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Dr	
  Esther	
  MF	
  Wong	
  
Associate	
  Consultant	
  
Department	
  of	
  Radiology	
  
Pamela	
  Youde	
  Nethersole...
Outline	
  
•  Overview	
  
•  Brief	
  review	
  on	
  FIGO	
  staging	
  system	
  
•  Protocol	
  and	
  preparation	
 ...
Background	
•  3rd	
  most	
  common	
  cancer	
  death	
  in	
  women	
  worldwide	
  
•  Declining	
  incidence	
  in	
 ...
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%
...
Scheme	
  of	
  treatment	
  
1A1

Fertility
Preservation
(Cone biopsy, LEEP
Radical trachelectomy

1A2

I B1
II A1

I B2,...
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	
...
Initial	
  assessment	
•  Clinical	
  examination	
  
•  Simple	
  investigations:	
  
•  CXR	
  
•  IVU/	
  Ultrasound	
 ...
Staging	
  MRI	
  for	
  cervical	
  
carcinoma	
  
Protocol	
  
•  WHOLE	
  PELVIS:	
  	
  
•  T1	
  TRA	
  
•  T2	
  FS	
  TRA	
  
•  DWI	
  ADC	
  (b=	
  50,	
  500,	
  10...
Preparation	
  
•  Fast	
  for	
  6	
  hours	
  
•  Intramuscular	
  Glucagon	
  

à Reduce bowel motion

	
  

•  Half	
...
MRI	
  –	
  what	
  to	
  look	
  for?
FIGO	
  2009	
  
MRI	
  –	
  what	
  to	
  look	
  for	
•  Parametrial	
  invasion	
  
•  Vaginal	
  involvement	
  
•  Hydroureter	
  
•  ...
How	
  accurate	
  are	
  we?	
  
Imaging	
  Finding	
  
Source	
  
Parametrial	
  invasion	
  
Vaginal	
  extension	
  
P...
1.	
  Parametrial	
  invasion
Parametrial	
  invasion	
  
	
  
•  Soft	
  tissue	
  mass	
  extending	
  to	
  the	
  parametrium	
  
•  Preservation	
 ...
Bilateral	
  parametrial	
  invasion
Diagnostic	
  dilemma	
  

	
  	
  

•  Disrupted	
  stromal	
  line	
  without	
  frank	
  soft	
  tissue	
  mass	
  

in...
2.	
  Vaginal	
  extension
Vaginal	
  involvement	
  can	
  
be	
  evaluated	
  on	
  PV	
  
examination.	
  Why	
  bother	
  
about	
  it	
  on	
  M...
MRI	
  

PV	
  examination	
  

Seeing	
  Signal	
  change	
   Seeing	
  masses/	
  
mucosal	
  change	
  
–	
  microscopi...
Vaginal	
  invasion	
  
•  Disruption	
  of	
  hypointense	
  wall	
  at	
  T2	
  weighted	
  

imaging	
  
Vaginal	
  Gel	
  
•  In	
  resting	
  state,	
  the	
  anterior	
  and	
  posterior	
  

vaginal	
  walls,	
  fornices	
 ...
Expel	
  all	
  large	
  air	
  
bubbles	
  to	
  reduce	
  
susceptability	
  artefact
	
  
1.  Stand	
  the	
  syringe	
...
Vote	
  time!	
  What	
  do	
  you	
  think	
  about	
  
the	
  vaginal	
  involvement?	
  
•  A.	
  Anterior	
  and	
  po...
3.	
  Pelvic	
  sidewall	
  
involvement
Pelvic	
  side	
  wall	
  involvement	
  
•  By	
  clinical	
  examination	
  –	
  tumour	
  attached	
  to	
  pelvic	
  
...
Obturator
internus

Levator
ani
Piriformis
4.	
  Hydronephrosis
Hydronephrosis	
  
•  Look	
  for	
  distended	
  ureter	
  
5.	
  Lymphadenopathy
lateral	

Hypoga
stric	

Uterine arteryexternal iliac Internal
iliac

Poster
ior	
  
lateral
sacral
Predictability	
  of	
  Lymph	
  node	
  
involvement	
  on	
  MRI	
•  Size	
  criteria	
  
•  Upper	
  limit	
  6-­‐15mm	...
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	
 ...
4.	
  Invasion	
  to	
  adjacent	
  organs	
  
This	
  is	
  not	
  Stage	
  IV!!!	
  
