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Ultrasonography in Gynaecological Cancers 121
patients with deep myometrial and/or cervical invasion unit study, altogether 211 patients with histologically
as at high risk of lymph node metastases and recurrency confirmed endometrial cancer were included from
and complete lymphadenectomy might be indicated in 2009 to 2011 (44). Surprisingly, the expected correlation
such cases (Scheme 1). between ultrasound failure and obesity (BMI), position
of the uterus or the quality of ultrasound imaging was
Based on European multicenter study results, a not confirmed. In this study there was a tendency to
two-step strategy combining preoperative pathological underestimate cervical stromal invasion (10%) in the
grading and subjective assessment of myometrial and presence of small tumours with superficial myometrial
cervical stroma invasion helped to identify eight from invasion, minimal tumour perfusion and favourable
ten women with high risk of lymph node metastases histological grading. Conversely myometrial invasion
(sensitivity 83%) and spare seven from ten low-risk was often overestimated (17%) in the presence of bulky
women radical surgery (specificity 71%)(47). Similar and less differentiated tumours with a thin rim of healthy
results were obtained by an Ortoft et al. study in which myometrium and rich tumour perfusion. The study
the combination of preoperative transvaginal sonography showed a tendency to underestimate local tumour stage
and endometrial biopsy reached 72% accuracy in the in tumours with favourable sonomorphological and
diagnosis of endometrial cancer at high risk of metastasis Doppler features and overestimate tumours with a less
(high risk endometrial cancer) (42). It is obvious that the favourable pattern.
combination of preoperative biopsy and imaging findings
had limited ability to discriminate correctly between Reproducibility of Results Between
low-risk and high-risk endometrial cancer and further investigators
research is needed to improve our clinical decisions.
In the recently published study by Ericsson et al., fifteen
Ultrasound Prediction of Histological Type sonographers with varying degrees of experience
evaluated clips of ultrasound examinations obtained
According to the literature data there is a notable lack from 53 cases with histologically verified endometrial
of correlation between preoperative histological grading cancer (35). In the study, a good agreement between
and definitive pathology (48). The main reason may investigators in determining myometrial invasion (expert
be a tumour heterogeneity or unrepresentative biopsy vs non-expert, kappa value 0.52 vs 0.48, P = 0.11) and
sampling. Therefore, an interesting scientific goal was cervical stromal invasion (expert vs non-expert, kappa
to find the ultrasound parameters that could predict the value 0.58 vs 0.45, P <0.001) was shown. Experienced
adverse histotype and grading of the tumour in cases examiners were more accurate in cervical stromal
where the preoperative biopsy was underestimated. invasion than less experienced examiners.
The multicenter prospective study organised by Epstein
et al. analysed data from 144 consecutive patients The results of this study contributed to the
included in a study from 2007 to 2009 (49). The results implementation of ultrasound alongside obligatory
revealed sonomorphological and Doppler characteristics staging examination in patients with biopsy-proven
associated with the presence of low-risk and high- endometrial cancer, with emphasis on the use of
risk endometrial cancer. These results were externally specialised ultrasound (51).
validated by a subsequent prospective study (44). Low-
risk endometrial cancers were often hyperechoic, either Ovarian Tumours
without or with minimal density of blood vessels within
the tumour. Non-hyperechoic tumours with moderate There is enough evidence to demonstrate a significant
or abundant tumour perfusion and multiple vessels difference in the outcome of patients operated on
multifocally entering at different locations in the tumour surgeons without adequate training and those referred
from the myometrium were more frequently found in for diagnosis and primary treatment to specialised
poorly differentiated tumours or tumours with deep gynaecologic oncology units with multidisciplinary
myometrial infiltration and/or cervical stromal invasion. teams (52, 53). One of the main reasons for an insufficient
As a consequence, if ultrasound tumour characteristics do centralisation of patients with ovarian cancer is the
not correlate with the findings of the preoperative biopsy, absence of an accurate preoperative diagnostic work-up
the intraoperative frozen section may be recommended in patients with pelvic masses. In the case of malignant
to eliminate inadequate surgical procedure. tumour, for individualisation of further management, it is
equally important to assess the tumour specific diagnosis
Factors Affecting the Preoperative Staging and to provide the clinicians with the detailed assessment
of tumour extension using modern imaging. The role of
Subjective evaluation of tumour spread into the ultrasound in these areas of interest has been evaluated
myometrium and cervix, whether during ultrasound or in recent studies.
MRI, remains imprecise in 15-25% cases (44, 50). Recent
research was attempted to identify significantly important
factors that contribute to the ultrasound failure. In a single
