cervical cancer: diagnosis, staging and surveillance

Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD

Cervical Cancer: Staging Cervical Cancer: Staging and Surveillanceand Surveillance

KiwitaKiwita PhillipsPhillips--ArnoldArnoldGillian Lieberman, MD Gillian Lieberman, MD

HMS IVHMS IV

September 2005


22

AgendaAgenda

Patient PresentationPatient Presentation

Introduction to Cervical Cancer Introduction to Cervical Cancer

Pertinent Anatomy Pertinent Anatomy

Imaging Imaging

Conclusion Conclusion

Reference Reference

AcknowledgementsAcknowledgements


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Index Patient: Liver Lesion on CT ScanIndex Patient: Liver Lesion on CT ScanDDX of Liver

Lesion:

1. Abscess

2. Cyst

3. Focal Steatosis

4. Focal Nodular hyperplasia

5. Hemangioma

6. HCC

7. Hematoma

8. Lymphoma

9. MetastasisPACS, BIDMC


44

Index Patient: History Index Patient: History

IS IS isis a 60 a 60 y.oy.o. G1P1 woman . G1P1 woman who presents to ED with who presents to ED with heavy postmenopausal heavy postmenopausal bleeding x 2 days bleeding x 2 days

Past GYN Past GYN HxHx::•• AbnlAbnl pap smear 1970 w/cone biopsy pap smear 1970 w/cone biopsy •• D&C for D&C for menorrhagiamenorrhagia while on while on OCPOCP’’ss•• vaginal bleeding 7 years ago ; vaginal bleeding 7 years ago ;

colposcopycolposcopy done; hysterectomy done; hysterectomy recommendedrecommended

Pt lost to followPt lost to follow--up until nowup until now

High Suspicion of Malignancy High Suspicion of Malignancy –– US and CT doneUS and CT done

DDX of abnormalDDX of abnormaluterine bleeding: uterine bleeding:

1.1. atrophic changesatrophic changes2.2. hormonal status hormonal status 3.3. carcinoma carcinoma 4.4. foreign body foreign body 5.5. traumatrauma6.6. infection infection 7.7. polypspolyps


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Cervical Cancer Cervical Cancer

22ndnd most common cause of cancer related morbidity most common cause of cancer related morbidity and mortality in the developing world and mortality in the developing world

44thth most common malignancy in women in U.S. most common malignancy in women in U.S.

In U.S. mean age of occurrence is 47 In U.S. mean age of occurrence is 47 y.oy.o. .

Signs/Signs/SxSx: : •• abnormal vaginal bleeding abnormal vaginal bleeding •• Post coital bleeding Post coital bleeding •• Vaginal discharge that is watery, purulent, or malodorousVaginal discharge that is watery, purulent, or malodorous

Staging: clinical Staging: clinical

Diagnosis: Diagnosis: abnlabnl Pap Smear, biopsy Pap Smear, biopsy

Imaging may be used for further staging and Imaging may be used for further staging and surveillance for metastasis or recurrencesurveillance for metastasis or recurrence


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Menu of Tests Used for StagingMenu of Tests Used for StagingFIGO Recommended Testing FIGO Recommended Testing

HysteroscopyHysteroscopy-- to inspect to inspect endocervicalendocervical//endometrial canal endometrial canal

CystoscopyCystoscopy –– bladder bladder involvement involvement

ProctoscopyProctoscopy-- bowel bowel involvement involvement

IVP IVP --

CXR + AXR CXR + AXR –– to look for to look for metastasis and spine metastasis and spine involvement involvement

Optional TestsOptional Tests

CT CT –– assess abdomen for assess abdomen for metsmets and pelvis for spread and pelvis for spread

MRI MRI –– gives more information gives more information about tumor size, degree of about tumor size, degree of stromalstromal penetration, nodal penetration, nodal metastasis and local tissue metastasis and local tissue extensionextension

PET PET –– may provide better may provide better assessment of assessment of extrapelvicextrapelvic metastasis esp. lymph nodes; but metastasis esp. lymph nodes; but expensive and not widely expensive and not widely availableavailable

Lymphangiography Lymphangiography –– older older modality used to assess for lymph modality used to assess for lymph node infiltration node infiltration

UltrasonographyUltrasonography


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Anatomy Anatomy

Frank Netter. Atlas of Human Anatomy, Second Edition, 1997.


