Answer for BIR CoW 20 Dec 2020
Endometrial carcinoma –Stage 1 A
Findings
Patient presented with post menopausal bleeding Large lesion with significantly low ADC values is noted distending the endometrial cavity of the uterus with a relatively smooth contour anteriorly and focal irregularities in posterior fundal aspect. On dynamic contrast administration , heterogenous contrast enhancement with no significant deep myometrial invasion noted. Features consistent with Endometrial Carcinoma Stage 1A .
Discussion
USG remains the first modality for evaluating a patient with post menopausal bleed(>5mm is considered as thickened endometrium) USG features include: heterogeneous and irregular endometrial thickening polypoid mass lesion intrauterine fluid collection frank myometrial invasion Disruption of a subendometrial halo on ultrasound may be suggestive of myometrial involvement. The combination of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced MR imaging provides a “one-stop shop” approach for the accurate staging of patients with endometrial cancer. Sequences angled perpendicularly to the endometrial cavity are critical to accurately assess the depth of myometrial invasion. It is important to distinguish stage IA from stage IB disease because stage IB is associated with a high risk of lymphovascular space invasion (LVSI), which directly correlates with the risk for lymph node metastases and relapse. The depth of myometrial invasion is important as the incidence of nodal metastases increases from 3% with superficial myometrial invasion to 40% with deep myometrial invasion. Uninterrupted subendometrial linear enhancement nearly excludes superficial myometrium invasion. Measuring the depth of tumor extension within the myometrium is done as follows: A line must be drawn along the expected inner edge of the myometrium (endometrium–myometrium junction) on axial oblique images acquired perpendicular to the endometrium Then, 2 lines are drawn: one measuring the thickness of the entire myometrium and another measuring the maximum tumor extent within the myometrium. The ratio of the 2 lines detailed represent the percentage of myometrial invasion. Pearl: An intact, low signal intensity junctional zone on T2WI and a smooth uninterrupted band of early subendometrial enhancement on DCE MR imaging almost completely excludes myometrial invasion. Pitfalls: Deep myometrial invasion should not be overcalled in certain situations. Occasionally, a large tumor can distend the endometrial cavity and compress the surrounding myometrium. Stage IA endometrial cancer with poor tumor-to-myometrium contrast at the interface on T2-weighted imaging (T2WI). Symmetry and smooth tumor contours favor stage IA . Cornual regions of the uterus demonstrate a thinner myometrium compared with other areas of the uterine corpus and the depth of myometrial invasion at this level is frequently overestimated.
References: From Staging to Prognostication Stephanie Nougaret MD, PhD, Yulia Lakhman MD, Hebert Alberto Vargas MD, Pierre Emmanuel Colombo MD, PhD Magnetic Resonance Imaging Clinics of North America, 2017-08-01, Volume 25, Issue 3, Pages 611-633, Advances in MR Imaging of the Female Pelvis Michelle D. Sakala MD, Kimberly L. Shampain MD and Ashish P. Wasnik MD Magnetic Resonance Imaging Clinics of North America, 2020-08-01, Volume 28, Issue 3, Pages 415-431,
Findings
Patient presented with post menopausal bleeding Large lesion with significantly low ADC values is noted distending the endometrial cavity of the uterus with a relatively smooth contour anteriorly and focal irregularities in posterior fundal aspect. On dynamic contrast administration , heterogenous contrast enhancement with no significant deep myometrial invasion noted. Features consistent with Endometrial Carcinoma Stage 1A .
Discussion
USG remains the first modality for evaluating a patient with post menopausal bleed(>5mm is considered as thickened endometrium) USG features include: heterogeneous and irregular endometrial thickening polypoid mass lesion intrauterine fluid collection frank myometrial invasion Disruption of a subendometrial halo on ultrasound may be suggestive of myometrial involvement. The combination of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced MR imaging provides a “one-stop shop” approach for the accurate staging of patients with endometrial cancer. Sequences angled perpendicularly to the endometrial cavity are critical to accurately assess the depth of myometrial invasion. It is important to distinguish stage IA from stage IB disease because stage IB is associated with a high risk of lymphovascular space invasion (LVSI), which directly correlates with the risk for lymph node metastases and relapse. The depth of myometrial invasion is important as the incidence of nodal metastases increases from 3% with superficial myometrial invasion to 40% with deep myometrial invasion. Uninterrupted subendometrial linear enhancement nearly excludes superficial myometrium invasion. Measuring the depth of tumor extension within the myometrium is done as follows: A line must be drawn along the expected inner edge of the myometrium (endometrium–myometrium junction) on axial oblique images acquired perpendicular to the endometrium Then, 2 lines are drawn: one measuring the thickness of the entire myometrium and another measuring the maximum tumor extent within the myometrium. The ratio of the 2 lines detailed represent the percentage of myometrial invasion. Pearl: An intact, low signal intensity junctional zone on T2WI and a smooth uninterrupted band of early subendometrial enhancement on DCE MR imaging almost completely excludes myometrial invasion. Pitfalls: Deep myometrial invasion should not be overcalled in certain situations. Occasionally, a large tumor can distend the endometrial cavity and compress the surrounding myometrium. Stage IA endometrial cancer with poor tumor-to-myometrium contrast at the interface on T2-weighted imaging (T2WI). Symmetry and smooth tumor contours favor stage IA . Cornual regions of the uterus demonstrate a thinner myometrium compared with other areas of the uterine corpus and the depth of myometrial invasion at this level is frequently overestimated.
References: From Staging to Prognostication Stephanie Nougaret MD, PhD, Yulia Lakhman MD, Hebert Alberto Vargas MD, Pierre Emmanuel Colombo MD, PhD Magnetic Resonance Imaging Clinics of North America, 2017-08-01, Volume 25, Issue 3, Pages 611-633, Advances in MR Imaging of the Female Pelvis Michelle D. Sakala MD, Kimberly L. Shampain MD and Ashish P. Wasnik MD Magnetic Resonance Imaging Clinics of North America, 2020-08-01, Volume 28, Issue 3, Pages 415-431,
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!