A prospective comparison of the diagnostic accuracies of ultrasound and magnetic resonance imaging in preoperative staging of endometrial cancer.

OBJECTIVE: To compare the diagnostic accuracies of ultrasound and magnetic resonance imaging (MRI) for deep (≥50%) myometrial invasion (DMI) and cervical stromal invasion (CSI) in women with endometrial cancer. METHODS: This was a prospective study at a gynecology clinic for women with postmenopausal bleeding. Between October 2015-October 2018, consecutive women with suspected endometrial cancer based on ultrasound subjective pattern recognition were simultaneously assessed for DMI and CSI on ultrasound. Subsequently, they also underwent preoperative MRI. We compared the diagnostic accuracies of ultrasound and MRI in predicting DMI and CSI with the final histology as the gold standard. RESULTS: We included 51 women. The prevalence of DMI and CSI were 22/51 (43%) and 7/51 (14%), respectively. The majority of malignancies were of endometrioid histological subtype (38/51, 75%) and FIGO stage 1 or 2 (40/51, 78%). Ultrasound diagnosed more cases of DMI compared to MRI (19/22 vs. 17/22), however, the difference was not statistically significant. The sensitivities and specificities of ultrasound and MRI for DMI were 86% vs. 77% and 66% vs. 76%, respectively. For CSI, ultrasound and MRI correctly diagnosed the same number of cases (5/7, 71%); their respective false-positive rates were low, 0/44 (0%) and 1/44 (2%). Ultrasound and MRI had a moderate agreement for DMI (ƙ=0.49; 95% confidence interval [CI]=0.26-0.73), whereas the agreement for CSI was substantial (ƙ=0.69; 95% CI=0.36-1.00). CONCLUSION: Endometrial cancer can be simultaneously diagnosed and staged at women's initial ultrasound assessment. The accuracies of ultrasound for DMI and CSI are comparable to MRI. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN24363390.

Risk of Pre-Malignancy or Malignancy in Postmenopausal Endometrial Polyps: A CHAID Decision Tree Analysis.

BACKGROUND AND AIMS: Postmenopausal endometrial polyps are commonly managed by surgical resection; however, expectant management may be considered for some women due to the presence of medical co-morbidities, failed hysteroscopies or patient's preference. This study aimed to identify patient characteristics and ultrasound morphological features of polyps that could aid in the prediction of underlying pre-malignancy or malignancy in postmenopausal polyps. METHODS: Women with consecutive postmenopausal polyps diagnosed on ultrasound and removed surgically were recruited between October 2015 to October 2018 prospectively. Polyps were defined on ultrasound as focal lesions with a regular outline, surrounded by normal endometrium. On Doppler examination, there was either a single feeder vessel or no detectable vascularity. Polyps were classified histologically as benign (including hyperplasia without atypia), pre-malignant (atypical hyperplasia), or malignant. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed with a range of demographic, clinical, and ultrasound variables as independent, and the presence of pre-malignancy or malignancy in polyps as dependent variables. A 10-fold cross-validation method was used to estimate the model's misclassification risk. RESULTS: There were 240 women included, 181 of whom presented with postmenopausal bleeding. Their median age was 60 (range of 45-94); 18/240 (7.5%) women were diagnosed with pre-malignant or malignant polyps. In our decision tree model, the polyp mean diameter (≤13 mm or >13 mm) on ultrasound was the most important predictor of pre-malignancy or malignancy. If the tree was allowed to grow, the patient's body mass index (BMI) and cystic/solid appearance of the polyp classified women further into low-risk (≤5%), intermediate-risk (>5%-≤20%), or high-risk (>20%) groups. CONCLUSIONS: Our decision tree model may serve as a guide to counsel women on the benefits and risks of surgery for postmenopausal endometrial polyps. It may also assist clinicians in prioritizing women for surgery according to their risk of malignancy.

The Natural History of Uterine Venous Plexus Thrombosis.

The management of incidental or unusual site venous thrombosis (VT) is challenging and is often extrapolated from studies on symptomatic deep venous thrombosis (DVT). There is a tendency to treat with anticoagulation, due to the theoretical risk of propagation and embolism; however, this is not without risk. Furthermore, there is little guidance on how to monitor incidental VT. The aim of this study was to describe the natural history of incidental uterine venous plexus thrombosis (UVPT) and provide a structured approach to its overall management. A prospective study was conducted in a university teaching hospital over a 16-month period. Women diagnosed with UVPT on transvaginal ultrasound (TVS) were followed up over a six-month period and managed based on an individualised risk assessments, in conjunction with haematologists. Fifty women were diagnosed with UVPT during the study period, of which 38 were managed expectantly. The resolution was documented in 70% of women. There were no cases of symptomatic DVT or pulmonary embolisms in either the expectant or treatment groups. Our study has shown that in a high proportion of women, incidental UVPT could be managed successfully without the need for anticoagulation. The overall management of UVPT should be based on individualised clinical risk assessments.

