International Endometrial Tumor Analysis Research Articles

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort.

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

International Endometrial Tumor Analysis (IETA) terminology for the evaluation of endometrial color flow and vascular pattern in women with abnormal uterine bleeding – a reproducibility study among ob-gyn ultrasound subspecialists in a tertiary training hospital

BACKGROUND: The International Endometrial Tumor Analysis (IETA) group developed a catalog of standardized terms to describe findings that may be associated with uterine pathology. However, there is a lack of reliability studies for these descriptors in the literature. OBJECTIVE: The objective of this study was to estimate interobserver and intraobserver reliability with regard to the IETA group descriptors for endometrial vascular characteristics in women with abnormal uterine bleeding. MATERIALS AND METHODS: Five nonexpert and five expert raters assessed stored still images of transvaginal ultrasound examinations obtained from 68 women with abnormal uterine bleeding and endometrial thickening. Endometrial vascularity was evaluated using the IETA group descriptors for color flow and vascular pattern. Interobserver agreement was estimated by comparing the assessments of the nonexpert and expert raters. Intraobserver agreement was estimated by repeating the raters’ assessment after 4 weeks. Interrater agreement to the subjective assessment of an expert investigator was also computed. RESULTS AND CONCLUSION: The reproducibility of assigning IETA color score is good regardless of the degree of expertise of the rater, although the experts displayed better interobserver reliability (κ = 0.74 vs. 0.57) and intraobserver reliability (κ = 0.84 vs. 0.63). However, the reproducibility of describing IETA vascular patterns is significantly worse for both expert and nonexpert raters in both interobserver reliability (experts κ = 0.49 vs. 0.34) and intraobserver reliability (experts κ = 0.65 vs. 0.42). Both expert and nonexpert raters exhibited acceptable agreement with the reference standard, with experts performing better for both color score (κ = 0.79 vs. 0.70) and vascular pattern (κ = 0.63 vs. 0.44).

Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3).

The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB. This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology. In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized. We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Application of International Endometrial Tumor Analysis in Abnormal Uterine Bleeding: A Case Report

BACKGROUND: Abnormal uterine bleeding (AUB) is one of the clinical symptoms found in malignant conditions where the incidence of newly diagnosed cancers reached 100,000 cases in Europe in 2012 with an incidence of around 14.7/100,000 women. The International Endometrial Tumor Analysis (IETA) group, formed in Chicago in 2008, published a consensus stating how to examine and measure the endometrium. CASE REPORT: Mrs. M, 49 years old, came to Gynecology Clinic of USU Hospital on February 22, 2021, at 13.00 WIB with the complaints of prolonged menstruation for 2 months with a volume of &gt;10 times changing pads. Menstrual pain was found. Low back pain was found. A history of bleeding between menstrual cycles was found. On ultrasound examination, anteflexed uterus was found with size of 6.95 × 4.2 × 3.85 cm, thickness of the endometrium: 1.64 cm and concluded as AUB-M (thickening of the endometrium). Then, the patient is diagnosed with AUB-M (thickening of the endometrium) and is planned to undergo a diagnostic curettage. Anatomical pathology results showed a complex hyperplasia endometrium without atypia cells. Acute AUB is defined as bleeding profusely so that prompt treatment is needed to prevent blood loss. Ultrasound examination is performed to assess the size, shape of the uterus, the presence of fibroids, polyps, adenomyosis, and uterine anomalies such as uterine didelphys, sometimes polycystic ovaries are also found. Endometrial biopsy can detect more than 90% of cancers. The pathology of the endometrium can diagnose endometrial cancer or determine the likelihood of cancer. These investigative modalities can assist in the diagnosis of endometrial polyps, adenomyosis, leiomyomas, uterine anomalies, and endometrial thickening associated with hyperplasia and malignancy. Curettage is considered to relieve ongoing menorrhagia. According to the SOGC, administration of nonsteroidal anti-inflammatory drugs can inhibit cyclo-oxygenase and reduce levels of endometrial prostaglandins. DISCUSSION: Acute AUB is defined as bleeding profusely so that prompt treatment is needed to prevent blood loss. Ultrasound examination is performed to assess the size, shape of the uterus, the presence of fibroids, polyps, adenomyosis, and uterine anomalies such as uterine didelphys, sometimes polycystic ovaries are also found. Endometrial biopsy can detect more than 90% of cancers. The pathology of the endometrium can diagnose endometrial cancer or determine the likelihood of cancer. These investigative modalities can assist in the diagnosis of endometrial polyps, adenomyosis, leiomyomas, uterine anomalies, and endometrial thickening associated with hyperplasia and malignancy. Curettage is considered to relieve ongoing menorrhagia. According to the SOGC, administration of nonsteroidal anti-inflammatory drugs can inhibit cyclo-oxygenase and reduce levels of endometrial prostaglandins. CONCLUSION: According to IETA, the vascular pattern in the endometrium is reported to be associated with the presence or absence of a “dominant vessel” or other specific pattern. Endometrial thickness is the maximum measurement in the sagittal plane. The accompanying ultrasound provides the measurement of endometrial thickness in the absence of intracavity fluid; the endometrium should be measured where it appears thickest. If intracavity pathology is present, total thickness of endometrium including the lesion should be recorded. Anatomic pathology by curettage is required in women with abnormal bleeding; histological evaluation of the endometrium may identify infectious or neoplastic lesions such as endometrial hyperplasia or cancer.

