Feasibility of a reduced field-of-view diffusion-weighted (rFOV) sequence in assessment of myometrial invasion in patients with clinical FIGO stage I endometrial cancer

Multiparametric magnetic resonance imaging-based assessment of the effect of adenomyosis on determining the depth of myometrial invasion in endometrial cancer

Background

Accurate preoperative diagnosis of endometrial cancer (EC) with deep myometrial invasion (DMI) is critical to deciding whether to perform lymphadenectomy. However, the presence of adenomyosis makes distinguishing DMI from superficial myometrial invasion (SMI) on magnetic resonance imaging (MRI) challenging. We aimed to evaluate the accuracy of multiparametric MRI (mpMRI) in diagnosing DMI in EC coexisting with adenomyosis (EC-A) compared with EC without coexisting adenomyosis and to evaluate the effect of different adenomyosis subtypes on myometrial invasion (MI) depth in EC.

Methods

Patients with histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stage I EC who underwent preoperative MRI were consecutively included in this 2-center retrospective study. Institution 1 was searched from January 2017 to November 2022 and institution 2 was searched from June 2017 to March 2021. Patients were divided into 2 groups: group A, patients with EC-A; group B, EC patients without coexisting adenomyosis, matched 1:2 according to age ±5 years and tumor grade. A senior radiologist assessed the MRI adenomyosis classification in group A. Then, 2 radiologists (R1/R2) independently interpreted T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), T1-weighted contrast-enhanced (T1CE), and a combination of all images (mpMRI) respectively, and then assessed MI depth. Accuracy, sensitivity, specificity, and the areas under the receiver operating curve (AUC) were calculated. The chi-square test was used to compare the accuracy of diagnosing DMI. Interobserver agreement was evaluated using the Kappa test.

Results

A total of 70 cases in group A and 140 cases in group B were included. The accuracy, sensitivity, and specificity of consensus were 94.3% [95% confidence interval (CI): 88.9-99.7%] vs. 92.1% (95% CI: 87.7-96.6%), 60.0% (95% CI: 17-92.7%) vs. 86.7% (95% CI: 68.4-95.6%), and 96.9% (95% CI: 88.4-95.5%) vs. 93.6% (95% CI: 86.8-97.2%) (group A vs. group B, respectively). There was no significant difference in the diagnostic accuracy of DMI on each sequence between the groups (Reviewer 1/Reviewer 2): PT2WI=0.14/0.17, PDWI=0.50/0.33, PT1CE=0.90/0.18, PmpMRI=0.50/0.37. The AUC for T2WI, DWI, T1CE, and mpMRI (Reviewer 1/Reviewer 2), respectively, were 0.54 (95% CI: 0.42-0.66)/0.78 (95% CI: 0.67-0.87), 0.63 (95% CI: 0.50-0.74)/0.77 (95% CI: 0.65-0.86), 0.69 (95% CI: 0.57-0.80)/0.79 (95% CI: 0.68-0.88), and 0.91 (95% CI: 0.82-0.97)/0.89 (95% CI: 0.79-0.95) (group A) and 0.83 (95% CI: 0.76-0.89)/0.85 (95% CI: 0.78-0.90), 0.83 (95% CI: 0.76-0.89)/0.86 (95% CI: 0.79-0.91), 0.88 (95% CI: 0.82-0.93)/0.86 (95% CI: 0.80-0.92), and 0.91 (95% CI: 0.85-0.95)/0.87 (95% CI: 0.80-0.92) (group B). Interobserver agreement was highest with mpMRI [κ=0.387/0.695 (case/control)]. The consensus results of MRI categorization of adenomyosis revealed no significant difference in the accuracy of diagnosing DMI by adenomyosis subtype (Pspatial relationship>0.99, Paffected area=0.52, Paffected pattern=0.58, Paffected size>0.99).

Conclusions

The presence of adenomyosis or adenomyosis subtype had no significant effect on the interpretation of the depth of MI. T1CE can increase the contrast between adenomyosis and cancer foci; therefore, the information provided by T1CE should be valued.

