Local-regional staging of endometrial carcinoma: role of MR imaging in surgical planning

Magnetic resonance imaging evaluation of gynecological mass lesions: A comprehensive analysis with histopathological correlation

Evaluating gynecological mass lesions and reviewing their morphological characteristics based on their imaging appearance on magnetic resonance imaging (MRI), and correlating the MRI findings with histopathological findings, was the central theme of our study. This observational cross-sectional study was conducted on 60 female patients with clinically suspected gynecological mass lesions upon physical examination and/or ultrasonography, referred for MRI at a tertiary care hospital over a 1-year period between June 2022 and July 2023. A broad spectrum of differential diagnoses of gynecological masses was observed. In our study, the ratio of benign versus malignant disease was 1.6:1, with 37 benign and 23 malignant masses identified. The most common benign masses were uterine fibroids (n = 14; 23.3%), followed by endometriosis (n = 8; 13.3%), and ovarian dermoid cysts (n = 4; 6.6%). Among the malignant lesions, cervical cancer was the most common (n = 11; 18.3%), followed by endometrial carcinoma (n = 7; 11.6%), ovarian carcinoma (n = 3; 5%), and vaginal carcinoma (n = 2; 3%). Benign lesions mostly appeared hypo- to isointense on T1-weighted imaging and iso- to hyperintense on T2-weighted imaging, while malignant lesions appeared isointense on T1-weighted and hyperintense on T2-weighted imaging. Hemorrhage and fat were well appreciated on MRI and aided in diagnosis. T2 shading was present in 7 out of 8 endometriotic cysts, demonstrating a specificity of 100% and a sensitivity of 83%. For determining parametrial invasion in cervical carcinoma, MRI showed an accuracy of 91%, specificity of 100%, and positive predictive value, negative predictive value, and sensitivity of 100%, 75%, and 88%, respectively. In cases of endometrial carcinoma, MRI demonstrated a sensitivity and specificity of 87% and 91%, respectively, with a positive predictive value of 87% and a negative predictive value of 91% for identifying myometrial invasion greater than 50%. Compared to other modalities, MRI provided substantial information regarding uterine and adnexal masses and surrounding structures, facilitating accurate staging of lesions.

A predictive model for lymph node metastasis using tumor location in presumed early-stage endometrioid endometrial cancer patients

OBJECTIVE

The aim of this study was to identify high- and low-risk subgroups of patients with lymph node (LN) metastasis in presumed early-stage endometrioid endometrial cancer (EC) patients.

METHODS

Clinicopathologic data of presumed early-stage endometrioid EC patients (n=361) treated with lymphadenectomy between March 2000 and July 2022 were analyzed. None of the patient had definite evidence of LN metastasis in a preoperative magnetic resonance imaging (MRI). A received operating characteristic curve analysis was conducted to define the sensitivity and specificity for the combined preoperative risk factors for LN metastasis, which was determined by multivariate analysis.

RESULTS

Nineteen patients (5.3%) had LN metastasis. Multivariate analysis identified cervical stromal invasion on MRI (odds ratio [OR]=4.386; 95% confidence interval [CI]=1.020-18.852; p=0.047), cornual location of tumor on MRI (OR=36.208; 95% CI=7.902-165.913; p<0.001), and lower uterine segment/isthmic location of tumor on MRI (OR=8.454; 95% CI=1.567-45.610; p=0.013) as independent prognostic factors associated with LN metastasis. Patients were categorized into low- and high-risk groups according to risk criteria. Significant differences in the rates of LN metastasis were observed between the two groups (0.4% vs. 22.2%, p<0.001).

CONCLUSION

Approximately 95% of presumed early-stage endometrioid EC patients did not have LN metastasis. A model using tumor location was significantly correlated with the risk of LN metastasis. Even in presumed early-stage endometrioid EC patients, therefore, tumor location should be investigated to determine whether to perform LN assessment.

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.

Nodal infiltration in endometrial cancer: a prediction model using best subset regression

OBJECTIVES

To build preoperative prediction models with and without MRI for regional lymph node metastasis (r-LNM, pelvic and/or para-aortic LNM (PENM/PANM)) and for PANM in endometrial cancer using established risk factors.

METHODS

In this retrospective two-center study, 364 patients with endometrial cancer were included: 253 in the model development and 111 in the external validation. For r-LNM and PANM, respectively, best subset regression with ten-time fivefold cross validation was conducted using ten established risk factors (4 clinical and 6 imaging factors). Models with the top 10 percentile of area under the curve (AUC) and with the fewest variables in the model development were subjected to the external validation (11 and 4 candidates, respectively, for r-LNM and PANM). Then, the models with the highest AUC were selected as the final models. Models without MRI findings were developed similarly, assuming the cases where MRI was not available.

RESULTS

The final r-LNM model consisted of pelvic lymph node (PEN) ≥ 6 mm, deep myometrial invasion (DMI) on MRI, CA125, para-aortic lymph node (PAN) ≥ 6 mm, and biopsy; PANM model consisted of DMI, PAN, PEN, and CA125 (in order of correlation coefficient β values). The AUCs were 0.85 (95%CI: 0.77-0.92) and 0.86 (0.75-0.94) for the external validation, respectively. The model without MRI for r-LNM and PANM showed AUC of 0.79 (0.68-0.89) and 0.87 (0.76-0.96), respectively.

CONCLUSIONS

The prediction models created by best subset regression with cross validation showed high diagnostic performance for predicting LNM in endometrial cancer, which may avoid unnecessary lymphadenectomies.

CLINICAL RELEVANCE STATEMENT

The prediction risks of lymph node metastasis (LNM) and para-aortic LNM can be easily obtained for all patients with endometrial cancer by inputting the conventional clinical information into our models. They help in the decision-making for optimal lymphadenectomy and personalized treatment.

KEY POINTS

•Diagnostic performance of lymph node metastases (LNM) in endometrial cancer is low based on size criteria and can be improved by combining with other clinical information. •The optimized logistic regression model for regional LNM consists of lymph node ≥ 6 mm, deep myometrial invasion, cancer antigen-125, and biopsy, showing high diagnostic performance. •Our model predicts the preoperative risk of LNM, which may avoid unnecessary lymphadenectomies.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Predictive Value of Magnetic Resonance Imaging in Risk Stratification and Molecular Classification of Endometrial Cancer

This study evaluated the magnetic resonance imaging (MRI) findings of endometrial cancer (EC) patients and identified differences based on risk group and molecular classification. The study involved a total of 175 EC patients. The MRI data were retrospectively reviewed and compared based on the risk of recurrence. Additionally, the associations between imaging phenotypes and genomic signatures were assessed. The low-risk and non-low-risk groups (intermediate, high-intermediate, high, metastatic) showed significant differences in tumor diameter (p < 0.001), signal intensity and heterogeneity on diffusion-weighted imaging (DWI) (p = 0.003), deep myometrial invasion (involvement of more than 50% of the myometrium), cervical invasion (p < 0.001), extrauterine extension (p = 0.002), and lymphadenopathy (p = 0.003). Greater diffusion restriction and more heterogeneity on DWI were exhibited in the non-low-risk group than in the low-risk group. Deep myometrial invasion, cervical invasion, extrauterine extension, lymphadenopathy, recurrence, and stage discrepancy were more common in the non-low-risk group (p < 0.001). A significant difference in microsatellite stability status was observed in the heterogeneity of the contrast-enhanced T1-weighted images (p = 0.027). However, no significant differences were found in MRI parameters related to TP53 mutation. MRI features can be valuable predictors for differentiating risk groups in patients with EC. However, further investigations are needed to explore the imaging markers based on molecular classification.

