Diagnostic Accuracy Of Quantitative Diffusion And Perfusion MRI Parameters In Pre-Operative Staging Of Endometrial Cancer

Diagnostic Accuracy Of Quantitative Diffusion And Perfusion MRI Parameters In Pre-Operative Staging Of Endometrial Cancer | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 25 January 2025 V1 Latest version Share on Diagnostic Accuracy Of Quantitative Diffusion And Perfusion MRI Parameters In Pre-Operative Staging Of Endometrial Cancer Authors : Ruchika Mohan , Ritu Misra , Neha Bagri [email protected] , Archana Mishra , and Scahin Kolte Authors Info & Affiliations https://doi.org/10.22541/au.173779563.35675101/v1 272 views 143 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract PURPOSE : To determine the Diagnostic Accuracy of Quantitative Diffusion and MR Perfusion parameters in characterising, staging and grading endometrial carcinoma (EC). MATERIALS AND METHOD : Diffusion and MR perfusion were performed on forty-five biopsy-proven patients of EC. The deep myometrial invasion (DMI), cervical stromal invasion (CSI) and lymph node metastasis (LNM) were assessed on T2WI. The quantitative diffusion (apparent diffusion coefficient ADC) and perfusion parameters (Ktrans, Kep, Ve, Vp, SImax, SIrel and TTP) were derived. The diagnostic accuracy of these parameters in the characterisation, staging and grading of EC was determined along with their validation with histological type, grading, and stage. Their relationship with type of inflammatory infiltrate and MVD (Micro-vessel density) using CD34 on histopathology was also studied. RESULTS : The ADC and perfusion parameters, Ktrans and Ve, showed significant results (p-value <0.05) for the characterization of tumour type (Endometroid vs non-endometroid), grade (Low grade vs High grade) and FIGO stage. There was substantial agreement between T2WI and HPE for DMI with a sensitivity and specificity of 96.6 % and 68.8 %, respectively. For CSI, sensitivity and specificity were 76.5 % and 85.7 %; for LNM, sensitivity and specificity were 82.4 % and 96.5 % respectively. There was a moderate negative correlation between Ktrans and MVD (Spearman correlation coefficient: 0.48 and p-value <0.001). CONCLUSION : Quantitative Diffusion and MR Perfusion parameters have a significant role in the characterization of EC in terms of histological type, grade and FIGO stage (taking into account DMI, CSI and LNM) on histopathology. TITLE: Diagnostic Accuracy Of Quantitative Diffusion And Perfusion MRI Parameters In Pre-Operative Staging Of Endometrial Cancer PURPOSE : To determine the Diagnostic Accuracy of Quantitative Diffusion and MR Perfusion parameters in characterising, staging and grading endometrial carcinoma (EC). MATERIALS AND METHOD : Diffusion and MR perfusion were performed on forty-five biopsy-proven patients of EC. The deep myometrial invasion (DMI), cervical stromal invasion (CSI) and lymph node metastasis (LNM) were assessed on T2WI. The quantitative diffusion (apparent diffusion coefficient ADC) and perfusion parameters (Ktrans, Kep, Ve, Vp, SImax, SIrel and TTP) were derived. The diagnostic accuracy of these parameters in the characterisation, staging and grading of EC was determined along with their validation with histological type, grading, and stage. Their relationship with type of inflammatory infiltrate and MVD (Micro-vessel density) using CD34 on histopathology was also studied. RESULTS : The ADC and perfusion parameters, Ktrans and Ve, showed significant results (p-value <0.05) for the characterization of tumour type (Endometroid vs non-endometroid), grade (Low grade vs High grade) and FIGO stage. There was substantial agreement between T2WI and HPE for DMI with a sensitivity and specificity of 96.6 % and 68.8 %, respectively. For CSI, sensitivity and specificity were 76.5 % and 85.7 %; for LNM, sensitivity and specificity were 82.4 % and 96.5 % respectively. There was a moderate negative correlation between Ktrans and MVD (Spearman correlation coefficient: 0.48 and p-value <0.001). CONCLUSION : Quantitative Diffusion and MR Perfusion parameters have a significant role in the characterization of EC in terms of histological type, grade and FIGO stage (taking into account DMI, CSI and LNM) on histopathology. KEYWORDS: Diffusion, MR Perfusion, Endometrial Carcinoma, Myometrial, Lymph Node INTRODUCTION Uterine cancer is the second most