The Risk of Endometrial Malignancy and Other Endometrial Pathology in Women with Abnormal Uterine Bleeding: An Ultrasound-Based Model Development Study by the IETA Group

Objectives: The aim of this study was to develop a model that can discriminate between different etiologies of abnormal uterine bleeding. Design: The International Endometrial Tumor Analysis 1 study is a multicenter observational diagnostic study in 18 bleeding clinics in 9 countries. Consecutive women with abnormal vaginal bleeding presenting for ultrasound examination (n = 2,417) were recruited. The histology was obtained from endometrial sampling, D&C, hysteroscopic resection, hysterectomy, or ultrasound follow-up for >1 year. Methods: A model was developed using multinomial regression based on age, body mass index, and ultrasound predictors to distinguish between: (1) endometrial atrophy, (2) endometrial polyp or intracavitary myoma, (3) endometrial malignancy or atypical hyperplasia, (4) proliferative/secretory changes, endometritis, or hyperplasia without atypia and validated using leave-center-out cross-validation and bootstrapping. The main outcomes are the model’s ability to discriminate between the four outcomes and the calibration of risk estimates. Results: The median age in 2,417 women was 50 (interquartile range 43–57). 414 (17%) women had endometrial atrophy; 996 (41%) had a polyp or myoma; 155 (6%) had an endometrial malignancy or atypical hyperplasia; and 852 (35%) had proliferative/secretory changes, endometritis, or hyperplasia without atypia. The model distinguished well between malignant and benign histology (c-statistic 0.88 95% CI: 0.85–0.91) and between all benign histologies. The probabilities for each of the four outcomes were over- or underestimated depending on the centers. Limitations: Not all patients had a diagnosis based on histology. The model over- or underestimated the risk for certain outcomes in some centers, indicating local recalibration is advisable. Conclusions: The proposed model reliably distinguishes between four histological outcomes. This is the first model to discriminate between several outcomes and is the only model applicable when menopausal status is uncertain. The model could be useful for patient management and counseling, and aid in the interpretation of ultrasound findings. Future research is needed to externally validate and locally recalibrate the model.

Differences between proximal and distal endometrial monolayer thickness in women aged over 50 years undergoing saline infusion sonohysterography.

Saline infusion sonohysterography (SIS) is a procedure performed to evaluate the endometrium in women with postmenopausal bleeding. To investigate differences in endometrial monolayer measurements in women aged >50 years undergoing SIS. Retrospective study of women aged >50 undergoing SIS. Endometrial echo (EE) was measured according to the International Endometrial Tumor Analysis (IETA) guidelines. Monolayer thickness was compared between anterior and posterior uterine walls and between the monolayer that was proximal or distal to the ultrasound probe. Presence and location of focal thickening and polyps on each of the monolayers were assessed. SIS was performed in 608 patients. Of them, 485 (79.8%) had anteverted, 85 (14%) retroverted, and 38 (6.2%) a midposition uterus. The mean posterior monolayer was thicker than the anterior monolayer (2.14 mm vs. 1.88 mm; P = 0.002). The distal monolayer was thicker than the proximal layer in both anteverted and retroverted uteri (2.18 mm vs. 1.84 mm; P < 0.0001). In 16% of women, the difference between distal and proximal monolayers was ≥1 mm. Focal thickening was seen 3.3 times more frequently in the distal endometrium. Among women with a double layer EE >4 mm, 18.8% had a proximal layer of <2 mm while only 4.6% had a distal EE <2 mm. Distal endometrium measures thicker than the proximal endometrium in most SIS cases and in one out of six women, the difference is >1 mm. The distal layer is three times more likely to contain focal thickening. Sonologists should be conscious of possible enhancement artifact when measuring the EE during SIS.