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.

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.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background: The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. Objectives: To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. Materials and Methods: ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. Results: The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. Conclusions: These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma. Hum Reprod Open 2023;2023:hoac057. [PMID: 36756380 PMCID: PMC9900425 DOI: 10.1093/hropen/hoac057]

STUDY QUESTION

How should fertility-sparing treatment of patients with endometrial carcinoma be performed?

SUMMARY ANSWER

Forty-eight recommendations were formulated on fertility-sparing treatment of patients with endometrial carcinoma.

WHAT IS KNOWN ALREADY

The standard surgical treatment of endometrial carcinoma consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in endometrial carcinoma in a multidisciplinary setting. While addressing also work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility-sparing treatment.

STUDY DESIGN SIZE DURATION

A collaboration was set up between the ESGO, the European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE), aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

PARTICIPANTS/MATERIALS SETTING METHODS

ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practising clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgement was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

MAIN RESULTS AND THE ROLE OF CHANCE

The multidisciplinary development group formulated 48 recommendations in four sections; patient selection, tumour clinicopathological characteristics, treatment and special issues.

LIMITATIONS REASONS FOR CAUTION

Of the 48 recommendations, none could be based on level I evidence and only 16 could be based on level II evidence, implicating that 66% of the recommendations are supported only by observational data, professional experience and consensus of the development group.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario.

STUDY FUNDING/COMPETING INTERESTS

All costs relating to the development process were covered from ESGO, ESHRE and ESGE funds. There was no external funding of the development process or manuscript production. G.S. has reported grants from MSD Italia S.r.l., advisory boards for Storz, Bayer, Astrazeneca, Metronic, TESARO Bio Italy S.r.l and Johnson & Johnson, and honoraria for lectures from Clovis Oncology Italy S.r.l. M.G. has reported advisory boards for Gedeon Richter and Merck. The other authors have reported no conflicts of interest.

DISCLAIMER

This document represents the views of ESHRE, ESGO and ESGE which are the result of consensus between the relevant stakeholders and where relevant based on the scientific evidence available at the time of preparation. The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

The standard surgical treatment of endometrial carcinoma, consisting of total hysterectomy with bilateral salpingo-oophorectomy, drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) provide comprehensive information on all relevant issues of diagnosis and treatment in endometrial carcinoma in a multidisciplinary setting. While addressing also work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility-sparing treatment.A collaboration was set up between the ESGO, the European Society of Human Reproduction and Embryology (ESHRE), and the European Society for Gynaecological Endoscopy (ESGE), aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment (patient selection, tumor clinicopathological characteristics, treatment, special issues) in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (11 experts from across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified by a systematic search, was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background

The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment.

Objectives

To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma.

Materials and Methods

ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

Results

The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues.

Conclusions

These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Preoperative and intraoperative assessment of myometrial invasion in patients with FIGO stage I non-endometrioid endometrial carcinoma-a large-scale, multi-center, and retrospective study

INTRODUCTION

Myometrial invasion is a prognostic factor for lymph node metastases and decreased survival in non-endometrioid endometrial carcinoma patients. Herein, we explored the mode of myometrial invasion diagnosis in FIGO stage I non-endometrioid carcinoma and evaluated the differences in diagnostic efficiency among intraoperative frozen section (IFS), intraoperative gross examination (IGE), magnetic resonance imaging (MRI), and computed tomography (CT) in clinical practice. Finally, we suggested which test should be routinely performed.

METHOD

This was a historical cohort study nationwide with 30 centers in China between January 2000 and December 2019. Clinical data, including age, histology, method of myometrial invasion evaluation (MRI, CT, IGE, and IFS), and final diagnosis of postoperative paraffin sections, were collected from 490 non-endometrioid endometrial carcinoma (serous, clear cell, undifferentiated, mixed carcinoma, and carcinosarcoma) women in FIGO stage I.

RESULTS

Among the 490 patients, 89.59% presented myometrial invasion. The methods reported for myometrial invasion assessment were IFS in 23.47%, IGE in 69.59%, MRI in 37.96%, and CT in 10.20% of cases. The highest concordance was detected between IFS and postoperative paraffin sections (Kappa = 0.631, accuracy = 93.04%), followed by IGE (Kappa = 0.303, accuracy = 82.40%), MRI (Kappa = 0.131, accuracy = 69.35%), and CT (Kappa = 0.118, accuracy = 50.00%). A stable diagnostic agreement between IFS and the final results was also found through the years (2000-2012: Kappa = 0.776; 2013-2014: Kappa = 0.625; 2015-2016: Kappa = 0.545; 2017-2019: Kappa = 0.652).

CONCLUSION

In China, the assessment of myometrial invasion in non-endometrioid endometrial carcinoma is often performed via IGE, but the reliability is relatively low in contrast to IFS. In clinical practice, IFS is a reliable method that can help accurately assess myometrial invasion and intraoperative decision-making (lymph node dissection or not). Hence, it should be routinely performed in non-endometrioid endometrial carcinoma patients.

Imaging Recommendations for Diagnosis, Staging, and Management of Uterine Cancer

Uterine cancers are classified into cancers of the corpus uteri (uterine carcinomas and carcinosarcoma) and corpus uteri (sarcomas) by the AJCC staging system (eighth edition). Endometrial carcinoma is the most common amongst these with prolonged estrogen exposure being a well-known risk factor. The FIGO staging system for endometrial carcinoma is primarily surgical and includes total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Imaging is useful in the preoperative evaluation of tumor stage, especially assessment of myometrial invasion and cervical stromal extension. Dynamic contrast enhanced MRI with DWI has a high staging accuracy and is the preferred imaging modality for primary evaluation with contrast-enhanced CT abdomen being indicated for recurrent disease. PET/CT is considered superior in evaluation of lymph nodes and extra pelvic metastases.

