MRI in Cervix and Endometrial Cancer · Carcinoma of the Cervix • Stage of disease has a profound influence on treatment options available to the patient • Fertility sparing vs.

MRI in Cervix and Endometrial

Cancer

Dr Sarah Swift

St James’s University Hospital

Leeds, UK

28th Congress of the

Hungarian Society of

Radiologists

RCR Session

Budapest June 2016

Objectives

• Cervix and endometrial cancer

– What it looks like on MRI

• What matters

– To the surgeon

– To the clinical oncologist

– To the radiologist!

– To the patient!!

Carcinoma of the Cervix

• Traditionally…

• FIGO Staging System

based on clinical

examination

• Introduced in 1928

• 8 revisions since

• Most recently 2009

• But…

• Inaccurate

• Clinical staging errors in

up to 25% of Stage I and

Stage II disease

• Up to 67% in Stage II –

IV

• Underestimation in 25 –

67%

• Overestimation in 2%

Carcinoma of the Cervix

• Stage of disease has a

profound influence on

treatment options

available to the patient

• Fertility sparing vs.

radical surgery

• Surgical vs. non-surgical

management

• Radical vs. palliative

intent

MRI and Carcinoma of the Cervix

• Established evidence

base for the use of MRI

• Provides sufficient

information for

management decision

making

• Revised FIGO staging –

influenced by imaging

findings

• Accuracy• Subak L et al. Obstet Gynecol

1995;86:43-39

• Cost effective• Hricak H et al. Radiology

1996;198:403-409

2009 FIGO Staging

Stage I Tumour confined to cervixIA Micro invasiveIB Clinically invasive

Stage II tumour extension beyond cervix but not to pelvic sidewallIIA involvement of

upper 2/3rds ofvagina

IIB parametrial invasion

MRI and Gynaecological malignancy

• Inherent soft tissue

contrast of T2W MRI

• See intrinsic

anatomy of uterine

body and cervix

• Identify pathology


• Increased fibrous tissue

in the normal cervical

stroma

• Lower signal intensity

than myometrium on

T2W

• Tumour visible as

increased SI against the

low SI stroma


• Increased fibrous tissue

in the normal cervical

stroma

• Lower signal intensity

than myometrium on

T2W

• Tumour visible as

increased SI against the

low SI stroma


• Squamous carcinoma

occurs at the squamo-

columnar junction

• Pre-menopausal

women – at the level of

the ectocervix

• Tumours often

exophytic


• Post menopausal status

• Junction migrates up

the endocervical canal

• Tumours grow

superiorly into the

uterine body

• May obstruct the

endometrial cavity


• Post menopausal status

• Junction migrates up

the endocervical canal

• Tumours grow

superiorly into the

uterine body

• May obstruct the

endometrial cavity

What information is needed from MRI

in Cervical Cancer?

? Surgery - 1

• Is the disease confined

to the cervix?

• Avoid inappropriate

surgery for advanced

disease

• Not deny suitable

patients curative

surgical option

? Surgery - 1

• Is the disease confined

to the cervix?

• Is there an intact

stromal ring?

• Intact stromal ring

• Negative predictive value

• Intact stromal ring has a high (95%) negative predictive value for parametrial invasion

– Subek LL et al, ObstetGynecol 1995

? Surgery - 1

? Surgery - 2

• Tumour size?

• Independent poor

prognostic factor

– Failure of local disease

control with increasing

tumour size

– Perez CA et al. Cancer; 1992:

2796-2806

• MRI can give an

accurate assessment of

tumour dimensions and

volume

? Surgery - 2

• Tumour size

• Independent poor

prognostic factor

• Recognised in new FIGO

Staging

• Stage IB – clinically

visible lesion

– IB1 - < 4cm

– IB2 - > 4cm

• Stage IIA FIGO 2009

– IIA1 - < 4cm

– IIA2 - > 4cm

? Surgery - 3

• Are there nodal

metastases?

