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Endometrial pathology – IETADr Anna Lee FRANZCOG DDU COGU

Monash Health – Advanced Gynaecology Ultrasound UPDATE

23 Feb 2019

Endometrial pathology - IETA

• Overview:– Background– Terms and definitions– Intracavity lesions/pathology– Applications – endometrial cancer

IETA – International Endometrial Tumor Analysis

• Background:- Group established in 2008 at ISUOG

Chicago

- Aim: standardise the terms and definitions used to describe US findings in the uterine cavity

- Form the basis of prospective studies to predict the risk of different endometrial pathologies based on the US appearance

IETA – Terms and Definitions• Examination technique: - Quantitative

assessment – the ET– Measure ET in mid sag– Magnify image– ID endometrium – trace from cervical canal if

difficult– Aim for 90deg angle– Calipers at EMJ at thickest perpendicular to the

midline– Report double layer in mm– If fluid present measure separately and report sum– If cannot be seen in its entirety should report as

“non-measurable” (Endo CA)– If intracavity pathology present, ET should include

the lesion

IETA- Terms and Definitions

• Qualitative Assessment:

1. Endometrial echogenicity2. Endometrial midline3. Endometrial myometrial junction4. Colour doppler

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IETA – Terms and Definitions• Endometrial echogenicity– Hyperechgenic/Isoechogenic/hypoechogenic– uniform (homogenous symmetrical) vs non-uniform

IETA – Terms and Definitions• Non-uniform -

heterogenous, asymmetrical or cystic

• Eg a/b homogenous background with cystic areas (reg/irreg)

• Eg c/d/e heterogenous background without or with cystic areas (reg/irreg)

IETA – Terms and Definitions• Endometrial midline– Linear– Non- linear– Irregular– Not defined

IETA – Terms and Definitions• Endometrial myometrial junction (EMJ)– Regular– Irregular– Interrupted– Not defined

IETA – Terms and Definitions• Colour and power Doppler assessment– Technique:

• Include endo and surrounding mometrium• Adjust settings for max sensitivity for blood flow – freq

>5MHz, PRF 0.3-0.9kH• Wall filter 30-50 H• Colour power doppler gain reduced until artefacts

disappear– Score using IOTA colour score (1-4) previously

applied to ovarian masses – subjective semiquantitative assessment

– Vascular pattern

IETA – Colour/doppler score• 1.No colour/flow• 2. Minimal• 3. Moderate• 4. Abundant

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IETA – Colour/doppler pattern•Vascular Pattern:

•“dominant vessels” •Single vs multiple•+/-branching

•Orderly vs disorderly•Focal vs multifocal origin

•Scattered

•Circular flow

Endometrial pathology - IETA

• Overview:– Background– Terms and definitions– Intracavity lesions/pathology– Applications – endometrial cancer

IETA – intracavity lesions/pathology

•= anything protruding into the cavity•Can arise from the endometrium or

myometrium

•Measure in 3 planes

•Aim to described its:

•Extent – localised (<25%) eg polyp vs

extended (>25%)

•Echogenicity (uniform vs non-uniform)

•Outline (regular vs irregular)•Colour score/pattern

Ie use IETA definitions and now apply to pathology and facilitate multicentre research

IETA 1 – Prospective Multicentre Study (Van den Bosch 2018, vol 52 USOG)

•2856 women with AUB•2417 underwent endometrial sampling – therefore aimed to apply IETA terms to predict/clarify underlying pathology•Came up with “typical” appearance of various outcomes:

•Atrophy•Proliferative•Secretory•Hyperplasia•Polyp•Fibroid•Atypical hyperplasia•cancer

• Easiest distinction:•Atrophy vs malignancy•More difficult: polyp vs myoma

IETA – intracavity pathologyPOLYP

-Localised lesion – sessile vspedunculated- Echogenicity - hyperechoic-Uniform (vs non-uniform)-Outline - regular-Interrupted/undefined midline-Regular EMJ-Vascularity – dominant single with/out branching, colour score 2-4

-WHY? Is it important? Will it influence management?

-Different risk of malignancy

IETA – Intracavity pathology

FIBROID-Localised lesion

-Iso/hypoechogenic-Smooth/regular outline

-Interrupted EMJ-Grade submucous fibroid:

-G0 – intracavity

-G1 – sessile with >50%

-G2 – endocavity <50%

-Colour score and pattern – circular, 0-1.

