechiae as echogenic bands bridging the uterine cavity. If the bands are thick and fibrotic, they may prevent complete uterine distention. Hysterosalpingography will demonstrate similar findings, with incomplete filling of the endometrial cavity and numerous irregular filling defects (Fig 27).
- Intrauterine contraceptive devices (IUD) should lie within the endometrial cavity IUDs should be readily detected at US as highly echogenic structures with distal acoustic shadowing (Fig 28). If US cannot help identify an IUD within the endometrial canal, conventional radiography or CT may be performed to determine whether it lies within the peritoneal cavity. If so, the diagnosis of perforation of the uterine wall can be made
- In an attempt to standardise the ultrasound examination of the endometrium and the uterine cavity, the International Endometrial Tumor Analysis (IETA) group on how to perform an ultrasound examination of the endometrium and of the uterine cavity and on the terms and definitions to be used to report the ultrasound findings
- The ultrasound examination should start with the acquisition of a proper midsagittal section of the uterus, followed by the measurement of the endometrium. The whole uterus should be scanned from right to left and from fundus to cervix. In case the endometrium is not readily visible at first glance, it can usually be traced starting from the endocervical canal and then moving up. Sometimes the uterus is twisted laterally, precluding the visualisation of a proper mid‐sagittal view. In these cases, minimal manipulation of a 3D volume usually enables the sonographer to achieve the correct section. If 3D acquisition is not available, the endometrial thickness should NOT be measured (it should be reported as ‘not measurable’, together with a short explanation of the reason why). If the endometrium is not visible on unenhanced ultrasound, switching on the colour/power Doppler may help the orientation by visualising the vascularisation of the myometrium stopping at the basal layers of the endometrium. Fluid instillation sonography will usually highlight the endometrium enabling a reliable endometrial measurement. The endometrium is measured in midsagittal section where the endometrium is considered to be at its thickest (and this is not necessarily in the fundus)
- The endometrium should be measured where it appears to be at its thickest. (b) When intracavitary fluid is present, the thickness of both single layers is measured in the sagittal plane and the sum is recorded
- After measurement, the examiner should report on the echogenicity of the endometrium (uniform or not uniform) Uniform endometrial echogenicity: (a) three‐layer pattern; (b) hypoechogenic; (c) hyper‐ echogenic; (d) isoechogenic
- the endometrial midline, the endometrial‐myometrial junction, the colour score Figure 3 (a) colour score of 1: no colour; (b) colour score of 2: minimal colour (i.e. minimal flow); (c) colour score of 3: moderate colour (i.e. moderate flow); (d) colour score of 4: abundant colour (i.e. abundant flow).
- and, if applicable, the vascular pattern Figure 4 Vascular pattern: single ‘dominant’ vessel (a) without branching and (b) with branching; multiple vessels with (c) focal origin, (d) multifocal origin or (e) scattered vessels; (f) circular flow.
- The principle of FIS is that fluid (saline or gel) acts as a negative contrast agent (fluid being echolucent). Especially focal lesions protruding into the uterine cavity (such as polyps, fibroids) are highlighted against the echolucent background of the instilled fluid
- An endometrial lesion may be localised or extended Estimation of the extend of an endometrial lesion: (a) localised, if the base of the lesion < 25% of the endometrial surface; (b) extended, if the base lesion > of the endometrial surface
- A localised lesion may be pedunculated of sessile Type of localized lesion: (a) pedunculated if the a/b ratio < 1; sessile if the a/b ratio >1
- An intracavitary fibroid should be graded as grade 0, grade 1 or grade 2 Proportion of the myoma protruding into the uterine cavity: (a) grade 0 (100% in the cavity); (b) grade 1 ( 3 50% in the cavity); (c) grade 2 (< 50% in the cavity). The colour score and, if applicable, the vascular pattern within the lesion should also be described
- There are many different imaging appearances of the normal and abnormal endometrium. Although US is almost always the first modality used in the radiologic work-up of endometrial disease, the use of multiple imaging modalities is common. Whether using US, MR imaging, sonohysterography, or hysterosalpingography, radiologists must understand that the appearance of the endometrium is dynamic. They must take into account the patient’s age, stage in the menstrual cycle, and pregnancy status and whether she has undergone hormonal replacement therapy or tamoxifen therapy.