Added Value of Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Predicting Advanced Stage Disease in Patients With Endometrial Carcinoma

Magnetic resonance imaging-based radiomics model for preoperative assessment of risk stratification in endometrial cancer

BACKGROUND

Preoperative risk stratification is significant for the management of endometrial cancer (EC) patients. Radiomics based on magnetic resonance imaging (MRI) in combination with clinical features may be useful to predict the risk grade of EC.

AIM

To construct machine learning models to predict preoperative risk stratification of patients with EC based on radiomics features extracted from MRI.

METHODS

The study comprised 112 EC patients. The participants were randomly separated into training and validation groups with a 7:3 ratio. Logistic regression analysis was applied to uncover independent clinical predictors. These predictors were then used to create a clinical nomogram. Extracted radiomics features from the T2-weighted imaging and diffusion weighted imaging sequences of MRI images, the Mann-Whitney U test, Pearson test, and least absolute shrinkage and selection operator analysis were employed to evaluate the relevant radiomic features, which were subsequently utilized to generate a radiomic signature. Seven machine learning strategies were used to construct radiomic models that relied on the screening features. The logistic regression method was used to construct a composite nomogram that incorporated both the radiomic signature and clinical independent risk indicators.

RESULTS

Having an accuracy of 0.82 along with an area under the curve (AUC) of 0.915 [95% confidence interval (CI): 0.806-0.986], the random forest method trained on radiomics characteristics performed better than expected. The predictive accuracy of radiomics prediction models surpassed that of both the clinical nomogram (AUC: 0.75, 95%CI: 0.611-0.899) and the combined nomogram (AUC: 0.869, 95%CI: 0.702-0.986) that integrated clinical parameters and radiomic signature.

CONCLUSION

The MRI-based radiomics model may be an effective tool for preoperative risk grade prediction in EC patients.

Role of Multiparametric MRI in the Preoperative Evaluation of Endometrial Carcinoma: A Cross-Sectional Study

Background Endometrial carcinoma (EC) is a major global concern in females throughout the world with increasing incidence in India. Hence, early detection and prompt intervention will reduce morbidity and mortality associated with it. Multiple studies showed a promising role of multiparametric magnetic resonance imaging (mpMRI) in the evaluation and early detection of the disease. In view of the paucity of such studies in the Indian population, we assessed the role of mpMRI in the evaluation of EC by utilizing a 3T MR scanner. Objectives To assess the efficacy of mpMRI in detecting myometrial invasion and locoregional staging in suspected or diagnosed cases of EC. Materials and methods Nineteen cases of EC with mpMRI were included in the study, and 15 of these underwent surgicopathological staging. The preoperative staging was done using the International Federation of Gynecology and Obstetrics (FIGO) 2009 staging system based on mpMRI findings and compared with postoperative FIGO staging. All the data were compiled in a Microsoft Excel (Microsoft® Corp., Redmond, WA) file and analyzed in Statistical Product and Service Solutions (SPSS, version 21.0; IBM SPSS Statistics for Windows, Armonk, NY) using appropriate tools. Results In our study, EC was commonly seen in more than 50-year females with a predominant complaint being postmenopausal bleeding. EC most commonly appeared heterogeneously hyperintense on T2-weighted sequence (T2W) and areas of diffusion restriction on diffusion-weighted imaging (DWI) in all cases. Dynamic contrast-enhanced (DCE) MRI (DCE-MRI) showed mild heterogeneous enhancement in all phases with better delineation of adjacent myometrial infiltration in the equilibrium phase. Diffusion tensor imaging (DTI) parameters had significantly lower values in involved myometrium vis-a-vis uninvolved myometrium. A statistically significant correlation was seen between preoperative mpMRI FIGO staging utilizing T2W, DWI, DCE-MRI, and DTI with surgicopathological FIGO staging. Conclusion mpMRI, particularly T2W, DWI, DCE-MRI, and DTI, yields a significant correlation between MR imaging and histopathological findings in assessing myometrial infiltration and thereby could be helpful in preoperative staging and extent of lymph-nodal dissection.

Contrast-Enhanced MRI in Women with Endometrial Cancer: Dynamic Versus Single-Phase Acquisitions

Background

The 2019 European Society of Urogenital Radiology (ESUR) guidelines for endometrial cancer recommend performing either dynamic contrast-enhanced magnetic resonance imaging (CE MRI) or single-phase CE MRI. However, no study has directly compared these options. Therefore, this study compared dynamic versus single-phase CE MRI for the evaluation of myometrial invasion in women with endometrial cancer.