Oncological outcomes in fertility-sparing treatment in stage IA-G2 endometrial cancer

Background

The gold standard treatment for early-stage endometrial cancer (EC) is hysterectomy with bilateral salpingo-oophorectomy (BSO) with lymphadenectomy. In selected patients desiring pregnancy, fertility-sparing treatment (FST) can be adopted. Our review aims to collect the most incisive studies about the possibility of conservative management for patients with grade 2, stage IA EC. Different approaches can be considered beyond demolition surgery, such as local treatment with levonorgestrel-releasing intra-uterine device (LNG-IUD) plus systemic therapy with progestins.

Study design

Our systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, EMBASE, and Scopus databases were consulted, and five studies were chosen based on the following criteria: patients with a histological diagnosis of EC stage IA G2 in reproductive age desiring pregnancy and at least one oncological outcome evaluated. Search imputes were “endometrial cancer” AND “fertility sparing” AND “oncologic outcomes” AND “G2 or stage IA”.

Results

A total of 103 patients were included and treated with a combination of LNG-IUD plus megestrol acetate (MA) or medroxyprogesterone acetate (MPA), gonadotrophin-releasing hormone (GnRH) plus MPA/MA, hysteroscopic resectoscope (HR), and dilation and curettage (D&C). There is evidence of 70% to 85% complete response after second-round therapy prolongation to 12 months.

Conclusions

Conservative measures must be considered temporary to allow pregnancy and subsequently perform specific counseling to adopt surgery. Fertility-sparing management is not the current standard of care for young women with EC. It can be employed for patients with early-stage diseases motivated to maintain reproductive function. Indeed, the results are encouraging, but the sample size must be increased.

A deep learning-based automatic staging method for early endometrial cancer on MRI images

Early treatment increases the 5-year survival rate of patients with endometrial cancer (EC). Deep learning (DL) as a new computer-aided diagnosis method has been widely used in medical image processing which can reduce the misdiagnosis by radiologists. An automatic staging method based on DL for the early diagnosis of EC will benefit both radiologists and patients. To develop an effective and automatic prediction model for early EC diagnosis on magnetic resonance imaging (MRI) images, we retrospectively enrolled 117 patients (73 of stage IA, 44 of stage IB) with a pathological diagnosis of early EC confirmed by postoperative biopsy at our institution from 1 January 2018, to 31 December 2020. Axial T2-weighted image (T2WI), axial diffusion-weighted image (DWI) and sagittal T2WI images from 117 patients have been classified into stage IA and stage IB according to the patient’s pathological diagnosis. Firstly, a semantic segmentation model based on the U-net network is trained to segment the uterine region and the tumor region on the MRI images. Then, the area ratio of the tumor region to the uterine region (TUR) in the segmentation map is calculated. Finally, the receiver operating characteristic curves (ROCs) are plotted by the TUR and the results of the patient’s pathological diagnosis in the test set to find the optimal staging thresholds for stage IA and stage IB. In the test sets, the trained semantic segmentation model yields the average Dice similarity coefficients of uterus and tumor on axial T2WI, axial DWI, and sagittal T2WI were 0.958 and 0.917, 0.956 and 0.941, 0.972 and 0.910 respectively. With pathological diagnostic results as the gold standard, the classification model on axial T2WI, axial DWI, and sagittal T2WI yielded an area under the curve (AUC) of 0.86, 0.85 and 0.94, respectively. In this study, an automatic DL-based segmentation model combining the ROC analysis of TUR on MRI images presents an effective early EC staging method.

Magnetic resonance imaging pitfalls in determining myometrial invasion in stage I endometrial cancer: A case report and literature review

The degree of myometrial invasion (MI) is crucial in the preoperative diagnosis of endometrial cancer (EC) using MRI in terms of therapeutic and prognostic implications. However, several pitfalls should be kept in mind when using this modality. We report a case of EC on a 64-year-old woman, identified preoperatively without MI based on ultrasonography and MRI, implying a low risk of lymph node metastasis; surprisingly, the uterine incision showed the lesion had invaded <50% of the myometrium. Thus, a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed, and histopathologic analysis confirmed that the EC was on stage IA (cancer is in the endometrium only or less than halfway through the myometrium). In our case, thinning myometrium and uterine atrophy due to aging, multiple leiomyomas, previous curettage, and blood clots were all pitfalls for MRI in detecting MI. By detecting tiny or isointense tumors and depicting distinct vascularity of the malignancy in postmenopausal women, functional MRI techniques such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced MRI (DCE-MRI) can help reduce pitfalls when assessing MI. Clinicians can employ DWI preoperatively, which is more reliable and superior to DCE-MRI in determining tumor areas without contrast injection and perform a postoperative histopathological examination to confirm MI in EC.

A Comparison of Dynamic Contrast-Enhanced Magnetic Resonance Imaging and T2-Weighted Imaging in Determining the Depth of Myometrial Invasion in Endometrial Carcinoma—A Retrospective Study

This study aims to compare dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with T2-weighted imaging (T2WI) in defining the depth of myometrial invasion in endometrial carcinoma. This retrospective study included 32 subjects with endometrial carcinoma who underwent 3.0T magnetic resonance imaging (MRI) prior to hysterectomy. DCE-MRI and T2WI were evaluated to determine the depth of myometrial invasion in endometrial carcinoma. A set of data consisting of the sensitivity, specificity, predictive values, and accuracy of DCE-MRI and T2WI were obtained and compared with the histopathological results. Out of the 32 cases included, the histopathological examination revealed that 50% myometrial invasion was found in 11 patients and ≥50% myometrial invasion was found in 21 patients. In the assessment of the tumor invasion, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of T2WI were 45.45%, 90.48 %, 71.43%, 76.0%, and 75.0%, respectively. The corresponding values for DCE-MRI were 81.82%, 76.19%, 64.29%, 88.89 %, and 78.12%, respectively. When T2WI were read together with DCE-MRI, the values were 90.91%, 90.48%, 83.33%, 95.0%, and 90.62%, respectively. Thus, the sensitivity and accuracy of DCE-MRI were greater compared to T2WI in defining the depth of myometrial invasion. However, the merging of T2WI and DCE-MRI increased the specificity and PPV value and improved the sensitivity, NPV and accuracy in detecting myometrial invasion. DCE-MRI was more sensitive but less specific than T2WI in defining the depth of myometrial invasion. In conclusion, combining DCE-MRI and T2WI further improves the diagnostic performance for myometrial invasion in endometrial carcinoma.

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

RATIONALE AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The Preeminent Value of the Apparent Diffusion Coefficient in Assessing High-Risk Factors and Prognosis for Stage I Endometrial Carcinoma Patients

Objectives

To evaluate the role of the apparent diffusion coefficient (ADC) value in the individualized management of stage I endometrial carcinoma (EC).

