Hello everyone. I'm Priyanka. I'm a radiologist at Melbourne. I work as a consultant with FMIG and Marina Radiology and I'm also the clinical director at HealthScreen. I will be speaking to you about MRI staging of uterine cancer today. It is very important because recently Figo underwent revision in 2018 and it incorporates radiological findings now for storage staging of the tumor. So the purpose of this talk is to help us identify the tumor and assign a correct tumor stage to it. Now this is going to be the overview of the talk. We will briefly touch on the epidemiology then the role of MRI, talk about Figo staging, individual stages and the recurrence of tumor. 95% of uterine cancers are endometrial cancers whereas the other uterine tumors are not so common and about less than 5% of all uterine cancers. So for the purpose of this talk you're going to be focused mainly on endometrial cancers. It is the sixth most common malignancy in women worldwide but for some reason is not so common in India. Its incidence is increasing because of longevity and obesity. Most of the cases tend to happen in postmenopausal women and they present with the postmenopausal bleeding. Skinning ultrasound is quite helpful. If you take a cut off of endometrium as 4 to 5 millimeters you will be able to detect more most of the cancers with a very high sensitivity and specificity. Endometrial cancers are classified into two different types, type one and type two. Now type one has endometrial ethystology and that includes adenocarcinoma whereas type two includes the papillary sears and clear cell cancers. Type two tend to be more aggressive and are associated with a figure grade three tumors. They tend to happen in postmenopausal women and have slightly lower survival rate of about 40% compared to 80% in type one cancers. There is no association with pre malignant diseases or with estrogen exposure in type two diseases whereas there is a direct correlation in type one cancers. Staging is phegosurgical staging but as I mentioned we now have MRI of the pelvis for local staging of the disease and a PET-CD scan or just a CD scan for full staging. The anesthesiological trail staging will include hysterectomy, banato-sulpinjoforectomy, lymph node dissection, peritoneal washings and the mental biopsies. Now MRI is the modality of choice for local staging. It accurately determines the depth of malnutrient relation which correlates with the tumor grade, lymph node metastasis and 5 year survival. Small field of view sequences are very helpful together with dynamic imaging. Rather I spoke about patient preparation in my previous talk and therefore I will not discuss all that again but this image is here to show you how to plan your sequences so that's the uterus and the tumor in the endometrial cavity. Your axial sections are meant to be planned perpendicular to the long axis of the endometrium and the coronal sequences, the small field of view are meant to be perpendicular to these axial sequences. On MRI the tumor is going to be iso intense to endometrium and myometrium so you will not really be able to identify the tumor. Whereas on T2 weighted sequences the tumor is going to be hypo intense or sometimes iso intense to the endometrium and it's going to be hyper intense to the myometrium. On dynamic sequences it is going to enhance earlier than the endometrium and slower than the myometrium and it is therefore going to be that's that's going to be maximum contrast between the tumor and myometrium at about 50 to 120 seconds. On diffusion the tumor is going to have low ADC values but be mindful of presence of blood products within the endometrial cavity. Patient did undergo a recent biopsy as they can also have low ADC. Now here is an example we can see this is a satatone C2 weighted sequence the endometrium is clearly thickened we cannot identify where is the known endometrium and where is the abnormal because it is so thick but there is some contrast we noticed between the myometrium and this endometrial lesion on T1 if you can see everything or rather the endometrium the tumor and the myometrium look pretty much similar. When we administer contrast we can see we've got here the tumor is enhancing earlier than the normal endometrium which is here but it is slower than the myometrium so the first structure to enhance is myometrium then the tumor and then the endometrium so at about 50 seconds we have we have maximum contrast between the normal myometrium the tumor in endometrium and the normal endometrium. This is just another image of another patient if you see there is a very poor visualization of tumor here in the endometrial cavity on T2 weighted image but there is this tiny focus of restricted diffusion to the right side of endometrial cavity and that is the tumor. Now this is an image of a patient who's got a really tiny lesion in the endometrial cavity it was enhancing less than the myometrium and slightly more than the adjacent endometrium and this is a zoomed up version of the same which shows you the tumor here so if we put together all the sequences there is a very high sensitivity and specificity for picking up even tiny lesions for lesions like this please bear in mind that sometimes there could be a small submicosal fibroid or just a polyp that can also look like this and in those cases there has to be histopathology to help you make the accurate diagnosis. This is just another example the image on your left is a sactile T2 weighted image which shows the tumor very nicely and the second one is a fused image of diffusion and T2 weighted sequence which is showing restricted diffusion in the tumor. So now we will move on to individual staging stage one is confined to uterus one A involves the endometrium and in a half of the myometrium where a stage one B involves the hour half of the myometrium. So here we see a tumor it's very easy to identify the tumor in the endometrium but that's not the purpose we have to stage it up accurately so we can see the tumor is here to the right side of the uterine corner and the mid in the middle of the endometrial cavity and then we have this junctional zone which is no T2 signal around the tumor and the endometrial cavity which so if we do see if there is a restricted diffusion within the tumor and there's some nodular component here on contrast enhanced scan. So there's definitely a tumor now we need to decide whether it's your stage one A or stage one B so if you can identify the junctional zone clearly on the small field of view sequences then it's likely going to be stage one A which means it's not disrupted that junctional lining and is going to be a stage one tumor this is just to show the presence of the endometrial junctional zone lining so this is as I said a stage one A tumor now the junctional lining that I just mentioned it has a sub endometrial enhancement on the contrast enhanced scans this is going to be helpful again if you cannot see the junctional zone on T2 sequences but you see intact this rim of sub endometrial enhancement the chances are that it's a stage one A tumor. Moving on in this case again there's no difficulty in identifying the tumor within the