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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 Patient Presentation Introduction to Cervical Cancer Pertinent Anatomy Imaging Conclusion Reference Acknowledgements 2 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 3 Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Index Patient: History 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 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 4 Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Cervical Cancer 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 Staging: clinical Diagnosis: abnl Pap Smear, biopsy Imaging may be used for further staging and surveillance for metastasis or recurrence 5 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 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 6 Ultrasonography Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Anatomy Frank Netter. Atlas of Human Anatomy, Second Edition, 1997. 7 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 8 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 10 PACS, BIDMC Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Index Patient: Ultrasound Diagnosis Cervix Transvaginal US shows enlarged uterus PACS, BIDMC 11 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 12 PACS, BIDMC Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Ultrasound Findings 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 13 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 14 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 15 PACS, BIDMC Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Index Patient CT: Abnormal Gallbladder w/Lymphadenopathy Gallbladder-distended w/thickened wall Node 16 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 17 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 18 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 20 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 21 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 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 22 Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD One Other Interesting Finding Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD Index Patient: Interesting Finding 24 Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD References 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. 25 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 26