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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 1  |  Page : 31-35

Role of sonoelastography in diagnosing endometrial lesions: Our initial experience


Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Web Publication21-May-2019

Correspondence Address:
Dr. Gulam Marfani
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_89_18

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  Abstract 


Context: Real-time elastography is a novel and dynamic imaging technique that is based on the softness or hardness of tissues or organs of interest under the appropriate compression and can be used with conventional ultrasonography (USG) probes after performing grayscale imaging and Doppler USG. Aims: The aim was to analyze the role of sonoelastography in diagnosing endometrial lesions. Subjects and Methods: A prospective study was conducted from August 2016 to 2018. 30 females were included who underwent sonographic examination. Diagnoses were made and later elastograms were obtained. Strain ratios were calculated and the final diagnosis was compared to histopathological diagnoses to evaluate the role of sonoelastography in diagnosing endometrial pathologies. Statistical Analysis Used: Statistical analysis was done be using descriptive and inferential statistic's using chi square test, students unpaired test, sensitivity and specificity and software used in the analysis were SPSS 22.0 version and graft pad prism 6.0 version. Results: Of the total 30 patients, 5 cases were misdiagnosed on USG compared to 1 on elastography which was of atypical endometrial hyperplasia. Sensitivity, specificity, and diagnostic accuracy of ultrasound were found to be 90.28%, 80%, and 88.5%, respectively. Sensitivity, specificity, and diagnostic accuracy of sonography with elastography were 93.06%, 86.67%, and 91.95%, respectively, showing better results. Conclusions: Sonography coupled with elastography showed better results and can be used to avoid dependency on computed tomography and magnetic resonance imaging avoiding radiation exposures and high cost, especially in a developing country like India, or unnecessary surgical interventions can also be avoided.

Keywords: Carcinoma, elastography, endometrium


How to cite this article:
Marfani G, Phatak SV, Madurwar KA, Samad S. Role of sonoelastography in diagnosing endometrial lesions: Our initial experience. J Datta Meghe Inst Med Sci Univ 2019;14:31-5

How to cite this URL:
Marfani G, Phatak SV, Madurwar KA, Samad S. Role of sonoelastography in diagnosing endometrial lesions: Our initial experience. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 9];14:31-5. Available from: http://www.journaldmims.com/text.asp?2019/14/1/31/258665




  Introduction Top


The anatomic female pelvis is quite complex, as it contains a number of organs and organ systems accomplishing different and independent functions. The genital system represents the main part of the female pelvis.[1] Pelvic mass of gynecological origin can present at any age group in lifetime. Approximately 20% of women population are at risk of developing some pelvic mass at certain point in their lifetime, and many of these women will have to undergo unnecessary laparoscopies/laparotomies.[2]

Ultrasound (US) is used in distinguishing the origin of pelvic masses whether uterine or adnexal and whether the pelvic mass is cystic, solid, or mixed. It gives the gynecologist the necessary information to plan the right therapeutic approach needed in the given situation.

Real-time elastography is a novel and dynamic imaging technique that is based on the softness or hardness of tissues or organs of interest under the appropriate compression and can be used with conventional ultrasonography probes after performing grayscale imaging and Doppler US. Sonoelastography increases the sensitivity and specificity of US and adds to the diagnostic confidence. This study was conducted with a view to find out the diagnostic value of sonoelastography in endometrial lesions.


  Subjects and Methods Top


Source and method of collection

The study was carried out in the Department of Radiodiagnosis, Acharya Vinoba Bhave Rural Hospital, attached to the Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, between August 2016 and August 2018 using standard protocol.

A total number of 30 patients with postmenopausal bleeding and irregular menstrual bleeding associated with abdominal pain had undergone real-time transvaginal US followed by elastography which was performed using Hitachi Aloka Arietta 70S ultrasound machine with transvaginal transducer (5–11 MHz), and histopathological sampling was done.

The study protocol was approved by the ethical committee. All the patients gave informed consent to participate. Patients (females) will be selected from those presenting with clinically suspected pathology of the endometrium. All cases irrespective of age referred to the department with suspected endometrial pathologies. Patients with the following conditions were excluded: patients on chemotherapy and radiotherapy, patients not willing to be a part of the study, and patients on hormonal therapy.

