Diagnostic Ultrasound - Abdomen and Pelvis

Cervical Carcinoma
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Diagnoses: Female Pelvis
○ Low- and high-grade intraepithelial lesions
○ Cervical intraepithelial neoplasia (CIN) grades I-III
Staging, Grading, & Classification
• Traditional FIGO staging: Clinical examination, examination
under anesthesia ± cystoscopy, sigmoidoscopy
• Revised FIGO staging uses information from CT or MR;
cystoscopy and sigmoidoscopy not mandatory
○ Stage I: Confined to cervix
– IA: Invasive but only diagnosed at microscopy
– IB: Clinically visible lesion; IB1 < 4 cm, IB2 > 4 cm
○ Stage II: Beyond uterus but not to pelvic sidewall or
lower 1/3 of vagina
– IIA: No parametrial invasion
□ IIA1 tumor < 4 cm, IIA2 > 4 cm
– IIB: Parametrial invasion
○ Stage III
– IIIA: Lower 1/3 of vagina
– IIIB: Pelvic side wall (within 3 mm of obturator
internus, levator ani or pyriformis muscles, or iliac
vessels) or hydronephrosis/nonfunctioning kidney
○ Stage IV: Bladder/rectal involvement or distant
metastases (lung, liver, bones)
• Presence of pelvic or paraaortic lymphadenopathy alters
prognosis but not FIGO stage
Gross Pathologic & Surgical Features
• Arises at squamocolumnar junction
○ Endocervical in older women with supravaginal and
lateral tumor growth
○ Ectocervical in younger patients with exophytic growth
inferiorly into vagina
Microscopic Features
• Approximately 80-90% are squamous carcinoma
• Approximately 10-20% are adenocarcinoma (~ 1-3%
adenoma malignum)
Prognostic factors
• Tumor size
• Parametrial and pelvic side wall invasion
• Bladder or rectal invasion
• Lymph node metastases
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Abnormal bleeding, pain, or discharge
• Other signs/symptoms
○ Often asymptomatic
○ Detected by screening cytology from Pap smear
○ Following primary screening for high risk human
papilloma virus (HPV) infections
Demographics
• Epidemiology
○ 3rd most common gynecologic malignancy in USA and
most common gynecologic malignancy worldwide,
detected at more advanced stages
○ Screening and prevention has decreased mortality and
morbidity significantly in developed countries
○ Average age at diagnosis is 50
○ Risk factors
– HPV infection most important risk factor
– Early onset sexual activity, multiple partners
– Smoking, immunosuppression, HIV infection
Natural History & Prognosis
• 10-20% of CIN 3 progress to invasive cancer if untreated
• Papanicolaou test screening alone or cotesting with high
risk HPV tests are mainstay of detection
• Treatment is successful if cancer is detected early
• 5-year survival rate: Early stage: 91%; locally advanced: 57%
and metastatic disease: 16%
• Pathways of spread
○ Lymphatic: Parametrial/obturator/internal-external iliac
○ Direct invasion: Vagina/bladder/uterosacral ligaments to
rectum
Treatment
• Prevention: Vaccine for oncogenic HPV strains 16 and 18
• Loop electrosurgical excision procedure (LEEP) procedure
or cone biopsy
○ To further evaluate abnormal Pap smear or abnormal
findings at colposcopy
○ To excise transformation zone
• Microinvasive disease IA1: Cone biopsy or trachelectomy
(for fertility sparing) or simple hysterectomy
○ MR essential for patient selection prior to trachelectomy
• Lower than stage IIA: Radical hysterectomy and bilateral
pelvic lymphadenectomy
○ Variations of chemotherapy and radiotherapy
• Bulky stage IB2 and IIA2 > 4 cm: Chemoradiation
• Stage IIB or higher: Radiation therapy ± concomitant or
neoadjuvant chemotherapy
DIAGNOSTIC CHECKLIST
Consider
• Traditional FIGO staging: Error rates up to 65% for stage III
• Detection of tumor beyond cervix is key for imaging, as this
determines surgical vs. nonsurgical treatment
Image Interpretation Pearls
• Do not mistake transposed ovaries for peritoneal masses or
adenopathy
○ Patient with history of cervical cancer and radiation
therapy
SELECTED REFERENCES
1. Dutta S et al: Image-guided radiotherapy and -brachytherapy for cervical
cancer. Front Oncol. 5:64, 2015
2. Koh WJ et al: Cervical Cancer, Version 2. J Natl Compr Canc Netw. 13(4):395-
404, 2015
3. Kusmirek J et al: PET/CT and MRI in the imaging assessment of cervical
cancer. Abdom Imaging. ePub, 2015
4. Epstein E et al: Early-stage cervical cancer: tumor delineation by magnetic
resonance imaging and ultrasound - a European multicenter trial. Gynecol
Oncol. 128(3):449-53, 2013
5. Thomeer MG et al: Clinical examination versus magnetic resonance imaging
in the pretreatment staging of cervical carcinoma: systematic review and
meta-analysis. Eur Radiol. 23(7):2005-18, 2013
6. Freeman SJ et al: The revised FIGO staging system for uterine malignancies:
implications for MR imaging. Radiographics. 32(6):1805-27, 2012
7. Park SB et al: Sonographic findings of uterine cervical lymphoma manifesting
as multinodular lesions. Clin Imaging. 36(5):636-8, 2012