Ultrasonographic findings of the endometrium – how to evaluate / interpretate them ???

1. Ultrasonographic findings of the endometrium – how to evaluate / interpretate them ??? Dr . Ofer Lavie Division of Gyn-Surgical & Oncology Carmel Medical Center , HAIFA

2. Polyps and endometrial thickness what a confusing state ? Dr . Ofer Lavie Division of Gyn-Surgical & Oncology Carmel Medical Center , HAIFA

3. Support ! different situationsby specific tools

4. Menu • Thick endometrium Early detection- Screening Clinical outcome • Endometrial Polyps The risk of malignancy - Theory The risk of malignancy - Clinical To treat or not to treat ?

5. Objective ? Pre Sym ? Post Thickness ? Pre Asym ? Post U.S & Endo ? Pre Sym ? Post Polyps ? Pre Asym ? Post

6. Other options Pre Sym Pipell Post Thickness Do not touch Pre Asym ? Post U.S & Endo ? Pre Sym Hysteroscopy Post Polyps ? Pre Asym ? Post

7. Menu • Thick endometrium Early detection- Screening Clinical outcome • Endometrial Polyps The risk of malignancy - Theory The risk of malignancy - Clinical To treat or not to treat ?

8. Clinical outcome ? Asymptomatic thick endometrium - do we have to sample ? Removing the tumor Thick endo Sampling ? Early detection ?

9. Different levels of endo. thickness

10. Asymptomatic thick endometrium - do we have to sample ?

11. Clinical outcome ? Asymptomatic thick endometrium - do we have to sample ? Removing the tumor Thick endo Sampling ? Early detection ?

12. Screening for early detection • >75% EC pts present with stage I disease • 5YS 88% • Not much scope for decreasing mortality • May provide genuine reasurance - if sensitivity high • May minimise treatment if achieves earlier diagnosis

13. Screening evidence • Minimal data on screening in high risk group • Limited data on EC screening in the general population • Unpublished data from UKCTOCS study

14. Screening evidence-Endometrial Bx in thick endometrium (>6mm)

15. Screening evidence-Endometrial Bx in thick endometrium (>6mm)

16. TVU findings on EC in UKCTOCS Study of the general population • 48,190 postmenopausal women aged 50 -74 who had completed initial UKCTOCS scan • 9069 had a hysterectomy • Baseline TVS screens on 38,668 asymptomatic women • 82 women with abn (73 with EC, 5 complex hyperplasia, 4 Atypical hyperplasia) • Last TVS before EC diagnosis • Endometrial thickness (ET) in mms • Endometrial abnormality (EA) includes polyp; thickened, cystic, irregular or heterogeneous endometrium; fluid in cavity

17. Endometrial Thickness on TVU Healthy women Endometrial Cancer

18. EC Screening in UKCTOCS

19. EC Screening recommendation-RCOG • There is no evidence based approach • In view of the high risk discuss the options of endometrial aspiration and TVU with women at risk • Offer annual TVU from 45y • Postmenopause 8-7mm cut off • Emphasise lack of evidence, risk of false positives and false negatives

20. Clinical outcome ? Asymptomatic thick endometrium - do we have to sample ? Removing the tumor Thick endo Sampling ? Early detection ?

21. Survival of Untreated Patients

22. Natural Course of Patient with Untreated Endometrial Ca

23. Early detection Prognosis • A lengthy survival of untreated patients with endometrial carcinoma indicates a slow natural progression of the disease. • The asymptomatic pre – treatment period should not influence the final outcome Endometrial endometrioid carcinoma : A glimpse at natural course Levy and Menczer AJOG 2006

24. More evidence • UP to Date (Clinical features of endometrial ca) : 6-8mm may be sampled /or await for symptoms Mean endo thickness in 759 endo ca was 20mm • Cochrane 2006 >6mm in menopause more than 15 y >8 mm in menopause 5-15 y.

25. CONCLUSIONS • No evidence for screening • No evidence for early detection value In asym thick endometrium • In post menopause endometrial sampling should be performed if endo thickness is above 8-10 mm (no HRT) • In late menopause be more active

26. Other options ? Pre Sym Pipell Post Thickness Do not touch Pre Asym ? Post U.S & Endo ? Pre Sym Hysteroscopy Post Polyps ? Pre Asym ? Post

27. Other options Pre Sym Pipell Post Thickness Do not touch Pre Asym No need for pipell Post U.S & Endo ? Pre Sym Hysteroscopy Post Polyps ? Pre Asym ? Post

28. Other options Pre Sym Pipell Post Thickness Do not touch Pre Asym No need for pipell Post U.S & Endo ? Pre Sym Hysteroscopy Post Polyps ? Pre Asym ? Post

29. Endometrial Polyps

30. Menu • Thick endometrium Early detection- Screening Clinical outcome • Endometrial Polyps The risk of malignancy - Theory The risk of malignancy - Clinical To treat or not to treat ?

31. Endometrial polyps - The risk of malignancy Clinical

32. Conclusions • Percentage of carcinomatosis polyps 1-3% • Almost all symptomatic • All menopausal • If > 15 mm high risk?

33. The clinical problem-Benign or Malignant

34. What else can be helpful ? • Symptomatic Polyps • History : TAM, HNPCC • Large Polyps > 15 mm

35. SMALL CYSTIC FORMATIONS AS A ULTRASONOGRAPHIC SIGN FOR BENIGN ENDOMETRIAL POLYPS Carmel Medical Center The Department of Obstetrics and Gynecology O.Lavie, R.Kedar, S.Cohen A.Sharon, M.Bardicef, D.Solomovich, A.Lissak and R.Auslander

36. Objective • To evaluate the risk for endometrial carcinoma in endometrial polyps presenting with small cystic formation as demonstrated in transvaginal ultrasonography.

37. Materials and Methods • Retrospective study • TVS photos with histologically proven endometrial polyps were assessed by two of the authors. • All polyps were examined for the presence of cystic formations and the presence of endometrial fluid. • The TVS finding were all compared to the hysteroscopic and to the final pathological reports.

38. Study population • 141 patients with histologically proven endometrial polyps. • All women had TVS demonstrated endometrial polyps • Hysteroscopy was performed to all women • Mean age 61.7

40. Results

41. Conclusion • Cystic formation is a common finding in endometrial polyps (above 50% of polyps)

42. Conclusion (2) • The cystic formations as demonstrated by TVS reflect the histological appearance of glandular atrophy.

43. Conclusion (3) • In our study the ultrasonographic documentation of cystic formations in endometrial polyps suggests a benign finding.

44. Conclusion (4) • In asymptomatic patients with a TVS finding of Endometrial Polyps and Cystic Formations a conservative management can be considered. • Symptomatic women with cystic formations ??

45. What else can be helpful ? • Symptomatic Polyps • History : TAM, HNPCC • Large Polyps > 15 mm • Cystic formations in polyps

46. Menu • Thick endometrium Early detection- Screening Clinical outcome • Endometrial Polyps The risk of malignancy - Clinical The risk of malignancy - Theory

47. Endo Polyps – Pre-cancer state? Theory Is endo polyp a precancer state ???

48. What are Pre-cancers states • Intermediate step in the continuous evolution of a neoplastic lineage • Pre-cancers are benign neoplasms in which the burden of genetic damage is insufficient for malignant behavior • Pre-cancers have monoclonal character and this has been shown for CIN, VIN etc.

49. Monoclonality Monocional Procancer Polycional Normal Monocional Cancer Malignant Transformation Initiation