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Table 5 MRI in endometrial cancer staging. Pitfalls and pearls

From: Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

Staging (FIGO) Pitfall Pearl
1. STAGE IA/IB: detection and myometrial invasion
• Small or isointense tumors
• Poor visualization of endometrium and/or poor tumor-to-myometrium interface:
- Presence of leiomyomas/adenomyosis
- Thin myometrium: postmenopause, cornual regions, or secondary to a compressive large endometrial mass
No detection
Underestimation or overestimation of myometrial invasion depth
- DCE and DWI improve detection of small and isointense tumors
- DWI improves tumor detection and delineation
- In DCE imaging, the presence of a contiguous band of subendometrial enhancement excludes myometrial invasion
2. STAGE II: cervical invasion
Tumor protruding or distending cervical os
Misdiagnosis of cervical invasion - Cervical stroma disruption is necessary for diagnosis of cervical stromal invasion
- DWI and DCE improve tumor delineation
3. STAGE IIIA
• Coexistent ovarian and endometrial tumor
Misinterpreting stage IIIA as synchronous cancer and vice versa - Synchronous ovarian and endometrial cancer
Uterus: early-stage endometrial cancer with minimal or no myometrial invasion
• Ovary: unilateral large mass in the background of endometriosis or borderline tumor
- Ovarian metastasis (IIIA)
• Uterus: deep myometrial invasion and/or tubal invasion
• Ovary: smaller mass, bilateral ovarian involvement
4. STAGE IV
Tumor invades bladder/bowel mucosa
The presence of bladder mucosal edema (bullous edema) is not indicative of mucosal invasion - Change the direction of phase and frequency
- A preserved fat plane between the tumor and bladder or rectum excludes stage IVA
- DWI (DWI+T2WI) and DCE help in tumor delineation