Роль трансвагинальной соноэластографии в дифференциации злокачественной и доброкачественной патологии эндометрия у женщин в постменопаузе

Objective. To study the clinical significance of transvaginal sonoelastography (TVSE) in the differential diagnosis of endometrial hyperplasia and carcinoma. Patients and methods. Fifty-four patients with postmenopausal bleeding and/or ultrasound features of endometrial pathology (mean age: 67.8 ± 3.2 years) were examined. The average length of postmenopause was 8.12 ± 3.4 years. The strain index (SI), which was measured automatically, was used as the main criterion of TVSE. Results. The mean SI varied widely depending on the histological type of endometrial pathology: 2.0 (0.8–4.0) in patients with endometrial carcinoma; 1.6 (0.4–3.2) in patients with atypical endometrial hyperplasia; 0.8 (0.30–1.60) in patients with endometrial hyperplasia without atypia; 0.6 (0.5–2.40) in patients with endometrial polyps against the background of mucosal atrophy. A significant difference for SI was found only when comparing the group of patients with carcinoma with other groups, regardless of the morphological type of benign pathology (p &lt; 0.05). Conclusion. TVSE allows to supplement the results of transvaginal ultrasound according to IETA (International Endometrial Tumor Analysis) system and improve the differential diagnosis of endometrial carcinoma with other benign endometrial pathologies. Key words: transvaginal ultrasound, sonoelastography, endometrial carcinoma, endometrial hyperplasia, endometrial polyps, strain index

Combination IETA Ultrasonographic Characteristics Simple Scoring Method With Tumor Biomarkers Effectively Improves the Differentiation Ability of Benign and Malignant Lesions in Endometrium and Uterine Cavity.

ObjectivesTo evaluate International Endometrial Tumor Analysis (IETA) ultrasonographic characteristics simple scoring method and tumor biomarkers for the diagnosis of uterine cavity and endometrial lesions.MethodsWe classified and scored the normalized description of IETA ultrasonic characteristics, according to IETA expert consensus literature, previous IETA-related research articles, and the previous research experience of this project group. We conducted a retrospective analysis of the ultrasound images of 594 patients enrolled from January 2017 to June 2020, scored them item by item, and finally calculated the total score of each case. Meanwhile, we combined the results of seven tumor biomarkers. The objective was to evaluate the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve of IETA ultrasonographic characteristics simple scoring method and tumor biomarkers for benign and malignant uterine cavity or endometrial lesions. The diagnostic efficiency between the combined method and the single method was compared.ResultsA total of 594 cases were confirmed by postoperative pathology or surgery records, including 475 benign lesions and 119 malignant lesions. In the simple ultrasound scoring method, the average score of benign lesions was 3.879 ± 1.279 and that of malignant lesions was 9.676 ± 4.491. If ≥6.5 points was taken as the cutoff value for the judgment of malignant lesions, the sensitivity, specificity, coincidence rate, and the area under receiver operating characteristic (ROC) curve (AUC) were 76.5%, 96.0%, 92.1%, and 0.935, respectively. The difference in tumor antigen 19-9 (CA19-9) and human epididymal protein 4 (HE4) between benign and malignant lesions was statistically significant (all p ≤ 0.01). The other five tumor biomarkers (CA125, CA15-3, SCC-Ag, AFP, and CEA) showed no statistically significant difference in benign and malignant lesions. If the value of CA19-9 ≥13.96 U/ml was taken as cutoff value, the sensitivity, specificity, and coincidence rate of the diagnosis of endometrial benign and malignant lesions were 54.8%, 74.7%, and 70.7%, respectively, and the AUC was 0.620. If the value of HE4 ≥ 39.075 pmol/L was taken as cutoff point, the sensitivity, specificity, coincidence rate, and AUC were 77.4%, 67.9%, 69.8%, and 0.796, respectively. The sensitivity was increased to 97.6% and the AUC was 0.939 when IETA ultrasound characteristics simple scoring method combined CA19-9 and HE4 in parallel test.ConclusionsIn IETA ultrasound characteristics simple scoring method, with ≥6.5 points as the cutoff value, it could quickly and accurately assess the benign and malignant in uterine cavity and endometrial lesions, with high diagnostic value. The diagnostic efficacy of seven tumor biomarkers was all mediocre. Combining with these two methods, the comprehensive diagnosis could improve sensitivity and accuracy and reduce the risk of missed diagnosis.