Preoperative Imaging Evaluation of Endometrial Cancer in FIGO 2023

The staging of endometrial cancer is based on the International Federation of Gynecology and Obstetrics (FIGO) staging system according to the examination of surgical specimens, and has revised in 2023, 14 years after its last revision in 2009. Molecular and histological classification has incorporated to new FIGO system reflecting the biological behavior and prognosis of endometrial cancer. Nonetheless, the basic role of imaging modalities including ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography, as a preoperative assessment of the tumor extension and also the evaluation points in CT and MRI imaging are not changed, other than several point of local tumor extension. In the field of radiology, it has also undergone remarkable advancement through the rapid progress of computational technology. The application of deep learning reconstruction techniques contributes the benefits of shorter acquisition time or higher quality. Radiomics, which extract various quantitative features from the images, is also expected to have the potential for the quantitative prediction of risk factors such as histological types and lymphovascular space invasion, which is newly included in the new FIGO system. This article reviews the preoperative imaging diagnosis in new FIGO system and recent advances in imaging analysis and their clinical contributions in endometrial cancer. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 3.

Targeting the GTV in medically inoperable endometrial cancer using brachytherapy

PURPOSE

We aimed to determine the relationship between gross tumor volume (GTV) dose and tumor control in women with medically inoperable endometrial cancer, and to demonstrate the feasibility of targeting a GTV-focused volume using imaged-guided brachytherapy.

METHODS AND MATERIALS

An endometrial cancer database was used to identify patients. Treatment plans were reviewed to determine doses to GTV, clinical target volume (CTV), and OARs. Uterine recurrence-free survival was evaluated as a function of CTV and GTV doses. Brachytherapy was replanned with a goal of GTV D98 EQD₂ ≥ 80 Gy, without regard for coverage of the uninvolved uterus and while respecting OAR dose constraints.

RESULTS

Fifty-four patients were identified. In the delivered plans, GTV D90 EQD₂ ≥ 80 Gy was achieved in 36 (81.8%) patients. Uterine recurrence-free survival was 100% in patients with GTV D90 EQD₂ ≥ 80 Gy and 66.7% in patients with EQD₂ < 80 Gy (p = 0.001). On GTV-only replans, GTV D98 EQD₂ ≥ 80 Gy was achieved in 39 (88.6%) patients. Mean D_2cc was lower for bladder (47.1 Gy vs. 73.0 Gy, p < 0.001), and sigmoid (47.0 Gy vs. 58.0 Gy, p = 0.007) on GTV-only replans compared to delivered plans. Bladder D_2cc was ≥ 80 Gy in 11 (25.0%) delivered plans and four (9.1%) GTV-only replans (p = 0.043). Sigmoid D_2cc was ≥ 65 Gy in 20 (45.4%) delivered plans and 10 (22.7%) GTV-only replans (p = 0.021).

CONCLUSIONS

OAR dose constraints should be prioritized over CTV coverage if GTV coverage is sufficient. Prospective evaluation of image-guided brachytherapy to a reduced, GTV-focused volume is warranted.

Development and Validation of an MRI-based Radiomics Nomogram for Assessing Deep Myometrial Invasion in Early Stage Endometrial Adenocarcinoma

RATIONALE AND OBJECTIVES

To establish a radiomics nomogram for detecting deep myometrial invasion (DMI) in early stage endometrioid adenocarcinoma (EAC).

MATERIALS AND METHODS

A total of 266 patients with stage I EAC were divided into training (n = 185) and test groups (n = 81). Logistic regression were used to identify clinical predictors. Radiomics features were extracted and selected from multiparameter MR images. The important clinical factors and radiomics features were integrated into a nomogram. A receiver operating characteristic curve was used to evaluate the nomogram. Two radiologists evaluated MR images with or without the help of the nomogram to detect DMI. The clinical benefit of using the nomogram was evaluated by decision curve analysis (DCA) and by calculating net reclassification index (NRI) and integrated discrimination index (IDI).

RESULTS

Age and CA125 were independent clinical predictors. The area under the curves of the clinical parameters, radiomics signature and nomogram in evaluating DMI were 0.744, 0.869 and 0.883, respectively. The accuracies of the two radiologists increased from 79.0% and 80.2% to 90.1% and 92.5% when they used the nomogram. The NRI of the two radiologists were 0.262 and 0.318, and the IDI were 0.322 and 0.405. According to DCA, the nomogram showed a higher net benefit than the radiomics signature or unaided radiologists. Cross-validation showed the outcome of radiomics analysis may not be influenced by changes in field strength.

