New FIGO Staging of Uterine malignancies with MR Imaging: Correlation with Surgical and Histopathologic Findings

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1 New FIGO Staging of Uterine malignancies with MR Imaging: Correlation with Surgical and Histopathologic Findings Poster No.: C-1548 Congress: ECR 2011 Type: Educational Exhibit Authors: J. Takahama, A. Takahashi, N. Marugami, M. Ogawa, M. Takewa, T. Itoh, S. Kitano, K. Kichikawa; Kashihara, Nara/JP Keywords: Pathology, Neoplasia, Staging, MR, Oncology, Genital / Reproductive system female DOI: /ecr2011/C-1548 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 31

2 Learning objectives To illustrate the spectrum of MRI features in uterine malignancies correlated with new FIGO staging system. Background To diagnose the uterine malignant tumors, radiologists are required accurate definition of local invasion. MRI is useful tool and standard guideline had already presented by European Society of Urogenital Radiology. Federation International Gynecology and Obstetrics (FIGO) staging system had been renewed in 2009 and TMN staging system was also revised. The histopathological classification is also alternated about uterine sarcoma. In this exhibits, we will describe MR features of the uterine malignant tumors and focus on the staging in new system and its MR feature correlated with surgical and histopathological appearance. Between April and September 2010, 52 patients with uterine malignancies were obtained in our institute. The technique, indications and contraindications are also described and illustrated. We also refer about imaging technique on 3.0-T MRI. Imaging findings OR Procedure details Imaging Findings: *Uterine endometrial cancer The Scientific community with the support of the Federation International Gynecology and Obstetrics (FIGO) as well as other international scientific societies and agencies has considered that revision of the classification of endometrial cancer was necessary. The main reason was based on the data of the prognosis that stage IA and IB showing similar 5-year survival. The new staging system was defined stage IA involves the endometrium and/or less than one-half myometrial invation and IB is equal to or greater than the outer one-half of the myometrium. Stage IC had been deleted. Stage II includes the tumors invades cervical stroma, but does not extend beyond the uterus. The former FIGO staging system, stage II was subclassified as IIa (extra-uterine invasion without cervical stroma) and IIb (with cervical stroma). In the new system, this subclassification dissapeared and stage II is manifested as tumor invades cervical stroma, but does not extend beyond the uterus. The previous stage IIa (invasion without cervical stroma) is included in stage I. Stage IIIc is now subclassified as IIIc1 and IIIc2. IIIc1 is defined as the lymph nodes metastasis to the pelvic wall and IIIc2 is to the para-aortic lymph nodes. Page 2 of 31

3 In this new FIGO 2008, they declared the staging of sarcomas. Leiomyosarcoma and adenosarcoma is classified in this category, though carcinosarcoma should be classified to this uterine corpus cancer staging. For the pre-operative staging, the MRI findings basically follow the ordinal diagnostic signs. Considering the changes in new FIGO system, the MRI findings are shown Table 1. We should pay special attention on the Stage Ia and Ib because the sub-classification is totally different from former one. The clinicians and radiologists should announce together about the shift for the new staging system. Table 1 FIGO 2008 staging for Uterine corpus cancer FIGO MRI findings on T2WI Stage I Tumor confined to the corpus uteri IA Tumor limited to endometrium or invading less than half of myometrium Tumor exits in endometrium and may have interuption of JZ but invading less than half of myometrium IB Tumor invades one half or more o myometrium Tumor extends to the subserosal myometrium Stage II Tumor invades cervical stroma, but does not extend beyond the uterus Tumor invades and destroy the cervical stromal ring on T2WI Stage III Local and/or regional spread of the tumor IIIA Tumor invades the serosa of the corpus uteri of adnexae (direct extension or metastasis Tumor invades beyond the uterine myometrium and shows irregular margine of serosa. IIIB Vaginal or parametrial involvement (direct extension or metastasis) Vaginal mass or spiculation with cervical outer lesion. IIIC Metastasis to pelvic or para-aortic lymph nodes IIIC1 Metastasis to pelvic lymph nodes >1cm pelvic lymphnodes IIIC2 Metastasis to para-aortic lymph nodes with or >1cm pelvic and paraaortic lymphnodes Page 3 of 31