Detailed menstrual, obstetric, and medical histories of each patient were taken, and general physical, systemic, and gynecological examination was done. Relevant investigations were done according to clinical findings.

Technique

The patient is informed about the procedure and consent is obtained to perform the procedure. A female attendant always accompanied the patient. A history of menstrual cycle is taken, and if the patient is bleeding at the time of investigation whether physiological/pathological, the appointment was rescheduled. The patient is placed in lithotomy position, and the transvaginal probe (5–11 MHz) is covered with a condom and then inserted into the vagina. When a pelvic mass is seen, gentle pressure is applied with the transvaginal probe, and elastogram was obtained. The elastogram was then classified into a 5-point scoring system based on Tsukuba elasticity score, and strain ratio was calculated wherever possible. A score of 1 denotes even strain for the entire hypoechoic lesion (i.e., the entire lesion was evenly shaded in green). A score of 2 indicates strain in most of the hypoechoic lesion, with some areas of no strain (i.e., the hypoechoic lesion has a mosaic pattern of green and blue). A score of 3 indicates strain at the periphery of the hypoechoic lesion, with sparing of the center of the lesion (i.e., the peripheral part of the lesion was green, and the central part was blue). A score of 4 indicates no strain in the entire hypoechoic lesion (i.e., the entire lesion was blue, but its surrounding area was not included). A score of 5 indicates no strain in the entire hypoechoic lesion or in the surrounding area (i.e., both the entire hypoechoic lesion and its surrounding area were blue). Lesions categorized as Elastographic score (ES) 1 and 2 were considered benign, and lesions categorized as ES 4 and 5 were suspicious for malignancy.[3] The calculation of Strain ratio (SR) was based on a comparison of the average strains measured in the lesion and adjacent tissue at the same depth. This method may provide another diagnostic method in addition to the 5-point scoring system used with ultrasonic elastography in the future.[4]

Statistical analysis was done by the following methods: sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, descriptive statistics, and Chi-square test.


  Results Top


Maximum numbers of patients were found in the age group of 41–50 years accounting for 10 patients (33.33%) and the least was found in the age group of 51–60 years and 61–70 years accounting for 4 patients (13.33%) [Table 1].
Table 1: Age-wise distribution of patients

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The most common presenting complaint was found to be menstrual irregularities in 45% of the patients followed by postmenopausal bleeding in 25% of the total patients and the least presenting complaint was abdominal distension and other nonspecific abdominal complaints accounting for 10% and 5%, respectively [Figure 1].
Figure 1: Presenting complaints of patients with endometrial lesions

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Maximum numbers of patients presented with endometrial polyp accounting for a total of 10 patients (33.33%) followed by endometrial hyperplasia accounting for 9 patients (30%) and endometrial carcinoma accounting for 8 patients (26.66%) [Table 2].
Table 2: Representing the total pathologies and number of patients encountered of particular pathology

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Based on parity, most of the benign pathologies were found in the reproductive age group and malignant lesions were found in the postmenopausal woman. The incidence of malignancy had an inverse relation with parity.

Maximum numbers of patients had elasticity score of 2 accounting for a total of 12 patients (40%) followed by a score of 1 accounting for 10 patients (33.33%) and the last being the elasticity score of 4 accounting for 8 patients (26.67%) [Table 3].
Table 3: Distribution of patients based on Tsukuba elasticity score

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Maximum numbers of patients were of strain ratio in the range of 1–3 accounting for 12 cases (40%), followed by strain ratio range of 3.1–5 accounting for 7 patients (23.33%), followed by straign ratio of >9 accounting for 6 patients (20%), and least in the range of 7.1–9 accounting for 2 cases (6.66%) [Table 4] and [Figure 2].
Table 4: Strain ratio for endometrial lesions

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Figure 2: Distribution of endometrial lesions based on strain ratio

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  Discussion Top


Evaluation of pelvic masses preceding surgery has important implications as it enables the surgeon to perform the most proper surgical procedure.

