MRI for cervical and endometrial cancers. Dr Robert Bleehen Consultant Radiologist Cardiff & Vale UHB

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1 MRI for cervical and endometrial cancers Dr Robert Bleehen Consultant Radiologist Cardiff & Vale UHB

2 RCR 06(1)

3 RCR 06(1)

4 Technique Pelvic multiphased-array coil Fasting? Buscopan? ABDOMEN!!! Cx:+/- HR T2 Cor obl cervical canal End: +/- T1 FS Pre/Post Gad

5 Cervical Cancer Staging FIGO staging Limitations Extra-uterine spread Inflamm. Response Excludes LN

6 Cervical Cancer Staging - MRI MRI preferred imaging technique >90% accuracy at detecting parametrial spread 70-96% accuracy in detecting IIa, III, IVa disease nearly 100% NPV for parametrial invasion 97% NPV for vaginal invasion? Assessing suitability for trachelectomy Comparable to CT for detecting LN

7 Cervical cancer: Who should be imaged? All patients with cytologically proven cervical cancer for staging Monitor response to Rx Detect recurrence Restaging for 2 nd line Rx

8 Staging objectives Size of Tumour Distance from internal cervical os Local extension LN Abdominal disease

9 Current Indications for CRTx >4cms (Ib2) Parametrial extension (>=2b) LN +

10 Cervical Cancer Stage I

11 Ib1

12 Ib1

13 Cervical Cancer Stage IIb

14 IV a

15 MRI Cervical cancer staging rtn staging N=20 Surgery N=14 No Surgery N=6 ptn staging N=12 pn staging N=2

16 Radiology Staging T staging Path Staging 0 1a 1b1 1b2 2a 2b 3 4 1a 1 1b b2 2 2a 2b 3 4

17 Results: Understaging rt1an1 - pt1b1n1 (25x7mm) 16mm L Iliac LN at bifurcation with internal high SI Conclusion: T1a N1. Please can we discuss in the MDT prior to surgery

18 Results: Overstaging rt1n0 - pt1a1n0. No management change Post Biopsy artefact anteriorly within the endocervical canal. A little further high SI at this point in the endocervical canal is of uncertain aetiology and could be related to the biopsy or could represent a small endocervical tumour (2/17). Conclusion: Stage 1 cervical cancer

19 Results: Overstaging rt1b1n0 pt0n0. No management change Incomplete margins cone Bx Radiology: Intermediate SI, at most Ib1 Surgery: No residual tumour

20 Results: T staging T stage accuracy =75-100%

21 Radiology Staging Results: N staging Path Staging pn0 pn1 rn rn1 0 4

22 Results: N staging N Stage accuracy = 100%! 1 pt Laparoscopic LN Bx & Frozen section rt1b1n1 - pn1 Did not proceed to Hysterectomy on this basis

23 Radiology Staging Results: Treatment planning: 2b or not 2b Path Staging <2b >=2b <2b 12 0 >=2b 0 0

24 Clinical staging Suitability for RHND Staging accuracy=100%

25 Results: Treatment planning: Radical Surgery & CRT 4 Pts: rt1a N1 pt1b1 N1 (Frz S +ve) rt1b1 N1 pt1b1 N1 (Frz S +ve) rt1b2 N0 pt1b2 N0 rt1b2 N1 pt1b2 N1 (No Frz S) i.e. all due to treatment plan selection rather than failure of radiological staging

26 1 A 11 1 B Endometrial Cancer Staging FIGO staging TAH +BSO for organconfined disease +/- pelvic lymhadenectomy TAH/BSO alone advocated for patients assessed to have low pre-op risk of spread (stage Ia, G1,G2) Wertheims if stage II

27 Endometrial Cancer Role of MRI Should not be relied upon for diagnosis(tvus/es) Better than clinical assessment, TVUS and CT at detecting deep myometrial invasion Can accurately detect LN, extension to LUS, Cx Recommended in cases thought clinically to be organ-confined

28 Endometrial cancer: Who should be imaged? Not firmly established All patients with High Grade disease Or.. All patients

29 Prognostic factors Grade Depth of Myometrial invasion Cervical involvement LN disease Abdominal disease

30 Staging objectives Stratify into Low risk and High Risk Patients Low Risk (1A,G1,G2) Unit TAH High Risk (>1A,G3) Centre Op +/- Lymphadenectomy LN sampling for IIIC instead of lympadenectomy Wertheims if confirmed stage II Identify need for extended radical surgery Confirm palliative cases

31 Endometrial Cancer: Stage Ia

32 Endometrial Cancer: Stage Ia (old 1b)

33 Endometrial Cancer: Stage Ib (old 1c)

34 Endometrial Cancer: Stage IIIa

35 National Audit of Imaging Staging of Cancer of the Uterus 2008 Response rate from UK depts: Departmental data 30/87 (34%) Staging data 37/87 (43%)

36 Referral Policy All 18 (60%) High grade only 7 (23%) Variable 5 (17%)

37 IV Contrast IV contrast used Always 57% Never 32% Sometimes 11% Cases where IV contrast Given 73% Not given 27%

38 Depth of myometrial invasion 635/775 cases concordance between histology and MRI (82%) 83% with IV Contrast 80% without IV contrast 140 cases disagreement between histology and MRI (18%) 83 cases undercalled on MRI 57 cases overcalled on MRI

39 Results: Depth Myo Invasion

40 Results Assessment of deep myometrial invasion with IV contrast Assessment of deep myometrial invasion without IV contrast Assessment of cervical stromal invasion with IV contrast Assessment of cervical stromal invasion without IV contrast Assessment of pelvic node involvement with IV contrast Assessment of pelvic node involvement without IV contrast Concordance 83% 80% 89% 91% 95% 91% Sensitivity 75% 66% 46% 26% 68% 50% Specificity 88% 88% 96% 98% 97% 93%

41 REB Audit 29 data sets IV Contrast: 0% (76% Nationally) Lymph nodes sampled: 12/29 1 case excluded (rn0:pn1) as N1=mesorectal LN only not pelvic S/W nodes Some data inconsistencies/difficulties interpreting path report

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43 Depth of Myometrial invasion MR <50% MR >50% Path Path <50% >50% Accuracy 61% n=28 (1 case, depth myo invn not stated on MR)

44 Cervical Involvement MR N MR Y Path Path N Y Accuracy 82% NPV 78% PPV 100%

45 LN Status MR 0 MR 1 Path Path Accuracy 82% NPV 82% PPV N/A

46 End ca Staging Accuracy Depth Myometrial Invasion 61% (82%, 80% non C) Cervical involvement 82% (90%, 89% non C) LN status 82% (94%, 91% non-c) Less than ½ of UK depts submitted data Reporting bias Skewed towards largest centres Small numbers (esp for LN Status) Reports not always easy to correlate. Would be better done in MDT Prediction of Depth Myo Invasion appears unreliable

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49 Summary: Cervical cancer Role of MR is surgery contraindicating Scan all patients Staging includes abdominal imaging Good accuracy for T, N stage and Treatment planning MDT must carefully consider Rx plan where Radiology & FIGO staging differ Conducting wider audit

50 Summary: Endometrial ca Role of MR is surgery modifying Staging includes abdominal imaging IV contrast for prediction of depth of Myometrial invasion needs your own evaluation Standardisation of MR / Path reporting methodology Network Audit of cases reviewed in MDT

51 Thank you!