Methods

This retrospective, single-institution comparative study was conducted among women with surgically proven endometrial cancer, including 30 consecutive women with single-phase CE MRI and 30 age- and pathologic stage-matched women with dynamic CE MRI. Three readers independently compared dynamic and single-phase CE MRI in terms of the tumor-myometrium signal intensity (SI) difference ratio, depth of myometrial invasion, image quality, and image number. Pathologic findings served as a reference standard for the depth of myometrial invasion.

Results

The estimated mean SI difference ratios of dynamic CE MRI and single-phase CE MRI fell within an equivalence margin of 0.05 (90% confidence intervals [CIs] = [-0.0497 to -0.0165], [-0.0226 to -0.0403], and [-0.0429 to -0.0433], respectively, for readers A, B, and C). The area under the receiver operating characteristic curve for the detection of deep myometrial invasion was not significantly different between the acquisitions (P = .3315, P = .3345, and P = .8593, respectively). Single-phase CE MRI showed significantly better image quality than dynamic CE MRI (P = .0143, P = .0042, and P = .0066, respectively), while the median number of images for dynamic CE MRI was 2.4 times higher than that for single-phase CE MRI.

Conclusion

Single-phase acquisition may be a better option for CE MRI in women with endometrial cancer than dynamic acquisition.

Diagnostic Performance of Preoperative Imaging in Endometrial Cancer

BACKGROUND

Endometrial cancer is one of the most common gynecological malignancies. Because the findings mentioned in radiogram interpretation reports issued by diagnostic radiologists influence treatment strategies, we aimed to evaluate the diagnostic accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) interpretation results in clinically relevant settings.

METHODS

The clinical records of patients diagnosed with endometrial cancer treated at Tohoku University Hospital from January 2012 to December 2021 were reviewed. The preoperative and pathologically estimated cancer stages were compared based on the results mentioned in the radiogram interpretation report.

RESULTS

The preoperative and postoperative cancer stages were concordant in 70.0% of the patients. By contrast, the cancer stage was underdiagnosed and overdiagnosed in 21.7% and 8.2% of the patients, respectively. The sensitivities of MRI for deep myometrial invasion, cervical stromal invasion, vaginal invasion, and adnexal metastasis were 65.1%, 58.2%, 33.3%, and 18.4%, respectively. The sensitivity and specificity for pelvic lymph node metastasis using a combination of CT and MRI were 40.9% and 98.4%, respectively. Those for para-aortic lymph node metastases using CT were 37.0% and 99.5%, respectively.

CONCLUSIONS

The low sensitivity observed in this study clarified the limitations of preoperative diagnostic performance in current clinical practice.

MR Imaging of Gynecologic Tumors: Pearls, Pitfalls, and Tumor Mimics

MR imaging is the modality of choice for the pre-treatment evaluation of patients with gynecologic malignancies, given its excellent soft tissue contrast and multi-planar capability. However, it is not without pitfalls. Challenges can be encountered in the assessment of the infiltration of myometrium, vagina, cervical stroma, and parametria, which are crucial prognostic factors for endometrial and cervical cancers. Other challenges can be encountered in the distinction between solid and non-solid tissue and in the identification of peritoneal carcinomatosis for the sonographically indeterminate adnexal mass.

The diagnostic accuracy of 3D ultrasound compared to 2D ultrasound and MRI in the assessment of deep myometrial invasion in endometrial cancer patients: A systematic review

Endometrial cancer is a common malignancy in women worldwide, with myometrial invasion (MI) being an important prognostic factor, usually assessed via imaging techniques. The aim of this review is to compare the diagnostic accuracy of 3D transvaginal ultrasound (3D-TVUS), a relatively new imaging modality, to that of 2D transvaginal ultrasound (2D-TVUS) and MRI in the prediction of deep myometrial invasion. Relevant articles were sought on MEDLINE/PubMed, Scopus, Web of Science and Wiley Online Library databases. Articles were included if they were primary studies comparing 3D-TVUS to 2D-TVUS and/or MRI in adult endometrial cancer patients, with histopathological confirmation of MI as a reference standard. Ultimately, 7 studies were included, with 714 participants, 242 with deep MI and a mean age of approximately 60 years. 3D-TVUS, 2D-TVUS, MRI and 3D-TVUS-MRI co-evaluation had a pooled sensitivity of 80.4%, 77.6%, 80.7% and 94.6% respectively and a specificity range of 82.8%, 81.6%, 87% and 69.1% respectively. Overall, no statistically significant differences were found in sensitivity and specificity among 3D-TVUS and the other methods, except for a significant increase in sensitivity (p = 0.038) when combined with MRI. This shows that 3D-TVUS is comparable to MRI as far as diagnostic accuracy is concerned, however remains cheaper, less time-consuming and more tolerable, while offering some advantages over 2D-TVUS as well. Therefore 3D-TVUS application in MI assessment seems promising, although more research is required to further assess this finding and ascertain 3D-TVUS's place in endometrial cancer MI assessment.

