How to avoid Errors in uterine imaging ?

1. How to avoid Errors in uterine imaging ?
Anatomopathological correlations.
S. Taïeb, M. Ben Haj Amor, A.S. Lemaire,
E. Leblanc, L. Ceugnart

2. How to shoot one self in the foot ?
 Not enough knowledge about pathology and treatment
 Bad choice of technique / pathology : US / CT / MRI ?
 Pitfalls in technique
 Mistakes when reading
 Omissions in report

3. Guide of the good use of imaging

4. Guide of the good use of imaging

5. Patients related limitation
 US :
 Anatomical, inadequate cycle
 Limited US access (size, pain, virgo)
 Disease specific problems : air, calcium, posterior localization
 MRI
 Contraindications : heart pacemaker, metallic foreign body,
claustrophobia (severe !)
 Motions or metallic device : artefacts

6. Uterine pathology = US, MRI
 Referred for clinical symptoms : Pain, Bleeding, Mass  US
 Diagnosis : STOP
 Diagnosis ? : if uterus or unknown origin  MRI

7. Uterine pathology = US, MRI
 Referred for clinical symptoms : Pain, Bleeding, Mass  US
 Diagnosis : STOP
 Diagnosis ? : if uterus or unknown origin  MRI
 Referred for known carcinoma of cervix or endometrium  MRI
SFR, ESUR, ESMO, ESGO, ACR

8. Uterine pathology = US, MRI
 Referred for clinical symptoms : Pain, Bleeding, Mass  US
 Diagnosis : STOP
 Diagnosis ? : if uterus or unknown origin  MRI
 Referred for known carcinoma of cervix or endometrium  MRI
SFR, ESUR, ESMO, ESGO, ACR
 Referred before specific treatment  symptomatic uterine fibroids
 SARCOMA ?  MRI
hysterectomy, myomectomy, uterine artery embolization, Magnetic resonance-
guided focused US, Radiofrequency volumetric thermal ablation

9. Uterine pathology = US, MRI
 Referred for clinical symptoms : Pain, Bleeding, Mass  US
 Diagnosis : STOP
 Diagnosis ? : if uterus  MRI
 Referred for known carcinoma of cervix or corpus  MRI
 Referred before specific treatment  symptomatic uterine fibroids
 SARCOMA ?  MRI

10. Cervix lesion
 Prognosis and Treatment planning according on :
 Lesion size
 Extension
 Lymph node
American College of Radiology 2016 :
 Early stage :
- MRI with contrast : Rating 8 (6 if without contrast)
- FDG-PET/CT : Rating 8 (with MRI)
 Late stage :
- MRI with contrast : Rating 9 (6 if without contrast)
- FDG-PET/CT : Rating 9 (with MRI)
https://www.guideline.gov/summaries/summary/49923

11. Pitfalls in cervix lesion
 Prognosis and Treatment planning according on :
 Lesion size : MRI
 Extension : MRI
 Lymph node : Lymphadenectomy > PET-CT > MRI = CT
American College of Radiology 2016 :
 Early stage :
- MRI with contrast : Rating 8 (6 if without contrast)
- FDG-PET/CT : Rating 8 (with MRI)
 Late stage :
- MRI with contrast : Rating 9 (6 if without contrast)
- FDG-PET/CT : Rating 9 (with MRI)
https://www.guideline.gov/summaries/summary/49923

12. Advanced stages : > IB2,
or N+
 RCC
[Green JA et al. Lancet 01]
Cervix carcinoma – FIGO 2009
STAGE DESCRIPTION
STAGE 0 Carcinoma in situ
STAGE I
IA
IA1
IA2
IB
IB1
IB2
Extension deeper into the cervix
Micro invasion
< 3mm deep ; < 7mm extension
>3mm et < 5mm deep et < 7mm extension
Clinically visible > Stage IA limited into the cervix
< 4cm in greatest dimension (MRI)
> 4 cm in greatest dimension
STAGE II
IIA
IIA1
IIA2
IIB
Extension limited beyond the uterus
Vagina (< 2/3 supérieur) but not parametrial
Clinically visible lesion < 4 cm
Clinically visible > 4 cm
Parametrial invasion
STAGE III
IIIA
IIIB
Large extension
Lower one third of the vagina
Pelvic wall, hydronephrosis, nonfunctioning kidney
STADE IV
IVA
IVB
Pelvic or extra pelvic extension
Bladder or rectum (biopsy proved)
Metastasis
Early stages : < IB1, N-
 Surgery
+/- Brachyttt (2-4 cm)