CONCLUSION

The radiomics nomogram based on radiomics features and clinical factors can help radiologists evaluate DMI and improve their accuracy in predicting DMI in early stage EAC.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

Evaluation of the Depth of Myometrial Invasion of Endometrial Carcinoma: Comparison of Orthogonal Pelvis-axial Contrast-enhanced and Uterus-axial Dynamic Contrast-enhanced MRI Protocols

RATIONALE AND OBJECTIVES

To compare the diagnostic performance of orthogonal pelvis-axial (OPA) contrast-enhanced (CE) and orthogonal uterus-axial (OUA) dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) protocols in assessing the depth of myometrial invasion (MI) of endometrial carcinoma (EC).

MATERIALS AND METHODS

Preoperative MRI of 398 consecutive EC patients (197 patients with OPA CE-MRI protocol and 201 patients with OUA DCE-MRI protocol) was analyzed. Two radiologists independently interpreted the depth of MI, with postoperative histopathology as the reference standard. The chi-square test, Fisher's exact test, and receiver operating characteristic curve analysis were used for diagnostic performance comparison.

RESULTS

OUA DCE-MRI showed a significantly larger area under the curve than OPA CE-MRI in detecting the presence of MI for radiologist 1 (0.71 versus 0.49, p < 0.05) but not for radiologist 2 or deep MI (all p > 0.05). Compared to OPA CE-MRI, OUA DCE-MRI significantly improved the diagnostic accuracy of non-MI and superficial MI (radiologist 1: 45.5% versus 0 and 88.7% versus 86.4%, p = 0.045 and 0.567, respectively; radiologist 2: 45.5% versus 12.5% and 88.7% versus 78.8%, p = 0.177 and 0.027, respectively) and of EC with adenomyosis/submucous myomas, cornual tumor, and antero-posterior diameter ≤ 10 mm (radiologist 1: 86.4% versus 71.4%, 91.2% versus 67.7%, and 90.1% versus 81.1%, p = 0.048, 0.018, and 0.081, respectively; radiologist 2: 86.4% versus 64.3%, 88.2% versus 64.5%, and 87.0% versus 71.6%, p = 0.006, 0.023, and 0.019, respectively).

CONCLUSION

The OUA DCE-MRI protocol was superior to the OPA CE-MRI protocol in assessing the depth of MI of EC.

Diffusion-weighted imaging versus dynamic contrast-enhanced imaging for pre-operative diagnosis of deep myometrial invasion in endometrial cancer: A meta-analysis

PURPOSE

This study investigates the differences in diagnostic performance between diffuse-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE), either alone or in combination with T2-weighted imaging (T2WI), for diagnosing deep myometrial invasion (dMI) of endometrial cancers (EC).

METHODS

We performed a comprehensive search for published studies comparing DWI and DCE for preoperatively diagnosing dMI of EC. The overall diagnostic accuracy of each test was calculated using the areas under the summary receiver operating characteristic curves (AUCs). The sensitivities and specificities were compared using bivariate meta-regression.

RESULTS

Pooled analysis of nineteen studies with 961 patients (main group) showed that DWI had a larger AUC (0.943, 95% confidence interval (CI) = 0.921-0.967) than DCE (0.922, 95% CI = 0.893-0.953). For the subgroup comprising 7 studies, DWI combined with T2WI and DCE combined with T2WI showed AUCs of 0.959 (95% CI, 0.932-0.986) and 0.929 (95% CI, 0.847-1.000), respectively. None of the differences in AUCs were statistically significant. All comparisons of the sensitivities and specificities of the main group and subgroup also showed no significant differences.

CONCLUSION

This meta-analysis found no significant difference in diagnostic performance between DWI and DCE for diagnosis of dMI in EC. DWI may be preferred for its ease of use in clinical practice.

Transforming acidic coiled-coil protein-3: a novel marker for differential diagnosis and prognosis prediction in endocervical adenocarcinoma

Background

Endocervical adenocarcinoma (ECA) is further classified as human papillomavirus (HPV)-associated (HPVA) or non-HPVA (NHPVA), per the International Endocervical Adenocarcinoma Criteria and Classification (IECC). HPVA is a glandular tumor with stromal invasion and/or exophytic expansile-type invasion, associated with the typical molecular characteristics of high-risk HPV (HR-HPV) infection. Transforming acidic coiled-coil protein-3 (TACC3),an oncogene that is frequently abnormally expressed,represents a vital biomarker for multiple human malignancies. This study aimed to examine the role of TACC3 in the diagnosis and prognosis of ECA.