The Correlation of the IETA Ultrasound Score with the Histopathology Results for Women with Abnormal Bleeding in Western Romania.

In the early differential diagnosis of endometrial cancer (EC), decisive and mandatory histological aspects are considered, in addition to obvious clinical manifestations. In addition, sonographic aspects are characteristic in relation to the stage, degree, and histological types of identified cancer. This bi-center retrospective observational study included 594 women with abnormal uterine bleeding outside pregnancy, for which a biopsy was performed in the Obstetrics and Gynecology Departments of the Emergency County Hospitals of Arad and Timis Counties, Romania, between 2015 and 2019. Most of the cases were represented by EC or endometrial hyperplasia (EH). Of the 594 cases, 25.5% (n = 153) were EC at women aged between 41 and 85 years. High International Endometrial Tumor Analysis (IETA) scores (3, 4) were associated with a relative risk of 2.9335 compared with other endometrial lesions (95% CI 2.3046 to 3.734, p < 0.0001, NNT 1.805). Histological aspects and pelvic ultrasound using IETA scores represent valuable noninvasive assets in diagnosing and differentiating endometrial cancer from benign uterine pathology.

Typical ultrasound features of various endometrial pathologies described using International Endometrial Tumor Analysis (IETA) terminology in women with abnormal uterine bleeding.

To describe the ultrasound features of different endometrial and other intracavitary pathologies inpre- and postmenopausal women presenting with abnormal uterine bleeding, using the International Endometrial Tumor Analysis (IETA) terminology. This was a prospective observational multicenter study of consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler and fluid-instillation sonography were performed. Endometrial sampling was performed according to each center's local protocol. The histological endpoints were cancer, atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (EIN), endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma and other. For fluid-instillation sonography, the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint, we report typical ultrasound features using the IETA terminology. The database consisted of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler was performed in all cases and fluid-instillation sonography in 1857. In 2216 women, endometrial histology was available, and these comprised the study population. Median age was 49 years (range, 19-92 years), median parity was 2 (range, 0-10) and median body mass index was 24.9 kg/m2 (range, 16.0-72.1 kg/m2 ). Of the study population, 843 (38.0%) women were postmenopausal. Endometrial polyps were diagnosed in 751 (33.9%) women, intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None (0% (95% CI, 0.0-5.5%)) of the 66 women with endometrial thickness < 3 mm had endometrial cancer or atypical hyperplasia/EIN. Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 (1.1% (95% CI, 0.4-3.1%)) endometria with a three-layer pattern, in three of 459 (0.7% (95% CI, 0.2-1.9%)) endometria with a linear endometrial midline and in five of 337 (1.5% (95% CI, 0.6-3.4%)) cases with a single vessel without branching on unenhanced ultrasound. The typical ultrasound features of endometrial cancer, polyps, hyperplasia and atrophy and intracavitary leiomyomas, are described using the IETA terminology. The detection of some easy-to-assess IETA features (i.e. endometrial thickness < 3 mm, three-layer pattern, linear midline and single vessel without branching) makes endometrial cancer unlikely. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Endometrial state in women with uterine factor of infertility at the stage of preconceptional care according to sonography and doplerometry data

