Imaging of cancer of the endometrium

Transvaginal US is often the initial imaging examination for women with dysfunctional (postmenopausal or intermenstrual) uterine bleeding. However, once the diagnosis of endometrial cancer has been made, contrast-enhanced MRI should be performed in patients who require multifactorial assessment (eg, depth of myometrial invasion, cervical involvement, lymph node metastasis). The results of contrast-enhanced MRI help distinguish patients who need more aggressive therapy and referral to a gynecologic oncologist from those who will do well treated by a community gynecologist.     

Imaging of cancer of the cervix

Cancer of the endometrium is the most common invasive gynecologic malignancy in North America. Although transvaginal sonography is often the initial imaging examination in women with dysfunctional uterine bleeding, MRI offers multifactorial assessment once the diagnosis of endometrial cancer has been established. Specifically, preoperative contrast-enhanced MRI alters the likelihood ratios for myometrial invasion, which in turn affects type and extent of surgery performed. This information also helps identify patients who would most benefit from referral to a tertiary care center for treatment by a gynecologic oncologist.     

MR imaging of pelvic masses in women: contrast-enhanced vs unenhanced images.

OBJECTIVE. We compared the value of contrast-enhanced MR images with that of T2-weighted MR images in the diagnosis and staging of pelvic masses in women. MATERIALS AND METHODS. The findings on preoperative MR studies of 97 patients with a total of 124 surgically proved lesions were retrospectively analyzed. Unenhanced T1- and T2-weighted spin-echo images were compared with contrast-enhanced T1-weighted images. The final diagnosis included benign (36 patients), borderline (six patients), and malignant (15 patients) ovarian masses, fallopian tube masses (15 patients), endometrial tumors (seven patients), cervical carcinomas (32 patients), subserous leiomyomas (11 patients), and two masses of extragenital origin. RESULTS. In the depiction of pelvic lesions, the sensitivity of contrast-enhanced MR imaging (96%) was equal to that of unenhanced T2-weighted imaging (97%). Contrast-enhanced images were useful in the definition of intratumoral architecture and tumor borders of 72 adnexal masses, resulting in better determination of malignancy (accuracy, 95%) than on T2-weighted images (85%). Size of viable tumor, differentiation of tumor from retained fluid, and depth of myometrial invasion of six endometrial carcinomas were most reliably shown on contrast-enhanced images. In the evaluation of cervical carcinoma, overall staging accuracy of contrast-enhanced imaging (80%) was slightly inferior to that of T2-weighted imaging (83%). However, contrast-enhanced images improved assessment of parametrial and organ invasion in seven cases in which findings on T2-weighted MR images were equivocal. Administration of contrast material was not helpful in the evaluation of subserous leiomyomas or masses of extragenital origin. CONCLUSIONS. The findings suggest that when results of unenhanced T1- and T2-weighted MR imaging of pelvic masses are equivocal, contrast-enhanced MR images should be used as supportive and complementary pulse sequences to (1) improve definition of intratumoral architecture and prediction of malignancy in adnexal tumors, (2) stage endometrial carcinoma, and (3) determine tumor extension in cervical carcinoma.     

FIGOⅠ Ⅱ期子宫内膜癌MRI征象分析与评价

目的:按照FIGO2009分期标准,分析ⅠⅡ期子宫内膜癌的MRI征象及其病理基础,评价MRI对子宫内膜癌肌层和宫颈侵犯的诊断价值。方法:43例ⅠⅡ期子宫内膜癌患者术前均行MRI检查,采用双盲法,描述肿瘤的MRI表现特征,并将MRI术前分期及判断肌层和宫颈浸润结果,与术后病理结果对照分析。结果:Ⅰa 26例,Ⅰb 8例,Ⅱ期9例。Ⅰ期MRI主要表现为子宫内膜增厚、腔内局限型或弥漫性软组织肿块呈中等强化、T2WI低信号结合带中断及肌层侵犯等,其病理基础为癌细胞呈腺样乳突状结构,突破粘膜层,向肌壁间浸润性生长。Ⅱ期以宫颈内出现与宫体肿瘤相连续的异常信号影及宫颈纤维间质破坏为特征。MRI评价肿瘤浸润肌层深度的诊断准确性为86%,判断宫颈侵犯的敏感性、特异性、准确性分别为78%、91%、88%,与病理结果比较无显著性差异(P0.05)。结论:MRI对Ⅰ、Ⅱ期子宫内膜癌的早期诊断、肌层和宫颈侵犯的判断及术前分期准确性高,具有较高的临床应用价值。     

