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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5809_Библиотеки_им_академика_М_И_Перельмана.pdf
156
S. M. Bocca et al.
a
b
Fig. 10.1 (a) Cystic polyp shown in longitudinal 2D
view of the uterus. (b) Sessile polyps (arrow) shown in a
transverse 2D view of the uterus distended by saline
Two- andThree-Dimensional
Transvaginal Ultrasound
The American College of Obstetrics and
Gynecology [16] recommends transvaginal ultrasound (TVUS) as the primary imaging test of the
uterus for the evaluation of abnormal uterine
bleeding (AUB), followed by sonohysterography
(SHG) or hysteroscopy and lastly magnetic resonance imaging (MRI) if images are not adequate
or further evaluation of the cavity is necessary.
Similarly, The American Association of
Gynecologic Laparoscopists’ (AAGL) guidelines
for the diagnosis of endometrial polyps [17] state
that TVUS provides reliable information for the
detection of endometrial polyps and should be
c
infusion. (c) Coronal view (3D) of the uterus showing a
pedunculated polyp (arrow)
the investigation of choice where available, the
addition of color or power Doppler increases the
capacity of TVUS to diagnose endometrial polyps, adding intrauterine contrast to sonography
(with or without 3D imaging) improves the diagnostic capacity for endometrial polyps, and blind
dilation and curettage or biopsy should not be
used for diagnosis of endometrial polyps.
Clark etal. [18] reported that the criteria for
diagnosis of uterine polyps vary according to
the test used, but optimal testing and standardized denitions are lacking. On US polyps
appear as nonspecic endometrial thickening
(Fig. 10.6b) or a focal mass identied as an
echogenic lesion (see Figs10.2a, 10.3a, 10.6a
and 10.10a), which disturbs the midline endo-
10 Uterine Polyps
157
a
c
b
d
Fig. 10.2 Endometrial polyps. A single polyp located in
a lateral wall at midcorpus, shown in two-dimensional
transvaginal ultrasonographic view (a) and in 3D imaging
metrial echo but does not disrupt the interface
between the myometrium and endometrium.
The lesion is usually oval shaped with a homogeneous texture, although hypoechoic cystic
spaces may be seen. Blood ow may be identied within a feeding vessel extending to the
polyp on color-ow Doppler imaging (see
Figs10.2c and 10.6b). Saline infusion sonography (SIS) and three- dimensional US (3D US)
help delineate the borders of the intracavity
lesion (see Figs10.1b and 10.7). None of these
(b). Multiple polyps and submucosal broids (by
Pathology) shown by 2D US (c) and 3D US (d)
ndings can reliably distinguish among polyps,
submucosal broids, adenomyosis, and neoplastic change. In premenopausal women, the
TVUS examination should be performed early
in the proliferative phase when the endometrium
is at its thinnest (4–8mm) [19, 20] to minimize
false-positive and false-negative ndings [21].
In a retrospective review of multiple studies,
Salim and his group [22] reported that for
TVUS, the sensitivity varies between 19 and
96%, specicity of 53 and 100%, positive pre-
158
S. M. Bocca et al.
a b c
Fig. 10.3 Large polyp (arrows) occupying the entire fundal area shown in a sagittal 2D view (a), in an HSG view (b)
giving a globular appearance of the uterus, and in a hysteroscopic view (c)
a b
dc
Fig. 10.4 Cornual polyps (arrows) clearly seen in HSG (a) and hysteroscopy (b, c) but not visualized in 2D US (d)
dictive value (PPV) of 75 and 100%, and
negative predictive value (NPV) of 87 and 9%,
when compared with hysteroscopy with guided
biopsy [23, 24, 25]. The ranges were tighter in a
single- large prospective study evaluating the
causes of menorrhagia: 86% sensitivity, 94%
specicity, 91% PPV, and 90% NPV [26]. In
general, TVUS appears to have a good degree of
bc
ab
10 Uterine Polyps
159
a
Fig. 10.5 Cervical polyp protruding from the external os (a) under speculum visualization. Polyp outlined by uid in
the endocervical canal visualized by TV US in coronal (b) and in sagittal (c) views
c
Fig. 10.6 Transvaginal ultrasonographic view of an
endometrial polyp (a, cursor) appearing as an echogenic
ovoid structure containing a feeding vessel visualized by
accuracy when performed with high-resolution
equipment by procient practitioners.
