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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 181-185
 

Magnetic resonance imaging in pre-operative staging of endometrial cancer


1 Department of Gynaecology Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Pathology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Radiology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India

Date of Web Publication28-Apr-2016

Correspondence Address:
S Shrivastava
Department of Gynaecology Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.180859

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 » Abstract 

Introduction: Endometrial cancer (EC) is one of the most common gynecological cancers and the fourth most common cancer in the female. Although clinical evaluation with diagnostic imaging has not yet proved to be accurate enough in the evaluation of tumor extent to replace surgical staging, it may enable optimization of the surgical procedure and a better tailored therapeutic strategy. This study will review the characteristic magnetic resonance imaging (MRI) findings in endometrial carcinomas in the pre-operative staging of endometrial carcinomas and compare it with the newly revised Federation of Gynecology and Obstetrics (FIGO) staging scheme of 2009 based on post-operative surgical histopathology. Materials and Methods: It is a retrospective analysis of 36 patients diagnosed and treated for endometrial carcinoma in our institute from January 2009 to December 2012. Results: Majority of the patients (61%) were between the age group of 41-60 years. Most of the patients (72%) were postmenopausal at the time of presentation. Most common histopathology of endometrial carcinoma was endometroid adenocarcinoma (27 patients, 75%). FIGO staging of 12 patients (85.7%) showed concordance with MRI Staging for Stage Ia, with up-gradation of two patients to Stage Ib. Conclusion: The information provided by MRI can define prognosis, help planning the surgical approach and identify those patients requiring neoadjuvant chemotherapy or radiation therapy.


Keywords: Endometrial cancer, endometroid adenocarcinoma, Federation of Gynecology and Obstetrics staging, magnetic resonance imaging staging, surgical staging


How to cite this article:
Shrivastava S, Barmon D, Kataki A C, Deka P, Sharma J D, Choudhary B K, Baruah U. Magnetic resonance imaging in pre-operative staging of endometrial cancer. Indian J Cancer 2016;53:181-5

How to cite this URL:
Shrivastava S, Barmon D, Kataki A C, Deka P, Sharma J D, Choudhary B K, Baruah U. Magnetic resonance imaging in pre-operative staging of endometrial cancer. Indian J Cancer [serial online] 2016 [cited 2019 Aug 25];53:181-5. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/181/180859



 » Introduction Top


Endometrial cancer (EC) is one of the most common gynecological cancer and the fourth most common cancer in the female. According to the National Cancer Registry Program, Indian Council of Medical Research (2009-2011) data for EC, Kamrup urban is at sixth position in India with an age adjusted ratio of 4/100,000 and EC is one among the top 10 sites of cancer in females in Kamrup urban district.[1]

Treatment and prognosis is influenced by surgical International Federation of Gynecology and Obstetrics (FIGO) stage with evaluation of the depth of myometrial invasion, cervical extension and the presence of lymph node and distant metastases.[2] The histological subtype and grade are also established prognostic markers influencing therapy.[2] The overall 5-year survival of endometrial carcinoma is 80%.[3]

Since 1988, endometrial carcinoma has been surgically staged according to the FIGO staging systems,[4] which were last revised in 2009.[5] Although clinical evaluation with diagnostic imaging has not yet proved to be accurate enough in the evaluation of tumor extent to replace surgical staging, it may enable optimization of the surgical procedure and a better tailored therapeutic strategy.[2],[3],[6]

Magnetic resonance imaging (MRI) has long been established as a valuable diagnostic tool in the preoperative diagnostic staging of endometrial carcinomas.[4],[6] Contrast enhanced MRI has been shown to be superior to unenhanced MRI, ultrasonography and computed tomography (CT) in the assessment of myometrial and cervical tumor invasion.[6],[7]

This study will review the characteristic MRI findings in endometrial carcinomas in the preoperative staging of endometrial carcinomas and compare it with the newly revised FIGO staging scheme of 2009 based on post-operative surgical histopathology [Table 1].[8]
Table 1: Revised surgical FIGO staging (2009) of endometrial carcinoma with corresponding MRI findings[8]

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 » Materials and Methods Top


It is a retrospective analysis of patients diagnosed and treated for endometrial carcinoma in our institute from January 2009 to December 2012. Case records of the patients treated for EC at our institute were studied. Data collected includes case demographics, clinical diagnosis, MRI report, treatment received and histology report from the case record.

Inclusion criteria

All patients with proven histology of endometrial carcinoma are included.

Exclusion criteria

Patients with advanced disease requiring chemotherapy prior to surgery were excluded. Patients with histopathology other than endometrial carcinoma such as carcinosarcoma and lieomyosarcoma were excluded.