• Not included in FIGO

staging

• Profound influence on

treatment strategy

• Poor prognostic factor

Nodal disease

• MRI = CT

• Accuracies ~ 85 – 90%

• Low sensitivity 43 –

73%

• Inability to identify

metastases in normal

sized nodes

Nodal disease

• Size

• Other features

– Extracapsular

extension

– Central necrosis

• Obstruction

Nodal disease

• Size

• Other features

– Extracapsular

extension

– Central necrosis

• Obstruction

• PET CT

Non-surgical management

• Chemo-radiotherapy

• Concurrent

chemotherapy and

external beam

radiotherapy

• 3 x intracavitary

brachytherapy

Non-surgical management

• Aim to deliver a

tumouricidal dose of

radiation to a well

defined target volume

• Spare surrounding

normal tissue

• Curative or palliative

intent

Radiotherapy Volumes

CTV

PTVGTV

GTVCTV

PTV

Irradiated Volume

External Beam Radiotherapy

What does the Radiation Oncologist

want to know - 1

• Anatomical detail

• Where exactly is the

tumour?

– Accurate delineation of

the GTV

• CT planned

• Need bony and tissue

electron density

information


want to know - 2

• Tumour size

• Particularly

craniocaudal extent

• Planning intracavitary

treatment


want to know - 2

• Tumour size

• Particularly

craniocaudal extent

• Planning intracavitary

treatment


want to know - 3

• Is there vaginal

involvement

• What is the inferior

extent?

• Affects RT volumes

– GTV and CTV


want to know - 3

• Is there vaginal

involvement

• What is the inferior

extent?

• Affects RT volumes

– GTV and CTV


want to know - 4

• Where are the nodal

metastases?

• Significant impact on management planning

• Nodal GTV and CTV

• Node negative on MR -external iliac level ~ L5/S1

• Node positive - one level above the positive nodes

• Inguinal nodes if macroscopic lesion in lower third of the vagina


• Central role in patient assessment

• In most patients, in conjunction with clinical status, MRI alone provides sufficient information for decisions to be made about case management

MRI and Endometrial Cancer

• More contentious than

the use of MRI in

Cervical Cancer

• Surgery is the primary

treatment modality

• Extent of surgery

depends on pathology

and tumour stage

• Grade 1& 2, stage 1A

disease

– Hysterectomy

• Grade 3 all stages and

Grade 1 & 2 stage > 1B

– Lymphadenectomy


• Why?

• Stage disease

• Select patients who at

risk of relapse for more

radical surgery

• Plan adjuvant treatment

• Avoid over treating low-

risk patients


• Depth of myometrialinvasion

– Prognostic information

• Correlates

– Tumour grade

– Cervix involvement

– Likelihood of nodal metastases

How good is MRI for assessing depth of

invasion?

• Radiology literature

reports accuracy between

55 – 77% for T2W images

• 85 – 91% for dynamic

contrast enhanced images

– Kinkel K et al Radiology

1999

– Frei K et al Radiology 2000

Involvement of the Cervix

• Reported accuracy of

MRI in detecting cervical

invasion – up to 92%

• Sensitivities of 75 – 80%

• Specificities of 94 – 96%

• Adjuvant RT

Peritoneal disease

• Not a

contraindication to

surgery

• Identify preoperatively

• Need

chemotherapy

Uterine Dimensions

• Assess suitability for

laparoscopically assisted

vaginal hysterectomy (LAVH)

Limitations of MRI

• Myometrial thinning

by bulky tumours

• Cornual regions

• Coexisting benign

pathology

• Difficult to assess

depth of invasion

Coexisting benign pathologies

• Adenomyosis


• Cystic Adenomyosis


• Leiomyomata

• Distort uterine

anatomy

What do we want the Surgeons and

Oncologists to know?!

• Heterogeneous

polypoid mass on

T2W images

• Progressive

enhancement post

contrast

• Think sarcoma

What do we want the Surgeons and

Oncologists to know?!

• Lesions which

prolapse down into

the cervix and vagina

• Uterine inversion

• Think sarcoma

MRI for Cervix and Endometrial

Cancers

• Demonstrates and

stage the disease

• Can answer the

questions that are

needed to plan

patient management

Thank you

MRI in Cervix and Endometrial Cancer · Carcinoma of the Cervix • Stage of disease has a profound influence on treatment options available to the patient • Fertility sparing vs.

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