common gynaecological malignancy worldwide; cervical cancer being the most common. [1] More than 90% of uterine cancers are endometrial, originating in the epithelium; majority of the remainder being mesenchymal. [2] Well known risk factors for the occurrence of Endometrial Carcinoma (EC) include nulliparity, obesity, diabetes, unopposed oestrogen intake, Lynch syndrome, Stein–Leventhal syndrome and tamoxifen therapy. [3] Although surgical staging is done for EC, knowledge about the locoregional spread and extrauterine extent prior to surgery is important to optimise treatment planning. This has been made possible by non-invasive diagnostic imaging modalities including Ultrasound (US), Computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), and nowadays, co-registered imaging technologies like PET-CT or PET-MRI. A pelvic US usually serves as a first and baseline imaging tool. An endometrial thickness (ET) of more than 4 mm in a postmenopausal female is suspicious and should be sampled. [4] For assessing deep myometrial invasion, the sensitivity and specificity of transvaginal US (TVUS) are 69% and 70% respectively, however, limited field of view is a limitation. [3] CT scan is not used routinely for local staging of EC due to less sensitivity (40-83%) and specificity (42-75%) as compared to MRI. [5] Presently CT scan is used for detecting lymph nodal and distant metastasis in advanced-stage disease. Fluorine-18 fluorodeoxyglucose (18F-FDG) PET scan has a definitive role in detection of distant metastasis with a sensitivity and specificity of 100% and 94% respectively. [6] MRI has an excellent soft-tissue delineating ability and hence, is considered the most appropriate imaging tool for local staging of EC with a diagnostic accuracy of 83‑92%. [3,7] MRI is best to assess the depth of myometrial invasion and cervical involvement which correlates well with the stage & grade of tumour, presence of lymph node (LN) metastases and overall patient survival rates. [8] In recent years, a number of functional MRI techniques have developed, like diffusion-weighted imaging (DWI), MR spectroscopy and Dynamic contrast-enhanced (DCE) MRI. Lately, DWI has become a part of the standard imaging protocols for female pelvis. [9] EC appears hyperintense on high b-values and hypointense on Apparent Diffusion Coefficient (ADC) maps as compared to the normal endometrium due to restricted diffusion in malignant cells. [10] Another functional imaging technique to assess changes at the microstructural level; like tissue oxygenation and perfusion in tumour is DCE-MRI or MR Perfusion. [11] The benefit of MR Perfusion is that it can help in predicting aggressiveness and even the probability of recurrence of EC. [7] Also, the quantitative parameters which reflect tissue vascularity help discriminate malignant masses from benign ones. [12] Thus, it is obligatory to validate this information with histopathological (HPE) outcomes. The current literature shows that how functional imaging protocols combined with conventional imaging, have the ability to define the extent and aggressiveness of EC and help the clinician in treatment planning. However, there is still a paucity of data to standardise these parameters for pre-operative stratification. Thus, the present study is an attempt to identify the role of quantitative DWI and Perfusion MR parameters and their correlation with HPE prognostic factors, which would aid in evaluating the tumour aggressiveness preoperatively and add to the little available data in this arena. MATERIALS AND METHODS The current prospective, observational, cross-sectional study was carried out in the Department of Radio-diagnosis in collaboration with the Departments of Obstetrics and Gynaecology and Pathology, VMMC and Safdarjung Hospital, New Delhi, India. Informed consent was obtained from all the patients. Ethical approval was obtained (IEC/VMMC/SJH/Thesis/06/2022/CC-274). Forty-five patients with biopsy-proven endometrial cancer underwent MRI (DWI and Perfusion). ADC values and Perfusion MR parameters were derived and their statistical correlation with HPE prognostic factors was performed . Patients who were not operated upon or failed to undergo surgery, who received neoadjuvant chemo or radiotherapy treatment or having severe respiratory, cardiac disease, or renal disease were excluded from the study. Image Acquisition : The patient was imaged in the supine position using 16 channels pelvic-phased array coil on 3 Tesla MRI scanner (General Electric Discovery MR 750 W). 