13. Pitfalls in cervix lesion – Lesion size
 IS, IA1 < 5mm : not seen
 IA2 – IB1 : > 5mm

14. Pitfalls in cervix lesion – Lesion size
64 y-o. TSE T2
15 x 14 x 17 mm, N-, no extension

15. Pitfalls in cervix lesion – Lesion size
46 y-o. TSE T2
15 x 14 x 17 mm, N-, no extension
Post contrast : 1mn15, 2mn30 , 6mn

16. Pitfalls in cervix lesion – Lesion size
• 41 y-o. Conization : lesion 15mm, non in sano
• IRM 6 weeks later : TSE T2, DWI, ADC

17. Pitfalls in cervix lesion – Lesion size
• 41 y-o. Conization : lesion 15mm, non in sano
• IRM 6 weeks later : TSE T2, DWI, ADC
Post contrast : 30 sec, 1 mn 30 – Residual lesion 10mm

18.  > IB2
47 x 34 x 43 = Concomitent RTCT
Pitfalls in cervix lesion – Lesion size

19. Pitfalls in cervix lesion – Lesion size
46 y-o. lesion size ?
TSE T2 ?

20. Pitfalls in cervix lesion – Lesion size
46 y-o. lesion size ?
TSE T2 ? DCE-MRI 60 sec

21. Pitfalls in cervix lesion – Lesion size
62 y-o. lesion size ?
TSE T2 : 2 cm

22. Pitfalls in cervix lesion – Lesion size
62 y-o. lesion size ?
TSE T2 : 15 mm Post contrast 60 sec : 4 cm ADC map : 4cm
PET : 4 cm

23.  Sequences : T2 with motion correction artefact
Fast SE with echo train : Propeller (GE) – Blade (Siemens) – MultiVane
(Philips)
Pitfalls in cervix lesion – Lesion size

24.  58 y-o, vaginal bleeding, Clinical Ex : RAS
 Cervical SMEAR : AGUS
 Biopsy endocervix : adenocarcinoma
 MRI for endometrium carcinoma
GE : T2 Sag propeller, 2mn post contrast fat sat
 Endometrium lesion 1A, no extension

25. Staff pre treatment
 58 y-o, vaginal bleeding, Clinical Ex : RAS
 Cervical SMEAR : AGUS
 Biopsy endocervix : adenocarcinoma
 MRI for endometrium carcinoma

26. Staff pre treatment
 58 y-o, vaginal bleeding, Clinical Ex : RAS
 Cervical SMEAR : AGUS
 Biopsy endocervix : adenocarcinoma
 MRI for endometrium carcinoma
Axial TSE T2,
6 cm

27. Staff pre treatment
 58 y-o, vaginal bleeding, Clinical Ex : RAS
 Cervical SMEAR : AGUS
 Biopsy endocervix : adenocarcinoma
 MRI for endometrium carcinoma
Axial TSE T2, Sag T2 propeller
6 cm
?

28. T2 Sag propeller, 2mn post contrast fat sat

29.  Siemens
Sag T2 blade,
Staff : new MRI (16 days)

30.  Siemens
Sag T2 blade, Axial : TSE T2
Staff : new MRI (16 days)

31. Staff : new MRI (16 days)
Sag T2 blade, DCE-MRI fat sat : 60 sec, 2mn

32.  T2 sagittal : TSE or propeller if motion artefact,
 T2 coronal : TSE in pelvis axis whole pelvis
 T2 axial : TSE in pelvis axis from perineum to S1/S2
 T2 axial : SS-TSE whole pelvis and abdomen (lymph node)
 DWI axial (less artefact / sagittal) b value 0, 1000, whole pelvis
 DCE-MRI sagittal : Every 15 sec during 3 mn (not optional )
 GRE 3D post contrast small fov (++ for perineum, urethra, vagina)
Our protocole – 16-18 mn

33. Cervix lesion – some help for therapists
 Anatomical variants for surgeons
 Critical extension for radiotherapists

34. retro-aortic left kidney vein

35. left iliac vein

36. 51 y-o. Squamous cell .
RT CT
Stage IV

37. 56 y-o. Residual cervix after incomplet hysterectomy.
Concomitant RT CT
Stage IV

38. 51 y-o. Squamous cell .
RT CT

39. Cervix Lesion
Take home messages
 TSE T2 : Sagittal, Axial, coronal : bigger axis of lesion – ! fast T2
 DCE-MRI : help in small and big lesion  not an option
 DWI MRI : help if enough big lesion
 Don’t forget to describe items may impact treatment
• anatomical vascular (or other) variations
• Specific extension