88

my.webmd.commy.webmd.com/hw/health_ guide_atoz/zm2768.asp/hw/health_ guide_atoz/zm2768.asp

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 non- functioning kidney

Stage IV: Extends beyond pelvis or has involved the bladder mucosa or rectal mucosa

Cervical Cancer StagingCervical Cancer Staging

http://my.webmd.com/hw/health_guide_atoz/zm2768.asp

http://my.webmd.com/hw/health_guide_atoz/zm2768.asp


Index PatientIndex Patient’’s Imagings Imaging


1010

Index Patient:Index Patient: Ultrasound DiagnosisUltrasound 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

PACS, BIDMC


1111

Index Patient:Index Patient: Ultrasound DiagnosisUltrasound Diagnosis

Cervix

PACS, BIDMC

Transvaginal US shows enlarged uterus


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Index Patient: Ultrasound DiagnosisIndex Patient: Ultrasound Diagnosis

Left Ovary:

Normal size and echogenicity

Enlarged Right Ovary:

Normal diameter of ovary is 2x2x3 cm

PACS, BIDMC


1313

Ultrasound FindingsUltrasound Findings

Check for normal size and diameter of pelvic Check for normal size and diameter of pelvic organs organs

Note any areas of Heterogeneity Note any areas of Heterogeneity

Distinct planes should be noted between Distinct planes should be noted between endometrial lining and endometrial lining and myometriummyometrium –– ““Sandwich signSandwich sign”” may be noted or simple may be noted or simple hyperechoichyperechoic stripe stripe


1414

Index Patient: Index Patient: CT Staging and SurveillanceCT Staging and Surveillance

PACS, BIDMC

Large, round, heterogeneous, low attenuation liver mass overlying hepatic vein confluence and IVC noted on contrast delay CT scan


1515

Index Patient CT: Liver MetastasisIndex Patient CT: Liver Metastasis

Impingement of mass on Middle Hepatic Vein

Right Hepatic Vein

PACS, BIDMC

Impingement of middle and right hepatic veins

Lead to hypervascularity seen in other cuts


1616

Index Patient CT: Index Patient CT: Abnormal Gallbladder Abnormal Gallbladder w/Lymphadenopathyw/Lymphadenopathy

Gallbladder-distended w/thickened wall

Node

PACS, BIDMC


1717

Large heterogeneous cervical mass with areas of low attenuation representing necrosis and/or hemorrhage

Uninvolved Rectum

Index Patient CT:Index Patient CT: Suspected Primary Lesion Suspected Primary Lesion –– Cervical MassCervical Mass

PACS, BIDMC


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enlarged, heterogeneous R ovary w/areas of low attenuation suggestive of ovarian primary or spread from endocervical primary

Normal L ovary

Index Patient CT: Ovarian InvolvementIndex Patient CT: Ovarian Involvement

PACS, BIDMC


Companion Imaging Companion Imaging ProceduresProcedures


2020

Grigsby, PW mednews.wustl.edu/ tips/page/normal/910.html

Companion Imaging: PET Imaging of Cervical Cancer

http://mednews.wustl.edu/tips/page/normal/910.html


2121

Companion MR Imaging of Uterine /Cervical Companion MR Imaging of Uterine /Cervical MassMass

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

Bladder Cervical mass

Invasion into paravesical fat

Yoshikazu Okamoto, et al. MR Imaging of the Uterine Cervix: Imaging-Pathologic Correlation. RadioGraphics 2003; 23: 425.


