Endometrial cancer is the most typical female genital cancer, with the most common kind being adenocarcinoma. Carcinoma that the endometrium may construct in normal, atrophic, or hyperplastic endometrium. Most endometrial cancers are detected at an early stage, v the tumor confined come the uterine corpus in 75% the patients. The prognosis normally is favorable. <1, 2, 3, 4> Multiple threat factors connected with endometrial cancer incorporate conditions linked with obstacle of menstruation, increased perimenopausal bleeding, menopause after period 52 years, long time duration between menarche and menopause, estrogen instead of therapy, tamoxifen treatment for chest cancer, endometrial hyperplasia, obesity, nulliparity, diabetes mellitus, and also hypertension. Genetic predisposition appears to play a role, because risk factors also include a family history of endometrial or breast cancer and also a personal history of ovarian or chest cancer. <5, 6>

Approximately 75% that women through endometrial cancer space postmenopausal. Thus, the most usual symptom is postmenopausal bleeding. Because that the 25% of endometrial cancers in patients who space perimenopausal or premenopausal, the symptom suggestive that cancer may be subtler. <5, 6>


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A 76-year-old woman v poorly identified endometrial adenocarcinoma. Sagittal transvaginal ultrasound photo of the uterus shows a central mass instead of the endometrial stripe, through hyperechoic and hypoechoic regions.
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A 76-year-old woman with poorly differentiated endometrial adenocarcinoma. CT image shows a relatively hypoattenuated mass in the an ar of the endometrial cavity. Diffuse myometrial thinning is evident. Operation pathology revealed roughly 4.0 cm of pedunculated endometrial tumor linked with just superficial myometrial intrusion (limited come inner one third).
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one 83-year-old woman through moderately distinguished endometrioid endometrial adenocarcinoma. Axial T1-weighted MR photo of the uterus mirrors a multilobulated, short signal intensity, polypoid tumor arising from the appropriate side the the endometrium and surrounded through fluid. The liquid markedly distending the endometrial cavity is hyperintense on T1- and T2-weighted images, continual with hematometra. Check under anesthesia revealed far-reaching benign stenosis that the atrophic cervix. Dilatation and also curettage shown the liquid to it is in old blood and established the diagnosis of endometrial malignancy. Note that the significant myometrial thinning, as result of both the elderly age and the significant distension the the uterine cavity, boundaries the evaluate of myometrial invasion.

Preferred examination

Endometrial biopsy, typically using an aspiration-type curet or other device, is generally accepted as the first-step office procedure for the diagnosis that endometrial cancer and also should be coupled through endocervical curettage. The procedure is definitive if outcomes are hopeful for malignancy. The reported accuracy of the procedure is roughly 90%.

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Ultrasonography is the modality of an option for the early stage imaging evaluation of mrs pelvic organs. <7> united state is widely available in many regions the the world, is relatively inexpensive, is noninvasive, and also does not use ionizing radiation. Common examinations include transabdominal ultrasonography (TAUS) and also transvaginal ultrasonography (TVUS), which room supplemented by color Doppler imaging together needed. <8, 9, 10, 11, 12, 2, 13, 14, 15, 16, 17>

TAS is performed v subcutaneous fat and abdominal wall muscles and also uses the complete urinary bladder together an acoustic window. TAS transducers, required in most patients to permeate the abdominal wall and adequately visualize pelvic organs, have actually lower frequency and also resolution than TVS probes.

TVS has the benefit of making use of high-frequency transducers the are placed close to the areas of interest and also produce high-resolution pictures of significantly much better quality 보다 transabdominal images. When both TAS and TVS enable visualization the the endometrium, exquisitely finer endometrial details are feasible to depict transvaginally fairly than transabdominally. <18, 19, 20, 21, 22, 23>

TVS is clinically created as the preferred method for testimonial of endometrial disorders and also is especially beneficial in the workup that abnormal uterine bleeding. Hysterosonography deserve to be supplied to recognize the cause of endometrial strip thickening in some patients. <24, 25, 13, 26, 27, 28, 29, 30> The procedure is composed of TVS performed v sterile liquid placed in ~ the endometrial cavity and also may aid show a thick endometrial stripe as secondary to diffusive or focal endometrial thickening, endometrial polyp, submucosal leiomyoma, or synechiae. This may help further diagnostic planning.


TVS is remarkable to CT and approaches MRI in its capability to depict endometrial carcinoma and to administer information regarding myometrial, cervical, and, perhaps, parametrial tumor invasion. However, us is unable to depict the whole intrapelvic or intra-abdominal anatomic regions adequately; therefore, united state is not suitable for the an extensive staging that endometrial carcinoma. Us has significantly lower sensitivity 보다 CT in detecting enlarged abdominal or pelvic lymph nodes and in illustrating intraperitoneal, omental, or mesenteric metastases. In addition, us is worse to CT in assessing pelvic sidewall expansion and adjacent organ invasion.


