Luc Rotenberg mri and management of cervix malignancies jfim ifupi milan 2018

1. IMAGING AND MANAGEMENT OF CERVIX MALIGNANCIES?
Luc Rotenberg, Didier Bourgeois, Eric Sebban, Gregory Lenczner,
Jean Guigui, Catherine Beges, Mehdi Cadi, Jonathan Barukh
RPO – ISHH, Clinique Hartmann - CMC Ambroise Paré
26-27 bd Victor Hugo
92200 Neuilly Sur Seine - France
dr.rotenberg@radiologieparisouest.com
1st Italian-French Update Imaging – IFUPI
Advanced Multiparametric Imaging - How to use in daily practice
MILAN March 23-24 2018

2. Acknowledgement to Doctors Sophie Taieb and Corinne Balleyguier
by courtesy of their iconography
Acknowledgement to Doctors Didier Bourgeois and Eric Sebban
by courtesy of their operating Da Vinci videos

3. Initial assessment
• Clinical examination
• Simple investigations:
– CXR
– IVU/ Ultrasound
– Cystoscopy/ proctoscopy
MRI/CT

4. Where is the tumour?
• Cervical cancer in peri-
menopausal woman

5. Where is the tumour?
• Small endocervical tumour in
peri-menopausal woman

6. Indications of MRI
• Uterus
– Endometrial and cervical cancer staging
– Multiple leiomyoma (before /after embolization)
– Evaluation of complex abnormalities
• Ovary
– Characterization of complex underminated adnexal masses
• Other
– Chronic pelvic pain (Endometriosis)
– Complex prolapsus evaluation

7. Protocol
• WHOLE PELVIS:
– T1 TRA
– T2 FS TRA
– DWI ADC (b= 50, 500, 1000)
• CERVIX
– T2 TRA
– T2 SAG

8. 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

9. Basic sequence at 3T and 1,5T
§ T2-weighted sequence
§ WITHOUT FAT SUP
§ High tissue contrast
§ Anatomical information
§ Zonal anatomy of uterus:
§ Junction zone : hypointense signal
§ Myometrium : isointense signal
§ Endometrium : hyperintense signal

10. endometrium
myometrium
junction zone

11. Examples of very bad protocols…
§ They comes from real life :
§ One plan only
§ No T2w slices
§ T2w with FS
§ Lesion is not in the field of view
§ Field of view is too small
§ Injection not done, as it is required
§ Injection performed as it is not required..
§ No upper slices in cancer staging examination
§ ….

12. T2-w sequence
• Protocol 1,5 T or 3T :
– Should include at least 2 orthogonal sequences T2-w (axial, sagittal
usually)
• And most often 1 additional plan :
• Uterine cervical cancer : perpendicular to the cervix
• Endometrium cancer: parallel or perpendicular to uterus long axis
• Endometriosis : parallel to uterosacral ligaments
• 3D T2w sequence :
• Time gain
• Lacks of resolution in small lesions detection

13. Uterine Cervical Cancer
• Axial oblique T2w sequence perpendicular
to cervix axis
– Parametrial involvement
– 4 mm/0.4 mm

14. Endometrial Cancer
• Axial oblique T2w sequence
• Perpendicular to uterus axis
• Or parallel to uterus axis
• Myometrial invasion detection
A
C
Sagittal
To adapt slices to uterus anatomy ( double oblique axes)
Gaiane M, Radiographics 2014
Courtesy : Dr A. Thille

15. SCOPE
• Optimal Local Staging of Gynaecological Malignancies - Cervical, Uterine, Vaginal and Vulva Cancers.
• Guidance for Radiation Therapy
OTHER ROLES OF MRI
• Differentiate between Tumour and Benign conditions.
• Assessment of Response on Follow-up
• Before Pelvic Exenteration
• Follow up
• Complications

16. News in Staging MRI for cervical carcinoma

17. Staging of uterine carcinoma = MRI
• European guidelines
– Staging of Uterine Cervical cancer with MRI. Balleyguier et al. Eur Radiol. 2011
– Staging of endometrial cancer with MRI.
Kinkel et al, Eur Radiol 2009
• American College of Radiology (ACR) http://www.guideline.gov/content.aspx?id=35158…
– IRM : grade 8 or 9 (1 to 9)
– TEP : grade 8 or 9 (1 to 9)
– Tdm : 4-5

