Ultrasound of the Endometrium

False Positives and Problems

What are some false positives and problems?

Air bubbles are the enemy of ultrasound.

Here we can see an air bubble up towards the
fundus of the endometrium.

Balloon obscuring the lower uterine segment.

Deflate the balloon,

grunge that looks like a mass.

You see that thing on the back of the uterus there.

We deflated the balloon
and then just kind of scooped it around
and sucked the fluid out, put some new fluid in.

And by the time we were done,
we had a beautiful look at the endometrium right there.

Again, blood clots.

You start out here and you're like, wow, that's a polyp.
That's cancer. But you spend five
or 10 minutes putting fluid in, sucking it out,
putting it in, sucking it out,
and you get a nice normal study.

Mechanical shearing of the endometrium.

This has been called a pseudo polyp here.

And you can see you put the catheter in,
you've made a little shelf in the endometrium.

But bottom line, you should not be doing this study in
somebody who's in the luteal phase.

If you do everybody on day five to 10,
you won't have an issue.

Color Doppler and 3D Imaging

Colored opera, how much does it help?

Classic teaching is one.

Vessels polyp multiple vessels as fibroids.

That works, but you can't take it to the bank.

3D more and more of us are getting that there.

In reality, all you really need is a cine clip.

Just get a sweep sagittal, sweep coronal, and you're done.

But if you have 3D by all means, use it.

Here's a second polyp right there
that we missed on the initial 2D scan.

You can do this kinda CT type imaging right here
and get the cplan so pretty.

Pathology

Okay, and let's finish up in the last 15 minutes with
pathology right here.

SIS and endometrial polyps there.

Endometrial Polyps

Most polyps are homogeneous
and they're hypo coic, hyper coic,
and they have a narrow base of attachment.

Oftentimes they're multiple.

You wanna describe to your GYN friends how many they are,
where they are, what the base of attachment is,
so they know how to snare them.

Here's one here, just a big polyp,
totally looks like a polyp,
but remember that literature talking about two to 4% of
supposedly benign polyps will have a small
focus of cancer in them.

And this one had a grade one
adenocarcinoma within the polyp.

Our job is surgical versus medical.

Here's another one right here, just a pretty polyp.

Again, homogeneous hyper coic.

Here's another one. This looked like Pac-Man,
that old video game on the left there.

And as we go through, you can see the Pac-Man appearance,
but this again turned out to be a benign endometrial polyp.

Really pathognomonic appearance almost.

And then again, remember the second polyp,
there are multiple here.

The balloon is obscuring the lower uterine segment.

When we deflate the balloon, we see the second polyp there.

Fibroids

Fibroids incredibly common right there.

A nice New England Journal paper a couple weeks ago talking
about the pathophysiology of these.

Here, like most things in life,
there are these obscure staging systems,
but all you need to remember is,
is it more than half in or half out?

Because if it's more in the endometrial cavity,
like the grade zero and the grade one,
you can take them out hysteroscopically.

If it's more than half in the myometrium,
you have to do surgery there.

That's the information they want
and we're good at giving it to 'em.

This is from mjs paper.

You can see the classic appearance of a fibroid
with this cap of endometrium
and then the hypo coic fibroid underneath.

Here's another one on the right cap of endometrium.

Here's another one here.

Hopefully I'd call this,
but on a bad day I might miss it.

But then you do the SIS
and it's totally obvious you get that cap of endometrium
around it there and solitary vessel.

Here's another one, cap of endometrium, hypo coic.

The vast majority of it's in the endometrial cavity.

These are the easy ones to take out hysteroscopically.

Here's another one. You can see it transvaginally.

There you do the SIS though you see the multiple blood
vessels characteristic of a fibroid, the cap of endometrium.

And again, it's almost all in the cavity.

It's amenable to hysteroscopic resection.

Here's another one, classic appearance of this thin cap
of hyper coic endometrium on this exophytic fibroid.

Endometrial Hyperplasia

Now we're gonna start moving along the spectrum to cancer.

And there's endometrial hyperplasia, which makes up about 6%
of postmenopausal bleeding.

And there's a spectrum of endometrial hyperplasia from
simple without ayia through a few steps to severe ayia,
which is one step short of cancer.

Here you can see at trans vg.

And then with the SIS we have this kind of uniform,
lumpy, bumpy appearance to the endometrium.

And this turned out to be simple endometrial hyperplasia.

Here's another one right here.

There's a little bit of a polyp,
but this turned out to be complex endometrial hyperplasia
without atypia within the polyp.

Surgical versus medical disease.

Here's a flat plaque, like one in mjs paper right there.

This turned out to be mild ayia.

Endometrial Cancer

And then finally, the point of this whole talk is getting
to endometrial cancer.

And again, this is the most common GYN cancer,
the force most common cancer in women.

They tend to be large and broad based.

Is this from our study patient right here, there.

Here is a classic appearance of this irregular, lumpy,
bumpy, partially cystic appearance,
taking up much of the endometrium.

Here's another one with a malignant hemato omeros
with irregular lumpy, bumpy appearance to the lining.

Here's one coming in. And we may start.

There's been a change in Europe.

We've been asking the GYNs for years to do MR for these
and they haven't done 'em, they've just taken the or.

But there's a real sea change out there in Europe
that's starting to hit in the us

The idea being if we can say
that there's only minimal invasion of the uterus,
then the hysterectomy can be done at your local,
community hospital.

