Imaging of Uterine Cancer

Utility of CT Scan in Detecting Bladder Involvement Among Patients With Cervical Carcinoma

Background Cervical cancer is a widespread health issue in India, particularly affecting women as the second most common cancer. The burden of cervical cancer in the country necessitates accurate staging for treatment optimization. The revised International Federation of Gynecology and Obstetrics (FIGO) staging system is vital for this purpose, emphasizing the extent of parametrial and pelvic sidewall involvement. Cervical cancer's propensity to infiltrate neighboring pelvic organs, including the bladder, necessitates precise staging. In India, traditional methods like cystoscopy have been relied upon, but they have limitations. Recent advancements in medical imaging, notably the increased use of computed tomography (CT) scans, provide a non-invasive alternative for staging and evaluating bladder involvement. This study aimed to evaluate the utility and accuracy of CT scans in assessing bladder involvement. Methods This cross-sectional study examined 127 newly diagnosed cervical carcinoma cases in women over a two-year period from August 2021 to July 2023. Patients underwent CT scans (plain) and cystoscopy, and bladder involvement was determined following the revised FIGO staging. Data collected comprised patient demographics, medical history, clinical symptoms, and FIGO staging. Cystoscopy was performed using an Olympus CYF-5 flexible cystoscope, and CT scans utilized a 64-slice multidetector CT scanner. Radiological reports detailed primary tumor characteristics and proximity to the bladder. Statistical analysis encompassed descriptive statistics, and calculation of sensitivity, specificity, positive predictive value, and negative predictive value for CT scans in comparison to cystoscopy. Statistical significance was considered at p < 0.05. Results In our study, the mean participant age was 45.3 years, with 61.4% falling in the 40-60 years age group. Socioeconomic status (SES) varied, with 37.8% classified as low SES, 48.8% as middle SES, and 13.4% as high SES. Parity data showed that 76.4% had three or more pregnancies. Among presenting symptoms, abnormal vaginal bleeding (65.4%) was the most prevalent, and squamous cell carcinoma (78.7%) was the predominant histological type. The prevalence of bladder involvement was 9.4% by cystoscopy and 30.7% by CT scans. CT scan demonstrated a high sensitivity (100%) but lower specificity (76.52%), with 78.80% overall accuracy. Conclusion A combined approach, using CT scans as a screening tool and cystoscopy as a confirmatory method, could provide the most comprehensive and reliable assessment of bladder involvement in cervical carcinoma patients, ultimately contributing to improved patient care and management.

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.

Clinical Value Analysis of Combined Vaginal Ultrasound, Magnetic Resonance Dispersion Weighted Imaging, and Multilayer Spiral CT in the Diagnosis of Endometrial Cancer Using Deep VGG-16 AdaBoost Hybrid Classifier

Endometrial carcinoma is one of the most common disorders of the female reproductive system. Every year, around 76,000 women die from endometrial cancer around the world. Endometrial cancer is a significant factor in women’s health, particularly in industrialized nations, where the prevalence of this tumor type is the greatest. It is an important concern in women’s health because of disease mortality and the rising number of new diagnoses. The aim of the study was to investigate the clinical value of combined transvaginal ultrasound, magnetic resonance dispersion weighted imaging, and multilayer spiral computed tomography (CT) in the diagnosis of early-stage endometrial cancer. Initially, the dataset is collected that consisted of a total of 100 cases and split into the control group and experimental group of 50 cases in each group. The control group is diagnosed using conventional Doppler ultrasound diagnostic machine. The experimental group is diagnosed with combined ultrasound method. The ultrasound images thus obtained are preprocessed using the speckle-free adaptive wiener filter. The preprocessed images are segmented using the fuzzy clustering segmentation method. The features are extracted by the independent component analysis (ICA) method. We have proposed the deep VGG-16 AdaBoost hybrid classifier for classifying the normal and abnormal images. The clinical value of the diagnosis is analyzed using the parameters like diagnostic accuracy, specificity, sensitivity, and kappa coefficient. It is observed that the clinical value is better for the experimental group than the control group.