20 mg buscopan was injected intravenously to suppress bowel peristalsis and a partially filled urinary bladder was preferred to improve visualisation of the pelvic organs. The scanning area included whole pelvis and the acquisition parameters included Sagittal T2W TR/TE: 10543/109.2, Flip Angle 160º, Slice thickness 5mm, Interslice gap 6mm, matrix 512x512 mm; Axial T2W TR/TE: 9247/106.8, Flip Angle 160º, Slice thickness 5mm, Interslice gap 7mm, matrix 512x512 mm; Coronal T2W TR/TE: 14760/109.9, Flip Angle 160º, Slice thickness 5mm, Interslice gap 6.5mm, matrix 512x512 mm; Axial T1W TR/TE: 635/7.2, Flip Angle 111º, Slice thickness 5mm, Interslice gap 7mm, matrix 512x512 mm. The focussed DWI was obtained in para-axial planes and wide FOV DWI of the pelvis in axial planes. Diffusion was acquired by applying b values of 0 & 600 for Focus DWI and 0 & 800 for wide FOV DWI of the pelvis. MRI perfusion was done using Gadolinium-based iv contrast given at a dose of 0.2 ml per kg body weight using a power injector at a rate of 2 ml/s, followed by 20ml of normal saline to flush the tubing. MR perfusion images from the uterine fundus to the vulva based on the findings of the initial non-enhanced sequence was acquired. DCE images were obtained sequentially every 8 s beginning 12 s (first phase) before the bolus injection. A total of 32 sequential slices were taken with no interslice gap, Rapid acquisition (every 8 s) were performed for 32 consecutive phases with a total time sequence of 256 seconds (8 seconds for every 32 phases). Finally, delayed enhanced axial, sagittal, and coronal T1-fat saturated images with breath-hold was obtained 5 minutes after injection. MRI Image Analysis: The T2WI were studied to assess deep myometrial invasion (DMI), cervical stromal invasion (CSI) and lymph node metastasis (LNM). (Figure 1) DMI was defined as a tumour involving 50% or more of the myometrial thickness. CSI as disruption of hypointense cervical stroma by the tumour. LNM was based on size criteria with a short-axis diameter of more than 8 mm in pelvic nodes and 10 mm in para-aortic nodes along with other features like round shape, irregular margins and heterogeneous enhancement. [37] ADC maps were calculated on a pixel-by-pixel basis and the central slice that would manifest the largest part of the tumor was selected, regions of interest (ROIs) of at least 10 mm 2 were placed in the solid part of the tumor, excluding necrotic areas, with the aid of the corresponding T2WI. The ADC value of adjacent normal myometrium was used as a reference. Three readings were taken and the mean ADC value was calculated in (x 10 -3 ) mm 2 /sec. Pharmacokinetic Analysis: Ktrans maps with appropriate colour coding were created from the MR Perfusion. The time-intensity curves (TIC) of specific regions were generated with a highlight on the brightest red foci (area of maximum enhancement) on the Ktrans map. ROI was copied to the corresponding Kep, Ve, and Vp maps automatically. The mean value of every perfusion parameter for each ROI was generated. (Figure 2) The quantitative MR perfusion parameters included Ktrans: the volume transfer constant from blood plasma to extravascular extracellular space (EES), Kep: the rate constant from EES to plasma, Ve: the volume of EES per unit volume of tissue and Vp: the fraction of plasma volume. The semiquantitative parameters were SImax: maximum signal intensity over the time course of the enhancement curve, SIrel: (SImax-SI 0 )/ SI 0 ×100 and TTP: Time-to-peak. Within a month following the MRI examination, surgical intervention was carried out and each of the sample was reviewed by an experienced pathologist. A thorough histological assessment was conducted, encompassing Histological type, Grade, FIGO Stage, presence or absence of DMI, CSI, LNM, type of tumor associated inflammatory infiltrate and MVD using CD34. MVD was assessed in five FOVs, under a magnification of 400x. Mean value of five most vascularised FOVs (“Hot spots”) was considered as MVD. Positive patterns on slides included CD34 stained structures, showing lumens (fully formed vessels) and cluster of stained cells not forming lumens. Statistical Analysis: Data was coded and recorded in MS Excel