Staging endometrial cancer: role of magnetic resonance imaging

Assessment of cervical involvement in endometrial carcinoma by hysteroscopy and directed biopsy

The objective of this study was to assess the diagnostic validity of hysteroscopy and directed biopsy for assessing cervical involvement in endometrial carcinoma. We conducted a study of 240 hysteroscopies and 44 cervical biopsies performed on 240 patients with endometrial carcinoma between 2000 and 2005. Hysteroscopy results suggested cervical involvement in 55 cases, of which only 31 were confirmed (a subtotal hysterectomy was performed in two cases, and the resection margins were examined for tumor invasion). In the 31 patients with confirmed cervical involvement, 19 of the hysteroscopy-directed biopsies were positive, 3 were negative, and 3 provided insufficient material. Six patients did not undergo biopsy. In the 24 patients with hysteroscopy false positive, 10 directed biopsies were positive and 9 were negative. Five patients did not undergo biopsy. Hysteroscopy suggested an absence of cervical involvement in 185 patients. Diagnosis was confirmed in 177 cases, and there were eight false negatives. In our case, office hysteroscopy proved to be a valid means of ruling out cervical involvement in endometrial carcinoma. However, it was not a valid means of detecting tumor involvement, even when combined with directed biopsy.

Indications for body MRI Part II: retroperitoneum, intestines and pelvis

In this article an overview is given of the present knowledge of whole body MRI, MRI of the retroperitoneum, intestines and pelvis. Recommendations are based on current literature and clinical applications in daily routine focusing on efficacy rather than cost considerations. The contribution and complementary role of MRI relative to those of its competing modalities was the most important endpoint assessed. Perfusion and functional information, as well as specific contrast agents in the area of the pelvis are still considered research indications.

PET/CT and cross sectional imaging of gynecologic malignancy

Gynecologic cancers are a common cause of morbidity and mortality in women of all ages. While many gynecologic cancers are staged clinically using the International Federation of Gynecology and Obstetrics (FIGO) staging system, imaging can be a useful adjunct to clinical staging. Cross sectional imaging techniques such as ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) have been used to detect and follow patients with gynecologic cancer. These imaging modalities can show anatomic detail and morphologic changes in the female genitourinary tract to good advantage. Positron emission tomography (PET) differs in that it shows functional information that is not easily obtained by the other cross sectional imaging techniques. The fusion of PET with CT allows anatomic localization of functional abnormalities in the female genital tract and thereby allows the detection of gross disease in many malignant conditions both within and outside the confines of the female pelvis. The utility and limitations of imaging common gynecologic tumors such as cervical, ovarian and endometrial cancer are discussed with particular emphasis on PET/CT imaging.

The role of vaginal hysterectomy in the treatment of endometrial cancer

OBJECTIVE

The objective of the study was to evaluate the role of vaginal hysterectomy in the treatment of endometrial cancer.

STUDY DESIGN

Medical records were retrospectively reviewed for patients undergoing vaginal hysterectomy for endometrial cancer at the University of South Florida. The medical data were reviewed for medical comorbidities, preoperative and postoperative diagnosis, hospital course, surgical and postoperative complications, adjuvant treatments, and follow-up.

RESULTS

Sixty-three women underwent vaginal hysterectomy for endometrial carcinoma between May 1987-September 2006. Mean age was 62.1 years and body mass index [BMI] was 40; 73% of patients were obese (BMI > or = 30 or greater). Medical comorbidities included hypertension (76.2%), cardiovascular disease (34.9%), diabetes mellitus (31.7%), and pulmonary disease (28.6%). Eighty-one percent of patients had at least 2 and 55.5% had 3 or more comorbid surgical risk factors. Postoperative complications included infection (4.8%), blood transfusion (11.1%), and prolonged hospital stay (6.3%). Of patients with intrauterine pathology, 89.5% had endometrioid adenocarcinoma.

CONCLUSION

Vaginal hysterectomy may be appropriate treatment of endometrial carcinoma for select patients.

