The use of MRI for selecting patients with endometrial cancer and significant co-morbidities for vaginal hysterectomy.

ABSTRACT

OBJECTIVE: The objective of this study is to ascertain the presence of extrauterine spread in radiologically early stage and grade endometrial cancer. This could be the basis for offering vaginal hysterectomy without salpingo-oophorectomy as an alternative option to primary radical radiotherapy in women with significant medical co-morbidities in whom laparotomy will be contraindicated. MATERIALS AND METHODS: A retrospective cohort study assessing patients with clinically early stage endometrioid adenocarcinoma of the endometrium, treated at the Gynaecological Oncology Centre, Norfolk and Norwich University Hospital and James Paget University Hospital between January 2003 and July 2008. The cancer registry was reviewed, and 542 endometrial cancer cases were identified during the study period, of these 439 were endometrioid type. MR is the standard staging investigation unless there are contraindications. Demographic, clinic-pathologic and surveillance data were collected from hospital records, operative notes and histopathology reports. The histology included tumour type, stage and grade. Post-operative histopathological findings served as a reference standard. Sensitivity and specificity of pre-operative MRI scan were assessed. RESULTS: Of the 439 cases treated during the study periods, 415 patients had an MRI pre-operatively imaging and 14% of these cases showed signs of extrauterine spread. MRI staging was then compared with the histopathology staging; the latter was taken as the gold standard. In 8% of the cases where no spread was seen on MRI, the disease was actually spread outside uterine corpus mainly to the cervix and pelvic lymph nodes. The sensitivity, specificity, positive predictive value and negative predictive value for MRI were 56, 93, 60, and 92, respectively, while predicting early stage disease. There were three cases of adnexal metastases, where the tumour had already spread to uterine serosa. Two cases had poorly differentiated and one had moderately differentiated tumour. CONCLUSIONS: The risk of adnexal metastasis is less than 1% in clinically early stage disease and highly unlikely if MRI suggests that the disease is confined to the inner half of the myometrium and low-grade disease. MRI has a high specificity and negative predictive value in endometrial cancer staging with reduced sensitivity of detecting cervical, adnexal and lymphatic spread. We suggest that vaginal hysterectomy might be a safe alternative to laparotomy in the treatment of radiological early stage disease in medically compromised elderly patients. The possibility of converting a vaginal approach to an abdominal route should be always taken into consideration.