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Ultrasonography in Gynaecological Cancers 119

Figure 6. Lymph nodes detection. Scheme (A), ultrasound detection of infiltrated lymph nodes in interiliac bifurcation left using
endoluminal probe (infiltrated lymph node is characterised as hypoechogenic lesion with rounded shape and peripheral perfusion) (B).
Transabdominal scan of left obturator fossa showing two tightly packed lymph nodes (C). TVS-transvaginal scan, TRS-transrectal scan,
TAS-transabdominal scan, LN-lymph node.

assessing myometrial and cervical stromal invasion, diagnostic inaccuracy reflects the same limitations in
ruling out ovarian disease (3, 34, 35). both methods. Both methods have a similar tendency
to overestimate myometrial invasion and underestimate
Transvaginal ultrasound plays a pivotal role in the cervical stromal invasion (43, 44). Because of imaging
management of women with postmenopausal bleeding availability, ultrasound remains the preferred option,
(36). Women with endometrial thickness ≤4 mm as whereas MRI is used in cases of reduced acoustic visibility
measured by transvaginal ultrasound have a low risk of due to myomas, acoustic shadows, uterine position etc.
endometrial cancer (1 in 100 if they do not use hormone
replacement therapy, 1 in 1000 if they do), and it is Subjective vs Objective Evaluation of
safe to refrain from endometrial sampling to obtain a Myometrial and Cervical Stromal Tumour
histological diagnosis in these women (37-39). Invasion

Moreover, ultrasound might be a valuable tool in the The radiological assessment of myometrial invasion
triaging of patients to less or more radical surgical staging remains a diagnostic challenge and the research is
depending on tumour extent. Currently there are two focused on replacing less accurate subjective assessment
comparably accurate methods for determining the local with objective measurements. Subjective assessment of
extent of endometrial cancer, and those are MRI and myometrial invasion correlates the width of myometrium
ultrasound (36). To date three studies published by Savelli with the depth of tumour invasion (Figure 7). Among
et al., Antonsen et al. and Ørtoft et al. have evaluated the objective measurements, the most frequently used are
the accuracy of both imaging methods in detecting Karlsson (anteroposterior endometrial tumour thickness/
myometrial and cervical invasion (40-42). Using MRI anteroposterior uterine diameter ratio) and Gordon
and ultrasound, the accuracy of myometrial invasion approaches (ratio of the distance between endometrium-
assessment reached 66-82% and 72-84% and of cervical myometrium interface and maximum tumour depth
invasion 82-85% and 78-92% (40-42). Comparable to the total myometrial thickness) (Figure 7). The

Figure 7. Subjective and objective evaluation of myometrial invasion. Subjective assessment of myometrial invasion based on evaluation
of disrupted endometrial/myometrial border and a subjective correlation of the width of myometrium along with the depth of tumour
invasion (A). Karlssonś ratio (the maximum anteroposterior [AP] thickness of the endometrial lesion measured in the sagittal plane [d1]
divided by the AP uterine diameter [d2] indicates deep invasion if d1/d2≥50% (B). Gordon‘s ratio (the distance between the maximum
tumour depth [d1] and the total myometrial thickness [d2]) with d1/d2≥50% indicating the deep myometrial invasion (C).