Methods

A retrospective analysis was performed on 180 patients with stage I EC who underwent 1.5-T magnetic resonance imaging. The mean ADC (mADC), minimum ADC (minADC), and maximum ADC (maxADC) values of each group were measured and compared. We analyzed the relationship between ADC values and stage I EC prognosis by Kaplan-Meier method and Cox proportional hazards analysis.

Results

Patients with lower ADC values were more likely to be characterized by higher grades, specific histological subtypes and deeper myometrial invasion. The mADC, minADC and maxADC values (×10^-3 mm²/s) were 1.045, 0.809 and 1.339, respectively, in grade 1/2 endometrioid carcinoma with superficial myometrial invasion, which significantly differed from those in grade 3 or nonendometrioid carcinoma or with deep myometrial invasion (0.929, 0.714 and 1.215) (P=<0.001, <0.001 and <0.001). ADC values could be used to predict these clinicopathological factors. Furthermore, the group with higher ADC values showed better disease-free survival and overall survival.

Conclusions

The present study indicated that ADC values were associated with the high-risk factors for stage I EC and to assess whether fertility-sparing, ovarian preservation or omission of lymphadenectomy represent viable treatment options. Moreover, this information may be applied to predict prognosis. Thus, ADC values could contribute to managing individualized therapeutic schedules to improve quality of life.

Preoperative magnetic resonance imaging predicts clinicopathological parameters and stages of endometrial carcinomas

BACKGROUND

We investigated the agreement and accuracy of preoperative magnetic resonance imaging (MRI) with postoperative pathological characteristics and stages of endometrial endometrioid carcinoma (EEC).

METHODS

We recruited 527 women with EEC who underwent staging surgery at a single medical institution. The preoperative MRI, stages, and clinical and pathological parameters, including myometrial invasion (MI), cervical invasion (CI), adnexal metastasis (AM), intra-abdominal metastasis, and pelvic and/or para-aortic nodal metastasis, were recorded and analyzed. The agreement and accuracy between the preoperative MRI findings and these parameters and stages were assessed.

RESULTS

The rate of the preoperative MRI-based clinical stage matching the postoperative surgical stage was 85.2% in International Federation of Gynecology and Obstetrics stage IA, 51.9% in stage IB, 35.5% in stage II, 5.3% in stage IIIA, 33.3% in stage IIIB, 28.6% in stage IIIC1, 64.3% in stage IIIC2, and 93.8% in stage IVB. The consistency between radiologists and pathologists was 80.5% for deep MI, 91.5% for cervical invasion, 92.2% for adnexal metastasis, 98.9% for intra-abdominal metastasis, and 87.5% and 92.2% for pelvic and para-aortic nodal metastases, respectively. The negative predictive value of intra-abdominal metastasis was the highest with 99.8%.

CONCLUSIONS

Preoperative MRI could be an excellent tool for routine preoperative assessment to predict pathological parameters and stages of EEC, especially in excluding intra-abdominal metastatic disease.

Conservative Surgery in Endometrial Cancer

Endometrial cancer (EC) is the sixth most common female cancer worldwide. The median age of diagnosis is 65 years. However, 4% of women diagnosed with EC are younger than 40 years old, and 70% of these women are nulliparous. These data highlight the importance of preserving fertility in these patients, at a time when the average age of the first pregnancy is significantly delayed and is now firmly established at over 30 years of age. National Comprehensive Cancer Network (NCCN guidelines state that the primary treatment of endometrial endometrioid carcinoma, limited to the uterus, is a total hysterectomy, bilateral salpingo-oophorectomy and surgical staging. Fertility-sparing treatment is not the standard of care, and patients eligible for this treatment always have to undergo strict counselling. Nowadays, a combined approach consisting of hysteroscopic resection, followed by oral or intrauterine-released progestins, has been reported to be an effective fertility-sparing option. Hysteroscopic resection followed by progestins achieved a complete response rate of 95.3% with a recurrence rate of 14.1%. The pregnancy rate in women undergoing fertility-sparing treatment is 47.8%, but rises to 93.3% when only considering women who tried to conceive during the study period. The aim of the present review is to provide a literature overview reflecting the current state of fertility-sparing options for the management of EC, specific criteria for considering such options, their limits, the implications for reproductive outcomes and the latest research trends in this direction.

Dynamic contrast-enhanced (DCE) imaging: state of the art and applications in whole-body imaging

Dynamic contrast-enhanced (DCE) imaging is a non-invasive technique used for the evaluation of tissue vascularity features through imaging series acquisition after contrast medium administration. Over the years, the study technique and protocols have evolved, seeing a growing application of this method across different imaging modalities for the study of almost all body districts. The main and most consolidated current applications concern MRI imaging for the study of tumors, but an increasing number of studies are evaluating the use of this technique also for inflammatory pathologies and functional studies. Furthermore, the recent advent of artificial intelligence techniques is opening up a vast scenario for the analysis of quantitative information deriving from DCE. The purpose of this article is to provide a comprehensive update on the techniques, protocols, and clinical applications - both established and emerging - of DCE in whole-body imaging.

Using amide proton transfer-weighted MRI to non-invasively differentiate mismatch repair deficient and proficient tumors in endometrioid endometrial adenocarcinoma

OBJECTIVES

To investigate the utility of three-dimensional (3D) amide proton transfer-weighted (APTw) imaging to differentiate mismatch repair deficient (dMMR) and mismatch repair proficient (pMMR) tumors in endometrioid endometrial adenocarcinoma (EEA).

METHODS

Forty-nine patients with EEA underwent T1-weighted imaging, T2-weighted imaging, 3D APTw imaging, and diffusion-weighted imaging at 3 T MRI. Image quality and measurement confidence of APTw images were evaluated on a 5-point Likert scale. APTw and apparent diffusion coefficient (ADC) values were calculated and compared between the dMMR and pMMR groups and among the three EEA histologic grades based on the Federation of Gynecology and Obstetrics (FIGO) grading system criteria. Student's t-test, analysis of variance with Scheffe post hoc test, and receiver operating characteristic analysis were performed. Statistical significance was set at p < 0.05.

RESULTS

Thirty-five EEA patients (9 with dMMR tumors and 26 with pMMR tumors) with good image quality were enrolled in quantitative analysis. APTw values were significantly higher in the dMMR group than in the pMMR group (3.2 ± 0.3% and 2.8 ± 0.5%, respectively; p = 0.019). ADC values of the dMMR and pMMR groups were 0.874 ± 0.104 × 10-3 mm2/s and 0.903 ± 0.100 × 10-3 mm2/s, respectively. No significant between-group difference was noted (p = 0.476). No statistically significant differences were observed in APTw values or ADC values among the three histologic grades (p = 0.766 and p = 0.295, respectively).

CONCLUSIONS

APTw values may be used as potential imaging markers to differentiate dMMR from pMMR tumors in EEA.

