Urology gynecology mri staging for ca cervix

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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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