European Radiology

, Volume 19, Issue 7, pp 1565–1574 | Cite as

Staging of endometrial cancer with MRI: Guidelines of the European Society of Urogenital Imaging

  • K. Kinkel
  • R. Forstner
  • F. M. Danza
  • L. Oleaga
  • T. M. Cunha
  • A. Bergman
  • J. O. Barentsz
  • C. Balleyguier
  • B. Brkljacic
  • J. A. Spencer


The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2 min ± 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.


Uterus, endometrium Uterine neoplasms, staging, uterine neoplasms Magnetic resonance (MR), gynecologic oncology 


  1. 1.
    Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ (2007) Cancer statistics, 2007. CA Cancer J Clin 57:43–66PubMedCrossRefGoogle Scholar
  2. 2.
    Bakkum-Gamez JN, Gonzalez-Bosquet J, Laack NN, Mariani A, Dowdy SC (2008) Current issues in the management of endometrial cancer. Mayo Clin Proc 83:97–112PubMedCrossRefGoogle Scholar
  3. 3.
    Sorosky JI (2008) Endometrial cancer. Obstet Gynecol 111:436–447PubMedGoogle Scholar
  4. 4.
    Zuurendonk LD, Smit RA, Mol BW, Feijen HW, de Graaff J, Sykora D, de Winter KA, vd Wurff A, Snijders MP, Kruitwagen RF (2006) Routine pelvic lymphadenectomy in apparently early stage endometrial cancer. Eur J Surg Oncol 32:450–454 Epub 2006 Mar 2020PubMedCrossRefGoogle Scholar
  5. 5.
    Querleu D, Leblanc E, Cartron G, Narducci F, Ferron G, Martel P (2006) Audit of preoperative and early complications of laparoscopic lymph node dissection in 1,000 gynecologic cancer patients. Am J Obstet Gynecol 195:1287–1292 Epub 2006 May 1283PubMedGoogle Scholar
  6. 6.
    Savino L, Borruto F, Comparetto C, Massi GB (2001) Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer. Eur J Gynaecol Oncol 22:31–35PubMedGoogle Scholar
  7. 7.
    Bottke D, Wiegel T, Kreienberg R, Kurzeder C, Sauer G (2007) Stage IB endometrial cancer. Does lymphadenectomy replace adjuvant radiotherapy? Strahlenther Onkol 183:600–604PubMedCrossRefGoogle Scholar
  8. 8.
    Boronow RC, Morrow CP, Creasman WT, Disaia PJ, Silverberg SG, Miller A, Blessing JA (1984) Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study. Obstet Gynecol 63:825–832PubMedGoogle Scholar
  9. 9.
    Kinkel K, Kaji Y, Yu KK, Segal MR, Lu Y, Powell CB, Hricak H (1999) Radiologic staging in patients with endometrial cancer: a meta-analysis. Radiology 212:711–718PubMedGoogle Scholar
  10. 10.
    Frei KA, Kinkel K, Bonel HM, Lu Y, Zaloudek C, Hricak H (2000) Prediction of deep myometrial invasion in patients with endometrial cancer: clinical utility of contrast-enhanced MR imaging—a meta-analysis and Bayesian analysis. Radiology 216:444–449PubMedGoogle Scholar
  11. 11.
    Scoutt LM, McCarthy SM, Flynn SD, Lange RC, Long F, Smith RC, Chambers SK, Kohorn E, Schwartz P, Chambers JT (1995) Clinical stage I endometrial carcinoma: pitfalls in preoperative assessment with MR imaging. Work in progress. Radiology 194:567–572PubMedGoogle Scholar
  12. 12.
    Kinkel K (2005) Pitfalls in staging uterine neoplasm with imaging: a review. Abdom Imaging 5:5Google Scholar
  13. 13.
    Yamashita Y, Harada M, Sawada T, Takahashi M, Miyazaki K, Okamura H (1993) Normal uterus and FIGO stage I endometrial carcinoma: dynamic gadolinium-enhanced MR imaging. Radiology 186:495–501PubMedGoogle Scholar
  14. 14.
    Manfredi R, Gui B, Maresca G, Fanfani F, Bonomo L (2005) Endometrial cancer: magnetic resonance imaging. Abdom Imaging 6:6Google Scholar
  15. 15.
    Ohguri T, Aoki T, Watanabe H, Nakamura K, Nakata H, Matsuura Y, Kashimura M (2002) MRI findings including gadolinium-enhanced dynamic studies of malignant, mixed mesodermal tumors of the uterus: differentiation from endometrial carcinomas. Eur Radiol 12:2737–2742 Epub 2002 May 2709PubMedGoogle Scholar
  16. 16.
    Joja I, Asakawa T, Shiraiwa M, Shibutani O, Okuno K, Akaki S, Togami I, Kudo T, Hiraki Y (1999) Endometrial carcinoma: multisection dynamic MR imaging using a three-dimensional FLASH technique during breath holding. Radiat Med 17:211–218PubMedGoogle Scholar
  17. 17.
    Yamashita Y, Torashima M, Takahashi M, Tanaka N, Katabuchi H, Miyazaki K, Ito M, Okamura H (1993) Hyperintense uterine leiomyoma at T2-weighted MR imaging: differentiation with dynamic enhanced MR imaging and clinical implications. Radiology 189:721–725PubMedGoogle Scholar
  18. 18.
    Messiou C, Spencer JA, Swift SE (2006) MR staging of endometrial carcinoma. Clin Radiol 61:822–832PubMedCrossRefGoogle Scholar
  19. 19.
    Cabrita S, Rodrigues H, Abreu R, Martins M, Teixeira L, Marques C, Mota F, de Oliveira CF (2008) Magnetic resonance imaging in the preoperative staging of endometrial carcinoma. Eur J Gynaecol Oncol 29:135–137PubMedGoogle Scholar
  20. 20.
    Shen SH, Chiou YY, Wang JH, Yen MS, Lee RC, Lai CR, Chang CY (2008) Diffusion—weighted single-shot echo-planar imaging with parallel technique in assessment of endometrial cancer. AJR Am J Roentgenol 190:481–488PubMedCrossRefGoogle Scholar
  21. 21.
    Park JY, Kim EN, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH (2008) Comparison of the validity of magnetic resonance imaging and positron emission tomography/computed tomography in the preoperative evaluation of patients with uterine corpus cancer. Gynecol Oncol 108:486–492 Epub 2008 Jan 2016PubMedCrossRefGoogle Scholar
  22. 22.
