Evaluation of three-dimensional ultrasound measurement techniques used to assesses myometrial invasion in endometrial cancer

Purpose: To assess interobserver variation and efficiency of various measurements on 3-dimensional transvaginal ultrasound (3DTVS) and saline infusion sonography (3D-SIS) for preoperative measurement of deep myometrial invasion (DMI) in endometrial cancer. Materials and Methods: One hundred ten women with atypical endometrial hyperplasia or endometrial adenocarcinoma had preoperative 3D-TVS and 3D-SIS. Endometrial thickness (ET), ET in percent of uterine diameter (PAP) and various volumes were measured. AUC, sensitivity, and specificity of most optimal cut-points, and kappa statistics for observer variation were calculated. Results: PAP identified two-thirds of women with DMI. ET and 3D volume measurements had substantial observer agreement compared to moderate agreement of subjective evaluation of DMI. AUC for measurements ranged 0.63–0.73 for identification of DMI. Subjective evaluation of DMI had highest AUC only marginally improved by adding PAP. Conclusion: Preoperative staging of endometrial cancer is not improved by adding 3D volume measurements to subjective evaluation, but PAP could be used to select women with a high risk of DMI for further MRI.

Endometrial neoplasms; Imaging; 3-dimensional; Ultrasonography; Tumor burden; Preoperative procedures.

[1] Frost J., Webser K., Bryant A., Morrison J.: “Lymphadenectomy for the management of endometrial cancer (Review)”. Cochrane Database Syst. Rev., 2015, 9, 52.

[2] Mirza M., Jørgensen M., Larsen S., Henrik K., Kahn R., Franzmann M.: “Dansk Gynækologisk Cancer Gruppe: Retningslinier for Visitation, Diagnostik, Behandling og Kontrol af Cancer Corporis Uteri”. Available at: http://www.dgcg.dk/images/retningslinier/Corpuscancer/Endometriecancer_2010-jan.pdf

[3] Çetin Ç., Özdemir S., Esen H., Balc O., Yilmaz O.: “The clinical value of preoperative and intraoperative assessments in the management of endometrial cancer”. Int. J. Gynecol. Cancer, 2010, 20, 358.

[4] Frumovitz M., Slomovitz B.M., Singh D.K., Broaddus R.R., Abrams J., Sun C.C., et al.: “Frozen section analyses as predictors of lymphatic spread in patients with early-stage uterine cancer”. J. Am. Coll. Surg., 2004, 199, 388.

[5] Furukawa N., Takekuma M., Takahashi N., Hirashima Y.: “Intraoperative evaluation of myometrial invasion and histological type and grade in endometrial cancer: Diagnostic value of frozen section”. Arch. Gynecol. Obstet., 2010, 281, 913.

[6] Özdemir S., Çelik Ç., Emlik D., Kiresi D., Esen H.: “Assessment of myometrial invasion in endometrial cancer by transvaginal sonography, doppler ultrasonography, magnetic resonance imaging and frozen section”. Int. J. Gynecol. Cancer, 2009, 19, 1085.

[7] Quinlivan J.A., Petersen R.W., Nicklin J.L.: “Accuracy of frozen section for the operative management of endometrial cancer”. Br. J. Obstet. Gynaecol., 2001, 108, 798.

[8] Traen K., Hølund B., Mogensen O.: “Accuracy of preoperative tumor grade and intraoperative gross examination of myometrial invasion in patients with endometrial cancer”. Acta Obstet. Gynecol. Scand., 2007, 86, 739.

[9] Franchi M., Ghezzi F., Melpignano M., Cherchi P.L., Scarabelli C., Apolloni C., et al.: “Clinical value of intraoperative gross examination in endometrial cancer”. Gynecol. Oncol., 2000, 76, 357.

[10] Vorgias G., Hintipas E., Katsoulis M., Kalinoglou N., Dertimas B., Akrivos T.: “Intraoperative gross examination of myometrial invasion and cervical infiltration in patients with endometrial cancer: decision-making accuracy”. Gynecol. Oncol., 2002, 85, 483.

[11] Cunha T.M., Félix A., Cabral I.: “Preoperative assessment of deep myometrial and cervical invasion in endometrial carcinoma: Comparison of magnetic resonance imaging and gross visual inspection”. Int. J. Gynecol. Cancer, 2001, 11, 130.

[12] Akbayir O., Corbacioglu A., Numanoglu C., Goksedef B.P.C., Guraslan H., Akagunduz G., et al.: “Combined use of preoperative transvaginal ultrasonography and intraoperative gross examination in the assessment of myometrial invasion in endometrial carcinoma”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2012, 165, 284.

[13] Christensen J.W., Dueholm M., Hansen E.S., Marinovskij E., Lundorf E., Ortoft G.: “Assessment of myometrial invasion in endometrial cancer using three-dimensional ultrasound and magnetic resonance imaging”. Acta Obstet. Gynecol. Scand., 2016, 95, 55.

[14] Ortoft G., Dueholm M., Mathiesen O., Hansen E.S., Lundorf E., Møller C., et al.: “Preoperative staging of endometrial cancer using TVS, MRI, and hysteroscopy”. Acta Obstet. Gynecol. Scand., 2013, 92, 536.

[15] Antonsen S.L., Ulrich L., Høgdall C.: “Patients with atypical hyperplasia of the endometrium should be treated in oncological centers”. Gynecol. Oncol., 2012, 125, 124.