Imaging in Carcinoma Cervix and Revised 2018 FIGO Staging System: Implications in Radiology Reporting

The International Federation of Gynecology and Obstetrics (FIGO) staging system of carcinoma cervix saw a radical change in 2018 with the inclusion of cross-sectional imaging tools for the assessment of disease extent and staging. One of the major revisions is the inclusion of lymph node status, detected either on imaging or pathological evaluation, in the staging system. The changes were based on long-term patient follow-up and survival rates reported in literature. Thus, it becomes imperative for a radiologist to be well versed with the recent staging system, its limitations, and implications on the patient management.

Magnetic resonance imaging findings in 11 cases of dedifferentiated endometrial carcinoma of the uterus

Purpose

We evaluated magnetic resonance imaging (MRI) findings of dedifferentiated endometrial carcinoma (DEC), comprising undifferentiated carcinoma and low-grade endometrioid carcinoma.

Materials and methods

We recruited 11 patients with pathologically proven DEC treated at our institute. We evaluated primary lesion size, location and signal intensity on MRI, and prognosis. MRI and pathological findings were compared in eight resected patients.

Results

Primary tumors ranged from 16 to 206 mm in diameter. DEC was located at the endometrium in 9 of the 11 patients; the remaining two patients showed diffuse involvement of the enlarged myometrium. These two patients with diffuse involvement type died within 4 months. Of the eight patients who underwent resection, seven had macroscopic intratumoral hemorrhage and six showed a high signal on T1-weighted images or low signal on T2-weighted images. Of the eight resected patients, four had tumor necrosis > 25% and tumor size > 5 cm. In these patients, necrosis appeared as nonenhanced areas on contrast-enhanced MRI.

Conclusion

MRI findings of DEC showed two patterns: mass-forming type and diffuse myometrial type with poor prognosis. Most patients with DEC had intratumoral hemorrhage, and large tumors (> 5 cm) had gross necrosis, which appeared as nonenhanced areas on contrast-enhanced MRI.

Multiparametric magnetic resonance imaging of endometrial polypoid lesions

Endometrial polypoid lesions encompass various conditions from physiologic changes to benign or malignant disease. Differentiating between the various causes of endometrial polypoid lesions remains difficult by transvaginal sonography. Magnetic resonance imaging (MRI) can provide valuable information regarding endometrial polypoid lesions in situations where it is difficult to obtain histologic samples. Multiparametric MRI including T2-weighted images, T1-weighted fat-saturation contrast-enhanced images, and diffusion-weighted images may be helpful for differentiating the various endometrial polypoid lesions and establishing specific diagnoses and appropriate treatment.

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.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis of endometrial pathology

Ultrasound is the reference imaging procedure used for the exploration of endometrial pathology. As medical procedures improve and the requirements of modern medicine become more demanding, gray-scale ultrasound is insufficient in establishing gynecological diagnosis. Thus, more complex examination techniques are required: Doppler ultrasound, contrast-enhanced ultrasound (CEUS), 3D ultrasound, etc. Contrast-enhanced ultrasound is a special examination technique that gains more and more ground. This allows a detailed real-time evaluation of microcirculation in a certain territory, which is impossible to perform by Doppler ultrasound. The aim of this review is to synthesize current knowledge regarding CEUS applications in endometrial pathology, to detail the technical aspects of endometrial CEUS and the physical properties of the equipment and contrast agents used, as well as to identify the limitations of the method.

Imaging in endometrial carcinoma

Endometrial carcinoma (EC) is the most common gynecologic malignancy in the United States. Prognosis depends on patient age, histological grade, depth of myometrial invasion and/or cervical invasion, and the presence of lymph node metastases. Although EC is staged surgically according to the International Federation of Gynecology and Obstetrics (FIGO) system, preoperative imaging can assist in optimal treatment planning. Several imaging techniques such as transvaginal ultrasonography (TVUS), computed tomography (CT), and magnetic resonance imaging (MRI) have been used as diagnostic tools for preoperative staging of EC. Recently, positron emission tomography (PET), PET/CT, and PET/MRI have also been used in staging these patients. In this article, we review the value of imaging in diagnosis, staging, treatment planning, and detection of recurrent disease in patients with EC.

