MRI is a valuable tool for assessing endometrial cancer by depicting tumor size, extension into the myometrium or parametrium, cervical invasion, and lymphadenopathy. It plays an important role in pre-operative planning by identifying high-risk features that may require lymph node dissection or adjuvant therapy. While endometrial cancer is surgically staged, MRI can accurately assess key features to guide treatment. It can also differentiate endometrial cancer from benign conditions like hyperplasia, adenomyosis, or fibroids.

1. Dr/ ABD ALLAH NAZEER. MD.
Radiological Imaging of endometrial carcinoma.

2. Endometrial cancer
-4th most common cancer in women
-Most common gynecologic malignancy
-Peak incidence: 55 and 65 years
-Risk factors:
-Obesity.
-Nulliparity.
-Late menopause.
-Unopposed estrogen exposure.
-Tamoxifen.

3. -Over 80% of patients present with early stage
disease due to symptoms of abnormal uterine
bleeding, with an overall excellent prognosis.
-Endometrial cancer is traditionally surgically staged
and the treatment varies by stage, grade, regional
guidelines, and expertise.
-MRI is a valuable adjunct to pre-operative planning
as it can accurately depict endometrial cancer . The
goal of MRI is to identify patients preoperatively who
would benefit from abdominopelvic lymph node
dissection and adjuvant therapy while avoiding
overtreating early stage patients with unnecessary
lymphadenectomies.

10. Imaging techniques
Ultrasound
TVUS is often used for the initial evaluation in women with history
of postmenopausal bleeding because it is quick, inexpensive, and
does not expose the patient to ionizing radiation. ECs typically
present as thickening of the endometrium and TVUS diagnosis of
endometrial cancer is based on endometrial thickness that is
measured in the anteroposterior dimension. The sensitivity and
specificity of TVUS for detecting EC approach 96% and 61%,
respectively, when an endometrial thickness threshold of 5 mm, in
postmenopausal women, is used to define abnormal endometrial
thickening. A meta-analysis suggested a sensitivity of 68-100% and a
specificity of 71-90% for subjective assessment of deep myometrial
invasion. Furthermore, the negative predictive value of a thin
endometrium is very high. Also, cancer is more likely when the
endometrium has a heterogeneous echotexture and irregular or
poorly defined margins.

11. A 67-year-old female with endometrial cancer. (A) Longitudinal transabdominal scan. (B) Transvaginal
scan and a 3-D reconstructed ultrasonography image (C) through the uterus demonstrate a thickened and
heterogeneous endometrium measuring 2.0 cm (arrows). Note regular endometrial–myometrial border
with no signs of invasion (arrowheads). (D) Note increased vascularity in the color Doppler US (black arrow).

12. Endometrial carcinoma.

14. Doppler showing increased endometrial
vascularity in endometrial carcinoma.

15. Ultrasound images of a female patient, aged 55 years with malignant thickened
endometrium (confirmed to be endometrial adenocarcinoma by pathological examination).
B-mode ultrasound image (A), Power Doppler image (B) and TV elastogram (C) show
endometrial thickness = 18 mm with increase vascularity, dark blue color and SR = 11.54.

17. Image planes for high-resolution T2-weighted imaging of the uterus. Initial high resolution
T2-weighted sagittal images of the pelvis are obtained. Axial oblique images are obtained
by scanning perpendicular (dotted blue lines) to the long axis of the endometrial cavity
(solid red line). These sequences can then be used for accurate assessment of myometrial
invasion by tumour. If there is suspected cervical invasion, further imaging is recommended
on a plane perpendicular to the long axis of the endocervical canal.

35. Classification of Endometrial carcinoma using TNM and FIGO Staging systems.

44. Grade I endometrial carcinoma
on top of endometrial
hyperplasia. A and B Sagittal and
axial T2-weighted images of the
uterus show endometrial mass
with bright signal intensity filling
and distending the endometrial
cavity with thinning of the
myometrium. C Axial T1-
weighted. D Axial Gd- T1-
weighted image showing the
endometrial mass enhancing less
than the myometrium. E and F
DW-MRI and corresponding ADC
map. There is heterogeneous iso-
intense signal with foci of high
signal intensity and
corresponding low signal on ADC
map (consistent with endometrial
hyperplasia with foci of
malignant transformation). ADC
value was 1.4 × 10−3 mm2/s in
areas of endometrial hyperplasia
and 0.74 × 10−3 mm2/s in areas
of endometrial carcinoma.

49. Stage 11A (A) Sagittal T2W image show a hyperintense signal intensity tumor distending the endometrial cavity (arrow). (B) On T1W
post-contrast image, the tumor (arrow) is low in signal compared to the enhancing adjacent myometrium. It presents restricted diffusion
with high signal on DW images (C) and low signal on ADC map (D) (arrows). (E) It presents with high FDG uptake on FDG-PET/CT (arrow)

55. (A,B) cervical
cancer and (C,D)
endometrial
cancer on
sagittal T2-
weighted (left
column) and
contrast-
enhanced T1-
weighted (right
column) MRI
images.
Abbreviations:
T, tumor; M,
myometrium.

56. 77-year-old female patient with
pathologically diagnosed G2
endometrioid endometrial carcinoma. A
and B: Sagittal and axial T2 W images
showing a hyper-intense endometrial
mass relative to the myometrium
occupying the fundus and anterior wall
of the uterine cavity. C and D: Sagittal
and Axial Delayed Gd-T1 W images
showing the endometrial mass to be
more conspicuous and contrasting
against the enhanced myometrium with
deep myometrial invasion >50%. E, F:
Axial ADC map and corresponding high b
value DW image showing diffusion
restriction of the mass in the form of low
signal on ADC map and high signal on
DWI. The ADC value 0.75 × 10−3 mm2/s.
On DWI, there is well delineation of
depth of myometrial invasion >50%.
Note the associated Right ovarian
endometrioid carcinoma (∗).

57. Mimics of Endometrial Cancer
Benign lesions:
1- Submucous Fibroid.
2- Adenomyosis.
3- Endometrial Polyp.
4- Endometrial hyperplasia.
5-Placental Polyp.
Malignant lesions:
-Uterine sarcomas.

60. MRI shows fibroid inside the uterine cavity.

62. Uterine
adenomyosis.

64. A) Axial T2-weighted image shows a 6 cm sized endometrial mass with multiple
hyperintense cystic lesions (arrowhead) and hypointense fibrous stroma (arrow) .

67. Endometrial
Hyperplasia.

69. Summary.
- MRI is excellent at depicting uterine anatomy and
assessing endometrial cancer.
-Tumor size and extension
-Myometrial invasion
-Parametrial/cervical invasion
-Lymphadenopathy
-Although currently endometrial cancer is staged
surgically, MRI does play a critical role in pre-operative
planning.
-Differentiating endometrial cancer from co-existing
endometrial hyperplasia, adenomyosis, fibroids,
and polyps is important in the accurate assessment
of endometrial cancer.

70. Thank You.