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.

MRI to assess deep myometrial invasion in patients with endometrial cancer:A multi-reader study to evaluate the diagnostic role of different sequences

OBJECTIVE

The identification of deep myometrial invasion (DMI) represents a fundamental aspect in patients with endometrial cancer (EC) for accurate disease staging. It can be detected on MRI using T2-weighted (T2-w), diffusion weighted (DWI) and dynamic contrast enhanced sequences (DCE). Aim of the study was to perform a multi-reader evaluation of such sequences to identify the most accurate and its reliability for the best protocol.

METHODS

In this multicenter retrospective study, MRI were independently evaluated by 4 radiologists (2 senior and 2 novice) with a sequence-based approach to identify DMI. The performance of the entire protocol was also evaluated. A comparison between the different sequences assessed by the same reader was performed using receiver operating curve and post-hoc analysis. Intraclass Correlation Coefficient (ICC) was used to assess inter- and intra-observer variability.

RESULTS

A total of 92 patients were included. The performance of the readers did not show significant differences among DWI, DCE and the entire protocol. For only one senior radiologist, who reached the highest diagnostic accuracy with the entire protocol (82,6 %), both DWI (p = 0,0197) and entire protocol (p = 0,0039) were found significantly superior to T2-w. The highest inter-observer agreement was obtained with the entire protocol by expert readers (ICC = 0,77).

CONCLUSIONS

For the detection of DMI, the performances of DWI and DCE alone and that of a complete protocol do not significantly differ, even though the latter ensures the highest reliability particularly for expert readers. In cases in which T2-w and DWI are consistent, an unenhanced protocol could be proposed.

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Endometrial Cancer

To date, there is little consensus on the role of pelvic imaging in assessing local disease extent during initial staging in patients with endometrial carcinoma, with practices differing widely across centers. However, when pretreatment assessment of local tumor extent is indicated, MRI is the preferred imaging modality. Preoperative imaging of endometrial carcinoma can define the extent of disease and indicate the need for subspecialist referral in the presence of deep myometrial invasion, cervical extension, or suspected lymphadenopathy. If distant metastatic disease is clinically suspected, preoperative assessment with cross-sectional imaging or PET/CT may be performed. However, most patients with low-grade disease are at low risk of lymph node and distant metastases. Thus, this group may not require a routine pretreatment evaluation for distant metastases. Recurrence rates in patients with endometrial carcinoma are infrequent. Therefore, radiologic evaluation is typically used only to investigate suspicion of recurrent disease due to symptoms or physical examination and not for routine surveillance after treatment. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic value of 18F-FDG PET/MRI for staging in patients with endometrial cancer

Background

Preoperative accurate assessment of endometrial cancer can assist in the planning of additional surgical options, and in predicting the prognosis. The aim of the present study was to evaluate the diagnostic potential of non-contrast PET/MRI with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) for assessment in preoperative staging of endometrial cancer.

Methods

Thirty-six patients with biopsy-proven endometrial cancer underwent preoperative ¹⁸F-FDG PET/MRI, contrast-enhanced CT (ceCT) and pelvic dynamic contrast-enhanced MRI (ceMRI) for initial staging. The diagnostic performance of ¹⁸F-FDG PET/MRI and ceMRI for assessing the extent of the primary tumor (T stage), and ¹⁸F-FDG PET/MRI and ceCT for assessing nodal (N stage) and distant (M stage) metastasis, was evaluated by two experienced readers. Histopathological and follow-up imaging results were used as the gold standard. The McNemar test was employed for statistical analysis.

Results

Accuracy for T status was 77.8 and 75.0% for ¹⁸F-FDG PET/MRI and ceMRI, respectively. Patient-based accuracy for detecting regional nodal and distant metastasis was 91.3 and 81.8% for ¹⁸F-FDG PET/MRI, and 87.0 and 81.8% for ceCT. None of these parameters was statistically significant (p > 0.05). Lesion-based sensitivity, specificity and accuracy for detecting regional nodal metastasis were 100, 96.9 and 97.0% for ¹⁸F-FDG PET/MRI, and 14.3, 97.6 and 93.3% for ceCT; sensitivity was statistically significant (p < 0.05).

Conclusions

Non-contrast ¹⁸F-FDG PET/MRI, which combines the individual advantages of PET and MRI, offers a high diagnostic value equivalent to that of ceMRI for assessment of the primary tumor, and equivalent to that of ceCT for the assessment of nodal and distant metastatic staging, in patients with endometrial cancer. These findings suggest that ¹⁸F-FDG PET/MRI might provide an alternative diagnostic strategy to conventional imaging modalities in the preoperative staging of endometrial cancer.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s40644-020-00357-4.

