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Urology gynecology mri staging for ca cervix
1. Dr
Esther
MF
Wong
Associate
Consultant
Department
of
Radiology
Pamela
Youde
Nethersole
Eastern
Hospital
Hong
Kong
2. Outline
• Overview
• Brief
review
on
FIGO
staging
system
• Protocol
and
preparation
• MRI
• Parametrial
invasion
• Vaginal
Invasion
• DWI
• Lymph
node
status
• Recent
advances
3. 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
4. Survival
rate
by
stage
Stage
5-Year
0
IA
IB
IIA
IIB
IIIA
IIIB
IVA
IVB
93%
93%
80%
63%
58%
35%
32%
16%
15%
Adopted from American cancer society
5. Scheme
of
treatment
1A1
Fertility
Preservation
(Cone biopsy, LEEP
Radical trachelectomy
1A2
I B1
II A1
I B2, II A 2
II B – IV A
IV B
Radical
hysterectomy
+/- Pelvic
lymphadenectomy
Radiotherapy
Chemotherapy
9. 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
16. MRI
–
what
to
look
for
• Parametrial
invasion
• Vaginal
involvement
• Hydroureter
• Pelvic
side
wall
involvement
• Mucosa
of
rectum
and
bladder
• Pelvic
lymphadenopathy
19. 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
27. MRI
PV
examination
Seeing
Signal
change
Seeing
masses/
mucosal
change
–
microscopic
disease
Fornices
clearly
visualized
Errors
in
bulky
tumour
distorting
the
fornices
28.
29.
30. Vaginal
invasion
• Disruption
of
hypointense
wall
at
T2
weighted
imaging
31.
32. 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.
33. 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
34.
35. 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!!!
38. 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
59. FIGO/
TNM
staging
• The carcinoma has extended beyond the true pelvis or has
involved (biopsy proven) the mucosa of the bladder or
rectum. A bullous oedema , as such, does not permit a
case to be allotted to Stage IV
62. 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
64. Problem
with
FIGO
staging
• Non-‐mucosal
involvement
of
adjacent
organ
Q: Would you like to know if there is nonmucosal 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!
65. Do
we
need
a
new
/
modihied
staging
system?
MRI/CT
85. Pitfalls
• The
following
may
exhibit
restricted
diffusion:
• Blood
products
(e.g.
after
cone
biopsy)
• Fibrosis
(post-‐irradiation/desmoplastic
reaction)
86. Cut
off
ADC
value?
Article
B
value
Normal
cervical
Cervical
tumour
(x
10-‐3
mm
2
)
stroma
(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
89. 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
90. Conclusion
• MRI
signs
for
staging
Ca
cervix
• Current
FIGO
staging
system?
Appropriate
• Functional
imaging
-‐
DWI
91. 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
92. 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
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2011
Jul;122(1):19-‐24.