Is Prophylactic Irradiation to Para-aortic Lymph Nodes in Locally Advanced Cervical Cancer Necessary?

Purpose

This study evaluated the efficacy of extended field irradiation (EFI) in patients with locally advanced cervical cancer without para-aortic nodal involvement.

Materials and Methods

A total of 203 patients with locally advanced cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stage, IB2-IIIB) treated with radiotherapy at Keimyung University Dongsan Medical Center from 1996 to 2010 were retrospectively analyzed. The median patient age was 59 years (range, 29 to 83 years). None of the patients had para-aortic node metastases. Of the 203 patients, 88 underwent EFI and 115 underwent irradiation of the pelvis only. Concurrent chemoradiotherapy (CCRT) was administered to 133 patients. EFI field was used for treatment of 26 patients who received radiotherapy alone and 62 who received CCRT.

Results

The median follow-up period was 60 months. The 2- and 5-year overall survival (OS) rates were 87.8% and 73.5%, respectively, and the 2- and 5-year disease-free survival rates were 81.7% and 75.0%, respectively, however, no survival differences were observed between the two treatment field groups. EFI tended to increase OS in the radiotherapy alone group, but not in the CCRT group.

Conclusion

These findings suggest that EFI does not have a significant effect in patients with locally advanced cervical cancer, especially in patients receiving CCRT. Conduct of additional studies will be required in order to confirm these findings.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgery for endometrial cancers with suspected cervical involvement: is radical hysterectomy needed (a GOTIC study)?

Background:

Radical hysterectomy is recommended for endometrial adenocarcinoma patients with suspected gross cervical involvement. However, the efficacy of operative procedure has not been confirmed.

Methods:

The patients with endometrial adenocarcinoma who had suspected gross cervical involvement and underwent hysterectomy between 1995 and 2009 at seven institutions were retrospectively analysed (Gynecologic Oncology Trial and Investigation Consortium of North Kanto: GOTIC-005). Primary endpoint was overall survival, and secondary endpoints were progression-free survival and adverse effects.

Results:

A total of 300 patients who underwent primary surgery were identified: 74 cases with radical hysterectomy (RH), 112 patients with modified radical hysterectomy (mRH), and 114 cases with simple hysterectomy (SH). Median age was 47 years, and median duration of follow-up was 47 months. There were no significant differences of age, performance status, body mass index, stage distribution, and adjuvant therapy among three groups. Multi-regression analysis revealed that age, grade, peritoneal cytology status, and lymph node involvement were identified as prognostic factors for OS; however, type of hysterectomy was not selected as independent prognostic factor for local recurrence-free survival, PFS, and OS. Additionally, patients treated with RH had longer operative time, higher rates of blood transfusion and severe urinary tract dysfunction.

Conclusion:

Type of hysterectomy was not identified as a prognostic factor in endometrial cancer patients with suspected gross cervical involvement. Perioperative and late adverse events were more frequent in patients treated with RH. The present study could not find any survival benefit from RH for endometrial cancer patients with suspected gross cervical involvement. Surgical treatment in these patients should be further evaluated in prospective clinical studies.

Diagnostic accuracy of preoperative tests for lymph node status in endometrial cancer: a systematic review

Background: Approximately 72% of endometrial cancers are FIGO stage I at diagnosis and about 10% have lymph node metastases. An ideal diagnostic test for nodal disease would be able to prevent both overtreatment (i.e. unnecessary lymphadenectomy) and undertreatment (i.e. withholding lymphadenectomy or adjuvant postoperative treatment to patients with lymph node metastases). Objectives: In this review we compare the accuracy of preoperative tests (computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, CA-125 serum levels, and ultrasonography) for the detection of lymph node metastases in endometrial cancers with the final histopathologic diagnosis after complete pelvic and para-aortic lymphadenectomy as the gold standard. Method: A systematic search in MEDLINE (using PubMed), Embase and The Cochrane Library was performed up to 23 July 2012. Results: We found one article that met our inclusion criteria for computed tomography, none for magnetic resonance imaging, 2 for positron emission tomography/computed tomography), 2 for CA-125 and none for ultrasonography. Conclusions: Due to the lack of high-quality articles on a preoperative test for lymph node status in endometrial cancer, no proper comparison between these modalities can be made.