The usefulness of diffusion-weighted MRI in the differentiation between focal uterine endometrial soft tissue lesions

Background

Several endometrial conditions may be challenging for radiologists due to the overlap of imaging features and variable endometrial pathologies. MRI with DWI is the most commonly used imaging technique for the diagnosis and characterization of endometrial focal lesions.

Results

The 50 studied lesions were classified according to their histopathological results into the benign group (28 lesions, 56%) and the malignant group (22 lesions, 44%). Conventional MRI could correctly diagnose 39 of the 50 lesions (22/28 benign and 17/22 malignant lesions), achieving a sensitivity of 77.27%, specificity of 78.56%, accuracy of 78%, predictive positive value (PPV) of 73.91%, and negative positive value (NPV) of 81.48%. By combining DWI and apparent diffusion coefficient (ADC) value mapping at a high b value (b = 1000) in MRI, we could correctly diagnose 47 of the 50 lesions (26/28 benign and 21/22 malignant lesions), with increased sensitivity (95.45%), specificity (92.86%), accuracy (94%), PPV (91.3%), and NPV (96%).

Conclusion

Combining DWI with ADC mapping at a high b value in pelvic MRI examination is valuable in differentiating endometrial focal lesions with increased diagnostic sensitivity, specificity, and accuracy.

Aim of the work

This study aimed to evaluate the role of DWI in the diagnosis and differential diagnosis of benign and malignant focal endometrial masses.

The added value of diffusion-weighted imaging in the preoperative assessment of endometrial cancer

Objective

To evaluate the added value of diffusion-weighted imaging (DWI) in the preoperative assessment of myometrial invasion in endometrial cancer, in comparison with T2-weighted imaging (T2WI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

Materials and Methods

This was a retrospective study involving 44 women with endometrial cancer who underwent preoperative 1.5 T MRI. Two radiologists, both of whom were blinded to the histopathology reports, performed a consensus interpretation of the depth of myometrial invasion and of the stage of the cancer, considering three sets of sequences: T2WI, DCE-MRI+T2WI, and DWI+T2WI. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each set. The accuracy was compared with p-value adjustment by the Benjamini-Hochberg procedure.

Results

Among the 44 patients evaluated, DWI+T2WI demonstrated better diagnostic performance in assessing deep myometrial invasion and correctly staged more patients (n = 41) than did DCE-MRI+T2WI (n = 34) and T2WI (n = 22). The superior diagnostic accuracy of DWI+T2WI was statistically significant in comparison with T2WI (p < 0.05) but not in comparison with DCE-MRI+T2WI (p > 0.05).

Conclusion

The addition of DWI apparently improves the diagnostic accuracy of MRI in the preoperative assessment of the depth of myometrial invasion in endometrial cancer, which may be particularly helpful in patients for whom contrast agents are contraindicated.

Myometrial invasion and overall staging of endometrial carcinoma: assessment using fusion of T2-weighted magnetic resonance imaging and diffusion-weighted magnetic resonance imaging

Background

The age of onset of endometrial carcinoma has been decreasing in recent years. In endometrial carcinoma, it is important to accurately assess invasion depth and preoperative staging. Fusion of T2-weighted magnetic resonance imaging (T2WI) and diffusion-weighted magnetic resonance imaging (DWI) may contribute to the improvement of anatomical localization of lesions.

Materials and methods

In our study, a total of 58 endometrial carcinoma cases were included. Based on the revised 2009 International Federation of Gynecology and Obstetrics staging system, a fusion of T2WI and DWI was utilized for the evaluation of invasion depth and determination of the overall stage. Postoperative pathologic assessment was considered as the reference standard. The consistency of T2WI image staging and pathologic staging, and the consistency of fused T2WI and DWI and pathologic staging were all analyzed using Kappa statistics.

Results

Compared with the T2WI group, a significantly higher diagnostic accuracy was observed for myometrial invasion with fusion of T2WI and DWI (77.6% for T2WI; 94.8% for T2WI-DWI). For the identification of deep invasion, we calculated values for diagnostic sensitivity (69.2% for T2WI; 92.3% for T2WI-DWI), specificity (80% for T2WI; 95.6% for T2WI-DWI), positive predictive value (50% for T2WI; 85.7% for T2WI-DWI), and negative predictive value (90% for T2WI; 97.7% for T2WI-DWI). In summary, T2WI-DWI fusion exhibits higher diagnostic accuracy with respect to staging relative to T2WI only (81.0% for T2WI; 94.8% for T2WI-DWI).

