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120 Ultrasonography in Gynaecological Cancers

Figure 8. Cervical stromal invasion. Absence of cervical stromal invasion is demonstrated on schemes as bulging or protrusion
of endometrial tumour (A, B), while cervical invasion is suspected if there is no clear demarcation of the endometrial lesion toward
the cervical canal (C). Note: objective measurement of the distance from the outer cervical orificium, outer cervical orificium to the
lower margin of the tumour with cut-off less than 20 mm was correlated to the probability of cervical stromal invasion, but subjective
assessment of cervical stromal invasion performed significantly better (46).

recently published metaanalysis by Alcazár et al found Scheme 1. Preoperative diagnosis of low and high risk
that the overall diagnostic performance of transvaginal endometrial cancer. Two step strategy is based on preoperative
ultrasound in detecting deep myometrial invasion in biopsy firstly, supplemented in the second step by ultrasound
women with endometrial cancer gave a pooled sensitivity assessment of myometrial and cervical invasion only in cases
of 82% and pooled specificity of 81% without statistical with biopsy revealing well or moderately differentiated cancer.
differences in terms of diagnostic performance between
subjective impression and both objective measurements assess the depth of tumour invasion into the myometrium
(45). The finding is not surprising, because when taking and into the cervical stroma (34). If a stratification of
measurements, subjective assessment is used first to patients for surgery were based solely on the preoperative
define, what is tumour and what is normal, healthy tissue. grading (low-risk endometrial cancer: grade 1 and 2,
endometrial or mucinous cancer; high-risk cancer: grade
As with myometrial invasion, a cervical stromal 3), then 64% of high risk patients would be erroneously
invasion may be assessed subjectively or using an underestimated (47).
objective test. Using subjective assessment, the dynamic
test helps to differentiate the bulging or protrusion Therefore, in clinical practice a two-step strategy
of tumour into the endocervical canal from the true is advisable, when grade 3 tumours are automatically
cervical stromal invasion (Figure 8). Movement of the assessed as high risk while well and moderately
vaginal probe over the cervix will cause the protruding, differentiated endometrial cancers are supplemented
but not infiltrative, tumour to slide within the canal. In by subjective assessment of myometrial and cervical
contrast, the cervical stromal infiltration is characterised invasion on ultrasound. Subjective assessment classifies
by the loss of clear demarcation of the endometrial lesion
toward the cervical stroma accompanied by enhanced
tumour perfusion. Only one study has assessed objective
measurement techniques to predict cervical invasion.
The measurement of the distance from the outer cervical
orifice to the lower margin of the tumour was correlated
to the probability of cervical stromal invasion (cut off
less than 20 mm for cervical invasion), but subjective
assessment performed significantly better (specificity of
subjective vs objective measurement, 93 vs 63%, P<0.001)
(46).

Preoperative Triage of Women to Less or More
Advanced Surgical Staging

Complete lymphadenectomy is reserved for cases
with high-risk features in order to define prognostic
parameters, determine adjuvant treatment and in addition
has a therapeutic impact. Preoperative stratification for
surgery is based on the results of preoperative biopsy and
an appropriate imaging technique that should reliably