SCBT 11: Revised FIGO: What Every Radiologists Needs to Know. Susan M. Ascher, M.D. Georgetown University School of Medicine Washington, DC

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1 SCBT 11: Revised FIGO: What Every Radiologists Needs to Know Susan M. Ascher, M.D. Georgetown University School of Medicine Washington, DC

2 GYNECOLOGIC MALIGNANCY: LECTURE OUTLINE ENDOMETRIAL & CERVICAL CA Relevant questions for imaging/mri Protocol Staging Criteria (Revised FIGO) Pearls & Pitfalls Cases throughout Imaging recommendations

3 GYNECOLOGIC CANCER: IMAGING OBJECTIVES Detection Most cost effective way to detect? Staging: International J of Gyn & OB 2009;105:103 Criteria: Pearls and pitfalls Surveillance

4 BUT FIRST: GYN CANCER: PROTOCOL Sequence Ax T2 SS FSE Sag/Ax T2 FSE Cor T2 FSE* Ax T1 SGE (w/ & w/o FS) Cor 3D RARE* Dynamic & delayed Sag Gd 3D VIBE/FAME DWI/ADC Rationale Assess ut/cervix axis ID & stage tumor Assess para & vagina Assess spread & LN MR urogram Assess tumor viability, LN & fistula formation Detection & tx response * For Cervix Cancer

5 ENDOMETRIAL CANCER: EPIDEMIOLOGY Incidence 43,470 new cases/year* Most common invasive gyn malignancy 4 th most common cancer in women Mortality rate: 7,950 deaths/year* Overall 5 year survival: 75% (present early) Peak incidence: years Known risk factors Common pathway: Unopposed E stimulation *NCI 2010 (cancer.gov)

6 ENDOMETRIAL CANCER: EPIDEMIOLOGY Adenocarcinoma: 80-90% Grade 1-Grade 3* Adenosquamous carcinoma Papillary serous carcinoma* Clear-cell carcinoma* * Poor prognosis: mimics ovarian cancer should know histo & grade!

7 ENDOMETRIAL CANCER: 5 YEAR SURVIVAL RATES Stage I: 85.3% (40-100%)* * REFLECTS DIFFERENCES IN MYO INV Stage II: 70.2% < 50% IA/IB (IA) Stage III: 49.2% 50% IC (IB) Stage IV: 18.7% % (New FIGO) 40-60% (New FIGO) * Para-aortic lymph node involvement < 50% IA/IB (IA) 5% (New FIGO) IC (IB) 50% (New FIGO) DiSaia PJ, et al. Am J Obstet Gynecol 1985; 151:10009

8 ENDO CA STAGING: RELEVANT QUESTIONS FOR MRI Depth of myometrial invasion? Extension to cervix? Lymph node metastases? Frei K, et al Radiology 2000; 216:

9 OLD ENDO CA NEW IA IB > < 50% myo inv IA IC 50% myo inv IB IIA Endocervical canal I A/B IIB IIIA IIIB Cervical stromal inv Serosa & perit fat ext Vaginal ext II IIIA IIIB

10 OLD ENDO CA NEW IIIC Lymphadenopathy < IIIC1 IIIC2 Pelvic Para Ao IVA Bladder +/- bowel inv IVA IVB Distant metastases IVB Sarcomas Different staging MMMT (Eca) LMS & ESS AS

11 STAGING DIRECTS THERAPY! Multidisciplinary approach depending on tumor stage & histology Early Stage: Simple TAH & BSO LN sampling if poor histology Adjuvant RT/chemo if poor prog factors Late Stage: TAH, BSO & Lymphadenectomy RT for local control if poor prog factors

12 ENDOMETRIAL CA What Stage?

13 ENDOMETRIAL CA: MR THE VALUE OF CONTRAST tumor-myometrial interface!? Sala E, et al Int J Gynecol Cancer 2009; 19:141

14 Co-Existent Pathology & Thinned Myometrium??

15

16 Diagnostic Imaging: Gynecology Case 4: ENDOMETRIAL CA: Stage?

17 ? ENDO CA: STAGE IA IB

18 Endometrial CA: Stage? NO! ENDO CA:? STAGE II

19 ENDO CA: STAGE: II Courtesy of S. Mironov, MD, NY, NY

20 Endometrial CA: Stage?

21 ENDOMETRIAL CA: STAGE IB vs IIIA? Courtesy of Diagnostic Imaging: Gynecology, Amirys 2007

22 ENDOMETRIAL CA: Stage?

23 A WORD ABOUT LYMPH NODES Pelvic nodes > 8 mm are abnormal (100%) Pelvic nodes > 6 mm are suspicious (80%) MRI > CT for small nodes (< 10mm) Fukuda et al. Clin Rad, 1999 Brown et al. Radiology, 2003