Conclusion

Fused T2WI-DWI may represent a noninvasive, lower cost approach for the effective assessment of myometrial invasion and staging of endometrial carcinoma.

Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

The diagnostic value of multimodality MRI in endometrial carcinoma staging

Background Multimodality magnetic resonance imaging (MRI) is an imaging technology that is used to integrate the structural and functional information of lesions. MRI can determine the staging of endometrial carcinoma, provide guidance for selection of surgical treatment and postoperative prognostic assessment, and has an important role in improving the survival of patients with endometrial carcinoma. Purpose To evaluate multimodality MRI staging accuracy for endometrial carcinoma based on the International Federation of Gynecology and Obstetrics (FIGO 2009) staging system. Material and Methods This is a retrospective study of the complete clinical and surgical pathology data from 83 patients with endometrial carcinoma treated between June 2011 and August 2015. Using a blind design, the preoperative clinical staging according to the current FIGO2009 MRI-based staging for each endometrial carcinoma was analyzed and corrected by postoperative histopathological results, which served as the staging standard. The role of multimodality MRI on clinical staging accuracy for endometrial carcinoma was studied. Results Based on the pathological evaluation after surgery, the 83 endometrial carcinoma patients were staged according to the current FIGO2009 staging criteria as: stage I, n = 56; stage II, n = 17; stage III, n = 7; and stage IV, n = 3. The multimodality MRI staging accuracy for endometrial carcinoma stages I-IV by FIGO2009 were 91.6% (76/83), 91.6% (76/83), 92.8% (77/83), and 97.6% (81/83), respectively. Conclusion Multimodality MRI is an important imaging tool in the pre-operative clinical staging of endometrial carcinoma. The current FIGO staging system appears to be a concise, reasonable, and practical set of criteria for the clinical management of endometrial carcinoma.

What Is the Best Preoperative Imaging for Endometrial Cancer?

Although endometrial cancer is surgicopathologically staged, preoperative imaging is recommended for diagnostic work-up to tailor surgery and adjuvant treatment. For preoperative staging, imaging by transvaginal ultrasound (TVU) and/or magnetic resonance imaging (MRI) is valuable to assess local tumor extent, and positron emission tomography-CT (PET-CT) and/or computed tomography (CT) to assess lymph node metastases and distant spread. Preoperative imaging may identify deep myometrial invasion, cervical stromal involvement, pelvic and/or paraaortic lymph node metastases, and distant spread, however, with reported limitations in accuracies and reproducibility. Novel structural and functional imaging techniques offer visualization of microstructural and functional tumor characteristics, reportedly linked to clinical phenotype, thus with a potential for improving risk stratification. In this review, we summarize the reported staging performances of conventional and novel preoperative imaging methods and provide an overview of promising novel imaging methods relevant for endometrial cancer care.

Functional MR imaging in gynecologic malignancies: current status and future perspectives

Using functional MR imaging techniques, we can approach the functional assessment of gynecologic malignancies. Among them, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced MR imaging (DCE-MRI) are two important techniques. This article provides an overview of functional MR imaging techniques, focusing DWI and DCE-MRI on clinical application in gynecologic malignancies. Functional MR imaging techniques play an important role in detection, characterization, staging, treatment response, and outcome prediction, as well as providing conventional morphologic imaging. Familiarity with the characteristics and imaging features of functional MR imaging in gynecologic malignancies will facilitate prompt and accurate diagnosis and treatment.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

Application of FLASH-3D dynamic contrast-enhanced imaging for diagnosis of endometrial carcinoma

OBJECTIVE

To investigate the application and value of fast low-angle shot three-dimensional (FLASH-3D) dynamic contrast-enhanced MRI for the pre-operative staging of endometrial carcinoma.

METHODS

This prospective study enrolled 48 patients with complete clinical data and pathologically confirmed endometrial carcinoma from July 2012 to March 2014. After routine MRI examination, subjects underwent FLASH-3D dynamic contrast-enhanced examination. The dynamically enhanced features of the uterine wall and tumours were analyzed. FLASH-3D pre-operative staging and findings in relation to myometrial invasion were compared with post-operative pathological results in a double-blind manner.

RESULTS

There were 48 cases of pathologically proven endometrial carcinoma, including 34 patients with Stage I (Stage Ia 22 cases and Stage Ib 12 cases), 9 with Stage II, 3 with Stage III and 2 with Stage IV. The staging accuracy for endometrial carcinoma was 81% (39/48) using FLASH-3D dynamic contrast-enhanced sequences. The sensitivity, specificity and accuracy for the determination of deep myometrial invasion were 84%, 90% and 88%, respectively. There was no significant difference compared with the results of post-operative pathology (p > 0.05).

