Uterine Cancer

Preliminary Diagnosis: Uterine cancer

I. What imaging technique is first-line for this diagnosis

• Ultrasound (US) of the pelvis with transabdominal and transvaginal imaging.

• For a known diagnosis of uterine cancer: Magnetic resonance imaging of the pelvis with intravenous gadolinium for preoperative assessment, staging, or post-therapy response.

II. Describe the advantages and disadvantages of this technique for diagnosis of uterine cancer.

Advantages

• Allows for evaluation of endometrial thickness and the myometrium.

• Relatively quick examination

• Does not utilize ionizing radiation.

• Can allow for assessment of vascular flow to endometrial lesions.

• Cost-effective imaging modality.

• Can be diagnostic of other causes of postmenopausal bleeding such as polyps, fibroids, and atrophy

Disadvantages

• Very operator-dependent, and relies heavily on the skill of the technologist or physician performing the exam.

• Image quality can be significantly degraded by patient body habitus and bowel gas content.

• Transvaginal ultrasound, while more sensitive, is uncomfortable to many patients.

III. What are the contraindications for the first-line imaging technique?

• There are no significant contraindications to transabdominal US examination of the pelvis.

• Transvaginal US is much more sensitive, but may be declined by a subset of patients.

IV. What alternative imaging techniques are available?

• Hysterosonogram: Ultrasound examination of the uterus following catheter instillation of saline into the endometrial cavity.

• Magnetic resonance imaging with intravenous gadolinium contrast.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of uterine cancer.

Hysterosonogram

Advantages

• Allows for distention of the endometrial cavity, which allows for better evaluation of the endometrium and lesions within the endometrial cavity.

• Does not utilize ionizing radiation.

• 3D ultrasound imaging can be utilized if intracavitary finding is suspected.

• Cost-effective.

Disadvantages

• Semi-invasive procedure that requires catheterization of the cervical canal and the instillation of saline, which can result in cramping and patient discomfort.

• Image quality can be significantly degraded by patient body habitus and bowel gas content.

• Operator-dependent.

Magnetic resonance Imaging (MRI) with contrast

Advantages

• Allows for high resolution evaluation of the endometrial cavity and myometrium in multiple planes.

• Allows for reliable assessment of other causes of bleeding such as fibroids, polyps, cervical and ovarian pathology.

• Does not use ionizing radiation.

• In a known diagnosis of uterine cancer, MRI reliably allows for assessment of myometrial and parametrial invasion.

Disadvantages

• Expensive

• Time-consuming

• Requires significant patient cooperation to minimize motion artifact

• Cannot be performed in a select number of patients with pacemakers and other metallic non-titanium hardware or medical devices.

• Gadolinium contrast has been implicated in nephrogenic systemic fibrosis and should not be administered with a GFR<30. Department policies vary for GFR 30-60 and often require a reduced dose.

VI. What are the contraindications for the alternative imaging techniques?

Hysterosonogram

• Severe cervical stenosis.

• Examination should be performed only if the patient has a negative pregnancy test and is preferred on day 7-14 of the menstrual cycle.

MRI with contrast

• Patients with embedded metallic devices not made of titanium such as cardiac pacers, stents, and other non-MR approved metallic devices may not enter the magnet for imaging.

• Patients with GFR <30 cannot receive gadolinium intravenous contrast.