A retrospective review of magnetic resonance imaging in assessing the extent of myometrial infiltration for patients with endometrial carcinoma

Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large Multicentre Series

BACKGROUND

Sentinel lymph node (SLN) biopsy is considered the standard of care in early-stage endometrial cancer (EC). For SLN failure, a side-specific lymphadenectomy is recommended. Nevertheless, most hemipelvises show no nodal involvement. The authors previously published a predictive score of lymphovascular involvement in EC. In case of a negative score (value 3-4), the risk of nodal metastases was extremely low. This multicenter study aimed to analyze a predictive score of nodal involvement in EC patients.

METHODS

The study enrolled patients with EC who had received comprehensive surgical staging with nodal assessment. A preoperative predictive score of nodal involvement was calculated for all the patients before surgery. The score included myometrial infiltration, tumor grading (G), tumor diameter, and Ca125 assessment. The STARD (standards for Reporting Diagnostic accuracy studies) guidelines were followed for score accuracy.

RESULTS

The study analyzed 1038 patients and detected 155 (14.9%) nodal metastases. The score was negative (3 or 4) for 475 patients and positive (5-7) for 563 of these patients. The score had a sensitivity of 83.2%, a specificity of 50.8%, a negative predictive value of 94.5%, and a diagnostic value of 55.7%. The area under the curve was 0.75. The logistic regression showed a significant correlation between a negative score and absence of nodal metastasis (odds ration [OR], 5.133, 95% confidence interval [CI], 3.30-7.98; p < 0.001).

CONCLUSION

The proposed predictive score is a useful test to identify patients at low risk of nodal involvement. In case of SLN failure, the application of the current score in the SLN algorithm could allow avoidance of unnecessary lymphadenectomies.

Fertility-Sparing Treatment of Endometrial Cancer with Initial Infiltration of Myometrium by Resectoscopic Surgery: A Pilot Study

Three women with a well-differentiated grade 1 endometrioid adenocarcinoma of the endometrium with minimal myometrial infiltration were treated with hysteroscopic resection and hormone therapy. The presence of myometrial infiltration has often been mentioned as an exclusion criterion for conservative management in young patients because of worsening cancer prognosis. The subsequent 5-year follow-up and the pregnancies achieved may confirm the choice of this temporary treatment and indicate a new option for fertility-sparing treatment in highly motivated patients.

Are preoperative histology and MRI useful for classification of endometrial cancer risk?

Background

The 2010 guidelines of the French National Cancer Institute (INCa) classify patients with endometrial cancer into three risk groups for lymph node invasion and recurrence on the basis of MRI and histological analysis of an endometrial specimen obtained preoperatively. The classification guides therapeutic choices, which may include pelvic and/or para-aortic lymphadenectomy. The purpose of this study was to evaluate the diagnostic performance of preoperative assessment to help identify intermediate- or high-risk patients requiring lymphadenectomy.

Methods

The study included all patients who underwent surgery for endometrial cancer between January 2010 and December 2013 at either Rennes University Hospital or Vannes Regional Hospital. The criteria for eligibility included a preoperative assessment with MRI and histological examination of an endometrial sample. A histological comparison was made between the preoperative and surgical specimens.

Results

Among the 91 patients who underwent a full preoperative assessment, the diagnosis of intermediate- or high-risk endometrial cancer was established by MRI and histology with a sensitivity of 70 %, specificity of 82 %, positive predictive value (PPV) of 87 %, negative predictive value (NPV) of 61 %, positive likelihood ratio (LR+) of 3.8 and negative likelihood ratio (LR-) of 0.3. The risk group was underestimated in 32 % of patients and overestimated in 7 % of patients. MRI underestimated endometrial cancer stage in 20 % of cases, while endometrial sampling underestimated the histological type in 4 % of cases and the grade in 9 % of cases.

Conclusion

The preoperative assessment overestimated or underestimated the risk of recurrence in nearly 40 % of cases, with errors in lesion type, grade or stage. Erroneous preoperative risk assessment leads to suboptimal initial surgical management of patients with endometrial cancer.

