C. Marciante

Sonohysterography in the preoperative grading of submucous myomas: considerations on three‐dimensional methodology

Lee et al.1 report good intraand interobserver reproducibility of three-dimensional (3D) saline contrast sonohysterography (SCSH) in the preoperative grading of submucous myomas. This is good news, as presurgical sonohysterographic assessment of submucous myomas simplifies the diagnostic triage of women with this lesion. However, no method for the reproducible 3D assessment of submucous myomas with intramural extension (G1, G2) – for which accuracy is lower than that for intracavitary myomas (G0)2 – was given. We tried to define strict criteria in our recent study, which used traditional monoplanar transvaginal sonohysterographic assessment3. We believe that a 3D technique could simplify this methodology when step-by-step processing of the acquired volume is performed as follows:

OC045: Prognostic markers of malignancy at sonohysterography in post‐menopausal patients with post‐menopausal bleeding and thickened endometrium at transvaginal sonography

negative values. The aim was to determine the number of acquisitions needed to detect micturition and to calculate precise diuresis. Methods: Prospective observational study of bladder acquisions with 3D and volume measurement with VOCAL, using a 4–7 RAB volumetric transducer in a Voluson 730 Expert. The acquisition performed in High 1 definition, 30◦, with the image centered in the bladder avoiding shadows. Unselected, 126 normal singleton pregnancies from 20 to 38 weeks were included. The operators were asked to perform 2 to 5 acquisitions with a 3 to 5 minute interval during normal scan, without taking into account if the bladder subjectively growed. The volume was calculated manually with 30◦ rotation, after the scan. Results: 74, 42, 8 and 2 pregnancies had 2, 3 4 and 5 acquisitions. When 2 acquisitions, the mean time interval was 4 : 33 (min : sec), range 00 : 13–20 : 16. From these, 11% (8) had decreasing volumes, not being possible to measure diuresis. For those cases with three acquisitions, the mean time interval from the first to the last was 7 : 33, with 10% (4) cases in which all volumes were decreasing, being not possible to measure diuresis. In ten cases with 4 or 5 acquisitions there were always two growing phases that allowed diuresis measurement. The mean time interval from the first to the last acquisition was 10 : 06, range 5 : 31–19 : 04. Only two fetuses had two negative diuresis and these were always consecutive, suggesting that micturition may take some time. Conclusion: At least 4 bladder acquisitions in a time interval of 10 minutes are needed to detect micturition and perform precise diuresis calculations. This has to be considered for future fetal diuresis studies.

OP17.06: Endometrial hyperplasia at 3D transvaginal sonography by VCI analysis

Objectives: To assess the impact of ultrasound at the time of initial assessment. Methods: Referrals to the two-week referral (TWR) clinic between 28 October 2005 and 9 June 2006 were analyzed. Referrals were made on a criteria-based form. The indication for urgent referral, procedures performed in clinic, further investigations and referrals and final diagnosis were recorded. 96% of ultrasound scans were transvaginal and 4% transabdominal. Results: 116 women were seen, mean age 56 (range 19–94) years. An ultrasound scan was indicated in 97 women (83%), 54 (56%) of which showed abnormal findings. Sixty-two women were referred with postmenopausal bleeding (PMB), 60 had ultrasound scans (two were hysterectomized). 50% (30) showed abnormal findings and all underwent endometrial sampling. Twenty-two women required hysteroscopy. The three endometrial cancers and 11 polyps/submucuous fibroids suspected on ultrasound scans were confirmed at hysteroscopy. Ten women were referred with pelvic masses and had ultrasound scans. Six ovarian cysts were detected, one of which was ovarian cancer. A further four benign ovarian cysts were noted in women referred for PMB. Seventeen (14.6%) of women required colposcopy. All six women with abnormal cervical cytology or histology were followed up in the colposcopy clinic and no cancers were found. A total of seven cancers were detected – three endometrial, three vulval and one ovarian. 71% of ultrasound scans (69/97) were normal or suggestive of benign pathology. Of these, 42/97 (43%) did not require further follow-up. 48% of referrals did not conform to criteria and there were no malignancies in this group. Conclusions: The majority of women required ultrasound scans. Two of three referrals were for PMB. Suspected cancers were immediately referred for urgent assessment, and the detection rate was 100%. The prevalence of cancer was low, at 6%. Women referred outside the criteria are at low risk of cancer. Utilizing ultrasound scans in the TWR clinic allows effective triage, appropriate immediate investigation and referral or discharge, resulting in a streamlined service.