Three-dimensional US is a noninvasive imaging technique with the ability to generate multiplanar reconstructed images (Fig. 10.8) through
the uterus and its external contours. Coronal
views of the uterus allow more accurate visualization between the endometrium and myometrium
at the fundus and cornual angles, providing superior diagnostic accuracy in detecting endometrial
polyps compared to 2D TVUS.We demonstrated
d
Doppler (b) or as a nonspecic endometrial thickening (c.
2D TV US, d. hysteroscopy)
that physicians who learn the Z technique [27] are
able to retrieve the mid- coronal plane of the uterus
faster and improve its image quality in volume
sonography. In a prospective blinded study to
evaluate the costs, accuracy, risks, and benets of
3D TV sonography compared to hysterosalpingography [28], we concluded that 3D TV sonography provides visualization and evaluation of the
uterine cavity with similar or better accuracy than
standard hysterosalpingography (HSG) in the
ofce setting, without radiation exposure, with
160
S. M. Bocca et al.
Fig. 10.7 3D-rendered view of the uterus during sonohysterography. The arrow points to an endometrial polyp in the
left midcorpus
lower cost and morbidity. Studies with non-contrast 3D TVUS show limited improvement to
diagnosing endometrial polyps when compared to
hysteroscopy with biopsy, reporting 3D US to
have sensitivity of 100%, specicity of 71–99%,
PPV of 89–99%, and NPV of 100% [29, 30, 31].
Addition of saline solution contrast to 3D sonography results in slightly higher specicity (88–
99%) and PPV (97–100%) for endometrial polyps
than those of 3D US, with reasonably high sensitivity of 92–95% and NPV of 97% [30]. Despite
the multiple advantages of performing 3D US,
including having diagnostic accuracy comparable
to MRI or combined laparoscopy and hysteroscopy, it is still not widely available and accepted
as a diagnostic tool, and multiple insurance carriers deny its reimbursement.
Radiographic Indices: Polyp
Morphology, Endometrial Thickness
andPolyp Size, Color Doppler
andPedicle Artery, Interrupted
Mucosal Sign, Combination
Polyp Morphology andEndometrial
Thickness
The AAGL practice guidelines [17] describe that,
on TVUS, polyps typically appear as a hyperechoic
lesion with regular contours within the uterine
lumen, surrounded by a thin hyperechoic halo,
occasionally with cystic within, or the polyp may
appear as a nonspecic endometrial thickening or
focal mass within the endometrial cavity. These
sonographic ndings are not specic and may be
found with other diseases such as myomas [32].
10 Uterine Polyps
161
Polyp size should be assessed at the time of
US as this can provide useful information in aiding management. An increase in polyp diameter
appears to correlate with risk of malignancy [33],
with smaller polyps being more likely to resolve
spontaneously. Ultrasonographic measurement
of endometrial thickness is of limited value in
detecting benign abnormalities in the premenopausal woman due to physiologic menstrual
changes as compared with its ability to exclude
malignancy in the postmenopausal woman [34,
35]. Endometrial thickening (see Fig.10.6) is a
nonspecic nding of endometrial hyperplasia
(Fig.10.9b) as well as other causes such as polyp,
endometrial cancer, trophoblastic disease
(Fig. 10.9d), retained products of conception
(Fig. 10.9c), or submucosal leiomyoma
(Fig.10.10) [36]. Song etal. [37] reported that,
although TV US is poor at detecting them, its
diagnostic value for endometrial polyps in infertile women could be improved by adding the
measurement of endometrial thickness to the
variables that are routinely assessed. The main
use of endometrial thickness measured on TV US
a1 b1 b2 b3
a2
c1 c2
Fig. 10.8 Intrauterine lesions that may not be easily
detected by TVUS. (a1) Apparently normal 2D sagittal
view of the uterus. (a2) Same uterus as in (a1), containing
at hyperemic lesions visualized directly by hysteroscopy
(benign polyp on pathology). (b1) Apparently normal 3D
coronal view of the uterus. (b2) Multiple thin bands of
synechiae seen on 3D SIS and hysteroscopy (b3). (c1)
