Diagnostic ultrasound ( PDFDrive )

CHAPTER 15 The Uterus 551
FIG. 15.22 Endometrial Carcinosarcoma. TVS shows a heterogeneous endometrial mass (calipers) that measures 27 mm in thickness.
myometrial invasion. 164-166 An intact subendometrial halo (inner
layer of myometrium) usually indicates no more than supericial
invasion, whereas obliteration of the halo indicates deep invasion.
166 Several objective sonographic parameters have been
evaluated for staging, but subjective assessment of myometrial
or cervical invasion has been shown to be as good or better than
objective measurements. 167 TVS and unenhanced T2-weighted
MRI have been reported to have similar accuracy, 168 but contrastenhanced
MRI has been shown to be superior to both in
demonstrating myometrial invasion. 169-172 In stage IA, cancer is
in the endometrium only or less than halfway through the
myometrium. In stage IB, the tumor is still localized to the uterus
but has spread halfway or more into the myometrium. In stage
II, cancer has spread into connective tissue of the cervix, but
has not spread outside the uterus. In stage III, the cancer has
spread outside of the uterus or into nearby tissues in the pelvic
area. In stage IV, the cancer has spread to the inner surface of
the urinary bladder or the rectum (lower part of the large
intestine), to lymph nodes in the groin, and/or to distant organs,
such as the bones, omentum, or lungs. 173 MRI can also assess
cervical extension (stage II) and extrauterine extension (stages
III and IV).
Endometrial Sarcoma
Uterine sarcomas are a rare and heterogeneous group of malignancies.
174 Leiomyosarcomas have been discussed previously.
Other uterine sarcomas may arise from the endometrium and
include carcinosarcomas (also termed “malignant mixed müllerian
tumors,” and many now consider this a subtype of carcinoma
rather than a sarcoma) (Fig. 15.22), endometrial stromal
sarcoma, adenosarcomas, and undiferentiated sarcomas. 174,175
here is little information available regarding the sonographic
appearance of these rare tumors and no speciic appearance is
known. Endometrial stromal sarcoma may appear as a difuse
or focal mass; may involve the myometrium, hampering
determination of the origin of the lesion; and can be mistaken
for a leiomyoma. 174,176
Endometrial Adhesions
Endometrial adhesions (synechiae) are posttraumatic, postinfection,
or postsurgical in nature and may be a cause of infertility
or recurrent pregnancy loss. Asherman syndrome is the combination
of synechiae that lead to menstrual dysfunction or infertility.
he endometrium usually appears normal on TAS and TVS,
although adhesions may be seen transvaginally as irregularities
or a hypoechoic bridgelike band within the endometrium. 177
his is best seen during the secretory phase, when the endometrium
is hyperechoic. he sonographic diagnosis is diicult unless
there is endometrial luid. SHG is an excellent technique for
demonstrating adhesions. 178 hick, broad-based adhesions may
prevent distention of the uterine cavity, 108 and thus the patient
may experience pain when luid is being instilled. Synechiae
appear as bridging bands of tissue that distort the cavity (Fig.
15.23, Video 15.10) or as thin, undulating membranes best seen
on real-time sonography. 4 he adhesions can be divided under
hysteroscopy.
Endometrial Ablation
he endometrium is typically indistinct ater global endometrial
ablation procedures (Fig. 15.24A). 179 Complications
may arise when there is residual nonablated endometrium
(which is common ater endometrial ablation) and adjacent
endometrial scarring. 180 his can result in a cornual
hematometra (localized to the cornual region) or central
hematometra (within the uterine cavity), and either may
cause pain (Fig. 15.24B). Postablation tubal sterilization
syndrome is a delayed complication of endometrial ablation
that may occur in patients who previously had tubal ligation;
these patients usually have pain due to a hematosalpinx of the
proximal tubal stump and a cornual hematometra. 180,181 When