FIGO/	
  TNM	
  staging	
  
•  The carcinoma has extended beyond the true pelvis or has

involved (biopsy proven) the muco...
This	
  is	
  also	
  not	
  Stage	
  IV!!!	
  
Radiologist:	
  …..	
  Tumour	
  penetrates	
  the	
  
mesorectal	
  fascia	
  and	
  involves	
  the	
  perirectal	
  
fa...
C’est la vie!
Problem	
  with	
  FIGO	
  staging	
  
•  Non-­‐mucosal	
  involvement	
  of	
  adjacent	
  organ	
  
Q: Would you like to...
Do	
  we	
  need	
  a	
  new	
  /	
  
modihied	
  staging	
  system?	
  
MRI/CT	
  
Recent	
  advances
Diffusion	
  weighted	
  imaging	
  
•  Increase	
  lesion	
  conspicuity	
  
•  Isointense	
  tumour	
  
•  Small	
  tumo...
DWI	
  
•  b	
  values	
  (50,	
  500,	
  1000)	
  
•  Low	
  b	
  values	
  -­‐>	
  black	
  blood	
  sequence	
  
•  Hig...
b=50

b=1000

b=500

ADC
Inverted	
  ADC	
  

Tumour	
  

ADC

Tumour	
  

Inverted ADC
Tumour	
  

Inverted ADC

T2	
  
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...
Cut	
  off	
  ADC	
  value?	
  	
  
Article	
  

B	
  value	
  

Normal	
  cervical	
   Cervical	
  tumour	
  
(x	
  10-­‐...
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?	
  Appropria...
Acknowledgement	
  	
  
•  Dr.	
  KK	
  Tang	
  
•  Consultant	
  	
  
•  Department	
  of	
  Obstetrics	
  and	
  Gynaeco...
References	
  
•  Management	
  of	
  Cervical	
  cancer.	
  A	
  national	
  guideline	
  .	
  Scottish	
  Intercollegiat...
esthermfwong@gmail.com
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
Urology gynecology mri staging for ca cervix
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Urology gynecology mri staging for ca cervix

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Transcript of "Urology gynecology mri staging for ca cervix"