[16] DelMaschio A., Vanzulli A., Sironi S., Spagnolo D., Belloni C., Garancini P., et al.: “Estimating the depth of myometrial involvement by endometrial carcinoma: Efficacy of transvaginal sonography vs MR imaging”. Am. J. Roentgenol., 1993, 160, 533.

[17] Das S.K., Niu X.K., Wang J.L., Zeng L.C., Wang W.X., Bhetuwal A., et al.: “Usefulness of DWI in preoperative assessment of deep myometrial invasion in patients with endometrial carcinoma: a systematic review and meta-analysis”. Cancer Imaging, 2014, 14, 1.

[18] Dueholm M., Christensen J.W., Rydbjerg S., Hansen E.S., Ørtoft G.: “Two- and three-dimensional transvaginal ultrasound with power Doppler angiography and gel infusion sonography for diagnosis of endometrial malignancy”. Ultrasound Obstet. Gynecol., 2015, 45, 734.

[19] De Smet F., De Brabanter J., Van Den Bosch T., Pochet N., Amant F., Van Holsbeke C., et al.: “New models to predict depth of infiltration in endometrial carcinoma based on transvaginal sonography”. Ultrasound Obstet. Gynecol., 2006, 27, 664.

[20] Mercé L.T., Alcázar J.L., López C., Iglesias E., Bau S., Alvarez de los Heros J., et al.: “Clinical usefulness of 3-dimensional sonography and power Doppler angiography for diagnosis of endometrial carcinoma”. J. Ultrasound Med., 2007, 26, 1279.

[21] Mascilini F., Testa A.C., Van Holsbeke C., Ameye L., Timmerman D, Epstein E.: “Evaluating myometrial and cervical invasion in women with endometrial cancer: Comparing subjective assessment with objective measurement techniques”. Ultrasound Obstet. Gynecol., 2013, 42, 353.

[22] Schink J.C., Lurain J.R., Wallemark C.B., Chmiel J.S.: “Tumor size in endometrial cancer: a prognostic factor for lymph node metastasis”. Obstet. Gynecol., 1987, 70, 216.

[23] Alcazar J.L., Pineda L., Martinez-Astorquiza Corral T., Orozco R., Utrilla-Layna J., Juez L., et al.: “Transvaginal/transrectal ultrasound for assessing myometrial invasion in endometrial cancer: a comparison of six different approaches”. J. Gynecol. Oncol., 2015, 26, 201.

[24] Van Holsbeke C., Ameye L., Testa A.C., Mascilini F., Lindqvist P., Fischerova D., et al.: “Development and external validation of new ultrasound-based mathematical models for preoperative prediction of high-risk endometrial cancer”. Ultrasound Obstet. Gynecol., 2014, 43, 586.

[25] Danish Gynecologic Cancer Group: “Guideline for reference, diagnosis, treatment and follow-up of uterine corpus cancer”. Available at: http://www.dgcg.dk/ index.php/guidelines/corpuscancer [26] Karlsson B., Norström A., Granberg S., Wikland M.: “The use of endovaginal ultrasound to diagnose invasion of endometrial carcinoma”. Ultrasound Obstet. Gynecol., 1992, 2, 35.

[27] Raine-Fenning N., Campbell B., Collier J., Brincat M., Johnson I.: “The reproducibility of endometrial volume acquisition and science measurement with the Vocal-imaging program”. Ultrasound Obstet. Gynecol., 2002, 19, 69.

[28] Froud R., Abel G.: “Using ROC curves to choose minimally important change thresholds when sensitivity and specificity are valued equally: The forgotten lesson of pythagoras. Theoretical considerations and an example application of change in health status”. PLoS One, 2014, 9, 1.

[29] Sawicki W., Śpiewankiewicz B., Stelmachów J., Cendrowski K.: “The value of ultrasonography in preoperative assessment of selected prognostic factors in endometrial cancer”. Eur. J. Gynaecol. Oncol., 2003, 24, 293.

[30] Prömpeler H.J., Madjar H., du Bois A., Lattermann U., Wilhelm C., Kommoss F., et al.: “Transvaginal sonography of myometrial invasion depth in endometrial cancer”. Acta Obstet. Gynecol. Scand., 1994, 73, 343.

[31] Weber G., Merz E., Bahlmann F., Mitze M., Weikel W., Knapstein P.G.: “Assessment of myometrial infiltration and preoperative staging by transvaginal ultrasound in patients with endometrial carcinoma”. Ultrasound Obstet. Gynecol., 1995, 6, 362.

[32] Gabrielli S., Marabini A., Bevini M., Linsalata I., Falco P., Milano V., et al.: “Transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma”. Ultrasound Obstet. Gynecol., 1996, 7, 443.

[33] Kurjak A., Kupesic S., Sparac V., Bekavac I.: “Preoperative evaluation of pelvic tumors by Doppler and three-dimensional sonography”. J. Ultrasound Med., 2001, 20, 829.

[34] Mercé L.T., Alcázar J.L., Engels V., Troyano J., Bau S., Bajo J.M.: “Endometrial volume and vascularity measurements by transvaginal three-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: Intraobserver reproducibility”. Gynecol. Oncol., 2006, 100, 544.

[35] Abuhamad A.Z., Singleton S., Zhao Y., Bocca S.: “The Z technique: an easy approach to the display of the mid-coronal plane of the uterus in volume sonography”. J. Ultrasound Med., 2006, 25, 607.

[36] Dueholm M., Marinovskij E., Hansen E.S., Moller C., Ortoft G.: “Diagnostic methods for fast-track identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm”. Menopause, 2015, 22, 616.