Staging of carcinoma of the uterine cervix and endometrium

Carcinoma of the uterine cervix and endometrium are common gynecologic malignancies. Both carcinomas are staged and managed by means of the International Federation of Gynecology and Obstetrics (FIGO) staging system. In uterine cervical cancer, the FIGO staging system is determined preoperatively by limited conventional procedures. Although this system is effective for early stage disease, it has inherent inaccuracies in advanced stage diseases and does not address nodal involvement. CT and MR imaging are widely used as comprehensive imaging modalities to evaluate tumor size and extent, and nodal involvement. MR imaging is an excellent modality for depicting invasive cervical carcinoma and can provide objective measurement of tumor volume, and provides high negative predictive value for parametrial invasion and stage IVA disease. In contrast, endometrial cancer is surgically staged. Beside recognition of the important prognostic factors, including histologic subtype and grade, accurate assessment of the tumor extent on preoperative MR imaging is expected to greatly optimize surgical procedure and therapeutic strategy. Contrast-enhanced MR imaging can offer "one stop" examination for evaluating the depth of myometrial invasion cervical invasion and nodal metastases. Evaluation of myometrial invasion on MR imaging may be an alternative to gross inspection of the uterus during the surgery.

Evaluation of endometrial carcinoma on magnetic resonance imaging

Our aims were to assess diagnostic performance of T2-weighted (T2W) and dynamic gadolinium-enhanced T1-weighted (T1W) magnetic resonance imaging (MRI) in the preoperative assessment of myometrial and cervical invasion by endometrial carcinoma and to identify imaging features that predict nodal metastases. Two radiologists retrospectively reviewed MR images of 96 patients with endometrial carcinoma. Tumor size, depth of myometrial and cervical invasion, and nodal enlargement were recorded and then correlated with histology. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the identification of any myometrial invasion (superficial or deep) were 0.94, 0.50, 0.93, 0.55 on T2W and 0.92, 0.50, 0.92, 0.50 on dynamic T1W, and for deep myometrial invasion were 0.84, 0.78, 0.65, 0.91 on T2W and 0.72, 0.88, 0.72, 0.88 on dynamic T1W. The sensitivity, specificity, PPV and NPV for any cervical invasion (endocervical or stromal) were 0.65, 0.87, 0.57, 0.90 on T2W and 0.50, 0.90, 0.46, 0.92 on dynamic T1W, and for cervical stromal involvement were 0.69, 0.95, 0.69, 0.95 on T2W and 0.50, 0.96, 0.57, 0.95 on dynamic T1W. Leiomyoma or adenomyosis were seen in 73% of misdiagnosed cases. Sensitivity and specificity for the detection of nodal metastases was 66% and 73%, respectively. Fifty percent of patients with cervical invasion on MRI had nodal metastases. In conclusion, MRI has a high sensitivity for detecting myometrial invasion and a high NPV for deep invasion. MRI has a high specificity and NPV for detecting cervical invasion. Dynamic enhancement did not improve diagnostic performance. MRI may allow accurate categorization of cases into low- or high-risk groups ensuring suitable extent of surgery and adjuvant therapy

MR Imaging of Malignant Uterine Disease

The role of MR imaging in the diagnosis and management of patients who have uterine malignancy continues to evolve. MR imaging has been shown to be effective for preoperative characterization and staging of endometrial and cervical carcinoma, and for the evaluation of posttreatment changes and recurrent disease. Because of its potential to provide detailed information about local extent and metastatic disease, MR imaging has enormous potential to help triage patients to appropriate treatment groups and provide imaging surveillance after therapy. This article reviews the MR imaging technique and the imaging characteristics of malignant disease of the uterine corpus and cervix.

MR staging of endometrial carcinoma

Endometrial cancer is the second most common gynaecological malignancy. The usual presentation with post-menopausal bleeding results in an early diagnosis in most cases and thus there is opportunity for cure. Magnetic resonance (MR) imaging is pivotal in the decision-making process regarding treatment options. We present a review of the magnetic resonance (MR) findings to illustrate its role in the staging of endometrial cancer.

