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

Accuracy of MRI in predicting deep myometrial invasion in endometrial cancer and the influence of leiomyoma, adenomyosis and the microcystic elongated and fragmented tumour pattern

INTRODUCTION

The most common form of endometrial cancer is Type 1 endometrioid adenocarcinoma. Depth of myometrial invasion is the most important prognostic factor correlating with overall patient survival. The objective was to investigate how accurate magnetic resonance imaging (MRI) is in predicting the depth of myometrial invasion in preoperative assessment, and the influence of leiomyoma and/or adenomyosis, or microcystic, elongated and fragmented (MELF) pattern of invasion on MRI diagnostic performance.

METHOD

Retrospective audit of 235 endometrial cancer patients from the regional Gynaecology Oncology multidisciplinary meeting at Auckland City Hospital, between January 2020 and January 2021. Radiologist assigned stage was compared to histopathology. Presence of leiomyoma, adenomyosis and MELF pattern evaluated followed by analysis under a Biostatistician's supervision.

RESULTS

Overall MRI diagnostic accuracy for depth of myometrial invasion was 86%. For deep myometrial invasion, MRI had a sensitivity of 72% and specificity 91%. Out of the misreported 32/235 cases, 16 demonstrated fibroids and/or adenomyosis leading to a sensitivity of 57% and specificity 93% for deep invasion, compared with 94% and 74% respectively in the population without, demonstrating statistical significance. Thirty seven cases with MELF pattern of invasion showed a sensitivity of 81% and specificity 80% for deep invasion, compared with 63% and 92% respectively in the group without, demonstrating no statistical significance.

CONCLUSION

MRI assessment of the depth of myometrial invasion in endometrial cancer has high accuracy. In the presence of background uterine fibroids/adenomyosis, pre-operative MRI accuracy of evaluating deep invasion shows a statistically significant reduction.

Endometrial Cancer Staging: Is There Value in ADC?

PURPOSE

To assess the ability of apparent diffusion coefficient (ADC) measurements in predicting the histological grade of endometrial cancer. A secondary goal was to assess the agreement between MRI and surgical staging as an accurate measurement.

METHODS

Patients with endometrial cancers diagnosed between 2018-2020 and having received both MRI and surgical staging were retrospectively enrolled. Patients were characterized according to histology, tumor size, FIGO stage (MRI and surgical stage), and functional MRI parameters (DCE and DWI/ADC). Statistical analysis was performed to determine if an association could be identified between ADC variables and histology grade. Secondarily, we assessed the degree of agreement between the MRI and surgical stages according to the FIGO classification.

RESULTS

The cohort included 45 women with endometrial cancer. Quantitative analysis of ADC variables did not find a statistically significant association with histological tumor grades. DCE showed higher sensitivity than DWI/ADC in the assessment of myometrial invasion (85.00% versus 65.00%) with the same specificity (80.00%). A good agreement between MRI and histopathology for the FIGO stage was found (kappa of 0.72, p < 0.01). Differences in staging between MRI and surgery were detected in eight cases, which could not be justified by the interval between MRI and surgery.

CONCLUSIONS

ADC values were not useful for predicting endometrial cancer grade, despite the good agreement between MRI interpretation and histopathology of endometrial cancer staging at our center.

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] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

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.

Diagnostic value of T2 and diffusion-weighted imaging (DWI) in local staging of endometrial cancer

BACKGROUND

Endometrial cancer (EC) is the eighth most prevalent cancer globally. T2-weighted magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) help anatomical localization and local staging of lesions. The present study was performed to assess the diagnostic value of the simultaneous use of T2 and DWI techniques in EC evaluation.

METHODS

Seventy-eight histopathological-proven EC cases were included in this study. Patients were assessed using a complete MRI exam, including T2 and DWI. The myometrial invasion, cervical, serosal or adnexal, vaginal or parametrial, and pelvic lymph node involvements and accuracy, sensitivity, specificity, and positive and negative predictive values were evaluated in each sequence distinctly and was compared with the pathology findings and full standard protocol using post-contrast multiphasic contrast-enhanced series.

