Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma

Premenopausal EndometriumDuring 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

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.

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 .

On Ultrasound

Endometrial thickness is measured from echogenic border to echogenic border across the endometrial cavity on a sagittal midline image.

Normal premenopausal endometrium. Sagittal US image of the uterus obtained during menstruation shows a thin endometrial lining with a trace of fluid.

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 .

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.

The normal endometrium is of uniformly high

signal intensity, and the inner myometrium, or junctional zone, is of uniformly low signal intensity

Normal premenopausal endometrium. T2-weighted MR image shows the normal endometrium and junctional zone.

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.

The endometrium in a patient undergoing

hormonal replacement therapy may vary up to 3 mm if cyclic estrogen and progestin therapy is being used

Postmenopausal endometrial atrophy. Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid.

Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma

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

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

Sonohysterography

Polyps are best seen at sonohysterography

appear as echogenic, smooth, intracavitary masses outlined by fluid

Hysterosalpingography

seen as pedunculated filling defects within the uterine cavity.

MRI

T2-weighted MR imaging

Appears as low-signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium.

Sonohysterogram reveals a small polyp attached by a stalk to the endometrium.

Anteroposterior (left) and oblique (right) hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).

T2-weighted MR image demonstrates a low-signal-intensity lesion within the endometrial canal (arrow).

Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma

an abnormal proliferation of endometrial

stroma and glands

represents a spectrum of endometrial changes ranging from glandular atypia to frank neoplasia.

Endometrial hyperplasia

Causes

Polycystic ovaries

Obesity

Exogenous hormones

Endogenous excess estrogen production

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.

On histology, three types of endometrial

hyperplasia (cystic, adenomatous, atypical)

All types can cause diffusely smooth or, less commonly, focal hyperechoic endometrial thickening.

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.

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 .

Because endometrial hyperplasia has a

nonspecific appearance, any focal abnormality should lead to biopsy if there is clinical suspicion for malignancy.

Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia. This finding was confirmed at biopsy.

Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma

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

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.

Risk factorsIncreased estrogen levelsHypertensionObesityDiabetesMultiparityLate onset menopause

Prognosisstage,

depth of myometrial invasion,

lymphovascular invasion,

histologic grade, and

nodal status.

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.

IMAGING MODALITIES

UltrasonographyIncreased endometrial thicknessIrregular hypoechoic intracavitary massEnlarged diffusely infiltrated uterus.

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.

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.

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.

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.

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.

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);

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.

Stage IVA tumors extend into adjacent

bladder or bowel, and

Stage IVB tumors have distant metastases (eg, to the liver or lungs)

MR ImagingIdeal 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.

Diffusion-weighted and Dynamic Contrast-enhanced MR ImagingHave improved the staging accuracyallow 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.

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.

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.

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 .

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.

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.

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 .

Stage IB. Axial oblique contrast-enhanced MR image shows tumor enhancement with invasion of the outer half of the myometrium .

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.

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.

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

Stage IIIC1 endometrial cancer in a 66-year-old woman.On an axial dynamic contrast-enhanced MRI the node (N) demonstrates avid enhancement.

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 .

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