Laparoscopic Myomectomy - Converting to Laparotomy for a Suspicious Intraoperative Appearance with Subsequent Benign Histology - a Pre- and Intra-Operative Dilemma.

BACKGROUND: Although the most common uterine tumour is leiomyoma, the differential diagnoses also include the rarer adenomyoma and leiomyosarcoma. A lack of clear reliable clinical and radiological features makes the triage of uterine masses to the appropriate surgical procedure difficult. In the case of suspicious appearance of a presumed leiomyoma, an open surgical approach is recommended and morcellation is avoided. CASE: We present a case of a woman undergoing an elective laparoscopic myomectomy for a fibroid that appeared benign on ultrasound but had suspicious features intraoperatively. The operation was converted to a laparotomy to avoid the risk of morcellation-related seeding in the event that the histology was malignant. The histology was subsequently a benign exophytic adenomyoma. CONCLUSION: The assessment of the nature of fibroids can be difficult both pre- and intraoperatively, and the need for difficult decision making to convert to open surgery during a laparoscopic myomectomy but with subsequent benign histology should be part of patient counselling.

The prevalence of incidental uterine venous plexus thrombosis in women attending a gynecology clinic.

BACKGROUND: The uterine venous plexus (UVP) is an unusual site for venous thrombosis (VT). Our aim was to determine the prevalence of UVP thrombosis (UVPT) and identify associated risk factors. METHODS: We conducted a cross-sectional study on consecutive nonpregnant women attending our general gynecology clinic with a wide variety of presenting symptoms over a 16-month period. All women underwent a transvaginal ultrasound scan which involved detailed examination of the uterine venous plexus. Women diagnosed with incidental UVPT had thrombophilia screening, lower limb venous duplex imaging, and specialist hematological review. Logistic regression was used to examine associations between various risk factors and UVPT. RESULTS: We screened 1383 women, 39 of whom had an incidental UVPT, giving a prevalence of 3.0% (95% confidence interval [CI], 2.1%-4.1%). Multivariate analysis showed positive associations between multiparity (odds ratio [OR] 5.75 [95% CI 2.10, 15.7]), recent surgery (OR 3.10 [95% CI 1.19, 8.07]), presence of leg varicose veins (OR 3.15 [95% CI 1.32, 7.49]), and a family history of venous thromboembolism (OR 8.74 [1.65, 46.4]) and negative associations between postmenopausal status (OR 0.36 [95% CI 0.13, 0.95]) and the development of UVPT. Thrombophilia was detected in 12.8% women diagnosed with UVPT. CONCLUSIONS: The prevalence of incidental UVPT in a general gynecology population was 3.0%. Several demographic and clinical factors were found to be associated with UVPT. This could help to identify women at risk of this condition, and facilitate its early detection and development of evidence-based management strategies.

Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy.

INTRODUCTION: Acute pancreatitis is a recognised rare complication in pregnancy. The reported incidence varies between 3 and 7 in 10 000 pregnancies and is higher in the third trimester. The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia. Non-gallstone pancreatitis is associated with more complications and poorer outcome with hypertriglyceridaemia-induced acute pancreatitis having mortality rates ranging from 7.5 to 9.0% and 10.0 to 17.5% for mother and foetus, respectively. CASE HISTORY: A 40-year-old para 4 woman, who presented at 15(+4) weeks' gestation, was diagnosed with acute pancreatitis. Past medical history included Graves' disease and hypertriglyceridaemia. Fenofibrate was discontinued immediately after discovery of the pregnancy. Initial investigations showed elevated amylase (475.0 µ/L) and triglycerides (46.6 mmol/L). Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced acute pancreatitis. Laboratory tests gradually improved (triglyceride 5.2 mmol/L on day 17). On day 18, ultrasound confirmed foetal demise (18(+1) weeks) and a hysterotomy was performed as she had had four previous caesarean sections. CONCLUSION: Management of acute pancreatitis in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced acute pancreatitis has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre-pregnancy and antenatally can allow close monitoring through pregnancy to optimise care.