Kasr El Aini Journal of Surgery VOL., 10 , NO 2 May 2009 57 The Impact of Two & Three Dimensions Transvaginal Ultrasonography and Color Doppler on the Surgical Management of Endometrial Carcinoma Ibrahim Fakhr, MD, MRCS 1 , Nawara Hasheesh, MD 2 , Ayman Marzouk, MD 2 , Nermeen Abou-Salem, MD 2 , Sahar Tabakh MD 3 1 Surgical Oncology Department - National Cancer Institute (NCI), 2 Obstetrics & Gynecology Department, 3 Pathology department, Cairo University ABSTRACT The purpose of this study was to evaluate the accuracy of Two and Three Dimensions Trans-Vaginal Ultrasound (2D & 3D-TVUS) in the preoperative assessment of the depth of myometrial invasion in endometrial carcinoma and to compare them with the histopathologic findings in these patients. The study combined color Doppler to examine its usefulness in predicting tumor myoinvasion. Twenty-seven patients with endometrial carcinoma were prospectively evaluated with 2D, 3D-TVUS and Color Doppler to assess the depth of myometrial invasion. Intraoperative gross visual inspection was also performed. (The data were analyzed twice; myometrial invasion defined once as absent, less than 50% or 50% or greater and the second time as less than 50% or 50% or greater). Imaging findings, gross visual inspection and the final histologic results were compared and correlated. The accuracy in assigning the correct International Federation of Gynecology & Obstetrics (FIGO) stage for 2D, 3D-TVUS and Gross Visual Inspection (GVI) was 77%, 85%, and 59% respectively, however when myometrial invasion was defined as less than 50% or 50% or greater, accuracy improved to 92%, 96% and 77%. Intratumoral blood flow analysis assessed by Color Doppler correlated significantly with myometrial invasion. Significantly lower Resistance Index (RI) was found in deeply infiltrating tumors (0.39 vs 0.56; p<0.001). Twenty-three radical type III hysterectomies with pelvic and para-aortic lymph nodes dissection (LND) operations were done. An upgrade of three cases from stage IC to IIIC occurred as a result of this lymph node dissection (LND) staging. For assessment of the depth of myometrial invasion in endometrial carcinoma TVUS provides acceptable accuracy compared to histologic examination. Three-D-TVUS is slightly superior to 2D-TVUS especially in superficial myoinvasion and intraluminal lesions but the difference between them is not statistically significant. Combined morphologic and vascular imaging improves preoperative assessment of the clinical stage of the disease. LND remains an indispensable tool for accurate and complete staging in high risk patients. Keywords: Endometrial cancer, endometrial thickness, 2D-TVUS, 3D-TVUS, Doppler, LND INTRODUCTION Endometrial Carcinoma (EC) is the fourth cancer in females (1) and the most common malignant neoplasm of the female genital tract (2) . The prognosis and treatment of the disease are based mainly on histological type, tumor grade, depth of myometrial invasion, cervical extension, and the presence of nodal metastases (3, 4) . The depth of myometrial invasion is one of the most important aspects in staging and prognosis because the prevalence of pelvic and para-aortic nodal metastases is directly related to this parameter (5,6) . The revised staging classification of the International Federation of Gynecology and Obstetrics (FIGO) for endometrial carcinoma considers three degrees of myometrial invasion: stage IA, no invasion; stage IB, invasion of the inner half of the myometrium and stage IC, invasion of the outer half of the myometrium. The frequency of nodal metastases was reported to be around 3% if the myometrium was not invaded (7) . This frequency rose to 40% when the invasion was deep (8) . In grade 1 tumors, pelvic lymph nodes dissection (PLND) is not necessary with superficial myometrial invasion since nodal metastasis is only rarely present. These patients can primarily be treated with total abdominal hysterectomy and bilateral salpingo-