Endometrial cancer — staging

ESUR endometrial cancer guidelines with FIGO 2023

The measurement that drives management is depth of myometrial invasion, and it can only be made in a plane perpendicular to the endometrial cavity. Straight axial imaging systematically distorts it, so the vetting decision is as much about geometry as about contrast.

Histologically confirmed endometrial carcinoma, usually after biopsy for postmenopausal bleeding, requiring local staging before surgery.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

MRI Pelvis — endometrial cancer staging

MRI Pelvis (Gynaecological)

What we'd amend, and why

The junctional zone is a low-signal band on T2 and its interruption is what defines myometrial invasion, so the study lives or dies on T2 resolution and plane. An oblique-axial acquisition angled perpendicular to the endometrial cavity is the only geometry in which invasion depth is actually measurable; a straight axial plane cuts obliquely through the myometrium and systematically over- or under-states it. Diffusion in the same plane adds junctional-zone assessment where the T2 interface is equivocal, and the delayed post-contrast acquisition supplies the tumour-to-myometrium contrast that early images do not.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwaystandard — Adults — local staging
rulerule-mr-device-screening — MR safety screening for implants and foreign bodies; checked by Radiographer at the scanner
rulerule-contrast-reaction-premed — Prior contrast reaction and elective premedication; checked by Nurse before the scan
rulerule-gadolinium-renal — Kidney function and gadolinium-based contrast; checked by Radiographer at the scanner
rulerule-pregnancy-gadolinium — Gadolinium in known or possible pregnancy; checked by Radiographer at the scanner
rulerule-iv-access — Intravenous access adequate for the planned injection; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(2)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

MR safety screening for implants and foreign bodies
Complete the MR safety questionnaire, verify implant labelling and its stated conditions of use against this scanner and this protocol, and ensure no ferromagnetic object enters Zone IV.
Radiographer at the scannerBefore the scan
Flags back if: An implant or retained foreign body that is MR Unsafe, unlabelled, or cannot be identified; or an MR Conditional device whose stated conditions this scanner or the requested protocol cannot satisfy; or a credible unexcluded intraocular metallic foreign body history.
Intravenous access adequate for the planned injection
Site and test a cannula that supports the protocol flow rate, preferring an antecubital or large forearm vein, and observe the injection for extravasation. A 20-gauge or larger cannula is preferred for flow rates of 3 mL/s or more.
Radiographer at the scannerAt the scanner
Flags back if: No cannula can be sited that supports the protocol flow rate — for example only a 22-gauge hand or foot cannula for a CT angiogram needing 4–5 mL/s; or the only available access is a central line or port that is not labelled power-injectable; or an extravasation occurs.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Adults — local staging

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	MRI Pelvis (Gynaecological) MRI Pelvis — endometrial cancer staging usually appropriate	The junctional zone is a low-signal band on T2 and its interruption is what defines myometrial invasion, so the study lives or dies on T2 resolution and plane. An oblique-axial acquisition angled perpendicular to the endometrial cavity is the only geometry in which invasion depth is actually measurable; a straight axial plane cuts obliquely through the myometrium and systematically over- or under-states it. Diffusion in the same plane adds junctional-zone assessment where the T2 interface is equivocal, and the delayed post-contrast acquisition supplies the tumour-to-myometrium contrast that early images do not.
Second line	CT Abdomen and Pelvis CT Abdomen and Pelvis — Portal Venous Phase	For distant and nodal disease rather than local extent, and the alternative where MRI cannot be performed. It cannot resolve the junctional zone and therefore cannot stage myometrial invasion, which is the finding the surgical plan turns on.
Second line	CT Chest CT Chest — Contrast-Enhanced (Venous Phase)	Thoracic staging in high-grade or advanced disease, where pulmonary metastases would change treatment from primary surgery to systemic therapy.
Problem solving	FDG PET-CT FDG PET-CT — skull base to mid-thigh	Adds nodal and distant information in high-risk histology and in suspected recurrence, where a single equivocal node on CT would otherwise decide between surgery and chemoradiotherapy.

Pitfalls

Straight axial images instead of a plane perpendicular to the cavity, which distorts the measurement that decides the operation.
Using only an early post-contrast acquisition, when the discriminating tumour-to-myometrium contrast appears later.
Coverage stopping at the pelvis when nodal staging was the point of the request.
A markedly distended cavity or a large fibroid thinning the myometrium, producing an overcall of deep invasion.
Scanning without an antiperistaltic agent, so bowel motion degrades exactly the high-resolution T2 sequences the diagnosis depends on.

Priors — what to pull first

The biopsy histology and grade should be available before the scan — they determine whether para-aortic nodal coverage and thoracic imaging are needed.
Where fertility-sparing management is being considered, say so: the question becomes whether invasion is present at all rather than how deep it is.

What makes a good request

Imaging follows histology here. Ultrasound and biopsy establish the diagnosis; MRI stages it.
The discriminating post-contrast image for myometrial invasion is an equilibrium-type acquisition a couple of minutes after injection, when tumour-to-myometrium contrast is greatest — not the earliest post-contrast series.
Cervical stromal involvement changes the operation, and nodal staging requires superior coverage extended to the para-aortic station; a pelvis-only field of view answers half the question.
The 2023 FIGO revision incorporates molecular classification alongside anatomical extent, and current European guidance maps MRI findings onto that framework.

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

MRI Pelvis — endometrial cancer staging CT Abdomen and Pelvis — Portal Venous Phase CT Chest — Contrast-Enhanced (Venous Phase)FDG PET-CT — skull base to mid-thigh

Confirm locally

MRI Pelvis — endometrial cancer staging: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.