But if there's major invasion of the uterus,
then you may need to go see a gyno with nodal dissection.

Take a stab at grading depth of invasion on
your SIS or transvaginal ultrasound there.

But in reality, MR is gonna be much better.

Another thing to think about is incomplete
distension right there.

Think of Linus plastic and gastric cancer there.

Those of you old enough to have done upper GI there,
the cancer, whether it's a primary gastric
or metastatic breast infiltrates, the lining
of the stomach in its thick, like a leather bottle
and you can't distend it.

The same thing often happens in endometrial cancer.

The lining gets stiff and you start putting in fluid
and the fluid just heads out the fallopian tubes
or back leaks around your balloon out the oss,
but you can't distend it.

And the odds ratio
for cancers almost an order of magnitude there.

7.3. Here's another example.

We had the balloon in down low.

And no matter how much we pushed here,
we just couldn't distend this.

And this whole thing up here turned out
to be endometrial cancer.

And then here's one of our study patients
who obviously didn't complain of pain
after we took her uterus out,
but in this case, I put Kelly's on the fallopian tubes,
inflated the balloon all the way in the endometrial cavity
and put in fluid as much as I could,
and I could barely distend it.

Think of this stiff endometrium as being a risk factor
for infiltrating endometrial cancer.

Here's another one. This looks totally like a polyp there.

And at path it was benign, benign, benign, benign,
papillary, serous, endometrial carcinoma, benign,
benign, benign, benign.

And also notice here how we have the single feeding vessel,
kind of the classic appearance for a polyp.

Here's another one here.

You look at this, and this is a classic example of
lumpy bumpy endometrium.

I would call this endometrial cancer every single time.

And this turned out to be metastatic breast
cancer to the uterus.

I've seen four cases of this.

Now, tamoxifen, again, don't ask, don't tell.

We just don't wanna look in these situations right here.

But here you can see this weird looking
mass in there.

This turned out to have severe atypia in it,
but we really don't even wanna look
because most patients on tamoxifen are gonna look abnormal.

And the bottom line is if they're not bleeding,
we're not gonna do anything.

Here's another one. This turned out to be a polyp
with carcinoma in situ two.

Other Applications of SIS

There's a whole nother area of using SISs
for infertility right there.

You can see the uterine fusion abnormality here.

Here's a patient who had multiple prior DNCs.

This was an asherman's right there.

And then one of the really cool areas coming up
that people are talking about is
the only time we're doing HSGs now is
for our infertility patients right there
to see if the tubes fill and spill
because HSG is awful for the endometrium.

What if we could get the information with SIS,
we'll get a much better look at the endometrium
and then we're not gonna get detailed
morphology of the tubes.

We're not gonna see SIN,
but if all we wanna see is tub will fill
and spill, why don't we inject a contrast agent?

And these contrast agents range from the cheap,
just grabbing 60 ccs
of room air and injecting it.

Too expensive. They're kinda like barbershop
shaving creams that have little bubbles in them
where you can use FIN or Le Vista or whatever.

There's a lot of work looking at this now
to save women the radiation into procedures there,

retain products.

Again, we said indications are anything to do
with the endometrium the year.

If you have a bunch of trans badges that are normal
and you're worried about something,
this is from mjs paper showing
RPOC intervention.

That is the weakness of SIS hysteroscopy.

You can deal with it. I've got a buddy who's an inventor,
he's an REI doc
and he's kind of come up with these
Rube Goldberg contraptions with different balloons
and snares and all that.

But again, this works in his hands
and even in his hands he admits it's really hard.

But for the rest of us, it's never gonna work there.

Bottom line, not a lot of luck with intervention there.

One thing that you can do, if you're doing this
for cancer there, you think it's malignancy.

You just suck the fluid out after you're done
and send it for cytology.

And there's a fair amount of recent work just talking about
positive cytology
and endometrial cancer there.

Efficacy of SIS

Okay, how good is SIS Basically it's as good
as diagnostic hysteroscopy under general
anesthesia at detecting things.

It's like optical colonoscopy versus virtual colonoscopy.

Virtual colonoscopies is probably better at finding
significant lesions there,
but the issue is you can't deal with them there.

As you do the math, you go through,
here's one paper that said two outta three hot
hysteroscopies can be avoided.

SIS hurts less, requires less medical innovation
and is a lot cheaper than doing ambulatory
office hysteroscopy.

Summary and Take Home Points

Here's what we talked about here.

We talked about why we worry terminology
and technique, what's abnormal
abnormalities seen on transvaginal ultrasound,
other diagnostic modalities like DNC and endometrial biopsy.

Then we had a lecture within a lecture
of saline infusion sonohysterography really emphasizing
technique and how to do it.

And then we showed a whole bunch of different examples
that can be elucidated by SIS.

The take home points, how to measure it.

Remember John Wooden's quote, attention
to little details is the foundation of excellence.

Less than five millimeters reliably excludes endometrial
cancer in the postmenopausal patient with bleeding,

use 11 millimeters in the asymptomatic postmenopausal
patient take home point SIS is easy to perform, has a short,
short learning curve.

Works for all of us there.

I don't think it's quite as easy as Tom Cruise
and Katie Holmes right there
where you can buy an ultrasound machine
and use it at home right there.

But it's a really good test
and I'd like to thank these folks for the help
with the talk and we're all done.

I.