MR diffusion imaging for preoperative staging of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis.

OBJECTIVES: To compare the diagnostic accuracy of dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MR imaging in detecting deep myometrial invasion in endometrial cancer, using surgical-pathological staging as reference standard. METHODS: After searching a wide range of electronic databases and screening titles/abstracts, we obtained full papers for potentially eligible studies and evaluated according to predefined inclusion criteria. Quality assessment was conducted by adapting the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. From each study, we extracted information on diagnostic performance of DW and DCE sequences. After exploring heterogeneity, we adopted a bivariate generalized linear mixed model to compare the effect of the two MR sequences jointly on sensitivity and specificity. RESULTS: Nine studies (442 patients) were considered. Significant evidence of heterogeneity was found only for specificity, both in DW and DCE imaging (I (2) = 70.8 % and 70.6 %). Pooled sensitivity of DW and DCE was 0.86 and specificity did not significantly differ (p = 0.16) between the two sequences (DW = 0.86 and DCE = 0.82). No difference was found between 3-T and 1.5-T MR. There was no evidence of publication bias. CONCLUSIONS: MR diagnostic accuracy in presurgical detection of deep myometrial infiltration in endometrial cancer is high. DCE and DW imaging do not differ in sensitivity and specificity. KEY POINTS: Myometrial invasion is the most important morphological prognostic feature of endometrial cancer. MR diagnostic accuracy in presurgical detection of deep myometrial infiltration is high. MR examination including T2 and DCE imaging is considered the reference standard. DW imaging has been increasingly employed with heterogeneous results. This meta-analysis shows that DCE and DW do not differ in diagnostic accuracy.

ADC maps in the prediction of pelvic lymph nodal metastatic regions in endometrial cancer.

OBJECTIVES: To evaluate the usefulness of apparent diffusion coefficient (ADC) in discriminating metastatic from non-metastatic pelvic lymph nodal sites in endometrial cancer. MATERIALS AND METHODS: This retrospective study included 40 patients with endometrial cancer who underwent MRI [T2-weighted, dynamic T1-weighted images and diffusion-weighted images with body background suppression (DWIBS), b-values 0 and 1,000 s/mm(2)], total hysterectomy and pelvic lymphadenectomy. Lymph nodes identifiable on DWIBS were evaluated, classified into six nodal regions, and for each node ADC values, short- and long-axis diameters were measured by two readers. Histopathological findings and follow-up information served as the reference standard. RESULTS: Average (± standard deviation) mean and minimum ADC region value (0.87 ± 0.15 and 0.74 ± 0.07 × 10(-3) mm(2)/s) of metastatic sites (n = 7) were significantly lower than those of non-metastatic ones (n = 89; 1.07 ± 0.20 and 1.02 ± 0.20; p-value = 0.010 and 0.0004). Mean short-axis and short-to-long axis ratios of metastatic nodes were 7.47 mm and 0.68. Using the minimum ADC region value with threshold 0.807 × 10(-3) mm(2)/s, sensitivity, specificity, positive and negative predictive value and accuracy were 100 %, 98.3 %, 63.6 %, 100 % and 98.3 %, respectively (reader 1). CONCLUSION: In endometrial cancer, mean and minimum ADC region values of metastatic nodal sites are significantly lower than those found at normal sites.

Endometrial cancer: correlation of apparent diffusion coefficient with tumor grade, depth of myometrial invasion, and presence of lymph node metastases.

OBJECTIVE: The objective of our study was to investigate whether apparent diffusion coefficient (ADC) values of endometrial cancer differ from those of normal endometrium and myometrium and whether they vary according to histologic tumor grade, the depth of myometrial invasion, or lymph node status. SUBJECTS AND METHODS: Seventy patients with histologically proved endometrial cancer and 36 control subjects with normal endometrium were enrolled in this prospective study. T2-weighted, dynamic T1-weighted, and diffusion-weighted images with b values of 0 and 1000 s/mm(2) were obtained of all patients. The ADC values of endometrial cancer, normal endometrium, and normal myometrium were recorded. Tumor grade, the depth of myometrial invasion, and lymph node status were assessed at postoperative histopathologic analysis. RESULTS: The mean (± SD) ADC value (10(-3) mm(2)/s) of endometrial cancer (0.77 ± 0.12) was significantly lower than that of normal endometrium (1.31 ± 0.11, p < 0.0001) and normal myometrium (1.52 ± 0.21, p < 0.0001), with no overlap between the two former distributions. There was no significant difference between ADC values of endometrial cancer tissue in patients with tumor grade 1 (0.79 ± 0.08, n = 14), grade 2 (0.76 ± 0.14, n = 40), or grade 3 (0.75 ± 0.12, n = 16) (p = 0.67); in patients with deep (0.77 ± 0.13, n = 18) and those with superficial (0.76 ± 0.12, n = 52) myometrial invasion (p = 0.87); and in patients with (0.78 ± 0.10, n = 6) and those without (0.75 ± 0.14, n = 39) lymph node metastases (p = 0.64). CONCLUSION: ADC values allow normal endometrium to be differentiated from endometrial carcinoma; however, they do not correlate with histologic tumor grade, the depth of myometrial invasion, or whether lymph node metastases are present.

