Role of Imaging in the Management of High-Risk Endometrial Cancer

Endometrial cancer (EC) is the second most frequent gynecological malignancy worldwide with an overall favorable prognosis. However, there is a subgroup of patients with a higher rate of recurrence and worse prognosis who benefit from a specific pre- and post-treatment radiological evaluation that allows the adjustment of the therapeutic attitude towards the biology of the tumor. The main factors that determine high-risk disease are non-endometrioid tumor histology, histopathological grade 3, lymphovascular space invasion (LVSI), myometrial invasion ≥50%, and cervical stroma involvement. Radiological evaluation helps identify high-risk cases prior to surgical staging and is an important tool both in pre-treatment and in case of clinical recurrence suspicion. As for imaging techniques, both transvaginal ultrasound and MRI can assess local tumor extent while CT and positron emission tomography/CT (PET/CT) help assess lymph nodes and distant metastases. The central purpose of this article is to review the specific factors that determine high-risk endometrial cancer, and the main specificities in the pre-treatment and follow-up evaluation according to the most recent international guidelines.