Improved differentiation between stage I-II endometrial carcinoma and endometrial polyp with combination of APTw and IVIM MR imaging

Endometrial carcinoma (EC) is one of the most common types of cancer in the uterus, while endometrial polyp (EP) is a type of benign lesion of the uterus. The clinical manifestations were generally similar between the stage I-II EC and EP patients. EP patients were treated by hysteroscopy, while EC patients were mainly treated by surgery [1,2]. Endometrial curettage is a common method for clinical diagnosis of endometrial lesions, but it is easy to cause trauma and patients' acceptance is not high. Therefore, it is very important to adopt effective means of preoperative examination, preferably noninvasive, in order to differentiate these two kinds of diseases. Magnetic resonance imaging (MRI) with non-invasive and multiple contrasts can reveal the anatomical structure of the uterus with high accuracy, and has become one of the most common methods in diagnosis of pelvic gynecological diseases [3,4].

T2WI is helpful to display the anatomical structure of the lesion, but it cannot be quantitatively analyzed. Diffusion weighted imaging (DWI) can reflect the microscopic movement of intracellular and extracellular water molecules, and it has been widely used in differential diagnosis between stage I-II EC and EP where the conventional MRI show less efficacy [5]. However, the apparent diffusion coefficient (ADC) measured by DWI from the single exponential model is proved to be less reliable in some circumstances because of the complex movement of water molecules in human tissues and the influence of macromolecules, cell membrane, histomorphological changes and other factors [6]. Intra-voxel incoherent motion (IVIM) imaging is a novel MR method using a biexponential model with consideration of contribution from both the free movement of tissue water molecules and blood perfusion in microcirculation [6]. Compared with conventional DWI, IVIM enables quantification of the pure diffusion movement of water molecules in endometrial lesions, as well as microcirculation perfusion and other information, suggesting more comprehensive reflection of the pathophysiological state of the endometrium [7,8].

Amide proton transfer weighted (APTw) imaging, which indirectly detect the intracellular concentration of free proteins and peptides through the chemical exchange between amide and water protons, can help evaluate the cellular proliferative activity from a more metabolic perspective [9]. APTw imaging has recently been widely investigated in examination of the central nervous system diseases, such as brain tumor grading [10], Parkinson's disease [11], acute cerebral infarction [12], etc., with its application in female pelvic system still in infancy. In previous studies, Meng et al. [13] have used APTw imaging to identify and grade cervical squamous cell carcinoma and adenocarcinoma. Zhang et al. [14] have used the APTw technique to investigate changes of APT value in the endometrium, myometrium and junction area in healthy young women at different time periods of the menstrual cycle.

Recent studies have applied APTw and IVIM imaging respectively in diagnosing female pelvic system diseases including cervical carcinoma and endometrial carcinoma [7,9]. Combination of these two methods have been preliminarily reported in the diagnosis of cervical squamous cell carcinoma, and the study found that APT may show a better performance than IVIM-derived parameters in predicting cervical squamous cell carcinoma differentiation [15]. To our knowledge, there is no study using combinational APTw and IVIM imaging for differential diagnosis between benign and malignant uterine mucosal lesions. Herein, the value of APTw combined with IVIM imaging in differential diagnosis of stage I-II EC and EP was assessed.

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