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Dr Esther MF Wong Associate Consultant
Department of Radiology Pamela Youde Nethersole Eastern Hospital
Hong Kong
Outline • Overview
• Brief review on FIGO staging system
• Protocol and preparation
• MRI • Parametrial invasion
• Vaginal Invasion • DWI
• Lymph node status
• Recent advances
Background • 3rd most common cancer death in women worldwide
• Declining incidence in developed countries
• In Hong Kong 2010 • 400 new cases of cervical cancer
• crude incidence rate was 10.7 per 100000 female population..
• Histology: • Squamous carcinoma 85% • adenocarcinoma, for 15% • adenoid cystic, small cell, adenosquamous carcinoma, and lymphoma
Survival rate by stage
Stage 5-Year 0 93% IA 93% IB 80% IIA 63% IIB 58% IIIA 35% IIIB 32% IVA 16% IVB 15%
Adopted from American cancer society
Scheme of treatment 1A1 1A2 I B1
II A1 I B2, II A 2 II B – IV A IV B
Fertility Preservation
(Cone biopsy, LEEP Radical trachelectomy
Radiotherapy
Radical hysterectomy
+/- Pelvic lymphadenectomy
Chemotherapy
FIGO
• International Federation of Obstetric and Gynaecology
• Most widely adopted
Ca cervix
• FIGO 2009
FIGO -‐weakness
• Based on clinical assessment and simple investigation • errors in clinical staging
• Stage I:22% • Stage III: 75%
• Failure to recognize parametrial invasion, pelvic side wall, bladder or rectal wall spread clinically
• Does not address presence of lymphadenopathy, an important prognostic indicator
Initial assessment • Clinical examination
• Simple investigations: • CXR
• IVU/ Ultrasound
• Cystoscopy/ proctoscopy
MRI/CT
Staging MRI for cervical carcinoma
Protocol • WHOLE PELVIS:
• T1 TRA
• T2 FS TRA
• DWI ADC (b= 50, 500, 1000)
• CERVIX • T2 TRA • T2 SAG
Preparation
• Fast for 6 hours
• Intramuscular Glucagon
à Reduce bowel motion
• Half full bladder • Urinary bladder invasion
• Lubricant Jelly given per-‐vaginally immediately before scanning
MRI – what to look for?
FIGO 2009
MRI – what to look for • Parametrial invasion
• Vaginal involvement
• Hydroureter
• Pelvic side wall involvement
• Mucosa of rectum and bladder
• Pelvic lymphadenopathy
How accurate are we?
Imaging Finding Accuracy (%) Sensitivity (%)
Specihicity (%)
Source Parametrial invasion 90–94 71 94 Vaginal extension 83–94 … … Pelvic sidewall extension 86–95 … … Bladder extension 96–99 83 100 Lymph node invasion 88–91 89 70–95 Overall 76–91 … …
1. Parametrial invasion
Parametrial invasion
• Soft tissue mass extending to the parametrium
• Preservation of T2 hypointense hibrous stroma ring. • High negative predictive value for parametrial invasion
• Stromal ring disruption: sign of microscopic invasion
Bilateral parametrial invasion
Diagnostic dilemma • Disrupted stromal line without frank soft tissue mass in the parametria • Pre-‐existing endometriosis
• Microscopic invasion
2. Vaginal extension
Vaginal involvement can be evaluated on PV examination. Why bother about it on MRI?
MRI PV examination
Seeing Signal change – microscopic disease
Seeing masses/ mucosal change
Fornices clearly visualized
Errors in bulky tumour distorting the fornices
Vaginal invasion • Disruption of hypointense wall at T2 weighted imaging
Vaginal Gel • In resting state, the anterior and posterior vaginal walls, fornices are collapsed and opposed to each other.
• The anterior/ posterior 40-‐60 ml sterile lubricant jelly.
Expel all large air bubbles to reduce
susceptability artefact
1. Stand the syringe tip upwards for 1 hour
2. Hit the syringe forcefully against hard surface
Vote time! What do you think about the vaginal involvement? • A. Anterior and posterior vaginal walls both involved.
• B. Anterior vaginal wall involved. Posterior not involved.
• C. Posterior vaginal wall involved. Anterior not.
• D. I don’t know!!!
3. Pelvic sidewall involvement
Pelvic side wall involvement
• By clinical examination – tumour attached to pelvic side wall
• Predictability on MRI • Direct tumour extension to pelvic musculature /iliac vessel
• include tumor within 3 mm of or abutment of the internal obturator, levator ani, and pyriform muscles and the iliac vessels
Obturator internus
Levator ani
Piriformis
4. Hydronephrosis
Hydronephrosis • Look for distended ureter
5. Lymphadenopathy
lateral Hypogastric
Posterior
Uterine artery-external iliac Internal
iliac
lateral sacral
Predictability of Lymph node involvement on MRI
• Size criteria • Upper limit 6-‐15mm
• Sensitivity 36-‐89.5%
• Accuracy 76-‐100%
• Shape • Spiculated margin and heterogenous intensity strong predictor of nodal involvemnet • Due to desmoplastic reaction/ inhiltration into the perinodal fat
Short axis: 0.8cm
ADC = 0.817 x 10(-3)mm(2)/s
SUV Max 4.4
Nodal staging • Problems:
• Micrometastasis
• Normal sized lymph node harbouring small metastases.
