Cervical Cancer Staging: - PowerPoint Presentation

Slide1

Cervical Cancer Staging:A Resident’s Primer

Presented as an education exhibit at the 2014 RSNA Annual Meeting – OBE117.All authors have disclosed no relevant relationships.

Anish

Raithatha, BSc, MBBS,1* Ioanna Papadopoulou, FRCR,1 Victoria Stewart, BMed Sci, BMBS, MRCP, FRCR,1 Tara D. Barwick, MBChB, MSc, MRCP, FRCR,1,2 Andrea G. Rockall, BSc, MBBS, MRCP, FRCR,1,2 Nishat Bharwani, BSc (Hon), MBBS, MRCP, FRCR1,21 Department of Radiology, Imperial College Healthcare NHS Trust, London, England2 Department of Surgery and Cancer, Imperial College London, England

Address correspondence to: Department of Radiology, Imperial College Healthcare NHS Trust, St Mary’s Hospital,

Praed

Street, London W2 1NY, England (*email: anish.raithatha@gmail.com), Tel 020 3312 6666

ext

27616

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Learning Objectives

After viewing this online presentation, participants will be able to:Describe the International Federation of Gynecology and Obstetrics (FIGO) staging of cervical cancer and the magnetic resonance (MR) imaging appearances of each stage of the primary tumor.Explain the appropriate role of each imaging modality in staging, follow-up, and assessment of recurrent cervical cancer.Recognize potential imaging and interpretative pitfalls.AbbreviationsAx = axial, CECT = contrast-enhanced CT, Cor = coronal, CTPA = CT pulmonary angiogram, FIGO = International Federation of Gynecology and Obstetrics, LFOV = large field of view, Obl = oblique, Sag = sagittal, SFOV = small field of view, T1 = T1-weighted, T2 = T2-weighted

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Key Concepts

The use of cross-sectional imaging is important as a noninvasive means to determine accurate staging in patients with cervical cancer.MR imaging is the modality of choice to determine local-regional tumor spread and is used to establish the FIGO stage prior to treatment.Contrast material–enhanced computed tomography (CT) and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT are used in locally advanced cervical cancer to assess the extent of distant disease spread.Imaging plays an important role in planning initial management and in follow-up. Accurate reporting of radiologic findings is dependent on knowledge of common imaging and interpretive pitfalls.

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IntroductionCervical cancer is the

fourth most common cancer worldwide in women and the seventh most common cancer overall.1Cervical cancer accounted for 7.5% of female cancer deaths worldwide in 2012.1It is the most common cause of cancer-related death in the younger than 35 age group.2Around 85% of cervical cancers occur in middle- and low-income countries.21International Agency for Research on Cancer, 2 Cancer Research UK Web site (all accessed November 2015)

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Cervical Cancer: Risk Factors

Risk FactorCommentHuman papillomavirus (HPV 16 and 18) Associated with 99% of cases.1While HPV infection is common, malignant transformation is relatively rare. Immunosuppression2 Immunosuppressed and human immunodeficiency virus– positive patients.Smoking2- Approximately twice the risk. Smoking is associated with high-risk behavior. Smoking weakens the immune system, allowing HPV to persist.Early first pregnancy2- Women who have their first full-term pregnancy before age 17 are twice as likely to develop cervical cancer.Poverty2

- Associated with inadequate access to health services and screening facilities.Family history2- Two to three times higher risk if mother or sister have been diagnosed.

