CLINICAL ARTICLE
Endometrial volume as predictor of malignancy in women with postmenopausal bleeding
G.M.Mansour a ,I.K.I.El-Lamie a ,M.A.El-Kady a ,S.F.El-Mekkawi a ,M.Laban b,⁎,A.I.Abou-Gabal a
a Department of Obstetrics and Gynecology,Ain Shams University,Cairo,Egypt
b
Department of Gynecology and Obstetrics,Taibah University,Almadinah Almonwarah,Saudi Arabia
Received 27April 2007;received in revid form 25July 2007;accepted 30July 2007
Abstract
Objective:To asss endometrial volume as a predictor of endometrial malignancy in women with postmenopausal bleeding.Methods:Endometrial volume was measured by virtual organ computer-aided analysis in 170women with postmenopausal bleeding,and histopathologic results of endometrial biopsies were obtained for all.A group of 100women without postmenopausal bleeding was ud for co
ntrol.Results:There were 90cas of benign dia,53cas of atypia,and 27cas of endometrial cancers in the study group.Whereas endometrial thickness was 9.61±5.12mm (range,5–20mm)and endometrial volume was 3±1.1mL (range,1.8–5.4mL)in women with atypia or cancer ,they were 4.87±3.43mm (range,2–8mm)and 1.52±0.82(range,0.6–2.2mL),respectively,in women with benign dia.In the control group,endometrial volume was 1.15±0.14mL (range,0.6–1.3mL).Volume was more nsitive than thickness for predicting malignancy,and a cutoff value of 1.35mL was found to provide the best nsitivity.Conclusion:An endometrial volume of 1.35mL or greater may predict malignancy in women with postmenopausal bleeding.
©2007International Federation of Gynecology and Obstetrics.Published by Elvier Ireland Ltd.All rights rerved.
KEYWORDS
Endometrial volume;
Postmenopausal bleeding;Three-dimensional ultrasound;Virtual organ
computer-aided analysis
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1.Introduction
Uterine cancer is the most common malignant neoplasm of the female genital tract and the fourth most common cancer in women.It was reported that 6000women died of the dia in the United States in 1997[1],and an annual incidence of 19.5cas per 100,000women was recorded in Canada in 1993[2].Postmenopausal bleeding with endome-trial atypia carries a risk of progression to cancer [3],but
⁎Corresponding author.Department of Gynecology and Obstetrics,College of Medicine,Taibah University,Almadinah Almonwarah,(KSA),P .O.Box 30001,Saudi Arabia.Tel.:+966568281015;fax:+96648461407.
E-mail address: (M.
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Laban).
0020-7292/$-e front matter ©2007International Federation of Gynecology and Obstetrics.Published by Elvier Ireland Ltd.All rights rerved.
doi:
10.1016/j.ijgo.2007.07.024
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International Journal of Gynecology and Obstetrics (2007)99,206–210
the risk of atrophic endometritis developing into cancer is minimal.
Endometrial thickness has been ud as an indicator of risk for endometrial carcinoma in asymptomatic menopausal and postmenopausal women.In 2-dimensional (2D)ultrasound,the thickest anteroposterior diameter of the endometrium is measured using the 2endometrial layers,and a cutoff value of 4to 5mm has been found to be predictive of pathologic changes [4–7].However ,the same thickness does not express the same endometrial volume in different endometria becau uterine lengths may be different and endometrial irregularities may exist.
Volume estimation is more reliably obtained by 3-dimen-sional (3D)than by 2D ultrasound [8].The smallest unit of a 2D image is called a pixel and the smallest unit of a 3D image is called a voxel [9].
Although the interobrver and intraobrver reproduci-bility of endometrial volume estimation by VOCAL is well established [10–15],no cutoff value has been propod for the endometrial volume of postmenopausal women who may be at risk for malignancy.The prent study was conducted to determine the cutoff value for endometrial volume,as measured by VOCAL,that could be considered a predictor of malignancy in women with postmenopausal bleeding.
2.Patients and methods
A total of 170women prenting to the outpatient clinics of Ain Shams University Maternity Hospital with complaints of post-menopausal bleeding were recruited between January 2005and August 2006,and 100healthy postmenopausal women acted as
controls.Neither study patients nor controls were taking hor-mone replacement at the time of the study.
The study was approved by the hospital ethics committee and informed connt was obtained from all participants.History taking included age,years since menopau,smoking and hor-mone therapy status,and prence or abnce of any medical disorders such as diabetes mellitus or hypertension.Body mass index (calculated as weight in kilograms divided by the square of height in
meters)was calculated for all.
Patients with associated gynecologic lesions were not included in the study;nor were tho with bleeding tendencies or general or local caus for bleeding,or tho taking anticoagulants.
