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Endometrial pathologies

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  • 1. Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma

2. Premenopausal Endometrium During menstruation---- a thin echogenic line, 14 mm in thickness In early proliferative phase of the menstrual cycle(after day 6) becomes thicker (57 mm) and more echogenic relative to the myometrium, (glands, blood vessels, and stroma) Normal endometrium 3. Late proliferative (periovulatory) phase a multilayered appearance. an echogenic basal layer and hypoechoic inner functional layer, separated by a thin echogenic median layer. may measure up to 11 mm in thickness. 4. During the secretory phase, becomes even thicker (7 16 mm) and more echogenic . stromal edema and glands distended with mucus and glycogen. increased posterior acoustic enhancement. The endometrium typically reaches a maximum thickness during the mid secretory phase . 5. On Ultrasound Endometrial thickness is measured from echogenic border to echogenic border across the endometrial cavity on a sagittal midline image. 6. Normal premenopausal endometrium. Sagittal US image of the uterus obtained during menstruation shows a thin endometrial lining with a trace of fluid. 7. Normal premenopausal endometrium. Sagittal US image of the uterus obtained during the late proliferative phase of the menstrual cycle demonstrates the endometrium with a multilayered appearance . 8. 9. On MRI uterus has homogeneous intermediate signal intensity with T1-weighted sequences. T2-weighted images delineate the uterine zonal anatomy. So endometrium is best visualized on T2. 10. The normal endometrium is of uniformly high signal intensity, and the inner myometrium, or junctional zone, is of uniformly low signal intensity 11. Normal premenopausal endometrium. T2-weighted MR image shows the normal endometrium and junctional zone. 12. Postmenopausal Endometrium should be thin, homogeneous, and echogenic. Homogeneous, smooth endometria measuring 5 mm or less are considered within the normal range with or without hormonal replacement therapy. 13. The endometrium in a patient undergoing hormonal replacement therapy may vary up to 3 mm if cyclic estrogen and progestin therapy is being used 14. Postmenopausal endometrial atrophy. Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid. 15. Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma 16. a common cause of postmenopausal bleeding most frequently seen in patients receiving tamoxifen or HRT. may be broad-based and sessile or pedunculated. Typically measure 5-15mm. The point of attachment should not disrupt the endometrial lining. Endometrial Polyps 17. Ultrasonographic appearance frequently identified as focal masses within the endometrial canal. OR as nonspecific endometrial thickening. Color Doppler US may be used to image vessels within the stalk 18. Sonohysterography Polyps are best seen at sonohysterography appear as echogenic, smooth, intracavitary masses outlined by fluid 19. Hysterosalpingography seen as pedunculated filling defects within the uterine cavity. 20. MRI T2-weighted MR imaging Appears as low-signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium. 21. Sonohysterogram reveals a small polyp attached by a stalk to the endometrium. 22. Anteroposterior (left) and oblique (right) hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows). 23. T2-weighted MR image demonstrates a low-signal-intensity lesion within the endometrial canal (arrow). 24. Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma 25. an abnormal proliferation of endometrial stroma and glands represents a spectrum of endometrial changes ranging from glandular atypia to frank neoplasia. Endometrial hyperplasia 26. Causes Polycystic ovaries Obesity Exogenous hormones Endogenous excess estrogen production 27. A definitive diagnosis can be made only with biopsy imaging cannot reliably allow differentiation between hyperplasia and carcinoma. Up to one-third of endometrial carcinoma is believed to be preceded by hyperplasia. 28. On histology, three types of endometrial hyperplasia (cystic, adenomatous, atypical) All types can cause diffusely smooth or, less commonly, focal hyperechoic endometrial thickening. 29. Ultrasonographic appearance Endometrial hyperplasia is considered when the endometrium exceeds 10 mm in thickness, especially in menopausal patients In postmenopausal women 5mm thickness is significant. 30. may also cause asymmetric thickening with surface irregularity, an appearance that is suspicious for carcinoma. The US appearance can simulate that of normal thickening during the secretory phase, sessile polyps, submucosal fibroids, cancer, and adherent blood clots, yielding potentially false-positive results . 31. Because endometrial hyperplasia has a nonspecific appearance, any focal abnormality should lead to biopsy if there is clinical suspicion for malignancy. 32. Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia. This finding was confirmed at biopsy. 33. Normal endometrium Endometrial polyps Endometrial hyperplasia Endometrial carcinoma 34. Fourth most common malignancy in females. Most common malignancy of the female reproductive tract The prevalence of endometrial cancer is increasing with rising levels of obesity. App. 75% cases occur in postmenopausal women, median age at diagnosis is 70 years. Endometrial carcinoma 35. Postmenopausal bleedingmost common symptom. Adenocarcinomas account for 90% of endometrial neoplasms, uterine sarcomas-- only 2%6%; remaining include adenocarcinoma with squamous cell differentiation and adenosquamous carcinoma. 36. Risk factors Increased estrogen levels Hypertension Obesity Diabetes Multiparity Late onset menopause 37. Prognosis stage, depth of myometrial invasion, lymphovascular invasion, histologic grade, and nodal status. 38. Depth of myometrial invasion is the most important morphologic prognostic factor, correlating with tumor grade, presence of lymph node metastases, and overall patient survival. 3% lymph node metastases with superficial myometrial invasion to 46% with deep myometrial invasion. 39. IMAGING MODALITIES Ultrasonography Increased endometrial thickness Irregular hypoechoic intracavitary mass Enlarged diffusely infiltrated uterus. 40. 41. Endometrial cancer is staged with the International Federation of Gynecology and Obstetrics (FIGO) system, which recently underwent a major revision. First proposed in 1988, and the staging system was updated in 2009. 42. 43. The previous iteration of the FIGO system subdivided stage I tumors into IA, IB, and IC tumors. Stage IA tumors are confined to the endometrial complex, stage IB tumors invade

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