1WHO Web site, 2www.cancer.org (Accessed March 2015)

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Cervical Cancer: ScreeningScreening involves cervical sampling and examination of samples with microscopy to identify

dyskaryotic changes.Dyskaryosis describes the microscopic appearance of abnormal squamous epithelial cells characterized by hyperchromatic nuclei or irregular nuclear chromatin. United Kingdom Screening Program1:If moderate or severe dyskaryosis is found, colposcopy and formal biopsy are performed to rule out malignancy. If the histologic findings of the biopsy confirm invasive cervical cancer, the disease in the patient will require staging before choosing an appropriate management plan. Normal Papanicolaou test staining.3Papanicolaou stain demonstrating atypical cells.3

Age group Frequency of screening

25First screening visit25-49Every 3 years50-64Every 5 years65+Only if not screened after age 50 or recent abnormal resultsUnited States Screening Program:21NHS Cervical Screening Programme, 2U.S. Preventative Services Task Force, 3Courtesy of Roberto Dina, MD Age groupFrequency of screening21First screening visit

21–30

Every 3 years

30–65

Every 3-5 years

65+

Only if patient does not meet criteria

for adequate prior testing

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Cervical Cancer: FIGO StagingThe most widely used staging system for cervical cancer is the FIGO staging system, which was revised in 2009.

The FIGO system is based on clinical examination and inspection to allow uniform classification of patients worldwide, as the disease is prevalent in countries with limited access to imaging.However, the 2009 revision encourages the use of cross-sectional imaging where it is available to assess prognostic factors such as parametrial or pelvic sidewall invasion and nodal involvement, which are not easily evaluated clinically.Pecorelli (2010)

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FIGO Staging of Cervical Cancer (2009)

IA: invasive carcinoma that can only be diagnosed with microscopy and is less than 7 mm in width.Stage I: The carcinoma is confined strictly to the cervix.Image taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/

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FIGO Staging of Cervical Cancer (2009)

Stage I: The carcinoma is confined strictly to the cervix. IB: clinically visible tumor confined to the cervix. IB1: 4 cm or less

in greatest dimension. IB2: greater than 4 cm in greatest dimension.

Image taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/

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Stage I: Confined to the CervixStage IA tumors are only diagnosed with microscopy and are not clinically visible.Stage IB tumors are

subclassified on the basis of their size (smaller or larger than 4 cm).Stage IB1: The intermediate-signal-intensity tumor (*) can be visualized within the low- signal-intensity cervical stroma (arrow) and measures less than 4 cm in diameter. *T2 Sag

Stage IB2: A 4.3-cm tumor is visualized at the anterior cervical lip (*) projecting into but not involving the anterior vaginal fornix.

*T2 Sag*T2 Ax Obl*T2 Ax Obl

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Stage II:

The carcinoma invades beyond the uterus but spares the lower third of the vagina and pelvic sidewall.FIGO Staging of Cervical Cancer (2009)IIA: with upper vaginal involvement but no parametrial invasion. IIA1: less than 4 cm in greatest dimension IIA2: greater than 4 cm in greatest dimensionIIB: involving the parametrium.The parametrium is defined as “connective tissue that extends laterally from the cervix between the layers of the broad ligament.”

Images taken with permission from the patient information Web site of Cancer Research UK:

http://www.cancerresearchuk.org/about-cancer/

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Stage II: Beyond the CervixStage IIB: Parametrial invasion

Stage IIA2: The primary cervical tumor (*) measures more than 4 cm in maximal dimension and involves the upper third of the vagina (arrow), in keeping with FIGO stage IIA2. The T2-weighted low-signal- intensity cervical stromal ring is intact, and there is no evidence of parametrial invasion.Stage IIA1: <4 cmStage IIA2: >4 cm

Stage IIB: There is loss of the normal T2- hypointense cervical stroma surrounding the majority of the tumor, a finding suggestive of parametrial invasion. No involvement of the pelvic sidewall or lower third of the vagina.

T2 Ax*T2 Sag

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Complete preservation of the low  signal cervical stromal ring, excuding parametrial invasion.

T2 AxPearls and Pitfalls–Parametrial InvasionLoss of the low signal intensity ring of cervical stroma  … ?Parametrial invasion

T2 Ax

T2 AxWhile an intact ring of hypointense cervical stroma surrounding the tumor excludes parametrial invasion…

Learning point:

Look for extension beyond the cervical contour to confirm parametrial involvement.

