Diagnostic ultrasound ( PDFDrive )

548 PART II Abdominal and Pelvic Sonography
A
B
FIG. 15.19 Endometrial Hyperplasia in Two Patients. (A) Endometrial hyperplasia in a 58-year-old woman not taking hormones with abnormal
bleeding. Sagittal TVS shows uniform hyperechoic thickening (calipers, 14 mm). (B) Complex endometrial hyperplasia without atypia in a 52-year-old
postmenopausal woman with vaginal bleeding. Sagittal TVS shows numerous small cystic spaces diffusely in an endometrium that measured
16 mm in thickness.
seen within the endometrium in cystic hyperplasia; however,
a similar appearance may be seen in cystic atrophy, and cystic
changes can also be seen in endometrial polyps. hese cystic
areas represent the dilated cystic glands seen at histology. 150,151
Although cystic changes within a thickened endometrium are
more frequently seen in benign conditions, they can also be
seen in endometrial carcinoma. 133 Because hyperplasia has
a nonspeciic sonographic appearance, biopsy is necessary
for diagnosis.
Endometrial Polyps
Endometrial polyps are common benign lesions frequently seen
in perimenopausal and postmenopausal women. Polyps may
cause bleeding at any point in the menstrual cycle, although
many are asymptomatic. Histologically, polyps are localized
overgrowths of endometrial tissue covered by epithelium and
projecting above the adjacent surface epithelium. 149 hey may
be pedunculated or broad based, or may have a thin stalk.
Approximately 20% of endometrial polyps are multiple. Malignant
degeneration is uncommon. Occasionally a polyp will have a
long stalk, allowing it to protrude into the cervix or even into
the vagina.
On sonography, polyps may appear as nonspeciic echogenic
endometrial thickening, which may be difuse or focal. However,
they may also appear as a focal, round, echogenic mass within
the endometrial cavity 152 (Fig. 15.20, Video 15.6). At times they
will have a cystic appearance and distend the endometrial cavity
(Video 15.7). his speciic diagnosis of a polyp is much more
easily made when there is luid within the endometrial cavity
outlining the mass and in premenopausal patients is better seen
during the proliferative phase when the endometrium is typically
less echogenic than the polyp. Because luid is instilled into the
endometrial cavity during SHG, this technique is ideal for
demonstrating polyps (Fig. 15.20C–D). SHG is also a valuable
technique when TVS is unable to diferentiate an endometrial
polyp from a submucosal leiomyoma. A polyp can be seen
arising from the endometrium, whereas a normal layer of
endometrium may be seen overlying a submucosal ibroid (see
Fig. 15.11I). Cystic areas may be seen within a polyp representing
the histologically dilated glands. 150,151 A feeding artery in the
pedicle can frequently be seen with color Doppler ultrasound
(pedicle artery sign). 153 he hyperechoic line sign may also be
useful for identifying a polyp, helping one to recognize that there
is a focal abnormality of the endometrium. 154
Endometrial polyps may not be diagnosed on endometrial
biopsy because a polyp on a pliable stalk may be missed by the
curette. If abnormal bleeding persists ater nondiagnostic dilation
and curettage (D&C) in a postmenopausal woman with an
endometrial thickness greater than 8 mm, hysteroscopy
with direct visualization of the endometrial cavity is
recommended. 155
Endometrial Carcinoma
Endometrial carcinoma is the most common gynecologic
malignancy in North America. he National Institute of Health
estimated that there were 54,870 cases of endometrial cancer in
the United States in 2015, with 10,170 deaths. here is an 82%
overall 5-year survival rate. For endometrial cancer, 67% are
diagnosed at the local stage. he 5-year survival for these localized
cancers is 95.3%. 156
Most endometrial carcinomas (75%-80%) occur in postmenopausal
women. he most common clinical presentation is uterine
bleeding, although only about 10% of women with postmenopausal
bleeding will have endometrial carcinoma. here is a
strong association with estrogen replacement therapy in postmenopausal
women and anovulatory cycles in premenopausal
women. Other risk factors include obesity, diabetes, hypertension,
and low parity. Approximately 25% of patients with atypical
endometrial hyperplasia will progress to develop well-diferentiated
endometrial carcinoma. 149