In recent years, the number of cases of uterine factors infertility is constantly growing. Unfortunately, the analysis of scientific works is characterized by the lack of data on the improvement of the diagnostic algorithm and the expediency of accentuating the significance of the preconceptional stage. The purpose of this study was to develop sonographic criteria for endometrial readiness for implantation at the stage of preconceptional care in women with uterine factor infertility. The first group included 80 women with uterine factor infertility, the second group (40 women) consisted of patients who entered the IVF program for the first time. The control group consisted of 30 women with normal fertility. Studies of the structure of the endometrium, myometrium and ovarian tissue were performed on a Voluson 760, on the 4th-6th days of the menstrual cycle (according to the International Endometrial Tumor Analysis (IETA) – consensus of ultrasound description of endometrial changes) and on the 20th-24th days of the cycle. To assess the indirect signs of chronic endometritis the echographic criteria developed by V.N. Demidov et al. were used. The sonographic diagnosis was verified during morphological and immunohistochemical examination. The most common menstrual disorders in women with uterine factor infertility were algodysmenorrhea – 33.3%, algohypomenorrhea –22.2%, hypoopsomenorrhea – 64.4%. Thinning of the endometrium was significantly more often observed in the group with uterine factor of reproductive disorders; one third of patients (33.8%) had dyschronosis of the endometrial echotexture; heterogeneity of M-echo with a predominance of hyperechoic areas was diagnosed in 41.3% of cases. Hyperechogenic inclusions in the basal layer, multiple structures of a linear nature and increased echogenicity were revealed in every fifth patients and hypoechoic uterine contour – in 47.5% of cases. The most significant odds ratio associated with IVF failures and early reproductive loss was found in patients with endometriosis (OR – 5.85; 95% CI: 1.32-13.32), synechiae (OR – 2.27; 95% CI: 0.96-10.16) and polyps (OR – 2.48; 95% CI: 0.84-11.36). It was possible to distinguish the following criteria of functional readiness of the endometrium for implantation: endometrial thickness was more than 8 mm, compliance with the echostructure phase of the menstrual cycle, homogeneity of M-echo, absence of hyper-and hypoechoic inclusions, and full hemodynamics in the vascular pool of the pelvis.

Dynamic contrast‐enhanced ultrasound improves diagnostic performance in endometrial cancer staging

To compare the sensitivity and specificity of conventional two-dimensional transvaginal ultrasound/power Doppler (2D-TVU/PD) alone and 2D-TVU/PD combined with dynamic contrast-enhanced ultrasound (DCE-US) in diagnosing deep myometrial invasion (MI) and cervical stromal involvement (CSI) in women with endometrial cancer (EC), and to assess the association of DCE-US semiquantitative and qualitative variables with International Federation of Gynecology and Obstetrics (FIGO) Stage ≥ IB and 'high-risk' cancer. This was a prospective study of 101 consecutive women with biopsy-confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, a tertiary referral center. All consenting women underwent DCE-US using a 1.5-2.5-mL intravenous bolus of SonoVue contrast agent, as well as conventional 2D-TVU/PD examination. DCE-US videoclips were analyzed with regard to filling (global or focal), wash-in (prior, simultaneous or after) and wash-out (global or focal) patterns of the contrast agent in the tumor compared with the surrounding tissue, as well as semiquantitative DCE-US parameters (wash-in slope, time-to-peak, peak intensity and area under the time-intensity curve (TIC)) obtained from a TIC. The study cohort was compared with a control cohort of women with EC examined at our center according to the International Endometrial Tumor Analysis protocol using 2D-TVU/PD only, matched at a ratio of 3:1 for FIGO stage and grade. The sensitivity and specificity of 2D-TVU/PD alone in the control cohort and in combination with DCE-US in the study cohort in the diagnosis of deep MI, CSI and high-risk cancer (defined as FIGO Stage ≥ IB and/or Grade 3 endometrioid and/or non-endometrioid histology) were compared, using pathological evaluation after hysterectomy as the 'gold standard'. After exclusions, 93 women were included in the study cohort and were matched to 279 women in the control cohort. The prevalence of FIGO Stage IA, Grade 1-2 EC was 52% in both cohorts. The sensitivity of 2D-TVU/PD with DCE-US in the study cohort was higher than that of 2D-TVU/PD alone in the control cohort in diagnosing both deep MI (0.74 vs 0.62; P = 0.036) and CSI (0.75 vs 0.51; P < 0.001), whereas the specificity was not significantly different (0.87 vs 0.85 and 0.96 vs 0.95, respectively). Compared with 2D-TVU/PD alone, the specificity of 2D-TVU/PD with DCE-US was higher in detecting high-risk cancer (0.94 vs 0.85; P = 0.024) but the sensitivity did not differ (0.73 vs 0.71). High-risk cancer and FIGO Stage ≥ IB were characterized by a 'focal' filling pattern, with a 'prior' wash-in pattern and a 'focal' wash-out pattern on subjective assessment of DCE-US videoclips. All semiquantitative DCE-US parameters were significantly predictive of FIGO Stage ≥ IB but not of high-risk cancer, despite a clear trend. Compared with 2D-TVU/PD alone, combining 2D-TVU/PD with DCE-US can significantly improve the detection of deep MI and CSI in women with EC, without increasing the false-positive rate. It can also improve the correct classification of high-risk disease, mainly by increasing specificity, thereby possibly reducing the number of unnecessarily extensive surgeries by almost 10%. Semiquantitative DCE-US parameters, as well as a 'focal' filling pattern, endometrial wash-in prior to the myometrium and a 'focal' wash-out pattern, are all associated with more advanced disease. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women: A community-based study.