endometrial cavity but we have lost the junctional zone there is no sub endometrial enhancement so this is going to be a stage one V tumor. How do you define endometrial inversion so you just draw a line parallel to the inner myometrium here and then measure the thickness of the myometrium and then the thickness of the tumor here when you do that you will be able to identify whether it's superficial or invasion or deep invasion ratio of these two is going to give you the depth of myometrial inversion if it's more than 50 percent it's deep invasion so the image on left is superficial invasion and the image on right it's deep invasion of the tumor now it's very important because the prevalence of lymph node menostasis with stage one A is only about three percent whereas with stage one B is about 46 percent so we should be able to identify this correctly there are limitations in accurate assessment of myometrial invasion that is because of a few factors there's there can be myometrial thinning and loss of zonal anatomy in post-menopausal women there can sometimes be perituminal information which is going to lead to overestimation of the depth of invasion sometimes the cavity or the myometrium is distorted due to our coexisting fibroids sometimes the tumor extends to corner in which in which area that is normally very thin myometrium so it's difficult to decide or sometimes the endometrial cavity is significantly distended by the tumor and the myometrium is compressed around the tumor in which case it's going to be difficult to accurately stage the disease moving on to stage two stage two tumors extend to these cervix so they're going to disrupt the low cervical stroma of the cervix or that's going to be direct extension into the endosavakha canal but if you see a polypoidal tumor in the endometrial cavity extending into the endosavics that's not stage two that's still stage one disease it has to definitely improve the endosavakha lining or the cervix for it to be labelled as stage two here we can see the tumor is extending into the cervix directly this part and this part so that is stage two disease in stage three that's tumor extension into the uterine cirrhosa and next say vagina and or pelvic or parietic lymph nodes and there's going to be stage three A B three C one and three C two so in terms of ovarian metastasis you're going to have bilateral involvement the tumor is going to look similar to the primary tumor in the endometrial cavity and the uterine mass is going to be larger than the ovarian masses if it's primary synchronous tumors in the ovaries it's going to be a large unilateral ovarian mass there's going to be precursor lesions such as endometriosis or endometriotic cis and the uterine mass is going to be low-grade tumor what i mean is it's going to be let's say a stage one tumor then it's unlikely to be ovarian metastasis whereas if you see a stage one B or a stage two tumor definitely on imaging then it could be ovarian metastasis here we've got a tumor in the endometrial cavity appearing very heterogeneous with presence of cystic necrosis areas and some hemorrhage here if you pay attention to the uterine fundal area there's loss of low signal of the uterine serosa and this is going to be a stage three A disease see when it's a very big tumor clearly growing out of the serosa it's very easy to identify but we need to be paying attention to such tiny extensions another example we see tumor into these cervix that is thickening the cervical stroma which is expanded because of the tumor and then there are regional lymph nodes that we see this is an axial image and this is a pariotic lymph node that we're seeing so this is going to be a stage three B for the tumor stage but then because of lymph node involvement it becomes stage three C2 because we also have pariotic lymph nodes now there's a stricter diffusion that we see in this lymph node in the pelvis and that means nothing even benign lymph nodes have been shown to demonstrate stricter diffusion so that doesn't help for lymph node evaluation if you go with a measurement of one centimetre you could have a very high specificity but low sensitivity but as if you start taking 0.8 centimetres as cutoff there will be increased sensitivity so at our place we take 0.8 centimetres of pelvic lymph nodes and more than one centimetre of pariotic lymph node as abnormal a lymph node having irregular contour internal necrosis or presence of cluster lymph nodes favour it to be metastatic in movement pet CT or additional CT scan is going to help your NNM staging of the disease but it's not part of standard of care for initial staging stage four tumors directly extend to the pelvic sidewalls lower third of vagina because of the bladder or rectum and result in high tonic process or non-functioning kidney stage four A is bladder or rectal mucosal involvement stage four B is distant menostasis invasion of pelvic sidewall is suggested when distance between tumor and the pelvic wall is less than three millimeters because of edema that you see on T2 weighted sequences or just enhancement is not sufficient to call it tumor the rectal and bladder wall invasion is best assessed on sagittal sequences and if you have a clear flat fat plane between the tumor and these organs then you can confidently say that there's no rectal or bladder invasion so this is going to be a reporting checklist you talk of T stage you talk of deep myometal invasion any cervical stromal invasion you try and see rosaline adnexal extension vaginal invasion urinary bladder or rectal invasion and then your N staging with pelvic or pariotic lymph aninopathy when there's a doubt please tend to assign a lower tumor stage so that patient can get appropriate treatment and not have to go for radical treatment this is how the patients are managed so this is the risk stratification based on histology and MRI findings so if you've got a low risk tumor which is grade one or grade two I'm talking of grades and not stages which is grade one or two remember the endomete shared grade tumors that we talked about earlier so in low risk that's going to be very low risk of lymph node disease so these patients do not need to undergo lymph aninectomy grade one or two with a higher tumor with a larger tumor which is stage one b or grade three with a smaller tumor which is stage one a they have slightly increased risk of lymph node invasion and then you have to consider individually for these patients whereas someone who has a grade three disease or a stage one b low grade tumor these patients are recommended to undergo lymph aninectomy recurrence now that's defined as tumor regrowth and or presence of distant metastatic disease after treatment it's going to have very similar appearance as primary tumor patients who have advanced age at presentation have high grade disease or were found to have lymphomascular invasion on the original staging scan at a higher risk of recurrence the overall recurrence rate is still about 15% and 80% of these are going to present in the first three years with lymph node movement or vaginal vault movement MRIs perform for local staging and pet series scan for distant metastasis