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Focal Intracavitary Masses Recognized with the Hyperechoic Line Sign at Endovaginal US and Characterized with Hysterosonography¹

¹ From the Department of Radiology, Mayo Medical Center, 200 First St SW, Rochester, MN 55905. Recipient of a Certificate of Merit award for a scientific exhibit at the 1997 RSNA scientific assembly. Received April 9, 1998; revision requested June 11 and received September 8; accepted September 8. Address reprint requests to K.M.D.

View larger version (140K): [in a new window]   Figure 1a.  Hyperechoic line sign. (a) Longitudinal endovaginal US scan shows a focal mass. There is a hyperechoic line (arrows) partially surrounding a thickened central endometrial complex. An underlying polyp was demonstrated with hysterosonography. (b) Drawing shows the hyperechoic line surrounding the thickened central endometrial complex.

View larger version (31K): [in a new window]   Figure 1b.  Hyperechoic line sign. (a) Longitudinal endovaginal US scan shows a focal mass. There is a hyperechoic line (arrows) partially surrounding a thickened central endometrial complex. An underlying polyp was demonstrated with hysterosonography. (b) Drawing shows the hyperechoic line surrounding the thickened central endometrial complex.

View larger version (64K): [in a new window]   Figure 2a.  Two sequential technical steps necessary to performing hysterosonography. (a) Drawing shows introduction of a catheter into the endometrial cavity with the aid of a long-ringed forceps. (b) Drawing shows replacement of the speculum by an endovaginal probe and distention of the uterine cavity with sterile saline solution.

View larger version (58K): [in a new window]   Figure 2b.  Two sequential technical steps necessary to performing hysterosonography. (a) Drawing shows introduction of a catheter into the endometrial cavity with the aid of a long-ringed forceps. (b) Drawing shows replacement of the speculum by an endovaginal probe and distention of the uterine cavity with sterile saline solution.

View larger version (24K): [in a new window]   Figure 3.  Diagram shows the proposed algorithm for diagnosis and management of endometrial disease. CEC = central endometrial complex, D&C = dilation and curettage, EMB = endometrial biopsy, MRI = MR imaging, TVS = transvaginal (endovaginal) US.

View larger version (139K): [in a new window]   Figure 4a.  Hyperechoic line related to an underlying endometrial polyp. (a) Transverse endovaginal US scan shows a hyperechoic line surrounding the central endometrial complex (arrowheads). There are also cystic spaces within the central endometrial complex (arrows). (b) Subsequently obtained longitudinal hysterosonogram shows an endometrial polyp (arrow) with a narrow attachment to the endometrium (arrowheads).

View larger version (151K): [in a new window]   Figure 4b.  Hyperechoic line related to an underlying endometrial polyp. (a) Transverse endovaginal US scan shows a hyperechoic line surrounding the central endometrial complex (arrowheads). There are also cystic spaces within the central endometrial complex (arrows). (b) Subsequently obtained longitudinal hysterosonogram shows an endometrial polyp (arrow) with a narrow attachment to the endometrium (arrowheads).

View larger version (127K): [in a new window]   Figure 5a.  Hyperechoic line related to an underlying submucosal fibroid. (a) Transverse endovaginal US scan shows a hyperechoic line partially surrounding a thickened central endometrial complex with a bland internal architecture (arrows). (b) Subsequently obtained longitudinal hysterosonogram shows a submucosal fibroid with a large intracavitary component (arrow). (c) Sagittal T2-weighted MR image shows the large intracavitary component of the fibroid (arrowhead), which is hypointense.

View larger version (124K): [in a new window]   Figure 5b.  Hyperechoic line related to an underlying submucosal fibroid. (a) Transverse endovaginal US scan shows a hyperechoic line partially surrounding a thickened central endometrial complex with a bland internal architecture (arrows). (b) Subsequently obtained longitudinal hysterosonogram shows a submucosal fibroid with a large intracavitary component (arrow). (c) Sagittal T2-weighted MR image shows the large intracavitary component of the fibroid (arrowhead), which is hypointense.

View larger version (128K): [in a new window]   Figure 5c.  Hyperechoic line related to an underlying submucosal fibroid. (a) Transverse endovaginal US scan shows a hyperechoic line partially surrounding a thickened central endometrial complex with a bland internal architecture (arrows). (b) Subsequently obtained longitudinal hysterosonogram shows a submucosal fibroid with a large intracavitary component (arrow). (c) Sagittal T2-weighted MR image shows the large intracavitary component of the fibroid (arrowhead), which is hypointense.

View larger version (139K): [in a new window]   Figure 6a.  Endometrial thickening related to diffuse endometrial carcinoma. (a) Longitudinal endovaginal US scan shows a thickened endometrium with no associated hyperechoic line surrounding the central endometrial complex. (b) Subsequently obtained longitudinal hysterosonogram shows diffusely thickened endometrium.

View larger version (130K): [in a new window]   Figure 6b.  Endometrial thickening related to diffuse endometrial carcinoma. (a) Longitudinal endovaginal US scan shows a thickened endometrium with no associated hyperechoic line surrounding the central endometrial complex. (b) Subsequently obtained longitudinal hysterosonogram shows diffusely thickened endometrium.

View larger version (123K): [in a new window]   Figure 7a.  Hysterosonographic appearance of endometrial polyps. (a) Longitudinal hysterosonogram shows an endometrial polyp with a long stalk (arrows). (b) Transverse hysterosonogram shows an endometrial polyp with central cystic changes (arrows) and a narrow attachment to the endometrium (arrowhead).

View larger version (125K): [in a new window]   Figure 7b.  Hysterosonographic appearance of endometrial polyps. (a) Longitudinal hysterosonogram shows an endometrial polyp with a long stalk (arrows). (b) Transverse hysterosonogram shows an endometrial polyp with central cystic changes (arrows) and a narrow attachment to the endometrium (arrowhead).

View larger version (119K): [in a new window]   Figure 8a.  Hysterosonographic appearance of submucosal fibroids. (a) Transverse hysterosonogram shows a submucosal fibroid with an overlying rim of endometrium (arrow). (b) Transverse hysterosonogram shows a submucosal fibroid with a similar overlying rim of endometrium (arrow).

View larger version (141K): [in a new window]   Figure 8b.  Hysterosonographic appearance of submucosal fibroids. (a) Transverse hysterosonogram shows a submucosal fibroid with an overlying rim of endometrium (arrow). (b) Transverse hysterosonogram shows a submucosal fibroid with a similar overlying rim of endometrium (arrow).

View larger version (143K): [in a new window]   Figure 9a.  Hysterosonographic appearance of asymmetric endometrial thickening. (a) Longitudinal hysterosonogram shows a focus of endometrial thickening along the anterior aspect of the endometrium (arrow). (b) Longitudinal hysterosonogram shows a focus of endometrial thickening near the fundal and posterior aspect of the endometrial cavity (arrow).

View larger version (117K): [in a new window]   Figure 9b.  Hysterosonographic appearance of asymmetric endometrial thickening. (a) Longitudinal hysterosonogram shows a focus of endometrial thickening along the anterior aspect of the endometrium (arrow). (b) Longitudinal hysterosonogram shows a focus of endometrial thickening near the fundal and posterior aspect of the endometrial cavity (arrow).

View larger version (116K): [in a new window]   Figure 10.  Hysterosonographic appearance of diffuse endometrial thickening. Longitudinal hysterosonogram shows globally thickened endometrium (arrows).