Normal cervical contour

Site of parametrial invasion

Complete loss

of the low-signal-intensity ring

does not always

confirm

parametrial

invasion.

This appearance may also represent complete involvement of the cervical

stroma

without invasion into the

parametrium

.

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Pearls and Pitfalls–Postbiopsy Change

When examining the patient preoperatively, it is important to take into consideration the timing of MR imaging.

MR imaging was performed fewer than 4 days after cone biopsy of a 6-mm tumor.What is the local-regional staging at imaging?

Is there parametrial involvement (yellow arrow)? Does the disease involve the right pelvic sidewall (blue arrow)? Do the left pelvic sidewall lymph nodes (red arrow) represent metastatic spread?Pathologic findings demonstrated no residual tumor; there are fibrosis and granulation changes only. The nodes are likely to have been reactive. FIGO stage IA1.Learning point: Be aware of postbiopsy inflammatory changes. Perform MR imaging at least 7–10 days after biopsy. T2 Ax

*

Note also gas in the cervical canal (*).

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Stage III: The tumor extends to the pelvic wall and/or involves the lower third of the vagina and/or causes

hydronephrosis or nonfunctioning kidney.FIGO Staging of Cervical Cancer (2009)IIIA: Involvement of the lower third of the vagina.IIIB: Hydronephrosis or extension to the pelvic sidewall.Images taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/

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Stage III: Involvement of the Lower Vagina and/or Pelvic SidewallStage IIIA

: Extension to the lower third of the vagina.*#Note the large mass (#) centered on the cervix that is obstructing the endometrial canal, resulting in fluid accumulation within the endometrial cavity (*) and extending to involve the lower vagina (arrow).Stage IIIB: Extension to the pelvic sidewall.Figure A: The primary cervical

tumor (*) with evidence of parametrial invasion. Figure B: Right-sided hydronephrosis and an enlarged aortocaval lymph node (arrow). The dilated ureter could be traced to the level of the

tumor, in keeping with right pelvic sidewall involvement. T2 SagFig A: T2 SagFig B: T2 Ax*

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Learning point:

An arbitrary line extending posteriorly from the point of insertion of the urethra into the urinary bladder divides the vagina into its upper two-thirds and lower third.Pearls and Pitfalls: Vaginal Involvement

Normal study:

Cervical cancer:Patient 1: T2 SagPatient 2: T2 Sag

Stage IIA2

Stage IIIA

T2 Sag

Upper ⅔

Lower ⅓

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Stage IV: The tumor extends beyond the true pelvis or there is biopsy-proven involvement of the bladder or rectal mucosa.

FIGO Staging of Cervical Cancer (2009)IVA: Spread of tumor to the adjacent organs.IVB: Distant spread of disease.Images taken with permission from the patient information Web site of Cancer Research UK:

http://www.cancerresearchuk.org/about-cancer/

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Stage IV DiseaseStage IVA: Extension to adjacent organs or invasion through the rectal or bladder wall to involve mucosa.Stage IVB: Distant disease.

Stage IVA: Rectosigmoidinvolvement (arrow).Stage IVA: Bladder wall involvement. Note hydroureter (arrows).Stage IVB: FDG PET image shows bone and pulmonary metastases.

T2 Sag

T2 SagT2 AxFDG PET

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The Role of ImagingThe clinically based FIGO (2009) staging system results in

understaging of cervical cancer in 20%–30% of stage IB patients and up to 64% of stage IIIB patients.1 Imaging modalities such as MR imaging, contrast-enhanced CT, and FDG PET/CT can improve preoperative staging and influence treatment decisions and the accuracy of radiotherapy fields. MR imaging is suitable for local-regional staging of biopsy-proven cancers, while contrast-enhanced CT and FDG PET/CT are well suited to provide information on disease extent.The American College of Radiology (ACR) Appropriateness Criteria can be used to guide choice of imaging modality.1Lagasse et al (1980)