Synechiae not clearly visualized on 3D-SIS but more
clearly identied upon evaluation of the multiplanar views
(c2) of the uterus
162
ab
S. M. Bocca et al.
a1 b1 c1
a2
Fig. 10.9 Examples of different endometrial pathologies
presenting as endometrial thickening in TV US. (a)
Endometrial polyp (a1 2D US, a2 3D SIS); (b) complex
hyperplasia without atypia (b1 2D US, b2 at lesions in
b2
hysteroscopy); (c) retained products of conception (c1
HSG, c2 3D US, c3 3D SIS); (d) trophoblastic disease
(multivessel signal)
d
c2
c3
Fig. 10.10 Echogenic mass on 2D US (a) cannot be differentiated from a 2 cm broid resected hysteroscopically (b)
is the high negative predictive value of a thin distinct echo [16]. In women with postmenopausal
bleeding, endometrial thickness less than 4mm
has a risk of malignancy of 1in 917 and does not
require endometrial sampling. In premenopausal
patients with AUB, an endometrial echo less than
5 mm early in the cycle excludes signicant
pathology. Cavkaytar S [38]. assessed the role of
sonographic endometrial thickness and hysteroscopic polyp size in predicting premalignant and
malignant polyps in 328 postmenopausal women
with AUB and thickened endometrium.
Premalignant and malignant polyps were identied in 26 (7.9%) of cases. Sonographic measurement showed a greater endometrial thickness in
cases of premalignant and malignant polyps
10 Uterine Polyps
163
when compared to benign polyps. Endometrial
thickness demonstrated a sensitivity of 53.8%,
specicity of 85.8%, PPV of 24.6%, and NPV of
95.6% at a cutoff limit of 11.5mm with diagnostic accuracy of 83.2%. Polyp size has a diagnostic accuracy of 94.8% with a sensitivity of 92.3%,
specicity of 95.0%, PPV of 61.5%, and NPV of
99.3% at a cutoff point of 19.5mm.
Color Doppler andPedicle Artery
The addition of color-ow or power Doppler may
improve the diagnostic capability of TVUS [17].
Color-ow Doppler may demonstrate the single
feeding vessel typical of endometrial polyps.
Power Doppler is reported to increase sensitivity
to 91% and 97% in patients with and without
symptoms, respectively [39]. Specicity and
NPV may be increased to 95% and 94%, respectively, when color-ow Doppler is added to grayscale TVUS to identify the feeding vessel (see
Figs. 10.2c and 10.6b) [40]. There are limited
data to support color-ow or power Doppler aiding in the differentiation of hyperplasia and
malignancy in polyps [41, 42, 43], with no differ-
ence in the histologic grading of polyps on the
basis of their resistive index, pulsatility index, or
size [20]. Power Doppler has been reported to be
more accurate than color ow for demonstrating
vascular networks in one study assessing postmenopausal women with abnormal bleeding and
thickened endometrium on baseline US [39].
Cogendez etal. [44] studied the role of TV power
Doppler US in the differential diagnosis of
benign intrauterine focal lesions in 480 premenopausal women with AUB.Three different vascular ow patterns were dened: single-vessel
pattern, multiple-vessel pattern, and circular ow
pattern. Histopathological results after hysteroscopy were as follows: endometrial polyp, 69%,
and submucous myoma, 31%. Of the cases with
endometrial polyps, 80% demonstrated a singlevessel pattern, 7.5% a multiple-vessel pattern,
and 0% a circular pattern. Vascularization was
not observed in 12.5% of patients with polyps. Of
the cases with submucosal myomas, 72.2% demonstrated a circular ow pattern and 27.8% a
multiple-vessel pattern, and none of them showed
a single-vessel pattern. The sensitivity, specic-
ity, and positive and negative predictive values of
the single-vessel pattern in diagnosing endometrial polyps were 80, 100, 100, and 69.2%,
respectively; and for the circular pattern in diagnosing submucous myoma, these were 72.2, 100,
100, and 88.9%, respectively. Power Doppler
blood ow mapping is a useful, practical, and
noninvasive diagnostic method for the differential diagnosis of benign intrauterine focal lesions.
The combination of SHG with feeding artery
visualization was reported to increase polyp
detection by Anioł etal. [45]. Sonography detection of endometrial polyp based on feeding artery
visualization had a 40% sensitivity, whereas SHG
polyp detection had a sensitivity of 75% and a
specicity of 100%. The PPV and NPVs of SHG
in diagnosing endometrial polyps were estimated
at 75% and 72% (95% CI, 52–86%), respectively.
The combination of SHG and feeding artery
imaging in TV US was 84% sensitive and 95%
specic in detecting endometrial polyps. The
positive and negative predictive values were
PPV=96% and NPV=89%. These authors concluded that SHG with feeding artery visualization may become a standard method in the
diagnostics of endometrial polyps in perimenopausal women. The diagnostic utility of saline
infusion Doppler (SIS-D) in endometrial mass
lesions was also evaluated by Ogutcuoglu etal.
