Transvaginal us and hysterosonography in postmenopausal women with breast cancer receiving tamoxifen_ correlation with hysteroscopy and pathologic study _ radiographics

Tamoxifen citrate is a selective estrogen receptor modulator that is widely used for the treatment of breast cancer ( 1). Bleeding after endometrial biopsy Recently, it has been found to prevent breast cancer in high-risk women ( 2). What is endometrial biopsy Although it acts as an antiestrogen in breast tissue, it has an estrogenic effect in the postmenopausal endometrium and myometrium. Endometrial biopsy results how long Long-term tamoxifen therapy is reported to be associated with an increased number of uterine lesions, including endometrial polyps, leiomyomas, endometrial hyperplasia, endometrial carcinoma, and adenomyosis ( 2– 5). What is an endometrial biopsy However, the beneficial effects of tamoxifen in women with breast cancer outweigh the potential endometrial adverse effects of the drug.

Transvaginal ultrasonography (US) is frequently used for endometrial assessment. Biopsy endometrial A thin, atrophic endometrium requires no further work-up. Skin biopsy results time However, a thickened central endometrial complex, with or without cystic changes, is often nonspecific.

Pipelle endometrial biopsy Hysterosonography is a useful adjunct to transvaginal US. Endometrial biopsy procedure The procedure involves the instillation of sterile saline solution into the endometrial cavity through a small catheter, under continuous US guidance. Endometrial biopsy side effects It allows identification of intracavitary lesions and focal and diffuse endometrial abnormalities and can be used to determine whether an abnormality is endometrial or subendometrial.

In this article, we review the spectrum of uterine and endometrial findings at transvaginal US and hysterosonography in postmenopausal women with breast cancer who were undergoing tamoxifen therapy. Liver biopsy recovery time Various pathologic conditions produced within the uterus by this therapy are described and illustrated. Abnormal endometrial biopsy results The limitations and potential pitfalls of both imaging techniques are also discussed.

1. Endometrial biopsy recovery Asymptomatic women who were recruited between June 1996 and March 2000 for a prospective study to evaluate transvaginal US and hysterosonography in the diagnosis of endometrial abnormality. Endometrial biopsy video They underwent transvaginal US and hysterosonography, followed within 2 weeks by office hysteroscopy (with or without directed biopsy) and Pipelle endometrial biopsy. Pain after endometrial biopsy The combined hysteroscopic-histopathologic diagnosis was the reference standard. Cervical biopsy recovery The results of this study were previously reported ( 6). Endometrial biopsy complications From this series of 117 patients, some cases were chosen as examples for this pictorial essay. Hysteroscopy endometrial biopsy There were no cases of endometrial hyperplasia or carcinoma in this group of asymptomatic women.

2. Breast biopsy recovery time Asymptomatic and symptomatic women who were referred to our institution for transvaginal US with or without hysterosonography between August 2000 and September 2001. Endometrial biopsy ivf These clinical cases were not collected as part of a prospective study and were not consecutive. Endometrial biopsy pain However, these women underwent Pipelle endometrial biopsy, operative hysteroscopy, or hysterectomy within 4 months of the US examinations, the findings of which were correlated with the final histopathologic diagnosis.

Leiomyomas, or fibroids, are common in postmenopausal women who undergo tamoxifen treatment. Breast biopsy recovery As they enlarge, submucosal fibroids may protrude into the endometrial cavity.

At transvaginal US, a submucosal fibroid may appear hypoechoic or show heterogeneous echogenicity and often demonstrate acoustic attenuation ( Fig 7a). Endometrial biopsy results time frame The fibroid may displace or distort the endometrium or cause false endometrial thickening.

At hysterosonography, a submucosal fibroid is seen as a round structure arising from the myometrium. Endometrial biopsy results interpretation The thin, overlying echogenic endometrium usually can be identified ( Fig 7b) ( 15). Endometrial biopsy results It usually appears with a wide attachment to the myometrium but may be pedunculated.

At hysteroscopy, submucosal fibroids appear as rounded masses that bulge to varying extents into the endometrial cavity. Bleeding after endometrial biopsy They may also form pedunculated tumors that appear as soft or firm polypoid masses protruding through the external cervical os or, rarely, through the vaginal introitus. What is endometrial biopsy The mucosal surface tends to be smooth and relatively flat, although it may also be congested, ulcerated, or hemorrhagic. Endometrial biopsy results how long The fibroid may be vascular but tends to be of a firmer consistency than an endometrial polyp. What is an endometrial biopsy To help differentiate fibroids from polyps, hysteroscopists often probe the lesion with the grasper to determine its consistency. Biopsy endometrial Upon resection of the fibroid, it has a typical swirl appearance similar to that of myometrium.