• Techniques to improve nodal staging • Contrast
• DWI
4. Invasion to adjacent organs
This is not Stage IV!!!
FIGO/ TNM staging • The carcinoma has extended beyond the true pelvis or has
involved the of the bladder or rectum. A , as such, does not permit a case to be allotted to Stage IV
mucosa bullous oedema
(biopsy proven)
This is also not Stage IV!!!
Radiologist: ….. Tumour penetrates the mesorectal fascia and involves the perirectal
fat…
Gynaecologist: No! I did not feel any rectal involvement on PR and there is nothing wrong on proctoscopy!
Pathologist: No malignant cell is seen in rectal biopsy
C’est la vie!
Problem with FIGO staging • Non-‐mucosal involvement of adjacent organ
Q: Would you like to know if there is non-mucosal involvement of adjacent organ as in this case? A: Yes! Q: Would you consider this as a Stage IVa disease? A: No! Q: Would you treat it like one Stage down? A: No!
Do we need a new / modihied staging system? MRI/CT
Recent advances
Diffusion weighted imaging • Increase lesion conspicuity
• Isointense tumour
• Small tumour
• Nodal assessment
• Assessment of treatment response
• Prognostic implication
DWI • b values (50, 500, 1000)
• Low b values -‐> black blood sequence
• High b values -‐> increase tumour conspicuity
b=50
ADC b=1000
b=500
Inverted ADC
Tumour Tumour
ADC Inverted ADC
Tumour T2
Inverted ADC
ADC Inverted ADC
ADC
Inverted ADC
Co-‐registration with T2 image
ADC affected side
ADC unaffected side
Pitfalls
• The following may exhibit restricted diffusion:
• Blood products (e.g. after cone biopsy)
• Fibrosis (post-‐irradiation/desmoplastic reaction)
Cut off ADC value? Article B value Normal cervical
stroma (x 10-‐3 mm 2 )
Cervical tumour (x 10-‐3 mm 2 )
Chen Jianyu et. al 0, 800 1.593 +/-‐ 0.151 1.11 +/-‐0.175
Fei Kuang et al 0, 600 1.55 +/-‐ 0.28 0.91 +/-‐ 0/15 0. 1000 1.41 +/-‐ 0.28 0.81+/-‐0.13
ADC min 0.881 x 10-3mm2
Mean ADC 0.68x 10-3 mm 2
Mean ADC 0.51x 10-3 mm 2
Min ADC 0.35 x 10-3 mm 2
Conclusion • MRI signs for staging Ca cervix
• Current FIGO staging system? Appropriate
• Functional imaging -‐ DWI
Acknowledgement • Dr. KK Tang
• Consultant • Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital
• Dr. Catherine Wong • Associate Consultant
• Department of Nuclear Medicine, Pamela Youde Nethersole Eastern Hospital
• Dr. Soong Sung, Inda • Associate Consultant
• Department of Oncology, Pamela Youde Nethersole Eastern Hospital
• Grace Chan • Department Operation manager
• Department of Radiology, Pamela Youde Nethersole Eastern Hospital
• PO Chan • Radiographer I • Pamela Youde Nethersole Eastern Hospital
References • Management of Cervical cancer. A national guideline . Scottish Intercollegiate guidelines network
• Nicolet V, Carignan L, Bourdon F, Prosmanne O. MR imaging of cervical carcinoma: a practical staging approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 2000;20(6):1539-‐1549.
• Kaur H, Silverman PM, Iyer RB, Verschraegen CF, Eifel PJ, Charnsangavej C. Diagnosis, Staging, and Surveillance of Cervical Carcinoma. American Journal of Roentgenology. 2003 Jun;180(6):1621-‐1631.
• Hawnaur JM, Johnson RJ, Buckley CH, Tindall V, Isherwood I. Staging, volume estimation, and assessment of nodal status in carcinoma of the cervix: comparison of magnetic imaging with surgical hindings.
• Chen J, Zhang Y, Liang B, Yang Z. The utility of diffusion-‐weighted MR imaging in cervical cancer. European journal of radiology. 2010 Jun;74(3).
• Kuang F, Ren J, Zhong Q, Liyuan F, Huan Y, Chen Z. The value of apparent diffusion coefhicient in the assessment of cervical cancer. European radiology. 2013 Apr;23(4):1050-‐1058.
• Liu Y, Liu H, Bai X, Ye Z, Sun H, Bai R, et al. Differentiation of metastatic from non-‐metastatic lymph nodes in patients with uterine cervical cancer using diffusion-‐weighted imaging. Gynecologic oncology. 2011 Jul;122(1):19-‐24.