The preoperative assessment of deep myometrial invasion by three-dimensional ultrasound versus MRI in endometrial carcinoma

Three-dimensional transvaginal ultrasound vs magnetic resonance imaging for preoperative staging of deep myometrial and cervical invasion in patients with endometrial cancer: systematic review and meta-analysis

OBJECTIVES

To evaluate and compare the diagnostic test accuracy (DTA) of three-dimensional transvaginal ultrasound (3D-TVS) and magnetic resonance imaging (MRI) for deep myometrial infiltration (DMI) and cervical invasion for preoperative staging and surgery planning in patients with endometrial cancer (EC).

METHODS

This systematic review and meta-analysis investigated the DTA of MRI and 3D-TVS for DMI and cervical invasion in patients with EC. A literature search was performed using MEDLINE, Scopus, EMBASE, ScienceDirect, The Cochrane library, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, EU Clinical Trials Register and World Health Organization International Clinical Trials Registry Platform to identify relevant studies published between January 2000 and December 2021. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

RESULTS

Five studies, including a total of 450 patients, were included in the systematic review. All five studies compared the DTA of 3D-TVS vs MRI for DMI, and three studies compared the DTA of 3D-TVS vs MRI for cervical invasion. Pooled sensitivity, positive likelihood ratio and negative likelihood ratio for detecting DMI using 3D-TVS were 77% (95% CI, 66-85%), 4.57 and 0.31, respectively. The respective values for detecting DMI on MRI were 80% (95% CI, 73-86%), 4.22 and 0.24. Bivariate metaregression indicated a similar DTA of 3D-TVS and MRI (P = 0.80) for the correct identification of DMI. Pooled ln diagnostic odds ratio for detecting cervical invasion was 3.11 (95% CI, 2.09-4.14) for 3D-TVS and 2.36 (95% CI, 0.90-3.83) for MRI. The risk of bias was low for most of the four domains assessed in QUADAS-2.

CONCLUSION

3D-TVS demonstrated good diagnostic accuracy in terms of sensitivity and specificity for the evaluation of DMI and cervical invasion, with results comparable with those of MRI. Thus, we confirmed the potential role of 3D-TVS in the preoperative staging and surgery planning in patients with EC. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

Synergic role of preoperative 18F-fluorodeoxyglucose PET and MRI parameters in predicting histopathological features of endometrial cancer

BACKGROUND

The aim of the present study is to explore the correlation between PET and MRI parameters of primary tumour and clinicopathological features and to determine their synergic predictive role in patients with endometrial cancer candidate to surgery.

METHODS

Retrospective study including 27 patients with endometrial cancer and preoperative 18F-fluorodeoxyglucose (18F-FDG)-PET and MRI scan. The following parameters, calculated on the primary tumour, were used for analysis: maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV) and total lesion glycolysis (TLG) for PET scans; mean apparent diffusion coefficient (ADCmean) and volume index for MRI scans. FIGO stage, grade, histotype, lymphovascular space invasion (LVSI) and myometrial invasion were the considered clinicopathological features.

RESULTS

MRI volume index was a good predictor for deep myometrial invasion [area under the curve (AUC) = 0.85; P = 0.003] and for LVSI (AUC = 0.74; P = 0.039). A cutoff value of 9.555 for MRI volume index was predictive for deep myometrial invasion (sensitivity = 84.6%; specificity = 76.9%); a cutoff of 12.165 was predictive for LVSI (sensitivity = 69.2%; specificity = 83.3%). A TLG cutoff value of 26.03 was predictive for deep myometrial invasion (sensitivity = 84.6%; specificity = 76.9%). A high-direct correlation was found with MRI volume index (rho = 0.722; P < 0.001); low-direct correlation with SUVmax (rho = 0.484; P = 0.012), SUVmean (rho = 0.47; P = 0.015) and TLG (rho = 0.482; P = 0.013) were identified. The SUVmax/ADCmean ratio showed a low-direct correlation with percentage of myometrial invasion (rho = 0.467; P = 0.016).