Methods

We analyzed 264 patients with ECA who underwent surgical resection, classifying their tumors into HPVA and NHPVA subtypes. The expression levels of TACC3, P16, MLH1, PMS2, MSH2, MSH6 and Ki-67 in tumors were evaluated by tissue microarray using immunohistochemistry (IHC). HPV subtypes were identified in formalin-fixed paraffin-embedded (FFPE) ECA tissues by the polymerase chain reaction (PCR).

Results

ECA samples showed increased TACC3 expression relative to adjacent non-carcinoma samples. TACC3 expression was higher in HPVA than in NHPA. In the HPVA subtype, high TACC3 expression was significantly correlated with P16-positive, Ki-67-high expression. Furthermore, TACC3 levels were significantly related to tumor histological type (P = 0.006), nerve invasion (P = 0.003), differentiation (P = 0.004), surgical margin (P = 0.012), parametrium invasion (P = 0.040), P16 expression (P < 0.001), and Ki-67 (P = 0.004). Additionally, Kaplan–Meier analysis showed that TACC3 upregulation was associated with poor overall survival (OS, P = 0.001), disease-free survival (DFS, P < 0.001), and recurrence survival (P < 0.001). Multivariate analysis indicated that elevated TACC3 expression served as a marker to independently predict ECA prognosis. ROC curve analyses indicated that TACC3, P16, and HPV subtypes showed similar utility for distinguishing HPVA from NHPVA, with areas under the ROC curves of 0.640, 0.649, and 0.675, respectively. The combination of TACC3 and HPV subtypes improved the diagnostic performance of ECA compared with TACC3, P16, and HPV subtypes alone.

Conclusions

Taken together, our findings identify that TACC3 is a promising complementary biomarker for diagnosis and prognosis for patients with ECA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10020-021-00298-z.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.

Evaluation of amide proton transfer-weighted imaging for endometrial carcinoma histological features: a comparative study with diffusion kurtosis imaging

OBJECTIVES

To investigate whether amide proton transfer-weighted imaging (APTWI) and diffusion kurtosis imaging (DKI) can be used to evaluate endometrial carcinoma (EC) in terms of clinical type, histological grade, subtype, and Ki-67 index.

METHODS

Eighty-eight patients with EC underwent pelvic DKI and APTWI. The non-Gaussian diffusion coefficient (D_app), apparent kurtosis coefficient (K_app), and magnetization transfer ratio asymmetry (MTRasym (3.5 ppm)) were calculated and compared based on the clinical type (type I, II), histological grade (high- and low-grade), and subtype (endometrioid adenocarcinoma (EA) and non-EA). Correlation coefficients were calculated for each parameter with histological grades and the Ki-67 index.

RESULTS

The MTRasym (3.5 ppm) and K_app values were higher in the type II group and high-grade group than in the type I and low-grade groups, respectively, while the D_app values were lower in the type I and low-grade groups, respectively (all p < 0.05). The K_app value was higher in the EA group than in the non-EA group (p = 0.022). The K_app value was the only independent predictor for the histological grade of EA and the clinical type of EC. The AUC (DKI) was higher than the AUC (APTWI) in the identification of type I and II EC and high- and low-grade EA (Z = 2.042, 2.013, p = 0.041, 0.044), while in the identification of EA and non-EA, only the difference in K_app was statistically significant. Moreover, the K_app and MTRasym (3.5 ppm) values and D_app values correlated positively and negatively, respectively, with histological grade (r = 0.759, 0.555, 0.624, and 0.462, all p < 0.05) and Ki-67 index (r = -0.704, -0.507, all p < 0.05).

CONCLUSION

Both DKI- and APTWI-related parameters have potential as imaging markers in estimating the histological features of EC, while DKI shows better performance than APTWI in this study.

KEY POINTS

• DKI and APTWI can be used to preliminarily evaluate the histological characteristics of endometrial carcinoma (EC). • The K_app was the only independent predictor for the histological grade of EA and the clinical type of EC. • The K_app, MTRasym (3.5 ppm), and D_app correlated positively and negatively, respectively, with histological grade and Ki-67 index.

Machine Learning-Based Integration of Prognostic Magnetic Resonance Imaging Biomarkers for Myometrial Invasion Stratification in Endometrial Cancer

BACKGROUND

Estimation of the depth of myometrial invasion (MI) in endometrial cancer is pivotal in the preoperatively staging. Magnetic resonance (MR) reports suffer from human subjectivity. Multiparametric MR imaging radiomics and parameters may improve the diagnostic accuracy.

