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
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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
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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.
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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
Kiwita Phillips-Arnold, HMS IV Gillian Lieberman, MD
Index PatientIndex Patient’’s Imagings Imaging
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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
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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
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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
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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
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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
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Index Patient CT: Index Patient CT: Abnormal Gallbladder Abnormal Gallbladder w/Lymphadenopathyw/Lymphadenopathy
Gallbladder-distended w/thickened wall
Node
PACS, BIDMC
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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
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Companion Imaging Companion Imaging ProceduresProcedures
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Grigsby, PW mednews.wustl.edu/ tips/page/normal/910.html
Companion Imaging: PET Imaging of Cervical Cancer
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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
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One Other Interesting One Other Interesting FindingFinding
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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