Utility of the relative apparent diffusion coefficient for preoperative assessment of low risk endometrial carcinoma

  • Yiqing Shen
    Department of Radiology, the First Affiliated Hospital of Chongqing, Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China
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  • Fajin Lv
    Corresponding author at: Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China.
    Department of Radiology, the First Affiliated Hospital of Chongqing, Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China
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  • Zhibo Xiao
    Department of Radiology, the First Affiliated Hospital of Chongqing, Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China
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  • Qiu Bi
    Department of Radiology, the First Affiliated Hospital of Chongqing, Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China
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      • We use rADC values in predicting patients with low risk EC for the first time.
      • meanADC, minADC and rADC were significantly higher in the low risk EC than they were in the intermediate-high risk EC.
      • rADC values yield the best diagnostic efficiency.
      • ADC values aid in the selection of treatment strategies of stage I EC.



      Lymphadenectomy is not recommended for low risk stage I endometrial carcinoma (EC) patients. This study was to investigate the predictive value of apparent diffusion coefficient (ADC) values in predicting patients with low risk EC, and to identify an optimum ADC measurement for preoperative assessment.

      Materials and methods

      Eighty-one patients with stage I EC who underwent diffusion-weighted imaging (DWI) at 1.5T were included and divided into low group and intermediate-high risk group based on the ESMO-ESGO-ESTRO classification. Clinical indexes, conventional MRI parameters, minimum ADC values (minADC), mean ADC values (meanADC) and relative ADC values (rADC) were compared between those two groups. rADC was calculated using the equation ADC (cancer)/ADC (reference) with the obturator internus muscle as reference. The optimal ADC measurement and cut-off ADC value for low risk EC were calculated using the receiver operating characteristic (ROC) curve.


      The low risk group had significantly higher meanADC, minADC, and rADC values than did the intermediate-high risk group (1.095 vs. 0.902 × 10−3 mm2/s, 0.755 vs. 0.657 × 10−3 mm2/s, 0.754 vs. 0.603, respectively). In assessments of low risk EC patients, the area under the curve (AUC) values for meanADC, minADC, and rADC were 0.840 (95%CI, 0.749,0.931), 0.681 (95% CI: 0.561,0.800), and 0.876(95% CI: 0.798,0.954), respectively. The optimal cut-off rADC value for prediction was 0.669, the maximum Youden index, sensitivity, specificity, and accuracy values were 0.683, 81.8%, 86.5%, and 84.0%, respectively.


      rADC is superior to minADC and meanADC for predicting patients with low risk EC, and could potentially aid to the surgical management of these patients in avoiding unnecessary lymphadenectomy.


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        • Morice P.
        • Leary A.
        • Creutzberg C.
        • et al.
        Endometrial cancer.
        Lancet. 2016; 387 ([00130-0]): S0140-6736(15)
        • Nayyar N.
        • Lakhwani P.
        • Goel A.
        • et al.
        The futility of systematic lymphadenectomy in early-stage low-grade endometrial cancer.
        Indian J Surg Oncol. 2018 Jun; 9: 204-210
        • Creasman W.T.
        • Odicino F.
        • Maisonneuve P.
        • et al.
        Carcinoma of the corpus uteri. FIGO 26th annual report on the results of treatment in gynecological cancer.
        Int J Gynaecol Obstet. 2006; 95: S105-S143
        • Colombo N.
        • Creutzberg C.
        • Amant F.
        • et al.
        ESMOESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up.
        Ann Oncol. 2016; 27: 16-41
        • Benedetti Panici P.
        • Basile S.
        • Maneschi F.
        • et al.
        Systematic pelvic lymph-adenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.
        J Natl Cancer Inst. 2008; 100: 1707-1716
        • Mariani A.
        • et al.
        Prospective assessment of lymphatic dissemination in endometrial 880 cancer: a paradigm shift in surgical staging.
        Gynecol Oncol. 2008; 109: 11-18
        • ASTEC study group, Kitchener H, Swart AM, et al.
        Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
        Lancet. 2009; 373: 125-136
        • Mariani A.
        • Webb M.J.
        • Keeney G.L.
        • Haddock M.G.
        • Calori G.
        • Podratz K.C.
        Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary ?.
        Am J Obstet Gynecol. 2000; 182: 1506-1519
        • Kang S.
        • Nam J.H.
        • Bae D.S.
        • Kim J.W.
        • Kim M.H.
        • Chen X.
        • et al.
        Preoperative assessment of lymph node metastasis in endometrial cancer: a Korean Gynecologic Oncology Group study.
        Cancer. 2017; 123: 263-272
        • Chino J.P.
        • Jones E.
        • Berchuck A.
        • Secord A.A.
        • Havrilesky L.J.
        The influence of radiation modality and lymph node dissection on survival in early-stage endometrial cancer.
        Int J Radiat Oncol Biol Phys. 2012; 82: 1872-1879
        • Jeong N.H.
        • Lee J.M.
        • Lee J.K.
        • Kim M.K.
        • Kim Y.J.
        • Cho C.H.
        • et al.
        Role of systematic lymphadenectomy and adjuvant radiation in early-stage endometrioid uterine cancer.
        Ann Surg Oncol. 2010; 17: 2951-2957
        • Kim H.S.
        • Suh D.H.
        • Kim M.K.
        • et al.
        Systematic lymphadenectomy for survival in patients with endometrial cancer: a meta-analysis.
        Jpn J Clin Oncol. 2012; 42: 405-412
        • McAlpine J.N.
        • Temkin S.M.
        • Mackay H.J.
        Endometrial cancer: not your grandmother's cancer.
        Cancer. 2016; 122: 2787-2798
        • Hidaka T.
        • Nakashima A.
        • Shima T.
        • et al.
        Systemic lymphadenectomy cannot be recommended for low-risk corpus cancer.
        Obstet Gynecol Int. 2010; 2010: 490219
      1. SGO Clinical Practice endometrial Cancer working group, burke WM, Orr J, et al. endometrial cancer: a review and current management strategies: part I. Gynecol Oncol 2014;134:385–392.