The endometrial thickness of patients with suspected endome-trial dia was assd transvaginally by both 2D and 3D explo-ration using the Voluson Pro 730machine (General Electric Medical Systems,Waukesha,Wisconsin,
USA).
Figure 1Multiplanar view of endometrium.Endometrial volumes were manually calculated in the coronal plane with 30°rotation steps and 1-mm shell thickness (12mm thickness by 2D and 3.5mL volume by 3D).
Table 1Endometrial thickness and volume in women tested for endometrial atypia or cancer and in healthy controls a Group studied
Thickness,mm Volume,mL All study women (n =170)8.75±4.05(2–20) 2.74±0.9(1–5.4)Tho positive for
atypia or cancer (n =80)9.61±5.12(5–20)3±1.1(8–5.4)Tho negative for
atypia or cancer (n =90) 4.87±3.43(2–8) 1.52±0.82(0.6–2.2)Controls (n =100)企业养老保险
2.7±1.2(1–5)
1.15±0.14(0.6–1.3)
a
Values are given as mean ±SD (range).
出自历史故事的成语207
Endometrial volume as predictor of malignancy in women with postmenopausal bleeding
The axial,midsagittal(anteroposterior2D ction),and mid-coronal planes were ud to capture endometrial volumes,and the starting points for the manual tracing of the endometrium were centered superiorly and inferiorly(manual tracing permit-ting the preci outline of any irregularity in the endometrium) (Fig.1).Endometrial volumes were calculated in the coronal plane with30°rotation steps and1-mm shell thickness(Fig.1). All scans were done by the first author.
The standardization of the technique's prerequisites is necessary,as changes in angle of rotation,shell thickness,or views ud would affect the accuracy of the results.
Power Doppler was ud to asss the degree of perfusion of the endometrium and subendometrial area.Subendometrial blood flow resistance indices were determined using Doppler waveform impuls.
Dilation and curettage or Novak biopsy was done in all cas and histopathologic results were obtain
ed.
After tabulation,all data were analyzed using SPSS software, version11.0(SPSS,Chicago,IL,USA).The Pearsonχ2test was ud for nominal values and the paired t test and analysis of variance were ud for numerical values.P b0.05indicated statistical significance.
3.Results
There were no statistical differences between the study and control groups regarding age,parity,or body mass index.
In the study group the mean±SD age was55±3.72years (range,50–83years);parity was5.08±0.72(range,0–12); endometrial thickness was8.75±4.05(range,3–20mm);and endometrial volume was 2.74±0.9mL(range,1–5.4mL (Table1).
Power Doppler ultrasound detected perfusion in20study patients.The subendometrial blood flow resistance index was0.56±0.025(range,0.5–0.6).No Doppler signal was detected in the endometrial or subendometrial areas in any of the healthy controls.
Histopathologic results revealed53cas of atypia,27 cas of endometrial cancer,and20cas of atrophic endo-metritis.A result of atypia or endometrial cancer was con-sidered positive and a result of atrophic endometritis was considered negative.
Endometrial thickness was4.87±3.43mm and endome-trial volume was1.52±0.82mL for the90study patients testing negative for endometrial atypia or cancer,and they were9.61±5.12mm and3±1.1mL in the80patients testing positive(Table1).
The operating characteristic curve revealed that using endometrial volume rather than endometrial thickness pro-vided a greater nsitivity for predicting atypia or malig-nancy.Overall,nsitivity was79%(95%confidence interval [CI],72%–86%,P b0.001)using endometrial thickness,and 91%(95%CI,87%–96%,P b0.001)using endometrial volume (Fig.2).A cutoff value of1.35mL was predictive of atypia or malignancy with100%nsitivity and71%specificity (Table2
). Figure2Receiver operating characteristic(ROC)curve.
Table2Cutoff values for endometrial volume as predictor
of endometrial atypia or cancer,with their corresponding
nsitivity and specificity
Volume,mL Sensitivity,%Specificity,% 1.05 1.000.06
1.15 1.000.11
1.25 1.000.47
1.35a 1.000.71
1.450.910.78
1.550.870.78
1.650.810.84
1.750.800.84
1.850.790.90
1.950.760.90
2.050.720.90
2.150.700.90
2.350.670.90
2.550.660.56
2.650.610.56
2.750.600.56
a1.35mL was chon as a cutoff value for its100%nsitivity (with71%specificity).Table3Comparison between benign,malignant and normal controls regarding endometrial thickness and volume a Histologic result b Thickness,mm Volume,mL Study patients
Negative/benign 4.87±3.43 1.52±0.82 Atypia or cancer9.61±5.12 3.00±1.10 t test 3.24 2.50 Controls 2.70±1.20 1.15±0.14 Study patients,
negative/benign
4.87±3.43 1.52±0.82
t test 5.41 1.10 Controls 2.70±1.20 1.15±0.14 Study patients,
atypia/cancer
9.61±5.12 3.00±1.10 t test12.5015.40
P value b0.001b0.001
a Values are given as mean±SD unless otherwi indicated.
b Of170study patients80were found positive for endometrial atypia or cancer;100healthy postmenopausal women acted as controls.