-Other important information for management:

-SIZE - <2cm Gd 1-2 – hysteroscopy cf >4cm

experienced hysteroscopist

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IETA - atrophy

-Thin regular endometrium-Seen throughout the cavity-IETA – “typical”

-3-7mm-Uniform hyperechoic-Midline undefined-Colour score 1

- <3mm 100% NPV for cancer- practice 4-5mm generally used with good NPV eg ET <4mm has NLR of 0.1

IETA - HyperplasiaHyperplasia Hyperplasia with

atypiaET 8-11mm 8-18echogenicity Non-uniform

heterogenouswithout cysts

Non-uniform heterogenouswithout cysts

midline undefined undefinedEMJ regular regularvessels Multiple vessels

of multifocal origin or scattered

Multiple vessels of multifocal origin or scattered

Colour score 1-2 3-4

Endometrial pathology - IETA

• Overview:– Background– Terms and definitions– Intracavity lesions/pathology– Applications – endometrial cancer

IETA - Cancer•Background

•Most common gynae cancer• 1:80 women by age 75y – cumulative risk of 1.8%•10% PMB not on HRT•RF: age, obesity, unopposed estrogen(PCOS in premen), late menopause, •Often diagnosed early – S1 (localised to uterus) only 4% will die of their disease – 96% 5 year survival•HIGH RISK type:

•Size•Grade 3•Histology - non-endometrioid•Myometrial invasion >50%•Cervical invasion

IETA - Cancer

•US Features:•ET 11-26mm (remember: non-measurable endometrium is suspicious and should prompt referral for sampling)•Extended lesion•Irregular outline•Non-uniform heterogenous with/without cysts•Undefined midline•Interrupted EMJ (myometrial invasion)•Colour score – 3-4•Any pattern except single vessel without branching

IETA - Cancer

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IETA - Cancer•Colour score 3-4

•Moderate-abundant•Any pattern except single

•Multiple•Focal/nonfocal origin•Branching

•Scattered

IETA4 – Cancer – detection of “High Risk” disease

•HIGH RISK type:•Size•Grade 3•Histology - non-endometrioid•Myometrial invasion >50%•Cervical invasion

•AIM: want to identify these patients bc increased risk of LN mets, distant spread and tumour recurrence.•Size, myometrial invasion, stromal invasion – detectable preop by US/MRI• IETA 4 – sonographic findings of “high risk disease”

•Histological type•Tumour grade•Stage

IETA 4 – HR CancerEpstein et al USOG 2018; 51:818-828 US characteristics of endometrial cancer as defined by IETA consensus

nomenclature

•. Prospective cross-sectional MC study 17 European centres•1714 women with endo ca, 1538 in final analysis post hyst•TVUS and doppler

•Features assessed (using IETA terminology) :•Endometrial echogenicity

•Uniform – hyper/iso/hypo•Non uniform

•Endometrial myometrial border•Regular•Irregular •interrupted.

•Vascularity•Scale 1-4•Vessel pattern – single/single branching/multiple focal/multiple branching/scattered/circular.

IETA4 – HR Cancer•HR cancer:

BiggerNon-uniformIrregular EMJHigh colour score

•Conc: US features change with increasing grade and stage and differ between high and low risk endoca

IETA - ConclusionsReassuring Features

NPV

Thin regular endometrium<3mm

100%

3 layer type 99%

Linear midline 99%

Single vesselwithout branching

99%

= LOW RISK MALIGNANCY

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IETA - Conclusions

•IETA nomenclature can be used to• provide consistency in describing/reporting endometrial pathology•Clarify risk of malignancy/predict histology•Facilitate multicentre research – form the basis for prospective studies•Adds to ET in assessing endometrium– ie is the whole picture

Resources1. Leone et al USOG 2010; 35: 103-112. Terms, definitions and measurements to

describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group

2. Van den Bosch AJUM 2012; 15 (1): 7-12. Ultrasound in the diagnosis of endometrial and intracavity pathology: an update

3. Sladkevicius et al USOG 2018;51:259-268. International Endometrial Tumor Analysis (IETA) terminology in women with postmenopausal bleeding and sonographicendometrial thickness> 4.5mm: agreement and reliability study

4. Epstein et al USOG 2018; 51:818-828 US characteristics of endometrial cancer as defined by IETA consensus nomenclature

5. Van den Bosch: Reporting the endometrium and intracavity lesions using the IETA terminology: results of the IETA-1 multicentric prospective study (incorporating OC12.01) Lecture delivered at ISUOG World Congress Singapore 2018

6. E Epstein: US characteristics of endometrial cancer as defined by the IETA consensus nomenclature Lecture July 2018