ARTICLE INFO

Article Type

Original Research

Authors

Seyed Abkenari   S.K. (1)
Faeghi   F. (*)
Arian   A. (2)






(*) Radiology Technology Department, Allied Medical Sciences School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
(1) Radiology Technology Department, Allied Medical Sciences School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
(2) Imaging Center of Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Correspondence

Address: Radiology Technology Department, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Darband Street, Tehran, Iran
Phone: +982122718531
Fax: +982122521170
f_faeghi@sbmu.ac.ir

Article History

Received:  July  20, 2015
Accepted:  May 10, 2016
ePublished:  June 30, 2016

BRIEF TEXT


Endometrial cancer is the fourth most common malignancy in women and the most common malignancy in women`s reproductive system. The prevalence of endometrial cancer increases in accordance with aging and obesity. 75% of cases occur in postmenopausal women with the mean age of 70. Endometrial cancer is staged based on FIGO phasing system (International Federation of Gynecology and Obstetrics) [1].

... [2] Nowadays, Magnetic Resonance Imaging (MRI) is widely used as a noninvasive imaging technique in diagnosing cervix and myometrium invasion and detecting lymph nodes` metastasis [3]. Preoperative diagnosis of patients with high-risk invasion to cervix stroma is paramount. Preoperative cervical involvement is accomplished through endo-cervical curettage procedure. This method often requires general anesthesia and may cause some problems in older patients. In addition, the reported accuracy for endo-cervical curettage is variable in examining cervical involvement and indicates that this method has some defects apart from being costly [4]. An ideal imaging technique of choice must be able to reveal and display the location and structural changes of lymph nodes and to accurately differentiate malignant and benign lymph nodes as well as being widely available, easy to interpret, non-invasive and without radiation. Unfortunately, conventional imaging methods are based on morphological and anatomical examination and provide little information about functional aspects of lymph nodes [5]. …[6]

This study aimed to investigate the diagnostic accuracy of diffusion and dynamic imaging techniques in staging endometrial cancers and to differentiate metastatic and non-metastatic lymph nodes.

This is a prospective study.

The study was carried out from October 2013 to October 2014 in MRI imaging center of Imam Khomeini Hospital, Tehran.

30 endometrial cancer patients with a mean age of 58.00 ± 2.06 underwent pelvic MRI before surgery. These people were chosen purposefully. The criteria for entering the study were confirmation of endometrial cancer histology in patients, lack of cardiac prosthetic valve, absence of renal disorders, and not having shrapnel and metal objects in the body.

The study was conducted using a 3 Tesla machine (Siemens TIM TRIO; Germany) with the gradient strength of 45 m Tesla per meter. Before starting the test patients were fasting for 8 hours and in order to reduce their intestinal peristalsis, butyl hyoscine bromide was injected to them. While scanning, patients had half full bladders because completely full bladders would damage the images. Patients lied on MRI beds in supine position. Then quad-channel matrix coil was plugged to the patient's body, and T1W, T2W sequences, dynamic techniques in phases 25, 60, 120 and 240 seconds after injection and a diffusion by “b” factor equal to zero and 1000 seconds per square millimeters were employed for imaging the patient. Pelvic dynamic imaging was performed after the injection of dotarem contrast (gadoterate meglumine 5/0 M) with a dose of 2/0 mM per kg regarding patient`s weight. Dynamic images were obtained in multi phases after injecting contrast material. Images were taken before injection in sagittal and axial views and after the injection in 25, 60, 120 seconds in sagittal view and 240 seconds in axial view. These images were evaluated by experienced radiologists in the field of pelvic imaging. The radiologist was unaware of the histopathologic results. He examined T1W and T2W anatomic images and diffusion illustrations according to FIGO phasing table regarding the depth of invasion to the myometrium, cervical stroma invasion, serous and adnexal involvement, involvement of the vagina and the external layer of the uterus, pelvic and para-aortic lymph node invasion and distant metastasis. The radiologist determined a general stage according to FIGO system for each patient. To distinguish between metastatic and non-metastatic or reactive lymph nodes in T2W images, all the features of lymph nodes in terms of shape, the ratio of short axis to the long one, internal structure and the signal inside the lymph node were considered; if the signal inside the lymph node was homogeneous, it would be normal, but in case of being heterogeneous it would be regarded as metastatic. Diffusion images were assessed to differentiate lymph nodes and omitting restrictive factors in determining the stage of the disease. Delayed images were selected 4 minutes after injection in dynamic imaging for the cervical invasion to be examined more precisely. Multi-planar T2W sequence has high resolution of a key sequence to assess the depth of invasion into the myometrium because it accurately describes the anatomy of the uterus and indicates the intermediate signal of the tumor versus the low signal of junctional zone. However, the performance of this sequence is limited in postmenopausal women, because regional anatomy is less obvious in these patients and tumor may have the same signal intensity as myometrium [7]. Data analysis was accomplished using SPSS 22 software. Kappa statistics were used to investigate the agreement between radiologist`s report and the pathological finding in staging endometrial cancer and to differentiate metastatic and non-metastatic lymph nodes. For the sensitivity and specificity of these techniques, lymph nodes were considered in two conditions of metastatic and non-metastatic. Two independent samples T-test was used to examine the effect of age and the number of fertility in both groups with metastatic and non-metastatic lymph nodes. The effect of age and the number of fertility at different stages of cancer was studied using ANOVA test.