24 A WORD ABOUT LYMPH NODES LYMPHADENOPATHY: DISTANT DZ Above the renal hilum Inguinal

25 CERVIX CANCER: EPIDEMIOLOGY Incidence: 12,200 new cases/year* 3 rd most common gyn malignancy Mortality rate: 4,210/year Overall 5 year survival: 67% 5 year survival for early stage dz: 90% Median age: 45 years Known risk factors Histology: Squamous cell ca (85%) *NCI 2010 (cancer.gov)

26 CERVIX CANCER: 5 YEAR SURVIVAL RATES Stage I: % Stage II: 60-88% Stage III: 25-48% Stage IV: 18-34%

27 CERVIX CA STAGING: RELEVANT QUESTIONS FOR MRI Tumor location? Cervical vs endometrial Tumor size? Within.5 cm at pathology Parametrial invasion? Lymph node metastases? Kaur et al. AJR, 2003; Sahdev et al. IJGO, 2007

28 CERVICAL CANCER: REVISED STAGING Use of diagnostic imaging is encouraged but not mandated

29 CERVIX CANCER OLD NEW IB1 Tumor 4cm IB1 IB1 Tumor > 4cm IB2 IIA Upper 2/3 vag ext < IIA1 IIA2 4cm > 4cm IIB Parametrial inv IIB

30 CERVIX CANCER OLD IIIA IIIB IVA IVB Lower 1/3 of vagina ext Sidewall inv or hydro Bladder +/- bowel inv Distant metastases NEW IIIA IIIB IVA IVB

31 CERVICAL CANCER: WHY STAGE? Treatment Distinguish early from late stage Early Stage SURGERY Late Stage RT +/- chemotherapy Trachelectomy for wanting fertility Stage IA or small IB (< 2cm) tumors

32 Cervix CA: Stage?

33 IB2 SIZE MATTERS! > 4 CM IN ANY DIMENSION RT

34 Abnormal Pap Smear Stage? Courtesy of S. Mironov, MD,

35 CERVIX CA: STAGE? SIZE MATTERS! IIA1 vs IIA2

36 Cx CA: Parametrial Invasion (IIB) Higher acc for small Ca 96% vs 74% Complete disruption of stromal ring (40-70% w/ inv) Intact low SI stromal ring % NPV Tumor extends into parametrium Vessel encasement Thickening of uterosacral ligament

37 Case 18:CERVIX CA: Stage?

38 Case 20: CERVIX CANCER: STAGE IB vs IIB?

39 CERVIX CANCER: STAGE IB vs IIB Tumor is > 4cm Don t sweat it: Tx RT Tumor < 4cm & intact cervical stroma IB1 with confidence: Tx surgery Tumor < 4cm & full thickness stroma inv IIB (overstage): Tx RT

40

41 ENDOMETRIAL CANCER: CONCLUSIONS Stage IA & 1B collapsed 1A < 50% myometrial invasion Gd-MRI:Multifactorial assessment: 1B 50% myometrial invasion (old 1C) Myometrial invasion Stage II simplified Cervical involvement Must have cervical stromal invasion Lymphadenopathy Stage IIIC expanded Kinkel K, et al. Radiology 1999;212:711; Frei K, et al. Radiology 2000;216:444 IIIC1 pelvic lymphadenopathy IIIC2 para aortic lymphadenopathy

42 OLD ENDO CA NEW IA IB IC IIA > IA IB I A/B IIB IIIC < II IIIC1 IIIC2

43 CERVIX CANCER: CONCLUSIONS Use of diagnostic imaging in encouraged but not mandated Stage IIA tumors MR Staging subcategorized IB1 vs IB2 & IIA1 vs IIA 2 > 4 cm RT! IIA1 4 cm (SURGERY!) Parametrial invasion: High NPV IIA2 > 4 cm (RT!) EUA (with cystoscopy and proctoscopy) are optional

44 CERVIX CANCER OLD IIA < NEW IIA1 IIA2

45

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