Pre-operative Evaluation and Implications Michal Zikan Gynecologic Oncology Center Charles University in Prague, First Faculty of Medicine
No recommendation for screening of EC (HNPCC annual biopsies starting @ 35 y) >95% of EC in women >40 y >80% of EC in postmenopausal women Only 15% of EC in asymptomatic women High-risk characteristics: Significant obesity, PCOS, chronic anovulation, tamoxifen exposure
Longitudinal section Transverse section
3 2 1 C
- endometrial vs. myometrial (1:10) - focal vs. difuse - phase of menstrual cycle - homogenity - acustic shadow or augmentation - vessels - doppler - mobility - surroudings
Early proliferation phase Late proliferation phase Early secretional phase Late secretional phase
US = Excellent NPV endometrial thickness 4 mm low risk of cancer (1/100 in non-users of HRT and 1/1000 of users)
Ultrasound in Diagnosis and Management of Endometrial Cancer - To detect cancer US, biopsy US = No information about histology (low sensitivity), but gives indication to biopsy - Local staging MRI, US
Hysteroscopy vs. D&C vs. Office Endometrial Biopsy Office endometrial biopsy pipelle accuracy 91-99% Hysteroscopy + D&C OR 3.88 for positive peritoneal washing Type of carcinoma endometroid vs. non-endometroid Grade Hormone receptors (ER, PgR) LVSI
Preoperative Assessment Evaluation of local extension of the disease Evaluation for possible spread (incl. lymph nodes) Evaluation of surgical risks
Preoperative Assessment Physical examination supraclavicular or inguinal LN, pleural effusion, ascites Chest X-ray pulmonary mets and cardiopulmonary status Imaging of pelvis and abdomen invasion, local spread and LN ESMO/ESGO/ESTRO Consensus Conference Endometrial Cancer 2014 CA125 prediction of LN mets (78% sensitivity) vs. advanced disease and type II
Predicting nodal disease Grade Grade I 3% Grade II 9% Grade III 18% LVSI No LVSI 7% With LVSI 27% Depth of invasion Endometrium only 1% Inner 1/3 5% Middle 1/3 6% Outer 1/3 25%
Stage I depth of myometrial invasion US 68 93% CT 67-76% MRI 85-95% Frozen section 30-87%
Accuracy of myometrial invasion assessment Subjective assessment by expert sensitivity 68 93 % specificity 82 83 % Antonsen S.L. Gynecol Oncol 2013 Mascillini F. Ultrasound Obstet Gynecol 2013 Ortoft G. Acta Obstet Gynecol Scand 2013 Savelli L. Ultrasound Obstet Gynecol 2008 Fischerova D. Ultrasound Obstet Gynecol 2015 tends to overestimate deep myometrial invasion
Stage IA
Stage IB
Cervical stroma invasion Subjective assessment by expert senzitivity 54 93 % specificity 85 99 % Akbayr O. Gynecol Oncol 2011 Mascillini F. Ultrasound Obstet Gynecol 2013 Savelli L. Ultrasound Obstet Gynecol 2008 Fischerova D. Ultrasound Obstetrics Gynecol 2015 Tends to underestimate cervical stroma infiltration Eriksson L.S.Ultrasound Obstet Gynecol 2014
Stage II + IIIB AdenoCa cervix vs. endometrium Vimentin neg/poz, ER/PR neg/poz, HPV poz/neg, CEA poz/neg
Stage IIIA
Stage IIIC1+2
Staging of lymph nodes Involvement of pelvic and paraaortic lymph nodes
US in staging of endometrial carcinoma No information about histology (low sensitivity), but gives indication to biopsy Sensitivity and specifity in staging comparable to other imaging methods
OPTIMAL IMAGINGCT, METHOD (PET) PET, CT CT, US, (MRI, PET) US, MRI