A total of 30 patients who presented with endometrial lesions were part of the study spread over a period of 2 years. Of the 30 patients, 1 case was incorrectly diagnosed on elastography compared to US that had incorrectly diagnosed 5 cases. Sensitivity, specificity, and diagnostic accuracy of elastography were 93.06%, 86.67%, and 91.95%, respectively. Sensitivity, specificity, and diagnostic accuracy of US were found to be 90.28%, 80%, and 88.5%, respectively [Figure 3].
Figure 3: Comparing sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of ultrasound and elastography

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In our study, of 30 patients, endometrial malignancy accounted for 8 patients and was from the age group of 51–60 and 61–70 patients signifying the correlation between age and endometrial carcinoma, whereas benign lesions were encountered in younger patients. Malignant lesions of the endometrium were commonly associated with postmenopausal status. Findings were coherent with studies conducted by Bharatnur et al.[5] in which they concluded that the maximum patients of endometrial carcinoma were in the age group of 61–70 accounting for maximum patients and least common below the age of 40.accounting for 5%–6%.

In our study, we found that the most common presenting complaint was found to be menstrual irregularities in 45% of the total patients, followed by postmenopausal bleeding in 25% of the cases and the least presenting complaint was abdominal distension and other nonspecific abdominal complaints accounting for 10% and 5%, respectively. Malignant lesion of the endometrium was associated with postmenopausal bleeding.

The results were in agreement with the study conducted by Krissi et al.[6] which was conducted on 181 patients and concluded that the primary symptoms the patients presented with were postmenopausal bleeding accounting for 69.6%, whereas the remaining women presented with irregular bleeding (21.0%), abdominal pain (3.9%), and other symptoms (5.5%).

Of the total 30 patients included in the study based on parity, it was found that maximum number of lesions were found in patients with parity 1 accounting for 14 (46.66%) and the least number of lesions were found in patients with parity 4 accounting for 4 (13.33%). Results were in agreement with the study conducted by Chen et al.[7] who concluded that there was an inverse relationship between parity and incidence of endometrial carcinoma as the cases decreased with increasing parity.

Of the total 30 patients, 10 patients were diagnosed as endometrial polyp, 9 were diagnosed with endometrial hyperplasia, and 8 cases were diagnosed with endometrial carcinoma. US findings of endometrial hyperplasia include an endometrial thickness ranging from 12 to 17 mm in premenopausal and >5 mm in postmenopausal and show soft colors on elastography scale (green and red) [Figure 4]. In endometrial polyp, there is a polyp with a stalk that shows vascularity on color Doppler imaging and picking up softer colors, i.e., green and red on elastography with strain ratio of <4 suggesting benign pathology. In endometrial carcinoma, US appearance is that of an ill-defined lesion in the endometrium causing thickening of the endometrium, and occasionally with myometrial invasion, the malignant growth has stiffer tissues with higher strain values appearing dark blue on elastography [Table 5].
Figure 4: There is thickening of the endometrium with no solid component which is showing softer colors on elastography which is the green and red with strain ratio of 0.16 s/o endometrial hyperplasia proven on biopsy

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Table 5: Sonographic features of endometrial pathologies

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Findings were comparable with the study conducted by Belozerova and Mikhaylina,[8] that endometrium walls were dyed predominantly to blue color, which correspond to score of 4 and in some patient's endometrium substantially had deep blue color, which corresponds to a score of 5. The strain ratios of the patient are diagnosed with endometrial carcinoma (six patients) and were in the range of 9–28 with a mean strain ratio of 15.36 [Figure 5].
Figure 5: There is endometrium ill.defined endometrial stiff mass lesion showing dark blue color on elastography and strain ratio of 28 s/o endometrial carcinoma confirmed on biopsy