CONCLUSION

Volume index, TLG and SUVmax/ADCmean ratio are associated with deep myometrial invasion. As myometrial invasion is the index used to predict lymph node involvement in endometrial cancer, the synergic use of these imaging parameters may be suggested to predict lymphnodal metastases.

Preoperative assessment of endometrial cancer

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.

Prognostic role of FDG PET-derived parameters in preoperative staging of endometrial cancer

PURPOSE

To investigate the preoperative prognostic role of ¹⁸F-FDG PET/CT in patients with endometrial carcinoma (EC).

METHODS

¹⁸F-FDG PET/CT was performed in 57 patients for EC preoperative staging. Maximum and mean standardized uptake values (SUVmax, mean), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) of primary tumors, at different thresholds of 40%, 50%, 60% (40-50-60), were evaluated and compared with anatomopathological features. The diagnostic performance of PET-parameters (categorized by ROC analysis) in discriminating low-intermediate and high-risk disease and the prognostic role on survival (overall survival -OS; disease free survival - DFS) was evaluated.

RESULTS

The categorized TLG40-50-60 were the only parameters related to FIGO stage I versus II-III-IV (p = 0.0035 for all). The cut-off values for risk stratification were 83.69, 61.81 and 41.32, respectively (sensitivity: 60.00%; specificity; 71.43% for all parameters). Pathological stage 1 (pT1) of the primary tumor was predicted by MTV60 and TLG40-50 (p = 0.0328, 0.0240, 0.0147, respectively). The optimal thresholds were 7.795, 99.55 and 77.58, respectively (sensitivity: 38.46%, 53.85% and 53.85%, respectively; specificity: 88.64%, 79.55% and 81.82%, respectively). SUVmax and SUVmean40-50-60 were the only parameters discriminating endometrioid from non-endometrioid subtype. The corresponding sensitivity was 64.86% and 62.16% for SUVmax and SUVmean 50-60 and 62.16% for SUVmean40; specificity was 70.00% for all parameters. The mean (SD) OS was 79.77% (3.34%) and the mean DFS was 77.89% (3.73%). The tumor type was the only variable significantly associated with OS (p = 0.0486). TLG50 > 77.58 cm³ was the only variable associated with a higher risk of relapse (p = 0.0472).

CONCLUSION

TLG40-50-60 and MTV60 of primary EC have prognostic value in discriminating FIGO and pathological staging. These results suggest a possible role of these parameters in predicting EC aggressiveness, thus improving the preoperative characterization of endometrial cancer.

Predictive Value of Three-Dimensional Transvaginal Sonography for Staging of Endometrial Neoplasia

The goal of this study was to compare the sonographic assessment of endometrial cancer diagnosis and staging using three-dimensional transvaginal sonography with the staging that was ultimately found at surgery. Three-dimensional transvaginal sonography was performed for 20 consecutive cases of presumptive endometrial cancer using power Doppler angiography, virtual organ computer-aided analysis, and volume contrast imaging. These results were compared with the surgical staging found for those identified cases. The sonographic findings predicted the correct minimum endometrial cancer staging in 100% of the 20 cases that were examined and correlated to surgical outcomes. The successful prediction of endometrial cancer staging demonstrated by others was replicated in the organization of this case series. The findings compared favorably with other imaging modalities used for this purpose. This study assists in demonstrating the value of using presurgical three-dimensional sonography to plan for the optimal surgical excision and overall treatment of endometrial cancer.

Preoperative Assessment of Myometrial Invasion in Endometrial Cancer by 3D Ultrasound and Diffusion-Weighted Magnetic Resonance Imaging: A Comparative Study

OBJECTIVE

The prognosis of endometrial cancer depends on the correct surgical staging. In early stages, 18% to 30% rate of positive lymph nodes is reported with a myometrial invasion of 50% or more. According to this, patients with International Federation of Gynecology and Obstetrics stage Ib would benefit from staging lymphadenectomy. Therefore, it is important to classify these patients preoperatively to plan the surgery. In the recent years, 3-dimensional (3D) ultrasound and diffusion-weighted magnetic resonance imaging (DW-MRI) have been incorporated in the preoperative management of these patients. The aim of this study was to assess the usefulness of 3D ultrasound and DW-MRI as predictor of myometrial invasion in endometrial cancer.