        • Hameeduddin A.
        • Sahdev A.
        Diffusion-weighted imaging and dynamic contrast- enhanced MRI in assessing response and recurrent disease in gynaecological malignancies.
        Cancer Imaging. 2015; 15: 3
        • Deng L.
        • Wang Q.P.
        • Yan R.
        • et al.
        The utility of measuring the apparent diffusion coefficient for peritumoral zone in assessing infiltration depth of endometrial cancer.
        Cancer Imaging. 2018; 03: 18-26
        • Das S.K.
        • Niu X.K.
        • Wang J.L.
        • Zeng L.C.
        • Wang W.X.
        • Bhetuwal A.
        • et al.
        Usefulness of DWI in preoperative assessment of deep myometrial invasion in patients with endometrial carcinoma: a systematic review and metaanalysis.
        Cancer Imaging. 2014; 14: 32
        • Yan B.
        • Zhao T.
        • Liang X.
        • et al.
        Can the apparent diffusion coefficient differentiate the grade of endometrioid adeno-carcinoma and the histological subtype of endometrial cancer?.
        Acta Radiol. 2018; 59: 363-370
        • Nougaret S.
        • Reinhold C.
        • Alsharif S.S.
        • et al.
        Combined MR volumetry and diffusion-weighted imaging for assessment of myometrial and lymphovascular invasion and tumor grade.
        Radiology. 2015; 276: 797-808
        • Kuwahara R.
        • Kido A.
        • Tanaka S.
        • et al.
        A predictor of tumor recurrence in patients with endometrial carcinoma after complete resection of the tumor, the role of pretreatment apparent diffusion coefficient.
        Int J Gynecol Cancer. 2018; 28: 861-868
        • Park S.O.
        • Kim J.K.
        • Kim K.A.
        • et al.
        Relative apparent diffusion coefficient: determination of reference site and validation of benefit for detecting metastatic lymph nodes in uterine cervical cancer.
        J Magn Reson Imaging. 2009; 29: 383-390
        • Itatani R.
        • Namimoto T.
        • Yoshimura A.
        • et al.
        Clinical utility of the normalized apparent diffusion coefficient for preoperative evaluation of the aggressiveness of prostate cancer.
        Jpn J Radiol. 2014; 32: 685-691
        • Haldorsen L.S.
        • Salvesen H.B.
        Staging of endometrial carcinomas with MRI using traditional and novel techniques.
        Clin Radiol. 2012; 67: 2-12
      2. Husby JA, Salvesen ØO, Magnussen IJ, et al. Tumour apparent diffusion coefficient is associated with depth of myometrial invasion and is negatively correlated to tumour volume in endometrial carcinomas.Clin Radiol 2015 May;70(5):487–94.

        • Higano S.
        • Yun X.
        • Kumabe T.
        • et al.
        Malignant astrocytic tumors: clinical importance of apparent diffusion coefficient in prediction of grade and prognosis.
        Radiology. 2006; 241: 839-846
        • Rudolph P.
        • Gloeckner K.
        • Parwaresch R.
        • et al.
        Immunophenotype, proliferation, DNA ploidy, and biological behavior of gastrointestinal stromal tumours: a multivariate clinicopathologic study.
        Hum Pathol. 1998; 29: 791-800
        • Kishimoto K.
        • Tajima S.
        • Maeda I.
        • et al.
        Endometrial cancer: correlation of apparent diffusion coefficient (ADC) with tumor cellularity and tumor grade.
        Acta Radiol. 2016; 57: 1021-1028
        • Bollineni V.R.
        • Kramer G.
        • Liu Y.
        • et al.
        A literature review of the association between diffusion -weighted MRI derived apparent diffusion coefficient and tumour aggressiveness in pelvic cancer.
        Cancer TreatRev. 2015 Jun; 41: 496-502
        • Inoue C.
        • Fujii S.
        • Kaneda S.
        • et al.
        Apparent diffusion coefficient (ADC) measurement in endometrial carcinoma: effect of region of interest methods on ADC values[J].
        J Magn Reson Imaging. 2014; 40: 157-161
        • Ma C.
        • Guo X.Y.
        • Liu L.
        • et al.
        Effect of region of interest size on ADC measurements in pancreatic adenocarcinoma.
        Cancer Imaging. 2017; 17: 13
        • Inoue C.
        • Fujii S.
        • Kaneda S.
        • et al.
        Correlation of apparent diffusion coefficient value with prognostic parameters of endometrioid carcinoma.
        J Magn Reson Imaging. 2015; 41: 213-219
        • Padhani A.R.
        • Liu G.
        • Koh D.M.
        • et al.
        Diffusion-weighted magnetic resonance imaging as a cancer biomarker: consensus and recom mendations.
        Neoplasia. 2009; 11: 102-125
        • Koc Z.
        • Erbay G.
        • Ulusan S.
        • Seydaoglu G.
        • Aka-Bolat F.
        Optimization of b value in diffusion- weighted MRI for characterization of benign and malignant gynecological lesions.
        J Magn Reson Imaging. 2012; 35: 650-659
        • Karakas O.
        • Karakas E.
        • Dogan F.
        • et al.
        Diffusion-weighted MRI in the differential diagnosis of uterine endometrial cavity tumors [J].
        Wien Klin Wochenschr. 2015; 127: 266-273