Objective: To investigate the performance of fused T2WI-diffusion-weighted imaging (DWI) in the preoperative evaluation of the depth of myometrial invasion in endometrial cancer. Materials and Methods: Twenty-nine patients with histologically proven endometrial carcinoma were enrolled in this study. All of them underwent a full magnetic resonance imaging exam including T2-weighted images and DWI with b values of 0, 500, and 1000 s/mm2. The ADC value in endometrial cancer and normal endometrium of control cases was calculated. The myometrial invasion depth was judged in each sequence separately as well as by fused images, and was correlated with the surgical pathology results. Results: In the evaluation of superficial myometrial invading lesions using the fused T2WI-DWI, the sensitivity was found to be 94.7%, specificity was 90%, and accuracy was 94.7%, while the values of about 90% sensitivity, 94.9% specificity, and 90% accuracy of fused T2WI-DWI in the evaluation of deep myometrial invading lesions were obtained. On the ADC maps, the mean ADC value of endometrial cancer was 0.9±0.17×10−3 mm2/s and the mean ADC value of normal endometrium of control cases was 1±0.11×10−3 mm2/s. Conclusion: The fusion of T2WI and DWI showed a good noninvasive diagnostic method of staging of invasion and preoperative depth. It can be used as an alternative diagnostic tool for endometrial carcinoma staging with reduced cost and injection of a contrast agent.
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CACancer J Clin 2018; 68(6): 394–24.
2. Rockall AG, Qureshi M, Papadopoulou I, Saso S, Butterfield N, Thomassin-Naggara I, et al. Role of imaging in fertility-sparing treatment of gynecologic malignancies. Radiographics 2016; 36(7): 2214–33.
3. Zhang H, Cui J, Jia L, Hong S, Kong B, Li D. Comparison of laparoscopy and laparotomy for endometrial cancer. Int J Gynecology Obstet 2012; 116(3): 185–91.
4. Hahn HS, Yoon SG, Hong JS, Hong SR, Park SJ, Lim JY, Kwon YS, Lee IH, Lim KT, Lee KH, Shim JU. Conservative treatment with progestin and pregnancy outcomes in endometrial cancer. Int J Gynecol Cancer 2009; 19(6): 1068–73.
5. Aloisi A, Plotti F, Scaletta G, Capriglione S, Laraud F, Miranda A, et al. Chemotherapy as Adjuvant Treatment for Intermediate-High Risk Early-Stage Endometrial Cancer: A Pilot Study. Int J Gynecol Cancer 2015; 25(8): 1418–23.
6. Burke WM, Orr J, Leitao M, Salom E, Gehrig P, Olawaiye AB, et al. Endometrial cancer: a review and current management strategies: part II. Gynecol Oncol 2014; 134(2): 393–402.
7. Guo Y, Wang P, Wang P, Gao W, Li F, Yang X, et al. Myometrial invasion and overall staging of endometrial carcinoma: assessment using fusion of T2-weighted magnetic resonance imaging and diffusionweighted magnetic resonance imaging. OncoTargets Ther 2017; 10: 5937–43.
8. Capriglione S, Plotti F, Miranda A, Lopez S, Scaletta G, Moncelli M, et al. Further insight into prognostic factors in endometrial cancer: the new serum biomarker HE4. Expert Rev Anticancer Ther 2017; 17(1): 9–18.
9. Haldorsen IS, Salvesen HB. Staging of endometrial carcinomas with MRI using traditional and novel MRI techniques. Clinical Radiol 2012; 67(1): 2–12.
10. Chen T, Jansen L, Gondos A, Ressing M, Holleczek B, Katalinic A, et al. Survival of endometrial cancer patients in Germany in the early 21st century: a period analysis by age, histology, and stage. BMC Cancer 2012; 12: 128.
11. Panici PB, Basile S, Maneschi F, Lissoni A, Signorelli M, Scambia G, et al. Systematic pelvic lymphadenectomy vs no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial J Natl Cancer Inst 2008; 100(23): 1707–16.
12. Dhanda S, Thakur M, Kerkar R, Jagmohan P. Diffusion-weighted imaging of gynecologic tumors: diagnostic pearls and potential pitfalls. Radiographics 2014; 34(5): 1393–416.
13. Armstrong AJ, Hurd WW, Elguero S, Barker NM, Zanotti KM.Diagnosis and management of endometrial hyperplasia. J Minim Invasive Gynecol 2012; 19(5): 562–71.
14. Soneji ND, Bharwani N, Ferri A, Stewart V, Rockall A. Pre-operative MRI staging of endometrial cancer in a multicentre cancer network: can we match single centre study results?. Eur Radiol 2018 ;28(11): 4725–34.
15. Rechichi G, Galimberti S, Signorelli M, Franzesi CT, Perego P, Valsecchi MG, et al. Endometrial cancer: correlation of apparent diffusion coefficient with tumor grade, depth of myometrial invasion, and presence of lymph node metastases. AJR Am J Roentgenol 2011; 197(1): 256–62.
16. Nishie A, Stolpen AH, Obuchi M, Kuehn DM, Dagit A, Andresen K. Evaluation of locally recurrent pelvic malignancy: performance of T2- and diffusion-weighted MRI with image fusion. J Magn Reson Imaging 2008; 28(3): 705–13.
17. Rosenkrantz AB, Mannelli L, Kong X, Niver BE, Berkman DS, Babb JS, et al. Prostate cancer: Utility of fusion of T2-weighted and high b-value diffusion-weighted images for peripheral zone tumor detection and localization. J Magn Reson Imaging 2011; 34(1): 95–100.
18. Brenner R, Metens T, Bali M, Demetter P, Matos C. Pancreatic neuroendocrine tumor: added value of fusion of T2-weighted imaging and high b-value diffusion-weighted imaging for tumor detection. Eur J Radiol 2012; 81(5): e746–9.
19. Andreano A, Rechichi G, Rebora P, Sironi S, Valsecchi MG, Galimberti S. MR diffusion imaging for preoperative staging of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis. Eur Radiol 2014; 24(6): 1327–38.
20. Beddy P, O’Neill AC, Yamamoto AK, Addley HC, Reinhold C, Sala E. FIGO staging system for endometrial cancer: added benefits of MR imaging. Radiographics 2011; 32(1): 241–54. 21. Dogan D, Inan N, Sarisoy HT, Gumustas S, Akansel G, Muezzınoğlu B, et al. Preoperative evaluation of myometrial invasion in endometrial carcinoma: diagnostic performance of 3T MRI. Abdominal Imaging 2013; 38(2): 388–96.
22. Wu LM, Xu JR, Gu HY, Hua J, Haacke EM, Hu J. Predictive value of T2-weighted imaging and contrast-enhanced MR imaging in assessing myometrial invasion in endometrial cancer: a pooled analysis of prospective studies. European Radiol 2013; 23(2): 435–49.
23. Emlik D, Kiresi D, Özdemir S, Celik C, Karaköse S. Preoperative assessment of myometrial and cervical invasion in endometrial carcinoma: Comparison of multi-section dynamic MR imaging using a three dimensional FLASH technique and T2-weighted MR imaging. J Med Imaging Radiat Oncol 2010; 54(3): 202–10.
24. Gallego JC, Porta A, Pardo MC, Fernández C. Evaluation of myometrial invasion in endometrial cancer: comparison of diffusion-weighted magnetic resonance and intraoperative frozen sections. Abdom İmaging 2014; 39(5): 1021–6.