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The Ability of Helical CT to Preoperatively Stage Endometrial Carcinoma

¹ Department of Radiology, Magee Women's Hospital, University of Pittsburgh, 300 Halket St., Pittsburgh, PA 15213.
² Department of Pathology, Magee Women's Hospital, University of Pittsburgh, Pittsburgh, PA 15213.

Received July 19, 2000; accepted after revision August 30, 2000.

 
Presented at the annual meeting of the American Roentgen Ray Society, Washington, DC, May 2000.

Address correspondence to L. A. Hardesty.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. This study evaluated helical CT as an imaging modality for preoperative staging of endometrial carcinoma.

MATERIALS AND METHODS. Three radiologists retrospectively and independently reviewed the preoperative helical CT scans of 25 consecutive patients with endometrial carcinoma. The presence or absence of deep myometrial invasion and the presence or absence of cervical involvement were evaluated on helical CT and compared with pathologic findings at hysterectomy.

RESULTS. Helical CT has a sensitivity of 83% and a specificity of 42% for the detection of deep myometrial invasion (stage IC). Helical CT has a sensitivity of 25% and a specificity of 70% for the detection of cervical involvement (state II). These results compare poorly with those of MR imaging (sensitivity 92%, specificity 90% for the detection of deep myometrial invasion; sensitivity 86%, specificity 97% for the detection of cervical involvement).

CONCLUSION. Helical CT is insensitive and nonspecific compared with MR imaging for the preoperative staging of endometrial carcinoma. MR imaging remains the imaging modality of choice.

Introduction

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Endometrial carcinoma is the fourth most common cancer in women and is the most common gynecologic malignancy in the United States [1]. Endometrial carcinoma is staged surgically with the International Federation of Gynecology and Obstetrics (FIGO) staging system [2] (Table 1). Preoperative clinical examination understages 22% of cases [3]; therefore, gynecologic oncologists obtain imaging studies preoperatively to stage the tumor and to predict whether lymph node dissection will be necessary. Lymph node dissection is necessary if greater than 50% of the myometrial thickness is invaded (FIGO stage IC) or if the cervix is involved (FIGO stage II). MR imaging is the current imaging modality of choice. The superiority of MR imaging over conventional axial CT was determined in a study by Kinkel et al. [4]. To our knowledge, the ability of helical CT to stage endometrial carcinoma has not been previously evaluated.

Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Twenty-five consecutive patients with newly diagnosed endometrial carcinoma who underwent preoperative enhanced helical CT and subsequent hysterectomy at our institution between November 2, 1998, and August 30, 1999, were included. Patients ranged from 44 to 84 years old (mean age, 69 years).

CT was performed with a CTI helical scanner (General Electric Medical Systems, Milwaukee, WI). Oral contrast agent was administered, and then iodinated contrast agent (100 mL of ionic or nonionic) was administered IV. After 60 sec, 7-mm axial images through the liver and "early" 5-mm axial images through the uterus were obtained. Last, 7-mm axial images from the inferior edge of the liver through the remainder of the abdomen and pelvis were obtained so that the uterus was scanned a second time on delayed images. Early thin sections of the uterus were enlarged for interpretation by scanning them on a small field of view.

Three blinded observers, all with expertise in gynecologic imaging, independently and retrospectively evaluated the helical CT scans for the following two variables: first, what was the depth of myometrial invasion by tumor? Was it superficial, with less than 50% of the myometrial thickness invaded by tumor (FIGO stages IA and IB)? Was it deep, with greater than 50% of the myometrial thickness invaded by tumor (FIGO stage IC)? Second, does the tumor involve the cervix? (yes = FIGO stage II; no = FIGO stage I).

The time delay between helical CT and hysterectomy ranged from 1 to 17 days (mean, 6 days). The benchmark for the extent of tumor invasion was determined pathologically after hysterectomy.

The local standard of care was the use of intraoperative pathologic evaluation of the hysterectomy specimen to direct lymph node dissection. CT of the uterus did not direct surgery or other therapy.

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
The cell types of endometrial carcinoma included the following: 18 (72%) of 25 endometrioid, one (4%) of 25 clear cell, three (12%) of 25 mucinous, and three (12%) of 25 papillary serous. Deep myometrial invasion by tumor was seen in six (24%) of 25 patients, and superficial myometrial invasion occurred in 19 (76%) of 25 patients. Cervical involvement was present in three (12%) of 25 patients and absent in 22 (88%) of 25 patients.