CT and MRI are much more accurate staging modalities than US. <31> Both techniques enable survey of the whole pelvis, abdomen, thorax, and also brain. CT is available an ext widely, is less costly than MRI, gives rapid image acquisition, and has high spatial resolution. The benefits of CT likewise include the accessibility of GI and also intravenous (IV) comparison materials. Opacification the the GI tract with oral and also rectal comparison facilitates optimal testimonial of the bowel and also helps identify intraperitoneal and retroperitoneal masses native bowel. IV comparison injection enhances evaluation the vascular structures and also detection of mass lesions in parenchymatous organs. Spiral/helical and also multidetector modern technology has enhanced the multiplanar capability of CT. <32, 33, 34>


The advantages of MRI incorporate superior spatial and also tissue comparison resolution, multiplanar capabilities, lack of exposure to ionizing radiation, and ease of access of noniodinated, nonnephrotoxic IV contrast material. <35>


Kaneda et al found that use of 3.0T MRI to recognize the depth that myometrial invasion was indistinguishable to use of 1.5T MRI in a cohort the 50 women with histopathologically shown endometrial carcinoma. <36>


Alcazar and Galvan evaluated the role of 3-dimensional strength Doppler angiography (3D-PDA) to discriminate in between benign and malignant endometrial condition in women through postmenopausal bleeding and thickened endometrium, and they uncovered that endometrial volume, vascularity index (VI), and vascularity-flow index to be significantly greater in malignant conditions. Receiver operating characteristic analysis revealed that vi was the finest parameter because that the forecast of endometrial cancer. Histologic diagnoses were endometrial cancer (44 cases), hyperplasia (13 cases), polyp (23 cases), cystic atrophy (14 cases), and also submucous myoma (5 cases). <14>


Signorelli et al carry out a retrospective research to determine the diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in detecting nodal metastases in patients v high-risk endometrial cancer; pelvic node metastases were discovered at histopathologic evaluation in 9 the the 37 patient (24.3%). Patient-based sensitivity, specificity, optimistic predictive value, an adverse predictive value, and also accuracy to be 77.8%, 100.0%, 100.0%, 93.1%, and also 94.4%, respectively. Nodal lesion site-based sensitivity, specificity, hopeful predictive value, an adverse predictive value, and also accuracy were 66.7%, 99.4%, 90.9%, 97.2%, and also 96.8%, respectively. <37>


Khoury-Collado et al defined sentinel lymph node (SLN) detection prices in endometrial cancer and also estimated just how many instances are needed to achieve greater 보다 90% SLN detection: when examining an individual provider"s performance, after ~ the an initial 30 cases, the price of effective mapping significantly increased from 78% come 94%. The study consisted of 115 patients through endometrial cancer. In the initial 27 month of the study, one SLN was determined in 50 the 64 cases (78%), with 2 false negatives. In the succeeding 15 months, effective mapping was accomplished in 48 the 51 situations (94%), v no false negatives. <38>


Histopathologic attributes of the tumor and clinical result at presentation influence the selection of imaging modality because that preoperative staging the endometrial cancer. Kinkel et al <39> detailed clinical exercise guidelines because that staging based on a meta-analysis the the usefulness that MRI, CT, and also US in imaging patients with endometrial cancer:


Patients with grade 1 tumor, a clinically normal-sized uterus, and no clinical evidence of coexisting pelvic an illness generally require no preoperative imaging due to the fact that the threat for myometrial, cervical, or lymph node an illness is low. If the clinical testimonial is inconclusive or if coexisting pelvic condition is suggested, then US, CT, or MRI may be used for the early stage imaging evaluation.


In patient at risk for disease dissemination and lymph node involvement in ~ presentation (because that tumor grade, histologic cabinet type, or clinical findings), CT or MRI of the abdomen and pelvis need to be performed to determine the degree of tumor spread.


MRI, v its exquisite soft tissue contrast and multiplanar capability, is superior to US and also CT in helping assess the depth the myometrial invasion, cervical invasion, and early parametrial invasion. <15> MRI is about equivalent to CT in detecting enlarged lymph nodes, however CT is substantially superior to MRI in detecting and also distinguishing intraperitoneal, omental, and mesenteric metastases indigenous bowel.


Although MRI is superior to CT in evaluating myometrial and also cervical invasion and also is the best alternative for patients with far-reaching contrast allergies or renal malfunction, CT is an ext sensitive 보다 MRI in the as whole detection the tumor spread external the uterus. In addition, CT remains the imaging modality provided most typically in clinical exercise for substantial preoperative testimonial of the extent of disease. <41>


CT is clinically supported in the testimonial of patients v poorly differentiated or high-grade tumor, serous papillary carcinoma, or clear cell carcinoma due to the fact that of the high risk for advanced condition and metastatic lymphadenopathy at the moment of presentation. CT additionally is advised because that patients who have actually abnormal liver role test results, elevated serum cancer antigen-125 levels, clinical pointer of progressed disease, or inconclusive clinical evaluation.


