Pathological characteristics and risk stratification in patients with stage I endometrial cancer: utility of apparent diffusion coefficient histogram analysis

Abstract

Objectives: Accurate pre-operative prediction of risk stratification using a non-invasive imaging tool is clinically important for planning optimal treatment strategies, particularly in early-stage endometrial cancer (EC). This study aimed to investigate the utility of apparent diffusion coefficient (ADC) histogram analysis in evaluating the pathological characteristics and risk stratification in patients with Stage I EC. Methods: Between October 2009 and December 2014, a total of 108 patients with surgically proven Stage I EC (endometrioid type = 91; non-endometrioid type = 17) excluding stage ≥II that underwent preoperative 3T-diffusion-weighted imaging without administration of contrast medium were enrolled in this retrospective study. Risk stratification was divided into four risk categories based on the ESMO-ESGO-ESTRO Guidelines: low, intermediate, high-intermediate, and high risk. The ADC histogram parameters (minimum, mean [ADCmean], 10th–90th percentile, and maximum [ADCmax]) of the tumor were generated using an in-house software. The ADC histogram parameters were compared between patients with endometrioid type and non-endometrioid type, between Stage IA and IB, between histological grades, and evaluated for differentiating non-high risk group from high risk group. Inter-reader agreement for tumor ADC measurements was also evaluated. Statistical analyses were performed using the Student’s t-test, Mann–Whitney U test, receiver operating characteristics (ROC) analysis, or intraclass correlation coefficient (ICC). Results: In differentiating endometrioid type from non-endometrioid type EC, all ADC histogram parameters were statistically significant (p < 0.05). In differentiating histological grades, 90th percentile ADC and ADCmax showed significantly higher values in tumor Grade III than in tumor Grade I-II (p < 0.05). In differentiating superficial myometrial invasion from deep myometrial invasion, all ADC histogram parameters were statistically significant (p < 0.05), except ADCmax. In differentiating non-high risk group from high risk group, ADCmean, 75th–90th percentile ADC, and ADCmax were statistically significant (p < 0.05). For predicting the high risk group, the area under the ROC curve of ADCmax was 0.628 and the highest among other histogram parameters. All histogram parameters revealed moderate to good inter-reader reliability (ICC = 0.581‒0.769). Conclusion: The ADC histogram analysis as reproducible tool may be useful for evaluating the pathological characteristics and risk stratification in patients with early-stage EC. Advances in knowledge: ADC histogram analysis may be useful for evaluating risk stratification in early-stage endometrial cancer patients.

Evaluation of Amide Proton Transfer-Weighted Imaging for Risk Factors in Stage I Endometrial Cancer: A Comparison With Diffusion-Weighted Imaging and Diffusion Kurtosis Imaging

“…The study of An et al. showed that the ADC histogram was conducive to the evaluation of stage I EC histological subtype, grade, FIGO stage, and even risk stratification ( 18 ). Meng et al.…”

“…The new ESMO clinical practice guidelines were used to assess the risk stratification, and eventually, all included participants were classified into four groups: low, intermediate, high-intermediate, and high risk ( 3 ). Then, the low-risk stage I EC patients were categorized into the low-risk group and the intermediate, high-intermediate, and high-risk stage I EC patients, who are usually considered to have undergone lymphadenectomy, were categorized into the non-low-risk group ( 18 ).…”

“…A few studies have briefly reported the role of these techniques in stage I EC risk stratification ( 18 , 19 ). However, these studies either explored the application of only a single imaging technique or assessed only risk stratification without evaluating the risk stratification factors.…”

Whole‐tumor apparent diffusion coefficient histogram analysis for preoperative risk stratification in endometrial endometrioid adenocarcinoma

“…Multiple ADC values showed a decreasing tendency from the low-to high-intermediate-risk EEAs, consistent with previous studies. 13,14,16,17 Contrarily, An et al 15 reported a significantly higher meanADC, maxADC, P75, and P90 ADCs in high-risk…”

“…Several studies have explored the utility of multiple models of DWI for predicting risk stratification in early-stage EC. [13][14][15][16][17] However, preoperative imaging cannot identify small lymph node metastasis, which makes it difficult to accurately determine the stages of EC before surgery. 18 Moreover, all these studies included non-EEAs, which are definite intermediate-or high-risk (absence or presence of myometrial invasion) according to the ESMO-ESTRO-ESP guidelines.…”