Ultrasonic diagnosis method for determining hyperplastic processes in endometrium

FIELD: medicine.

SUBSTANCE: method involves recording middle uterus echo and endometrium volume. Uterus body volume is additionally determined and endometrium volume to uterus body volume ratio index (EV/UV) is calculated. The index values within 5 to 10% are thought to be norm for reproductive age women. The EV/UV value being between 10 and 19%, the women are thought to belong to risk group and ultrasonic control is advised for being carried out within 1 year. The value being between 19 and 40%, it is advised to the female patients to pass through diagnostic endometrectomy procedure and carry out histological examination. The value being greater than 40%, the women are sent to be treated in oncological clinical centers. The EV/UV value between 3 and 7% is considered to be norm for female patients within their 5 years long postmenopausal period. The value being between 7 to 13%, the women are included into risk group and ultrasonic control is to be carried out within six months. The value being between 13 to 35% corresponding to endometrium hyperplasia, it is advised to the female patient group to pass through diagnostic endometrectomy procedure and then to carry out histological examination. The value being greater than 35%, treatment in an oncological clinical center is recommended.

EFFECT: high reliability and accuracy of diagnosis.

2 dwg, 3 tbl

 

The present invention relates to medicine, namely to a method of diagnostic ultrasound in gynecology, and can be used for detection of hyperplastic endometrium of the uterus.

It is known that for suspected endometrial hyperplastic processes in ultrasonic diagnosis is widely used in clinical practice, with special attention to the definition of increasing the value of the median uterine echo M-echo (maximum anterior-posterior dimension of the reflection from the endometrium and the walls of the uterus). The thickness of the altered endometrium in women of reproductive age 5-7 day of the menstrual cycle in normal is 5.3±0,49 mm, and in postmenopausal women in the first 5 years - 3.2±0,37 mm [Baykin, thesis... doctor of medical Sciences. Moscow, 2001, s]. According to a study Strukova A.V. et al. [Ultrasound diagnosis in obstetrics, gynecology and Pediatrics, 1992, No. 1, p.23-25] in the early stage of proliferation 5-7 days of the menstrual cycle the endometrium has a thickness of 6-9 mm V.N. Demidov. et al. [Clinical guidelines for ultrasonic diagnosis, Vol.3, Ed. by ITV and Mvenezia, Moscow, Vidar, 1997, s-122] for 5-7 day of the menstrual cycle its thickness ranges from 3 to 6 mm According to most foreign and some domestic experts, the thickness of the M-echo in postmenopausal women in the first 5 years will not exceed Iset 5 mm [Mavodones, Velkomin. Ultrasound diagnosis. The literature review, 1995, No. 3, p.14-20]. The excess of the age regulations M-echo regarded as hyperplasia of the endometrium. [Clinical guidelines for ultrasonic diagnosis, Vol.3, Ed. by ITV and Mvenezia, Moscow, Vidar, 1997, s-129].

The disadvantage of this diagnostic criterion is a wide variation range of average values hyperplastic endometrium: according to Botsis et al. [Clin. Exp. Obstet. Gynecol., 1992, 19, No. 3, R-92] the average thickness of the endometrium when hyperplasia is 9.5 mm; Fistonic et al. [J. Clin. Ultrasound 1997, Oct. 25, No. 8, R-5] range M-echo with hyperplasia - 12,4-13,4 mm; Gruboeck et al. - to 15.6 mm [Ultrasound Obstet. Gynecol. 1994. V.8. R-276]; according to Chou C.Y. et al. [J. Clin. Ultrasound, 1994, V.22, No. 8, R-496] the thickness of the lining of the uterus is already 17,4 mm In studies of our compatriot Baykin [2001] endometrial hyperplasia is characterized by the thickness of the M-echo of 15.3±2,96 mm Range of the thickness of the lining of the uterus with endometrial hyperplasia 9.5-17.4 mm - not effective in clinical practice. In addition it should be noted that Kekre et al. [Aust NZJ Obstet. Gynecol. 1997, Nov.37, No. 4, R-51] consider the average thickness of endometrial cancer figure M-echo of 12.6±5 mm Clear that for endometrial hyperplasia indicator M-the echo is not determinative. The inefficient use of the thickness of the lining of the uterus as the sole criterion obvious in the following example: Auslender et al. [Ultrasound Obstet. Gynecol. 1991. V.1. Suppl. 1. R.27] hyperplasia - endometrial thickness is 15.8 mm, while carcinoma - 17,8 mm while Fistonic et al. [J. Clin. Ultrasound 1997, Oct. 25, No. 8, R-5] hyperplasia - endometrial thickness is of 12.4 mm, and when carcinoma - 14,1 mm Impossibility of accurate differential diagnosis of endometrial pathology on the basis only of its thickness indicates the need for other, more adequate sonographic criteria.