PURPOSE

To discriminate between patients with MI ≥ 50% using a machine learning-based model combining texture features and descriptors from preoperatively MR images.

STUDY TYPE

Retrospective.

POPULATION

One hundred forty-three women with endometrial cancer were included. The series was split into training (n = 107, 46 with MI ≥ 50%) and test (n = 36, 16 with MI ≥ 50%) cohorts.

FIELD STRENGTH/SEQUENCES

Fast spin echo T2-weighted (T2W), diffusion-weighted (DW), and T1-weighted gradient echo dynamic contrast-enhanced (DCE) sequences were obtained at 1.5 or 3 T magnets.

ASSESSMENT

Tumors were manually segmented slice-by-slice. Texture metrics were calculated from T2W and ADC map images. Also, the apparent diffusion coefficient (ADC), wash-in slope, wash-out slope, initial area under the curve at 60 sec and at 90 sec, initial slope, time to peak and peak amplitude maps from DCE sequences were obtained as parameters. MR diagnostic models using single-sequence features and a combination of features and parameters from the three sequences were built to estimate MI using Adaboost methods. The pathological depth of MI was used as gold standard.

STATISTICAL TEST

Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, accuracy, positive predictive value, negative predictive value, precision and recall were computed to assess the Adaboost models performance.

RESULTS

The diagnostic model based on the features and parameters combination showed the best performance to depict patient with MI ≥ 50% in the test cohort (accuracy = 86.1% and AUROC = 87.1%). The rest of diagnostic models showed a worse accuracy (accuracy = 41.67%-63.89% and AUROC = 41.43%-63.13%).

DATA CONCLUSION

The model combining the texture features from T2W and ADC map images with the semi-quantitative parameters from DW and DCE series allow the preoperative estimation of myometrial invasion. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 3.

Reduced field-of-view versus full field-of-view diffusion-weighted imaging for the evaluation of complete response to neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer

PURPOSE

To determine whether reduced field-of-view (rFOV) DWI sequences can improve image quality and diagnostic performance compared with conventional full FOV (fFOV) DWI in the prediction of complete response (CR) to neoadjuvant chemoradiotherapy (CRT) in patients with locally advanced rectal cancers.

METHODS

Between September 2015 and December 2017, seventy-three patients with locally advanced rectal cancers (≥ T3 or lymph node positive) who underwent CRT and subsequent surgery were included in this retrospective study. All patients had tumor located no more than 10 cm from the anal verge, and underwent rectal MRI including fFOV b-1000 DWI and rFOV b-1000 DWI at 3 T before and after CRT. Image quality and diagnostic performance in predicting CR were compared between rFOV DWI and fFOV DWI sets by two reviewers.

RESULTS

Based on a 12-point scale, rFOV DWI provided better image quality scores than fFOV DWI (9.1 ± 1.7 vs. 8.4 ± 1.0, respectively, P < 0.001). Diagnostic accuracy (A_z) in evaluating CR was better with the rFOV DWI set than with the fFOV DWI set for both reviewers: reviewer 1, 0.78 vs. 0.57 (P = .004); reviewer 2, 0.72 vs. 0.61 (P = .031).

CONCLUSION

rFOV DWI of rectal cancer can provide better overall image quality, and its addition to conventional rectal MRI may provide better diagnostic accuracy than fFOV DWI in the evaluation of CR to neoadjuvant CRT in patients with locally advanced rectal cancer.

ESGO/ESTRO/ESP Guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.

Application of Field-of-View Optimized and Constrained Undistorted Single Shot (FOCUS) with Intravoxel Incoherent Motion (IVIM) in 3T in Locally Advanced Rectal Cancer

Purpose

To evaluate the efficacy of field-of-view (FOV) optimized and constrained undistorted single shot (FOCUS) with IVIM in 3T MRI in the grading of patients with locally advanced rectal cancer.

Methods

From January 1st to December 31st, 2019, patients with locally advanced rectal cancer were retrieved. FOCUS DWI and FOCUS IVIM were obtained. Apparent diffusion coefficient (ADC) and IVIM parameters including mean true diffusion coefficient (D), pseudodiffusion coefficient associated with blood flow (D∗), and perfusion fraction (f) of the tumor parenchyma and normal rectal wall, as well as the normalized tumor parameters by corresponding normal intestinal wall parameters (ADC_NOR, D_NOR, D∗_NOR, and f_NOR), were compared between the well/moderately differentiated and poorly differentiated groups by Student's t-test. The relationship between the above parameters and the histologic grade was analyzed using Spearman's correlation test, with the ROC curve generated.