To describe the ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women and to describe the prevalence of ultrasound-detected pathologies in a Sri Lankan population. A large community-based longitudinal study using a randomly selected sample of postmenopausal women who have never used hormone replacement therapy. Uterine, endometrial and ovarian measurements at pelvic ultrasonography as described by the International Endometrial Tumor Analysis and the International Ovarian Tumor Analysis groups. A total of 815 postmenopausal women were approached and all volunteered to participate. This included women between the ages of 45 and 74 years with a median (interquartile range (IQR)) of 62.0 (10.0) years. The median (IQR) uterine volume was 18.1 (17) ml, while the median (IQR) of right and left ovarian volumes were 17.3 (22.9) ml and 18.2 (21.5) ml. Both uterine and ovarian volumes showed an age-related decline (p < 0.01). Furthermore, the ovarian volumes demonstrated an increase in size with a higher body mass index (p < 0.03 for left and p < 0.01 for right, respectively). Median (IQR) endometrial thickness among the population was 3.0 (1.0) mm and there was no age-related change observed. Sixty-one women had an ultrasound-detected gynaecological pathology with a prevalence of 7.5% (95% confidence interval (CI) 5.6-9.5). This study aimed at describing ultrasound parameters of pelvic organs among postmenopausal women of Sri Lanka was able to provide the reference values for uterine and ovarian volume among asymptomatic postmenopausal women. Both uterine and ovarian volumes demonstrated an age-related decline, whereas the endometrial thickness does not seem to relate to the age.

Postmenopausal Vaginal Bleeding Analysis and Sonographic Criteria in Diagnosis of Endometrial Carcinoma

Postmenopausal vaginal bleeding has a sign that should not be Ultrasound imaging has become an effective diagnostic tool of gynecological practice throughout the years. Endometrial diagnosis typically involves invasive investigational approaches. Today, however, with the advent of high-resolution transvaginal ultrasound and Doppler ultrasonography (non-invasive diagnostic tool), has an alternative candidate to replace invasive approaches. But in order to obtain an efficient ultrasound report there has must be unified the terms to define ultrasound diagnosis uterine pathology, and to develop the prediction and diagnosis of endometrial pathology. This problem has solved by The International Endometrial Tumor Analysis (IETA) group. There has no absolute diagnostic agreement on the presence of carcinoma, several research including patient characteristics and sonographic characteristics have been conducted to develop a model for endometrial cancer then estimate it has probability and clinical effectiveness, but these models have still not externally validated. The aim of this study has to evaluate the contribution of the terms and definitions described by the IETA group when designing a malignancy model for better diagnosis of malignancy in cases with postmenopausal uterine bleeding. In the present study 120 patients with postmenopausal bleeding have included in the study. The study has conducted from April 2017 to April 2019 at Pune University Pharmacy College, Pharmacology and Pharmaceutical Chemistry departments.Both patients have subjected to the following: full history taking, general examination, local examination, 2D transvaginal ultrasonography, Doppler study, hysteroscopy examination, endometrial biopsy. Symptomatic postmenopausal women with endometrial thickness > 5 mm have been chosen because women with a lower endometrial thickness have a very low incidence of cancer and a prospective evaluation.