spreadsheet program (SPSS v23 (IBM Corp.) Group comparisons for continuously distributed data were made using independent sample ‘t’ test. If data were found to be non-normally distributed, appropriate non-parametric Wilcoxon Test was used. Linear correlation between two continuous variables was explored using Pearson’s correlation (if the data were normally distributed) and Spearman’s correlation (for non-normally distributed data). Sensitivity Specificity, PPV, NPV and Diagnostic accuracy were calculated for assessing the diagnostic performance of predictors, by making a 2x2 cross-table with the outcome. A p value of <0.05 was considered statistically significant. The quantitative diffusion and perfusion data was first subjected to tests of normality, then tested for association with histopathological variables, and finally, subjected to the receiver-operator characteristic (ROC) curve analysis, thus obtaining deterministic cut-off values for prediction of tumor aggressiveness in terms of histological type, grade and stage of tumor. RESULTS The study comprised forty-five patients with biopsy proven EC, of which forty had endometroid and five had non-endometroid carcinoma. Sixteen patients belonged to 61-70 years age group and the mean age was 58.4 ± 10.3 yrs. Majority of the patients were FIGO Stage IIIC (33.3%), followed by Stage IA (26.7%). As a result of false positives and negatives, MRI FIGO stage was incorrectly diagnosed in 25 % patients in Group Ib, 37.5 % patients in FIGO II and 6.7 % patients in FIGO IIIc. Thus, the overall diagnostic accuracy of MRI for FIGO stage was 84.4%. On T2WI, 33 patients had DMI, 17 had CSI and 15 had LNM which was in close agreement with HPE findings (p-value < 0.001). This substantial agreement between the two methods (T2WI and HPE) for assessment of DMI has a sensitivity and specificity of 96.6 % and 68.8 % respectively. For CSI, sensitivity and specificity was 76.5 % and 85.7 % respectively and for LNM, sensitivity was 82.4 % and specificity was 96.5 %. The mean ADC value of EC was significantly low ( 0.77 x 10 -3 mm²/s ) vs reference myometrium ( 1.06 x 10 -3 mm²/s). A significant association was found between the histological type (endometrioid vs non-endometrioid) and mean ADC value (0.78 ± 0.09 vs 0.67 ± 0.09 x 10 -3 /mm 2 ) (p-value 0.036); histopathological grade (low grade vs high grade) and mean ADC value (0.80 ± 0.08 vs 0.68 ± 0.07 x 10 -3 /mm 2 ) (p-value <0.001) and FIGO stage and mean ADC value (p value of 0.03). Other variables which were significantly associated with the mean ADC of tumor include DMI, CSI and lympho-vascular space invasion on HPE. Among quantitative MR perfusion parameters, Ktrans and Ve showed statistically significant results for characterization of histological type, grade and FIGO stage. Higher values were associated with endometrioid type (Ktrans: 0.61 ± 0.22 mL/min/100mL; Ve: 0.69 ± 0.12 mL) and lower values with non-endometrioid type (Ktrans: 0.36 ± 0.10 mL/min/100mL; Ve: 0.52 ± 0.07 mL). With a cut-off value of 0.604, the diagnostic accuracy of Ve in predicting histological type was higher (84%), with a sensitivity and specificity of 82% and 100% respectively. A notable association of Ktrans and Ve was found with the histological grade (p-values 0.004 and <0.001, respectively). Specifically, higher values were observed in more differentiated low-grade tumors (Ktrans: 0.65 ± 0.23 mL/min/100mL; Ve: 0.73 ± 0.11 mL), in contrast to lower values in high grade tumors (Ktrans: 0.44 ± 0.11 mL/min/100mL; Ve: 0.55 ± 0.07 mL). At a cut-off of Ktrans ≤ 0.604, it could predict high histological grade with a sensitivity of 100%, and a specificity of 55%.(Table 1) Best quantitative parameter in terms of AUROC for predicting grade was Ve at a cut-off ≤ 0.661, with a sensitivity and specificity of 100% and 81% respectively. (Table 2, Figure 3) There was significant association between Ktrans and Ve with FIGO stage on HPE (p-value 0.017 and 0.006 respectively) showing a decrease with increase in FIGO stage. At a cut-off of Ktrans ≤ 0.59, it could predict DMI with a sensitivity of 72%, and a specificity of 75%. At a cut-off of ≤ 0.63 Ve had 55% sensitivity and 94% specificity to predict the same. (Figure 4) Kep and Vp were not significantly associated with these HPE outcomes. Among the semi-quantitative analysis, significantly lower values of SI max and