Diagnostic Accuracy in Assessment of Depth of Myometrial Invasion in Low-grade Endometrioid Carcinoma: A 2 Center Comparative Study by MRI and Intraoperative Assessment

The role of lymphadenectomy in endometrial carcinomas is controversial, especially in low-grade endometrioid carcinomas. In many institutions, lymphadenectomy in the latter neoplasms is undertaken only when there is deep myometrial invasion, defined as invasion involving 50% or more of the myometrium (FIGO stage IB). There has been considerable debate as to the best modality to detect deep myometrial invasion. In Europe, preoperative magnetic resonance imaging (MRI) is the most commonly used modality while in North America, intraoperative assessment (IOA) is undertaken in most, but not all, institutions. The aim of this study was to compare the diagnostic accuracy of these 2 modalities in identifying deep myometrial invasion in low-grade endometrioid carcinomas. Two patient cohorts were studied from Belfast, UK (n=253) and Boston, USA (n=276). With respect to detecting deep myometrial invasion, MRI had a sensitivity of 72.84%, positive predictive value of 75.64% and a positive likelihood ratio of 6.59 (95% confidence interval; 4.23-10.28). IOA had a sensitivity of 78.26%, positive predictive value of 80% and a positive likelihood ratio of 20.00 (95% confidence interval; 10.35-38.63). The superior positive likelihood ratio suggests that IOA is better than MRI in determining deep myometrial invasion and the nonoverlapping 95% confidence intervals suggest this is a significant finding. However, there are significant resource implications associated with IOA and preoperative MRI carries other advantages that are discussed herein.

MRI of the endometrium - from normal appearances to rare pathology

MRI was recently included as a standard pre-operative diagnostic tool for patients with endometrial cancer. MR findings allow a better risk assessment and ultimately guides the surgical planning. Therefore, it is vital that the radiological interpretation is as accurate as possible. This requires essential knowledge regarding the appropriate MRI protocol, as well as different appearances of the endometrium, ranging from normal peri- and post-menopausal changes, benign findings (e.g. endometrial hyperplasia, polyp, changes due to exogenous hormones) to common and rare endometrium-related malignancies. Furthermore, this review will emphasize the role of MRI in staging endometrial cancer patients and highlight pitfalls that could result in the underestimation or overestimation of the disease extent.

The prominent value of apparent diffusion coefficient in assessing high-risk factors and prognosis for patients with endometrial carcinoma before treatment

BACKGROUND

To date, there are no consensus methods to evaluate the high-risk factors and prognosis for managing the personalized treatment schedule of patients with endometrial carcinoma (EC) before treatment. Apparent diffusion coefficient (ADC) is regarded as a kind of technique to assess heterogeneity of malignant tumor.

PURPOSE

To explore the role of ADC value in assessing the high-risk factors and prognosis of EC.

MATERIAL AND METHODS

A retrospective analysis was made on 185 patients with EC who underwent 1.5-T magnetic resonance imaging (MRI). Mean ADC (mADC), minimum ADC (minADC), and maximum ADC (maxADC) were measured and compared in different groups.

RESULTS

Among the 185 patients with EC, the mADC and maxADC values in those with high-risk factors (type 2, deep myometrial invasion, and lymph node metastasis) were significantly lower than in those without. According to receiver operating characteristic (ROC) curve analysis, the areas under the curve (AUC) were significant for mADC, minADC, and maxADC predicting high-risk factors. Furthermore, the AUCs were significant for mADC and maxADC predicting lymph node metastasis but were not significant for minADC. Patients with lower mADC were associated with worse overall survival and disease-free survival; the opposite was true for patients with higher mADC.

CONCLUSION

Our study showed that ADC values could be applied to assess the high-risk factors of EC before treatment and might significantly relate to the prognosis of EC. It might contribute to managing initial individualized treatment schedule and improve outcome in patients with EC.

Predictive value of T2-weighted imaging and dynamic contrast-enhanced MRI for assessing cervical invasion in patients with endometrial cancer: a meta-analysis

PURPOSE

To obtain the diagnostic accuracy of T2-weighted imaging (T2WI), and dynamic contrast-enhanced MRI (DCE-MRI) in the preoperative assessment of cervical invasion in patients with endometrial cancer (EC).

METHODS

Databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials were searched for relevant articles published from January 2000 to August 2020. Pooled estimation data were obtained by statistical analysis.

RESULTS

In total, 24 articles were included. For assessing cervical invasion of EC, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) for T2WI were 0.70 (0.61-0.77), 0.92 (0.89-0.94), 8.7 (6.5-11.6), 0.33 (0.25-0.43), 26 (17-41), and 0.92 (0.89-0.94), respectively. For DCE-MRI, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.75 (0.60-0.85), 0.95 (0.89-0.98), 14.7 (6.6-32.9), 0.27 (0.16-0.44), 55 (18-165), and 0.92 (0.89-0.94), respectively; for T2WI combined with DCE-MRI, they were 0.58 (0.41-0.73), 0.98 (0.95-0.99), 28.1 (12.8-62.1), 0.43 (0.30-0.63), 65 (29-146), and 0.94 (0.91-0.96), respectively.

CONCLUSIONS

DCE-MRI demonstrated higher diagnostic performance than T2WI in the prediction of cervical invasion in patients with EC. T2WI combined with DCE-MRI improved the pooled specificity, PLR, DOR, and AUC compared to T2WI alone or DCE-MRI alone.

Three-dimensional turbo-spin-echo amide proton transfer-weighted and intravoxel incoherent motion MR imaging for type I endometrial carcinoma: Correlation with Ki-67 proliferation status

BACKGROUND

To evaluate 3-dimensional amide proton transfer weighted (APTw) imaging for type I endometrial carcinoma (EC), and investigate correlations of Ki-67 labelling index with APTw and intravoxel incoherent motion (IVIM) imaging.

METHODS

54 consecutive patients suspected of endometrial lesions underwent pelvic APTw and IVIM imaging on a 3 T MR scanner. APTw values and IVIM-derived parameters (Dt, D*, f) were independently measured by two radiologists on 22 postoperative pathological confirmed of type I EC lesions. Results were compared between histological grades and Ki-67 proliferation groups. ROC analysis was performed. Pearson's correlation analysis was performed for APTw values and IVIM-derived parameters with Ki-67 labeling index.