[46] demonstrating that, according to SIS-D,
92.2% of the lesions that had single-vessel feeding patterns were endometrial polyps (p<0.0001)
and 57.1% of the lesions that had multiple-vessel
feeding patterns were submucous myomas
(p<0.0001). At this time, sonographic examination either with or without color-ow or power
Doppler sonography is not a substitute for pathologic evaluation after surgical removal.
Interrupted Mucosa Sign
The most widely accepted and commonly used
sonographic features of a polyp are an echogenic
endometrial lesion with a single feeding vessel.
Although these ndings are extremely helpful,
they are not always sonographically evident, and
visualization may depend on body habitus or timing of imaging during the phase of menstrual
cycle. Kamaya et al. [47] reports that in their
164
S. M. Bocca et al.
clinical practice, the additional sonographic nding of the interrupted mucosa sign (see Fig.10.2a)
helps in the diagnosis of endometrial polyps. The
interrupted mucosa sign is identied when the
highly echogenic linear interface where opposing
endometrial mucosal surfaces coapt can be followed to a point at which it is focally interrupted
(typically by an endometrial polyp). This sign
may also be helpful during the latter half of the
menstrual cycle, when polyps may be isoechoic
to the endometrium and their borders indistinct.
A single feeding vessel was visualized in 62.07%,
whereas the interrupted mucosa sign was visualized in 58.62% of patients with polyps. The presence of a feeding vessel, the interrupted mucosa
sign, or both detected 82.76% of the polyps. In
the multivariate analysis, only the interrupted
mucosa sign was a statistically signicant predictor of pathologic diagnosis of a polyp (p=0.035),
with an odds ratio of 3.83 (95% condence interval, 1.10–13.29). Other sonographic ndings
were not independent predictors of a polyp: mass
(p=0.35), single feeding vessel (p=0.31), endometrial thickness (p = 0.88), and endometrial
echogenicity (p=0.45). The sensitivity, specicity, and positive predictive value of the interrupted mucosa sign were 59%, 75%, and 85%,
respectively. The interrupted mucosa sign is a
promising sonographic sign for identication of
endometrial polyps, with greater predictive
power than previously described signs.
Sonoelastography (SE)
Ultrasound elastography or sonoelastography
(SE) has been recently developed to display similar information on tissue stiffness as an image
[48]. It demonstrates the displacement and elasticity of the tissue that has developed secondary
to pressure. With this method, it is possible to
measure the differences in parenchymal strain
and the amount of compression by using the
color spectrum (elastographic scoring) technique, as well as obtaining the strain rates as
numerical values by the help of the technical
properties of the device. With an increasing
number of studies, it has been used to detect
lesions that are overlooked due to similar echogenicity in B-mode imaging and to differentiate
benign and malignant masses in supercial tissues. Czuczwar etal. [49] designed a study to
assess whether SE may be used to visualize the
different stiffness of endometrial polyps and
submucosal broids. Due to their histologic
structure, authors assumed that on strain elastography, endometrial polyps should appear as soft
lesions, whereas submucosal broids should
appear as hard lesions. The diagnostic accuracy
rates for B-mode sonography, power Doppler
imaging, and SE in distinguishing endometrial
polyps and submucosal broids were 70.2%,
65.9%, and 89.4%, respectively. The proportion
of correct ndings was signicantly higher for
strain elastography than for B-mode sonography
(p = 0.0265) and power Doppler imaging
(p=0.0153). They concluded that SE complements sonography in differentiating intrauterine
lesions and it may be used to visualize the different stiffness of endometrial polyps and submucosal broids.
Combination ofRadiographic Indices
Fang etal. [50] evaluated the usefulness of combined radiographic indices for diagnosis of
endometrial polyps and concluded that a combination of endometrial echogenicity, thickness,
and volume on sonography may be better than a
single indicator for predicting endometrial polyps in infertility. However, the endometrial or
subendometrial vascularization index, ow
index, and vascularization ow index were not
useful for prediction. Bhaduri etal. [51] studied
the likelihood ratio (LR) of SHG ndings for
discriminating endometrial polyps from submucosal broids. The LR of 13.4 was achieved for
polyps when there was a combination of an
intact endometrial- myometrial interface, a single
vessel, an acute angle, and homogeneous echogenicity. The highest LR of 27.8 was achieved
for submucosal broids when the combination
of sonographic features included an absent
endometrial- myometrial interface, an arborized/
multiple vascular pattern, an obtuse angle, and
heterogeneous echogenicity. A combination of
sonographic ndings may provide high LRs for
discriminating endometrial polyps from submucosal broids.