Validation of ultrasound strategies to assess tumor extension and to predict high-risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)-4 cohort.

To compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low- or high-grade disease separately, and to validate published measurement cut-offs and prediction models to identify MI, CSI and high-risk disease (Grade-3 endometrioid or non-endometrioid cancer and/or deep MI and/or CSI). The study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)-4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist-OCO) for detecting CSI. We also validated two two-step strategies for the prediction of high-risk cancer; in the first step, biopsy-confirmed Grade-3 endometrioid or mucinous or non-endometrioid cancers were classified as high-risk cancer, while the second step encompassed the application of a mathematical model to classify the remaining tumors. The 'subjective prediction model' included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the 'objective prediction model' included biopsy grade (Grade 1 vs Grade 2) and minimal tumor-free margin. The predictive performance of the two two-step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade-3 endometrioid or mucinous or non-endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard. In 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade-1 or -2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade-3 endometrioid or mucinous or a non-endometrioid tumor. The corresponding values for the detection of CSI were 51% and 94% vs 50% and 91%. Tumor AP diameter and tumor/uterine AP diameter ratio showed the best performance for predicting deep MI (area under the receiver-operating characteristics curve (AUC) of 0.76 and 0.77, respectively), and Dist-OCO had the best performance for predicting CSI (AUC, 0.72). The proportion of patients classified correctly as having high-risk cancer was 80% when simply combining SA with biopsy grade vs 80% and 74% when using the subjective and objective two-step strategies, respectively. The subjective and objective models had an AUC of 0.76 and 0.75, respectively, when applied to Grade-1 and -2 endometrioid tumors. In the hands of experienced ultrasound examiners, SA was superior to ultrasound measurements for the prediction of deep MI and CSI of endometrial cancer, especially in patients with a Grade-1 or -2 tumor. The mathematical models for the prediction of high-risk cancer performed as expected. The best strategies for predicting high-risk endometrial cancer were combining SA with biopsy grade and the subjective two-step strategy, both having an accuracy of 80%. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Clinical and Ultrasound Characteristics of the Microcystic Elongated and Fragmented (MELF) Pattern in Endometrial Cancer According to the International Endometrial Tumor Analysis (IETA) criteria.

To describe sonographic features of the microcystic elongated and fragmented (MELF) pattern of myometrial invasion (MI) using the International Endometrial Tumor Analysis (IETA) criteria; to assess the effect of the MELF pattern on preoperative ultrasound evaluation of MI; and to determine the relationship of the MELF pattern to more advanced stage (≥ IB) and lymph node metastases in women with endometrioid endometrial cancer. We included 850 women with endometrioid endometrial cancer from the prospective IETA 4 study. Ultrasound experts performed all ultrasound examinations, according to the IETA protocol. Reference pathologists assessed the presence or absence of the MELF pattern. Sonographic features and accuracy of ultrasound assessment of MI were compared in cases with the presence and the absence of the MELF pattern. The MELF pattern was correlated to more advanced stage (≥IB) and lymph node metastases. The MELF pattern was present in 197 (23.2%) women. On preoperative ultrasound imaging the endometrium was thicker (p = 0.031), more richly vascularized (p = 0.003) with the multiple multifocal vessel pattern (p < 0.001) and the assessment of adenomyosis was more often uncertain (p < 0.001). The presence or the absence of the MELF pattern did not affect the accuracy of the assessment of MI. The MELF pattern was associated with deep myometrial invasion (≥ 50%) (p < 0.001), cervical stromal invasion (p = 0.037), more advanced stage (≥ IB) (p < 0.001) and lymph node metastases (p = 0.011). Tumors with the MELF pattern were slightly larger, more richly vascularized with multiple multifocal vessels and assessment of adenomyosis was more uncertain on ultrasound imaging. The MELF pattern did not increase the risk of underestimating MI in preoperative ultrasound staging. Tumors with the MELF pattern were more than twice as likely to have more advanced stage (≥ IB) and lymph node metastases.

OC08.08: Clinical and ultrasound characteristics of the microcystic elongated and fragmented (MELF) pattern in endometrial cancer according to the International Endometrial Tumor Analysis (IETA) criteria

OC08.08: Clinical and ultrasound characteristics of the microcystic elongated and fragmented (MELF) pattern in endometrial cancer according to the International Endometrial Tumor Analysis (IETA) criteria

International Endometrial Tumor Analysis (IETA) terminology in women with postmenopausal bleeding and sonographic endometrial thickness ≥ 4.5 mm: agreement and reliability study.