RESULTS

APTw values and Dt, D*, f of all type I EC were 2.9 ± 0.1%, 0.677 ± 0.027 × 10-3 mm2/s, 31.801 ± 11.492 × 10-3 mm2/s, 0.179 ± 0.050 with inter-observer ICC 0.996, 0.850, 0.956, 0.995, respectively. APTw values of Ki-67 low-proliferation group (<30%, n = 8) were 2.5 ± 0.2%, significantly lower than the high-proliferation group (>30%, n = 14) with APTw values of 3.1 ± 0.1% (p = 0.016). Area under the curve was 0.768. APTw values of type I EC were moderately positively correlated with Ki-67 labelling index (r = 0.583, p = 0.004). There was no significant difference of Dt (p = 0.843), D* (p = 0.262), f (p = 0.553) between the two groups. No correlation was found between IVIM-derived parameters and Ki-67 labelling index (Dt, p = 0.717; D* p = 0.151; f, p = 0.153).

CONCLUSION

3D TSE APTw imaging is a feasible approach for detecting type I EC. Ki-67 labeling index positively moderately correlates with APTw not with IVIM.

Diagnostic Accuracy of MRI for Detecting Cervical Invasion in Patients with Endometrial Carcinoma: A Meta-Analysis

Objectives: To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) in the preoperative assessment of cervical invasion and to analyse the influence of different imaging protocols in patients with endometrial carcinoma.

Methods: An extensive search of articles about MRI for assessing cervical invasion in patients with endometrial carcinoma was performed on PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials from January 2000 to July 2020. Two reviewers independently evaluated the methodological quality of each study by using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Diagnostic accuracy results and additional useful information were extracted. The pooled estimation data was obtained by statistical analysis.

Results: A total of 42 eligible studies were included in the meta-analysis. Significant evidence of heterogeneity was found for detecting cervical invasion (I² = 74.1%, P = 0.00 for sensitivity and I² = 56.2%, P = 0.00 for specificity). The pooled sensitivity and specificity of MRI were 0.58 and 0.95 respectively. The use of higher field strength (3.0 T) demonstrated higher pooled sensitivity (0.74). Using diffusion weighted imaging (DWI) alone presented higher pooled sensitivity (0.86) than using other sequences. The studies that used dynamic contrast-enhanced MRI (DCE-MRI) alone showed higher sensitivity (0.80) and specificity (0.96) than those that used T2-weighted imaging (T2WI) alone.

Conclusions: MRI shows high specificity for detecting cervical infiltration in endometrial carcinoma. Using DWI or a 3.0-T device may improve the pooled sensitivity. DCE-MRI demonstrates higher pooled sensitivity and specificity than T2WI.

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.

Differentiation of endometrial adenocarcinoma from adenocarcinoma of cervix using kinetic parameters derived from DCE-MRI

PURPOSE

This prospective study aimed to investigate the value of kinetic parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in differentiating uterine endometrioid adenocarcinoma (EAC) from adenocarcinoma of cervix (AdC).

METHODS

Seventy-five newly diagnosed patients with distinctive pathology underwent DCE-MRI. Observers independently calculated the tumor diameters and DCE-MRI parameters using both population and individual-based arterial input function (AIF). Inter-observer consistency was evaluated, and a comparative analysis between EAC (n = 47) and AdC (n = 28) was performed. Regression analysis was used to select parameters that best distinguished EAC from AdC, and to generate predictive models. Receiver operating characteristic curve (ROC) was applied to calculate the diagnostic efficiency of single parameter and the predictive models.

RESULTS

Inter-observer consistency was excellent (intra-class correlation [ICC] = 0.902-0.981), especially when calculated via population AIF with relatively higher ICC and smaller SD on Bland-Altman plot. Tumor diameters were not correlated with tumor types. All the DCE-MRI parameters were lower in EAC compared to AdC, except K_ep by population AIF and TTP by both sets of AIFs. The statistical parameters were V_e, Maxslop, and Maxconc by population AIF, and Maxslop and K^trans by individual AIF included in the predictive models, respectively. The two predictive models with combined parameters showed improved diagnostic efficiency in differentiating these two diseases compared with a single parameter.

CONCLUSION

DCE-MRI can quantitatively evaluate the perfusion difference between EAC and AdC, thus improving the identification of uterine adenocarcinoma with uncertain biopsy pathology.

The Diagnostic Value of MRI for Preoperative Staging in Patients with Endometrial Cancer: A Meta-Analysis

OBJECTIVES

To assess the diagnostic accuracy of magnetic resonance imaging (MRI) for detecting myometrial invasion, cervical invasion, and lymph node metastases in endometrial cancer.

MATERIALS AND METHODS

A systematic literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, and Clinical trials. The methodological quality of each study was assessed by using the standard Quality Assessment of Diagnostic Accuracy Studies-2. Statistical analysis included evaluating publication bias, assessing threshold effect, exploring heterogeneity, pooling data, meta-regression, forest plot, and summary receiver-operating characteristics curves construction.

RESULTS

Fourteen studies could be analyzed. For detecting deep myometrial invasion, the pooled sensitivity and specificity were 0.79 and 0.81 respectively, and patients younger than 60 years old demonstrated higher sensitivity (0.84) and specificity (0.90). The diagnostic accuracy is highest by jointly using T2-weighted image, dynamic contrast-enhanced MRI, and diffusion weighted imaging to detect the deep myometrial invasion. There were low sensitivity and high specificity for the diagnosis of cervical invasion (0.53, 0.95), cervical stromal invasion (0.50, 0.95), pelvic or/and para-aortic lymph node metastases (0.59, 0.95), and pelvic lymph node metastases (0.65, 0.95).

CONCLUSION

MRI has good diagnostic performance for assessing myometrial invasion in patients with endometrial cancer, especially in patients younger than 60 years old. Dynamic contrast-enhanced MRI and diffusion weighted imaging can help improve sensitivity and specificity for detecting myometrial invasion. MRI shows high specificity for detecting cervical invasion and lymph node metastases in endometrial cancer.

Microcystic, Elongated and Fragmented Pattern Invasion Can Adversely Influence Preoperative Staging for Low-grade Endometrial Carcinoma

Purpose:

To investigate the influence of microcystic, elongated and fragmented (MELF) pattern invasion on preoperative evaluation of lymph node (LN) metastasis and myometrial invasion in patients with low-grade endometrial carcinoma.

Methods:

The study included 192 consecutive patients with low-grade endometrial carcinoma who underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI), followed by surgery. One hundred sixty one of 192 patients underwent LN dissection and were analyzed for LN metastasis. All patients were analyzed for myometrial invasion. Presence of enlarged LN was evaluated by using size criteria on CT. Depth of myometrial invasion was evaluated on MRI using T₂-weighted imaging, diffusion-weighted imaging and contrast-enhanced T₁-weighted imaging comprehensively. Sensitivity and specificity for LN metastasis and deep myometrial invasion were evaluated for MELF group and non-MELF group. The difference of sensitivity between two groups was compared using Chi-square and Fisher’s exact test.