    Ortashi O, Jain S, Emannuel O, Henry R, Wood A, Evans J (2008) Evaluation of the sensitivity, specificity, positive and negative predictive values of preoperative magnetic resonance imaging for staging endometrial cancer. A prospective study of 100 cases at the Dorset Cancer Centre. Eur J Obstet Gynecol Reprod Biol 137:232–235PubMedCrossRefGoogle Scholar
  23. 23.
    Sala E, Wakely S, Senior E, Lomas D (2007) MRI of malignant neoplasms of the uterine corpus and cervix. AJR Am J Roentgenol 188:1577–1587PubMedCrossRefGoogle Scholar
  24. 24.
    Chung HH, Kang SB, Cho JY, Kim JW, Park NH, Song YS, Kim SH, Lee HP (2007) Accuracy of MR imaging for the prediction of myometrial invasion of endometrial carcinoma. Gynecol Oncol 104:654–659PubMedCrossRefGoogle Scholar
  25. 25.
    Nakao Y, Yokoyama M, Hara K, Koyamatsu Y, Yasunaga M, Araki Y, Watanabe Y, Iwasaka T (2006) MR imaging in endometrial carcinoma as a diagnostic tool for the absence of myometrial invasion. Gynecol Oncol 102:343–347PubMedCrossRefGoogle Scholar
  26. 26.
    Barwick TD, Rockall AG, Barton DP, Sohaib SA (2006) Imaging of endometrial adenocarcinoma. Clin Radiol 61:545–555PubMedCrossRefGoogle Scholar
  27. 27.
    Nasi F, Fiocchi F, Pecchi A, Rivasi F, Torricelli P (2005) MRI evaluation of myometrial invasion by endometrial carcinoma. Comparison between fast-spin-echo T2w and coronal-FMPSPGR Gadolinium-Dota-enhanced sequences. Radiol Med (Torino) 110:199–210Google Scholar
  28. 28.
    Manfredi R, Mirk P, Maresca G, Margariti PA, Testa A, Zannoni GF, Giordano D, Scambia G, Marano P (2004) Local-regional staging of endometrial carcinoma: role of MR imaging in surgical planning. Radiology 231:372–378PubMedCrossRefGoogle Scholar
  29. 29.
    Utsunomiya D, Notsute S, Hayashida Y, Lwakatare F, Katabuchi H, Okamura H, Awai K, Yamashita Y (2004) Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol 182:399–404PubMedGoogle Scholar
  30. 30.
    Tanaka YO, Nishida M, Tsunoda H, Ichikawa Y, Saida Y, Itai Y (2003) A thickened or indistinct junctional zone on T2-weighted MR images in patients with endometrial carcinoma: pathologic consideration based on microcirculation. Eur Radiol 13:2038–2045PubMedCrossRefGoogle Scholar
  31. 31.
    Cunha TM, Felix A, Cabral I (2001) Preoperative assessment of deep myometrial and cervical invasion in endometrial carcinoma: comparison of magnetic resonance imaging and gross visual inspection. Int J Gynecol Cancer 11:130–136PubMedCrossRefGoogle Scholar
  32. 32.
    Ueda M, Otsuka M, Hatakenaka M, Sakai S, Ono M, Yoshimitsu K, Honda H, Torii Y (2001) MR imaging findings of uterine endometrial stromal sarcoma: differentiation from endometrial carcinoma. Eur Radiol 11:28–33PubMedCrossRefGoogle Scholar
  33. 33.
    Grasel RP, Outwater EK, Siegelman ES, Capuzzi D, Parker L, Hussain SM (2000) Endometrial polyps: MR imaging features and distinction from endometrial carcinoma. Radiology 214:47–52PubMedGoogle Scholar
  34. 34.
    Shibutani O, Joja I, Shiraiwa M, Asakawa T, Miyagi Y, Kudo T, Hiraki Y (1999) Endometrial carcinoma: efficacy of thin-section oblique axial MR images for evaluating cervical invasion. Abdom Imaging 24:520–526PubMedCrossRefGoogle Scholar
  35. 35.
    Lee EJ, Byun JY, Kim BS, Koong SE, Shinn KS (1999) Staging of early endometrial carcinoma: assessment with T2-weighted and gadolinium-enhanced T1-weighted MR imaging. Radiographics 19:937–945 discussion 946–937PubMedGoogle Scholar
  36. 36.
    Koyama T, Togashi K, Konishi I, Kobayashi H, Ueda H, Kataoka ML, Itoh T, Higuchi T, Fujii S, Konishi J (1999) MR imaging of endometrial stromal sarcoma: correlation with pathologic findings. AJR Am J Roentgenol 173:767–772PubMedGoogle Scholar
  37. 37.
    Benedet JL, Bender H, Jones H 3rd, Ngan HY, Pecorelli S (2000) FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet 70:209–262PubMedCrossRefGoogle Scholar
  38. 38.
    Hricak H, Stern JL, Fisher MR, Shapeero LG, Winkler ML, Lacey CG (1987) Endometrial carcinoma staging by MR imaging. Radiology 162:297–305PubMedGoogle Scholar
  39. 39.
    Matsushita H, Kodama S, Kase H, Kurata H, Tanaka K (1996) [Usefulness of magnetic resonance imaging in the determination of cervical involvement in endometrial cancer]. Nippon Sanka Fujinka Gakkai Zasshi 48:821–826PubMedGoogle Scholar
  40. 40.
    Spencer JA, Messiou C, Swift SE (2008) MR staging of endometrial cancer: needed or wanted? Cancer Imaging 8:1–5PubMedCrossRefGoogle Scholar
  41. 41.
    Koyama T, Tamai K, Togashi K (2007) Staging of carcinoma of the uterine cervix and endometrium. Eur Radiol 17:2009–2019PubMedCrossRefGoogle Scholar
  42. 42.
    Rockall AG, Sohaib SA, Harisinghani MG, Babar SA, Singh N, Jeyarajah AR, Oram DH, Jacobs IJ, Shepherd JH, Reznek RH (2005) Diagnostic performance of nanoparticle-enhanced magnetic resonance imaging in the diagnosis of lymph node metastases in patients with endometrial and cervical cancer. J Clin Oncol 23:2813–2821PubMedCrossRefGoogle Scholar
  43. 43.
    Harisinghani MG, Saksena MA, Hahn PF, King B, Kim J, Torabi MT, Weissleder R (2006) Ferumoxtran-10-enhanced MR lymphangiography: does contrast-enhanced imaging alone suffice for accurate lymph node characterization? AJR Am J Roentgenol 186:144–148PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2009

