Endometrial pathologies


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Endometrial pathologies

  1. 1.   Normal endometrium  Endometrial polyps  Endometrial hyperplasia  Endometrial carcinoma
  2. 2.  Premenopausal Endometrium During menstruation---- a thin echogenic line, 1–4 mm in thickness In early proliferative phase of the menstrual cycle(after day 6) becomes thicker (5–7 mm) and more echogenic relative to the myometrium, (glands, blood vessels, and stroma) Normal endometrium
  3. 3.   Late proliferative (periovulatory) phase  a multilayered appearance.  an echogenic basal layer and hypoechoic inner functional layer, separated by a thin echogenic median layer.  may measure up to 11 mm in thickness.
  4. 4.   During the secretory phase, becomes even thicker (7– 16 mm) and more echogenic .  stromal edema and glands distended with mucus and glycogen.  increased posterior acoustic enhancement.  The endometrium typically reaches a maximum thickness during the mid secretory phase .
  5. 5.  On Ultrasound Endometrial thickness is measured from echogenic border to echogenic border across the endometrial cavity on a sagittal midline image.
  6. 6.  Normal premenopausal endometrium. Sagittal US image of the uterus obtained during menstruation shows a thin endometrial lining with a trace of fluid.
  7. 7.  Normal premenopausal endometrium. Sagittal US image of the uterus obtained during the late proliferative phase of the menstrual cycle demonstrates the endometrium with a multilayered appearance .
  8. 8.
  9. 9.  On MRI uterus has homogeneous intermediate signal intensity with T1-weighted sequences. T2-weighted images delineate the uterine zonal anatomy. So endometrium is best visualized on T2.
  10. 10.   The normal endometrium is of uniformly high signal intensity, and the inner myometrium, or junctional zone, is of uniformly low signal intensity
  11. 11.  Normal premenopausal endometrium. T2-weighted MR image shows the normal endometrium and junctional zone.
  12. 12.  Postmenopausal Endometrium should be thin, homogeneous, and echogenic. Homogeneous, smooth endometria measuring 5 mm or less are considered within the normal range with or without hormonal replacement therapy.
  13. 13.   The endometrium in a patient undergoing hormonal replacement therapy may vary up to 3 mm if cyclic estrogen and progestin therapy is being used
  14. 14.  Postmenopausal endometrial atrophy. Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid.
  15. 15.   Normal endometrium  Endometrial polyps  Endometrial hyperplasia  Endometrial carcinoma
  16. 16. a common cause of postmenopausal bleeding most frequently seen in patients receiving tamoxifen or HRT. may be broad-based and sessile or pedunculated. Typically measure 5-15mm. The point of attachment should not disrupt the endometrial lining. Endometrial Polyps
  17. 17.  Ultrasonographic appearance frequently identified as focal masses within the endometrial canal. OR as nonspecific endometrial thickening. Color Doppler US may be used to image vessels within the stalk
  18. 18.  Sonohysterography Polyps are best seen at sonohysterography appear as echogenic, smooth, intracavitary masses outlined by fluid
  19. 19.  Hysterosalpingography seen as pedunculated filling defects within the uterine cavity.
  20. 20.  MRI T2-weighted MR imaging Appears as low-signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium.
  21. 21.  Sonohysterogram reveals a small polyp attached by a stalk to the endometrium.
  22. 22.  Anteroposterior (left) and oblique (right) hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).
  23. 23.  T2-weighted MR image demonstrates a low-signal-intensity lesion within the endometrial canal (arrow).
  24. 24.   Normal endometrium  Endometrial polyps  Endometrial hyperplasia  Endometrial carcinoma
  25. 25.   an abnormal proliferation of endometrial stroma and glands  represents a spectrum of endometrial changes ranging from glandular atypia to frank neoplasia. Endometrial hyperplasia
  26. 26.  Causes Polycystic ovaries Obesity Exogenous hormones Endogenous excess estrogen production
  27. 27.   A definitive diagnosis can be made only with biopsy  imaging cannot reliably allow differentiation between hyperplasia and carcinoma.  Up to one-third of endometrial carcinoma is believed to be preceded by hyperplasia.
  28. 28.   On histology, three types of endometrial hyperplasia (cystic, adenomatous, atypical)  All types can cause diffusely smooth or, less commonly, focal hyperechoic endometrial thickening.
  29. 29.  Ultrasonographic appearance Endometrial hyperplasia is considered when the endometrium exceeds 10 mm in thickness, especially in menopausal patients In postmenopausal women 5mm thickness is significant.
  30. 30.   may also cause asymmetric thickening with surface irregularity, an appearance that is suspicious for carcinoma.  The US appearance can simulate that of normal thickening during the secretory phase, sessile polyps, submucosal fibroids, cancer, and adherent blood clots, yielding potentially false-positive results .
  31. 31.   Because endometrial hyperplasia has a nonspecific appearance, any focal abnormality should lead to biopsy if there is clinical suspicion for malignancy.
  32. 32.  Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia. This finding was confirmed at biopsy.
  33. 33.   Normal endometrium  Endometrial polyps  Endometrial hyperplasia  Endometrial carcinoma
  34. 34.   Fourth most common malignancy in females.  Most common malignancy of the female reproductive tract  The prevalence of endometrial cancer is increasing with rising levels of obesity.  App. 75% cases occur in postmenopausal women, median age at diagnosis is 70 years. Endometrial carcinoma
  35. 35.   Postmenopausal bleeding—most common symptom.  Adenocarcinomas account for 90% of endometrial neoplasms,  uterine sarcomas-- only 2%–6%;  remaining include adenocarcinoma with squamous cell differentiation and adenosquamous carcinoma.
