Preliminary Diagnosis: Uterine cancer

I. What imaging technique is first-line for this diagnosis

  • Ultrasound (US) of the pelvis with transabdominal and transvaginal imaging.

  • 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.

  • Allows for evaluation of endometrial thickness and the myometrium.

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  • Relatively quick examination

  • Does not utilize ionizing radiation.

  • Can allow for assessment of vascular flow to endometrial lesions.

  • Cost-effective imaging modality.

  • Can be diagnostic of other causes of postmenopausal bleeding such as polyps, fibroids, and atrophy

  • Very operator-dependent, and relies heavily on the skill of the technologist or physician performing the exam.

  • Image quality can be significantly degraded by patient body habitus and bowel gas content.

  • Transvaginal ultrasound, while more sensitive, is uncomfortable to many patients.

III. What are the contraindications for the first-line imaging technique?

  • There are no significant contraindications to transabdominal US examination of the pelvis.

  • Transvaginal US is much more sensitive, but may be declined by a subset of patients.

IV. What alternative imaging techniques are available?

  • Hysterosonogram: Ultrasound examination of the uterus following catheter instillation of saline into the endometrial cavity.

  • Magnetic resonance imaging with intravenous gadolinium contrast.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of uterine cancer.

  • Allows for distention of the endometrial cavity, which allows for better evaluation of the endometrium and lesions within the endometrial cavity.

  • Does not utilize ionizing radiation.

  • 3D ultrasound imaging can be utilized if intracavitary finding is suspected.

  • Cost-effective.

  • Semi-invasive procedure that requires catheterization of the cervical canal and the instillation of saline, which can result in cramping and patient discomfort.

  • Image quality can be significantly degraded by patient body habitus and bowel gas content.

  • Operator-dependent.

Magnetic resonance Imaging (MRI) with contrast
  • Allows for high resolution evaluation of the endometrial cavity and myometrium in multiple planes.

  • Allows for reliable assessment of other causes of bleeding such as fibroids, polyps, cervical and ovarian pathology.

  • Does not use ionizing radiation.

  • In a known diagnosis of uterine cancer, MRI reliably allows for assessment of myometrial and parametrial invasion.

  • Expensive

  • Time-consuming

  • Requires significant patient cooperation to minimize motion artifact

  • Cannot be performed in a select number of patients with pacemakers and other metallic non-titanium hardware or medical devices.

  • 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?

  • Severe cervical stenosis.

  • 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
  • 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.

  • Patients with GFR <30 cannot receive gadolinium intravenous contrast.