18. Staging of uterine carcinoma = MRI
• Patients refered for staging uterine carcinoma
• For cervical cancer :
– Figo staging
– If young women their wish about fertility preservation
– Delay since loop electrosurgical excision procedure
• excision électrochirurgicale à l'anse (LEEP)
• For endometrial cancer :
– Histology
– Tumor grade
• Radiologists have to know how to perform MRI

19. Advanced stades: > 4 cm, or N+
RCC + Brachytherapy
[Green JA et al. Lancet 01]
Cervical carcinoma– FIGO 2009
STADES
DEFINITION
STADE 0
In situ carcinoma
STADE I
IA
IA1
IA2
IB
IB1
IB2
Carcinoma confined to the cervix
Micro Invasion
< 3mm depth ; Extension < 7mm
>3mm et < 5mm depth, & extension t < 7mm
Invasive > 5 mm depth or extension > 7 mm
< 4cm / MRI
> 4 cm
STADE II
IIA
IIA1
IIA2
IIB
Beyond the uterus
Vagina (< 2/3 supérieur), no parametrial invasion
Visible lesion < 4 cm
Visible lesion > 4 cm
Parametrial invasion
STADE III
IIIA
IIIB
Large extension
Vagina lower one-third
Pelvic wall, hydronephrosis, nonfunctioning kidney
STADE IV
Extension beyond the true pelvis or
involvement of the bladder or rectal
mucosa (biopsy proved)*
Lower stades :
< 4 cm, limité col Surgery
+/- preop Brachytherapy (2-4 cm)

20. 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

21. 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

22. Cervical carcinoma
Information given by MRI for therapeutic decision-making
§ Tumor size
§ Parametrial and vaginal extension
§ Hydronephrosis
§ Involvement of the bladder or rectum
§ Lymph nodes (pelvic and para aortic)
§ Ovary
§ Peritoneal carcinosis

23. Cervical carcinoma : tumor size
35 yo. Adénocarcinoma. IB2, N-.

24. 46 yo.
Cervical carcinoma : tumor size

25. 46 ans. Lesion 4 X 3,5 cm. N-
45 sec post contrast
Cervical carcinoma : tumor size

26. 86 Y. IIA : 4 cm

27. 41 yo. LEEP : lesion 15mm, Residual disease ?
MRI 6 weeks later : 10mm histo + : 25mm (15 + 10)
Pelvic lymph nodes : N -
Cervical carcinoma : tumor size
After LEEP

28. 49 yo. LEEP 11 mm, MRI : 2 weeks later : 4 mm : 15 mm.
Surgery : no residual lesion. N -

29. 56 yo. LEEP 11 mm, MRI 5 weeks later : 9 mm. Surgery : Lesion 8 mm.

30. Cervical carcinoma
Tumor size
§ Largest dimension
§ DCE-MRI : 45 to 60 sec
§ If after LEEP : MRI 4 to 6 weeks later

31. Resection area
Trachelectomy

32. Trachelectomy
Criteria [Schneider A et al IJGC 2012]
§ SCC or adenocarcinoma
§ Stade 1A2, 1B1 ≤ 2 cm without embolus in vessels
§ pN0 in pelvis
§ Children project without known infertility
§ Superior limits
§ 7- 8mm above lesion
§ 3-4 mm below uterine arteries to perform uterine cerclage

34. Trachelectomy
27 yo.

35. Ureter
Uterine artery
Cervico-vaginal
artery
Resection area
Trachelectomy
• Lakhman & al. Stage 1b1 cervical cancer : Role of preoperative MR imaging in selection of patients for fertility sparing radical
trachelectomy Radiol Juin 2013
• Sadhev A & al; The performance of magnetic resonnance imaging in early cervcial carcinoma : a long term expereience. Int J Gynecol
Cancer 2007
• Bipat S & al. The role of magnetic resonance imaging in determining the proximal extension of early stage of cervical cancer to the
internal os. Eur J Radiol 2011

36. Lésion
Distance PS-AU
Plan de coupe

37. Post trachelectomy follow up : every 6 months until
pregnancy and then hysterectomy

38. Post trachelectomy follow up : every 6 months until
pregnancy and then hysterectomy
• 5% of recurrences,
• Healthy babies in 60-65 %,
• Rate of late abortion : 15%