Pitfalls in staging uterine neoplasm with imaging: a review

This review analyzes current pitfalls in pretreatment staging of endometrial and cervical carcinoma with magnetic resonance imaging (MRI) based on a critical review of the literature. Technical, patient, and tumor-related characteristics were analyzed to improve further staging of uterine neoplasm with MRI. For endometrial carcinoma staging, contrast-enhanced dynamic imaging appears essential to avoid false-positive findings for deep myometrial invasion by better delineating tumor from normal myometrium. However, leiomyomas, adenomyosis, and grade 3 tumors provide difficulties in staging for pathologists and radiologists. Slice orientation perpendicular to the long axis of the cervical channel might improve false-negative findings for deep stromal invasion on T2-weighted images in endometrial and cervical cancer. Contrast-enhanced sequences do not improve diagnosis of parametrial or vaginal invasion in cervical cancer. Assessment of lymph node invasion by any imaging modality has limited sensitivity in detecting lymph node metastasis smaller than 5 mm. Knowledge of diagnostic criteria is critical to avoid false-negative findings for bladder wall invasion. Higher spatial resolution with dedicated multichannel pelvic phase array coils, smaller fields of view and section thickness, and careful comparison of T2-weighted and contrast-enhanced sequences are strategies that might avoid misinterpretation of pelvic MRI in staging uterine neoplasm.

MR imaging in endometrial carcinoma as a diagnostic tool for the absence of myometrial invasion

OBJECTIVE

To evaluate whether magnetic resonance imaging (MRI) is a reliable modality for verifying preoperative diagnosis of stage IA endometrial carcinoma.

METHODS

One hundred sixteen patients with endometrial carcinoma underwent preoperative pelvic non-contrast T2-weighted or dynamic MRI. We compared the interpretations of the MRI results with the histological findings of the resected uterus.

RESULTS

In assessing the depth of myometrial invasion, the accuracy of MRI was 62.1%. As to the presence of cancerous myometrial invasion, the positive predictive value was 94.4% as high as previously reported by other institutions. However, the negative predictive value, the probability of the absence of myometrial invasion, was only 42.2%. Even when dynamic study was applied to the patient, the value only improved up to 60.0%.

CONCLUSION

MRI has a definite advantage in evaluating deep myometrial invasion, but not the absence of invasion. We should take precautions against the risk of under-diagnosis when selecting stage IA endometrial carcinoma with use of MRI to preserve fertility or to eliminate lymphadenectomy.

In vivo perfusion, T1, and T2 measurements in the female pelvis during the normal menstrual cycle: A feasibility study

PURPOSE

To quantify T(1), T(2), and regional tissue perfusion in uterine tissues, with MR imaging in clinically feasible imaging times, using echo planar imaging (EPI) techniques over a single menstrual cycle.

MATERIALS AND METHODS

A total of 24 healthy ovulating women were scanned; however, complete data sets through the menstrual cycle were not obtained from all women. Three scans were performed to coincide prospectively with the follicular, periovulatory, and luteal phases of the cycle. T(1) and perfusion were measured simultaneously using flow alternating inversion recovery (FAIR), while T(2) was measured using a single Hahn spin-echo (SE) EPI sequence.

RESULTS

Between the follicular and periovulatory phases, statistically significant increases (P < 0.05) were seen for the T(2) of the endometrium and perfusion of the myometrium as well as the T(2)/T(1) ratio for both endometrium and myometrium. A statistically significant decrease was seen in the endometrial T(2) between the periovulatory and luteal phases of the cycle. Tissue differentiation was achieved using the parameters measured, with T(1) and T(2) being statistically greater for the endometrium than for the myometrium, and endometrial perfusion being statistically lower than myometrial perfusion.

CONCLUSION

These results show the feasibility of using these techniques to measure T(1), T(2), and perfusion in uterine tissues and of extending this work to study pathological conditions.