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Index PatientIndex Patient’’s Story Continuess Story Continues

IS was taken to the OR for an exam under anesthesia (EUA); D&C aIS was taken to the OR for an exam under anesthesia (EUA); D&C and nd cervical biopsy:cervical biopsy:•• Palpable lesions w/small cysts deep to cervical mucosaPalpable lesions w/small cysts deep to cervical mucosa•• 10 cm enlarged uterus 10 cm enlarged uterus •• No evidence of No evidence of parametrialparametrial disease, rectal lesions, or culdisease, rectal lesions, or cul--dede--sac sac

nodularitynodularity•• Punch biopsy taken Punch biopsy taken

An USAn US--guided liver biopsy was taken guided liver biopsy was taken

Pathology: Pathology: •• Cervical cyst biopsy showed Cervical cyst biopsy showed adenocarcinomaadenocarcinoma w/ necrotic material and w/ necrotic material and

calcificationscalcifications•• Liver mass was consistent with poorly differentiated Liver mass was consistent with poorly differentiated adenocarcinomaadenocarcinoma

taken from cervix taken from cervix

Stage IB1 by clinical assessment but stage IVB based on imaging Stage IB1 by clinical assessment but stage IVB based on imaging

Patient consented to simple total abdominal hysterectomy; palliaPatient consented to simple total abdominal hysterectomy; palliative tive radiation may be considered radiation may be considered


One Other Interesting One Other Interesting FindingFinding


2424

Index Patient: Interesting Finding


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ReferencesReferences

ChoiChoi, , JoonJoon--Il, Il, SeungSeung HyupHyup Kim, Chang Kim, Chang KyuKyu SeongSeong, Jung , Jung SukSuk SimSim, , HakHak JongJong Lee, KyungLee, Kyung-- Hyun Do. Recurrent Uterine Cervical Carcinoma: Spectrum of ImagiHyun Do. Recurrent Uterine Cervical Carcinoma: Spectrum of Imaging Findings. Korean ng Findings. Korean Journal of Radiology, 2000; 4:198Journal of Radiology, 2000; 4:198--207.207.

JeongJeong, Yong , Yong YeonYeon, , HeoungHeoung KeunKeun Kang, Tae Kang, Tae WoongWoong Chung, Chung, JeongJeong Jin Jin SeoSeo, Jin , Jin GyoonGyoon Park. Park. Uterine cervical carcinoma after therapy: CT and MR imaging findUterine cervical carcinoma after therapy: CT and MR imaging findings. ings. RadiographicsRadiographics. 2003; . 2003; 23(4):96923(4):969--81. 81.

Okamoto, Yoshikazu, Yumiko O. Tanaka, Masato Nishida, Hajime Okamoto, Yoshikazu, Yumiko O. Tanaka, Masato Nishida, Hajime TsunodaTsunoda, Hiroyuki , Hiroyuki Yoshikawa, and Yuji Yoshikawa, and Yuji ItaiItai. MR Imaging of the Uterine Cervix: Imaging. MR Imaging of the Uterine Cervix: Imaging--Pathologic Pathologic Correlation. Correlation. RadioGraphicsRadioGraphics 2003; 23: 425.2003; 23: 425.

PannuPannu, , HarpreetHarpreet K., Frank M. K., Frank M. CorlCorl, and Elliot K. Fishman. CT Evaluation of Cervical Cancer: , and Elliot K. Fishman. CT Evaluation of Cervical Cancer: Spectrum of Disease. Spectrum of Disease. RadioGraphicsRadioGraphics 2001; 21: 11552001; 21: 1155--1168. 1168.

ScheidlerScheidler, , JuergenJuergen, Andreas F. , Andreas F. HeuckHeuck. Imaging of Cancer of the Cervix. Radiologic Clinics . Imaging of Cancer of the Cervix. Radiologic Clinics of North America, 2002; 40: 577of North America, 2002; 40: 577--590.590.

Williams, Penny L., Williams, Penny L., SherelleSherelle L. L. LaiferLaifer--NarinNarin, and , and NageshNagesh RagavendraRagavendra. US of Abnormal . US of Abnormal Uterine Bleeding. Uterine Bleeding. RadiographicsRadiographics, 2003; 23:703, 2003; 23:703-- 718. 718.


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Acknowledgements Acknowledgements Thanks to Following People:Thanks to Following People:

Gillian Lieberman, MD Gillian Lieberman, MD

TejasTejas Mehta, MDMehta, MD

Mary Ellen Sun, MDMary Ellen Sun, MD

Pamela Pamela LepkowskiLepkowski

Larry Larry Barbaras,WebmasterBarbaras,Webmaster

cervical cancer: diagnosis, staging and surveillance

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