RESULTS

Deep myometrial invasion in EC cases was detected in 38.5% by T2-DWI and 37.2% by pathology. The pathology diagnosed cervical, serosal, and vaginal involvements and pelvic lymph node metastases in 20.5%, 7.7%, 6.4% and 11.5% of cases respectively, while the numbers for T2-DWI were 26.9%, 7.7%, 7.7%, and 15.4%, respectively. The accuracy, sensitivity, specificity, PPV, and NPV of T2-DWI in the diagnosis of myometrial invasion were 93.5%, 93.1%, 93.8%, 90%, and 93.8%, respectively. A slightly higher Kappa coefficient of DWI (0.973) in the diagnosis of myometrial invasion was identified compared to T2 (0.946). The T2-DWI technique had a 52.6% intraclass correlation coefficient in the diagnosis of IA stage.

CONCLUSION

The simultaneous consideration of T2 and DWI technique may signify a noninvasive, rapid, safe, and accurate approach for precisely assessing myometrial invasion and EC staging. Elimination of intravenous contrast material result in prevention of contrast related side effects beside significant cost reduction for health care systems and patients with a comparable result to contrast enhanced MRI.

Utility of the Diffusion Weighted Sequence in Gynecological Imaging: Review Article

Simple Summary

Diffusion weighted imaging (DWI) is a magnetic resonance imaging sequence with diverse clinical applications in malignant and nonmalignant gynecological conditions. It provides vital supplemental information in the diagnosis and management of various gynecological conditions. Radiologists should be aware of fundamental concepts, clinical applications and pitfalls of DWI. Additionally we briefly discuss potential scope of newer advanced techniques based on DWI including diffusion tensor imaging and diffusion-weighted whole-body imaging with background signal suppression.

Abstract

Functional imaging with diffusion-weighted imaging (DWI) is a complementary tool to conventional diagnostic magnetic resonance imaging sequences. It is being increasingly investigated to predict tumor response and assess tumor recurrence. We elucidate the specific technical modifications of DWI preferred for gynecological imaging, including the different b-values and planes for image acquisition. Additionally, we discuss the problems and potential pitfalls encountered during DWI interpretation and ways to overcome them. DWI has a wide range of clinical applications in malignant and non-malignant gynecological conditions. It provides supplemental information helpful in diagnosing and managing tubo-ovarian abscess, uterine fibroids, endometriosis, adnexal torsion, and dermoid. Similarly, DWI has diverse applications in gynecological oncology in diagnosis, staging, detection of recurrent disease, and tumor response assessment. Quantitative evaluation with apparent diffusion coefficient (ADC) measurement is being increasingly evaluated for correlation with various tumor parameters in managing gynecological malignancies aiding in preoperative treatment planning. Newer advanced DWI techniques of diffusion tensor imaging (DTI) and whole body DWI with background suppression (DWIBS) and their potential uses in pelvic nerve mapping, preoperative planning, and fertility-preserving surgeries are briefly discussed.

Staging of Endometrial Cancer Using Fusion T2-Weighted Images with Diffusion-Weighted Images: A Way to Avoid Gadolinium?

Simple Summary

This work aims to evaluate the utility of fusing T2-weighted images with diffusion-weighted images to determinate the depth of myometrial invasion and the stage of endometrial cancer. By showing its superior diagnostic performance, we aim to encourage its use in endometrial cancer staging, and, in the future, obviate the need for intravenous contrast medium administration.

Abstract

Endometrial cancer is the eighth most common cancer worldwide, and its prognosis depends on various factors, with myometrial invasion having a major impact on prognosis. Optimizing MRI protocols is essential, and it would be useful to improve the diagnostic accuracy without the need for other sequences. We conducted a retrospective, single-center study, which included a total of 87 patients with surgically confirmed primary endometrial cancer, and who had undergone a pre-operative pelvic MRI. All exams were read by an experienced radiologist dedicated to urogenital radiology, and the depth of myometrial invasion was evaluated using T2-Weighted Images (T2WI) and fused T2WI with Diffusion-Weighted Images (DWI). Both results were compared to histopathological evaluations. When comparing both sets of imaging (T2WI and fused T2WI-DWI images) in diagnosing myometrial invasion, the fused images had better accuracy, and this difference was statistically significant (p < 0.001). T2WI analysis correctly diagnosed 82.1% (70.6–88.7) of cases, compared to 92.1% correctly diagnosed cases with fused images (79.5–97.2). The addition of fused images to a standard MRI protocol improves the diagnostic accuracy of myometrial invasion depth, encouraging its use, since it does not require more acquisition time.

