Images in Women's Health

Cervical Adenocarcinoma and Endometrial Biopsy-Site Hematoma

Carrie Swartz, MD; Kara Danner, MD; Rebecca Hall, PhD

CASE HISTORY

An 86-year-old woman, gravida 2, para 2, presented with recent Papanicolaou findings of atypical glandular cells. She had a history of breast cancer 7 years previously, followed by adjuvant chemotherapy with tamoxifen.

On clinical examination, the patient was found to have a Òbulky" uterus comparable to 10 weeks' gestation in size. Vaginal ultrasonography revealed a complex, markedly thickened endometrium.

An attempt to perform endometrial biopsy (EMB) in the clinic failed, so the patient was taken to the operating room. Sampling was accomplished under ultrasonographic guidance, which confirmed a complex, heterogeneous area in the posterior endometrium measuring 20 x 30 mm. Scant tissue was obtained via EMB, with pathologic evaluation revealing atypical and complex villoglandular proliferation of the endometrium.

The patient was referred to a gynecologic oncologist, and underwent repeat EMB and ultrasonography. Pathologic findings again indicated complex hyperplasia with atypia. Ultrasonography showed a uterus of normal size and echogenicity, but with a poorly delineated myometrial-endometrial interface. The endometrial thickness was unchanged and indistinct. The echo pattern was heterogeneous, complex, and primarily solid. Cystic components were also observed, mostly within the endometrial fundus (Figure 1).

Figure not available online

FIGURE 1. Midline sagittal image reveals normal uterine contour with an indistinct myometrial-endometrial interface. The endometrial echo pattern is heterogeneous and 12.2 mm thick, with an irregular contour. Courtesy of Carrie Swartz, MD; Kara Danner, MD; Rebecca Hall, PhD.

As Doppler assessment revealed a paucity of color-flow pattern in the endometrial cavity, a resistive index could not be obtained. A round, 1.64 x 1.5 cm lesion was noted at the uterine-cervical interface, with posteroinferior layering of solid components against nondependent debris; this was thought to be an iatrogenic, EMB-induced hematoma (Figure 2).

Figure not available online

FIGURE 2. Postendometrial biopsy-site hematoma with Óyin-yangÓ comparative views of hemorrhage layer-layering (sagittal and transverse views). With the vaginal transducer in the sagittal plane, the left side of the screen is anterior and the right is posterior. In both the sagittal and transverse planes, the top of the screen is inferior and the bottom is superior; therefore, the fluid-fluid appearance demonstrates gravity-dependent layering. Courtesy of Carrie Swartz, MD; Kara Danner, MD; Rebecca Hall, PhD.

The patient was admitted for exploratory laparotomy and total abdominal hysterectomy/bilateral salpingo-oophorectomy. Analysis of the surgical specimens revealed adenocarcinoma in situ of the endocervix, extending to the lower uterine segment. A benign endometrial polyp was also noted. No abnormalities were found in the patient's ovaries and fallopian tubes. The patient recovered with no postoperative complications.

back to top

DISCUSSION

To avoid unnecessary EMB, the ultrasonographic criterion for endometrial thickness has been set at > 5 mm in women with suspected endometrial carcinoma. 1,2 In a study of 1,110 subjects with postmenopausal bleeding, patients with endometrial thickness > 8 mm were most likely to have endometrial pathology.3 In the presence of pathology, loss of the distinct myometrial-endometrial interface makes it difficult to distinguish the true endometrial border. All imaging specialties describe hematoma formation at biopsy sites, and recognition of preprocedure versus postprocedure appearance should be a part of the specialistÕs diagnostic capabilities.4

back to top

CONCLUSION

This case illustrates the importance of applying endometrialthickness criteria in women with abnormal uterine bleeding and/or pathologic uterine findings. Although EMB proved difficult in this patient and ultimately resulted in an iatrogenic hematoma, the procedure was justified in view of the need to carefully weigh the risk of major surgery in an elderly woman.

back to top

Carrie Swartz, MD, is resident physician; Kara Danner, MD, is resident physician; and Rebecca Hall, PhD, is associate professor and Resident Ultrasound Program clinical director. All are at the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

References

1. Dubinsky TJ. Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound. 2004;32(7):348-353.
2. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004;24(5):558-565.
3. Granberg S, Ylostalo P, Wikland M, Karlsson B. Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding. Maturitas. 1997;27(1):35-40.
4. Urrutia M, Mergo PJ, Ros LH, Torres GM, Ros PR. Cystic masses of the spleen: radiologic-pathologic correlation. Radiographics. 1996;16(1):107-129.

back to top