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ACR Appropriateness CriteriaThe ACR Appropriateness Criteria provide guidance to supplement a clinician’s judgment as to whether a patient is a

reasonable candidate for an imaging study. Guidance is based on the initial tumor staging:FIGO Stage IB1FIGO Stage IB2FIGO Stage >IBMR imaging, pelvis with and without contrast materialUsually appropriateUsually appropriateUsually appropriateFDG PET/CT, whole bodyUsually appropriateUsually appropriate

Usually appropriateCT, abdomen/pelvis with contrast materialMay be appropriateMay be appropriateUsually appropriate

CT, thorax with contrast material--Usually appropriateChest radiographyMay be appropriateMay be appropriate-ACR Appropriateness Criteria (http://www.guideline.gov/content.aspx?id=43887). Accessed November 2015.

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MR Imaging Protocol

SequencePlaneField of ViewReasonTumor CharacteristicsT1 weightedAxialLarge(renal hila to symphysis pubis)Identify pelvic lymph nodes; assess bone marrowIsointense compared with pelvic musclesT2 weightedAxialLarge(renal hila to symphysis pubis)Overview of pelvic sidewalls; assess for hydronephrosisHigh signal intensity relative to low-signal-intensity cervical stroma

T2 weightedSagittalLargeAssess tumor position and invasion of vagina and/or adjacent tissues

T2 weightedOblique(perpendicular to long axis of cervix)SmallAssess for parametrial invasionDiffusion-weighted imaging (DWI)Axial or oblique axialLargeTumor assessment and an aid in detection of local lymph nodesTumor or nodes demonstrate restricted diffusion

Ax T2 LFOV

T2 Ax

Obl

SFOV

T2 Sag LFOV

LFOV: large field of view

SFOV: small field of view

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MR Imaging ProtocolDWI can be useful in detection of cervical cancers to help differentiate normal cervical tissue from cervical cancer, particularly with small tumors.

A cervical tumor typically will retain high signal intensity at high b values and demonstrate low signal intensity on the corresponding apparent diffusion coefficient (ADC) map, in keeping with reduced diffusivity within the lesion.Fig 1: High-b-value DWI sequence demonstrates the hyperintense cervical tumor (arrow).Fig 2: Corresponding ADC map confirms restricted diffusion (arrow).DWI (high b value)Fig 1

ADC map

Fig 2

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CT Imaging

Contrast-enhanced CT plays an important role in determining disease extent in locally advanced cervical cancer.Patients with positive para-aortic lymph nodes have a poor prognosis, with an overall survival of less than 20%–30% at 5 years.1 Evaluation of lymph node status has an effect on radiotherapy planning and dose escalation to the affected areas. MR images demonstrate a large cervical tumor (*), with upper vaginal extension and enlarged external iliac lymph nodes (arrows). CT image in the same patient demonstrates a single aortocaval lymph node (arrow) that measures 8 mm in the short axis.

*

1Herrera and Prior (2013)T2 AxT2 SagAx CT

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FDG PET/CTFDG PET/CT does not play a role in cervical cancer screening or in accurate T staging of the primary tumor because MR imaging is the optimal modality for delineating local tumor extension.

However, the degree of FDG activity of the primary tumor at diagnosis, measured by the maximum standardized uptake value, is a predictive biomarker of lymph node status and disease outcome.1In locally advanced tumors (>stage IB1), the overall staging accuracy is higher with FDG PET/CT than with standard MR imaging or CT.21 Grigsby et al (2001), 2 Choi et al (2010), 3 RCR Recommendations (2014), 4NCCN (2015) Indications for PET/CT3,4Determining the extent of disease in locally advanced cervical cancer (>stage IB1), where the patient is being considered for radical chemoradiation therapy.Assessment of disease extent for patients being considered for pelvic exenteration surgery.

