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Prediction of Benign and Malignant Endometrial Disease: Hysterosonographic-Pathologic Correlation

¹ Department of Radiology, University of Washington, Harborview Medical Center, Box 728359, 325 Ninth Ave, Seattle, WA 98104 (T.J.D.)
² Departments of Pathology (K.S.)
³ Radiology, Obstetrics, Gynecology, and Reproductive Health Sciences (N.M.), University of Texas, Houston
⁴ Department of Radiology, Amman Hospital, Jordan (Y.A.G.)
⁵ Department of Radiology, Veterans Affairs Medical Center, St Louis, Mo (H.R.P.).

View larger version (174K): [in a new window]   Figure 1a. (a) Midsagittal transvaginal hysterosonographic image from a 49-year-old woman shows mild irregularity of the endometrium but no endoluminal masses. The high-amplitude echogenic foci producing posterior acoustic shadowing (arrows) are gas inadvertently introduced during the procedure. (b) Photomicrograph of corresponding histologic section shows normally developing glands (arrows) within proliferative endometrium. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (173K): [in a new window]   Figure 1b. (a) Midsagittal transvaginal hysterosonographic image from a 49-year-old woman shows mild irregularity of the endometrium but no endoluminal masses. The high-amplitude echogenic foci producing posterior acoustic shadowing (arrows) are gas inadvertently introduced during the procedure. (b) Photomicrograph of corresponding histologic section shows normally developing glands (arrows) within proliferative endometrium. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (199K): [in a new window]   Figure 2a. (a) Transverse transvaginal hysterosonographic image from a 36-year-old woman shows smooth diffuse endometrial thickening. The endometrium (arrows) is more echogenic than that in the proliferative phase, which is a finding consistently seen in a secretory endometrium because of increasing tortuosity of the glandular structures. (b) Photomicrograph of corresponding histologic section shows mature glandular structures (arrows) within a secretory endometrium. (Hematoxylin-eosin stain; original magnification, x400.)

View larger version (199K): [in a new window]   Figure 2b. (a) Transverse transvaginal hysterosonographic image from a 36-year-old woman shows smooth diffuse endometrial thickening. The endometrium (arrows) is more echogenic than that in the proliferative phase, which is a finding consistently seen in a secretory endometrium because of increasing tortuosity of the glandular structures. (b) Photomicrograph of corresponding histologic section shows mature glandular structures (arrows) within a secretory endometrium. (Hematoxylin-eosin stain; original magnification, x400.)

