Endometrial carcinoma: efficacy of thin-section oblique axial MR images for evaluating cervical invasion

[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.

Magnetic Resonance Imaging in Local Staging of Endometrial Carcinoma: Diagnostic Performance, Pitfalls, and Literature Review

Aims and background

To assess the diagnostic accuracy of magnetic resonance imaging in local staging of endometrial carcinoma, and to review the results and pitfalls described in the literature.

Methods

Thirty women with a histological diagnosis of endometrial carcinoma underwent magnetic resonance imaging. Unenhanced T2-weighted and dynamic contrast-enhanced T1-weighted sequences were obtained. Hysterectomy and salpingo-oophorectomy was performed in all patients. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for the detection of deep myometrial and cervical infiltration.

Results

For deep myometrial infiltration T2-weighted sequences reached a sensitivity of 85%, specificity of 76%, PPV of 73%, NVPof 87%, and accuracy of 80%, while contrast-enhanced scans reached a sensitivity of 90%, specificity of 80%, PPV of 82%, NPV of 89%, and accuracy of 85%. For cervical infiltration T2-weighted sequences reached a sensitivity of 75%, specificity of 88%, PPV of 50%, NPV of 96%, and accuracy of 87%, while contrast-enhanced scans reached a sensitivity of 100%, specificity of 94%, PPV of 75%, NPV of 100%, and accuracy of 95%.

Conclusions

Unenhanced and dynamic gadolinium-enhanced magnetic resonance allows accurate assessment of myometrial and cervical infiltration. Information provided by magnetic resonance imaging can define prognosis and management.

Imaging Features of Uncommon Gynecologic Cancers

OBJECTIVE

The role of imaging in patients with suspected gynecologic malignancies is to provide an accurate diagnosis to achieve the best and most tailored treatment plan. Uncommon cancers pose a distinct challenge, because current knowledge of these diseases is still limited. Our purpose is to highlight the role of cross-sectional imaging techniques, including ultrasound, CT, MRI, and PET/CT, in the diagnosis and pretreatment stratification of patients with rare gynecologic cancers.

CONCLUSION

This review shows the relevance of imaging findings for diagnosis, staging, and treatment planning in patients with uncommon uterine, cervical, vaginal, vulvar, and ovarian cancers.

Role of imaging in the pretreatment evaluation of common gynecological cancers

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

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

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

Staging of endometrial cancer with MRI: guidelines of the European Society of Urogenital Imaging

The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2 min +/- 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.

MRI of malignant neoplasms of the uterine corpus and cervix

OBJECTIVE

In this article, we review the role of MRI in the imaging of malignant neoplasms of the uterine corpus and cervix, describing its role in staging, treatment planning, and follow-up.

CONCLUSION

MRI is not officially incorporated in the International Federation of Gynecology and Obstetrics (FIGO) staging system, but is already widely accepted as the most reliable imaging technique for the diagnosis, staging, treatment planning, and follow-up of both endometrial and cervical cancer. MRI protocols need to be optimized to obtain the best results and avoid pitfalls.

MR Imaging of Malignant Uterine Disease

The role of MR imaging in the diagnosis and management of patients who have uterine malignancy continues to evolve. MR imaging has been shown to be effective for preoperative characterization and staging of endometrial and cervical carcinoma, and for the evaluation of posttreatment changes and recurrent disease. Because of its potential to provide detailed information about local extent and metastatic disease, MR imaging has enormous potential to help triage patients to appropriate treatment groups and provide imaging surveillance after therapy. This article reviews the MR imaging technique and the imaging characteristics of malignant disease of the uterine corpus and cervix.

The role of MRI in the conservative management of endometrial cancer

BACKGROUND

Young patients with endometrial cancer who desire to preserve their fertility often decline hysterectomy in favor of conservative progestin therapy. Proper candidates should have disease confined to the uterus and a well-differentiated tumor. One of the evolving techniques to evaluate the extent of the disease and myometrial or cervical invasion is magnetic resonance imaging (MRI).

CASE

A young patient with early-stage endometrial cancer initially declined surgery and was treated with megestrol. MRI suggested myoinvasion, and the patient consented to surgical staging. The final pathology revealed no residual carcinoma.

CONCLUSIONS

The accuracy of MRI in detecting myoinvasion is limited, and as such results should be interpreted with caution when this information is used in counseling a young patient regarding surgical staging for endometrial cancer.

Evaluation of endometrial cancer with 3D-VIBE (volume interpolated breath-hold examination) using intrauterine CO2 gas

To evaluate the myometrial infiltration of the endometrial cancer prior to aggressive treatment, dynamic MRI (magnetic resonance imaging) has attracted attention. However, it has also been found that in a number of cases, MRI exhibits inconsistent results with regards to the extent of the infiltration into this component of the uterine body. To overcome this limitation, the authors designed a method to delineate the tumor morphology more clearly by injecting CO2 gas into the uterine cavity. This procedure was combined with VIBE (volumetric interpolated breath-hold examination) to determine more precisely the depth of the tumor invasion. From our clinical results, the efficacy of the method was evaluated. On four patients with endometrial cancers (stage Ia-Ic), CO2 was injected to dilate the intra-uterine space through a catheter equipped with a balloon that had been introduced into the uterine cavity, after which VIBE was conducted. The images were interpreted by MPR (multiplanar reconstruction) and the findings from these images were compared against the histopathological findings. By employing this method, it was possible to delineate clearly the tumorous lesion in the uterine body, and three-dimensional images of the tumor invasion was acquired. The site and extent of tumor invasion in the myometrium were generally consistent with the histopathological findings. This method allows one to observe multiple planes by using thin slices. By dilating the uterine cavity, the site of involvement and the extent of invasion can be more precisely defined before treatment. It is truly a revolutionary procedure for determining-prior to surgery-the depth of invasion of a cancer located in the uterine body.

Accuracy of frozen section for the operative management of endometrial cancer

OBJECTIVE

To assess the accuracy of intra-operative frozen section reports at identifying the features of high risk uterine disease compared with final histopathology.

DESIGN

Retrospective study.

METHODS

The records of 460 patients with uterine cancer registered with the Queensland Centre for Gynaecological Cancer between January 1, 1996 and December 31, 1998 were reviewed. Intra-operative frozen section was undertaken in 260 patients with endometrial adenocarcinoma. Frozen section pathology was compared with the final histopathology reports. Inter-observer reliability was assessed using percentage agreement and kappa statistics. Clinical notes were also reviewed to determine if errors resulted in sub-optimal patient care.

RESULTS

Respectively, tumour grade and depth of myometrial invasion were accurately reported in 88.6% of cases (expected 61.5%, Kappa 0.70) and 94.7% (expected 53.8%, Kappa 0.89). Errors were predominantly attributable to difficulties with respect to the interpretation of tumour grade. The error resulted in the patient receiving sub-optimal surgical management in only 11 cases (5.3%)

CONCLUSION

Frozen section is accurate at identifying the features of high risk uterine disease in the setting of endometrial cancer and can play an important role in directing primary operative management.