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FDG PET/CT

Case A:

Staging

with FDG PET/CT in a patient with pelvic nodes seen on MR image

(A)

and

nonenlarged

para-aortic lymph nodes seen on contrast-enhanced CT image

(B)

. FDG PET/CT images

(C, D)

demonstrate that these are metabolically active (arrows). The patient required extended-field retroperitoneal radiotherapy.

A: T2

Ax

Case B:

Stage IIIB at MR imaging (not shown) with left pelvic sidewall extension and pelvic and retroperitoneal nodes. FDG PET/CT (maximum intensity projection [MIP] and axial fused) images demonstrate active primary

tumor

(blue arrows) and pelvic and retroperitoneal (pink arrows) and mediastinal and left supraclavicular (orange arrows) nodal involvement.

B: CT

Ax

C: Fused

Ax

FDG PET/CT

D: Fused

Ax

FDG PET/CT

MIP and fused

Ax

FDG PET/CT

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Prognostic FactorsThe clinical stage is an important predictor of progression-free interval and survival.

Other important prognostic factors include:Barwick et al (2013)Tumor sizeHistologic subtype

Histologic grade

Lymph node statusPerformancestatus

Slide28

Lymph Node StatusLymph node metastases are not

a component of FIGO staging; however, lymph node involvement is known to have an adverse effect on survival.1FDG PET/CT is therefore recommended for assessment of locally advanced cervical cancer for stages greater than IB1, where there is a higher pretreatment risk for lymph node involvement.3-5

1 Herrera and Prior (2013), 2Choi et al (2010), 3 NCCN (2015), 4RCR Recommendations (2014),

5SIGN guidelines (2008) Learning point: Confirmation of the extent of nodal disease is important as it may alter patient management.

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Nodal Involvement

Currently, nodal assessment at imaging relies on size and morphologic criteria.In locally advanced tumors, FDG PET/CT is useful in identifying metastatic disease, which can substantially alter patient management. MR and PET/CT images demonstrate a large necrotic right pelvic lymph node (pink arrow) and a homogeneous rounded intermediate-signal-intensity left-sided node (blue arrow). Both show increased tracer uptake at FDG PET/CT.Left pelvic lymph node (arrow) has an irregular posterior contour and has similar signal intensity to that of the primary tumor (*).

*

T2 AxFDG PET/CT AxRCR Recommendations (2014)T2 Ax

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Recommended

treatmentFertility-sparing optionLate Stage: IB2–IVAParametrial invasion substantially increases the risk for lymph node involvement and distal spread.A combination of chemotherapy and radiotherapy should be used.Radiotherapy includes:External beam radiotherapy (conformal or intensity modulated)Internal brachytherapy*Only offered if the tumor maximal diameter is less than 2 cm1

1SIGN guidelines (2008)Early Stage

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Posttreatment Imaging Appearances

Trachelectomy This fertility-sparing procedure involves excision of the cervix as well as surrounding parametrial tissues and local lymph nodes, with formation of a uterovaginal anastomosis. Note the intermediate-signal-intensity cervical tumor on the initial study (arrow) and the appearance after trachelectomy.

After extended cone biopsy Large cone-shaped defect in the cervix is seen on sagittal (Fig 1) and coronal (Fig 2) T2-weighted images. The tumor was completely excised with good margins and confirmed to be stage IA1. Note some postbiopsy irregularity (arrows), which is frequently seen if the biopsy was recent.