Magnetic resonance imaging in the characterization of pelvic masses

Female pelvic masses most commonly arise from the reproductive tract, although masses may arise from other structures in the pelvis, such as the gastrointestinal or urinary tracts. The evaluation of a pelvic mass often begins with the physical exam and proceeds to ultrasound, computed tomography, or magnetic resonance imaging. Each of these modalities has a role in the work-up of pelvic masses and each modality has inherent advantages and disadvantages. The focus of this article is to demonstrate the imaging features and role of MRI, in contrast to CT, for detecting, characterizing, and staging pelvic masses. The differential diagnosis for pelvic masses is extremely broad. Clinical history, precise anatomical localization, and MR imaging characterization can significantly narrow the differential diagnosis. With recent advances in therapeutic strategies, a non-invasive, preoperative diagnosis is highly desirable to suggest prognosis and to tailor the treatment approach.

Endometrial cancer: magnetic resonance imaging

Carcinoma of the endometrium is the most common invasive gynecologic malignancy of the female genital tract. Clinically, patients with endometrial carcinoma present with abnormal uterine bleeding. The role of magnetic resonance imaging (MRI) in endometrial carcinoma is disease staging and treatment planning. MRI has been shown to be the most valuable imaging mod-ality in this task, compared with endovaginal ultrasound and computed tomography, because of its intrinsic contrast resolution and multiplanar capability. MRI protocol includes axial T1-weighted images; axial, sagittal, and coronal T2-weighted images; and dynamic gadolinium-enhanced T1-weighted imaging. MR examination is usually performed in the supine position with a phased array multicoil using a four-coil configuration. Endometrial carcinoma is isointense with the normal endometrium and myometrium on noncontrast T1-weighted images and has a variable appearance on T2-weighted images demonstrating heterogeneous signal intensity. The appearance of noninvasive endometrial carcinoma on MRI is characterized by a normal or thickened endometrium, with an intact junctional zone and a sharp tumor-myometrium interface. Invasive endometrial carcinoma is characterized disruption or irregularity of the junctional zone by intermediate signal intensity mass on T2-weighted images. Invasion of the cervical stroma is diagnosed when the low signal intensity cervical stroma is disrupted by the higher signal intensity endometrial carcinoma. MRI in endometrial carcinoma performs better than other imaging modalities in disease staging and treatment planning. Further, the accuracy and the cost of MRI are equivalent to those of surgical staging.

Clinical utility of magnetic resonance imaging and the preoperative identification of low risk endometrial cancer

BACKGROUND

Magnetic resonance imaging (MRI) is reported to offer the best imaging of local disease in endometrial cancer. We audited MRI scans to identify their clinical utility, particularly in the preoperative identification of 'low risk' endometrial cancer (grade one or two endometrioid tumours confined to the inner half of the myometrium).

AIM

To correlate histological and MRI findings and to establish our ability to preoperatively identify women with 'low risk' tumours.

STUDY DESIGN

A retrospective audit of MRI scans in women with a new diagnosis of endometrial cancer from July 1998 to November 2002. Radiology and pathology reports and surgical staging data were extracted. Independently a team of radiologists reviewed MRI films and the findings were compared to pathology.

RESULTS

Thirty-nine patients were included. Only 10% of original reports contained all the clinically relevant information. On review, the sensitivity for the detection of myometrial invasion was 90%, specificity 71%, positive predictive value (PPV) 93% and negative predictive value (NPV) 63%. For the detection of deep invasion, sensitivity was 56%, specificity 77%, PPV 64% and NPV 71%. All women with grade one or two tumours having no invasion or grade one having superficial invasion detected on MRI had pathological 'low risk' disease.

CONCLUSIONS

Magnetic resonance imaging scans as reported offered limited clinical benefit. Attention needs to be given to MRI sequencing and reporting protocols. If the review results can be confirmed by prospective studies, MRI offers significant clinical utility in the identification of low risk patients and their surgical treatment planning.

