Imaging in cervical Malignancy radiology.pptx

IMAGING IN CERVICAL MALIGNANCY

1. CERVICAL MALIGNANCY

2. Cervical cancer is the fourth most common cancer and the fourth most common cause of cancer death in women worldwide. The difference in prevalence between high- and low-income coun -tries is also in part attributed to the difference in access to population screening, which in turn leads to an increase in the risk of long-term untreated human papillomavirus (HPV) infection. The 2009 FIGO staging classification for cervical cancer relied on plainradiography, colposcopy, hysteroscopy, intravenous urography, cystoscopy, proctoscopy, and clinical examination. Assessment for the presence of lymphnode metastases was not included . The new staging classification acknowledges the importance of cross-sectional imaging for more ac-curate staging and prognostication. The inclusion of nodal involvement places greater emphasis on the role of imaging in staging cervical cancer.

3. Pathophysiology

4. PATIENT PREPARATION Field strength should be 1.5T or higher , using a pelvic phased-array coil. Patient in supine position Patients are asked to void their bladder and empty their rectum 30minutes before the examination - the bladder is partially distended at the time of imaging, providing optimal uterine position and preventing image degradation from a full urinary bladder . Pelvic diffusion-weighted imaging (DWI) is susceptible to distortion arising from residual rectal gas Use of saturation bands on the subcutaneous fat (anterior and posterior) is recommended. Patient preparation: Fasting (4-6 hours), empty bladder Use of anti-peristaltic agents ( Buscopan or Glucagon ) - To reduce artifact from small-bowel peristalsis and uterine contractions Optional: vaginal gel to assess upper vaginal involvement Note that contrast-enhanced images are not required for cervical cancer staging. Scheduling the examination according to the menstrual cycle is not required. 

5. MRI PROTOCOL P elvic phased-array coil placed on a patient in the supine position. Sagittal T2-weighted imaging through the pelvis is performed followed by high-resolution small field of view (FOV) imaging planned perpendicular to the long axis of the cervix - local staging of the tumor. H igh-resolution small FOV - morphologic appearances of the primary lesion parametrial and vaginal involvement Large FOV axial T1-weighted and T2-weighted imaging is performed from the renal hila to the pubic symphysis. Large FOV imaging is used to depict disease outside the cervix such as para-aortic lymph node enlargement, hydronephrosis, and bone involvement. P rovides excel-lent soft-tissue contrast that helps distinguish lymph nodes from surrounding fat and helps detect the presence of a nodal fatty hilum

6. Tumor type and size Measured in the largest possible diameter – sagittal plane.

7. Vaginal Invasion

8. Parametrial Invasion vs expansion At MRI, normal cervical stroma demonstrates low T2-weighted signal intensity. Focal or diffuse full-thickness disruption of this low T2-weighted signal intensity cervical stromal ring with tissue extending into the parametrial fat is highly sensitive for parametrial invasion A 3-mm rim of circumferential low T2- weighted signal intensity cervical stroma (the hypointense rim sign) has been found to be 96%–99% specific in excluding parametrial invasion at MRI

9. Pelvic sidewall invasion

10. Sacro -uterine ligament

11. Bladder wall invasion Vs bullous edema

12. LYMPH NODAL STAGING

13. RESPONSE ASSESSMENT

14. The patient was referred to surgery, which is the standard treatment for patients with incomplete response after CRT + brachytherapy.

15. STAGE I Histopathologic analysis as tumors are not visible at MRI . However , pelvic MRI - to ensure that lesions have not been underestimated and to assess for skip lesions and nodal metastases, If malignant cells do not involve the subepithelial layers- as pre invasive disease does not require MRI of the pelvis . T he presence of lymphovascular space invasion (LVSI) depicted at histopathology examination does not change the FIGO stage of a lesion but does affect management . Patients with LVSI at this stage should undergo ad- ditional pelvic lymph node sampling . Tumours less than <2 cms have two-fold increase in the prognosis.

16. STAGE II Upper 2-3rds of the vagina with or without the parametrial involvement Masses larger than 4 cm have a higher chance of recurrence and nodal metastases than do tumors measuring less than 4 cm . Loss of the normal low T2-weighted signal intensity of the vaginal wall that is contiguous with the primary cervical tumor mass When a tumor extends from the cervix into the vagina but does not invade it, a rim of high T2-weighted signal intensity surrounding the mass improves the radiologist’s confidence that the vagina is not involved However , the vaginal wall should be depicted in its entirety in at least two orthogonal planes , as high T2-weighted signal intensity fluid or inflammation can be present in addition to muscle invasion.