Results:

MELF pattern invasion was identified in 43/192 patients (22%). LN metastases were observed in 18/39 patients in MELF group and 6/122 patients in non-MELF group for pelvic LN and 11/29 patients in MELF group and 4/57 patients in non-MELF group for para-aortic LN. Sensitivity for the detection of pelvic LN metastasis in MELF group was significantly lower than in non-MELF group (16.7% vs 66.7%). As for the assessment of the deep myometiral invasion, pathological deep myometrial invasion were found in 31/43 patients in MELF group and 32/149 patients in non-MELF group. Sensitivity in MELF group showed lower values than in non-MELF group (54.8% vs 78.1% for reader 1, 54.8% vs 62.5% for reader 2), although there was no statistically significant difference (P = 0.09 for reader 1 and P = 0.72 for reader 2).

Conclusion:

In case of low-grade endometrial carcinoma with MELF pattern invasion, preoperative staging by CT and MRI have a risk for underestimation.

[Magnetic Resonance Imaging for local preoperative staging in endometrial cancer: Nantes local experience]

OBJECTIVES

To determine the diagnostic accuracy of magnetic resonance imaging (MRI) for local preoperative staging in endometrial cancer in our center (Centre Hospitalier Universitaire de Nantes: CHU), since the French National Cancer Institute's surgery recommendations publication in 2010, especially for the prediction of myometrial and cervical stromal invasion.

METHODS

Retrospective monocentric study of consecutive women operated of endometrial cancer in gynecology department of CHU de Nantes, who underwent preoperative pelvic MRI in our Radiology department from November 2010 to November 2016. MRI data collected from initial report and compared to surgical histological findings as gold standard.

RESULTS

Sixty-four patients were included. Deep myometrial invasion was present in 35 patients in MRI versus 34 patients on postoperative histology (5 false positives, 4 false negatives). Cervical stromal invasion was present in 9 patients in MRI versus 19 patients on postoperative histology (2 false positives, 12 false negatives). The sensitivity and the specificity were respectively 88.23% (95% confidence intervals (CI) [0.71-0.96]) and 83.33% (CI [0.64-0.93]) for the deep myometrial invasion; 36.84% (CI [0.17-0.61]) and 95.55% (CI [0.83-0.99]) for the cervical stromal invasion.

CONCLUSION

Our results were comparable to the literature data, with a low sensitivity for the cervical stromal invasion detection, driving us to change our MRI protocol with optional high-resolution T2 sequences perpendicular to the cervical canal if necessary.

Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources

BACKGROUND

Approximately 70% of cancer-related deaths occur in low- and middle-income countries. In addition to social and racial inequalities, treatment options in these countries are usually limited because of the lack of trained staff and equipment, limited patient access to health services, and a small number of clinical guidelines.

OBJECTIVES

The Brazilian Society of Surgical Oncology developed this guideline to address these barriers and guide physicians treating patients with endometrial cancer (EC) in regions with limited resources and few specialized centers.

METHODS

The guideline was prepared from 10 January to 25 October 20192019 by a multidisciplinary team of 56 experts to discuss the main obstacles faced by EC patients in Brazil. Thirteen questions considered critical to the surgical treatment of these patients were defined. The questions were assigned to groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments for presentations in meetings, classified the level of evidence, and voted on the recommendations.

RESULTS

For all questions including staging, fertility spearing treatment, genetic testing, sentinel lymph node use, surgical treatment, and other clinical relevant questions, major agreement was achieved by the participants, always using accessible alternatives.

CONCLUSIONS

It is possible to provide adequate treatment for most EC patients in resource-limited areas, but the first option should be referral to specialized centers with more resources.

Frozen section accurately allows pathological characterization of endometrial cancer in patients with a preoperative ambiguous or inconclusive diagnoses: our experience

Background

The aim of this study was to assess the agreement rate between intraoperative evaluation (IOE) and final diagnosis (FD) in a series of surgically resected endometrial carcinoma (EC), with a preoperative ambiguous or inconclusive diagnosis by endometrial biopsies and imaging.

Methods

A retrospective study was performed selecting patients who underwent surgery with IOE for suspected EC at our institution from 2012 to 2018. A K coefficient was determined with respect to the histotype, tumor grade, myometrial infiltration and cervical involvement.

Results

Data analysis has been performed on 202 women. The IOE evaluation was distributed as Endometrioid (n = 180) and Non-Endometrioid (n = 22). The comparison between the frozen section (FS) and the definitive histological subtype showed an overall agreement rate of 93,07% (k = 0.612) and an agreement of 97.2% for Endometrioid vs 59% for Non-Endometrioid tumors. The FIGO system grading was the same in 91,1% of patients, none was upgraded and in 8,9% downgraded. Observed agreements were 89,11% and 95,54% for myometrial and cervical involvement, respectively.

Conclusions

The good agreement between intraoperative grading, myometrial invasion and their histological definition on permanent sections highlights that FS is a good predictor for surgical outcome, in particular in presence of a preoperative ambiguous or inconclusive diagnostic evaluation.

Endometrial Carcinoma: Texture Analysis of Apparent Diffusion Coefficient Maps and Its Correlation with Histopathologic Findings and Prognosis

PURPOSE

To determine the feasibility of texture analysis (TA) of apparent diffusion coefficient (ADC) maps for predicting histologic grade (HG) and recurrence-free survival (RFS) in patients with endometrial carcinoma (EMC).

MATERIALS AND METHODS

One hundred twenty-one patients with EMC were examined by using a 1.5-T MRI system and diffusion-weighted imaging (DWI) with b values of 0 and 1000 sec/mm². Software with volumes of interest on ADC maps was used to extract 45 texture features including higher-order texture features. Receiver operating characteristic analysis was performed to compare the diagnostic performance of the random forest (RF) model and ADC values for HG and recurrence.

RESULTS

Area under the curve (AUC) for predicting high-grade EMCs was significantly larger for RF model than for ADC values (0.967 vs 0.898; P = .0336). AUC for predicting recurrence was larger for the RF model than for ADC values (0.890 vs 0.875; P = .7248), although the difference was not significant. Mean RFS was significantly shorter for high-grade EMCs than for low-grade EMCs (P = .0002; hazard ratio, 4.9) and for ADC values less than or equal to 0.802 × 10^-3 mm²/sec than for ADC values greater than 0.802 × 10^-3 mm²/sec (P < .0001; hazard ratio, 32.9). RF model showed that the mean RFS was significantly shorter for the presence of recurrence than for its absence (P < .0001; hazard ratio, 94.7).

CONCLUSION

TA of ADC maps had significantly higher diagnostic performance than did ADC values for predicting HG and was a more useful indicator than HG and ADC values for predicting RFS in patients with EMC.Keywords: Comparative Studies, Genital/Reproductive, MR-Diffusion Weighted Imaging, MR-Imaging, Neoplasms-Primary, Pathology, Pelvis, Tissue Characterization, Uterus© RSNA, 2019.