Results

Eighty-eight patients (aged 31 to 77 years old, mean = 56) were included for analysis. D_tumor and f_tumor were positively correlated with the tumor grade (r = 0.483, p < 0.001 and r = 0.610, p < 0.001, respectively). All the normalized parameters (ADC_NOR, D_NOR, D∗_NOR, and f_NOR) were positively correlated with the tumor grade (r = 0.267, p = 0.007; r = 0.564, p = 0.001; r = 0.414, p = 0.005; and r = 0.605, p < 0.001, respectively). The best discriminative parameter was the f_tumor value, and the area under the ROC curve was 0.927. With a cut-off value of 22.0%, f_tumor had a sensitivity of 88.9% and a specificity of 100%.

Conclusion

FOCUS IVIM-derived parameters and normalized parameters are useful for predicting the histologic grade in rectal cancer patients.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multi-disciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

Can conventional DWI accurately assess the size of endometrial cancer?

PURPOSE

To compare T2-weighted image (T2WI) and conventional Diffusion-weighted image (cDWI) of magnetic resonance imaging (MRI) for sensitivity of qualitative diagnosis and accuracy of tumor size (TS) measurement in endometrial cancer (EC). Meanwhile, the effect of the lesion size itself and tumor grade on the ability of T2WI and cDWI of TS assessment was explored. Ultimately, the reason of deviation on size evaluation was studied.

MATERIALS AND METHODS

34 patients with EC were enrolled. They were all treated with radical hysterectomy and performed MR examinations before operation. Firstly, the sensitivity of T2WI alone and T2WI-DWI in qualitative diagnosis of EC were compared according to pathology. Secondly, TS on T2WI and cDWI described with longitudinal (LD) and horizontal diameter (HD) were compared to macroscopic surgical specimen (MSS) quantitatively in the entire lesions and the subgroup lesions which grouped by postoperative tumor size itself and tumor grade. Thirdly, the discrepancy of mean ADC values (ADC mean) and range ADC values (ADC range) between different zones of EC were explored.

RESULTS

For qualitative diagnosis, the sensitivity of T2WI-DWI (97%) was higher than T2WI alone (85%) (p = 0.046).For TS estimation, no significant difference (PLD = 0.579; PHD = 0.261) was observed between T2WI (LDT2WI = 3.90 cm; HDT2WI = 2.88 cm) and MSS (LD = 4.00 cm; HD = 3.06 cm), whereas TS of cDWI (LDDWI = 3.01 cm; HDDWI = 2.54 cm) were smaller than MSS (PLD = 0.002; PHD = 0.002) in all lesions. In subgroup of tumor with G1 (grade 1) and small lesion (defined as maximum diameter < 3 cm), both T2WI and cDWI were not significantly different from MSS; In subgroup of tumor with G2 + 3 (grade 2 and grade 3) and big lesion (maximum diameter ≥ 3 cm), T2WI matched well with MSS still, but DWI lost accuracy significantly. The result of ADC values between different zones of tumor showed ADC mean of EC rose from central zone to peripheral zone of tumor gradually and ADC range widened gradually.

CONCLUSION

cDWI can detect EC very sensitively. The TS on cDWI was smaller than the fact for the ECs with G2/3 and big size. The TS of T2WI was in accordance with the actual size for all ECs. The heterogeneity may be responsible for the inaccuracy of cDWI.

Reduced field-of-view diffusion-weighted MR imaging for assessing the local extent of uterine cervical cancer

Background

Recently, the evaluation of the tumor size and local extension of early-stage uterine cervical cancer on magnetic resonance imaging is important for the accurate clinical staging and to determine the indication of less extensive surgery such as fertility sparing radical trachelectomy.

Purpose

To compare the diagnostic ability of reduced field-of-view diffusion-weighted imaging with those of three-dimensional (3D) contrast-enhanced T1-weighted imaging and T2-weighted imaging for assessing the tumor margin delineation and local extent of uterine cervical cancer.

