CASE 2444 Published on 23.05.2007

Endometrial carcinoma: MR findings

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Deledda A, Sala S, Loiacono F, D'agostino F, Rignanese L

Patient

64 years, female

Categories
No Area of Interest ; Imaging Technique MR
Clinical History
64 years-old women with vaginal bleeding
Imaging Findings
A patient with a six months history of vaginal bleeding and occasional perineal pain consulted with her gynaecologist. Physical examination showed deformation of the cervix that was tender to palpation; endocavitary sonography revealed abnormal thickening of endometrium with myometrial invasion; endometrial biopsy revealed endometrial carcinoma. The patient underwent preoperative MRI examination wich showed marked thickening of the endometrium due to a large hyperintense lesion on T2-weighted images with invasion of the outer half of the myometrium and of the cervix. MRI showed absence of extrauterine spread and normality of the rectal and vescical walls; moreover, abdominal and pelvic lymph node involvement was excluded. The lesion was considered in stage IIB according to FIGO staging system. Pathological examination findings of surgically resected uterus confirmed the diagnosis of endometrial cancer (endometrioid adenocarcinoma) and showed a very good correlation with MRI findings.
Discussion
Endometrial carcinoma is among the most common female malignancies and may develop in normal, atrophic or hyperplastic endometrium. Most of the cancers are detected at an early stage, with the tumor confined to the uterine corpus in 75% of patients. Endometrial carcinoma is mainly a disease of menopausal and postmenpausal women with the peak of incidence in women aged 55-65 years. Multiple risk factors associated with endometrial cancer include estrogen replacement therapy, endometrial hyperplasia, obesity, nulliparity, menopause later than age 52 years. Genetic predisposition appears to play a role since risk factors also include a family history of endometrial or breast cancer. The most frequent risk factor contributing to the development of endometrial carcinoma is protracted exposure to endogenous or exogenous estrogen that is unopposed by progesterone. According to FIGO staging system, endometrial carcinoma may be confined to corpus (stage I), may invade the cervix (stage II) or may extend beyond uterus (stage III) or outside true pelvis (stage IV). According to Hricak et al., the accuracy of MRI in distinguishing between stage I and further stages is 94%, sensitivity is 97% and specificity is 83%. In differentiating stages I and II endometrium carcinoma from stages III and IV disease the accuracy is 96%, sensitivity is 100% and specificity is 71%. On non enhanced T1-weighted images endometrial cancer is not adequately delineated since it shows the same signal intensity of the uterus. Neverthless, T1-weighted images in sagittal and axial planes may help to detect extrauterine tumoral invasion in the surrounding hyperintensity of the periuterine fat and may have a role in lymph node assessment by MRI. If there is no visible junctional zone in T2 weighted images or in cases of small tumors, contrast enhanced T1 weighted dynamic gradient echo images may be helpful in evaluation of depth of myometrial invasion; moreover, contrast-enhanced T1 weighted images may be helpful in differentiation of viable tumor from necrosis or fluid and; neverthless, in our experience T1 weighted images play a limited role in advanced cancer as in the case that we here describe. Most informations are provided by T2-weighted images which shows thickening of the endometrial stripe with, in some cases, a lobulated feature of endometrial cavity. In T2 weighted images, invasion of the myometrium is well depicted by disruption of the hypointense junctional zone. Normal cervical stroma appears as a hypointense layer and its invasion by the hyperintense tumor is also well shown by on T2-weighted images. MRI with its high contrast resolution and multiplanar imaging capability is superior to US and CT in the preoperative assessment and correct staging of endometrial carcinoma and may easily rule out extrauterine involvement. MRI may be the imaging modality of choice for preoperative staging of endometrial carcinoma mainly in women with known endometrial cancer in whom transvaginal ultrasound (TVUS) is suboptimal (e.g. patients with concommitant fibroids). Moreover, instead of TVUS, MRI reveals pelvic and abdominal lymph node involvement and allows to choose the type of surgery and to define volume of radiotherapy offering "one-stop" examination with highest efficacy.
Differential Diagnosis List
Endometrial carcinoma
Final Diagnosis
Endometrial carcinoma
Case information
URL: https://www.eurorad.org/case/2444
DOI: 10.1594/EURORAD/CASE.2444
ISSN: 1563-4086