SI rel, with higher values of TTP were seen in tumor, as compared to the normal myometrium (p value <0.01). Among these parameters, the diagnostic performance of SI max was best in predicting the tumor vs normal myometrium with a diagnostic accuracy of 90 % and sensitivity and specificity of 84 % and 96 % respectively. However, a significant correlation between semi-quantitative parameters and HPE outcomes could not be established. The mean MVD of the tumor was 4.90 ± 1.94. Among all, 60% patients had Lymphocytic inflammatory infiltrate and 40% had neutrophilic infiltrate. MVD was also found to be significantly associated with tumor mean ADC, Ktrans, Ve, histological type, grade, FIGO Stage, DMI, CSI and LNM on HPE (p<0.05). A moderate negative correlation was observed between Ktrans and MVD, with a Spearman correlation coefficient of -0.48 and a p-value <0.001. Inflammatory infiltrate was significantly associated with FIGO Stage and CSI on HPE. Largely, Ve was the best MR perfusion parameter for predicting the histological type and grade of tumor with diagnostic accuracy of 84% and 87% respectively. All-inclusive, conventional T2WI, DWI and MR Perfusion (Ktrans and Ve) performed significantly well, in substantial agreement with the histopathological outcomes of EC. DISCUSSION To study the biological behaviour of tumor at cellular level, various modalities have been employed till date, such as Doppler US, contrast-enhanced CT, CT perfusion, and contrast-enhanced ultrasound. However, each modality has its own set of limitations, and a standardized approach has not yet been established. DCE-MRI provides in-vivo representation of tumor behaviour at a microscopic level due to gadolinium leakage from the intravascular compartment to the EES.[13] As tumours grow in size, they require more oxygen due to increased cellular density, inducing neo-angiogenesis with leaky and tortuous vessels, thus, contributing to tumor hypoxia. [14] With the advent of DWI and MR Perfusion, the analysis of tumoral neo-angiogenesis is possible, which helps in predicting the tumor aggressiveness and likely HPE outcomes. [7] The key sequence for staging EC on MRI is T2WI, which was supplemented with DWI and MR Perfusion in the present study. On comparing the T2WI with HPE, substantial agreement was found between the two methods for the assessment of DMI. Five cases were falsely reported as positive for DMI, while only one case was false negative. The false positive results might be due to endometrial polypoidal mass compressing the normal myometrium, presence of leiomyomas or adenomyosis and thinning of myometrium in post-menopausal women. Overall diagnostic accuracy of T2WI for identifying CSI was 82.2 % with false positive results in four cases. The likely reason might be isolated involvement of cervical mucosa over-diagnosed as stromal invasion. Three cases were reported falsely negative for lymph node metastasis, likely due to presence of micro-metastases in morphologically normal nodes. These findings are in accordance with Song et al. who found sensitivity of T2WI to be 85% for qualitative diagnosis of EC. They also suggested that while evaluating tumor size, dimensions observed on T2WI corresponded with the actual tumor size. [15] Another study with concordant results was by Shatat et al, using fused T2WI-DWI to evaluate the depth of myometrial invasion, with a sensitivity and specificity of 90% and 94.9% respectively. [10] Similar results were also found by Hori et al. who reported a 60-80% sensitivity of MRI to distinguish superficial and deep myometrial invasion. [16] In the present study, the presence of DMI, CSI, histological type, grade and FIGO stage were significantly associated with tumor mean ADC. Satta et al. conducted a similar study on DW-MRI parameters to assess pre-operative aggressiveness of EC and found similar results, with lower mean ADC values in non-endometrioid histological type and higher tumor grade. [7] Comparable results were also found by Muzio et al. with notably lower, average and lowest ADC values (ADC mean and ADC min ) in grade 2 and grade 3 endometrial tumors compared to those with grade 1 lesions. [24] High grade poorly differentiated tumors exhibit higher cellular density, leading to more constrained movement of water molecules. Thus, tumors with aggressive features, such as non-endometrioid subtype, high