  1. 1. Dr  Esther  MF  Wong   Associate  Consultant   Department  of  Radiology   Pamela  Youde  Nethersole  Eastern  Hospital   Hong  Kong  
  2. 2. Outline   •  Overview   •  Brief  review  on  FIGO  staging  system   •  Protocol  and  preparation   •  MRI   •  Parametrial  invasion   •  Vaginal  Invasion   •  DWI   •  Lymph  node  status   •  Recent  advances  
  3. 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. 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. 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
  6. 6. FIGO •  International  Federation  of  Obstetric  and   Gynaecology   •  Most  widely  adopted  
  7. 7. Ca  cervix   •  FIGO  2009  
  8. 8. 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
  9. 9. Initial  assessment •  Clinical  examination   •  Simple  investigations:   •  CXR   •  IVU/  Ultrasound   •  Cystoscopy/  proctoscopy       MRI/CT
  10. 10. Staging  MRI  for  cervical   carcinoma  
  11. 11. Protocol   •  WHOLE  PELVIS:     •  T1  TRA   •  T2  FS  TRA   •  DWI  ADC  (b=  50,  500,  1000)   •  CERVIX   •  T2  TRA   •  T2  SAG  
  12. 12. 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  
  13. 13. MRI  –  what  to  look  for?
  14. 14. FIGO  2009  
  15. 15. MRI  –  what  to  look  for •  Parametrial  invasion   •  Vaginal  involvement   •  Hydroureter   •  Pelvic  side  wall  involvement   •  Mucosa  of  rectum  and  bladder   •  Pelvic  lymphadenopathy  
  16. 16. How  accurate  are  we?   Imaging  Finding   Source   Parametrial  invasion   Vaginal  extension   Pelvic  sidewall  extension   Bladder  extension   Lymph  node  invasion   Overall   Sensitivity   Specihicity   Accuracy  (%)   (%)   (%)   90–94   83–94   86–95   96–99   88–91   76–91   …   …   …   71   94   …   …   83   100   89  70–95   …  
  17. 17. 1.  Parametrial  invasion
  18. 18. 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  
  19. 19. Bilateral  parametrial  invasion
  20. 20. Diagnostic  dilemma       •  Disrupted  stromal  line  without  frank  soft  tissue  mass   in  the  parametria   •  Pre-­‐existing  endometriosis   •  Microscopic  invasion      
  21. 21. 2.  Vaginal  extension
  22. 22. Vaginal  involvement  can   be  evaluated  on  PV   examination.  Why  bother   about  it  on  MRI?  
  23. 23. MRI   PV  examination   Seeing  Signal  change   Seeing  masses/   mucosal  change   –  microscopic   disease   Fornices  clearly   visualized   Errors  in  bulky   tumour  distorting   the  fornices  
  24. 24. Vaginal  invasion   •  Disruption  of  hypointense  wall  at  T2  weighted   imaging  
  25. 25. 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.  
  26. 26. 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  
  27. 27. 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!!!  
  28. 28. 3.  Pelvic  sidewall   involvement
  29. 29. 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        
  30. 30. Obturator internus Levator ani
  31. 31. Piriformis
  32. 32. 4.  Hydronephrosis
  33. 33. Hydronephrosis   •  Look  for  distended  ureter  
  34. 34. 5.  Lymphadenopathy
  35. 35. lateral Hypoga stric Uterine arteryexternal iliac Internal iliac Poster ior   lateral sacral
  36. 36. 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
  37. 37. Short axis: 0.8cm
  38. 38. ADC = 0.817 x 10(-3)mm(2)/s
  39. 39. SUV Max 4.4
  40. 40. Nodal  staging   •  Problems:   •  Micrometastasis   •  Normal  sized  lymph  node  harbouring  small  metastases.     •  Techniques  to  improve  nodal  staging   •  Contrast   •  DWI  
  41. 41. 4.  Invasion  to  adjacent  organs  
  42. 42. This  is  not  Stage  IV!!!  
  43. 43. 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
  44. 44. This  is  also  not  Stage  IV!!!  
  45. 45. 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  
  46. 46. C’est la vie!
  47. 47. 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!
  48. 48. Do  we  need  a  new  /   modihied  staging  system?   MRI/CT  
  49. 49. Recent  advances
  50. 50. Diffusion  weighted  imaging   •  Increase  lesion  conspicuity   •  Isointense  tumour   •  Small  tumour   •  Nodal  assessment   •  Assessment  of  treatment  response   •  Prognostic  implication    
  51. 51. DWI   •  b  values  (50,  500,  1000)   •  Low  b  values  -­‐>  black  blood  sequence   •  High  b  values  -­‐>  increase  tumour  conspicuity  
  52. 52. b=50 b=1000 b=500 ADC
  53. 53. Inverted  ADC   Tumour   ADC Tumour   Inverted ADC
  54. 54. Tumour   Inverted ADC T2  
  55. 55. ADC Inverted ADC
  56. 56. ADC  
  57. 57. Inverted  ADC  
  58. 58. Co-­‐registration  with  T2  image  
  59. 59. ADC  affected  side  
  60. 60. ADC  unaffected  side  
  61. 61. Pitfalls •  The  following  may  exhibit  restricted  diffusion:   •  Blood  products    (e.g.  after  cone  biopsy)   •  Fibrosis  (post-­‐irradiation/desmoplastic  reaction)
  62. 62. 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  
  63. 63. ADC min 0.881 x 10-3mm2
  64. 64. 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
  65. 65. Conclusion   •  MRI  signs  for  staging  Ca  cervix   •  Current  FIGO  staging  system?  Appropriate   •  Functional  imaging  -­‐  DWI  
  66. 66. 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  
  67. 67. 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.  
  68. 68. esthermfwong@gmail.com
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