Preliminary Diagnosis: Uterine cancer
I. What imaging technique is first-line for this diagnosis
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Ultrasound (US) of the pelvis with transabdominal and transvaginal imaging.
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For a known diagnosis of uterine cancer: Magnetic resonance imaging of the pelvis with intravenous gadolinium for preoperative assessment, staging, or post-therapy response.
II. Describe the advantages and disadvantages of this technique for diagnosis of uterine cancer.
Advantages
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Allows for evaluation of endometrial thickness and the myometrium.
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Relatively quick examination
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Does not utilize ionizing radiation.
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Can allow for assessment of vascular flow to endometrial lesions.
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Cost-effective imaging modality.
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Can be diagnostic of other causes of postmenopausal bleeding such as polyps, fibroids, and atrophy
Disadvantages
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Very operator-dependent, and relies heavily on the skill of the technologist or physician performing the exam.
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Image quality can be significantly degraded by patient body habitus and bowel gas content.
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Transvaginal ultrasound, while more sensitive, is uncomfortable to many patients.
III. What are the contraindications for the first-line imaging technique?
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There are no significant contraindications to transabdominal US examination of the pelvis.
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Transvaginal US is much more sensitive, but may be declined by a subset of patients.
IV. What alternative imaging techniques are available?
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Hysterosonogram: Ultrasound examination of the uterus following catheter instillation of saline into the endometrial cavity.
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Magnetic resonance imaging with intravenous gadolinium contrast.
V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of uterine cancer.
Hysterosonogram
Advantages
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Allows for distention of the endometrial cavity, which allows for better evaluation of the endometrium and lesions within the endometrial cavity.
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Does not utilize ionizing radiation.
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3D ultrasound imaging can be utilized if intracavitary finding is suspected.
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Cost-effective.
Disadvantages
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Semi-invasive procedure that requires catheterization of the cervical canal and the instillation of saline, which can result in cramping and patient discomfort.
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Image quality can be significantly degraded by patient body habitus and bowel gas content.
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Operator-dependent.
Magnetic resonance Imaging (MRI) with contrast
Advantages
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Allows for high resolution evaluation of the endometrial cavity and myometrium in multiple planes.
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Allows for reliable assessment of other causes of bleeding such as fibroids, polyps, cervical and ovarian pathology.
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Does not use ionizing radiation.
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In a known diagnosis of uterine cancer, MRI reliably allows for assessment of myometrial and parametrial invasion.
Disadvantages
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Expensive
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Time-consuming
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Requires significant patient cooperation to minimize motion artifact
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Cannot be performed in a select number of patients with pacemakers and other metallic non-titanium hardware or medical devices.
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Gadolinium contrast has been implicated in nephrogenic systemic fibrosis and should not be administered with a GFR<30. Department policies vary for GFR 30-60 and often require a reduced dose.
VI. What are the contraindications for the alternative imaging techniques?
Hysterosonogram
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Severe cervical stenosis.
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Examination should be performed only if the patient has a negative pregnancy test and is preferred on day 7-14 of the menstrual cycle.
MRI with contrast
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Patients with embedded metallic devices not made of titanium such as cardiac pacers, stents, and other non-MR approved metallic devices may not enter the magnet for imaging.
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Patients with GFR <30 cannot receive gadolinium intravenous contrast.
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