Methodology

The diagnosis of EC was confirmed by endometrial biopsy by dilataion and curettage or by pippelle aspirate. For pre-operative staging of EC MRI was done in our institute by Brilliance 230 W Philips machine. A 1.5 Tesla MR unit was used with a dedicated phased-array pelvic coil. After 3-plane scout images had been obtained, high-resolution sagittal T2-weighted fast spin-echo imaging (repetition time 5844 ms, echo time 96 ms, echo train length 8, 20 slices, slice thickness 3 mm, gap 0.3 mm, field of view 20-26 cm, matrix 384 × 256, 2 acquisitions) was performed. Then 2 T2-weighted scans coronally and axially to the longitudinal axis of the uterine body were acquired with the same acquisition parameters. Finally, a sagittal T1-weighted fast gradient echo (repetition time 140 ms, echo time 4.5 ms; flip angle 80°, 12 slices, thickness 5 mm, gap 0.5 mm, field of view 2026 cm, matrix 192 × 256, 2 acquisitions) was performed before and after intravenous administration of 10 mL of gadolinium followed by flushing with 20 mL of saline. Post-contrast images were acquired at 30, 60 and 120 s. All patients underwent standard surgical procedure, i.e., Total abdominal hysterectomy with bilateral salphingo-oopherectomy with pelvic lymph node dissection. The specimen was sent for the histopathological examination. The data is compiled into a Microsoft Excel ©(2007) spreadsheet. Data analysis is done by using Microsoft Excel © and SPSS (16.0.2/2008).


 » Results Top


From January 2009 to December 2012, a total of 36 patients were diagnosed and treated for EC at our institute. The case records of these patients were studied and analyzed.

Majority of the patients, 22 (61%) were between the age group of 41 and 60 years, followed by 10 patients (27.8%) who were more than 60 years (27.8%). Twenty-six patients (72%) attained menopause at the time of presentation. Ten patients (28%) presented at perimenopausal state with some menstrual irregularity.

Most common complaint was postmenopausal bleeding per vaginum seen in 26 patients (72%) patients. Ther patients of perimenopausal age group presented with irregular and heavy bleeding per vaginum (six patients, 16.7%), followed by intermittent spotting per vaginum (four patients, 11.1%). Most common histopathology of endometrial carcinoma was endometroid adenocarcinoma (27 patients, 75%), out of which 48% were Grade I, 37% were Grade II and 14.8% were Grade III.

Pre-operative MRI showed endometrial proliferation only in 8 (22%) patients with no myometrial invasion. Twenty-eight patients had myometrial invasion out of which 6 (16.67%) patients had less than half myometrial invasion and 20 (55.56%) had more than half of the myometrial invasion and 2 (5.56%) had full thickness involvement up to the serosa. Disruption of the low-signal intensity inner cervical stroma (T2) or disruption of the cervical epithelium enhancement (CE T1) was seen in 8 (22%) patients. Enlarged pelvic and/or para-aortic lymph nodes (cut-off value >10 mm for short-axis diameter) was seen in only 2 (5%) patients [Figure 1] and [Figure 2].
Figure 1: T1-weighted magnetic resonance imaging showing endometrial growth with heterogeneous intensity. There is no myometrial invasion seen

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Figure 2: T2-weighted magnetic resonance imaging endometrial growth with heterogeneous intensity extending into the endocervix. Invasion of myometrium seen in the inner half at the fundal region and at the anterior myometrial wall

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According to MRI staging 39% patients had Stage Ia disease, 28% had Stage Ib, 22% had Stage II disease. Stage IIIa and IIIc were seen in 5.5% patients each.

Post-operative histopathological examination of specimen showed endometrial proliferation only in 6 (16.67%) patients with no myometrial invasion. Thirty (83.3%) patients had myometrial invasion out of which 9 (25%) patients had less than half myometrial invasion, 16 (44%) had more than half of the myometrial invasion and 5 (13.88%) had full thickness involvement up to the serosa [Figure 3]. Tumor invasion into cervical stroma, but not extending beyond the uterus was seen in 10 (27.78%) patients. Metastases to pelvic and/or para-aortic lymph nodes were seen in 3 (8.33%) patients [Figure 4].
Figure 3: H and E, ×10 showing endometroid adenocarcinoma of endometrium with myometrial invasion

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Figure 4: H and E, ×10 showing endometroid adenocarcinoma of endometrial cancer showing lymph node invasion

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According to FIGO staging 42% patients had Stage Ia disease, 28% had Stage Ib, 17% had Stage II disease. Stage IIIa and IIIc were seen in 5% and 8% patients respectively.