Initial studyAfter trachelectomyFig 1Fig 2

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Follow-upIn a study of 993 patients with FIGO stage IB disease, reviewed after primary surgery or chemotherapy,

13% developed recurrent disease.1 In another study, 70% of recurrences occurred within the 1st year after treatment. 2Recurrent disease may not become symptomatic until a late stage, and cervical cytologic sampling has not proven effective in detecting recurrence. Contrast-enhanced CT, FDG PET/CT, or MR imaging are more accurate in detection of recurrent disease than examination alone.MR imaging or contrast-enhanced CT should be considered initially to assess suspected clinical recurrence.FDG PET/CT should be performed prior to pelvic exenteration.1SIGN guidelines (2008), 2Babar et al (2007), 3LCA Gynaecological Cancer Clinical Guidelines (2014), 4Schwarz et al (2007)

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Recurrent Disease

*

*

T2 SagT2 SagT2 SagT2 Ax

Slide34

Management of Recurrent DiseaseThe reported 5-year survival rates for patients with recurrent cervical cancer are

between 3.2% and 13%1. Therapeutic options are:1Lai (2004) 2Peiretti et al (2012)

Slide35

Case 126-year-old womanRoutine Papanicolaou

test positive (high-grade dyskaryosis).Histologic findings from colposcopy demonstrate poorly differentiated squamous cell carcinoma.T2 SagDWI (b = 1000)

ADC map

T2 Ax Results from CT of the thorax, abdomen, and pelvis did not show evidence of metastatic disease.Staging pelvic MR imaging was performed. …What is the local-regional stage?A T2-weighted intermediate-signal-intensity tumor is seen along the posterior lip of the cervix that demonstrates restricted diffusion (arrows), measuring 26 mm in maximal length. There is preservation of the T2 low-signal-intensity cervical stromal ring. There is no vaginal involvement. … Pelvic MR imaging appearances are in keeping with stage IB1.

26mm

The patient was treated with radical hysterectomy and pelvic lymph node dissection. This confirmed a poorly differentiated squamous cell tumor confined to the cervix and without

parametrial

invasion.

Slide36

The pretreatment MR image demonstrates a large cervical tumor (*) with extension into the myometrium and upper vagina. There is definite parametrial

invasion demonstrated on the axial image (arrow) with sparing at the 8–9 o’clock position.There is no involvement of the lower third of the vagina and no evidence of pelvic sidewall spread.… Pelvic MR image appearances are in keeping with stage IIB.What is the locoregional stage for the findings at pretreatment MR imaging?Case 242-year-old womanStaging CT did not demonstrate any extrapelvic diseasePretreatment MR imaging:*

*

The patient opted for an alternative treatment, and a repeat MR study was obtained after 6 months when she returned for medical care.Follow-up MR and restaging CT:

*

The patient then opted for

chemoradiotherapy

.

After

chemoradiotherapy

MR imaging:

There has been interval reduction in the size of the cervical

tumor

; however, a large residual mass remains. Note the left JJ stent within the urinary bladder (arrow).

T2 Sag

T2

Ax

T2 Sag

T2

Ax

Obl

T2

Ax

T2 Sag

CECT

Ax

There has been substantial interval enlargement of the cervical

tumor

(*) with extension to the lower third of the vagina.

Left-sided

parametrial

invasion is once again noted.

CT image demonstrates new left-sided

hydronephrosis

(arrow) and multiple para-aortic (PA) lymph nodes (indicated).

…Pelvic MR image appearances are in keeping with

stage IIIB with positive PA lymph nodes

.

Slide37

Staging MR imaging: the cervical mass (*) extends into the uterus with restricted diffusion. There is no obvious parametrial invasion, but there is abnormal tissue related to the right ovary (#) that is of similar signal intensity to the primary tumor

and also demonstrates restricted diffusion.FIGO staging - stage IIA with ovarian involvement.A staging MR study was performed. What is the stage according to MR imaging?Case 354-year-old woman presented to the emergency room acutely short of breath and was found to have multiple central pulmonary emboli (arrows on CT pulmonary angiogram). Sag CECT

T2 Sag

*T2 Ax*#DWI (b = 1000)*

#

ADC map

*

#

This demonstrates a large cervical mass lesion (*). No enlarged abdominopelvic lymph nodes were identified.

Contrast-enhanced CT performed to rule out occult malignancy.

