Presentation1, radiological imaging of endometrial carcinoma.

health &medicine

1. Dr/ ABD ALLAH NAZEER. MD. Radiological Imaging of endometrial carcinoma.

2. Endometrial cancer -4th most common cancer in women -Most common gynecologic malignancy -Peak incidence: 55 and 65 years -Risk factors: -Obesity. -Nulliparity. -Late menopause. -Unopposed estrogen exposure. -Tamoxifen.

3. -Over 80% of patients present with early stage disease due to symptoms of abnormal uterine bleeding, with an overall excellent prognosis. -Endometrial cancer is traditionally surgically staged and the treatment varies by stage, grade, regional guidelines, and expertise. -MRI is a valuable adjunct to pre-operative planning as it can accurately depict endometrial cancer . The goal of MRI is to identify patients preoperatively who would benefit from abdominopelvic lymph node dissection and adjuvant therapy while avoiding overtreating early stage patients with unnecessary lymphadenectomies.

4. Imaging techniques Ultrasound TVUS is often used for the initial evaluation in women with history of postmenopausal bleeding because it is quick, inexpensive, and does not expose the patient to ionizing radiation. ECs typically present as thickening of the endometrium and TVUS diagnosis of endometrial cancer is based on endometrial thickness that is measured in the anteroposterior dimension. The sensitivity and specificity of TVUS for detecting EC approach 96% and 61%, respectively, when an endometrial thickness threshold of 5 mm , in postmenopausal women, is used to define abnormal endometrial thickening. A meta-analysis suggested a sensitivity of 68-100% and a specificity of 71-90% for subjective assessment of deep myometrial invasion. Furthermore, the negative predictive value of a thin endometrium is very high. Also, cancer is more likely when the endometrium has a heterogeneous echotexture and irregular or poorly defined margins.

5. A 67-year-old female with endometrial cancer. (A) Longitudinal transabdominal scan. (B) Transvaginal scan and a 3-D reconstructed ultrasonography image (C) through the uterus demonstrate a thickened and heterogeneous endometrium measuring 2.0 cm (arrows). Note regular endometrial–myometrial border with no signs of invasion (arrowheads). (D) Note increased vascularity in the color Doppler US (black arrow).

6. Endometrial carcinoma.

7. Doppler showing increased endometrial vascularity in endometrial carcinoma.

8. Ultrasound images of a female patient, aged 55 years with malignant thickened endometrium (confirmed to be endometrial adenocarcinoma by pathological examination). B-mode ultrasound image (A), Power Doppler image (B) and TV elastogram (C) show endometrial thickness = 18 mm with increase vascularity, dark blue color and SR = 11.54.

9.   Image planes for high-resolution T2-weighted imaging of the uterus. Initial high resolution T2-weighted sagittal images of the pelvis are obtained. Axial oblique images are obtained by scanning perpendicular (dotted blue lines) to the long axis of the endometrial cavity (solid red line). These sequences can then be used for accurate assessment of myometrial invasion by tumour. If there is suspected cervical invasion, further imaging is recommended on a plane perpendicular to the long axis of the endocervical canal. 

10. Classification of Endometrial carcinoma using TNM and FIGO Staging systems.

11. Grade I endometrial carcinoma on top of endometrial hyperplasia. A and B Sagittal and axial T2-weighted images of the uterus show endometrial mass with bright signal intensity filling and distending the endometrial cavity with thinning of the myometrium. C Axial T1-weighted. D Axial Gd- T1-weighted image showing the endometrial mass enhancing less than the myometrium. E and F DW-MRI and corresponding ADC map. There is heterogeneous iso-intense signal with foci of high signal intensity and corresponding low signal on ADC map (consistent with endometrial hyperplasia with foci of malignant transformation). ADC value was 1.4 × 10−3 mm2/s in areas of endometrial hyperplasia and 0.74 × 10−3 mm2/s in areas of endometrial carcinoma.

12. Stage 11A ( A) Sagittal T2W image show a hyperintense signal intensity tumor distending the endometrial cavity (arrow). (B) On T1W post-contrast image, the tumor (arrow) is low in signal compared to the enhancing adjacent myometrium. It presents restricted diffusion with high signal on DW images (C) and low signal on ADC map (D) (arrows). (E) It presents with high FDG uptake on FDG-PET/CT (arrow)

13. (A,B) cervical cancer and (C,D) endometrial cancer on sagittal T2-weighted (left column) and contrast-enhanced T1-weighted (right column) MRI images. Abbreviations: T, tumor; M, myometrium.

14. 77-year-old female patient with pathologically diagnosed G2 endometrioid endometrial carcinoma. A and B: Sagittal and axial T2 W images showing a hyper-intense endometrial mass relative to the myometrium occupying the fundus and anterior wall of the uterine cavity. C and D: Sagittal and Axial Delayed Gd-T1 W images showing the endometrial mass to be more conspicuous and contrasting against the enhanced myometrium with deep myometrial invasion >50%. E, F: Axial ADC map and corresponding high b value DW image showing diffusion restriction of the mass in the form of low signal on ADC map and high signal on DWI. The ADC value 0.75 × 10−3 mm2/s. On DWI, there is well delineation of depth of myometrial invasion >50%. Note the associated Right ovarian endometrioid carcinoma (∗).

15. Mimics of Endometrial Cancer Benign lesions: 1- Submucous Fibroid. 2- Adenomyosis. 3- Endometrial Polyp. 4- Endometrial hyperplasia. 5-Placental Polyp. Malignant lesions: -Uterine sarcomas.

16. MRI shows fibroid inside the uterine cavity.

17. Uterine adenomyosis.

18. A) Axial T2-weighted image shows a 6 cm sized endometrial mass with multiple hyperintense cystic lesions (arrowhead) and hypointense fibrous stroma (arrow) .

19. Endometrial Hyperplasia.

20. Summary. - MRI is excellent at depicting uterine anatomy and assessing endometrial cancer. -Tumor size and extension -Myometrial invasion -Parametrial/cervical invasion -Lymphadenopathy -Although currently endometrial cancer is staged surgically, MRI does play a critical role in pre-operative planning. -Differentiating endometrial cancer from co-existing endometrial hyperplasia, adenomyosis, fibroids, and polyps is important in the accurate assessment of endometrial cancer.

21. Thank You.