208G.M.Mansour et al.
Endometrial thickness was2.7±1.2mm(range,1–5mm) and endometrial volume was1.15±0.14mL(range,0.6–1.3mL)in the control group(Table1).Using the t test,there were highly significant differences in endometrial thickness and volume between study patients with positive hist
ologic results and controls,but the differences between study patients with negative results and controls were significant as well(Table3).
4.Discussion
Abnormal vaginal bleeding is one of the most common pre-nting complaints in women of any age eking gynecologic care.T wo of the most frequently ud diagnostic tests to investigate the cau of bleeding are endometrial biopsy and transvaginal ultrasound.The most worrisome cau of abnormal bleeding is endometrial carcinoma.Endometrial biopsy and transvaginal ultrasound are equally nsitive in the detection of carcinoma,but ultrasound is far more effective in diagnosing benign dia[16].Studies examin-ing screening methods for endometrial carcinoma in asymp-tomatic postmenopausal women have accepted ultrasound-determined endometrial thickness as an indication of risk. The thickest anteroposterior diameter of the endometrium is measured during2D ultrasound,and a cutoff value of4to 5mm is considered predictive of pathologic changes[4–7]. Many trials were introduced to enhance the predictive u-fulness of ultrasound for endometrial malignancy,and Sheikh et al.[5]added abnormal focal echogenicity—the sign of a nonhomogenous endometrium—as a predictor of malignancy.
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Endometrial volume asssment by ultrasound was intro-duced in the last few years and most studies on the technique have examined its reproducibility[8–15].Martins et al.[17] ud3D ultrasound data ts obtained by VOCAL to measure a known volume of a portion of chicken chest muscle contained in a sample of bovine liver.The authors concluded that this technique of volume measurement was reliable and there-fore valid for small and irregular tissue,and suggested it as uful for measuring endometrial volume and other volumes of similar size.Merce et al.[13]stated that reproducibility was significantly higher in women with what they called a tumoral endometrium.
Concerning the degrees of rotation adopted for a better reproducibility of the test,Martins et al.[17]ud15°rotation steps whereas Raine-Fenning et al.[12]tried all degrees of rotation and concluded that endometrial volume acquisition was reproducible;however,in their study,rota-tion steps less than30°were associated with a significantly smaller variance in measurements and with significantly greater mean values for endometrial volume.In contrast,the study by Merce et al.[13]concluded that the reliability of measurements did not em to be significantly influenced by the rotation plane and degrees of rotation.
In this study we measured endometrial thickness in the sagittal view of the uterus,including the anterior and posterior walls of endometrium.Endometrial volume was measured by VOCAL using the
coronal plane of uterus,1-mm shell thickness,and rotation steps of30°.By the receiver operating characteristic curve,a higher nsitivity was found using endometrial volume than endometrial thickness for predicting atypia or malignancy.
Sensitivity was79%(95%CI,72%–86%,P b0.001)for en-dometrial thickness and91%(95%CI,87–96,P b0.001)for endometrial volume(Fig.2).
A cutoff value of 1.35mL was predictive of atypia or malignancy,with100%nsitivity and71%specificity (Table2);cutoff values less than1.35mL were predictive of negative histologic results for atypia or malignancy.
In a study by Gull et al.[18]endometrial thickness was measured by transvaginal ultrasound in394women with postmenopausal bleeding,and the women were followed up for at least10years.The authors concluded that women with recurrent bleeding were at high risk for atypia or endometrial cancer whereas tho who bleeding was not recurrent were not.No endometrial cancer was misd in their study when endometrial thickness measurement was ud(cutoff value,≤4mm).In the prent study,all women with an endometrial thickness less than the cutoff value of1.35mL tested nega-tive for atypia or malignancy—an important new finding that may decrea the
rates of unnecessary invasive procedures such as dilation and curettage,thereby avoiding complica-tions due to anesthesia,especially in elderly women.
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In conclusion,an endometrial volume greater than a cutoff value of1.35mL is predictive of endometrial atypia or malignancy.In our study,endometrial volume was a more nsitive and accurate predictor than endometrial thickness. However,considering the pilot nature of this study,further studies with much larger study and control populations are needed to verify its findings.
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二王书法
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