10 Uterine Polyps
165
Sonohysterography
Indications for SHG (also called saline infusion
sonography (SIS) or hydrosonogram) include,
but are not limited to, evaluation of abnormal
uterine bleeding; uterine cavity especially with
regard to uterine myomas, polyps, and synechiae; and abnormalities detected on endovaginal sonography, including focal or diffuse
endometrial or intracavitary abnormalities [52].
This technique which involves injection of sterile saline into the endometrial cavity followed
by a TVUS increases sonographic contrast of
the endometrial cavity, enabling delineation of
the size, number, and location of polyps that
could have been missed on grayscale TVUS,
and is likely to improve diagnostic accuracy
[53, 54]. With SIS, polyps appear as echogenic,
smooth, intracavitary masses with either broad
bases or thin stalks outlined by uid [55].
Differentiating endometrial polyps from submucosal broids can be difcult (see
Fig.10.10), but examination of lesion echotexture and identication of overlying echogenic
endometrium are useful features to distinguish
the two [56]. Jokubkiene etal. [57] studied the
appearance of the endometrium at SHG in the
luteal phase of the menstrual cycle and concluded that one should avoid performing SHG
in the luteal phase, not only because there may
be a fertilized ovum in the genital tract but also
because endometrial folds are common in this
phase and may lead to over diagnosis of focal
endometrial pathology, such as polyps.
Advantages of SIS include assessment of both
the uterine cavity and other uterine and pelvic
structures [58] and the potential to assess tubal
patency in patients with infertility.
Disadvantages of SIS include an inability to
determine nal endometrial disease, a slower
learning curve compared with non-contrast
TVUS [59], and patient discomfort caused by
uid leakage or pain during examination [60].
Several studies report SHG to be signicantly
more accurate than TVUS alone in making a
diagnosis of intracavitary leiomyomas or polyps [61, 62], with a higher sensitivity (93% versus 65%) and specicity (94% versus 76%)
than TVUS.Only SHG can distinguish between
focal and uniform thickening of the endometrium and structural abnormalities.
Some studies comparing the accuracy of
several diagnostic modalities show SHG to be
as effective as hysteroscopy in detecting structural versus histopathologic abnormalities [63,
64]. When compared with hysteroscopy with
guided biopsy, SIS has a sensitivity of 58–100%,
specicity of 35–100%, PPV of 70–100%, and
NPV of 83–100% [17]. A number of level II
studies report no signicant difference between
SIS and diagnostic hysteroscopy in diagnosing
endometrial polyps [64, 65]. Interestingly, the
risk of malignancy was increased sevenfold
(odds ratio, 7.3; 95% condence interval, 1.9–
27.8) in women with distension difculties at
saline contrast SHG, and two-thirds of the
women with a poorly distensible uterine cavity
had a malignant diagnosis. To the contrary, a
systematic accuracy review using hysteroscopy
with or without biopsy or hysterectomy as reference standards found that the accuracy of SIS
in the diagnosis of endometrial polyps was
lower than that for diagnosis of other uterine
cavity abnormalities such as submucous
broids. The pooled sensitivity was 0.86 (95%
CI 0.81–0.91), the pooled specicity was 0.81
(95% CI 0.72–0.88), and the likelihood ratios
(LRs) were 5.23 (95% CI 3.98–6.90) and 0.12
(95% CI 0.08–0.17), respectively, consistent
with a moderately accurate test for detecting
and excluding polyps [66].
A meta-analysis conducted by Nieuwenhuis
etal. [67] to compare 3D SHG to 2D SHG for the
diagnosis of focal intracavitary lesions found no
statistically signicant differences between these
modalities. Inoue etal. [68] compared 3D SHG
to preoperative MRI for the detection of endometrial polyps and for accurate identication of the
site of attachment within the uterine cavity.
Endometrial polyps could only be identied in
37.5% of women using MRI but could be identied in all women using 3D SHG.The accuracy
rate of the attachment site of endometrial polyps
was 87.5% on 3D-SISH and 18.8% (in all
patients) or 50.0% (in polyp-detected patients) on
MRI, indicating a higher accuracy rate using 3D