Imaging of endometrial carcinoma using contrast-enhanced sonography

OBJECTIVES

The purpose of this study was to evaluate the utility of contrast-enhanced sonography as an adjunct to conventional transvaginal sonography for detecting endometrial carcinoma and defining the depth of myometrial invasion.

METHODS

A total of 35 patients with endometrial carcinoma diagnosed by endometrial sampling were examined with transvaginal sonography followed by contrast-enhanced sonography before treatment. The contrast enhancement phases (ie, early wash-in/out and late wash-in/out) were visually observed before comparison of tumors grouped by average diameter and histopathologic grade. We evaluated the effectiveness of contrast-enhanced sonography as an adjunct to transvaginal sonography in tumor imaging. We calculated the accuracy of contrast-enhanced sonography for diagnosing the depth of tumor invasion into the myometrium by using arcuate vascular plexus involvement as the sonographic standard for diagnosis of deep myometrial infiltration.

RESULTS

Of the 34 tumors identified by contrast-enhanced sonography, 28 (82.4%) showed early wash-in, and 6 (17.6%) showed late wash-in. Similar numbers of cases showed early and late wash-out. The enhancement phases did not differ significantly across groups with different average tumor diameters or histologic grades (P > .05). Contrast-enhanced sonography contributed the most to tumor imaging in patients with a thin endometrium after endometrial biopsy because it enhanced the contrast between the tumor and tissue. The diagnostic accuracy of contrast-enhanced sonography for determining the myometrium infiltration depth was 85.3%.

CONCLUSIONS

This study revealed diagnostically useful characteristics of the enhancement phase of endometrial carcinoma. The ability to enhance tumor-to-tissue contrast makes contrast-enhanced sonography a valuable adjunct to conventional sonography of endometrial carcinoma, especially for the thin endometrium found after endometrial biopsy. Contrast-enhanced sonography performed well in the diagnosis of the myometrial infiltration depth when using arcuate vascular plexus involvement as a marker of deep myometrial infiltration.

Endometrial cancer state of the science meeting

There is a pressing need to improve our understanding of endometrial cancer (EC) and uterine carcinosarcoma and to develop new treatment strategies to improve outcomes. In recognition of this, a State of the Science meeting on EC was held last November 28 and 29, 2006, in Manchester, United Kingdom. The meeting was cosponsored by the National Cancer Research Institute (UK), the National Cancer Institute (US), and the Gynecological Cancer Intergroup. The objectives of the meeting were as follows: 1. To review current knowledge and understanding of EC and its treatments. 2. To identify key issues for translational research and clinical trials. 3. To identify the most important trials for women with endometrial carcinoma and uterine carcinosarcoma, both those already underway or to be done, for which the Gynecological Cancer Intergroup might facilitate international cooperation.

Issues in imaging malignant neoplasms of the female reproductive system

Radiological evaluation of malignant neoplasms of the female reproductive system is invaluable in the initial diagnosis, staging, treatment planning, and follow-up management. Radiologists serving as consultants for the general primary care internist, gynecologists, and specialists in gynecologic oncology should be familiar with the strengths and limitations of various modalities used to evaluate gynecologic cancer patients. This article discusses the most common female reproductive tract neoplasms (ie, cervical, endometrial, and ovarian cancers) and the role of ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography in their diagnosis and management. Imaging features that impact on clinical diagnostic or treatment algorithms are highlighted and illustrated. Finally, recent technical advances that demonstrate promise are described.

Management of Endometrial Cancer

Endometrial cancer is the fourth most common malignancy diagnosed in US women. Although most cases present in early stages and respond well to surgical staging with appropriately administered adjuvant radiation, the prognosis for advanced endometrial cancers is comparatively poor. Currently available treatments for advanced and recurrent metastatic endometrial cancer have significant toxicities, and are given to a population that is usually elderly with multiple other medical comorbidities. This article examines the pathogenesis of endometrial cancer as well as its diagnosis and management.