Comparison of dynamic contrast-enhanced magnetic resonance imaging with T2-weighted imaging for preoperative staging of early endometrial carcinoma

Purpose

This study aimed to compare dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with T2-weighted imaging (T2WI) for the preoperative staging of early endometrial carcinoma.

Methods

This retrospective study included 22 subjects with early endometrial carcinoma who underwent 3.0 T MRI examination prior to hysterectomy. DCE-MRI and T2WI were evaluated for the preoperative staging of endometrial carcinoma. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DCE-MRI and T2WI were assessed and compared using the revised International Federation of Gynecology and Obstetrics surgical staging guidelines (2009) as the reference standard.

Results

Out of the 22 cases of endometrial carcinoma, the use of the reference standard method led to the staging of 14 as IA and eight as IB. The sensitivity, specificity, PPV, NPV, and accuracy of DCE-MRI for preoperative staging were 100% (95% confidence interval: 0.73–1.0), 62.5% (95% CI: 0.26–0.90), 82.4% (95% CI: 0.56–0.95), 100% (95% CI: 0.46–1.0), and 86.4%, respectively, and these values were 85.7% (95% CI: 0.56–0.97), 75% (95% CI: 0.36–0.96), 85.7% (95% CI: 0.56–0.97), 75% (95% CI: 0.36–0.96), and 81.8%, respectively, for T2WI. Thus, the sensitivity and accuracy of DCE-MRI were greater than those of T2WI for preoperative endometrial carcinoma staging.

Conclusion

DCE-MRI was more sensitive but less specific than T2WI for the preoperative staging of early endometrial carcinoma. DCE-MRI may serve as a useful and reliable tool for the preoperative assessment of endometrial carcinoma.

Diagnostic Value of Pelvic MRI for Assessment of the Depth of Myometrial Invasion and Cervical Involvement in Endometrial Cancer: Comparison of New Versus Old FIGO Staging

BACKGROUND

Endometrial carcinoma is a highly prevalent gynecologic malignancy. The International Federation of Gynecology and Obstetrics (FIGO) staging system underwent significant revision on 2009. Key changes in the FIGO staging system include simplification of stage I endometrial cancer and removal of cervical mucosal invasion as a separate stage. MRI is a noninvasive diagnostic method for preoperative staging of endometrial cancer.

OBJECTIVES

The main purpose of this study was to investigate the diagnostic efficacy of pelvic MRI in determining the depth of myometrial invasion and cervical involvement in endometrial carcinoma. The other aim was to compare the accuracy of pelvic MRI using the old and new FIGO staging systems in endometrial carcinoma.

PATIENTS AND METHODS

Between November 2010 and January 2012, 54 patients underwent primary surgical staging in our department due to endometrial adenocarcinoma. Pre-operative pelvic MRI was performed and MRI staging was done according to old and new FIGO staging, separately. The sensitivity, specificity, positive and negative predictive values as well as the accuracy of MRI for deep myometrial invasion and cervical infiltration were calculated. MRI accuracy was also compared for old and new FIGO staging. Pathological staging was the standard of reference.

RESULTS

The mean age was 53.31 (SD = 11.52) and the most common histological subtype was the endometrioid type of endometrial adenocarcinoma (90.8%). In the evaluation of deep tumoral invasion of the myometrium (> 50%), sensitivity, specificity, diagnostic accuracy and positive and negative predictive values of MRI were 82.35%, 94.59%, 90.74%, 87.5% and 92.1%, respectively. For cervical stromal involvement, these values were 54.54%, 100%, 90.74%, 100% and 89.58%, respectively. In case of cervical mucosal involvement (in old FIGO staging), the positive predictive value was only 50% and the accuracy decreased to 74.07%. Agreement between MRI and the final histology using the old and new FIGO classification was appropriate with Kappa = 0.62 and 0.72, respectively (P < 0.001).