CONCLUSION

FLASH-3D dynamic contrast-enhanced imaging may be valuable for the early diagnosis and pre-operative staging of endometrial carcinoma. Its high accuracy for assessing deep myometrial invasion makes FLASH-3D imaging an important tool for selecting the optimal therapeutic protocol and for prognosis estimation.

ADVANCES IN KNOWLEDGE

FLASH-3D can significantly improve the accurate assessment of the depth of tumour invasion into the myometrium and may thus help to guide clinical surgical choices and post-operative evaluation. FLASH-3D is thus a promising technique for the routine examination of female pelvic tumours.

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.

Functional MR Imaging in Gynecologic Cancer

Dynamic-contrast enhanced (DCE) and diffusion-weighted (DW) MR imaging are invaluable in the detection, staging, and characterization of uterine and ovarian malignancies, for monitoring treatment response, and for identifying disease recurrence. When used as adjuncts to morphologic T2-weighted (T2-W) MR imaging, these techniques improve accuracy of disease detection and staging. DW-MR imaging is preferred because of its ease of implementation and lack of need for an extrinsic contrast agent. MR spectroscopy is difficult to implement in the clinical workflow and lacks both sensitivity and specificity. If used quantitatively in multicenter clinical trials, standardization of DCE- and DW-MR imaging techniques and rigorous quality assurance is mandatory.

MR assessment of myometrial invasion in women with endometrial cancer: discrepancy between T2-weighted imaging and contrast-enhanced T1-weighted imaging

PURPOSE

The purpose of the study was to investigate how frequently discrepant imaging findings are encountered between T2-weighted imaging and contrast-enhanced T1-weighted imaging in the preoperative magnetic resonance (MR) assessment of myometrial invasion in women with endometrial cancer.

METHODS

Seventy-one consecutive women (mean age, 59 years; age range 35-86 years) with endometrial cancer who underwent preoperative MR imaging were included in this single-institution, retrospective study. Depth of myometrial invasion was separately assessed on T2-weighted imaging and contrast-enhanced T1-weighted imaging, and the assessment was considered discrepant, when the two imaging sequences did not match each other. The image analysis also included potential pitfalls responsible for discrepant imaging findings, including the absence of the junctional zone, disruption of the junctional zone, extension to the uterine cornu, presence of leiomyoma and presence of adenomyosis. The results were correlated with histopathologic findings.

RESULTS

Of the 71 women, 19 (26.8%) showed discrepant imaging findings between T2-weighted imaging and contrast-enhanced T1-weighted imaging. Histopathologic findings revealed that contrast-enhanced T1-weighted imaging correctly depicted endometrial cancers in all women with discrepant MR imaging findings. Among the analyzed potential pitfalls, only disruption of the junctional zone showed a significant difference between women with concordant MR imaging findings (29.5%, 13/44) and women with discordant MR imaging findings (93.8%, 15/16) (p = 0.000).

CONCLUSION

In the preoperative MR assessment of myometrial invasion in women with endometrial cancer, discrepant imaging findings between T2-weighted imaging and contrast-enhanced T1-weighted imaging are frequently encountered, especially when the junctional zone is disrupted.

Optimization of MR imaging for pretreatment evaluation of patients with endometrial and cervical cancer

Endometrial and cervical cancer are the most common gynecologic malignancies in the world. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. The current International Federation of Gynecology and Obstetrics (FIGO) staging system does not include modern imaging modalities. However, magnetic resonance (MR) imaging has proved to be the most accurate noninvasive modality for staging endometrial and cervical carcinomas and often helps with risk stratification and making treatment decisions. Multiparametric MR imaging is increasingly being used to evaluate the female pelvis, an approach that combines anatomic T2-weighted imaging with functional imaging (ie, dynamic contrast material-enhanced and diffusion-weighted imaging). MR imaging helps guide treatment decisions by depicting the depth of myometrial invasion and cervical stromal involvement in patients with endometrial cancer and tumor size and parametrial invasion in those with cervical cancer. However, its accuracy for local staging depends on technique and image quality, namely thin-section high-resolution multiplanar T2-weighted imaging with simple modifications, such as double oblique T2-weighting supplemented by diffusion weighting and contrast enhancement.

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.

Role of imaging in the pretreatment evaluation of common gynecological cancers

Different treatment options are available for patients with gynecological cancers. Imaging plays an important role in assessment of patients with common cancers involving uterine body, cervix and ovaries, from detection to evaluation of the extent of disease. The purpose of this review is to highlight the role of cross-sectional imaging techniques in treatment stratification and overall management of patients with endometrial, cervical and ovarian cancers. Several imaging techniques used are described, including ultrasound, computed tomography (CT), MRI and PET/CT. Specific imaging appearances of the most common uterine, cervical and ovarian cancers are discussed. Imaging findings corresponding to the 2009 revised International Federation of Gynecology and Obstetrics (FIGO) staging of gynecologic malignancies are also described. In the multidisciplinary evaluation of patients with gynecologic malignancies, the role of the radiologist has become central for accurate diagnosis and evaluation of extent of disease to achieve better treatment selection and planning.

