Pretreatment Evaluation and Follow-Up of Endometrial Cancer

Variant: 1 Initial staging of pretreatment endometrial cancer; assessment of local tumor extension for all tumor grades.

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without and with IV contrast	Usually Appropriate	O
US pelvis transvaginal	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT pelvis with IV contrast	May Be Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).

Procedure	Appropriateness Category	Relative Radiation Level
US pelvis transabdominal	May Be Appropriate	O
MRI abdomen without and with IV contrast	May Be Appropriate	O
MRI pelvis without and with IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT chest abdomen pelvis with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
US abdomen	Usually Not Appropriate	O
Lymphangiography pelvis	Usually Not Appropriate	☢☢☢
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without and with IV contrast	Usually Appropriate	O
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Appropriate	☢☢☢☢
US abdomen	May Be Appropriate	O
US pelvis transabdominal	May Be Appropriate	O
MRI abdomen without and with IV contrast	May Be Appropriate	O
MRI abdomen without IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT chest abdomen pelvis without IV contrast	May Be Appropriate	☢☢☢☢
Lymphangiography pelvis	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Not Appropriate	O
US pelvis transabdominal	Usually Not Appropriate	O
US pelvis transvaginal	Usually Not Appropriate	O
Radiography chest	Usually Not Appropriate	☢
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
MRI pelvis without IV contrast	Usually Not Appropriate	O
CT chest abdomen pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Surveillance of asymptomatic patients with treated high-risk endometrial cancer.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	May Be Appropriate	☢
CT chest abdomen pelvis with IV contrast	May Be Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	May Be Appropriate	☢☢☢☢
US abdomen	Usually Not Appropriate	O
US pelvis transabdominal	Usually Not Appropriate	O
US pelvis transvaginal	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
MRI pelvis without IV contrast	Usually Not Appropriate	O
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 6 Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast	Usually Appropriate	O
MRI pelvis without and with IV contrast	Usually Appropriate	O
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Appropriate	☢☢☢☢
US abdomen	May Be Appropriate	O
Radiography chest	May Be Appropriate	☢
MRI abdomen without IV contrast	May Be Appropriate	O
MRI pelvis without IV contrast	May Be Appropriate	O
CT chest abdomen pelvis without IV contrast	May Be Appropriate	☢☢☢☢
US pelvis transabdominal	Usually Not Appropriate	O
US pelvis transvaginal	Usually Not Appropriate	O
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Initial staging of pretreatment endometrial cancer; assessment of local tumor extension for all tumor grades.

Variant 1: Initial staging of pretreatment endometrial cancer; assessment of local tumor extension for all tumor grades.
A. CT Pelvis

Variant 1: Initial staging of pretreatment endometrial cancer; assessment of local tumor extension for all tumor grades.
B. MRI Pelvis

Variant 1: Initial staging of pretreatment endometrial cancer; assessment of local tumor extension for all tumor grades.
C. US Pelvis Transvaginal

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
A. CT Chest, Abdomen, and Pelvis

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
C. Lymphangiography Pelvis

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
D. MRI Pelvis

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
E. MRI Abdomen

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
F. US Pelvis Transabdominal

Variant 2: Pretreatment evaluation of endometrial cancer; assessment of lymph node and distant metastasis for low-grade tumor (Type I, grade 1, 2).
G. US Abdomen

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
A. CT Chest, Abdomen, and Pelvis

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
B. FDG-PET/CT Skull Base to Mid-Thigh

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
C. Lymphangiography Pelvis

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
D. MRI Pelvis

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
E. MRI Abdomen

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
F. US Pelvis Transabdominal

Variant 3: Initial staging of pretreatment endometrial cancer; assessment of lymph node and distant metastasis for high-grade tumor (Type I, grade 3 and Type II).
G. US Abdomen

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
A. MRI Pelvis

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
B. MRI Abdomen

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
C. CT Chest, Abdomen, and Pelvis

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
D. Radiography Chest

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
E. US Pelvis Transvaginal

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
F. US Pelvis Transabdominal

Variant 4: Surveillance of asymptomatic patients with treated low- or intermediate-risk endometrial cancer.
G. US Abdomen

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
A. CT Chest, Abdomen, and Pelvis

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
B. MRI Pelvis

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
C. MRI Abdomen

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
D. Radiography Chest

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
E. US Pelvis Transvaginal

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
F. US Pelvis Transabdominal

Variant 5: Surveillance of asymptomatic patients with treated high-risk endometrial cancer.
G. US Abdomen

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
A. MRI Pelvis

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
B. MRI Abdomen

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
C. CT Chest, Abdomen, and Pelvis

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
D. FDG-PET/CT Skull Base to Mid-Thigh

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
E. Radiography Chest

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
F. US Pelvis Transvaginal

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
G. US Pelvis Transabdominal

Variant 6: Posttherapy evaluation of clinically suspected recurrence of known endometrial cancer.
H. US Abdomen

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.