Authors and Affiliations

  • K. Kinkel
    • 1
    • 12
  • R. Forstner
    • 2
  • F. M. Danza
    • 3
  • L. Oleaga
    • 4
  • T. M. Cunha
    • 5
  • A. Bergman
    • 6
  • J. O. Barentsz
    • 7
  • C. Balleyguier
    • 8
  • B. Brkljacic
    • 9
    • 10
  • J. A. Spencer
    • 11
  1. 1.Clinique des GrangettesGeneva University Hospital and Institut de RadiologieChêne-Bougeries/GenevaSwitzerland
  2. 2.ZentralröntgeninstitutLandesklinikenSalzburgSalzburgAustria
  3. 3.Dipartimento di Bioimmagini e scienze radiologicheUniversità Cattolica del S. CuoreRomeItaly
  4. 4.Radiology DepartmentHospital ClinicBarcelonaSpain
  5. 5.Department of RadiologyInstituto Português de Oncologia de Lisboa Francisco GentilLisboa CodexPortugal
  6. 6.Department of RadiologyUppsala University HospitalUppsalaSweden
  7. 7.Department of RadiologyRadboud University Nijmegen Medical CenterNijmegenThe Netherlands
  8. 8.Department of RadiologyInstitut de Cancérologie Gustave RoussyVillejuif CedexFrance
  9. 9.Department of Diagnostic and Interventional RadiologyUniversity Hospital “Dubrava”ZagrebCroatia
  10. 10.Medical SchoolUniversity of ZagrebZagrebCroatia
  11. 11.Department of Clinical RadiologySt James’s Institute of OncologyLeedsUK
  12. 12.Institut de radiologieClinique des GrangettesChêne-Bougerie/GenevaSwitzerland

Personalised recommendations