Material and Methods

3T magnetic resonance images, including T2-weighted imaging, reduced field-of-view diffusion-weighted imaging, and 3D contrast-enhanced T1-weighted imaging, in 27 women with surgically proven cervical cancer (19 FIGO stage IB1, 3 IB2, and 5 IIA1) were retrospectively evaluated. Tumor margins and local tumor extent, including the presence of invasion to parametrium and vagina were evaluated on both sagittal and oblique axial (short axis) images; the results were compared with histologically confirmed tumor extension.

Results

Reduced field-of-view diffusion-weighted imaging diagnosed the tumor margins, which was more accurate than T2-weighted imaging ( P<0.001) and slightly better than 3D contrast-enhanced T1-weighted imaging. Reduced field-of-view diffusion-weighted imaging could define the tumor margins well even in small lesions (≤ 20 mm). Histological examination revealed parametrial invasion in two cases (clinically under-staged) and vaginal invasion in four cases. Reduced field-of-view diffusion-weighted imaging could demonstrate local extension of all lesions, which was more accurate than clinical examination and T2-weighted imaging.

Conclusion

Addition of reduced field-of-view diffusion-weighted imaging may improve the staging accuracy of magnetic resonance imaging for cervical cancer in assessing the local tumor extent.

Histological grades of rectal cancer: whole-volume histogram analysis of apparent diffusion coefficient based on reduced field-of-view diffusion-weighted imaging

Background

To explore the role of whole-lesion histogram analysis of apparent diffusion coefficient (ADC) derived from reduced field-of-view (rFOV) diffusion-weighted imaging (DWI) technique in discriminating histological grades of rectal carcinoma.

Methods

Altogether, 49 patients with rectal cancer were enrolled in this retrospective study. All patients received preoperative 3.0 T MR scan. Histogram parameters from rFOV DWI were calculated and correlated with histological differentiation of rectal cancer. The parameters were compared between different histological grades of rectal cancer by independent Student's t-test or Man-Whitney U-test. The Spearman correlation test analyzed correlations between histological grade and histogram parameters. The diagnostic performance of individual parameters for distinguishing poorly from well-/moderately differentiated tumors was assessed by receiver operating characteristic curve (ROC) analysis.

Results

There were significant differences for ADCmean, 25^th, 50^th, 75^th, 90^th, 95^th percentiles, skewness, and kurtosis of rFOV DWI sequence between well-, moderately, and poorly differentiated rectal cancers (P<0.05). Significant correlations were noted between histological grades and the above histogram parameters (r=0.679, 0.540, 0.701, 0.730, 0.669, 0.574, -0.730, and -0.760 respectively, P<0.001). Among the individual histogram parameter, kurtosis achieved the highest AUC of 0.882 with an optimal cutoff value of 1.934 in distinguishing poorly from well-/moderately differentiated rectal cancers. The combination of ADCmean, 75^th percentile, and kurtosis yielded the highest AUC of 0.927 with a sensitivity of 88.00% and a sensitivity of 91.7% using logistic regression.

Conclusions

Quantitative whole-lesion ADC histogram analysis based on the rFOV DWI technique could help differentiate histological grades of rectal cancer. The combination of ADCmean, 75^th percentile, and kurtosis may be the best choice.

Rectal Cancer Invasiveness: Whole-Lesion Diffusion-Weighted Imaging (DWI) Histogram Analysis by Comparison of Reduced Field-of-View and Conventional DWI Techniques

To explore the role of whole-lesion histogram analysis of apparent diffusion coefficient (ADC) for discriminating between T stages of rectal carcinoma by comparison of reduced field-of-view (FOV) and conventional DWI techniques. 102 patients with rectal cancer were enrolled in this retrospective study. All patients received preoperative MR scan at 3 T, including reduced and full FOV DWI sequences. Histogram parameters from two DWI methods were calculated and correlated with histological T stage of rectal cancer. The diagnostic performance of individual parameter for differentiating stage pT1-2 and pT3-4 tumors from both DWI techniques was assessed by receiver operating characteristic curve analysis. There were significant differences for the parameters of ADCmean, 50th, 75th, 90th, 95th percentiles, skewness and kurtosis of both DWI sequences in patients with pT1-2 as compared to those with pT3-4 tumors (P < 0.05), in addition to parameters including ADCmin (P = 0.015) and 25th percentile (P = 0.006) from rFOV DWI. Correlations were noted between T staging and above histogram parameters from rFOV DWI (r: −0.741–0.682) and fFOV DWI (r: −0.449–0.449), besides parameters of ADCmin (0.370) and 25th percentile (−0.425) from rFOV DWI. The AUCs of 75th and 90th percentiles from rFOV DWI were significantly higher than that from fFOV DWI (P = 0.0410 and P = 0.0208). The whole-lesion histogram analysis based on rFOV DWI was overall more advantageous than the one based on fFOV DWI in differentiating T staging of rectal cancer and the 90th percentile ADC from rFOV DWI was the value with the highest AUC (0.932).