There is a method of ultrasound diagnosis of endometrial hyperplastic processes, which use two echographic parameters: the volume of the endometrium - MA (cm3) and the ratio of endometrial thickness to the thickness of the body of the uterus - TEM/TTM (%)proposed Biegiem [2001]. In women of reproductive age in the early stage of proliferation 5-7 day m/cycle, normal endometrial volume on average 5.9±3,7, while hyperplasia of 12.6±5,3, and in patients with endometrial cancer 26,7±13,8. In the postmenopausal period up to 5 years, the average volume of the endometrium are respectively equal to: 0,9±1,6, 10,5±7,5, 36,3±28,2 according to Baykin [2001]. Indicator TEM/THM among women of reproductive age, the standard of 13.6±1,1 when the hyperplasia was 30,9±7,4, and in malignant processes of endometrium - 40,3±5,27; in the postmenopausal period up to 5 years average TEM/THM soo is respectively equal to: of 10.58± 2,3, 24,7±7,53, 59,0±19,0 according to Baykin [2001]. The combined use of these diagnostic criteria, the sensitivity and specificity for differential assessment of endometrial pathology, respectively 83,8 and 82.5%.

The disadvantage of these diagnostic criteria is that with sufficient representativeness of absolute figures, the diagnostic accuracy is not adequate, because the sensitivity of 83.8 percent indicates that in 16.2% of patients with malignant hyperplasia endometrial pathology is not detected, and the specificity of 82.5%, indicates 17.5% of erroneous diagnosis of malignant processes in the endometrium. Therefore, 33.7% of women ultrasonic diagnosis based on the criteria of endometrial volume and index TEM/THM will be incorrect. In addition, although the volume measure of the endometrium and gives effective results, but this efficiency is only expressed in the changes of the endometrium, which is confirmed by high values of standard deviations. During the early stages of diffuse processes, including hyperplasia, regardless of size, assessment of the situation will be incomplete. You should also add that on the adequacy of diagnosis will always be affected by concomitant diseases of the uterus, therefore, to use the values of the volume of the endometrium, not comparing with such anatomical structure, as m the TKA, today is incorrect.

The objective of the invention is to improve the accuracy of ultrasound diagnosis of endometrial hyperplastic processes in gynecology, to predict the development of endometrial pathology and complications associated with it, in order to timely prevent diseases.

The task carried out due to the fact that additionally use the ratio of the endometrium to the body of the uterus - OE/OM (%):

in women of reproductive age, in the early stages of proliferation in normal OE/OM averages of 8.0±2,43, at rates ranging from 10 to 19% of women are at great risk, and they recommend ultrasonic inspection within 1 year from 19 to 40% - endometrial hyperplasia - this group of patients shows diagnostic curettage of the uterine cavity with histological study, over 40% of women referred for treatment in ancients;

in the postmenopausal period up to 5 years in normal OE/OM average of 5,2±2,07, with rates ranging from 7% to 13% of women are at great risk, and they recommend ultrasonic control within half a year, from 13 to 35% - endometrial hyperplasia - this group of patients shows diagnostic curettage of the uterine cavity with histological examination, more than 35% of women are recommended treatment at the cancer center.