  36. 36.  Risk factors Increased estrogen levels Hypertension Obesity Diabetes Multiparity Late onset menopause
  37. 37. Prognosis stage, depth of myometrial invasion,  lymphovascular invasion, histologic grade, and nodal status.
  38. 38.   Depth of myometrial invasion is the most important morphologic prognostic factor, correlating with tumor grade, presence of lymph node metastases, and overall patient survival.  3% lymph node metastases with superficial myometrial invasion to 46% with deep myometrial invasion.
  39. 39.  IMAGING MODALITIES Ultrasonography Increased endometrial thickness Irregular hypoechoic intracavitary mass Enlarged diffusely infiltrated uterus.
  40. 40.
  41. 41.   Endometrial cancer is staged with the International Federation of Gynecology and Obstetrics (FIGO) system, which recently underwent a major revision.  First proposed in 1988, and the staging system was updated in 2009.
  42. 42.
  43. 43.   The previous iteration of the FIGO system subdivided stage I tumors into IA, IB, and IC tumors.  Stage IA tumors are confined to the endometrial complex,  stage IB tumors invade <50% of the depth of the myometrium  stage IC tumors invade ≥50% of the depth of the myometrium.
  44. 44.   In the 2009 revised FIGO staging system,  tumors confined to the endometrium as well as those invading the inner half of the myometrium are designated as stage IA tumors,  tumors invading the outer half of the myometrium are designated as stage IB tumors.
  45. 45.   These changes may improve the diagnostic accuracy of MR imaging.  With the old staging system, differentiating between stage IA and IB tumors could be challenging in patients with loss of junctional zone definition or in lesions with poor tumor-to-myometrium contrast.
  46. 46.   Stage II tumors were previously subdivided into stage IIA and IIB tumors,  IIA tumors were characterized by endocervical glandular invasion and  IIB tumors by cervical stromal invasion.
  47. 47.  Stage III is composed of three subdivisions: Stage IIIA tumors invade the serosa or adnexa , Stage IIIB tumors invade the vagina or Previously, stage IIIC referred to any lymphadenopathy (pelvic or retroperitoneal);
  48. 48.  In the new FIGO system, however, stage IIIC is divided into stage IIIC1-- characterized by pelvic lymph node involvement, and stage IIIC2-- characterized by paraaortic lymph node involvement.
  49. 49.   Stage IVA tumors extend into adjacent bladder or bowel, and  Stage IVB tumors have distant metastases (eg, to the liver or lungs)
  50. 50.  MR Imaging Ideal imaging modality for staging of endometrial Ca.  an important predictor of lymph node metastases.  also allow accurate assessment of more advanced disease such as cervical stromal invasion or adnexal involvement.
  51. 51.  Diffusion-weighted and Dynamic Contrast-enhanced MR Imaging Have improved the staging accuracy allow tumor to be distinguished from blood products and debris. Endometrial tumors enhance earlier than does normal endometrium. Normal myometrium enhances intensely compared with hypointense endometrial tumor.
  52. 52.  MR Imaging Appearances On unenhanced T1-weighted images, Endometrial cancer is isointense relative to hypointense normal endometrium. On T2-weighted images, shows heterogeneous intermediate signal intensity relative to hyperintense normal endometrium.
  53. 53.   Relative to normal myometrium, the tumor is mildly hyperintense on T2-weighted images.  At conventional MR imaging, the depth of myometrial invasion is optimally depicted with T2- weighted sequences.
  54. 54.  Stage IA endometrial cancer in a 35-year-old woman. Sagittal T2- weighted MR image shows distention of the endometrial cavity by an intermediate-signal-intensity tumor .
  55. 55.  On an axial oblique contrast-enhanced MR image, the tumor is hypoenhancing relative to the hyperenhancing myometrium and appears to be confined to the endometrium.
  56. 56.  Stage IA endometrial cancer in a 61-year-old woman. Sagittal T2- weighted MR image shows distention of the endometrial cavity by an intermediate-signal-intensity tumor. Poor tumor-to-myometrium contrast is seen inferiorly.
  57. 57.  Sagittal contrast-enhanced MR image demonstrates excellent contrast between the hyperenhancing myometrium and the endometrial tumor , which appears to be confined to the endometrial cavity .
  58. 58.  Stage IB. Axial oblique contrast-enhanced MR image shows tumor enhancement with invasion of the outer half of the myometrium .
  59. 59.  Stage II endometrial cancer in a 64-year-old woman.Sagittal contrast- enhanced MR image shows extension of the endometrial tumor into the cervix. Invasion of the cervical stroma is present posteriorly and is better appreciated than on the T2-weighted image.
  60. 60.  Stage IIIA endometrial cancer in a 65-year-old woman.Axial oblique T2- weighted MR image shows extension of the endometrial tumor into both fallopian tubes (arrows). The tumor is isointense relative to the adjacent myometrium.
  61. 61.  Stage IIIA endometrial cancer in a 65-year-old woman.Axial oblique dynamic contrast-enhanced MR image shows enhancement of the tumor extension into the fallopian tubes . The primary tumor enhances less than the adjacent myometrium
  62. 62.  Stage IIIC1 endometrial cancer in a 66-year-old woman.On an axial dynamic contrast-enhanced MRI the node (N) demonstrates avid enhancement.
  63. 63.  Stage IVA endometrial cancer in a 72-year-old woman. Sagittal T2- weighted MR image shows a large endometrial tumor with invasion of the sigmoid colon as evidenced by loss of the normal fat plane between the tumor and colon .
  64. 64.  THANKS