Current Status of Magnetic Resonance Imaging in Patients with Malignant Uterine Neoplasms: A Review

In this study, we summarize the clinical role of magnetic resonance imaging (MRI) in the diagnosis of patients with malignant uterine neoplasms, including leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, uterine carcinosarcoma, and endometrial cancer, with emphasis on the challenges and disadvantages. MRI plays an essential role in patients with uterine malignancy, for the purpose of tumor detection, primary staging, and treatment planning. MRI has advanced in scope beyond the visualization of the many aspects of anatomical structures, including diffusion-weighted imaging, dynamic contrast enhancement-MRI, and magnetic resonance spectroscopy. Emerging technologies coupled with the use of artificial intelligence in MRI are expected to lead to progressive improvement in case management of malignant uterine neoplasms.

Assessment of Myometrial Invasion in Premenopausal Grade 1 Endometrial Carcinoma: Is Magnetic Resonance Imaging a Reliable Tool in Selecting Patients for Fertility-Preserving Therapy?

OBJECTIVES

The aim of this study was to evaluate the diagnostic ability of magnetic resonance imaging (MRI) in premenopausal women with G1 endometrial carcinoma.

METHODS

Twenty-six patients underwent T2W, diffusion weighted, and dynamic contrast-enhanced 3-T MRI. The degree of myometrial invasion was pathologically classified into no invasion, shallow (3 mm or less), and more. Two radiologists assessed myometrial invasion on MRI. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values, AUC, and interobserver agreement were analyzed.

RESULTS

For assessing myometrial invasion, mean accuracy, sensitivity, specificity, positive predictive values, negative predictive values, and AUC, respectively, were as follows: 63%, 42%, 85%, 79%, 47%, and 0.75. Mean interobserver agreement was fair (k = 0.36). Shallow invasions were underestimated as no invasion on MRI in all 6 cases.

CONCLUSIONS

Magnetic resonance imaging produced false-negative result on half of patients. The misjudgments tended to happen in patients with shallow invasion.

Evaluating Myometrial Invasion in Endometrial Cancer: Comparison of Reduced Field-of-view Diffusion-weighted Imaging and Dynamic Contrast-enhanced MR Imaging

PURPOSE

To compare the diagnostic ability of reduced FOV diffusion-weighted (DW) MR imaging with that of 3D dynamic contrast-enhanced (DCE) MR imaging in evaluating the depth of myometrial invasion in patients with endometrial cancer.

METHODS

Three tesla MR images including T₂-weighted imaging, reduced FOV DW imaging and 3D DCE MR imaging in sagittal and oblique axial (short axis) planes in 25 women with surgically proven endometrial cancer were retrospectively evaluated. The depth of myometrial invasion (stage S: < 50% vs stage D: ≥ 50%) on MR imaging was correlated with surgical pathology results.

RESULTS

The 25 endometrial cancers included 16 stage S and 9 stage D tumors. The depth of myometrial invasion could be accurately evaluated in 68% of the cases for T₂-weighted imaging, 92% for 3D DCE MR imaging, and 96% for reduced FOV DW imaging. In two patients with coexisting adenomyosis, both T₂-weighted imaging and 3D DCE MR imaging failed to reveal the deep myometrial invasion, and reduced FOV DW imaging clearly demonstrated the tumor margin in the cases. Combination of reduced FOV DW imaging reading together with T₂-weighted imaging improved the assessment of myometrial invasion with a diagnostic accuracy of up to 100%.

CONCLUSIONS

Addition of reduced FOV DW imaging may improve the staging accuracy of MR imaging for endometrial cancer in assessing the depth of myometrial invasion. Especially, reduced FOV DW imaging has an advantage in assessing the depth of myometrial invasion for patients with coexisting adenomyosis. Reduced FOV DW imaging can be an alternative to 3D DCE MR imaging in evaluating myometrial invasion of endometrial cancer without the use of contrast medium.