To estimate intra- and interrater agreement and reliability with regard to describing ultrasound images of the endometrium using the International Endometrial Tumor Analysis (IETA) terminology. Four expert and four non-expert raters assessed videoclips of transvaginal ultrasound examinations of the endometrium obtained from 99 women with postmenopausal bleeding and sonographic endometrial thickness ≥ 4.5 mm but without fluid in the uterine cavity. The following features were rated: endometrial echogenicity, endometrial midline, bright edge, endometrial-myometrial junction, color score, vascular pattern, irregularly branching vessels and color splashes. The color content of the endometrial scan was estimated using a visual analog scale graded from 0 to 100. To estimate intrarater agreement and reliability, the same videoclips were assessed twice with a minimum of 2 months' interval. The raters were blinded to their own results and to those of the other raters. Interrater differences in the described prevalence of most IETA variables were substantial, and some variable categories were observed rarely. Specific agreement was poor for variables with many categories. For binary variables, specific agreement was better for absence than for presence of a category. For variables with more than two outcome categories, specific agreement for expert and non-expert raters was best for not-defined endometrial midline (93% and 96%), regular endometrial-myometrial junction (72% and 70%) and three-layer endometrial pattern (67% and 56%). The grayscale ultrasound variable with the best reliability was uniform vs non-uniform echogenicity (multirater kappa (κ), 0.55 for expert and 0.52 for non-expert raters), and the variables with the lowest reliability were appearance of the endometrial-myometrial junction (κ, 0.25 and 0.16) and the nine-category endometrial echogenicity variable (κ, 0.29 and 0.28). The most reliable color Doppler variable was color score (mean weighted κ, 0.77 and 0.69). Intra- and interrater agreement and reliability were similar for experts and non-experts. Inter- and intrarater agreement and reliability when using IETA terminology were limited. This may have implications when assessing the association between a particular ultrasound feature and a specific histological diagnosis, because lack of reproducibility reduces the reliability of the association between a feature and the outcome. Future studies should investigate whether using fewer categories of variable or offering practical training could improve agreement and reliability. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

The patho-mechanism of incarceration of the gravid uterus; the pelvic structure and the placental position. A two-case report and review of literature.

Objective: Objective was to use terms and definitions described by the International Endometrial Tumor Analysis group (IETA) in evaluating the endometrium on gray scale ultrasound and Doppler imaging for testing the validity of these ultrasound variables in addition to patient clinical variables and creating a risk scoring model for better prediction of endometrial cancer trying to limit invasive procedures for risky cases only and performing a decision algorithm for their management. Study design: A prospective cross-sectional study, 60 patients with post-menopausal Bleeding (PMB) and endometrial thickness ≥5 mm were enrolled. TVS and color Doppler were done. Patient clinical variables and ultrasound endometrial assessment were compared to histopathology to identify the best predictors of endometrial cancer. Univariate, multivariate, and ROC curve analysis were used to design a risk-scoring model then test its validity. Results: The best predictors for endometrial cancer were endometrial thickness ≥12 mm (OR = 1.9), heterogeneous echogenicity of endometrium (OR = 2.7), irregular endometrial midline (OR = 1.9), ill-defined endometrium-myometrium interface (OR = 3.3), Doppler score > 2 (OR = 2.5). These variables were used to perform a risk-scoring model for the prediction of endometrial malignancy with accuracy about 95% and an area under the curve 0.9. At the best cut-off value (score ≥ 10) sensitivity and specificity were 80%, 97.8%, respectively. Conclusions: Terms used by IETA group were clinically valuable and reasonable in assessment of the endometrium. Applying a malignancy model for women with PMB allowed easy their risk classification, better identification, and management.

OC14.01: Ultrasound characteristics of endometrial cancer as defined by the International Endometrial Tumor Analysis (IETA) consensus nomenclature: a prospective multicentre study

OC14.01: Ultrasound characteristics of endometrial cancer as defined by the International Endometrial Tumor Analysis (IETA) consensus nomenclature: a prospective multicentre study