1. Dr
Esther
MF
Wong
Associate
Consultant
Department
of
Radiology
Pamela
Youde
Nethersole
Eastern
Hospital
Hong
Kong

2. Outline
• Overview
• Brief
review
on
FIGO
staging
system
• Protocol
and
preparation
• MRI
• Parametrial
invasion
• Vaginal
Invasion
• DWI
• Lymph
node
status
• Recent
advances

3. Background
• 3rd
most
common
cancer
death
in
women
worldwide
• Declining
incidence
in
developed
countries
• In
Hong
Kong
2010
• 400
new
cases
of
cervical
cancer
• crude
incidence
rate
was
10.7
per
100000
female
population..
• Histology:
• Squamous
carcinoma
85%
• adenocarcinoma,
for
15%
• adenoid
cystic,
small
cell,
adenosquamous
carcinoma,
and
lymphoma

4. Survival
rate
by
stage
Stage
5-Year
0
IA
IB
IIA
IIB
IIIA
IIIB
IVA
IVB
93%
93%
80%
63%
58%
35%
32%
16%
15%
Adopted from American cancer society

5. Scheme
of
treatment
1A1
Fertility
Preservation
(Cone biopsy, LEEP
Radical trachelectomy
1A2
I B1
II A1
I B2, II A 2
II B – IV A
IV B
Radical
hysterectomy
+/- Pelvic
lymphadenectomy
Radiotherapy
Chemotherapy

6. FIGO
• International
Federation
of
Obstetric
and
Gynaecology
• Most
widely
adopted

7. Ca
cervix
• FIGO
2009

9. FIGO
-­‐weakness
• Based
on
clinical
assessment
and
simple
investigation
• errors
in
clinical
staging
• Stage
I:22%
• Stage
III:
75%
• Failure
to
recognize
parametrial
invasion,
pelvic
side
wall,
bladder
or
rectal
wall
spread
clinically
• Does
not
address
presence
of
lymphadenopathy,
an
important
prognostic
indicator

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

11. Staging
MRI
for
cervical
carcinoma

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

13. 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

14. MRI
–
what
to
look
for?

15. FIGO
2009

16. MRI
–
what
to
look
for
• Parametrial
invasion
• Vaginal
involvement
• Hydroureter
• Pelvic
side
wall
involvement
• Mucosa
of
rectum
and
bladder
• Pelvic
lymphadenopathy

17. How
accurate
are
we?
Imaging
Finding
Source
Parametrial
invasion
Vaginal
extension
Pelvic
sidewall
extension
Bladder
extension
Lymph
node
invasion
Overall
Sensitivity
Specihicity
Accuracy
(%)
(%)
(%)
90–94
83–94
86–95
96–99
88–91
76–91
…
…
…
71
94
…
…
83
100
89
70–95
…

18. 1.
Parametrial
invasion

19. Parametrial
invasion
• Soft
tissue
mass
extending
to
the
parametrium
• Preservation
of
T2
hypointense
hibrous
stroma
ring.
• High
negative
predictive
value
for
parametrial
invasion
• Stromal
ring
disruption:
sign
of
microscopic
invasion

23. Bilateral
parametrial
invasion

24. Diagnostic
dilemma
• Disrupted
stromal
line
without
frank
soft
tissue
mass
in
the
parametria
• Pre-­‐existing
endometriosis
• Microscopic
invasion

25. 2.
Vaginal
extension

26. Vaginal
involvement
can
be
evaluated
on
PV
examination.
Why
bother
about
it
on
MRI?

27. MRI
PV
examination
Seeing
Signal
change
Seeing
masses/
mucosal
change
–
microscopic
disease
Fornices
clearly
visualized
Errors
in
bulky
tumour
distorting
the
fornices

30. Vaginal
invasion
• Disruption
of
hypointense
wall
at
T2
weighted
imaging

32. 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.

33. Expel
all
large
air
bubbles
to
reduce
susceptability
artefact
1. Stand
the
syringe
tip
upwards
for
1
hour
2. Hit
the
syringe
forcefully
against
hard
surface

35. 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!!!

