Clinical presentation and transvaginal ultrasound assessment

Fabio Barra, Simone Ferrero

Research output: Chapter in Book/Report/Conference proceedingChapter


Endometrial cancer (EC) is the most common gynecological cancer. Although EC is often (75%) diagnosed at early stage, tumors with G3 endometrioid or non-endometrioid histotypes, deep myometrial invasion (MI > 50%) or cervical invasion, have a high recurrence risk. In particular, the incidence of lymph node metastases increases from 3% in the presence of superficial MI to 46% in the presence of deep MI. Physicians need to correctly identify patients with high-risk EC in order to appropriately plan their surgical and medical management. The imaging routine in the preoperative assessment of EC includes ultrasonography, which is noninvasive, reproducible and cost effective. The examination of women where EC is suspected should preferentially be carried out by transvaginal ultrasound (TVS), complemented by transabdominal evaluation in the case of a large uterus or an eventual extra uterine disease. The diagnostic accuracy of TVS varies between clinical studies, often showing, in experienced hands, results comparable to that of magnetic resonance imaging (MRI). Standardized TVS examination should be based on predefined evaluation criteria, such as tumor size and echogenicity, endometrial/myometrial border, the amount of vascularization and vascular morphology, since low- and high-risk EC have a different sonomorphological appearance. Low-risk EC is characterized by the presence of superficial or no MI (<50%), no cervical stroma invasion, hyperechoic echogenicity, single or multiple vessels with focal origin, and no or sparse vascularization at Doppler ultrasonography. High-risk EC presents deep MI (>50%), cervical stroma invasion, mixed or hypoechoic echogenicity, moderate or high color score and multiple vessels with multifocal origin. At TVS, the uterine body should be scanned slowly in the sagittal plane from cornu to cornu, and in the transverse plane from the cervix to the fundus, to subjectively assess if the tumor invades deeply into the myometrium at any point. Several studies analyzing the subjective assessment for MI by TVS have reported a sensitivity (SE) of 68-93% and a specificity (SP) of 82-83%. Objective measurement techniques to detect MI have been formulated, such as those by Gordon et al., which evaluates the ratio between the distance of the maximum tumor invasion and total width of myometrium, and by Karlsson et al., which analyzes the tumor/uterine anteroposterior (AP) diameter ratio. Although TVS and RM have been shown to be similarly effective in assessing MI, no single meta-analysis has formally compared their diagnostic performance. At TVS, the tumor extension in relation to the internal cervical orifice should be established. In cases in which the tumor is present at the point of internal cervical orifice, the absence of the sliding sign may reveal tumor invasion in the cervical stroma. Vessels entering the tumor at the region of the inner cervical orifice may suggest invasive growth at Doppler ultrasonography. Fewer studies have evaluated the subjective assessment of cervical stromal invasion, reporting an SE of 25-93% and an SP of 85-99%. The aim of this chapter is to present the role of TVS in the preoperative assessment of EC.

Original languageEnglish
Title of host publicationEndometrial Cancer
Subtitle of host publicationRisk Factors, Management and Prognosis
PublisherNova Science Publishers, Inc.
Number of pages20
ISBN (Electronic)9781536138887
ISBN (Print)9781536138870
Publication statusPublished - Jan 1 2018


  • Cervical invasion
  • Endometrial cancer
  • High risk patients
  • Myometrial invasion
  • Preoperative assessment
  • Transvaginal ultrasound

ASJC Scopus subject areas

  • Medicine(all)


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