Use of diffusion-weighted imaging and diffusion tensor imaging in assessment of myometrial invasion in patients of endometrial carcinoma and its correlation with histopathological grading (Prospective study)

Background

Endometrial cancer (EMC) is considered one of the most common gynecological cancers worldwide. In particular, the depth of myometrial invasion and histological grade of endometrial cancers (EMCs) are strong prognostic factors. Diffusion tensor measurements as mean diffusivity (MD) and fractional anisotropy (FA) values could be useful for assessing the depth of tumor invasion and its histological grade. The study aimed to evaluate the role of diffusion-weighted imaging (DWI) and diffusion tensor imaging in the detection of myometrial invasion in cases of endometrial carcinoma and prediction of its grade in vivo.

Results

This study included 50 female patients with pathologically proved endometrial carcinoma, and their ages ranged from 38 to 67 years; the mean age was 56.15 years (± 8.229 standard deviation “SD”). There was a significant statistical difference regarding the mean values of diffusion tensor fractional anisotropy (DT-FA), diffusion tensor mean diffusivity (DT-MD) and diffusion-weighted apparent diffusion coefficient(DW-ADC) values in differentiating between intact and infiltrated myometrium with (P value ≤ 0.001). The accuracy of DT-MD, DT-FA and DWI-ADC was 98%, 90% and 86%, respectively, in the detection of myometrial invasion. There was a statistically significant difference in the mean values of DT-FA, DT-MD and DW-ADC for differentiating endometrioid adenocarcinoma grades with the overall P values (˂0.001). The accuracy of DT-FA, DT- MD and DWI-ADC for differentiating grade 3 from grade 1 or 2 endometrioid adenocarcinoma was 94.9%, 84.6% and 74.4%, respectively. For differentiating grade 1 from grade 2 or 3 endometrioid adenocarcinoma, the accuracy of DT-FA, DT-MD and DWI-ADC was 90%, 89.7% and 84.6%, respectively. Mean DT-FA, DT-MD and DW-ADC values were inversely proportional to the degree of pathological grading with r =  − 0.867, − 0.762 and − 0.706, respectively.

Conclusion

Diffusion tensor imaging and DWI are helpful in the assessment of myometrial invasion and have a high negative correlation with histopathological grading in patients with endometrial cancer.

Evaluation of the Depth of Myometrial Invasion of Endometrial Carcinoma: Comparison of Orthogonal Pelvis-axial Contrast-enhanced and Uterus-axial Dynamic Contrast-enhanced MRI Protocols

RATIONALE AND OBJECTIVES

To compare the diagnostic performance of orthogonal pelvis-axial (OPA) contrast-enhanced (CE) and orthogonal uterus-axial (OUA) dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) protocols in assessing the depth of myometrial invasion (MI) of endometrial carcinoma (EC).

MATERIALS AND METHODS

Preoperative MRI of 398 consecutive EC patients (197 patients with OPA CE-MRI protocol and 201 patients with OUA DCE-MRI protocol) was analyzed. Two radiologists independently interpreted the depth of MI, with postoperative histopathology as the reference standard. The chi-square test, Fisher's exact test, and receiver operating characteristic curve analysis were used for diagnostic performance comparison.

RESULTS

OUA DCE-MRI showed a significantly larger area under the curve than OPA CE-MRI in detecting the presence of MI for radiologist 1 (0.71 versus 0.49, p < 0.05) but not for radiologist 2 or deep MI (all p > 0.05). Compared to OPA CE-MRI, OUA DCE-MRI significantly improved the diagnostic accuracy of non-MI and superficial MI (radiologist 1: 45.5% versus 0 and 88.7% versus 86.4%, p = 0.045 and 0.567, respectively; radiologist 2: 45.5% versus 12.5% and 88.7% versus 78.8%, p = 0.177 and 0.027, respectively) and of EC with adenomyosis/submucous myomas, cornual tumor, and antero-posterior diameter ≤ 10 mm (radiologist 1: 86.4% versus 71.4%, 91.2% versus 67.7%, and 90.1% versus 81.1%, p = 0.048, 0.018, and 0.081, respectively; radiologist 2: 86.4% versus 64.3%, 88.2% versus 64.5%, and 87.0% versus 71.6%, p = 0.006, 0.023, and 0.019, respectively).

