DOI: 10.1148/radiol.2203010011
Endometrial Evaluation with Transvaginal US and Hysterosonography in Asymptomatic Postmenopausal Women with Breast Cancer Receiving Tamoxifen1
Katherine Fong, MB, BS, FRCPC,
Rose Kung, MD, MSc, FRCSC,
Alice Lytwyn, MD, MSc, FRCPC,
Maureen Trudeau, MD, FRCPC,
William Chapman, MD, FRCPC,
Patricia Nugent, MB, BS, FRCPC,
Phyllis Glanc, MD, FRCPC,
Lee Manchul, MD, FRCPC,
Diane Szabunio, RDMS and
Terri Myhr, MSc
1 From the Departments of Medical Imaging (K.F., P.N., P.G., D.S.), Obstetrics and Gynecology (R.K.), Pathology (A.L.), and Medical Oncology (M.T.), Sunnybrook and Women’s College Health Sciences Centre, 76 Grenville St, Toronto, Ontario, Canada M5S 1B2; the Departments of Pathology (W.C.) and Radiation Oncology (L.M.), Princess Margaret Hospital-University Health Network, Toronto, Ontario, Canada; and the Centre for Research in Women’s Health, University of Toronto, Ontario, Canada (T.M.). From the 2000 RSNA scientific assembly. Received November 26, 2000; revision requested January 22, 2001; revision received March 9; accepted April 3. Supported by the Canadian Breast Cancer Foundation (Ontario Chapter) and the Helen and Paul Phelan Foundation. Address correspondence to K.F. (e-mail: katherine.fong@swchsc.on.ca).
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Figure 1. Flowchart shows the number of women who underwent the different test procedures. Five women ( ) did not undergo hysterosonography (HSG) because transvaginal US (TVUS) depicted at least 2 mL of fluid in the endometrial cavity. One hundred seventeen women (*) completed hysteroscopy, 92 of whom underwent successful hysterosonography.
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Figure 2a. Endometrial polyp in a 70-year-old woman. (a) Sagittal transvaginal US image demonstrates a thickened heterogeneous endometrial echo complex (calipers) with cystic spaces. (b) Sagittal hysterosonogram shows fluid outlining the intracavitary mass (calipers); this finding enabled a confident diagnosis of a polyp. Correlative hysteroscopy and histopathologic analysis revealed a benign polyp.
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Figure 2b. Endometrial polyp in a 70-year-old woman. (a) Sagittal transvaginal US image demonstrates a thickened heterogeneous endometrial echo complex (calipers) with cystic spaces. (b) Sagittal hysterosonogram shows fluid outlining the intracavitary mass (calipers); this finding enabled a confident diagnosis of a polyp. Correlative hysteroscopy and histopathologic analysis revealed a benign polyp.
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Figure 3. Graph depicts the receiver operating characteristic curve for endometrial thickness at transvaginal US in the diagnosis of endometrial abnormality. This curve was generated by using multiple cutoff points of 1-mm endometrial thickness, from 1 to 24 mm. The numbers on the graph represent endometrial thicknesses, in millimeters. The area under the curve is 0.78 ± 0.04 (standard error). The cutoff point of endometrial thickness that maximized the accuracy of diagnosis was determined to be 6 mm. When an endometrial thickness greater than 6 mm was considered abnormal, transvaginal US had a sensitivity of 84.1%, specificity of 58.2%, positive predictive value of 56.9%, and negative predictive value of 84.8%. Thirty-seven cases were true-positive; seven, false-negative; 28, false-positive; and 39 true-negative, on the basis of combined hysteroscopic-histopathologic diagnoses.
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Figure 4. Management algorithm for postmenopausal women undergoing tamoxifen therapy. This algorithm was used to analyze the test performance of the sequential combination of transvaginal US (TVUS) and hysterosonography (HSG). At transvaginal US, an endometrial thickness cutoff point of either 5 or 6 mm was used. When transvaginal US depicted at least 2 mL of fluid in the endometrial cavity, hysterosonography was not attempted.
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Figure 5a. False-positive US appearance due to endometrial cystic atrophy in a 71-year-old woman. (a) Sagittal transvaginal US image demonstrates a retroverted uterus with a thickened heterogeneous endometrial echo complex (calipers) and small cystic spaces. The endometrial thickness measurement is 14 mm. F = fibroid. (b) Sagittal hysterosonogram shows fluid (*) in the endometrial cavity, which has a lobulated outline with scattered protuberances (arrows) that are indistinguishable from focal areas of endometrial thickening. Correlative hysteroscopy and histopathologic analysis revealed "tamoxifen mucosa," cystic atrophy, and dilated glands, with no evidence of endometrial hyperplasia or carcinoma. F = fibroid.
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Figure 5b. False-positive US appearance due to endometrial cystic atrophy in a 71-year-old woman. (a) Sagittal transvaginal US image demonstrates a retroverted uterus with a thickened heterogeneous endometrial echo complex (calipers) and small cystic spaces. The endometrial thickness measurement is 14 mm. F = fibroid. (b) Sagittal hysterosonogram shows fluid (*) in the endometrial cavity, which has a lobulated outline with scattered protuberances (arrows) that are indistinguishable from focal areas of endometrial thickening. Correlative hysteroscopy and histopathologic analysis revealed "tamoxifen mucosa," cystic atrophy, and dilated glands, with no evidence of endometrial hyperplasia or carcinoma. F = fibroid.
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Figure 6. Graph illustrates percentages of patients versus pain scores for transvaginal US (black bars), hysterosonography (gray bars), and hysteroscopy (white bars). 1 = no discomfort, 2 = minimal discomfort, 3 = mild discomfort, 4 = moderate discomfort, 5 = severe discomfort.
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Copyright © 2001 by the Radiological Society of North America.