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Findings were also similar to the study conducted by Latif et al.,[9] the findings of which were that there was a significant difference between mean SR ratio of endometrial carcinoma (11.4) and endometrial hyperplasia (2.7). The mean SR of atypical endometrial hyperplasia used was 5.6 which was comparatively much higher than that of typical endometrial hyperplasia which was 1.9, thus concluding that transvaginal sonoelastography can help in differentiating typical and atypical endometrial hyperplasia from endometrial cancer. Results were also comparable with the study conducted by Metin et al.[10] that evaluated 61 women with either postmenopausal bleeding or any other complaints, the results of which were that no significant differences in strain ratio values were found between endometrial hyperplasia group and control group, but significant differences in strain ratio values were found between endometrial carcinoma and hyperplasia groups and between endometrial carcinoma and control groups, concluding that transvaginal sonoelastography can provide important information that help discriminate between endometrial carcinoma and endometrial hyperplasia.

Limitation

The main limitation of our study was the small sample number as an initial experience, and further investigation on larger series in multiple centers is needed. Sonoelastography techniques require experienced and trained operators to perform valid cyclic compressions which can produce reliable and reproducible. The presence of arterial pulsations generated a variable amount of tissue deformations, and the ratio index may be altered leading to potential pitfalls in the SE evaluation. The strain indices of mass lesions could not be compared to those of the reference values as there is limited research on the application of elastography in pelvic masses of gynecological origin. Now, there are a growing number of studies about the use of elastography within the field of gynecology, but data are still rare. Only a few studies have been published about the assessment of uterine myomas. In the published literature, we used a simplified 5-point color scale based on previous breast, thyroid, and cervical lymph nodal elastographic studies.


  Conclusion Top


The present study was conducted on 30 patients with endometrial lesions concluded that sonoelastography is a new and a valuable tool in differentiating endometrial pathologies and adds to the diagnostic confidence of the radiologist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alessandrino F, Dellafiore C, Eshja E, Alfano F, Ricci G, Cassani C, et al. Differential Diagnosis for Female Pelvic Masses. In Erondu OF, editor. Medical Imaging in Clinical Practice. First ed. InTech. 2013. Available from: http://www.intechopen.com/books/medical-imaging-in-clinical-practice/differential-diagnosis-for-female-pelvic-masses.  Back to cited text no. 1
    
2.
Moore RG, Bast RC Jr. How do you distinguish a malignant pelvic mass from a benign pelvic mass? Imaging, biomarkers, or none of the above. J Clin Oncol 2007;25:4159-61.  Back to cited text no. 2
    
3.
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 3
    
4.
Zhi H, Xiao XY, Yang HY, Wen YL, Ou B, Luo BM, et al. Semi-quantitating stiffness of breast solid lesions in ultrasonic elastography. Acad Radiol 2008;15:1347-53.  Back to cited text no. 4
    
5.
Bharatnur S, Kustagi P, Krishnamohan D. Endometrial carcinoma in a young woman: “30 is not immune”. J Obstet Gynaecol India 2011;61:686-8.  Back to cited text no. 5
    
6.
Krissi H, Chetrit A, Menczer J. Presenting symptoms of patients with endometrial carcinoma. Effect on prognosis. Eur J Gynaecol Oncol 1996;17:25-8.  Back to cited text no. 6
    
7.
Chen Q, Tong M, Guo F, Lau S, Zhao M. Parity correlates with the timing of developing endometrial cancer, but not subtype of endometrial cancer. J Cancer 2015;6:1087-92.  Back to cited text no. 7
    
8.
Belozerova I, Mikhaylina AE. Possibilities of realtime sonoelastography in local staging of endometrial carcinoma. Eur Soc Radiol 201:C1898. [doi: 10.1594/ecr2012/C1898].  Back to cited text no. 8
    
9.
Latif MA, Shady M, Nabil H, Mesbah Y. Trans-vaginal sono-elastography in the differentiation of endometrial hyperplasia and endometrial carcinoma. Egypt J Radiol Nucl Med 2016;47:1123-31.  Back to cited text no. 9
    
10.
Metin MR, Aydın H, Ünal Ö, Akçay Y, Duymuş M, Türkyılmaz E, et al. Differentiation between endometrial carcinoma and atypical endometrial hyperplasia with transvaginal sonographic elastography. Diagn Interv Imaging 2016;97:425-31.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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