Standard 1.5-T MRI of endometrial carcinomas: modest agreement between radiologists

Objectives

To evaluate pelvic magnetic resonance imaging (MRI) interobserver agreement for the detection of deep myometrial invasion, cervical stroma invasion and lymph node metastases in endometrial carcinoma patients in relation to surgical staging.

Methods

Fifty-seven patients with histologically confirmed endometrial carcinoma were prospectively included in a study of preoperative 1.5-T MRI. Four radiologists, blinded to patient data, independently reviewed the images for the presence of deep myometrial invasion, cervical stroma invasion and lymph node metastases. Kappa coefficients for interobserver agreement and diagnostic performances for each observer were calculated using final surgical staging results (FIGO 09) as reference standard.

Results

Overall agreement among all observers was moderate for cervical stroma invasion (κ?=?0.50 [95% CI 0.27–0.73]) and lymph node metastases (κ?=?0.56 [0.09–0.80]) and fair for deep myometrial invasion (κ?=?0.39 [0.26–0.55]). Sensitivity (specificity) values for the four observers were 72–92% (44–63%) for deep myometrial invasion, 38–63% (82–94%) for cervical stroma invasion and 25–38% (90–100%) for lymph node metastases.

Conclusions

Conventional MRI showed only modest interobserver agreement and diagnostic accuracy for detection of deep myometrial invasion, cervical stroma invasion and lymph node metastases. Improved methods are needed for preoperative imaging in the staging of endometrial carcinomas.

Key Points

? MRI is an important tool for preoperative endometrial cancer staging. ? Staging agreement based on pelvic MRI was modest among different observers. ? Preoperative MRI alone was suboptimal in identifying high-risk patients. ? Improved imaging and biomarkers may refine preoperative risk stratification in endometrial cancer.     

Endometrial carcinoma: assessment of myometrial invasion with plain and gadolinium-enhanced MR imaging

The purpose of this study was to determine the accuracy of magnetic resonance imaging (MRI) for evaluating the depth of myometrial invasion, potential sources of pitfalls, and the usefulness of contrast-enhanced series. Eighty-five patients with a pathologic diagnosis of endometrial carcinoma underwent preoperative MRI (plain and contrast-enhanced). Grade of myometrial invasion, presence of junctional zone (JZ), fibromyomas, and tumoral thickness were evaluated by two groups of radiologists blinded to pathologic results. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI in determining the depth of myometrial invasion were evaluated. The sensitivity/specificity for plain MR was 64.1-64.1/93.5-100 for both observers. Assessing deep myometrial invasion, sensitivity, and NPV improved significantly (P = 0.002, P = 0.003 for both observers) when comparing plain and whole study series. Tumoral thickness (P = 0.16, P = 0.13, for the two observers) and presence or absence of JZ (P = 0.41, P = 0.14) did not influence myometrial invasion assessment. Gadolinium-enhanced series improve the assessment of deep myometrial invasion in endometrial carcinoma. J. Magn. Reson. Imaging 2000;12:460-466.     

Staging of carcinoma of the uterine cervix and endometrium

Carcinoma of the uterine cervix and endometrium are common gynecologic malignancies. Both carcinomas are staged and managed by means of the International Federation of Gynecology and Obstetrics (FIGO) staging system. In uterine cervical cancer, the FIGO staging system is determined preoperatively by limited conventional procedures. Although this system is effective for early stage disease, it has inherent inaccuracies in advanced stage diseases and does not address nodal involvement. CT and MR imaging are widely used as comprehensive imaging modalities to evaluate tumor size and extent, and nodal involvement. MR imaging is an excellent modality for depicting invasive cervical carcinoma and can provide objective measurement of tumor volume, and provides high negative predictive value for parametrial invasion and stage IVA disease. In contrast, endometrial cancer is surgically staged. Beside recognition of the important prognostic factors, including histologic subtype and grade, accurate assessment of the tumor extent on preoperative MR imaging is expected to greatly optimize surgical procedure and therapeutic strategy. Contrast-enhanced MR imaging can offer “one stop” examination for evaluating the depth of myometrial invasion cervical invasion and nodal metastases. Evaluation of myometrial invasion on MR imaging may be an alternative to gross inspection of the uterus during the surgery.     

