Download Cervical Cancer: Staging and Surveillance

Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
September 2005
Cervical Cancer: Staging
and Surveillance
Kiwita Phillips-Arnold
Gillian Lieberman, MD
HMS IV
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Agenda
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Patient Presentation
Introduction to Cervical Cancer
Pertinent Anatomy
Imaging
Conclusion
Reference
Acknowledgements
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient: Liver Lesion on CT Scan
DDX of Liver
Lesion:
1. Abscess
2. Cyst
3. Focal Steatosis
4. Focal Nodular
hyperplasia
5. Hemangioma
6. HCC
7. Hematoma
8. Lymphoma
PACS, BIDMC
9. Metastasis
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient: History
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IS is a 60 y.o. G1P1 woman
who presents to ED with
heavy postmenopausal
bleeding x 2 days
Past GYN Hx:
• Abnl pap smear 1970 w/cone biopsy
• D&C for menorrhagia while on OCP’s
• vaginal bleeding 7 years ago ;
colposcopy done; hysterectomy
recommended
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Pt lost to follow-up until now
High Suspicion of Malignancy
– US and CT done
DDX of abnormal
uterine bleeding:
1.
2.
3.
4.
5.
6.
7.
atrophic changes
hormonal status
carcinoma
foreign body
trauma
infection
polyps
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Cervical Cancer
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2nd most common cause of cancer related morbidity
and mortality in the developing world
4th most common malignancy in women in U.S.
In U.S. mean age of occurrence is 47 y.o.
Signs/Sx:
• abnormal vaginal bleeding
• Post coital bleeding
• Vaginal discharge that is watery, purulent, or malodorous
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Staging: clinical
Diagnosis: abnl Pap Smear, biopsy
Imaging may be used for further staging and
surveillance for metastasis or recurrence
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Menu of Tests Used for Staging
FIGO Recommended Testing
 Hysteroscopy- to inspect
endocervical/
endometrial canal
 Cystoscopy – bladder
involvement
 Proctoscopy- bowel
involvement
 IVP  CXR + AXR – to look for
metastasis and spine
involvement
Optional Tests
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CT – assess abdomen for mets
and pelvis for spread
MRI – gives more information
about tumor size, degree of
stromal penetration, nodal
metastasis and local tissue
extension
PET – may provide better
assessment of extrapelvic
metastasis esp. lymph nodes; but
expensive and not widely
available
Lymphangiography – older
modality used to assess for lymph
node infiltration
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Ultrasonography
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Anatomy
Frank Netter. Atlas of Human Anatomy, Second Edition, 1997.
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Cervical Cancer Staging
FIGO Staging System:
Stage 0: Carcinoma in situ
Stage I: Confined to Uterus
Stage II: Invades beyond Uterus
but not to pelvic side wall or lower
third of vagina
Stage III: Extends to pelvic wall,
and.or involves lower third of
vagina, and/or causes
hydronephrosis or nonfunctioning kidney
my.webmd.com/hw/health_
my.webmd.com/hw/health_ guide_atoz/zm2768.asp
Stage IV: Extends beyond pelvis
or has involved the bladder
mucosa or rectal mucosa
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient’s Imaging
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient:
Ultrasound Diagnosis
Enlarged endometrial circumference
in postmenopausal woman Normal
premenopausal endometrium
measures: 8 x 4 x 4 cm
Thickened endometrial lining noted;
> 10mm abnl
Widened cervical diameter +
heterogeneity and indistinct
margins consistent with
neoplastic infiltration
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient:
Ultrasound Diagnosis
Cervix
Transvaginal US shows enlarged uterus
PACS, BIDMC
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient: Ultrasound Diagnosis
Left Ovary:
Normal size and
echogenicity
Enlarged Right Ovary:
Normal diameter of
ovary is 2x2x3 cm
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Ultrasound Findings
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Check for normal size and diameter of pelvic
organs
Note any areas of Heterogeneity
Distinct planes should be noted between
endometrial lining and myometrium –
“Sandwich sign” may be noted or simple
hyperechoic stripe