CONCLUSION

Using 2009 FIGO classification increases the accuracy of pelvic MR imaging for preoperative staging of patients with early stages of endometrial cancer.

Accuracy of MRI with an endorectal coil for staging endometrial cancer

BACKGROUND

The very good results of magnetic resonance imaging (MRI) using an endorectal coil in staging prostate cancer at 1.5T suggested that this imaging technique might be able to be used to stage endometrial cancer, the most common tumor in postmenopausal women.

PURPOSE

To evaluate the accuracy of MRI with an endorectal surface coil for staging primary endometrial carcinoma.

MATERIAL AND METHODS

A total of 33 consecutive patients with biopsy-proven endometrial cancer underwent 1.5T MRI with an endorectal surface coil (eMRI) using sagittal and axial T2-weighted (T2w) turbo spin echo (TSE), axial T1 gradient echo 2D fat-saturated (fs), sagittal T1 gradient echo 3D with and without contrast enhancement (CE), and axial T1 TSE fs CE sequence. Evaluation of local tumor extension was based on the revised standard TNM classification for endometrial cancer. eMRI staging was compared with the histopathological results after surgery.

RESULTS

A total of 33 consecutive patients underwent eMRI for staging endometrial cancer, and 21 of these underwent primary surgery. The histological stages were as follows: T1a (n = 8), T1b (n = 10), T2b (n = 2), and T3a (n = 1). Overall staging accuracy by eMRI was 71% (15 of 21). With regard to depth of myometrial invasion, eMRI correctly diagnosed stage T1a in 75% (6/8) and stage T1b in 80% (8/10). eMRI overstaged the tumor in four patients and understaged it in two.

CONCLUSION

eMRI is highly accurate in staging myometrial invasion. However, eMRI at 1.5T does not seem to be significantly more accurate than pelvic MRI without an endorectal coil at 1.5T for staging primary endometrial cancer. eMRI for endometrial carcinoma therefore might not meet expectations compared with the results obtained using eMRI for staging prostate cancer at 1.5T.

[Endometrial cancer imaging]

Endometrial cancer is staged according to the International Federation of Gynecology and Obstetrics surgical system. Clinical estimation of stage, however, can be inaccurate in more than 20%, and therefore, preoperative imaging of the disease may assist in planning the optimal course of treatment. Magnetic resonance imaging (MRI) may detect gross myometrial extension or extension of tumor to the cervical stroma, which can alter management and therefore help in preoperative surgical planning. This issue is increasingly relevant as less invasive surgical techniques, such as laparoscopic surgeries, are becoming more commonplace for lower stage cancers. Currently, MRI is the most widely used modality for preoperative planning.

MR staging accuracy for endometrial cancer based on the new FIGO stage

BACKGROUND

Magnetic resonance imaging (MRI) has been frequently used to determine a preoperative treatment plan for gynecologic cancers. However, the MR accuracy for staging an endometrial cancer is not satisfactory based on the old FIGO staging system.

PURPOSE

To evaluate MR accuracy for staging endometrial cancer using the new FIGO staging system.

MATERIAL AND METHODS

Between January 2005 and May 2009, 199 women underwent surgery due to endometrial cancer. In each patient, an endometrial cancer was staged using MR findings based on the old FIGO staging system and then repeated according to the new FIGO staging system for comparison. Histopathologic findings were used as a standard of reference.

RESULTS

The accuracy of MRI in the staging of endometrial carcinoma stage I, II, III, and IV using the old FIGO staging system were 80% (159/199), 89% (178/199), 90% (179/199), and 99% (198/199), respectively, compared to 87% (174/199), 97% (193/199), 90% (179/199), and 99% (198/199), respectively, when using the new FIGO staging criteria. The overall MR accuracy of the old and new staging systems were 51% (101/199) and 81% (161/199), respectively.

CONCLUSION

MRI has become a more useful tool in the preoperative staging of endometrial cancers using the new FIGO staging system compared to the old one with increased accuracy.