Depth of invasion into the myometrium and the general stage of cancer were diagnosed properly in 25 cases. In 2 cases in addition to endometrial cancer, adenomyosis and leiomyomas were also identified. Ovarian cancer existed simultaneously in a patient, which led to overestimating the stage of the cancer by the radiologist. Agreement between the radiologist and pathologist in determining different stages of cancer was 0.796 (almost 0.8) and it was remarkable (p< 0.001). The rate of diagnostic accuracy regarding diffusion and dynamic techniques was 0.83. In differentiating between metastatic and non-metastatic lymph nodes, the sensitivity and specificity of the technique were 100% and they showed conformity in all the reports by the radiologist and pathologist (Table 1). The age and number of fertility were not the factors affecting the different stages of cancer and metastatic lymph nodes. The difference in mean age (p=0.788) and the number of fertility (p =0.848) were not significant in two groups of metastatic and non-metastatic lymph nodes, and the results obtained from pathology report were the same as the radiologist`s report. The mean age was minimum at IIIC2 stage and maximum in phase II. The mean of the number of fertility was also the lowest at IIIC2 stage and the highest in phase IIIA. According to the radiologist`s report the means of age and the number of fertility were not significantly different in various stages of cancer (p=0.143; Table 2).

In a study using 1-Tesla machine it was shown that dynamic techniques with contrast material injection have high diagnostic value in determining the depth of invasion into the myometrium and cervical stroma involvement and they can be helpful in designing treatments for patients. Thinning myometrium, polypoid tumors, adenomyosis and leiomyomas were the reasons for misdiagnosis in this study [8]. This study is in line with ours. In contrast, the accuracy of our study was more; because in addition to routine techniques, diffusion technique was employed and we were able to differentiate the benign case from endometrial cancer. The use of a 3-Tesla machine was another reason for higher diagnostic accuracy in our study. 3-Tesla systems provide signals to higher noises and CNR (Contrast-to-noise ratio); as a result, scan time decreases for some pelvic applications. ... [9-11] Investigations by Lin et al. on the efficiency of diffusion techniques have indicated that the combination of T2W and diffusion sequences with a high “b” factor (1000 seconds per square mm) accurately describes the depth of myometrium invasion and lymph nodes involvement and increases dynamic techniques [12]. … [13-26]

Non-declared

Non-declared

Using diffusion technique with routine injection sequences increases diagnostic accuracy in differentiating metastatic and non-metastatic lymph nodes in patients suffering from endometrial cancer.

This article is taken from MA thesis of medical imaging technology (specialty of MRI) in Shahid Beheshti University of Medical Sciences. The authors express their gratitude to the personnel of the imaging center and gynecology clinic of Imam Khomeini Hospital, Tehran.

Non-declared

This study has been approved by the ethics committee of Shahid Beheshti University of Medical Sciences.

This article is the resume of MA thesis of Shahid Beheshti University of Medical Sciences.

TABLES and CHARTS

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CITIATION LINKS

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