MATERIAL AND METHODS

We retrospectively compared the assessment of myometrial invasion by 3D ultrasound and DW-MRI with final pathologic evaluation on hysterectomy specimens, in 98 patients diagnosed of early-stage endometrial cancer, who underwent surgery at the Hospital Clinic of Barcelona between 2012 and 2015.

RESULTS

Evaluation of the depth of myometrial invasion with 3D ultrasound had a sensitivity, specificity, and accuracy of 77%, 83% and 81%, respectively. Evaluation of the depth of myometrial invasion with DW-MRI had a sensitivity, specificity, and accuracy of 69%, 86%, and 81%, respectively. Association of both techniques improved all the values, showing a sensitivity, specificity, and accuracy of 87%, 93%, and 91%, respectively. In both 3D ultrasound and DW-MRI, the presence of leiomyomas was the first detectable cause of false negative (3% and 4%, respectively) and false-positive (3% and 1%, respectively).

CONCLUSIONS

We conclude that the implementation of the 2 studies in early-stage endometrial cancer provides low false-negatives and false-positives rates. In cases of patients with leiomyomas, adenomiosis, or intrauterine fluid collection, definitive evaluation of myometrial invasion could be better deferred to intraoperative biopsy in an attempt to reduce false-negatives and false-positives rates.

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.

Application of Combined Two-Dimensional and Three-Dimensional Transvaginal Contrast Enhanced Ultrasound in the Diagnosis of Endometrial Carcinoma

Objective. The goal of this study was to explore the clinical value of combining two-dimensional (2D) and three-dimensional (3D) transvaginal contrast-enhanced ultrasounds (CEUS) in diagnosis of endometrial carcinoma (EC). Methods. In this prospective diagnostic study, transvaginal 2D and 3D CEUS were performed on 68 patients with suspected EC, and the results of the obtained 2D-CEUS and 3D-CEUS images were compared with the gold standard for statistical analysis. Results. 2D-CEUS benign endometrial lesions showed the normal uterine perfusion phase while EC cases showed early arrival and early washout of the contrast agent and nonuniform enhancement. The 3D-CEUS images differed in central blood vessel manifestation, blood vessel shape, and vascular pattern between benign and malignant endometrial lesions (P < 0.05). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of transvaginal 2D-CEUS and 2D-CEUS combined with 3D-CEUS for diagnosis of benign and malignant endometrial lesions were 76.9%, 73.8%, 64.5%, 83.8%, and 75.0% and 84.6%, 83.3%, 75.9%, 89.7%, and 83.8%, respectively. Conclusion. 3D-CEUS is a useful supplement to 2D-CEUS and can clearly reveal the angioarchitecture spatial relationships between vessels and depth of myometrial invasion in EC. The combined use of 2D and 3D-CEUS can offer direct, accurate, and comprehensive diagnosis of early EC.

Contrast-enhanced MRI in preoperative assessment of myometrial and cervical invasion, and lymph node metastasis: diagnostic value and error analysis in endometrial carcinoma

OBJECTIVE

To determine the ability of contrast-enhanced magnetic resonance imaging to predict myometrial invasion, cervical invasion, and pelvic lymph node metastasis in endometrial carcinoma and to analyze factors that lead to errors in this identification.

DESIGN

A retrospective study.

SETTING

University general hospital.

POPULATION

A total of 167 women diagnosed with endometrial carcinoma.

METHODS

All patients received a preoperative contrast-enhanced magnetic resonance imaging scan. Histopathological findings were used as the definitive diagnosis.

MAIN OUTCOME MEASURES

The results were compared with histopathological findings, factors that make accurate assessment of myometrial invasion, cervical invasion, and pelvic lymph node metastasis difficult by contrast-enhanced magnetic resonance imaging were analyzed.