grade (grade III) and higher FIGO stage have more restricted dynamics, and hence typically have lower ADC values as compared to non-aggressive tumors. MR perfusion allows quantification of vascular biomarkers like blood volume flow, permeability and properties related to wash in and wash out by calculation of Ktrans, Kep, Ve and Vp. [12,25] In the present study, Perfusion MR parameters Ktrans and Ve showed a statistically significant correlation with histological type of the tumor and higher values in endometrioid as compared to non-endometrioid type. Similar higher values of Ktrans (0.52 ± 0.31 mL/min/100mL) and Ve (0.28 ± 0.15 mL) were also found by Satta et al in the endometroid group, however, these were not statistically significant.[7] In the present study, higher values of Ktrans and Ve were observed in low-grade tumors. Similar results were reported by Satta et al., with higher values of Ktrans and Ve in Grade1-2 tumors (Ktrans: 0.55±0.31; Ve: 0.31±0.13) and lower values of Ktrans and Ve being associated with Grade-3 tumours (Ktrans: 0.32±0.25; Ve: 0.18±0.09) (p values 0.01 and comparable results with lower values of Ktrans, Kep and Vp in high-risk endometrial cancer. [17] In contrast to the present study results, Satta et al. did not find any significant correlation between MR perfusion and FIGO stage.[7] Overall, these findings, can be explained on the basis of microstructural dynamics as more aggressive tumors with higher cellular density result in lower Ktrans and Ve, which represent reduced volume of extracellular space into which the contrast will leak from the capillaries. To our knowledge, no studies have been published till date to indicate a significant correlation between semi-quantitative parameters and HPE outcomes in EC. However, we found a significant association, while comparing these parameters in tumor with the normal myometrium (p value < 0.001). In accordance, Ippolito et al. suggested that neoplastic lesions display lower values of relative enhancement (64.57% vs 53.39%), maximum enhancement (889.67% vs 1817.01%) and mean relative enhancement (77.60% vs 159.89%). Slower enhancement process in neoplastic tissue as compared to normal myometrium was indicated by higher TTP in endometrial cancer than the normal myometrium. [18] The present study also revealed a statistically significant correlation between Ktrans, Ve and MVD of the tumor. Our results contradict with a study by Lyndin et al., who reported an average MVD of 19.2 ±7.5 in endometroid adenocarcinomas and more aggressive larger tumours having higher MVD. [19] This could be due to differences in methodology, as Lyndin et al calculated MVD by examining the slides at a magnification of 200x, whereas we utilized a higher magnification of 400x. Furthermore, variations in microscopes, aperture settings, and the experience of pathologists may contribute to such discrepancies. This study stands out as one of the pioneering investigations to integrate Quantitative DWI and MR Perfusion in patients with endometrial cancer, effectively correlating these parameters with histological outcomes, widely regarded as the gold standard. Furthermore, it established a connection between MR Perfusion and tumor MVD, indirectly shedding light on tumor aggressiveness and patient prognosis. Additionally, the study determined cut-off values of MR Perfusion parameters to predict histological outcomes, enhancing the strength of its findings. However, few limitations do exist, as it was a single-center study on a limited number of patients. The assessment of semi-quantitative parameters relied on the analysis of TIC, which are subjected to inter-observer variations between acquisition systems and their reproducibility is poor. The calculation of MVD was based on biopsy samples, not representing the entire tumor, along with potential mismatches between imaging planes and histologic sections, thus, affecting the correlation between perfusion parameters and MVD. Lastly, the tumor genomic characterization was not included due to resource limited settings. Multi-centre studies with larger cohorts of participants are needed to standardize our results and establish definitive cut-offs for perfusion parameters in predicting tumor aggressiveness. Integration of Tumor genomic characterization in histological assessment can provide comprehensive insights. Additionally, longitudinal