Urology gynecology mri staging for ca cervix

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

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.

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Urology gynecology mri staging for ca cervix

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