Interstitial Lung Disease Associated With Autoimmune Rheumatic Diseases: Checklists for Clinical Practice.

Background: Interstitial lung diseases (ILDs) are often associated with rheumatic diseases. Their early diagnosis and management are not only difficult, but also crucial, because they are associated with major morbidity and mortality and can be the first cause of death in autoimmune rheumatic diseases (ARDs). Objectives: By using methodologies, such as Nominal Group Technique (NGT) and Delphi Survey, the aims of this study were (1) to measure consensus between pulmonologists, radiologists, and rheumatologists experienced in the management of ARD-ILD; (2) to highlight the importance of a multidisciplinary approach; and (3) to provide clinicians with a practical tool aimed at improving the prompt recognition and follow-up of ILD associated with ARDs and of any possible rheumatic conditions underlying ILD. Results: During the NGT round, the Steering Committee defined 57 statements to be used in the Delphi survey. A total of 78 experts participated in the Delphi survey, namely 28 pulmonologists, 33 rheumatologists, and 17 radiologists. During this round, consensus on agreement was reached in 47 statements, while disagreement was not reached in any statements. A secondary questionnaire was drafted by the Steering Committee to obtain clearer indications on ILD-ARD "red-flags" and follow-up. Delphi Panelists took part also in the second-questionnaire survey. Answers from both surveys were used to draft two checklists of "red flags" sign or symptom suggestive of ILD and ARD, respectively, and two checklists on identification and monitoring of rheumatoid arthritis (RA) and systemic sclerosis (SSc) ILD. Limitations: This study is a consensus work, which cannot produce empiric data, and is limited to the Italian scenario. Conclusions: This work showed a high level of agreement, but also shows some divergent opinions between different experts. This underlines the importance of a multidisciplinary approach. Eventually, we believe the drafted checklists can help clinicians in the diagnosis and follow-up of ILD-ARD.

Myometrial invasion in endometrial cancer: diagnostic performance of diffusion-weighted MR imaging at 1.5-T.

OBJECTIVE: To determine the diagnostic accuracy of diffusion-weighted (DW) magnetic resonance (MR) imaging in the preoperative assessment of myometrial invasion by endometrial cancer. MATERIALS AND METHODS: In this prospective study, 47 patients with histologically confirmed endometrial cancer underwent preoperative MR imaging and total hysterectomy. The MR protocol included spin-echo multishot T2-weighted, dynamic T1-weighted and DW images acquired with b-values of 0 and 500 s/mm(2). Myometrial tumour spread was classified as superficial (<50%) or deep (> or =50% myometrial thickness). Postoperative histopathological findings served as a reference standard. Indices of diagnostic performance were assessed for each sequence. RESULTS: At histopathological examination, superficial myometrial invasion was found in 34 patients and deep myometrial invasion in 13. In the assessment of tumour invasion, sensitivity, specificity, positive and negative predictive values of T2-weighted images were 92.3%, 76.5%, 60.0% and 96.3%, respectively. The corresponding values for dynamic images were 69.2%, 61.8%, 40.9% and 84.0%, and for DW images 84.6%, 70.6%, 52.4% and 92.3%. T2-weighted and DW imaging proved to be the most accurate techniques for tumour spread determination. CONCLUSION: DW imaging proved to be accurate in assessing myometrial invasion, and it could replace dynamic imaging as an adjunct to routine T2-weighted imaging for preoperative evaluation of endometrial cancer.