studies with patient follow-ups could be conducted in the future to track patient outcomes and assess prognostic implications. CONCLUSION Quantitative DWI and MR Perfusion parameters have a significant role in the characterization of Endometrial Carcinoma in terms of histological type, grade and FIGO stage. The present study shows that most important pre-operative prognostic factors for EC can adequately be predicted pre-operatively, using quantitative DWI and MR Perfusion parameters, thus, enabling informed decision-making in the best interest of patient. Conflict of interests The authors declare no conflict of interest. Funding This research did not receive any financial grant from funding agencies in the public or commercial sectors. REFERENCES 1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA A Cancer J Clin. 2021 May;71(3):209–49. 2. Uterine Cancer [Internet]. ACSO; 02/2022. Available from: https://www.cancer.net/cancer-types/uterine-cancer/statistics. 3. 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Endometrial carcinoma: use of tracer kinetic modeling of dynamic contrast-enhanced MRI for preoperative risk assessment. Cancer Imaging. 2022 Mar 9;22(1):14. 18. Ippolito D, Cadonici A, Bonaffini PA, Minutolo O, Casiraghi A, Perego P, et al. Semiquantitative perfusion combined with diffusion-weighted MR imaging in pre-operative evaluation of endometrial carcinoma: results in a group of 57 patients. Magn Reson Imaging. 2014;32(5):464–72. 19. Lуndіn M, Kravtsova O, Sikora K, Lуndіna Y, Sikora Y, Awuah WA, et al. Relationship of microvascular density on histological and immunohistochemical features in endometrioid adenocarcinomas of the uterus: experimental study. Ann Med Surg (Lond). 2023;85(7):3461–8. LEGENDS FIGURE 1: 66-yrs-old female with biopsy proven EC. (A) Axial T2WI showing lobulated hyperintense endometrial mass with <50% myometrial invasion. (B) ADC value 0.63 x 10 -3 mm 2 /sec (C) MR Perfusion showing Ktrans: 0.416, Ve: 0.467, Kep: 1.18, Vp:0.0522 (D) High power (400x) H&E image showing low grade (Grade 1) EC on post-operative HPE (E) High power (400x) FOV showing MVD (CD34) as low vascularisation. FIGURE 2: 70-yrs-old female with biopsy proven EC. (A) Axial T2WI showing lobulated hyperintense endometrial mass with 10 -3 mm 2 /sec (C) MR Perfusion showing Ktrans: 0.867, Ve: 0.501, Kep: 1.675, Vp:0.01 (D) High power (400x) H&E image showing low grade (Grade 2) EC on post-operative HPE (E) High power (400x) FOV showing MVD (CD34) as low vascularisation. FIGURE 3: ROC Curves of Ktrans and Ve in predicting histological type and grade FIGURE 4: ROC Curves of Ktrans and Ve in predicting Deep Myometrial & Cervical Stromal Invasion TABLE 1: Diagnostic Performance of MR Perfusion Quantitative Parameter: Ktrans in Predicting HPE Outcomes TABLE 2: Diagnostic Performance of MR Perfusion Quantitative Parameter: Ve in Predicting HPE Outcomes Supplementary Material File (tables.docx) Download 14.62 KB File (title page_1.docx) Download 18.90 KB File (title page_2.docx) Download 18.90 KB Information & Authors Information Version history V1 Version 1 25 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords carcinoma of the endometrium: basic science carcinoma of the endometrium: diagnosis gynaecological oncology gynaecology: diagnostic imaging radiological imaging: magnetic resonance scan Authors Affiliations Ruchika Mohan Vardhman Mahavir Medical College and Safdarjung Hospital View all articles by this author Ritu Misra Vardhman Mahavir Medical College and Safdarjung Hospital View all articles by this author Neha Bagri [email protected] Vardhman Mahavir Medical College and Safdarjung Hospital View all articles by this author Archana Mishra Vardhman Mahavir Medical College and Safdarjung Hospital View all articles by this author Scahin Kolte Vardhman Mahavir Medical College and Safdarjung Hospital View all articles by this author Metrics & Citations Metrics Article Usage 272 views 143 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Ruchika Mohan, Ritu Misra, Neha Bagri, et al. Diagnostic Accuracy Of Quantitative Diffusion And Perfusion MRI Parameters In Pre-Operative Staging Of Endometrial Cancer. Authorea . 25 January 2025. DOI: https://doi.org/10.22541/au.173779563.35675101/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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