RESULTS

The sensitivity, specificity, diagnostic accuracy, positive predictive values, and negative predictive values of contrast-enhanced magnetic resonance imaging were 90.9, 91.8, 91.6, 73.2 and 97.6%, respectively, for identifying deep myometrial invasion; 84.2, 96.0, 94.6, 72.7 and 97.9%, respectively, for identifying cervical invasion; and 45.0, 91.2, 85.6, 40.9 and 92.4%, respectively, for identifying pelvic lymph node metastasis. The main causes of error in contrast-enhanced magnetic resonance imaging were myomas, cornual lesions, deep myometrial invasion, large tumor size, non-endometrioid tumor type, and lower tumor grade.

CONCLUSION

Contrast-enhanced magnetic resonance imaging has a high accuracy and a low tendency to produce false-negative predictive values. Gynecological oncologists should combine the imaging data and clinical information to make therapeutic decisions and avoid diagnostic errors.

Three-dimensional ultrasound with volume contrast imaging for preoperative assessment of myometrial invasion and cervical involvement in women with endometrial cancer

OBJECTIVES

To evaluate the accuracy of transvaginal three-dimensional ultrasound with volume contrast imaging (VCI) for preoperative assessment of depth of myometrial invasion and cervical involvement in women with endometrial cancer.

METHODS

Transvaginal volume acquisition of the uterus was performed in 60 consecutive patients with histological diagnosis of endometrial cancer who were scheduled for primary surgical treatment. Depth of myometrial invasion and presence or absence of cervical involvement were assessed using VCI in multiplanar display mode. Results were compared to final postoperative histopathological findings. Patients with histological high-risk cell types, including Grade 3 endometrioid adenocarcinoma, clear cell carcinoma, papillary serous carcinoma and carcinosarcoma, were excluded.

RESULTS

Forty patients were included in the analysis. The accuracy of VCI in assessing single-stage myometrial invasion (superficial or deep) was 92.5%. In the prediction of deep myometrial invasion, sensitivity, specificity, PPV and NPV of VCI were 100%, 89.7%, 78.6% and 100%, respectively. The accuracy of VCI in assessing cervical involvement was 90.0%. Sensitivity, specificity, PPV and NPV of VCI in predicting the presence of cervical involvement were 100%, 86.2%, 73.3% and 100%, respectively.

CONCLUSION

Transvaginal VCI is an uncomplicated method that is able to predict with reasonable accuracy the depth of myometrial invasion and cervical involvement in women with endometrial cancer.

The preoperative maximum standardized uptake value measured by 18F-FDG PET/CT as an independent prognostic factor of overall survival in endometrial cancer patients

PURPOSE

The aim of this study was to determine if the preoperative maximum standardized uptake value (SUVmax) measured by 18F-FDG PET/CT in the primary tumor has prognostic value in the group of patients with endometrial cancer.

PATIENTS, MATERIALS, AND METHODS

A total of one hundred one consecutive endometrial cancer patients, age range 40-82 years (mean 62 years) and FIGO I-IV stage, who underwent 18-FDG-PET/CT within two weeks prior radical surgery, were enrolled to the study. The maximum SUV was measured and compared with the clinicopathologic features of surgical specimens. The relationship between SUVmax and overall survival was analyzed.

RESULTS

The mean preoperative SUVmax was 14.34; range (3.90-33.80) and was significantly lower for FIGO I than for higher stages (P = 0.0012), as well as for grade 1 than for grade 2 and 3 (P = 0.018), deep myometrial invasion (P = 0.0016) and for high risk group (P = 0.0004). The analysis of survival ROC curve revealed SUVmax cut-off value of 17.7 to predict high risk of recurrence. Endometrial cancer patients with SUVmax higher than 17.7 characterized by lower overall survival.

CONCLUSION

The preoperative SUVmax measured by 18F-FDG PET/CT is considered as an important indicator reflecting tumor aggressiveness which may predict poor prognosis. High value of SUVmax would be useful for making noninvasive diagnoses and deciding the appropriate therapeutic strategy for patients with endometrial cancer.