DWI联合M RI常规序列对早期子宫内膜癌术前评估的价值

目的：探讨DWI联合M RI常规序列对早期子宫内膜癌术前评估的应用价值。方法回顾性分析43例经手术病理证实的I～Ⅱ期子宫内膜癌的M RI资料,观察肿瘤信号、侵及范围,测量肿瘤实质部分的ADC值,并进行肌层浸润深度评估。结果与正常子宫内膜相比,肿瘤T1 WI多呈等信号,T2 WI呈高信号,DWI为明显高信号,ADC值降低。Ia、Ib及II期肿瘤实质部分ADC值比较,差异无统计学意义。M RI常规序列及DWI联合M RI常规序列判断肌层浸润深度的准确率分别为81．4％和86．0％。结论 DWI联合M RI常规序列对早期子宫内膜癌术前判断肌层浸润深度较准确,可作为子宫内膜癌术前评估的重要方法。     

Carcinoma of the uterus: use of gadopentetate dimeglumine in MR imaging

This prospective study assessed the role of gadopentetate dimeglumine-enhanced magnetic resonance imaging in the detection and staging of carcinomas of the endometrium and cervix. Surgical-pathologic findings were used as the standard of reference. In the evaluation of endometrial carcinoma, contrast-enhanced imaging improved tumor detection and differentiation between viable tumor and retained debris. Use of contrast material significantly improved the staging accuracy. The ability to assess the depth of myometrial invasion was also improved. In the evaluation of cervical carcinoma, assessment of tumor location and size did not improve following contrast enhancement. Use of gadopentetate dimeglumine resulted in overestimation of stromal, parametrial, vaginal, and/or bladder wall invasion in eight patients. However, evaluation of intratumoral architecture and large lesions was easier with contrast-enhanced imaging. When only stage II and higher disease was analyzed, use of contrast material improved the evaluation of disease extent. The authors conclude that gadolinium enhancement adds to the accuracy of evaluation of endometrial carcinoma but is useful in only advanced cases of cervical carcinoma.     

Staging endometrial cancer: role of magnetic resonance imaging

This review article summarizes and comments the role of magnetic resonance imaging (MRI) in the management of endometrial cancer. The MRI technique, appearance, and diagnostic criteria of endometrial carcinoma are discussed. The value of MRI in the preoperative staging of endometrial cancer is compared to alternative strategies. Contrast-enhanced MRI performs best in the pretreatment evaluation of myometrial or cervical invasion, compared to ultrasonography (US), computed tomography (CT), or nonenhanced MRI. The overall costs and accuracy are similar to those of the current methods of staging, including intraoperative gross dissection of the uterus. In addition, results of MRI might decrease the number of unnecessary lymph node dissections. J. Magn. Reson. Imaging 2001;13:850-855.     

Current imaging strategies for the evaluation of uterine cervical cancer

Uterine cervical cancer still remains an important socioeconomic issue because it largely affects women of reproductive age.Prognosis is highly depended on extent of the disease at diagnosis and,therefore,accurate staging is crucial for optimal management.Cervical cancer is clinically staged,according to International Federation of Gynecology and Obstetrics guidelines,but,currently,there is increased use of cross sectional imaging modalities [computed tomography(CT),magnetic resonance imaging(MRI),positron emission tomography-CT(PET-CT)] for the study of important prognostic factors like tumor size,parametrial invasion,endocervical extension,pelvic side wall or adjacent/distal organs involvement and lymph node status.Imaging indications also include cervical cancer follow-up,evaluation of tumor response to treatment and selection of suitable candidates for less radical surgeries like radical trachelectomy for fertility preservation.The preferred imaging method for local cervical cancer evaluation is MRI;CT is equally effective for evaluation of extrauterine spread of the disease.PETCT shows high diagnostic performance for the detection of tumor relapse and metastatic lymph nodes.The aim of this review is to familiarize radiologists with the MRI appearance of cervical carcinoma and to discuss the indications of cross sectional imaging during the course of the disease in patients with cervical carcinoma.     