OP19.02: Clinical history of recto‐vaginal septa deep infiltrating endometriosis during repeated ovulation induction: a case report

rectovaginal septum. When no lesion was seen, observers were asked to judge if the acquisition of the volume was defective, or if no lesion on the rectovaginal septum was evident; defective acquisition cases were discarded, a total number of 83 cases were evaluated. In order to calculate the performance of the introital 3D US, seven discordant cases were reviewed by a third observer. Interobserver agreement was assessed by calculating kappa index (κ), and Sensitivity, Specificity, PPV and NPV by the three observers were also determined. Results: Interobserver agreement was 0.816 (95% CI [0.69–0.93]) (representing a very good agreement). Sensitivity was 74.1%, Specificity 85.5%, PPV 71.4% and NPV 87%. Conclusions: Our results show that introital 3D US for diagnosis of deep endometriosis of the rectovaginal septum is reproducible with very good interobserver agreement.

OP24.05: Sonographic follow-up of solid ovarian lesion < 5 cm in post-menopausal women: preliminary results

endometrial-myometrial junction, presence of the ‘‘bright edge’’ sign at the edges of the lesions, and preservation of normal endometrial lining adjacent to the lesion. Patient clinical history and histological assessment of tumor grading were assessed. Results: 79 cases were analyzed, 26 were benign and 53 cases malignant. Antero-posterior lesion diameter was 8.89 ± 5.58, 14.8 ± 6.99, and 20 ± 10.57 millimeters for the benign, low grade and high grade malignancy lesions respectively, which was statistically significant (P < 0.05). High echogenicity, cystic formation within lesions, presence of ‘‘bright edge’’ and preservation of normal endometrium adjacent to the endometrial lesion were significantly more common in the benign group as compare to malignant lesions (P < 0.05). Complex echogenicity and loss of endometrial-myometrial junction were significantly more common in the malignant lesions group (P < 0.05). These parameters could not distinguish between low and high grade endometrial malignancy. Conclusions: Malignant endometrial lesions are associated with larger antero-posterior diameters. Sonographic parameters such as high echogenicity, cystic formation, presence of ‘‘bright edge’’ and preservation of normal endometrium might be used to distinguish between benign and malignant lesions. These parameters should be assessed, while considering a surgical intervention for endometrial lesions.

P15.06: Accuracy of a sonographic based triage with endometrial sampling during saline contrast sonohysterography in pre‐ and post‐menopausal women with abnormal uterine bleeding

and uterine and 10 mm shell myometrial 3D-PDA indices VI (vascularization index), FI (flow index) and VFI (vascularization flow index) were calculated. Signal attenuation in 3D-PDA was evaluated by categorizing the patients into two subgroups according to the distance to the center of the endometrium. The results were compared with a complete surgical staging. Results: A deep myometrial invasion was present in 23 patients. Of the color Doppler indices, the uterine artery RI and PI were statistically significantly lower in the group with deep invasion (P = 0.014 and 0.013, respectively). The uterine and myometrial 3D-PDA indices VI and VFI were statistically significantly higher in the group with deep invasion (P = 0.014 and 0.014; P = 0.013 and 0.022, respectively). No correlation was found between any of the measured indices and the presence of metastases. The subgroup analysis indicated that the uterine and myometrial VI was affected by distance, being statistically significantly higher in the group closer to the probe (P = 0.021 and 0.012, respectively). The multivariable analysis left the mean uterine artery RI as the only independent factor for the presence of deep invasion (OR 0.0003, 95%CI 0.00008–0.143, P = 0.010). Conclusions: The uterine artery RI correlates with the presence of deep invasion in endometrial carcinoma. 3D-PDA has potential in the preoperative assessment of endometrial carcinoma, but signal attenuation may bias the results.

OC19.02: Clinical history of asymptomatic endometrial polyps in postmenopausal women: a 10-years follow-up study: Oral Communication (OC) Abstracts

Objectives: To observe the clinical history of endometrial polyps on atrophic endometrium (thickness ≤ 4 mm) in asymptomatic postmenopausal women. Methods: 396 asymptomatic postmenopausal women with sonographic diagnosis of endometrial polyp were prospectively recruited. Patients on HRT and/or TMX treatment were excluded. All patients underwent transvaginal sonography (TVS) with color power-Doppler (CD) evaluation, and sonohysterography (SHG). Sonographic follow-up at 3, 6, 12 and every 12 months was proposed as an option to standard hysteroscopic polypectomy. Surgery was considered in case of a high blood flow score (color score 3–4 according to IETA definitions), or in case of bleeding and/or volume growth > 50% at follow-up. Demographic, sonographic and surgical data were recorded. Results: Sonographic follow-up was chosen by 292 patients (group A). At a median follow-up period of 60 months, 32 patients were lost at follow-up; 58 patients underwent surgery because of dropout, uterine bleeding or increased volume at follow up, or for other gynaecological indications; 3 endometrial cancers were diagnosed after uterine bleeding at follow-up. In group B, surgical removal was performed in 104 patients by hysteroscopic polipectomy. One pre-malignant lesion was found in surgically treated patients (simple hyperplasia with focal atypia confirmed at hysterectomy). Conclusions: This observational clinical study adds evidence to the debatable feasibility of a conservative management of asymptomatic polyps and on the role of a sonographic follow-up. Monitoring criteria by using TVS, CD and SHG assessment need to be established.

