Ten Takeaways from New Guidelines on Pre-Op MRI for Fertility-Sparing Treatments of Cervical, Endometrial and Ovarian Cancer
New guidelines from the European Society of Urogenital Radiology (ESUR) offer pertinent principles and recommendations for MRI use in considering fertility-sparing treatments for women with ovarian, endometrial, or cervical cancer.
Emphasizing the role of magnetic resonance imaging (MRI) in the preoperative assessment and risk stratification of women being considered for fertility-sparing treatments for cervical, ovarian and endometrial cancer, the European Society of Urogenital Radiology (ESUR) has provided new guidelines based on a literature review and insights from a structured survey about MRI protocols in this patient population.
Here are 10 key takeaways from the guidelines that were recently published in European Radiology.
1. For cervical cancer assessment, the researchers noted that sagittal dynamic contrast-enhanced (DCE) MRI is more advantageous than T2-weighted MRI for enhanced conspicuity and margin delineation of small lesions.
2. When evaluating for extra-cervical tumor extension, three studies have noted a negative predictive value (NPV) ranging between 94 to 100 percent for ruling out parametrial invasion when MRI reveals an intact cervical stroma ring around the tumor.
Here one can see the use of T1-weighted MRI, T2-weighted MRI, diffusion-weighted imaging (DWI) and apparent diffusion coefficient mapping for a 36-year-old patient with cervical squamous cell carcinoma. (Images courtesy of European Radiology.)
3. Emphasizing sagittal T2-weighted MRI for assessing cervical length, the guideline authors noted that a length shorter than 2.5 cm may lead to complications such as cervical incompetence and pre-term delivery.
4. For the assessment of cervical stromal invasion (CSI), the researchers advocated the use of diffusion-weighted imaging (DWI), pointing out the possibility of false-positive results with T2-weighted MRI due to edema and inflammation from previous procedures.
5. Noting that early sub-endometrial enhancement (SEE) is only reported in 10 to 30 percent of cases, the guideline authors said it is a key factor in ruling out myometrial invasion (MI) in the evaluation of endometrial cancer. A DCE MRI finding for excluding MI involves an uninterrupted rim between the endometrium and junctional zone (JZ), which can be attributed to SEE, according to the researchers.
6. Disruption of the hypointense cervical stroma by an intermediate to high signal intensity tumor raises the index of suspicion for CSI, which has been linked to elevated risk of lymph node metastasis in patients with endometrial cancer, according to the guideline authors.
7. Noting that ovarian metastases or synchronous ovarian cancer may occur in 10 percent of endometrial cancer cases, the researchers suggested that high signal intensity on high b-value DWI and low signal intensity on ADC mapping of the ovaries can help facilitate detection.
8. For the planning of fertility-sparing (FS) treatment in patients with ovarian cancer, the guideline authors maintained that MRI has a 92 percent accuracy in risk stratification for adnexal masses.
9. For benign ovarian tumors with solid components, the guideline authors noted that T2-weighted MRI or DWI will reveal a homogeneously low signal intensity for fibrous tissue or gradual enhancement without a plateau.
10. In patients with ovarian cancer, the researchers noted that the large, solid and homogenous tumor presentations with dysgerminomas are accompanied by uniform enhancement, fibrovascular septa and high signal intensity on T2-weighted MRI.
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