View larger version (201K): [in a new window]   Figure 3a. (a) Midsagittal transvaginal hysterosonographic image from a 64-year-old woman shows no apparent endometrial thickening and no endoluminal masses. The scattered echogenic foci (arrow) moved during fluid instillation and represent small gas bubbles. (b) Photomicrograph of corresponding histologic section shows that the endometrium (arrows) is only one cell layer thick over the underlying stroma, consistent with endometrial atrophy. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (172K): [in a new window]   Figure 3b. (a) Midsagittal transvaginal hysterosonographic image from a 64-year-old woman shows no apparent endometrial thickening and no endoluminal masses. The scattered echogenic foci (arrow) moved during fluid instillation and represent small gas bubbles. (b) Photomicrograph of corresponding histologic section shows that the endometrium (arrows) is only one cell layer thick over the underlying stroma, consistent with endometrial atrophy. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (211K): [in a new window]   Figure 4a. (a) Transvaginal hysterosonographic image from a 25-year-old woman shows a pedunculated, homogeneous mass (crosshairs) projecting into the endometrial canal. (b) Photomicrograph of corresponding histologic section shows the presence of blood vessels (arrows) within adenomatous-appearing tissue, consistent with a benign adenomatous polyp. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (194K): [in a new window]   Figure 4b. (a) Transvaginal hysterosonographic image from a 25-year-old woman shows a pedunculated, homogeneous mass (crosshairs) projecting into the endometrial canal. (b) Photomicrograph of corresponding histologic section shows the presence of blood vessels (arrows) within adenomatous-appearing tissue, consistent with a benign adenomatous polyp. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (189K): [in a new window]   Figure 5a. (a) Transverse transvaginal hysterosonographic image from a 65-year-old woman shows a broad-based irregular mass (arrows) projecting into the endoluminal canal from the posterior uterine wall. (b) Photomicrograph of corresponding histologic section shows numerous large anaplastic cells that have begun to invade the underlying stroma (straight arrows), consistent with a grade 2 endometrial carcinoma. Normal secretory endometrium (curved arrows) is also present in the image. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (210K): [in a new window]   Figure 5b. (a) Transverse transvaginal hysterosonographic image from a 65-year-old woman shows a broad-based irregular mass (arrows) projecting into the endoluminal canal from the posterior uterine wall. (b) Photomicrograph of corresponding histologic section shows numerous large anaplastic cells that have begun to invade the underlying stroma (straight arrows), consistent with a grade 2 endometrial carcinoma. Normal secretory endometrium (curved arrows) is also present in the image. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (202K): [in a new window]   Figure 6a. (a) Transverse transvaginal hysterosonographic image from a 53-year-old woman shows multiple inhomogeneous masses (straight arrows) projecting into the endoluminal canal. Synechiae (curved arrow) are also evident. This image initially was interpreted as multiple polyps. (b) Photomicrograph of corresponding histologic section demonstrates enlarged irregular glandular structures (arrows) without cellular atypia, consistent with endometrial hyperplasia without atypia. We subsequently discovered that hyperplasia frequently appears at transvaginal hysterosonography as multiple masses projecting into the endometrial canal. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (220K): [in a new window]   Figure 6b. (a) Transverse transvaginal hysterosonographic image from a 53-year-old woman shows multiple inhomogeneous masses (straight arrows) projecting into the endoluminal canal. Synechiae (curved arrow) are also evident. This image initially was interpreted as multiple polyps. (b) Photomicrograph of corresponding histologic section demonstrates enlarged irregular glandular structures (arrows) without cellular atypia, consistent with endometrial hyperplasia without atypia. We subsequently discovered that hyperplasia frequently appears at transvaginal hysterosonography as multiple masses projecting into the endometrial canal. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (156K): [in a new window]   Figure 7a. (a) Transverse transvaginal US image from a 39-year-old woman shows measurement of the uterine width (crosshairs) and an inhomogeneous thickened endometrium (arrows). (b) Corresponding transverse transvaginal hysterosonographic image shows an irregular inhomogeneous mass (crosshairs) with a sessile attachment to the posterior uterine wall. This image was interpreted as suspicious (suggestive of carcinoma). (c) Photomicrograph of corresponding histologic section shows innumerable polymorphonuclear cells (arrows) evident within all of the glandular structures and within the endometrial stroma, consistent with acute endometritis. No malignant cells were present in any of the specimens. This similarity in appearance of multiple endometrial disease processes causes the positive predictive value of transvaginal hysterosonography to be low. (Hematoxylin-eosin stain; original magnification, x400.)

View larger version (166K): [in a new window]   Figure 7b. (a) Transverse transvaginal US image from a 39-year-old woman shows measurement of the uterine width (crosshairs) and an inhomogeneous thickened endometrium (arrows). (b) Corresponding transverse transvaginal hysterosonographic image shows an irregular inhomogeneous mass (crosshairs) with a sessile attachment to the posterior uterine wall. This image was interpreted as suspicious (suggestive of carcinoma). (c) Photomicrograph of corresponding histologic section shows innumerable polymorphonuclear cells (arrows) evident within all of the glandular structures and within the endometrial stroma, consistent with acute endometritis. No malignant cells were present in any of the specimens. This similarity in appearance of multiple endometrial disease processes causes the positive predictive value of transvaginal hysterosonography to be low. (Hematoxylin-eosin stain; original magnification, x400.)

View larger version (186K): [in a new window]   Figure 7c. (a) Transverse transvaginal US image from a 39-year-old woman shows measurement of the uterine width (crosshairs) and an inhomogeneous thickened endometrium (arrows). (b) Corresponding transverse transvaginal hysterosonographic image shows an irregular inhomogeneous mass (crosshairs) with a sessile attachment to the posterior uterine wall. This image was interpreted as suspicious (suggestive of carcinoma). (c) Photomicrograph of corresponding histologic section shows innumerable polymorphonuclear cells (arrows) evident within all of the glandular structures and within the endometrial stroma, consistent with acute endometritis. No malignant cells were present in any of the specimens. This similarity in appearance of multiple endometrial disease processes causes the positive predictive value of transvaginal hysterosonography to be low. (Hematoxylin-eosin stain; original magnification, x400.)