Pre-operative MR evaluation of features that indicate the need of adjuvant therapies in early stage cervical cancer patients. A single-centre experience

OBJECTIVES

This study compared the MR measurement of minimum uninvolved cervical stroma and maximum stromal invasion, and the detection of positive lymph nodes with the pathological results. In addition, tumour type and grade were correlated with nodal status and apparent diffusion coefficient (ADC) values.

METHODS

Patients who underwent surgery and MR at our centre for early stage cervical cancer (FIGO IA1-IIB) were included. Data recorded included: age, date of MR, clinical FIGO (International Federation of Gynacology and Obstetrics) stage, histological type and grade, adjuvant therapy, pre-surgical conisation. MR evaluation included: measurement of the minimum uninvolved stroma, maximum thickness of stromal involvement, presence and site of positive pelvic lymph nodes, calculation of ADC values. Statistical analysis was performed to compare MR and pathological results. The agreement between MR and pathology in measuring depth of stromal invasion was analysed by Bland-Altman plot, calculating the limits of agreement (LoA).

RESULTS

113/217 patients underwent adjuvant therapies. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MR in evaluation of minimum thickness of uninvolved cervical stroma were 88%, 75%, 70%, 90% and 80%; the same values in evaluation of pelvic positive lymph nodes were 64%, 85%, 65%, 84% and 78%. The mean difference between MR and pathological results in measuring maximum depth of stromal invasion was -0.65mm (95% LoA: -9.37mm; 8.07mm). Depth of stromal invasion was strongly related to positive nodal status (p<0.001). ADC values (available in 51/217 patients) were not associated with the features assessed.

CONCLUSIONS

Pre-surgical MR is accurate (80%) in evaluating the minimum thickness of uninvolved cervical stroma; MR measurements of maximum depth of stromal invasion differed ±9mm from the pathological results in 95% of cases. Furthermore, a strong association was found between the depth of stromal invasion and the presence of positive lymph nodes, suggesting that inclusion of these measurements in the MR report might guide the choice of the best treatment option for early cervical cancer patients.

The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know

Many treatment options are available to patients with endometrial, cervical, or ovarian cancer. Magnetic resonance (MR) imaging plays an important role in the patient journey from the initial evaluation of the extent of the disease to appropriate treatment selection and follow-up. The purpose of this review is to highlight the added role of MR imaging in the treatment stratification and overall care of patients with endometrial, cervical, or ovarian cancer. Several MR imaging techniques used in evaluation of patients with gynecologic malignancies are described, including both anatomic MR imaging sequences (T1- and T2-weighted sequences) and pulse sequences that characterize tissue on the basis of physiologic features (diffusion-weighted MR imaging), dynamic contrast agent-enhanced MR imaging, and MR spectroscopy. MR imaging findings corresponding to the 2009 revised International Federation of Gynecology and Obstetrics staging of gynecologic malignancies are also described in detail, highlighting possible pearls and pitfalls of staging. With the growing role of the radiologist as a core member of the multidisciplinary treatment planning team, it is crucial for imagers to recognize that MR imaging has become central in tailoring treatment options and therapy in patients with gynecologic malignancies.

Pearls and pitfalls in MRI of gynecologic malignancy with diffusion-weighted technique

OBJECTIVE

Developments in MRI techniques have increased the role of MRI in assessment of the pelvis in women. The aims of this review are a short overview of pelvic MRI with an emphasis on diffusion-weighted MRI (DWI) and presentation of a practical approach that includes the pearls and pitfalls of DWI.

CONCLUSION

DWI provides indispensable information in the evaluation of gynecologic malignancies. Prudent application of this technique requires knowledge of the optimal protocols and pitfalls in interpretation.

New MR techniques in gynecologic cancer

OBJECTIVE

Functional MR techniques report on a variety of biologic features of tumors: dynamic contrast-enhanced, diffusion-weighted, and intrinsic susceptibility-weighted MRI and MR spectroscopy reflect, at a simplistic level, vascularity, cellularity, hypoxic status, and metabolism, respectively. This article reviews the evidence for each of the functional MR readouts to determine these clinical end points and thus influence the management of ovarian, endometrial, and cervical cancer.

CONCLUSION

These techniques may be implemented in gynecologic malignancies to detect, characterize, and stage tumors as well as potentially to predict the outcome and measure response to treatment.