17. STAGE III Stage IIIA: Lower One-Third of the Vagina.— The lower one-third of the vagina, based on MRI evaluation, is vaginal tissue below the level of the bladder base . Stage IIIA disease extends to the lower one-third of the vagina and is best appreciated with a sagittal sequence. Tumor demonstrates intermediate signal intensity at T2-weighted imaging and restricted diffusion Stage IIIB: Pelvic Sidewall Involvement.—Stage IIIB disease is defined in the 2018 FIGO staging classification as extension to the pelvic wall that may also manifest with hydronephrosis or a nonfunctioning kidney

18. STAGE IV A Stage IVA.—Extension of the cervical tumor through the full thickness of the bladder wall anteriorly or rectal wall posteriorly and into the mucosa and lumen constitutes stage IVA disease. If there is loss of the normal separating fat plane between the cervix and the bladder or rectum, or the tumor breaches the normal low T2-weighted signal intensity of the bladder or bowel serosa but does not invade into the lumen, this is not stage IVA. This superficial degree of involvement should still be reported to the clinical team to allow appropriate patient counseling. These image findings are normally best appreciated at T2-weighted sagittal and axial oblique imaging It is recommended that mucosal involvement at these sites be confirmed with a biopsy with cystoscopy or proctoscopy before assigning stage IVA A thickened, lobulated, T2-weighted hyperintense , layered appearance of the posterior bladder wall suggests bullous edema secondary to bladder wall inflammation and is not tumor tissue

19. Identifying Lymph Node Involvement Size is the main criterion used to diagnose nodal involvement, with lymph nodes larger than 10 mm in short axis or greater than 8 mm in short axis and round in morphology raising concern. Lymph nodes are considered particularly significant when seen along lymphatic drainage pathways of the primary tumor ( ie , pelvic and para-aortic lymph nodes in cervical cancer ). Morphology – lobulated/speculated/central necrosis. Necrotic nodes - Necrotic nodes have central low attenuation at CT and high T2-weighted with associated low T1-weighted signal intensity at MRI. Importantly, there may be poor central FDG uptake at PET/ CT

20. ROLE OF FDG-PET e depiction of nodal disease and distant metastases. Its role in evaluation of the primary tumor is limited because of low spatial resolution, meaning that it cannot accurately delineate local spread, for example, parametrial extension patients with stage IB1 disease or greater who are eligible for surgical treatment and in patients with stage II– IVA disease to help assess for nodal and distant metastatic disease

21. TREATMENT STRATEGIES 2018 FIGO Stage IA1 Patients with stage IA1 disease who wish to preserve their fertility should be offered conization with cone biopsy, which in the case of a negative margin may be curative. Other methods of conization include loop electrosurgical excision procedure (LEEP), cold knife, or laser techniques. Those with LVSI should also be offered surgical assessment of the lymph nodes with pelvic lymph node dissection

22. to preserve their fertility may be offered definitive surgical treatment with simple or modified radical hysterectomy. A modified radical hysterectomy as described by the gynecologic cancer group of the European Organisation of Research and Trials in Cancer (EORTC) involves removal of the uterus, cervix, and upper 1–2 cm of the vagina (55). The arteries supplying the uterus are tied off at origin, and the medial half of the parametria and proximal uterosacral ligaments are resected A modified radical approach should be accompanied by lymphadenectomy if there is evidence of LVSI or the biopsy margins are positive for carcinoma. A simple hysterectomy is recommended for patients with negative margins after cone biopsy and no LVSI

23. FIGO Stage IA2 For patients with stage IA2 disease who wish to preserve fertility, conization or radical trachelectomy with lymphadenectomy is recommended. Hysterectomy plus lymphadenectomy is the recommended non–fertility-sparing treatment option. For those with known or suspected pelvic nodal disease, para-aortic lymph node biopsy is recommended

24. FIGO Stages IB2 and IIA1 The most appropriate surgical option for patients with lesions between 2 and 4 cm is radical hysterectomy plus lymphadenectomy. combined external beam radiation therapy and brachytherapy with or without concurrent chemotherapy . IB3 and IIA2 onwards - Nonsurgical management, that is, chemoradiotherapy (CRT) is the most appropriate treatme