Endometrial cancer – preoperative identification of low and high risk endometrial cancer (a review of the most recent ultrasound studies)

Authors: D. Fischerová
Authors‘ workplace: Gynekologicko-porodnická klinika 1. LF UK a VFN, Praha, přednosta prof. MUDr. A. Martan, DrSc.
Published in: Ceska Gynekol 2014; 79(6): 456-465


Despite the high resolution of ultrasound or magnetic resonance imaging and modern bioptic approaches, diagnostic error of preoperative staging is around 20%. The preoperative staging is focused to differentiate low risk (< 50% myometrial invasion, histological grade 1 and 2, endometrioid cancer, no cervical invasion) or high risk endometrial cancer (all others).

Preoperative biopsy tends to underestimate the tumour histotype and grading in 20% of cases. Therefore, the sonomorphological and Doppler pattern have been identified that can preoperatively alert us to the presence of low or high risk endometrial cancer. With discrepancy between preoperative ultrasound tumour characteristics and results of endometrial biopsy a supplementary intraoperative frozen section of uterus is recommended.

Ultrasound examination performed by an experienced sonographer is accurate in most cases but tends to overestimate myometrial invasion and underestimate cervical stromal invasion. Based on the identification of factors that significantly affected the accuracy of ultrasound, it was recommended to restrict evaluation to sonomorphological tumour parameters within the preoperative tumour staging. This is in response to the tendency of ultrasound experts with knowledge of the clinical data of patients, and prognostic parameters of the disease who have encountered adverse tumour characteristics through ultrasound (e.g. inhomogeneous, hypo- or isoechogenous tumor with high tumour perfusion) to ‚intuitively‘ overestimate the stage of the disease and conversely.

The attempts to restrict the assessment of tumour invasion to those parameters that are easily and objectively evaluated has not so far proved effective. A promising objective parameter seems to be the minimum distance between the tumour and uterine serosa. When this parameter was included in the new objective model, the high-risk endometrial cancer was predicted with an accuracy similar to subjective assessment of tumour invasion by an expert.

The preoperative work-up for high-risk endometrial cancer prediction was designed and externally validated in order to triage the patients for adequate staging surgery. This approach was based on the combination of the results of preoperative endometrial biopsy and transvaginal ultrasound and reached the similar accuracy as a more complicated approach using a combination of magnetic resonance imaging and hysteroscopic-directed biopsies. Both approaches can identify eight of 10 women with high-risk of lymph node metastases and spare eight of 10 low-risk women extended surgery.

endometrial cancer, preoperative staging, transvaginal ultrasound


1. Antonsen, SL., Jensen, LN., Loft, A., et al. MRI, PET/CT and ultrasound in the preoperative staging of endometrial cancer – a multicenter prospective comparative study. Gynecol Oncol, 2013, 128, 2, p. 300–308.

2. Ben-Shachar, I., Pavelka, J., Cohn, DE., et al. Surgical staging for patients presenting with grade 1 endometrial carcinoma. Obstet Gynecol, 2005, 105, 3, p. 487–493.

3. Benedet, JL., Bender, H., Jones, H., 3rd, et al. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet, 2000, 70, 2, p. 209–262.

4. Berman, ML., Ballon, SC., Lagasse, LD., Watring, WG. Prognosis and treatment of endometrial cancer. Am J Obstet Gynecol, 1980, 136, 5, p. 679–688.

5. Cibula, D. Chirurgická léčba zhoubného nádoru děložního těla. In Cibula, D. a Petruželka, L. Onkogynekologie. Praha: Grada Publishing, 2009, s. 474–480.

6. Colombo, N., Preti, E., Landoni, F., et al. Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2013, 24, Suppl. 6, p. vi33–8.

7. Creasman, WT., Morrow, CP., Bundy, BN., et al. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer, 1987, 60, 8, Suppl., p. 2035–2041.

8. De Smet, F., De Brabanter, J., Van den Bosch, T., et al. New models to predict depth of infiltration in endometrial carcinoma based on transvaginal sonography. Ultrasound Obstet Gynecol, 2006, 27, 6, p. 664–671.

9. Dušek, L. Epidemiologie zhoubných nádorů v České republice. 2010.

10. Epstein, E., Van Holsbeke, C., Mascilini, F., et al. Gray-scale and color Doppler ultrasound characteristics of endometrial cancer in relation to stage, grade and tumor size. Ultrasound Obstet Gynecol, 2011, 38, 5, p. 586–593.