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient:
CT Staging and Surveillance
Large, round,
heterogeneous, low
attenuation liver mass
overlying hepatic
vein confluence and
IVC noted on contrast
delay CT scan
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
 Impingement of
middle and right
hepatic veins
 Lead to
hypervascularity
seen in other cuts
Index Patient CT: Liver Metastasis
Impingement of
mass on Middle
Hepatic Vein
Right Hepatic Vein
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient CT:
Abnormal Gallbladder w/Lymphadenopathy
Gallbladder-distended
w/thickened wall
Node
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient CT:
Suspected Primary Lesion – Cervical Mass
Uninvolved
Rectum
PACS, BIDMC
Large heterogeneous cervical
mass with areas of low
attenuation representing
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necrosis and/or hemorrhage
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient CT: Ovarian Involvement
Normal L ovary
enlarged, heterogeneous R ovary
w/areas of low attenuation
suggestive of ovarian primary or
spread from endocervical
primary
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PACS, BIDMC
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Companion Imaging
Procedures
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Companion Imaging: PET Imaging of Cervical Cancer
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Grigsby, PW mednews.wustl.edu/ tips/page/normal/910.html
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Companion MR Imaging of Uterine /Cervical
Mass
Invasion into
paravesical fat
Bladder
Cervical
mass
Sagittal T2-weighted MR image:
hyperintense, solid mass extending
along the anterior vaginal wall to lower
one-third of the vagina
(arrow)
Axial T2-weighted MR image: low
signal intensity of the anterior vaginal
wall is partly disrupted (arrowheads);
little fatty tissue but bladder uninvolved
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Yoshikazu Okamoto, et al. MR Imaging of the Uterine Cervix: Imaging-Pathologic Correlation.
RadioGraphics 2003; 23: 425.
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient’s Story Continues
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IS was taken to the OR for an exam under anesthesia (EUA); D&C and
cervical biopsy:
• Palpable lesions w/small cysts deep to cervical mucosa
• 10 cm enlarged uterus
• No evidence of parametrial disease, rectal lesions, or cul-de-sac
nodularity
• Punch biopsy taken
An US-guided liver biopsy was taken
Pathology:
• Cervical cyst biopsy showed adenocarcinoma w/ necrotic material and
calcifications
• Liver mass was consistent with poorly differentiated adenocarcinoma
taken from cervix
Stage IB1 by clinical assessment but stage IVB based on imaging
Patient consented to simple total abdominal hysterectomy; palliative
radiation may be considered
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
One Other Interesting
Finding
Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Index Patient: Interesting Finding
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
References
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Choi, Joon-Il, Seung Hyup Kim, Chang Kyu Seong, Jung Suk Sim, Hak Jong Lee, KyungHyun Do. Recurrent Uterine Cervical Carcinoma: Spectrum of Imaging Findings. Korean
Journal of Radiology, 2000; 4:198-207.
Jeong, Yong Yeon, Heoung Keun Kang, Tae Woong Chung, Jeong Jin Seo, Jin Gyoon Park.
Uterine cervical carcinoma after therapy: CT and MR imaging findings. Radiographics. 2003;
23(4):969-81.
Okamoto, Yoshikazu, Yumiko O. Tanaka, Masato Nishida, Hajime Tsunoda, Hiroyuki
Yoshikawa, and Yuji Itai. MR Imaging of the Uterine Cervix: Imaging-Pathologic
Correlation. RadioGraphics 2003; 23: 425.
Pannu, Harpreet K., Frank M. Corl, and Elliot K. Fishman. CT Evaluation of Cervical Cancer:
Spectrum of Disease. RadioGraphics 2001; 21: 1155-1168.
Scheidler, Juergen, Andreas F. Heuck. Imaging of Cancer of the Cervix. Radiologic Clinics
of North America, 2002; 40: 577-590.
Williams, Penny L., Sherelle L. Laifer-Narin, and Nagesh Ragavendra. US of Abnormal
Uterine Bleeding. Radiographics, 2003; 23:703- 718.
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Kiwita Phillips-Arnold, HMS IV
Gillian Lieberman, MD
Acknowledgements
Thanks to Following People:
 Gillian Lieberman, MD
 Tejas Mehta, MD
 Mary Ellen Sun, MD
 Pamela Lepkowski
 Larry Barbaras,Webmaster
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