FIGO staging of 12 patients (85.7%) showed concordance with MRI staging for Stage Ia, with up-gradation of two patients to Stage Ib. Six (60%) patients had concordance with MRI Staging for Stage Ib with up-gradation of one patient to Stage II and down-gradation of three patients to Stage Ia. Five (62.5%) patients had concordance with MRI staging for Stage II with up-gradation of one patient to Stage IIIc and down-gradation of two patients to Stage Ib [Table 2].
Table 2: Correlation of MRI staging with the FIGO staging

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 » Discussion Top


EC is the fourth most common cancer in the female. The peak age at presentation for endometrial carcinoma is approximately 60 years. Nearly 90% of these women present with abnormal vaginal bleeding and 75% present with Stage I disease.[9]

The prognosis of EC is more favorable in respect to other gynecological malignancies, with a 5-year survival rate of about 84%. Nearly 75% of patients with EC are diagnosed at Stage I [10],[11] and are curable by simple hysterectomy.[12]

Prior to 1988 endometrial carcinoma was staged by examination under anesthesia, hysteroscopy and dilatation and curettage. This resulted in understaging of 13-22% of cases. Routine surgical staging (total abdominal hysterectomy and bilateral salpingo-oophorectomy with peritoneal washes with or without pelvic and paraaortic lymphadenopathy) was recommended by FIGO in 1988. Since 1988, endometrial carcinoma has been surgically staged according to the FIGO staging systems,[4] which were last revised in 2009.[5]

In our study, 22 patients (61%) were between the age group of 41 and 60 years at the time of diagnosis, followed by 10 patients (28%) whose age were more than 60 years. The mean age at presentation was 52.77 ± 9.8 year. The mean age at presentation was 63 in a study done by Aderson et al.[13]

In the present study, majority of patients (26 patients, 72%) attained menopause at the time of presentation and 10 patients (28%) presented at perimenopausal state with some menstrual irregularity. Twenty-six patients (72%) patients presented with postmenopausal bleeding per vaginum. Perimenopausal patients presented with irregular and heavy bleeding per vaginum (in 16.7%), followed by intermittent spotting per vaginum (in 11.1%).

In a study done by Yoney et al.[14] median age of the patients was 53, ranging between 31 and 77. There were 58 patients (23.6%) under the age of 60 and 188 patients (76.4%) over the age of 60. The majority of patients, i.e. 156 of them (63.4%), were postmenopausal. In the study by Zandrino et al.[15] 26 patients (87%) were postmenopausal. The presenting symptoms were postmenopausal abnormal bleeding in 24/30 (80%), mucinous vaginal discharge in 3/30 (10%) and intermenstrual dysfunctional bleeding in 3/30 (10%) patients.

In the present study, most common histopathology of endometrial carcinoma was endometroid adenocarcinoma (27 patients, 75%), out of which 48% were Grade I, 37% were Grade II and 14.8% were Grade III. It was followed by papillary adenocarcinoma, i.e., 22% and adenosquamous carcinoma (3%). A study by Yoney et al.[14] also stated that most of the cases had endometrioid adenocarcinoma histology (227 patients, 92.3%) out of which 51 (61.4%) cases had Grade 1 disease.

The histological grade and the stage of the disease (depth of myometrial invasion, cervical involvement) are predictive of the occurrence of extrauterine spread, pelvic or lumboaortic nodal metastases [16],[17],[18],[19] and affect the prognosis and treatment. Based on the stage of the disease, the treatment options include surgery, radiation therapy, hormone therapy and chemotherapy.

After comparing MRI findings with pathologic finding of 36 cases, overall concordance was seen in 27 (75%) cases, with understaging in 4 (11.1%) cases and overstaging of 5 (13.89%) cases. MRI assessment of myometrial infiltration accurately assessed 66.67% (24/36) of cases, over estimating 13.89% (5/36) and under estimating myometrial invasion in 8.3% (3/36) cases.

MRI differentiation between Stage Ia and Stage Ib agreed with histopathological finding in 75% (18/24) of cases, making the correct assessment in 83% of patients with less than half of myometrial infiltration and in 86.3% patients with more than half of myometrial invasion. MRI showed a sensitivity of 80%, specificity of 80%, positive predictive value of 86% and negative predictive value of 72% and diagnostic accuracy of 80% for differentiating between Stage Ia and Ib disease.

Concerning cervical invasion (Stage II) MRI presented with 5 true positive, 27 true negative, 3 false positive and 1 false negative results. Analyzing this parameter we found a sensitivity of 83%, specificity of 90% and positive predictive value of 62.5%, negative predictive value of 96.4% and diagnostic accuracy of 88.9%.