11. Fischerova, D. Diagnostika a staging v onkologii. Mod Gynek, 2007, 16, 3, p. 517–522.

12. Fischerová, D., Burgetová, A., Seidl, Z., Bělohlávek, O. Diagnostika nádorů děložního těla. In Cibula, D. a Petruželka, L. Onkogynekologie. Praha: Grada Publishing, 2009, s. 470–474.

13. Fischerova, D. Patologie děložního těla v ultrazvukovém obraze. In Calda, P. Ultrazvuková diagnostika v těhotenství a gynekologii. Praha: Aprofema s.r.o., 2010, s. 443–453.

14. Fischerova, D. Ultrasound scanning of the pelvis and abdomen for staging of gynecological tumors: a review. Ultrasound Obstet Gynecol, 2011, 38, 3, p. 246–266.

15. Fischerova, D. Zhoubný nádor děložního těla – předoperační odlišení nádorů s nízkým a vysokým rizikem metastázování (přehled výsledků nejnovějších ultrazvukových studií). Čes Gynek, 2014, 79, 6, s. 456–465.

16. Fischerova, D., Fruhauf, F., Zikan, M., et al. Factors affec-ting sonographic preoperative local staging of endometrial cancer. Ultrasound Obstet Gynecol, 2014, 43, 5, p. 575–585.

17. Goudge, C., Bernhard, S., Cloven, NG., Morris, P. The impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer. Gynecol Oncol, 2004, 93, 2, p. 536–539.

18. Hricak, H., Rubinstein, LV., Gherman, GM., Karstaedt, N. MR imaging evaluation of endometrial carcinoma: results of an NCI cooperative study. Radiology, 1991, 179, 3, p. 829–832.

19. Karlsson, B., Norstrom, A., Granberg, S., Wikland, M. The use of endovaginal ultrasound to diagnose invasion of endometrial carcinoma. Ultrasound Obstet Gynecol, 1992, 2, 1, p. 35–39.

20. Larson, DM., Connor, GP., Broste, SK., et al. Prognostic significance of gross myometrial invasion with endometrial cancer. Obstet Gynecol, 1996, 88, 3, p. 394–398.

21. Mascilini, F., Testa, AC., van Holsbeke, C., et al. Evaluating myometrial and cervical invasion in women with endometrial cancer – comparing subjective assessment to objective measurement techniques. Ultrasound Obstet Gynecol, 2013.

22. Masciullo, V., Amadio, G., Lo Russo, D., et al. Controversies in the management of endometrial cancer. Obstet Gynecol Int, 2010, 2010, p. 638165.

23. Orr, JW., Jr., Holloway, RW., Orr, PF., Holimon, JL. Surgical staging of uterine cancer: an analysis of perioperative morbidity. Gynecol Oncol, 1991, 42, 3, p. 209–216.

24. Ortoft, G., Dueholm, M., Mathiesen, O., et al. Preoperative staging of endometrial cancer using TVS, MRI, and hysteroscopy. Acta Obstet Gynecol Scand, 2013, 92, 5, p. 536–545.

25. Pecorelli, S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet, 2009, 105, 2, p. 103–104.

26. Savelli, L., Ceccarini, M., Ludovisi, M., et al. Preoperative local staging of endometrial cancer: transvaginal sonography vs. magnetic resonance imaging. Ultrasound Obstet Gynecol, 2008, 31, 5, p. 560–566.

27. Shin, KE., Park, BK., Kim, CK., et al. MR staging accuracy for endometrial cancer based on the new FIGO stage. Acta Radiol, 2011, 52, 7, p. 818–824.

28. Silverberg, SG., Kurman, RJ., Nogales, F., et al. Tumour of the uterine corpus. In Tavassoli, FA. a Devillee, P. Pathology and genetics of tumour of the breast and female genital organs. Lyon: IARC Press, 2003, p. 217–287.

29. Tozzi, R., Malur, S., Koehler, C., Schneider, A. Analysis of morbidity in patients with endometrial cancer: is there a commitment to offer laparoscopy? Gynecol Oncol, 2005, 97, 1, p. 4–9.

30. Valentin, L. Ultrasound deserves to play a prominent role in the diagnosis and management of endometrial cancer. Ultrasound Obstet Gynecol, 2014, 43, 5, p. 483–487.

31. Van Holsbeke, C., Ameye, L., Testa, AC., et al. Development and external validation of new ultrasound-based mathematical models for preoperative prediction of high-risk endometrial cancer. Ultrasound Obstet Gynecol, 2014, 43, 5, p. 586–595.

32. Zikan, M., Fischerova, D. Endometriální patologie v ultrazvukovém obraze. Moderní Gynekologie a porodnictví, 2007, 16, 4, p. 731–739.

Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine
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