37. 3.
Pelvic
sidewall
involvement

38. Pelvic
side
wall
involvement
• By
clinical
examination
–
tumour
attached
to
pelvic
side
wall
• Predictability
on
MRI
• Direct
tumour
extension
to
pelvic
musculature
/iliac
vessel
• include
tumor
within
3
mm
of
or
abutment
of
the
internal
obturator,
levator
ani,
and
pyriform
muscles
and
the
iliac
vessels

39. Obturator
internus
Levator
ani

40. Piriformis

43. 4.
Hydronephrosis

44. Hydronephrosis
• Look
for
distended
ureter

47. 5.
Lymphadenopathy

48. lateral
Hypoga
stric
Uterine arteryexternal iliac Internal
iliac
Poster
ior
lateral
sacral

49. Predictability
of
Lymph
node
involvement
on
MRI
• Size
criteria
• Upper
limit
6-­‐15mm
• Sensitivity
36-­‐89.5%
• Accuracy
76-­‐100%
• Shape
• Spiculated
margin
and
heterogenous
intensity
strong
predictor
of
nodal
involvemnet
• Due
to
desmoplastic
reaction/
inhiltration
into
the
perinodal
fat

50. Short axis: 0.8cm

52. ADC = 0.817 x
10(-3)mm(2)/s

53. SUV Max 4.4

55. Nodal
staging
• Problems:
• Micrometastasis
• Normal
sized
lymph
node
harbouring
small
metastases.
• Techniques
to
improve
nodal
staging
• Contrast
• DWI

56. 4.
Invasion
to
adjacent
organs

58. This
is
not
Stage
IV!!!

59. FIGO/
TNM
staging
• The carcinoma has extended beyond the true pelvis or has
involved (biopsy proven) the mucosa of the bladder or
rectum. A bullous oedema , as such, does not permit a
case to be allotted to Stage IV

61. This
is
also
not
Stage
IV!!!

62. Radiologist:
…..
Tumour
penetrates
the
mesorectal
fascia
and
involves
the
perirectal
fat…
Gynaecologist:
No!
I
did
not
feel
any
rectal
involvement
on
PR
and
there
is
nothing
wrong
on
proctoscopy!
Pathologist:
No
malignant
cell
is
seen
in
rectal
biopsy

63. C’est la vie!

64. Problem
with
FIGO
staging
• Non-­‐mucosal
involvement
of
adjacent
organ
Q: Would you like to know if there is nonmucosal involvement of adjacent organ
as in this case?
A: Yes!
Q: Would you consider this as a Stage
IVa disease?
A: No!
Q: Would you treat it like one Stage
down?
A: No!

65. Do
we
need
a
new
/
modihied
staging
system?
MRI/CT

66. Recent
advances

67. Diffusion
weighted
imaging
• Increase
lesion
conspicuity
• Isointense
tumour
• Small
tumour
• Nodal
assessment
• Assessment
of
treatment
response
• Prognostic
implication

68. DWI
• b
values
(50,
500,
1000)
• Low
b
values
-­‐>
black
blood
sequence
• High
b
values
-­‐>
increase
tumour
conspicuity

70. b=50
b=1000
b=500
ADC

71. Inverted
ADC
Tumour
ADC
Tumour
Inverted ADC

72. Tumour
Inverted ADC
T2

74. ADC
Inverted ADC

80. ADC

81. Inverted
ADC

82. Co-­‐registration
with
T2
image

83. ADC
affected
side

84. ADC
unaffected
side

85. Pitfalls
• The
following
may
exhibit
restricted
diffusion:
• Blood
products
(e.g.
after
cone
biopsy)
• Fibrosis
(post-­‐irradiation/desmoplastic
reaction)

86. Cut
off
ADC
value?
Article
B
value
Normal
cervical
Cervical
tumour
(x
10-­‐3
mm
2
)
stroma
(x
10-­‐3
mm
2
)
Chen
Jianyu
et.
al
0,
800
1.593
+/-­‐
0.151
1.11
+/-­‐0.175
Fei
Kuang
et
al
0,
600
1.55
+/-­‐
0.28
0.91
+/-­‐
0/15
0.
1000
1.41
+/-­‐
0.28
0.81+/-­‐0.13

87. ADC min 0.881 x 10-3mm2

89. Mean ADC 0.68x 10-3 mm 2
Mean ADC 0.51x 10-3 mm 2
Min ADC 0.35 x 10-3 mm 2

90. Conclusion
• MRI
signs
for
staging
Ca
cervix
• Current
FIGO
staging
system?
Appropriate
• Functional
imaging
-­‐
DWI

91. Acknowledgement
• Dr.
KK
Tang
• Consultant
• Department
of
Obstetrics
and
Gynaecology,
Pamela
Youde
Nethersole
Eastern
Hospital
• Dr.
Catherine
Wong
• Associate
Consultant
• Department
of
Nuclear
Medicine,
Pamela
Youde
Nethersole
Eastern
Hospital
• Dr.
Soong
Sung,
Inda
• Associate
Consultant
• Department
of
Oncology,
Pamela
Youde
Nethersole
Eastern
Hospital
• Grace
Chan
• Department
Operation
manager
•
Department
of
Radiology,
Pamela
Youde
Nethersole
Eastern
Hospital
• PO
Chan
• Radiographer
I
• Pamela
Youde
Nethersole
Eastern
Hospital

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93. esthermfwong@gmail.com