OP29.08: Sonographic follow-up of unilocular > 5 cm and multilocular < 7 cm ovarian cysts in post-menopausal women

Objectives: To evaluate, sonographic, power-Doppler features and histological findings in cases of small unilocular-solid cyst in a normal-size ovary. Methods: All consecutive women with small ovarian unilocularsolid cyst in normal-size ovary detected by transvaginal ultrasound, were included in the study. Patients had either follow-up ultrasound examination every three months or underwent surgical removal of the cyst. CA 125 was also evaluated. Histological findings were reviewed. Results: A total of 45 cases were identified. The median age of the patients was 48 years (range 25–77). CA 125 was elevated (> 35 UI/mL) in 6/45 (13%) cases. The median size of the cyst was 18 mm (range 11–30). The vascularization was present in 20/45 (44%) cases. 15/45 (33%) women received followup ultrasound examination every three month. 30/45 (67%) undervent laparoscopic removal of the cyst. Hystological diagnosis of malignancy (three carcinoma, and six borderline tumors) was recorded in 9/45 (20%) cases and of benign lesion in 21/45 (47%). Conclusions: These data suggest that the presence of a papillary projection is more important than the size of the cyst. Small unilocular solid cysts even in a normal-size ovary have substantial risk of malignancy.

OP19.09: Clinical history of recto‐sigmoid endometriosis: a 6‐years follow‐up study

Objectives: To determine if a consistently retroverted or retroverted retroflexed uterine position is associated with pelvic pain. Methods: 969 sequential gynecological sonograms were reviewed by a radiologist on-line. Uterine position on transvaginal examination was categorized as anteverted (746–77%), retroverted (129–13%), axial (49–5%), anteverted retroflexed (40–4%), and retroverted anteflexed (5−.5%). 118 of the retroverted uteri had transabdominal and transvaginal examinatons. 41, anteverted on transabdominal exam, became retroverted on transvaginal exam (‘‘variable’’), 77 were retroverted on transabdominal and transvaginal views (‘‘fixed’’). The gynecological referral indication was compared between the ‘‘variable’’ and ‘‘fixed’’ groups. Results: Pelvic pain as an indication was commoner in the ‘‘fixed’’ group (27%) than in the ‘‘variable’’ group (14%). IUD issues (either malposition or ‘‘lost string’’) were more common in the variable group (24%) than in the fixed group (8%). Other indications such as abnormal uterine bleeding, abnormal uterine bleeding with pain, postmenopausal bleeding, retained products of conception, adnexal mass or ‘‘miscellaneous’’ were the equivalent in both groups. Conclusions: A consistently retroverted or retroverted retroflexed uterine position on both transabdominal and transvaginal ultrasound views is assocaited with pelvic pain. IUD issues occur more commonly if the uterine position changes from anteverted to retroverted between the transabdominal and endovaginal ultrasonic examinations.

OP20.01: 3D-transvaginal sonography by VCI analysis to differentiate endometrial polyp and hyperplasia in pre-menopausal women: Short Oral Presentation (OP) Abstracts

Objectives: To determine if a consistently retroverted or retroverted retroflexed uterine position is associated with pelvic pain. Methods: 969 sequential gynecological sonograms were reviewed by a radiologist on-line. Uterine position on transvaginal examination was categorized as anteverted (746–77%), retroverted (129–13%), axial (49–5%), anteverted retroflexed (40–4%), and retroverted anteflexed (5−.5%). 118 of the retroverted uteri had transabdominal and transvaginal examinatons. 41, anteverted on transabdominal exam, became retroverted on transvaginal exam (‘‘variable’’), 77 were retroverted on transabdominal and transvaginal views (‘‘fixed’’). The gynecological referral indication was compared between the ‘‘variable’’ and ‘‘fixed’’ groups. Results: Pelvic pain as an indication was commoner in the ‘‘fixed’’ group (27%) than in the ‘‘variable’’ group (14%). IUD issues (either malposition or ‘‘lost string’’) were more common in the variable group (24%) than in the fixed group (8%). Other indications such as abnormal uterine bleeding, abnormal uterine bleeding with pain, postmenopausal bleeding, retained products of conception, adnexal mass or ‘‘miscellaneous’’ were the equivalent in both groups. Conclusions: A consistently retroverted or retroverted retroflexed uterine position on both transabdominal and transvaginal ultrasound views is assocaited with pelvic pain. IUD issues occur more commonly if the uterine position changes from anteverted to retroverted between the transabdominal and endovaginal ultrasonic examinations.