Diagnostic Accuracy of Clinical Biomarkers for Preoperative Prediction of Lymph Node Metastasis in Endometrial Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

In endometrial carcinoma (EC), preoperative classification is based on histopathological criteria, with only moderate diagnostic performance for the risk of lymph node metastasis (LNM). So far, existing molecular classification systems have not been evaluated for prediction of LNM. Optimized use of clinical biomarkers as recommended by international guidelines might be a first step to improve tailored treatment, awaiting future molecular biomarkers.

AIM

To determine the diagnostic accuracy of preoperative clinical biomarkers for the prediction of LNM in endometrial cancer.

METHODS

A systematic review was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies identified in MEDLINE and EMBASE were selected by two independent reviewers. Included biomarkers were based on recommended guidelines (cancer antigen 125 [Ca-125], lymphadenopathy on magnetic resonance imaging, computed tomography, and ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography [¹⁸FDG PET-CT]) or obtained by physical examination (body mass index, cervical cytology, blood cell counts). Pooled sensitivity, specificity, area under the curve (AUC), and likelihood ratios were calculated with bivariate random-effects meta-analysis. Likelihood ratios were classified into small (0.5-1.0 or 1-2.0), moderate (0.2-0.5 or 2.0-5.0) or large (0.1-0.2 or ≥ 5.0) impact.

RESULTS

Eighty-three studies, comprising 18,205 patients, were included. Elevated Ca-125 and thrombocytosis were associated with a moderate increase in risk of LNM; lymphadenopathy on imaging with a large increase. Normal Ca-125, cytology, and no lymphadenopathy on ¹⁸FDG PET-CT were associated with a moderate decrease. AUCs were above 0.75 for these biomarkers. Other biomarkers had an AUC <0.75 and incurred only small impact.

CONCLUSION

Ca-125, thrombocytosis, and imaging had a large and moderate impact on risk of LNM and could improve preoperative risk stratification.

IMPLICATIONS FOR PRACTICE

Routine lymphadenectomy in clinical early-stage endometrial carcinoma does not improve outcome and is associated with 15%-20% surgery-related morbidity, underlining the need for improved preoperative risk stratification. New molecular classification systems are emerging but have not yet been evaluated for the prediction of lymph node metastasis. This article provides a robust overview of diagnostic performance of all clinical biomarkers recommended by international guidelines. Based on these, at least measurement of cancer antigen 125 serum level, assessment of thrombocytosis, and imaging focused on lymphadenopathy should complement current preoperative risk stratification in order to better stratify these patients by risk.

Magnetic Resonance Imaging (MRI) and Three-Dimensional Transvaginal Ultrasonography Scanning for Preoperative Assessment of High Risk in Women with Endometrial Cancer

Background

To evaluate the diagnostic performance of MRI and 3D-TVS for assessment of deep myometrial invasion (MI), cervical involvement (CI), and Lymph node metastases (LNM) in endometrial cancer staging before surgery.

Material/Methods

From January 2016 to December 2017, we reviewed data from 314 women with endometrial cancer who underwent preoperative MRI and 3D-TVS before surgery. The diagnostic sensitivity, specificity, PPV, NPV, and accuracy in detecting MI, CI, and LNM were estimated based on ultimate pathology results.

Results

The sensitivity, specificity, PPV, NPV, and accuracy of MRI in the diagnosis of MI were 89.19%, 88.97%, 67.35%, 97.99%, and 89.01%, respectively, and the indexes of 3D-TVS for MI were 86.36%, 91.07%, 79.17%, 94.44%, and 89.74%, respectively. The sensitivity, specificity, PPV, NPV, and accuracy of MRI for CI were 75% and 92.35%, 40.9%, 98.13%, and 91.2%, respectively. The indicators of 3D-TVS were 77.78%, 94.29%, 63.63%, 97.06%, and 92.4%, respectively. There were no significant differences in sensitivity, specificity, NPV, and accuracy between MRI and 3D-TVS in the diagnosis of MI and CI. For MI and CI, the sensitivity of combined MRI and 3D-TVS was higher than any other single method (P<0.05). For LNM, the sensitivity, specificity, PPV, NPV, and accuracy of MRI were 58.33%, 96.26%, 63.63%, 95.37%, and 92.43%, respectively.

Conclusions

3D-TVS is equivalent to MRI in predicting MI and CI. Combined MRI and 3D-TVS can improve the assessment sensitivity, and they are useful in optimizing individualized surgical procedures. The sensitivity of MRI for LNM prediction needs to be improved.

Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Endometrial cancer (EC) is the most common malignant tumor of the female genital tract in Western countries. EC patients are divided into risk categories based on histopathological tumor type, grade, and myometrial invasion depth. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) system. Since FIGO (2009) stage correlates with prognosis, preoperative staging is essential for tailored treatment. MRI reveals myometrial invasion depth, which correlates with tumor grade and lymph node metastases, and thus correlates with prognosis. Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. The FIGO Gynecologic Oncology Committee recently revised its CC staging guidelines, allowing staging based on imaging and pathological findings when available. The revised FIGO (2018) staging includes node involvement and thus enables both therapy selection and evaluation, prognosis estimation, and calculation of end results. MRI can accurately assess prognostic indicators, e.g., tumor size, parametrial invasion, pelvic sidewall, and lymph node invasion. Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Awareness of mimics that can simulate both cancers is critical. With careful application, functional MRI with DWI and DCE sequences can help establish a correct diagnosis, although it is sometimes necessary to perform biopsy and histopathological analysis.

A Prospective Observational Study Evaluating the Accuracy of MRI in Predicting the Extent of Disease in Endometrial Cancer

This prospective study looks into the accuracy of magnetic resonance imaging (MRI) in predicting the depth of MI, cervical invasion, lymph node metastasis, and extrauterine spread (EUS) of disease in endometrial cancer. Between June 2014 and December 2015, 58 patients with biopsy-proven endometrial cancer who underwent MRI prior to surgery were included in the study. MRI findings like myometrial invasion, extrauterine spread, lymph nodal metastasis, and cervical invasion were compared against the histopathology report. Sensitivity, specificity, PPV, NPV, and overall accuracy of MRI for myometrial depth assessment were 75.0%, 73.08%, 77.2%, 70.37%, and 74.14 respectively. Sensitivity, specificity, PPV, NPV, and overall accuracy of MRI in assessing lymph node spread were 88.64%, 66.67%, 95.12%, 44.44%, and 86.0% respectively. As for predicting extrauterine spread and cervical invasion, MRI showed poor sensitivity (37.5% and 50% respectively) and a high specificity (92% and 100% respectively). Our study shows that preoperative MRI has high sensitivity and specificity to predict myometrial invasion and lymph node involvement. But, it is not sensitive enough to predict cervical involvement or extrauterine spread.