Conservative treatment may be beneficial for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma

OBJECTIVE

To evaluate whether an alternative treatment to radical hysterectomy exists for young women with endometrial adenocarcinoma.

DESIGN

A review of the literature (70 articles) plus personal results.

SETTING

University hospital.

PATIENT(S)

Women with atypical endometrial hyperplasia or adenocarcinoma.

MAIN OUTCOME MEASURE(S)

The recurrence rate and the pregnancy rate after conservative therapy.

CONCLUSION(S)

Conservative treatment of well-differentiated stage I endometrial adenocarcinoma can be considered in young patients, with close surveillance to diagnose any possible recurrence.

[Endometrial cancer: what's new?]

OBJECTIVES

New and much debated data of the endometrial cancer concerning the preoperative assessment of myometrial invasion, the surgical staging, and the adjuvant treatment.

PATIENTS AND METHODS

Medline (1998-2002): searching for "endometrial carcinoma".

RESULTS

The pap smears are useful when it is difficult to have a transvaginal ultrasonography or an MRI. We can perform the pap smears and the endometrial biopsy in the clinic. If a patient has pap smears with malignant cells or elevated preoperative CA 125, it probably is a cancer with poor prognostic factors. Surgical staging with abdominal and node evaluation is necessary. The MRI seems to be the best preoperative imaging because we have information about adnexal and abdominal metastases, pelvic or aortic nodes and the invasion of the myometrium. So it gives us information on the surgical route, and provides indication for a lymphadenectomy. The surgical staging is a part of the treatment of the endometrial cancer: an exploration of the peritoneal cavity, a pelvic lymphadenectomy, a para-aortic lymphadenectomy if the pelvic nodes are positive or if there are factors of bad prognosis (deep stage IC, grade 3, adnexal or abdominal involvement, serous carcinoma of the endometrium). It can be performed if technical conditions are correct. The adjuvant teletherapy in the documented stage IpN0 (surgical staging with pelvic lymphadenectomy) does not seem to be necessary. But we can perform an adjuvant brachytherapy (high-dose rate if it is possible) in patients with a high local recurrence (stage IC, stage I with grade 3, stage IB grade 2).

CONCLUSION

The preoperative MRI is useful choosing the surgical approach, and the depth of the myometrial invasion, which can be an indication for a pelvic lymphadenectomy. The surgical staging must be a part of the treatment of the endometrial cancer. So the adjuvant teletherapy in patients with stage IpN0 documented should not be used.

Cellular environment of metabolites and a metabonomic study of tamoxifen in endometrial cells using gradient high resolution magic angle spinning 1H NMR spectroscopy

High resolution magic angle spinning (HRMAS) 1H NMR spectroscopy was used to metabolically characterise Ishikawa cells, a human cell line derived from endometrial adenocarcinoma. The spectra obtained had well-resolved resonances from the nucleotide derivatives of uridine and adenosine. Using a combination of diffusion- and relaxation-weighted spectroscopy, the cellular environment of key metabolites previously identified as related to cell growth was also investigated. As Ishikawa cells are hormone-responsive, the metabolic action of tamoxifen, a selective estrogen receptor modulator (SERM), was also investigated. Cells were exposed to 5, 1 and 0.1 microM tamoxifen. Using the statistical regression technique of prediction to latent structures by partial least squares, a predictive model was built modelling the metabolic profile of the cells against exposure to tamoxifen. These spectral changes were characterised by increased resonance intensities from ethanolamine (3.26 ppm), glucose (3.34-3.94 ppm), glutamate (2.14, 2.32 ppm), tyrosine (7.24 ppm), uridine (7.85 ppm) and adenosine (8.20 ppm), and a relative decrease in contributions from myo-inositol resonances (3.30, 3.62, 3.55 ppm). The nucleotide changes suggest that tamoxifen affects RNA transcription, while the changes in ethanolamine and myo-inositol concentrations are indicative of cell membrane turnover.