Cervical Cancer: Staging and Surveillance

Transcription

1 September 2005 Cervical Cancer: Staging and Surveillance Kiwita Phillips-Arnold HMS IV

2 Agenda Patient Presentation Introduction to Cervical Cancer Pertinent Anatomy Imaging Conclusion Reference Acknowledgements 2

3 Index Patient: Liver Lesion on CT Scan PACS, BIDMC DDX of Liver Lesion: 1. Abscess 2. Cyst 3. Focal Steatosis 4. Focal Nodular hyperplasia 5. Hemangioma 6. HCC 7. Hematoma 8. Lymphoma 9. Metastasis 3

4 Index Patient: History IS is a 60 y.o.. G1P1 woman who presents to ED with heavy postmenopausal bleeding x 2 days Past GYN Hx: Abnl pap smear 1970 w/cone biopsy D&C for menorrhagia while on OCP s vaginal bleeding 7 years ago ; colposcopy done; hysterectomy recommended Pt lost to follow-up until now High Suspicion of Malignancy US and CT done DDX of abnormal uterine bleeding: 1. atrophic changes 2. hormonal status 3. carcinoma 4. foreign body 5. trauma 6. infection 7. polyps 4

5 Cervical Cancer 2 nd most common cause of cancer related morbidity and mortality in the developing world 4 th most common malignancy in women in U.S. In U.S. mean age of occurrence is 47 y.o. Signs/Sx Sx: abnormal vaginal bleeding Post coital bleeding Vaginal discharge that is watery, purulent, or malodorous Staging: clinical Diagnosis: abnl Pap Smear, biopsy Imaging may be used for further staging and surveillance for metastasis or recurrence 5

6 Menu of Tests Used for Staging FIGO Recommended Testing Hysteroscopy- to inspect endocervical/ endometrial canal Cystoscopy bladder involvement Proctoscopy- bowel involvement IVP - CXR + AXR to look for metastasis and spine involvement Optional Tests CT assess abdomen for mets and pelvis for spread MRI gives more information about tumor size, degree of stromal penetration, nodal metastasis and local tissue extension PET may provide better assessment of extrapelvic metastasis esp. lymph nodes; but expensive and not widely available Lymphangiography older modality used to assess for lymph node infiltration 6 Ultrasonography

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

8 Cervical Cancer Staging my.webmd.com/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 nonfunctioning kidney Stage IV: Extends beyond pelvis or has involved the bladder mucosa or rectal mucosa 8

9 Index Patient s s Imaging

10 Index Patient: Ultrasound 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 10

11 Index Patient: Ultrasound Diagnosis Cervix Transvaginal US shows enlarged uterus PACS, BIDMC 11

12 Index Patient: Ultrasound Diagnosis Left Ovary: Normal size and echogenicity Enlarged Right Ovary: PACS, BIDMC Normal diameter of ovary is 2x2x3 cm 12

13 Ultrasound Findings Check for normal size and diameter of pelvic organs Note any areas of Heterogeneity Distinct planes should be noted between endometrial lining and myometrium Sandwich sign may be noted or simple hyperechoic stripe 13

14 Index Patient: CT Staging and Surveillance Large, round, heterogeneous, low attenuation liver mass overlying hepatic vein confluence and IVC noted on contrast delay CT scan 14 PACS, BIDMC

15 Index Patient CT: Liver Metastasis Impingement of middle and right hepatic veins Impingement of mass on Middle Hepatic Vein Lead to hypervascularity seen in other cuts Right Hepatic Vein PACS, BIDMC 15

16 Index Patient CT: Abnormal Gallbladder w/lymphadenopathy Kiwita Phillips-Arnold, HMS IV Gallbladder-distended w/thickened wall Node PACS, BIDMC 16

17 Index Patient CT: Suspected Primary Lesion Cervical Mass Uninvolved Rectum PACS, BIDMC Large heterogeneous cervical mass with areas of low attenuation representing 17 necrosis and/or hemorrhage

18 Index Patient CT: Ovarian Involvement Normal L ovary enlarged, heterogeneous R ovary w/areas of low attenuation suggestive of ovarian primary or spread from endocervical primary PACS, BIDMC 18

19 Companion Imaging Procedures

20 Companion Imaging: PET Imaging of Cervical Cancer 20 Grigsby, PW mednews.wustl.edu/ tips/page/normal/910.html

21 Companion MR Imaging of Uterine /Cervical Mass Invasion into paravesical fat Bladder Cervical mass 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 21 Yoshikazu Okamoto, et al. MR Imaging of the Uterine Cervix: Imaging-Pathologic Correlation. RadioGraphics 2003; 23: 425.

22 Index Patient s s Story Continues IS was taken to the OR for an exam under anesthesia (EUA); D&C and a cervical biopsy: Palpable lesions w/small cysts deep to cervical mucosa 10 cm enlarged uterus No evidence of parametrial disease, rectal lesions, or cul-de de-sac nodularity Punch biopsy taken An US-guided liver biopsy was taken Pathology: Cervical cyst biopsy showed adenocarcinoma w/ necrotic material and calcifications Liver mass was consistent with poorly differentiated adenocarcinoma taken from cervix Stage IB1 by clinical assessment but stage IVB based on imaging Patient consented to simple total abdominal hysterectomy; palliative radiation may be considered 22

23 One Other Interesting Finding

24 Index Patient: Interesting Finding 24

25 References Choi, Joon-Il, Seung Hyup Kim, Chang Kyu Seong,, Jung Suk Sim, Hak Jong Lee, Kyung- Hyun Do. Recurrent Uterine Cervical Carcinoma: Spectrum of Imaging Findings. Korean Journal of Radiology, 2000; 4: Jeong,, Yong Yeon, Heoung Keun Kang, Tae Woong Chung, Jeong Jin Seo,, Jin Gyoon Park. Uterine cervical carcinoma after therapy: CT and MR imaging findings. ings. Radiographics ; 23(4): Okamoto, Yoshikazu, Yumiko O. Tanaka, Masato Nishida, Hajime Tsunoda,, Hiroyuki Yoshikawa, and Yuji Itai.. MR Imaging of the Uterine Cervix: Imaging-Pathologic Correlation. RadioGraphics 2003; 23: 425. Pannu, Harpreet K., Frank M. Corl,, and Elliot K. Fishman. CT Evaluation of Cervical Cancer: Spectrum of Disease. RadioGraphics 2001; 21: Scheidler, Juergen,, Andreas F. Heuck.. Imaging of Cancer of the Cervix. Radiologic Clinics of North America, 2002; 40: Williams, Penny L., Sherelle L. Laifer-Narin Narin,, and Nagesh Ragavendra.. US of Abnormal Uterine Bleeding. Radiographics,, 2003; 23:

26 Acknowledgements Thanks to Following People: Tejas Mehta, MD Mary Ellen Sun, MD Pamela Lepkowski Larry Barbaras,Webmaster 26