40. Endometrium carcinoma – FIGO 2009
Stage Description
Stage I
I A
I B
Tumor confined to the uterus
< 50 % Invasion of the myometrium
> 50% Invasion of the myometrium
Stage II Tumor invades cervical stroma
not beyond the uterus
Stage III
III A
III B
III C
Local or regional spread of tumor
Serosal or adnexal invasion
Vaginal or parametrial involvement
Pelvic Lymph nodes (C1)
Paraaortic Lymph nodes (C2)
Stage IV
IV A
IV B
Extension beyond the uterus
serosa
Bladder or bowel mucosa
Metastases, inguinal lymph nodes
American College of Radiology 2013 :
Assessing the depth of myometrial invasion
MRI with or without contrast : Rating 9
Assessing endocervical tumor extent
MRI with or without contrast : Rating 9
https://www.guideline.gov/summaries/summary
/47687

41. Endometrium carcinoma
Prognosis and Treatment planning according on :
 Myometrium extension : MRI
 Cervical stroma extension : MRI
 Lymph nodes : surgery > PET > MRI = CT
 Lesion grade, type of lesion : pathology

42. Endometrium carcinoma
Type II
 Non Oestrogen dependant
 > 66 y-o
 10-23 %
 Serous, clear cells
Type I
 Oestrogen dependant
 50-59 y-o
 77-80%
 Endometrioid carcinoma

43. Treatment according to risk
90% diagnosis early stage : I or II
ESMO 2009
Total hysterectomy with bilateral salpingo-oophorectomy
No lymphadenectomy
STOP
No lymphadenectomy
(or for staging)
Vagina brachytherapy
Pelvic Lymphadenectomy
If + : Aortic Lymphadenectomy
Vagina Brachyttt + ERT
Low risk : Type 1
Stage IA, grade 1 or 2
Intermediate risk : Type 1
Stage IA, grade 3
Stage 1B, grade 1 or 2
High risk
Stage IB, grade 3, Type 1
Type 2 (all stages)
Stage II (cervix)
Vascular embols

44. Myometrium invasion
Courtesy F Penault-Llorca

45. Myometrium invasion

46. Median slice, in the most infiltrative zone
Courtesy F Penault-Llorca
Myometrium invasion

47. Courtesy F Penault-Llorca
Myometrium invasion

48. 72 y-o, TSE T2, DCE-MRI 60 sec
Myometrium invasion ?

49. 72 y-o, TSE T2, DCE-MRI 60 sec
IA < 50%
Myometrium invasion ?

50. 64 y-o, TSE T2, post contrast 2mn30 fat-sat : IA
Myometrium invasion ?

51. 75 y-o, TSE T2, DCE-MRI fat sat 60 sec : IB
No invasion of cervical stroma
Myometrium invasion ?

52. 64 y-o, TSE T2, post contrast 2mn30 fat sat : II
Invasion of cervical stroma

53. 64 y-o, TSE T2, post contrast 2mn30 fat sat : II
Invasion of cervical stroma

54. 57 y-o, TSE T2, No invasion of cervical stroma
Cervix invasion ?

55. 64 y-o, TSE T2, DCE-MRI 90 sec : invasion of cervical stroma
Cervix invasion ?

56.  T2 sagittal : TSE or propeller if motion artefact,
 T2 coronal : TSE in pelvis axis whole pelvis
 T2 axial : TSE in pelvis axis from perineum to S1/S2
 T2 axial : SS-TSE whole pelvis and abdomen (lymph node)
 DWI axial (less artefact / sagittal) b value 0, 1000, whole pelvis
 DCE-MRI sagittal : Every 15 sec during 3 mn
Or GRE 3D 2mn30 post contrast
Sala & al. Radiology 2013
Our protocole – 16-18 mn

57.  DWI > DCE-MRI > T2
 Time to stop contrast ?

58. 64 y-o, TSE T2, post contrast 2mn30 fat sat : II
Invasion of cervical stroma

59.  9 studies, 445 patients
No difference for sensitivity and specificity
 Time to stop contrast ?

60. 69 y-o. T2 : 1A, post contrast : 1A, DWI 1B.
Pathology : 1A, N-  DWI : overestimation

61. 82 y-o. T2 : 1A, Post contrast 1B, DWI 1B. N?
Pathology : 1B, N-.

62. 82 y-o. T2 : 1A, Post contrast 1B, DWI 1B. N?
Pathology : 1B, N-.

63. Fused DWI
FIGO IAInvasion >50%, Irregular margins +++
DWIT2
Courtesy I.Thomassin - Tenon

64. 67 y-o. T2 : 1A, Post contrast 1A, DWI ? But B500, Pathology 1B

65. Adenomyosis
Endometrioid
grade 1 > 50%

66. Adenomyosis
Endometrioid
grade 1 > 50%

67. Endometrium carcinoma
Take home messages
 TSE T2 : Sagittal, Axial, coronal
 DCE-MRI or 2mn30 post contrast and DWI MRI : B > 800
 Don’t forget to assess cervical stroma
 Laparoscopic retroperitonal lymph node dissection : don’t forget to
describe anatomical vascular variations