Guiding histological assessment of uterine lesions using 3D in vitro ultrasonography and stereotaxis

Abstract

Objective: To compare ultrasonographic features of uterine lesions with the findings at macroscopy and microscopy.

Methods: Case series of ten consecutive women undergoing a hysterectomy for uterine pathology. A preoperative transvaginal ultrasound examination was performed. After hysterectomy, the uterus was re-evaluated by 3D in vitro ultrasonography and in vitro gel instillation sonography (iGIS). The lesion of interest was pinpointed by inserting an intramuscular injection needle using a free-hand 2D-ultrasound guided technique to focus the macroscopic and the microscopic examination by the pathologist.

Results: Adenomyosis, benign fibroids and infiltrating endometrial cancer were diagnosed in six, five and one patient, respectively. We found that iGIS improved image quality of in vitro ultrasound. There was a good correlation between the reported ultrasound features and the final histological diagnosis. Some lesions had been misinterpreted during preoperative ultrasonography or at macroscopical examination: e.g. dense myometrial vessels reported as small myometrial cysts at grey scale ultrasound examination; absence of macroscopical lesions in a case of diffuse adenomyosis.

Conclusions: In vitro 3D ultrasonography and iGIS allow for accurate mapping of uterine lesions so that ultrasound features can be matched with final histology. Our series demonstrates some pitfalls in the interpretation of sonographic and macroscopic features of uterine lesions. Stereotaxis of focal uterine lesions could focus histological assessment and reduces examination time for the pathologist.

Keywords: 3D ultrasonography; adenomyosis; iGIS; in vitro; in vitro gel instillation sonography; myoma; stereotaxis.

Figure 1

— In vitro setting: the uterus is fixed to a cardboard reniform container and immersed in a 3-liter container filled with water

Figure 2

— Case #1: (A) Two-dimensional ultrasound image of the uterus in transverse plane showing a myometrial cyst in the anterior uterine wall. (B) In vitro under water ultrasound examination of the uterus in longitudinal section: the needle (red arrows) is caudal of the myometrial cyst (circle). (C) Macroscopy: in the anterior wall we notice a cyst suggestive for adenomyosis. (D) Microscopy of the needle-marked zone, corresponding to an adenomyosis focus with a dilated cystic gland. EM=endometrium; AM= adenomyosis.

Figure 3

— Case #7: (A) Three-dimensional ultrasound imaging of the uterus in transversal section using VCI, showing the impression of the fibroid on the uterine cavity. (B) In vitro under water ultrasound examination: the needle (arrows) points to the centre of the fibroid (47x45 mm). (C) Transverse section of the hysterectomy specimen (the red arrows indicating the impression of the broid on the endometrium. (D) Microscopy of the submucosal fibroid compressing the myometrium and causing pressure atrophy of the endometrium.

Figure 4

— Case #10: (A) Two-dimensional ultrasound image of the uterus in transverse plane showing myometrial cysts in the posterior wall (red circle). (B) In vitro under water ultrasound examination in transverse plane after gel instillation (iGIS). Notice the presence of the microcysts (red circle). (C) Macroscopy: transverse section of the hysterectomy specimen showing multiple cysts (red circle). (D) Microscopic overview of the on ultrasound marked region. Notice the presence of an adenomyosis cyst (red circle).