Endometrial cancer off-line staging using two-dimensional transvaginal ultrasound and three-dimensional volume contrast imaging: Intermethod agreement, interrater reliability and diagnostic accuracy

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CONTRIBUTIONWhat are the novel findings of this work? Subjective assessment of ultrasound images is the best method of predicting deep myometrial invasion and cervical stromal invasion of endometrial cancer, especially in patients with a Grade-1 or -2 tumor. To predict high-risk disease, mathematical models may be useful, but the best strategy is to combine subjective assessment with biopsy grade or to use the subjective two-step strategy. What are the clinical implications of this work?Ultrasound imaging has a central role in the preoperative evaluation of patients with endometrial cancer. In the hands of experienced ultrasound examiners, subjective assessment of extension of endometrial cancer performs better than does any ultrasound measurement or published risk-prediction model. ABSTRACTObjectives To compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low-or high-grade disease separately, and to validate published measurement cut-offs and prediction models to identify MI, CSI and high-risk disease . MethodsThe study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)-4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist-OCO) for detecting CSI. We also validated two two-step strategies for the prediction of high-risk cancer; in the first step, biopsy-confirmed Grade-3 endometrioid or mucinous or non-endometrioid cancers were classified as high-risk cancer, while the second step encompassed the application of 116 Verbakel et al.a mathematical model to classify the remaining tumors. The 'subjective prediction model' included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the 'objective prediction model' included biopsy grade (Grade 1 vs Grade 2) and minimal tumor-free margin. The predictive performance of the two two-step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade-3 endometrioid or mucinous or non-endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard. ResultsIn 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade-1 or -2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade-3 endometrioid or mucinous or a non-endometrioid tumor. The corresponding values for the ...

Section: Introductionmentioning

confidence: 99%

Validation of ultrasound strategies to assess tumor extension and to predict high‐risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)‐4 cohort

Verbakel

Mascilini

Wynants

et al. 2019

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“…Among radiologists using MRI in diagnosing deep MI, the average kappa is reported to be 0.39 34 . The corresponding figures for 2D-TVU are 0.41-0.53 in diagnosing deep MI and 0.55-0.58 for CSI 35,36 . Thus, perfect agreement between pathological evaluation and any imaging examination is unattainable, since neither procedure has perfect reliability.…”

Section: Discussionmentioning

confidence: 93%

Dynamic contrast‐enhanced ultrasound improves diagnostic performance in endometrial cancer staging

Green

Epstein

2020

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Objectives To compare the sensitivity and specificity of conventional two‐dimensional transvaginal ultrasound/power Doppler (2D‐TVU/PD) alone and 2D‐TVU/PD combined with dynamic contrast‐enhanced ultrasound (DCE‐US) in diagnosing deep myometrial invasion (MI) and cervical stromal involvement (CSI) in women with endometrial cancer (EC), and to assess the association of DCE‐US semiquantitative and qualitative variables with International Federation of Gynecology and Obstetrics (FIGO) Stage ≥ IB and ‘high‐risk’ cancer. Methods This was a prospective study of 101 consecutive women with biopsy‐confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, a tertiary referral center. All consenting women underwent DCE‐US using a 1.5–2.5‐mL intravenous bolus of SonoVue contrast agent, as well as conventional 2D‐TVU/PD examination. DCE‐US videoclips were analyzed with regard to filling (global or focal), wash‐in (prior, simultaneous or after) and wash‐out (global or focal) patterns of the contrast agent in the tumor compared with the surrounding tissue, as well as semiquantitative DCE‐US parameters (wash‐in slope, time‐to‐peak, peak intensity and area under the time–intensity curve (TIC)) obtained from a TIC. The study cohort was compared with a control cohort of women with EC examined at our center according to the International Endometrial Tumor Analysis protocol using 2D‐TVU/PD only, matched at a ratio of 3:1 for FIGO stage and grade. The sensitivity and specificity of 2D‐TVU/PD alone in the control cohort and in combination with DCE‐US in the study cohort in the diagnosis of deep MI, CSI and high‐risk cancer (defined as FIGO Stage ≥ IB and/or Grade 3 endometrioid and/or non‐endometrioid histology) were compared, using pathological evaluation after hysterectomy as the ‘gold standard’. Results After exclusions, 93 women were included in the study cohort and were matched to 279 women in the control cohort. The prevalence of FIGO Stage IA, Grade 1–2 EC was 52% in both cohorts. The sensitivity of 2D‐TVU/PD with DCE‐US in the study cohort was higher than that of 2D‐TVU/PD alone in the control cohort in diagnosing both deep MI (0.74 vs 0.62; P = 0.036) and CSI (0.75 vs 0.51; P < 0.001), whereas the specificity was not significantly different (0.87 vs 0.85 and 0.96 vs 0.95, respectively). Compared with 2D‐TVU/PD alone, the specificity of 2D‐TVU/PD with DCE‐US was higher in detecting high‐risk cancer (0.94 vs 0.85; P = 0.024) but the sensitivity did not differ (0.73 vs 0.71). High‐risk cancer and FIGO Stage ≥ IB were characterized by a ‘focal’ filling pattern, with a ‘prior’ wash‐in pattern and a ‘focal’ wash‐out pattern on subjective assessment of DCE‐US videoclips. All semiquantitative DCE‐US parameters were significantly predictive of FIGO Stage ≥ IB but not of high‐risk cancer, despite a clear trend. Conclusions Compared with 2D‐TVU/PD alone, combining 2D‐TVU/PD with DCE‐US can significantly improve the detection of deep MI and CSI in women with EC, without increasing the false‐positive...

“…It does not matter how accurate a diagnostic test is, if users cannot agree on the result. Since Study I, an additional interobserver reproducibility study on ultrasound staging has been published, and showes that 2D ultrasound predicts deep myometrial invasion and cervical stromal invasion with higher interobserver reproducibility than 3D volume contrast imaging (deep myometrial invasion: κ 0.41 vs. κ 0.31 and cervical stromal invasion: κ 0.55 vs. κ 0.45) 177 .…”

Section: Why Interobserver Reproducibility Is Importantmentioning

confidence: 99%

“…When summarizing the results of reproducibility studies on endometrial cancer staging, for the assessment of myometrial invasion, interobserver reproducibility has been found to be moderate for ultrasound 177,178 , fair to good for MRI [96][97][98] and good to very good for histopathology 99,101 . For the assessment of cervical stromal invasion, interobserver reproducibility has been found to be moderate for ultrasound 177,178 , moderate to good for MRI 96,97 and moderate for histopathology 100 . Interobserver reproducibility has been found to be good to very good for histotype 78 and fair to good for grade 78,102 .…”

Section: Why Interobserver Reproducibility Is Importantmentioning

confidence: 99%

Ultrasound‐based risk model for preoperative prediction of lymph‐node metastases in women with endometrial cancer: model‐development study

Eriksson

Epstein

Testa

et al. 2020

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Background: Endometrial cancer is the most common gynecological cancer in the industrialized world, constituting 4.5% of all cancer in Swedish women. Standard surgery is hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy, depending on the estimated risk of lymph node metastases. Adjuvant therapy is given, depending on the estimated risk of adverse outcome. Numerous risk stratification systems guide the choice on lymphadenectomy, but none is associated with a high accuracy. Lymph node metastases are found in 11-22% of women. If they could be accurately predicted, many lymphadenectomies could be avoided. The aim of this thesis was to improve preoperative risk assessment in women with endometrial cancer, with regard to predicting deep (≥ 50%) myometrial invasion (MI), cervical stromal invasion (CSI), lymph node metastases and recurrence or progression.