This document summarizes staging and investigations for cancers of the cervix and uterus. It discusses the epidemiology, risk factors, clinical presentation, screening, diagnosis and imaging for cervical cancer. Screening includes Pap smears, colposcopy and biopsy. Imaging includes pelvic MRI, cystoscopy and CXR/CT for staging. Similarly for endometrial cancer, it discusses epidemiology, risk factors, clinical presentation of abnormal bleeding, and diagnostic tools including endometrial biopsy and D&C. Imaging includes ultrasound, CT and MRI to assess myometrial invasion and metastatic workup includes chest imaging for staging.

1. Staging and investigations of Ca cervix and
body of uterus
Dr Atul Gupta
Junior Resident
Department of Radiation Oncology
AIIMS Jodhpur

2. Ca Cervix
Epidemiology
. The global cervical cancer burden is disproportionally high in low and
middle-income countries, where 83% of all new cases and 85% of
cervical cancer deaths occur .
. India accounts for nearly one-fourth of the world’s cervical cancer
deaths, with 60,078 deaths and 96,922 new cases in 2018 .
. This largely preventable disease is the second most common cause
of cancer mortality among Indian women.

3. Risk Factors
Various risk factors are implicated in development of cervical cancer-
1. Multiparity
2. Cigarette Smoking
3. Early onset of sexual intercourse(<17yrs)
4. Long term use of oral contraceptive pills
5. Multiple sex partners
6. HPV Infection (Type 16 & 18 are responsible for 70-80% of cervical
cancers)
7. Age- Bimodal age distribution (35-39yrs & 60-64yrs of age)

6. 1. Clinical presentation :-
. Pre invasive disease is usually detected during routine cervical cytologic
screening.
. Early invasive disease may not be associated with any symptoms and is
also usually detected during screening examinations.
. The earliest symptom of invasive cervical cancer is usually abnormal
vaginal bleeding, often following coitus or vaginal douching. This may be
associated with a clear or foul-smelling vaginal discharge.
. Pelvic pain may result from loco-regionally invasive disease or from
coexistent pelvic inflammatory disease.

7. Contd....
. Flank pain may be a symptom of hydronephrosis, which may be
complicated by pyelonephritis.
. Patients with very advanced tumors may have hematuria or
incontinence from a vesicovaginal fistula caused by direct extension
of tumor to the bladder.
.External compression of the rectum by a massive primary tumor may
cause constipation, but the rectal mucosa is rarely involved at initial
diagnosis.

8. Screening & Diagnosis of CA cervix
1. Cytological Examination (Pap Smear)
2. Colposcopy
3. Biopsy

9. 1. Cytological Examination (Pap smear)
. The US Preventive Services Task Force (USPSTF) recommends
screening for cervical cancer in women aged 21 to 65 years with cytology
every 3 years or,
. for women aged 30 to 65 years, screening with a combination of cytology
and HPV testing every 5 years.
. Women with risk factors that place them at higher risk for CIN may
require more frequent screening. These risk factors include HIV infection,
immunosupression, exposure to diethylstilbesterol in utero, and previous
treatment for CIN 2, CIN 3, or cervical cancer.

13. 2. Colposcopy:-
. Indications :-
. Women with ASC-US and a negative HPV screening may be
followed up in 1 year for a repeat Pap smear and HPV co-testing.
. If the HPV screen is positive, colposcopy is indicated.
.If HPV screening is unavailable, repeat cytology may be done at 12 months.
. All patients with SIL or atypical glandular cells should undergo colposcopy.

14. Interpretation :-
. Viewing the the size and margins of an abnormal transformation zone
cervix with 10–20 × magnification allows for assessment of and
determination of extension into the endocervical canal.
. The application of 3–5% acetic acid dissolves mucus, and the acid’s
desiccating action sharpens the contrast between normal and actively
proliferating squamous epithelium.
. Abnormal changes include white patches and vascular atypia, which
indicate areas of greatest cellular activity.

19. 3. Cervical Biopsy and Endocervical Curettage or Conisation:-
. These procedures are necessary steps after a positive Pap
smear to determine the extent and depth of invasion of the cancer.
. Even if the smear is positive, treatment with additional surgery or
radiation is never justified until definitive diagnosis has been
established through biopsy.

21. Cone Biopsy
. Cone biopsy (ie, conization) is recommended if the cervical punch
biopsy is inadequate to define invasiveness or if accurate
assessment of microinvasive disease is required

23. Imaging in Ca Cervix
1. Pelvic MRI with contrast- preferred for assessing local disease extent
(preferred for FIGO stage >1B2)
2. Cystoscopy and proctoscopy are only recommended if bladder or rectal
extension is suspected (ie, for ≥ stage IB3)
3. Chest Imaging-
. in stage 1, Plain CXR is preferred , if any abnormalities seen then
CECT
Thorax is done.
. In stage 2 onwards, CECT thorax is preferred.