The method of an ultrasonic diagnostic hyperplastic PR the processes of endometrium is as follows: the woman performed a transvaginal ultrasound. On ultrasound measure: the length of the body of the uterus (DTM mm), the thickness of the body of the uterus (THM mm), the width of the body of the uterus (STM mm), the length of the uterine cavity or otherwise the length of the endometrium (DPTM mm), the thickness of the endometrium, otherwise the median uterine echo (M-echo mm), the width of the endometrium (SHENG mm). Measuring biometrics carried out according to standard methods ultrasound in gynecology. Ultrasonic examination of the body of the uterus and endometrium have longitudinal and transverse scanning the shape of the ellipse (see Fig. 1 and 2). In normal endometrium saves the form of reduced copies of the uterus occupying a median position parallel to the external contour of the uterus (scheme uz-research). And when the values of OE/OM:

in women of reproductive age, in the early stages of proliferation, equal to 8.0±2,43, consider the norm, with rates ranging from 10 to 19% of women are at great risk, and they recommend ultrasonic inspection within 1 year from 19 to 40% - endometrial hyperplasia - this group of patients shows diagnostic curettage of the uterine cavity with histological study, over 40% of women referred for treatment in ancients;

in the postmenopausal period up to 5 years in normal OE/OM average of 5,2±2,07, with rates ranging from 7% to 13% of women are at great risk, and they recommend ultrasonic control within half a year, about the 13 to 35% - hyperplasia of the endometrium - this group of patients shows diagnostic curettage of the uterine cavity with histological examination, more than 35% of women are recommended treatment at the cancer center.

The volume of the endometrium MA (cm3) is calculated by the known formula of the ellipsoid:

MA(cm3)=DPTM(mm)×TE(mm)×SHENG(mm)×0,000523,

where DPTM - the length of the body cavity of the uterus (mm); TAE - endometrial thickness (mm); SHENG - width of the endometrium (mm); 0,000523 is a constant conversion factor for an ellipsoid with regard to translation mm3in cm3.

Taking into account that the configuration of the body of the uterus resembles the same way as the endometrium, an elongated ellipse, its volume, the author proposes to rely on the following formula:

Calculation of the volume of the body of the uterus Ω (cm3):

Ω(cm3)=FCN(mm)×THM(mm)×STM(mm)×0,000523,

where DTM is the length of the body of the uterus (mm)TTM - thickness uterine body (mm); STM - width of body of uterus (mm);

0,000523 is a constant conversion factor for an ellipsoid with regard to translation mm3in cm3.

On the basis of anatomical and functional relationships of the body of the uterus and endometrium, as well as from the scheme ultrasound scanning, it follows that the volume of the endometrium - MA (cm3and the amount of body of uterus Ω (cm3) are proportional, which we will henceforth denote the index of the ratio of the endometrium is the volume of the body of the uterus OE/OM (%):

MA/OHMS=DGGM(mm)×TE (mm)×SHENG(mm)×100%DTM(mm)×THM(mm)×STM (mm)

where DPTM - the length of the body cavity of the uterus (mm); TAE - endometrial thickness (mm); SHENG - width of the endometrium (mm);

DTM - length body of the uterus (mm)TTM - thickness uterine body (mm); STM - width of body of uterus (mm).

Endometrial hyperplastic processes cause significant diffuse increase of biometric parameters of the endometrium, therefore, contribute to an increase of the endometrium. For a constant volume of the body of the uterus ratio MA/OHMS with increase in endometrial will change. On reliable differences index OE/OM is based diagnosis of endometrial hyperplastic processes.

A total of 115 ultrasonic studies of them - practically healthy women 27 (23.5 percent) in their reproductive period and 31 (26,9%) in postmenopausal women (PPMS); women with suspected endometrial hyperplastic processes amounted to 23 (20%) in their reproductive period and 34 (29.6 per cent) in postmenopausal women. In the reproductive period ultrasound studies were performed on the 5-7th day of the menstrual cycle in the early phase of proliferation, i.e. in phase relative hormone of calm, in women in the postmenopausal period, the duration of which is up to 5 years, ultrasonic diagnostics was carried out at the time of treatment of the patient.

