Rationale and Objectives
To differentiate endometrial cancer (ECa) from benign lesions in endometrial or in submucosa (BLs-ESm), and investigate whether the signal-to-noise ratio (SNR) of choline-containing compounds (Cho) obtained from three-dimensional 1 H magnetic resonance spectroscopy (MRS) is associated with the aggressiveness of ECa.
Materials and Methods
Thirty-three patients with ECa and 15 patients with BLs-ESm underwent preoperative multivoxel 1 H MRS at 3 T MR. The amplitude of Cho peak of each voxel was recorded, and the corresponding SNR of Cho peak (Cho SNR ) was calculated. The maximum Cho SNR (max Cho SNR ) for each lesion was identified. The max Cho SNR of ECa and BLs-ESm, as well as type I ECa and type II ECa, was compared. The relationship between max Cho SNR and pathologic characteristics of tumors, including tumor grade, stage, type, and tumor size, was analyzed.
Results
The mean max Cho SNR (±standard deviation [SD]) was 30.93 ± 16.89 for ECa and 10.40 ± 3.07 for BLs-ESm ( P < .001). The mean max Cho SNR for type II ECa (48.54 ± 21.46) was higher than that for type I ECa (26.19 ± 12.02, P = .001). There were no significant differences among different grades ( P = .449). The Spearman coefficient between max Cho SNR and stage was 0.423 ( P = .014); the difference existed only between Ia and III ECa ( P = .048). The Pearson coefficient between Cho SNR and tumor size was 0.515 ( P = .002).
Conclusions
The max Cho SNR obtained from MRS can differentiate ECa from BLs and type I ECa and type II ECa, but cannot differentiate between each grade ECa and each International Federation of Gynecology and Obstetrics stage ECa. However, max Cho SNR increased with the increase in International Federation of Gynecology and Obstetrics stage and size of ECa.
Endometrial cancer (ECa) is one of the three most common female genital tract malignancies in China. The incidence of ECa is rising worldwide in recent years. Correct diagnosis of ECa and benign lesions in endometrial or in submucosa (BLs-ESm) before surgery is very important to personalize treatment. The ECa type (type I, estrogen dependent; type II, estrogen independent), grade, stage, and tumor size were fundamental biological indicators of aggressiveness and prognosis of ECa . Type II ECa generally contains rare but aggressive subtypes of ECa, that is, squamous cell carcinoma, adenosquamous carcinoma, papillary serous carcinoma, and clear cell carcinoma, which closely related to lymph node metastasis and prognosis. The endometrial sampling is not sensitive enough to be used alone to exclude ECa. As a traditional method of diagnosis of ECa, the fractional dilatation and curettage cannot always exclude ECa when endometrial hyperplasia, especially atypical hyperplasia, was diagnosed because of limited samples . There were 16.7%–62.5% patients with atypical hyperplasia in dilatation and curettage having a diagnosis of ECa in the hysterectomy specimens .
Magnetic resonance (MR) imaging is considered as the optimal imaging modality in assessing the invasion of uterine cancers . The accuracy of staging ECa using MR imaging was high . MR imaging has also been used in determining the origin of uterine cancer and differentiation of malignant tumors from benign lesions of uterus . As a noninvasive examination, MR spectroscopy (MRS) can provide the tissue biochemical information. The clinical application of MRS has been steadily increasing in recent years. MRS contributes to the diagnosis, differentiation of malignant tumors from benign lesions, and assessing tumor aggressiveness in brain , breast , and prostate . Choline-containing compounds (Cho) increased in actively proliferating tumors . The differentiation of malignant tumors from benign lesions of uterus with single voxel MRS has been reported in a study by Takeuchi et al. . The size of single voxel was often large. The large volume of a voxel may result in the restriction of measurement of small tumor, although a signal-to-noise ratio (SNR) of single voxel MRS was relatively high. However, the differentiation of ECa from BLs-ESm and the assessment of ECa aggressiveness with multivoxel MRS have not been systematically investigated.
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Materials and methods
Patients
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MR Imaging
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Table 1
Parameters of Magnetic Resonance Imaging Sequences
Sequences TR (ms) TE (ms) ST (mm) Average FOV (cm 2 ) Matrix Axial T2W 3110 101 3–4.5 2 20 × 20 320 × 256 Coronal T2W 3350 97 3–4 2 20 × 20 320 × 256 Sagittal T2W 2950 101 3–4 2 20 × 20 320 × 310 MRS ∗ 750 145 — 6 — — DWI † 6200 63 3–4.5 6 20 × 20 160 × 120 T1W-DCE (VIBE) 5.21 1.8 3–4 1 26 × 26 224 × 161
DCE, dynamic contrast–enhanced imaging; DWI, diffusion-weighted imaging; FOV, field of view; ST, slice thickness; T1W, T1-weighted; T2W, T2-weighted; TE, echo time; TR, repetition time; VIBE, volume interpolated body examination.
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MRS Data Analysis
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Root−mean−squareerror=(fittingerror)Cho(3.4−3.0)×1024/10−−−−−−−−−−−−√. Root
-
mean
-
square
error
=
(
fitting
error
)
Cho
(
3.4
−
3.0
)
×
1024
/
10
.
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SDnoise=(fittingerror)noise(9.5−7)×1024/10−−−−−−−−−−−√. SD
noise
=
(
fitting
error
)
noise
(
9.5
−
7
)
×
1024
/
10
.
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Histopathologic Analysis
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Table 2
The Number of Patients with Different Histopathologic Results
Lesions Value No. of lesions (no. of voxel) ECa 33 BLs-ESm 15 Type of ECa Type I (estrogen dependent) 26 Type II (estrogen independent) 7 Subtype of type II ECa Adenosquamous 2 Squamous cell 1 Endometrioid 2 Serous 1 Mixed endometrioid/clear cell 1 Histologic grade of ECa G1 9 G2 17 G3 7 FIGO stage of ECa Ia 17 Ib 8 II 2 III 6 No. of BL Polyp 4 Simple hyperplasia 3 Complex hyperplasia with or without atypia 5 Ploypoid adenomyoma 2 Leiomyomas 1
BLs-ESm, benign lesions in endometrial or in submucosa; ECa, endometrial cancer; FIGO, International Federation of Gynecology and Obstetrics.
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Statistical Analysis
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Results
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Discussion
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Conclusions
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