Tamoxifen therapy is associated with an increased risk of the development of endometrial cancer. Skin biopsy results time According to the National Surgical Adjuvant Breast and Bowel Project B-14 trial, the annual rate of endometrial cancer is 1.6 per 1,000 tamoxifen-treated women, a relative risk of 2.2 in comparison with population-based rates of endometrial cancer ( 3). Pipelle endometrial biopsy The risk of endometrial cancer increases with total duration of tamoxifen use and cumulative dose, prior estrogen replacement therapy, obesity, hypertension, and diabetes, as well as the presence of endometrial pathologic conditions before the use of tamoxifen ( 4). Endometrial biopsy procedure Most of the reported cases of endometrial cancers in tamoxifen users were in women with vaginal bleeding ( 17).

At transvaginal US, most endometrial carcinomas are either diffusely or partially echogenic ( 13). Endometrial biopsy side effects The endometrial thickening may be well defined ( Fig 9a). Liver biopsy recovery time Irregular or poorly defined endometrial thickening generally is suggestive of malignancy. Abnormal endometrial biopsy results However, in women who undergo treatment with tamoxifen, because of underlying adenomyosis, poor definition of endometrial thickening is not a helpful diagnostic feature for the diagnosis of endometrial carcinoma.

At hysterosonography, an irregular inhomogeneous mass or irregular, focally thickened endometrium is highly suggestive of endometrial carcinoma. Endometrial biopsy recovery Lack of distensibility of the endometrial cavity has been described as a potential sign of endometrial carcinoma ( 14). Endometrial biopsy video Magnetic resonance (MR) imaging is valuable in the evaluation of endometrial carcinoma, especially in cancer staging ( Fig 9b) ( 18).

At hysteroscopy, endometrial carcinomas typically look polypoid, either sessile or pedunculated. Pain after endometrial biopsy The tumor is composed of irregularly heaped-up tissue that often has a granular surface. Cervical biopsy recovery It appears opaque, dry, pale yellow or white, and friable. Endometrial biopsy complications Dark yellow areas are often conspicuous as a result of necrosis or the accumulation of lipid-filled cells of stromal origin between the neoplastic glands. Hysteroscopy endometrial biopsy Hemorrhage and ulceration are common, particularly when the tumor is poorly differentiated, and abnormal vascular patterns may be seen on the surface of the tumor.

It is not uncommon for more than one pathologic process (endometrial polyp, hyperplasia, and carcinoma) to be seen in any given patient ( Fig 10). Breast biopsy recovery time Therefore, complete evaluation of the entire endometrium is essential.

Although hysterosonography is relatively easy to perform and is usually well tolerated by women not receiving tamoxifen, the reported failure rate ranges from 8% to 37% in postmenopausal women who are receiving the drug ( 25– 28). Endometrial biopsy ivf In a recent study of asymptomatic women who were receiving tamoxifen, the overall failure rate of hysterosonography was 21.8% owing to cervical stenosis, severe pain, or both ( 6). Endometrial biopsy pain Because hysterosonography is technically difficult in some women receiving tamoxifen and often requires cervical dilation, we strongly advise that patients take oral analgesics before the procedure.

Figure 16b. Breast biopsy recovery False-positive appearance of focal endometrial thickening at hysterosonography due to endometrial cystic atrophy in a 71-year-old asymptomatic woman who had undergone tamoxifen therapy for 21 months. Endometrial biopsy results time frame (a) Sagittal transvaginal US image shows a thick heterogeneous endometrial echo (calipers) with small cystic areas. Endometrial biopsy results interpretation F = fibroid. Endometrial biopsy results (b) Sagittal hysterosonogram shows fluid (*) in the endometrial cavity, which has a lobulated outline with scattered protuberances (arrows) that are indistinguishable from focal areas of endometrial thickening. Bleeding after endometrial biopsy Hysteroscopic diagnosis was endometrial cystic atrophy; findings from endometrial biopsy were consistent with atrophic endometrium. What is endometrial biopsy F = fibroid. Endometrial biopsy results how long (Reprinted, with permission, from reference 6.)

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