Measurements of biometric parameters used in the present time: M-echo, TEM/THM, MA, and was additionally calculated the ratio of the endometrium to the body of the uterus - the index of the MA/OHMS. The results of ultrasound examination are shown in table 1. Diagnostic time was present to perform medical diagnostic invasive procedures, after receiving cytohistologic of the results was performed comparative analysis of the informativeness and efficiency index OE/OM, as well as indicators of the M-echo, TEM/THM, MA.

Table 1.
Comparative table of results uz-research index OE/OM and ecocritical, currently used (M-echo; TE/THM; MA) with hyperplastic processes of the endometrium.
M-echo (mm)TE/TTM(%)MA (cm3)OE/OM(%)
Reproductive age (n=27)5,0±0,1711,8±0,414,5±0,438,0±0,81
Hyperplasia of the endometrium (n=15)14,7±1,9326,9±2,7112,1±1,7225,3±1,79
Malignant hyperplasia of endomet the Oia (n=8) 17,3±1,0738,1±2,1425,2±1,2755,5±2,31
Post-menopause (n=31)3,2±0,1410,5±0,342,1±0,195,2±0,69
Hyperplasia of the endometrium (n=14)10,6±0,5324,3±1,8210,1±0,5119,1±1,71
Malignant endometrial hyperplasia (n=20)29,7±2,2154,3±3,2333,4±2,3561,1±2,11
where n is the number of patients

From table 1 it follows that proposed by the author of the ratio of the endometrium to the body of the uterus (MA/OHMS) in women of reproductive age, the standard of 8.0% for hyperplasia was increased to 25.3% (p<0.01)and in malignant diseases of the endometrium already to 55.5% (p<0,01). In RAP, the standard of 5.2% in patients with hyperplasia was increased to 19.1% (p<0.01), and in cancer - 61,1% (p<0,01). In patients with malignant processes in the endometrium in postmenopausal women middle age rate of 5.2% was exceeded by more than 11 times. Retrospective application threshold OE/OM>40% (during reproduction) and >35% (in the postmenopausal period) showed high values of sensitivity and specificity of endometrial cancer and reached the respectively br93.1 and 94,3% (table 2).

Table 2.
Comparative evaluation of the quality of application of the index OE/OM and ecocritical, currently used (M-echo; TE/THM; OE) in the ultrasonic diagnosis of endometrial hyperplastic processes according to a retrospective analysis morphophysiological results.
FELOPLIOSenseSpec. %Fine. %LPDD%LOD%PZPR%PCOR%
M-echo24562982,782,982,817,117,28085,3
TE/THM209112469,168,668,8of 31.431,0360,672,7
MA26333289,791,490,68,610,389,791,4
OE/OM272233br93.1 94,393.8the 5.76,9br93.194,3
PI is the number of true positive results; LO the number of false-negative results;

IO is the number of true-negative results; PL is the number of false-positive results;

Sensitivity (%) the proportion of true-positive diagnoses;

Specificity (%) - proportion of true-negative diagnoses;

The diagnostic accuracy (%);

LPDD (%) - false positive proportion of diagnoses (overdiagnosis);

LOD (%) - false negative proportion of diagnoses (mismatch diagnosis ultrasound with morphological data);

PZPR (%) - predictive value of a positive result;

PCOR (%) - predictive value of a negative result.

From table 2 clearly follows that proposed by the author of a new original index OE/OM the ultrasonographic diagnosis of endometrial hyperplastic processes has a high sensitivity, specificity, positive predictive value and negative results, and diagnostic accuracy compared with ecocriticism used in clinical practice at present. The percentage of falsely Polo is sustained fashion and false-negative diagnoses are minimal.

Thus, the use of an index of the ratio of the endometrium to the body of the uterus is another step towards early detection of oncological processes in the endometrium. Indicator OE/OM is part of a comprehensive us study, in order to enhance the early diagnosis of endometrial hyperplastic processes, therefore, adequately and timely to identify, select and adjust the further tactics of treatment.