Limitations that techniques

US is operator-dependent; that has fairly poor spatial and tissue comparison resolution compared with MRI and also CT; its image quality is degraded by huge body habitus; and visualization of parts of the pelvis and abdomen is precluded by bowel gas and also bony structures. The transabdominal approach also is affected by the level of bladder filling and is impeded by the presence of operation incision, dressings, drains, or skin lesions. Transvaginal probes have actually inherent limitations, including little field of view, short range of penetration the high-frequency transducers, and also occasional patience intolerance or absence of accept of the transvaginal approach.


CT supplies ionizing radiation and also has worse soft tissue contrast resolution, making that less qualified than MRI because that distinguishing in between tumor and also normal soft organization in the uterine corpus and also cervix. CT picture quality is degraded through metallic prostheses, an extremely big body habitus, and also patient or respiratory motion. The iodinated IV contrast easily accessible for CT is connected with a risk of far-ranging allergic reaction (including deadly anaphylaxis), nephrotoxicity, and also complications of comparison extravasation.


CT does not depict the endometrium consistently and is not reliable for exact evaluation of its thickness. Instant postcontrast dynamic CT scans of the uterus often show central hypoattenuation that might be pertained to secretions in the cavity or a lag in contrast enhancement the the endometrium compared to myometrium; however, the endometrium is not visualized distinctly as separate from the myometrium, and also accurate measurement of its thickness is not feasible. This is because the endometrium and also myometrium have similar attenuation and cannot be differentiated either on CT scans obtained without intravenous comparison or on regime or delay postcontrast CT scans.


MRI depicts the endometrium as a main zone the high signal soot on T2-weighted images, when the myometrium is depicted at the inner aspect as a region of low signal strongness (junctional zone) and also at that is outer aspect as a wider zone of intermediary signal intensity. Top top T1-weighted images, the endometrium has actually intermediate signal intensity comparable to the myometrium; therefore, the endometrium is not visualized patent as separate from the myometrium.


MRI is contraindicated in patients that have vital metallic biomedical gadgets or metallic objects in strategic anatomic regions. The is more costly and also less readily accessible than CT and also requires long picture acquisition times. MRI photo quality is degraded by artifacts related to respiratory motion and bowel peristalsis, which are most likely to occur during the long photo acquisition time. No reliable GI contrast material is currently available for MRI. Claustrophobia deters part patients from experience MRI.


Gadolinium-based comparison agents have actually been attached to the advance of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The an illness has arisen in patients with moderate to end-stage renal an illness after being offered a gadolinium-based comparison agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Attributes include red or dark job on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow point out on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip skeletal or ribs; and muscle weakness.


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CT is the imaging modality used most typically in clinical exercise to recognize the degree of spread of endometrial cancer. Oral, rectal, and IV management of contrast material is crucial for optimal CT evaluation. IV comparison injection is specifically useful to increase the conspicuity of the endometrial tumor and to facilitate the testimonial of myometrial and cervical invasion. <42, 43, 32, 44, 45>


Endometrial carcinoma and a regular myometrium demonstrate approximately comparable attenuation on CT images derived without IV comparison enhancement; therefore, the 2 cannot be reliably distinguished on noncontrast CT images. Following IV contrast administration, nonuniform comparison enhancement the the tumor may occur yet to a much lesser level than the typically intense and also uniform improvement of the regular myometrium. Thus, the endometrial tumor may become noticeable on postcontrast pictures as a lesion with reasonably low attenuation.

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In a prospective examine of 10 patient reported by Hamlin et al, nobody of the endometrial cancers were diagnosed unequivocally top top precontrast CT images, and also 30% of the cancers were no diagnosed ~ above postcontrast pictures (even retrospectively in both situations). <46> In 24 patients with primary endometrial malignancy reported by Walsh and Goplerud, CT showed normal uterine attenuation result in 50% the patients and 1- to 5-cm low-attenuation tumor areas in the uterus in the other 50% that patients. <47> dimensions of the figured out tumors were no evaluated accurately since of volume averaging and also the uterine position relative come the axial airplane of CT imaging.


In a examine of 151 patients with endometrial cancer compare SPECT/CT with lymphoscintigraphy, overall and bilateral SLN detection rate was better with SPECT/CT than through lymphoscintigraphy in patients with phase I/IIendometrial cancer. The bilateral pelvic SLN detection because that SPECT/CT to be 43% (65/151) versus 32% for lymphoscintigraphy (48/151). The overall pelvic SLN detection rate (at least one pelvic SLN detected) was 77% with SPECT/CT (116/151) matches 68% v lymphoscintigraphy (102/151). <34>


CT staging

The most commonly used staging system for endometrial carcinoma was developed by the Féderation Internationale de Gynécologie et d’Obstétrique (FIGO), in collaboration with several global scientific societies and also agencies specializing in research and also treatment of woman malignancies, including the American share Committee ~ above Cancer (AJCC). <48>


CT staging of endometrial cancer is based on the surgical/pathologic FIGO classification, as shown below: