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.  

esthermfwong@gmail.com