39. 42 yo. 1B1 : 17 mm
No parametrial extension
Parametrial extension
VPN 94-100% if internal stroma wall preserved

40. 51 yo. 1B1 : 18 mm
Paramètres : embols néoplasiques

41. T2 b (IIB)
§ Tumor with disruption of normal
cervical stroma and parametrial
spread
§ Involvement of uterosacral
ligament
OVARIAN FIBROMA
OVARIAN FIBROMA

42. T3 b (IIIB)
§ Extends to pelvic side wall
§ * Pelvic wall is defined as muscle, fascia, neurovascular structures, or skeletal
portions of the bony pelvis.
GM
P
Uterosacral tumour extension to left pelvic side
wall with infiltration of the piriformis (P).

43. Parametrium : In practice
< 2cm : Surgery
2cm < T < 4cm
> 4 cm : RT-CT
Surgery / BrachyT + surgery
IRM Se 80%, Sp 93%.

44. • Ia & IB1 < 2 cm
• pN- pelvic
• < 40 years old
Salpingo-oophorectomy
vs
ovarian transposition

46. • Radical Hysterectomy is often associated with severe
bladder dysfunction (13%) and colorectal motility disorders
• Result of damage to the motor and sensory autonomic
nerve supply
Nerve Sparing Radical Hysterectomy
Okabayashi’s surgery

47. • Inferior hypogastric plexus preservation without
compromising radicality
• In the middle of three spaces : paravaginal, pararectal
and paravesical space
• Preservation of bladder branch and uterine branch
• Significantly improve the recovery of bladder and rectal
function
• Sexual function impaired less with NSRH
Nerve Sparing Radical Hysterectomy
Okabayashi’s surgery

48. Cervical carcinoma
Bladder extension (IV)

49. 56yo. RT CT

50. 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.

52. 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!!!

54. T4 (IVA)
Bladder invasion
§ Direct tumour invasion through
posterior wall of bladder with
bladder mucosal involvement.

55. SIZE
< 0,5 cm.
< 2 cm
IB > 2cm
IIA
IIB
N+ Probability
7% pelvic, 0 Paraortic
13% pelvic, 1% Paraortic
12 - 22%
10 – 27 %
34 – 43%
Lymph Node Involvement
Ø Pelvic lymphadenectomy if stade IA2 to IB1.
Ø Pelvic radiation therapy if > IB2
Ø Superior level of RT : Paraaortic Lymphadenectomy or imaging ?
Se IRM = TDM (35-90%), Sp IRM = TDM (70-99%)

56. Lymph node dissection
vs
Sentinel node

59. Patent blue vs ICG fluorescens

61. How accurate are we?
Imaging Finding
Accuracy (%)
Sensitivity (%)
Specificity (%)
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
…
…

62. Diffusion-weighted imaging?
• Diffusion-weighted imaging is
optional
• Detection :
– ADC is lower in cervical
cancer
(image en b1000: informative car col
noir/ cancer blanc)
– Comparison of anatomy and
ADC map helps tumor
delineation
– Tumour response = Increased
ADC after chemoradiation therapy
• Lymph node staging : low impact
– Benign and malignant LN = bright with
low ADC
• Consider the high signal on b
1000 value, in comparison
with normal « bright » LN
(groin LN)
• Compare the signal intensity of
the LN with that of the primary
tumour
– C. Whittaker, Radiographics 2009

63. IIB cervical carcinoma
Malignant LN on T2w and DWI sequence

64. Fusion DWI + T2
Cervix Adenocarcinoma after CRT :
Complete response, high ADC, no residual uptake

65. Summary
• Knowledge of pattern of tumour spread as well as FIGO and TNM
Systems of Classification is important for planning MR imaging
protocol
• T2 –weighted sequences are the workhorses and DWI increases
confidence.
• MR can be used for guiding brachytherapy planning.

66. CONCLUSION
• Size
• Parameters
• Contiguous organs (vagina, bladder)
• Lymph nodes (MRI diff/ Pet CT)
FIGO IRM
Kaur, H. et al. Am. J. Roentgenol. 2003;180:1621-1631
IB1
IB2
IIB