Endometrial cancer: preoperative staging using three-dimensional T2-weighted turbo spin-echo and diffusion-weighted MR imaging at 3.0 T: a prospective comparative study

OBJECTIVES

To prospectively assess the efficacy of 3-T magnetic resonance (MR) imaging using the three-dimensional turbo spin-echo T2-weighted and diffusion-weighted technique (3D-TSE/DW) compared with that of conventional imaging using the two-dimensional turbo spin-echo T2-weighted and dynamic contrast-enhanced technique (2D-TSE/DCE) for the preoperative staging of endometrial cancer, with pathological analysis as the reference standard.

METHODS

Seventy-one women with endometrial cancer underwent MR imaging using 3D-TSE/DW (b = 1,000 s/mm(2)) and 2D-TSE/DCE. Two radiologists independently assessed the two imaging sets. Accuracy, sensitivity, and specificity for staging were analysed with the McNemar test; the areas under the receiver operating characteristic curve (Az) were compared with a univariate z-score test.

RESULTS

The results for assessing deep myometrial invasion, accuracy, sensitivity, specificity and Az, respectively, were as follows: 3D-TSE/DW-observer 1, 87 %, 95 %, 85 % and 0.96; observer 2, 92 %, 84 %, 94 % and 0.95; 2D-TSE/DCE-observer 1, 80 %, 79 %, 81 % and 0.89; observer 2, 86 %, 84 %, 87 % and 0.86. Most of the values were higher with 3D-TSE/DW without significant differences (P > 0.12). For assessing cervical stromal invasion, there were no significant differences in those values for both observers (P > 0.6).

CONCLUSIONS

Accuracy of 3D-TSE/DW was at least equivalent to that of the conventional technique for the preoperative assessment of endometrial cancer.

KEY POINTS

• New techniques in MR imaging help assess patients with endometrial cancer. • A 3D T2-weighted TSE sequence seems equally as accurate as conventional techniques. • Three-dimensional TSE/DW imaging does not require intravenous contrast material and is relatively quick. • Tumour extent of endometrial cancer can be clearly shown on diffusion-weighted images. • Junctional zone can be visualised well on 3D-TSE T2-weighted images.

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.

Predictive value of T2-weighted imaging and contrast-enhanced MR imaging in assessing myometrial invasion in endometrial cancer: a pooled analysis of prospective studies

BACKGROUND

To obtain diagnostic performance values of T2-weighted imaging (T2WI) and contrast-enhanced magnetic resonance imaging (CE-MRI) in the prediction of myometrial invasion in patients with endometrial cancer.

METHODS

Databases including MEDLINE and EMBASE were searched for relevant original articles published from January 1995 to March 2012. Pooled estimation data were obtained by statistical analysis.

RESULTS

Eleven articles (548 patients) were included. For assessing any myometrial involvement, the pooled sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for CE-MRI were 0.81 (95% CI, 0.72, 0.88), 0.72 (95% CI, 0.64, 0.79), 0.65 (95% CI, 0.56, 0.73) and 0.85 (95% CI, 0.78, 0.91); for T2WI, they were 0.87 (95% CI, 0.78, 0.94), 0.58 (95% CI, 0.47, 0.69), 0.64 (95% CI, 0.54, 0.73), 0.84 (95% CI, 0.73, 0.92) respectively. The pooled specificity of CE-MRI (0.72) was significantly higher than T2WI (0.58) (P < 0.05). For assessing deep myometrial involvement, there was no statistically significant difference between CE-MRI and T2WI, (P > 0.05).

CONCLUSIONS

CE-MRI has a good diagnostic performance in the prediction of any myometrial invasion and is superior to T2WI. But its PPV is somewhat suboptimal. For assessing deep myometrial involvement, its NPV appears relative high and negative findings strongly suggest an absence of deep myometrial involvement, which can guide therapeutic decision-making.

FIGO staging system for endometrial cancer: added benefits of MR imaging

Endometrial cancer is the most commonly diagnosed gynecologic malignancy in the United States. This pathologic condition is staged with the International Federation of Gynecology and Obstetrics (FIGO) system. The FIGO staging system recently underwent significant revision, which has important implications for radiologists. Key changes incorporated into the 2009 FIGO staging system include simplification of stage I disease and removal of cervical mucosal invasion as a distinct stage. Magnetic resonance (MR) imaging is essential for the preoperative staging of endometrial cancer because it can accurately depict the depth of myometrial invasion, which is the most important morphologic prognostic factor and correlates with tumor grade, presence of lymph node metastases, and overall patient survival. Diffusion-weighted MR imaging and dynamic contrast medium-enhanced MR imaging are useful adjuncts to standard morphologic imaging and may improve overall staging accuracy.