24. Contd...
4. Metastatic workup-
. Neck/chest/abdomen/pelvis/groin PET/CT (preferred) or
chest/abdomen/pelvic CT to evaluate for metastatic disease.
. Other initial imaging should be based on symptomatology and
clinical concern for metastatic disease.
. Contrast enhanced brain MRI is done as an initial investigation in
c/o small cell neuroendocrine cervical cancer.

27. Endometrial carcinoma
Epidemiology
. Endometrial cancer is the commonest gynaecological cancer mostly
affecting women in the post-menopausal age group.
. Rates vary worldwide and are highest in white women in Western
populations.
. In the United States, white women are more likely to be diagnosed
with endometrial cancer than African-American and Asian. The age-
adjusted incidence rate for white women is 24.8 per 100,000 women,
whereas it is 20.9, 18.2 for African-American and Asian respectively.

28. Risk factors:-
. Occurs principally in post-menopausal women, and the incidence rises
with age.
. Early age at menarche and late age of menopause
. Obesity and unopposed oestrogen as HRT are thought to increase the risk.
. Women with breast cancer taking tamoxifen, which exerts oestrogenic
agonist effects on the endometrium, have an increased risk of polyps,
hyperplasia, and sometimes carcinoma.
. Diabetes, nulliparity , PCOD with prolonged anovulation
. Higher parity, smoking, and use of estrogen-progestin hormonal
contraception are known to decrease risk.

29. Contd....
Genetic Risk Factors-
. Genetic factors contribute to only about 10% of endometrial cancers,
mostly due to hereditary nonpolyposis colorectal cancer (HNPCC), also
known as Lynch syndrome, and, to a lesser degree, Cowden syndrome.
. Both of these genetic conditions follow autosomal dominant inheritance
patterns.

30. Pathology :-
Two types of endometrial cancer are usually recognized—types 1 and 2.
• Type 1 is usually endometrioid and occurs in younger women with
obesity and excess oestrogen exposure and generally carries a better
prognosis.
.Type 2 occurs in older women with serous, clear cell, or other variants
and has a more aggressive pattern. Carcinosarcomas may be associated
with this type. The prognosis is usually much worse.

32. Clinical presentation:-
. The classic presenting sign of endometrial cancer is abnormal vaginal
bleeding mostly in postmenopausal period.
. However, other symptoms can be seen, including bloating, pelvic pain, or
dyspareunia.
. Type II endometrial cancers may not present with symptoms until
advanced disease is present, at which time, systemic symptoms
(nausea, vomiting, change in bowel habits, anorexia) may be present.

33. Diagnosis:-
1. Office Endometrial Biopsy-
. Office endometrial biopsy is the preferred approach to establish the
diagnosis of endometrial cancer.
.Its sensitivity in detecting endometrial cancer in postmenopausal
women is close to 99%, compared to about 91% in
premenopausal women, and its specificity is >98% for both groups

36. 2. Dilatation and curettage:-
. Office endometrial biopsies have a false-negative rate of about 10%.
So Negative Endometrial biopsy in a symptomatic patient must be
followed by a fractional dilation and curettage (D&C) under anesthesia.
.If symptoms persist, or the biopsy sampling is inadequate, or the
patient is being considered for conservative fertility-sparing
approaches, a dilatation and curettage should be performed instead.
. To confirm a diagnosis of endometrial cancer, a tissue diagnosis
is required and must not be substituted by imaging studies.

37. 3. Transvaginal USG-
. Transvaginal ultrasonography may be a useful imaging modality,
particularly in patients who are medically compromised such that
obtaining a tissue sample is not feasible.
. Normal endometrium looks thin and homogenously hyperechoic, but in
endometrial cancer, it becomes thickened and heterogenous with
hyperplasia, polyps, and tumors.
. The consensus statement from the Society of Radiologists in Ultrasound
has defined an endometrial thickness of ≥5 mm as being abnormal. If the
thickness of the endometrium is <5 mm, the risk of endometrial cancer is
minimal; the false-negative rate is approximately 4%.

38. 4. CT Imaging:-
. Computed tomography (CT) imaging can be helpful in assessing the
extent of disease, especially for those with higher grade histology and
high-risk histologic subtypes such as serous or clear cell carcinoma
as opposed to those with endometrial hyperplasia or endometrioid low-
grade carcinoma.

39. 5. MRI :-
. Magnetic resonance imaging (MRI), especially dynamic contrast-
enhanced MRI, is very useful in detecting
myometrial invasion, with an accuracy of 85% to 93%.
. In patients with suspected cervical involvement,
preoperative MRI may also help determine whether the uterine tumor
involves the lower uterine segment or truly extends into the cervix.
. Gross cervical involvement in endometrial cancer is rare but
important to document because it could influence surgical treatment
(radical hysterectomy as opposed to simple hysterectomy).

40. Metastatic workup:-
1. Consider chest imaging (chest x-ray). If an abnormality is seen,
then chest CT without contrast may be performed.
2. For high-grade carcinoma, consider chest/abdominal/pelvic CT to
evaluate for metastatic disease.
3. Consider neck/chest/abdomen/pelvis/groin PET/CT if metastasis
is suspected in select patients.
4. Other initial imaging should be based on symptomatology and
clinical concern for metastatic disease.

44. Thanks