子宫内膜癌的MRI应用现状及研究近况

子宫内膜癌是妇科最常见的恶性肿瘤之一,近年来发病率逐渐增加,严重威胁女性生命健康。术前准确分期对指导子宫内膜癌病人的治疗方案选择及判断预后具有重要意义。概述影像检查、宫腔镜及内膜活检在子宫内膜癌诊断及分期诊断中的优缺点,重点讨论MRI及其功能成像在子宫内膜癌诊断方面的应用现状及研究近况。     

Tumoren des weiblichen Beckens

Cervical, endometrial and ovarian carcinomas are the main malignant neoplasms of the female pelvis. For CT, a thin-slice venous phase with good bowel contrast is used. For MRI, an anti-peristaltic agent is necessary. Thin-slice T2- weighted TSE images with a high in-plane spatial resolution are particularly suitable for imaging the uterine wall; a parenteral contrast medium is absolutely necessary to demonstrate endometrial and ovarian carcinoma. In the guidelines, MRI is recommended only for cervical cancer FIGO 1b and higher stages; nevertheless, CT and MRI play an important role in preoperative diagnosis of these tumors. Lymph node staging is performed during surgery where possible. In patients with endometrial carcinoma, preoperative staging focuses on the infiltration depth in the myometrium. Preoperative diagnosis of ovarian cancer centers on any tumor spread in the abdomen, and diagnostic imaging methods are designed to provide the surgeon with information about compartments of a possible peritoneal carcinosis that are difficult to see. In patients with incidental findings of ovarian masses, CT and MRI can detect evidence of malignancy, although an exact differential diagnosis is not usually possible in this very heterogeneous group of ovarian tumors.     

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.     

Invited. Cervical cancer

The stage estimated by clinical FIGO staging is the main determinant in guiding the treatment decisions. However, clinical FIGO staging does have inherent inaccuracies, because it does not include significant prognostic factors. Presently, MRI is not officially incorporated in the staging workup system; however, it is widely accepted as the most reliable imaging modality in evaluating cervical cancer and in treatment planning. MRI offers direct tumor visualization, accurate assessment of the depth of stromal invasion and tumor volume, lymph node evaluation, and reliable staging accuracy. Published reports show the superiority of MRI over clinical staging, and several recent works on dynamic MRI suggest further improvement of MRI in evaluating cervical cancer.     

Zervixkarzinom

The treatment of uterine cervical carcinoma is largely dependent on the tumor stage. Despite significant inaccuracies in the clinical examination, uterine cervical cancer remains the only gynecological form of cancer still largely staged according to clinical findings. Although imaging is still not included in the staging the recently published revised FIGO (Fédération International de Gynécologie et d'Obstétrique) system encourages the use of modern cross-sectional imaging (magnetic resonance imaging MRI and computed tomography CT). Due to its high soft tissue contrast MRI allows excellent non-invasive assessment of the cervix with direct tumor delineation as well as assessment of the prognosis based on morphological factors. Studies in the literature report an accuracy of 93% for MRI in the preoperative assessment of tumor size and in the differentiation of operable from advanced cervical cancer. Therefore MRI is considered to be the optimal modality for diagnostic evaluation starting from FIGO stage IB1, for radiation therapy planning, and for exclusion of recurrence in follow-up. In this paper we give an overview of the role of magnetic resonance imaging in preoperative staging of uterine cervical cancer.     

Radiologic staging in patients with endometrial cancer: a meta-analysis.