Ax

CTPA

*

Slide38

Fused

Ax PET/CT MIP PETFDG PET/CT images show that the cervical mass (*) and right ovarian lesion (#) are metabolically active. In addition, there are multiple intensely avid pelvic and retroperitoneal lymph nodes that were below size criteria.Case 3 (continued)The patient completed a course of extended field radiotherapy and brachytherapy and had a complete response.

Fused Ax

PET/CT Fused Ax PET/CT In view of the local disease extent, FDG PET/CT was performed…*#

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SummaryThe FIGO (2009) staging system provides a clinical basis to guide patient management in cervical cancer.

MR imaging provides useful staging information that cannot be determined from clinical examination alone.FDG PET/CT plays a role in locally advanced disease and has good sensitivity and high specificity for detecting lymph node metastases that are indicative of a poorer prognosis.Regular posttreatment follow-up imaging is important to ensure that recurrent disease is identified early and further management options can be considered promptly.

Slide40

Suggested ReadingsThe authors thank Cancer Research UK for their permission to use the line diagrams in this presentation.

The Papanicolaou smear histopathologic slides (slide 6) were kindly contributed by Roberto Dina, MD, consultant histopathologist, Imperial College Healthcare NHS Trust, London, England.Acknowledgments

Freeman SJ, Aly AM, Kataoka MY, Addley HC, Reinhold C, Sala

E. The revised FIGO system for uterine malignancies: implications for MR imaging. RadioGraphics 2012; 32(6):1805-1827. Herrera FG, Prior JO. The role of PET/CT in cervical cancer. Front Oncol 2013; Feb 26;3:34. Sahdev A. Cervical tumors. Semin Ultrasound CT MR 2010; 31(5): 399-413. Sala E, Rockall AG, Freeman SJ, Mitchell DG, Reinhold C. The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know. Radiology 2013; 266(3):717-740. Testa AC, Di Legge A, De Blasis I, et al. Imaging techniques for the evaluation of cervical cancer. Best Pract Res Clin Obstet Gynaecol 2014; 28(5): 741-768.

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References

American College of Radiology Appropriateness Criteria (http://www.guideline.gov/content.aspx?id=43887). Accessed November 12, 2015.Babar S, Rockall A, Goode A, Shepherd J, Reznek R. Magnetic resonance imaging appearances of recurrent cervical carcinoma. Int J Gynaecol Cancer 2007; 17(3): 637–645.Barwick TD, Taylor A, Rockall A. Functional imaging to predict tumor response in locally advanced cervical cancer. Curr Oncol Rep. 2013 Dec;15(6):549-558.

Cancer Research UK. Lifetime risk of cervical cancer. www.cancerresearchuk.org/cancer-info/cancerstats/incidence/risk. Accessed May 13, 2015.Cancer Research UK. Cervical cancer stages. www.cancerresearchuk.org/about-cancer/type/cervical-cancer/treatment/cervical-cancer-stages. Accessed May 13, 2015.Cervical Cancer 2015. www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-risk-factors. Accessed May 13, 2015.Choi HJ, Woong J, Seung KM, Yeol

K. Diagnostic performance of computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with cervical cancer: meta-analysis. Cancer Science 2010; 101; 6:1471–1479.Final Recommendation Statement, Cervical Cancer: Screening March 2012. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening. Accessed May 13, 2015.Grigsby PW, Siegel BA, Dehdashti F. Lymph node staging by positron emission tomography in patients with carcinoma of the cervix. J. Clin. Oncol 2001;19:3745–3749.Guidelines for cervical cancer. National Comprehensive Cancer Network (NCCN). http://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf. Accessed May 13, 2015.Herrera FG, Prior JO. The role of PET/CT in cervical cancer. Front Oncol 2013; Feb 26;3:34.Lai C. Management of recurrent cervical cancer. Chang Gung Med J. 2004 Oct;27(10):711-717.

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References

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