CONCLUSION

The OUA DCE-MRI protocol was superior to the OPA CE-MRI protocol in assessing the depth of MI of EC.

Clinical Impact of Preoperative Magnetic Resonance Imaging in the Evaluation of Myometrial Infiltration and Lymph-Node Metastases in Stage I Endometrial Cancer

Abstract: Purpose: In the developed world, endometrial cancer is one of the most common malignant gynecological cancer types. Due to the highly available diagnostic modalities and patient education, the early detection of the tumor leads to high overall survival.

Methods: In this study we analyzed the reliability of preoperative MRI findings in the staging of early stage endometrial cancer, as well as the clinical characteristics of patients underwent radical hysterectomy and the histopathologic evaluation of their tumor, with the retrospective data of radical hysterectomies performed in our hospital between 2010 and 2019.

Results: The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI regarding stage were 94.7, 63.3, 94.8, 83.8, and 83.8%, respectively. The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI for the detection of the myometrial invasion were 69.8, 80.0, 60.8, 64.3, and 77.5%, respectively. The accuracy, sensitivity, specificity, negative- and positive predictive value of MRI for the detection of lymph node metastases were 78.1, 28.6, 82, 11.1, and 93.6%, respectively.

Conclusions: Based on our results, MRI is the method of choice in terms of evaluating overall staging, as well as myometrial invasion, as its specificity and negative predictive value are relatively high. However, systematic lymphadenectomy showed improved cancer-related survival and recurrence-free survival. Our studies showed that the diagnosis of lymph node metastases is difficult with MRI modality since hyperplastic and metastatic nodes cannot easily differentiate, leading to a high percentage of false-positive results. Therefore, other imaging modalities may be used for more accurate evaluation. New findings of our study were that the role of the radiologist’s expertise in the evaluation of MR imaging plays an essential role in lowering false-negative and false-positive results. Therefore, findings evaluated by a radiologist with high-level expertise in gynecological imaging can complement the clinical findings and help substantially define the needed treatment.

High resolution diffusion-weighted imaging with readout segmentation of long variable echo-trains for determining myometrial invasion in endometrial carcinoma

Background

We assessed the image quality of endometrial cancer lesions by readout segmentation of long variable echo-trains (RESOLVE) diffusion-weighted imaging (DWI) compared with that by single-shot echo-planar imaging (SS-EPI) DWI, aimed to explore the value of RESOLVE DWI for determining myometrial invasion and clinical stage in endometrial cancer.

Materials and methods

From April 2017 to March 2018, a total of 30 endometrial cancer patients (mean age 52.8 ± 9.0 years), who had undergone RESOLVE DWI and SS-EPI DWI, were included in the study. The image quality of endometrial carcinoma by two kinds of DWI scanning methods was compared qualitatively and quantitatively. The Spearman rank correlation test was used to assess the correlation of qualitative image quality scores between two readers. The accuracy of two DWI methods in detecting myometrial invasion and staging of endometrial carcinoma was calculated according to postoperative pathological results. The indexes were analyzed including sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

Results

The qualitative score of RESOLVE DWI group was superior to SS-EPI DWI group in every aspect of five aspects (all P < 0.001). Interobserver agreement of depiction was good or excellent in two DWI sequences. Signal to noise ratio and contrast to noise ratio values in RESOLVE DWI group were both higher than those in SS-EPI DWI group (P<0.001). No statistical difference of apparent diffusion coefficient value was observed between two DWI groups (P = 0.261). The specificity, accuracy, PPV, and NPV of estimating myometrial invasion by RESOLVE DWI in three cases (intramucosal lesion, <50% superficial invasion and ≥ 50% deep invasion) were all higher than those by SS-EPI DWI for endometrial carcinoma. Especially RESOLVE DWI was valuable in judging <50% superficial invasion (95%CI:0.586, 0.970). No significant difference in accuracy staging was between the two DWI groups (P = 0.125).

Conclusion

RESOLVE DWI can provide higher quality images of endometrial carcinoma than SS-EPI DWI. The high-quality images are helpful for precise assessment of myometrial invasion in endometrial cancer.