In assessing the lymph node invasion, MRI showed 2 true positive, 33 true negative and 1 false negative results. There was no false positive result of lymph node invasion in MRI. All three cases of lymph node invasion had a MRI staging with deep myometrial invasion. Considering lymph node invasion, MRI demonstrated a sensitivity of 66.67%, specificity of 100%, positive predictive value of 100% and negative predictive value of 97% and diagnostic accuracy of 97%.

Recent studies presenting data on the overall accuracy, sensitivity and specificity of MRI in the assessment of superficial versus deep myometrial invasion, cervical invasion and lymph node metastasis are compiled in [Table 3].
Table 3: Recent studies (2007-2010) reporting the accuracy, sensitivity and specifificity of MRI in staging of endometrial cancer

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Our study evaluated the role of MRI in the pre-operative staging of the EC by analyzing the results of the institution. Concerning the differentiation between Stage Ia and Stage Ib our results show accuracy of 80% that is comparable with previous studies done by Cabrita et al.,[21] Zandrino et al.,[15] Hori et al.[22] and Rockall et al.[23] with diagnostic accuracy of 77%, 80%, 77-88% and 80-83%, respectively.

Regarding the cervical invasion, though the MRI accuracy in the present study was comparable with the studies done by Hori et al.[22] and Rockall et al.,[23] but the positive predictive value for cervical invasion was found to be low, i.e., 62.5% in the present study.

Though accuracy for lymph node metastasis was 97% and was comparable with previous studies by Hori et al.[22] and Rockall et al.,[23] but total numbers of cases assessed in the present study were only three cases. Hence, to find out exact accuracy rate of MRI for the lymphnode invasion analysis we have study more cases with histopathologically positive lymph nodes.

The MRI diagnosis of lymph node metastases is based on a size criterion with a widely used cut-off value of >10 mm for the short-axis diameter.[7],[25] The reported sensitivity of MRI for the detection of metastatic lymph nodes in endometrial carcinomas is generally low, ranging from 17% to 80% in recent literature.[22],[23],[24] When reducing the cut-off value for pathological size from >10 to >8 mm, the sensitivity for the detection of lymph node metastases in one study increased from 44% to 66%, however, with a corresponding decrease in specificity from 98% to 73% respectively.[23]

Thus, we can conclude that contrast-enhanced MRI is considered the imaging method of choice in the pre-operative staging of endometrial carcinomas. MRI performs well in the detection of deep myometrial invasion and cervical stroma invasion but has low sensitivity for the identification of metastatic lymph nodes.

Diffusion-weighted MRI may represent a valuable adjunct to standard MRI in the assessment of myometrial invasion and in the differentiation between benign and malignant endometrial lesions. Other novel MRI techniques, such as MR perfusion, MR spectroscopy, blood oxygen level-dependent-MRI and MRI with new contrast agents like magnetic iron oxide nanoparticles, having a long blood retention time and biodegradability and a low toxicity, may potentially reveal important aspects of the tumor biology in endometrial carcinomas. This may in the future provide valuable tools to improve preoperative diagnostic accuracy for a refined and tailored surgical procedure, monitoring of treatment response and prediction of treatment outcomes.[8]



 
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Scoutt LM, McCarthy SM, Flynn SD, Lange RC, Long F, Smith RC, et al. Clinical stage I endometrial carcinoma: Pitfalls in preoperative assessment with MR imaging. Work in progress. Radiology 1995;194:567-72.  Back to cited text no. 16
    
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Nasi F, Fiocchi F, Pecchi A, Rivasi F, Torricelli P. MRI evaluation of myometrial invasion by endometrial carcinoma. Comparison between fast-spin-echo T2w and coronal-FMPSPGR gadolinium-dota-enhanced sequences. Radiol Med 2005;110:199-210.  Back to cited text no. 17
    
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Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer. A gynecologic oncology group study. Cancer 1987;60:2035-41.  Back to cited text no. 18
    
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Sala E, Crawford R, Senior E, Shaw A, Simcock B, Vrotsou K, et al. Added value of dynamic contrast-enhanced magnetic resonance imaging in predicting advanced stage disease in patients with endometrial carcinoma. Int J Gynecol Cancer 2009;19:141-6.  Back to cited text no. 24
    
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Narayanan P, Iyngkaran T, Sohaib SA, Reznek RH, Rockall AG. Pearls and pitfalls of MR lymphography in gynecologic malignancy. Radiographics 2009;29:1057-69.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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