For the detection of deep myometrial invasion, helical CT overstaged 11, understaged one, and correctly staged 13 patients (Figs. 1A, 2A, and 3A). Helical CT had a sensitivity of 83% (5/[5+1]) and a specificity of 42% (8/[8+11]).

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —58-year-old woman with endometrial carcinoma. Enhanced helical CT scan of markedly enlarged uterus shows enhancing myometrium peripherally and low-density tumor centrally, invading greater than 50% of myometrial thickness posteriorly. Hysterectomy confirmed invasion of greater than 95% of myometrial thickness.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —70-year-old woman with endometrial carcinoma. Enhanced helical CT scan shows endometrial cavity distended with low-density tumor that invades greater than 50% of enhancing myometrial thickness in left fundal region. Hysterectomy confirmed invasion of greater than 90% of myometrial thickness.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —79-year-old woman with endometrial carcinoma. Enhanced helical CT scan shows irregularly marginated low-density tumor centrally in endometrial cavity (asterisk), judged by all three radiologists to be tumor invading greater than 50% of myometrial wall on left. Hysterectomy found tumor invading only 30% of myometrial thickness. No leiomyoma or other pathologic explanation for CT findings and subsequent CT overstaging was found.

For the detection of cervical invasion, helical CT overstaged six, understaged three, and correctly staged 15 patients (Figs. 1B and 2B). One patient's cervix could not be evaluated because of artifact from a hip prosthesis. For detection of cervical invasion, helical CT had a sensitivity of 25% (1/[1+3]) and a specificity of 70% (14/[14+6]).

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —58-year-old woman with endometrial carcinoma. Enhanced helical CT scan shows enlarged ill-defined cervix containing irregularly marginated low-density tumor centrally. Hysterectomy confirmed cervical invasion.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —70-year-old woman with endometrial carcinoma. Enhanced helical CT scan of bulky uniformly low-density cervix (asterisk). All three radiologists incorrectly believed that cervix was invaded by tumor. At hysterectomy, cervix was unremarkable.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
At our institution, helical CT is more readily available than MR imaging, and gynecologic oncologists are more familiar with the anatomy defined by CT. Despite improvements in CT and helical CT technology, its ability to stage endometrial carcinoma is not comparable with that of MR imaging, the current imaging modality of choice.

Compare our findings of the ability of helical CT to evaluate the depth of myometrial invasion (sensitivity, 83%; specificity, 42%) with those of MR imaging in a recent metaanalysis of 25 published studies (sensitivity, 92%; specificity, 90%) [3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]. The sensitivity and specificity of MR imaging was calculated by averaging those published for each contrast-enhanced MR imaging study in the metaanalysis [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]. Helical CT is less sensitive and less specific than MR imaging for the detection of deep myometrial invasion.

Compare our findings of the ability of helical CT to evaluate the presence of cervical invasion by tumor (sensitivity, 25%; specificity, 70%) with those of MR imaging in the recent metaanalysis (mean sensitivity, 86%; mean specificity, 97%) [3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]. Helical CT is much less sensitive and less specific than MR imaging for the evaluation of cervical invasion by tumor.

We were unable to identify any shared characteristics of the uteri or tumors that helical CT incorrectly staged. We suspected that either the presence of leiomyomatosis or adenomyosis might have increased the difficulty of staging correctly with helical CT. Yet neither leiomyomatosis nor adenomyosis was present in most of the incorrectly staged patients, despite pathologic evaluation of the entire uterus.

A retrospective evaluation of a small sample is not ideal. The selection of helical CT rather than MR imaging by the gynecologic oncologists for these patients may have been influenced by variables that are not readily apparent. Selection bias alone is unlikely to account for the degree of difference between the ability of helical CT and that of MR imaging to preoperatively stage endometrial carcinoma.

All three observers independently commented on their preference for the sagittal images of the uterus that MR imaging provides. Future studies could evaluate the use of reconstructed sagittal images of the uterus obtained by helical CT to preoperatively stage endometrial carcinoma.

The ability of multidetector CT to preoperatively stage endometrial carcinoma is another potential area for future research. Multidetector CT technology is not currently available at our hospital.

In conclusion, helical CT is insensitive and nonspecific compared with MR imaging for the preoperative staging of endometrial carcinoma. MR imaging remains the imaging modality of choice.

References

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