PURPOSE: To apply a meta-analysis to compare the utility of computed tomography (CT), ultrasonography (US), and magnetic resonance (MR) imaging in staging endometrial cancer. MATERIALS AND METHODS: Data were obtained from a MEDLINE literature search and from manual reviews of article bibliographies. Articles were selected that included results in patients with proved endometrial cancer and imaging-histopathologic correlation and that presented data that allowed calculation of contingency tables. Data for the imaging evaluation of myometrial and cervical invasion were abstracted independently by two authors. Data on year of publication, International Federation of Gynecology and Obstetrics (FIGO) stage distribution, and methodologic quality were also collected. A subgroup analysis was performed to compare contrast medium-enhanced MR imaging with nonenhanced MR imaging, US, and CT. RESULTS: Six studies met the inclusion criteria for CT; 16, for US; and 25, for MR imaging. Summary receiver operating characteristic analysis showed no significant differences in the overall performance of CT, US, and MR imaging. In the assessment of myometrial invasion, however, contrast-enhanced MR imaging performed significantly better than did nonenhanced MR imaging or US (P < .002) and demonstrated a trend toward better results, as compared with CT. The lack of data on the assessment of cervical invasion at CT or US prevented meta-analytic comparison with data obtained at MR imaging. Results were not influenced by year of publication, FIGO stage distribution, or methodologic quality. CONCLUSION: Although US, CT, or MR imaging can be used in the pretreatment evaluation of endometrial cancer, contrast-enhanced MR imaging offers "one-stop" examination with the highest efficacy.     

The ability of helical CT to preoperatively stage endometrial carcinoma

OBJECTIVE: This study evaluated helical CT as an imaging modality for preoperative staging of endometrial carcinoma. MATERIALS AND METHODS: Three radiologists retrospectively and independently reviewed the preoperative helical CT scans of 25 consecutive patients with endometrial carcinoma. The presence or absence of deep myometrial invasion and the presence or absence of cervical involvement were evaluated on helical CT and compared with pathologic findings at hysterectomy. RESULTS: Helical CT has a sensitivity of 83% and a specificity of 42% for the detection of deep myometrial invasion (stage IC). Helical CT has a sensitivity of 25% and a specificity of 70% for the detection of cervical involvement (state II). These results compare poorly with those of MR imaging (sensitivity 92%, specificity 90% for the detection of deep myometrial invasion; sensitivity 86%, specificity 97% for the detection of cervical involvement). CONCLUSION: Helical CT is insensitive and nonspecific compared with MR imaging for the preoperative staging of endometrial carcinoma. MR imaging remains the imaging modality of choice.     

3.0T磁共振LAVA动态增强判断子宫内膜癌肌层浸润深度的价值

目的探讨3.0T磁共振肝脏快速容积采集技术(LAVA)动态增强判断子宫内膜癌肌层浸润深度的应用价值。资料与方法回顾性分析52例子宫内膜癌的T2WI和LAVA动态增强图像,以手术病理结果为标准,计算两种序列诊断子宫内膜癌肌层浸润的敏感性、特异性、阳性预测值、阴性预测值和准确性。结果 T2WI判断内膜癌肌层浸润及深肌层浸润的敏感性、特异性、阳性预测值、阴性预测值和准确性分别为84.4%、71.4%、95.0%、41.7%、82.7%和63.6%、82.9%、50.0%、89.5%、78.8%。LAVA动态增强判断内膜癌肌层浸润及深肌层浸润敏感性、特异性、阳性预测值、阴性预测值和准确性分别为93.3%、85.7%、97.7%、66.7%、92.3%和90.9%、95.1%、83.3%、97.5%、94.2%。LAVA动态增强判断子宫内膜癌深肌层受侵的准确性高于T2WI诊断的准确性,差异有统计学意义(P<0.05)。结论 3.0T磁共振LAVA动态增强扫描有助于提高子宫内膜癌肌层浸润术前诊断的准确性。     

MRI成像对子宫内膜癌侵犯肌层的评估

目的探讨MRI对子宫内膜癌肌层浸润深度的评估价值。方法回顾性分析67例经分段刮宫并施行手术治疗的子宫内膜癌患者MRI表现,并与术后病理结果进行对照。结果 MRI判断子宫内膜癌局限于内膜、浸润浅肌层、浸润深肌层及浸透浆膜层的准确性分别为92.5%、80.5%、88.0%、80.5%。结论磁共振可多方位、多序列、多角度成像,对软组织有较高分辨率,对准确判断子宫内膜癌肌层有无浸润具有明显优势。