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

The Added Value of ADC-based Nomogram in Assessing the Depth of Myometrial Invasion of Endometrial Endometrioid Adenocarcinoma

RATIONALE AND OBJECTIVES

To explore the potential value of the apparent diffusion coefficient (ADC)-based nomogram models in preoperatively assessing the depth of myometrial invasion of endometrial endometrioid adenocarcinoma (EEA).

MATERIALS AND METHODS

Preoperative magnetic resonance imaging (MRI) of 210 EEA patients were retrospectively analyzed. ADC histogram metrics derive from the whole-tumor regions of interest. Univariate and multivariate analyses were used to screen the ADC histogram metrics and clinical characteristics for nomogram model building. The diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of two radiologists without and with the assistance of models were calculated and compared.

RESULTS

Two nomogram models were developed for predicting no myometrial invasion (NMI) and deep myometrial invasion (DMI) with area under the curves of 0.85 and 0.82, respectively. With the assistance of models, the overall accuracies were significantly improved [radiologist_1, 73.3% vs 86.2% (p = 0.001); radiologist_2, 80.0% vs 91.0% (p = 0.002)]. In determining NMI, the sensitivity and PPV were greatly improved but not significant for radiologist_1 (51.9% vs 77.8% and 46.7% vs 75.0%, p = 0.229 and 0.511), and under/near the significance level for radiologist_2 (59.3% vs 88.9% and 57.1% vs 82.8%, p = 0.041 and 0.065), while the specificity, accuracy, and NPV were significantly improved (all p < 0.001). In determining DMI, all sensitivity, specificity, accuracy, PPV, and NPV were significantly improved (all p < 0.001).

CONCLUSION

The ADC-based nomogram models can improve the diagnostic performance of radiologist in preoperatively assessing the depth of myometrial invasion and facilitate optimizing clinical individualized treatment decisions.

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.

Multiparametric magnetic resonance imaging facilitates the selection of patients prior to fertility-sparing management of endometrial cancer

PURPOSE

To compare the diagnostic performance of biparametric magnetic resonance imaging (bpMRI) versus multiparametric MRI (mpMRI) for the staging of well-differentiated endometrioid endometrial cancer (EC) in potential candidates for fertility-sparing management.

METHODS

This multi-center retrospective study included 48 potential candidates for fertility-sparing management (age <46 years, grade 1 endometroid EC) who did not wish to undergo fertility-sparing management and thus underwent definitive surgery. Two readers (R1, R2) independently reviewed bpMRI (T1, T2, and diffusion-weighted imaging) and mpMRI (bpMRI and dynamic contrast-enhanced imaging, DCE) during two separate sessions spaced one month apart for the presence of myometrial invasion (MI), cervical stromal involvement (CSI), malignant adnexal disease (mAD), and pelvic lymphadenopathy (pLNM). Each reader also recorded maximum tumor diameter, tumor volume, and tumor-to-uterine volume ratio (TVR) on T2-weighted imaging. The diagnostic performance of bpMRI and mpMRI was determined for each reader with surgical pathology serving as a gold standard.

RESULTS

The area under the receiver operating curve (AUC) for bpMRI versus mpMRI was 0.76/0.78 (R1/R2) versus 0.84/0.83 for MI, 0.79/0.76 versus 0.99/0.80 for CSI, 0.84/0.84 versus 0.84/0.80 for mAD, and 0.82/0.82 for pLMN. The sensitivity and specificity of MRI for detecting tumor spread beyond the endometrium were 71%/77% and 71%/65% for bpMRI (R1/R2) vs. 84%/90% and 71%/65% for mpMRI (R1/R2), respectively. The AUC of maximum tumor diameter, tumor volume, and TVR for MI was 0.71/0.61, 0.73/0.75, and 0.75/0.77 for R1/R2, respectively.

CONCLUSION

MRI had moderate diagnostic performance across potential candidates for fertility-sparing treatment of EC. mpMRI outperformed bpMRI for detecting EC spreading beyond the endometrium.

Imaging modalities in fertility preservation in patients with gynecologic cancers

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.