Highly representative results of evaluation of the quality ultrasonic diagnostic index OE/OM in the detection of endometrial hyperplastic processes allow the author to propose their use in clinical practice. Given that the method of ultrasonic diagnostics is a visual method, the validity of the results obtained in the clinic obvious. The purpose of an adequate interpretation of the results of MA/Ω ultrasonic practice it is necessary to consider age a woman's period.

Table 3.
The threshold index OE/OM the ultrasonographic diagnosis of endometrial hyperplastic processes.
ParityIndicators OE/OM (%)
period reproductionsRAP (up to 5 years)
M±SDfluctuationsM±SDfluctuations
Norma8,0±2,435-105,2±2,073-7
Risk group10÷197÷13
Hyperplasia of endometrium25,3±5,3819-4019,1±5,1113-35
Malignant endometrial hyperplasia55,5±6,91≥4061,1±6,29≥35

The proposed threshold criteria (table 3) will purposefully and reasonable to apply minimally invasive, and surgical methods of diagnosis and treatment, as well as to expand opportunities for early detection of malignant processes in the endometrium. The allocation of risk will allow us to predict and to prevent the development of endometrial hyperplasia, therefore, and complications associated with this pathology.

This technique can be used in offices ultrasound in gynecology, screening ultrasound examinations in the clinic, as well as in cancer.

Examples

B-Oh M, 35 years transvaginal ultrasound examination during regular honey. inspection. Complaints and clinical manifestations side genitali is missing. Menstrual function is not violated: m/cycle regular (28 days), mensis - 5 days 6-th day m/cycle. Ultrasound - index MA/OHMS equal to 21.1%. Suspected hyperplastic process of the endometrium, the patient is directed to diagnostic curettage of the uterine cavity. Cytohistologic conclusion - glandular-cystic hyperplasia of the endometrium.

B-Aya D., 50 years old, came to the gynecologist about the design of sanatorium-resort card. Menopause 3 years. Complaints and clinical symptoms from genital denies. Appointed ultrasound examination with the preventive purpose. Ultrasound - index MA/OHMS equal to 43.9 per cent. From diagnostic curettage of the uterine cavity flatly refused. Three months later, he enrolled in the Department of gynecology in the emergency order with uterine bleeding. Upon receipt conducted transvaginal ultrasound examination: the index of the MA/Ω is equal to 51.2 per cent. Produced diagnostic curettage of the uterine cavity. Cytohistologic conclusion, adenocarcinoma of the endometrium.

The proposed method for ultrasonic diagnosis of endometrial hyperplastic processes has the following advantages:

1. The use of index MA/W for ultrasonic diagnosis in gynecology improves the accuracy of detection of endometrial hyperplastic processes to invasive diagnostic procedures.

2. The threshold until ately allow time to verify the rate of endometrial hyperplasia in the early preclinical stages of the process. The clinical stages of the process - to increase the effectiveness of the differential ultrasonic deagostini benign and malignant endometrial hyperplastic processes.

3. Prediction and prevention of hyperplasia of the endometrium due to the selection of risk groups.

4. The simplicity and accessibility of the method enable widespread use ecocritique - index MA/MD in gynecology, screening and preventive examinations, covering a wide layers of the population.

The method of ultrasonic diagnosis of endometrial hyperplastic processes, including registration of the median uterine echo - M-echo, volume endometrium (MA), characterized in that it further determine the volume of the body of the uterus (Ω) and compute the ratio of the endometrium to the body of the uterus (MA/OHMS): in women of reproductive age in the early stage of proliferation index MA/OHMS in the range of values from 5 to 10% is considered the norm, with rates ranging from 10 to 19% of women are at great risk and they recommend ultrasonic inspection within 1 year from 19 to 40% endometrial hyperplasia - this group of patients shows diagnostic curettage of the uterine cavity with histological study, over 40% of women referred for treatment in ancients; in the postmenopausal period up to 5 years MA/OHMS in the range of values from 3 to 7% considered the t-norm, at rates ranging from 7% to 13% of women are at great risk and they recommend ultrasonic control within half a year, at rates ranging from 13 to 35% - endometrial hyperplasia - this group of patients shows diagnostic curettage of the uterine cavity with histological examination, more than 35% recommended treatment at the cancer center.



 

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