4 without metastasis to pelvic lymph nodes Stage IV Tumor invades bladder and/or bowel mucosa, and/ or distant metastases IVA Tumor invasion of bladder and/or bowel mucosa IVB Distant metastasis, Distant metastasis including intra-abdominal metastases and/or inguinal lymph nodes. Tumor exdends to the bladder and bowel with mucosal disrruption *Uterine cervical cancer The stage 0 was deleted in uterine cervical cancer. The stage I has no modification. About stage IIA, FIGO 2008 applied subclassification for IIA(clinically viable lesion is equal or under 4cm diameter) and IIb(the lesion is over 4 cm diameter) because of the difference of prognosis, that is proved depending on the tumor size. In cervical carcinoma, former FIGO staging is clinically determined preoperatively by limited conventional procedures. In this new staging system, they made "NOTE" and mentioned about the CT and MRI as an assistant tool for the measurement of tumor size. For the staging of cervical carcinoma, th expected roles of imaging are evaluation of invasion to the parametrium, pelvic wall and adjacent organs. The role of imaging in evaluating tumor size in both stage IB and IIA is more important for subclassification. The MR imaging findings and its stages are correlated in Table 2. Table 2 FIGO 2008 staging for Uterine cervical cancer MRI findings on T2 weighted images Stage I Tumor confined to the cervix (extension to corpus should be disregaded) IA Invasive carcinoma usually difficult to depict diagnosed only by the tumor microscopy. Stromal invasion with a maximal depth of 5mm measured from the base of the epithelium and a horizontal spread of 7mm or less Page 4 of 31

5 IA1 Measured stromal invasion 3mm or less in depth and 7mm or less in horizontal spread IA2 Measured stromal invasion more than 3mm and not more than 5mm with a horizontal spread of 7mm or less IB Clinically visible lesion confined to the cervix or microscopic lesion greater than IA2 tumor shows relative high intensity and confined in uterine cervix with/without stromal invasion IB1 Clinically visible lesion 4cm or less in greatest dimension the tumor measured 4cm or less in greatest dimension IB2 Clinical visible lesion more than 4cm in greatest dimension the tumor measured more than 4cm in greatest dimension Stage II Tumor invades beyond uterus but not to pelvic wall or to lower third of vagina IIA Tumor without parametrial invasion Tumor spread to the vagina or disrupt the stromal ring of low intensity rim and protrude into the parametrium IIA1 Clinically visible lesion 4cm or less ingreatest dimension the tumor measured 4cm or less in greatest dimension IIA2 Clinically visible lesion more than 4cm in greatest dimension the tumor measured more than 4cm in greatest dimension IIb Tumor with parametrial invasion Tumor disrupt the stromal ring of low intensity rim and protrude into the parametrium Stage III Tumor extends to pelvic wall, involves lower third of vagina, causes Page 5 of 31

6 hydronephorosis or nonfunctioning kidney IIIA Tumor involves lower third of vagina Tumor invades to the vagina and extends to the lower third IIIB Tumor extends to pelvic wall, causes hydronephrosis or nonfunctioning kidney Tumor invades to the deep parametrial fat layer and close to the internal iliac artery. IVA Spread of the growth to adjust organs Tumor invades to the mucosa of rectum or urinary bladder IVB distant metastasis Lung metastasis to the lung field, mediastinal or other organ StageIV *Uterine sarcomas For the uterine sarcoma, the staging system is newly applied in FIGO2008. The tumor confined in uterus is stage I, and stage II invades to beyond uterus. The tumor with intra-abdominal tissue is defined as Stage III. Stage IV is distant metastasis or invasion to urinaly bladder or rectum or distant metastasis. Uterine leiomyosarcomas and endometrial stromal sarcomas are classfied for uterine sarcoma(1). Adnosarcomas are little differences in staging system(sarcoma(2)), they are very close to the old femal pelvic staging. MR imaging findings and its stages are correlated in Table 3,4. Table 3 FIGO 2008 staging for Uterine sarcoma(1) (Leiomyosarcoma and endometrial stromal sarcoma) Stage I Tumor limited to uterus IA # 5cm IB >5cm Stage II Tumor extends to the pelvis IIA Adnexal involvement IIb Tumor extends to extrauterine pelvic tissue Stage III Tumor invades abdominal tissues (not just protruding into the abdomen) Page 6 of 31

7 IIIA One site IIIB > one site IIIC Metastasis to pelvic and/or para-aortic lymph nodes Stage IV Tumor invades bladder and/or rectum and/or distant metastasis IVA Tumor invades bladder and/or rectum IVB Distant metastasis Table 4 FIGO 2008 staging for Uterine sarcoma(2) (adenosarcoma) Stage I Tumor limited to uterus IA Tumor limited to endometrium/endocervix (sithout myometrial invasion) IB Tumor invades up to less than half of myometrium IC Tumor invades to more than one half of myometrium StageII Tumor extends to the pelvis IIA Adnexal involvement IIb Tumor extends to extrauterine pelvic tissue Stage III Tumor invades abdominal tissues (not just protruding into the abdomen) IIIA One site IIIB > one site IIIC Metastasis to pelvic and/or para-aortic lymph nodes Stage IV Tumor invades bladder and/or rectum and/or distant metastasis IVA Tumor invades bladder and/or rectum IVB Distant metastasis Page 7 of 31

8 Procedure Details: Trained two readers retrospectively analyzed images. On Magnetom Verio 3T (Siemens), T2WI (axial and sagittal), T1WI (axial), 3D-fat sat Gd-dynamic T1WI (axial) were obtained, and we added 3D-T2WI(SPACE). Table 1 Protocols for female pelvis System Siemens MAGNETOM Siemens MAGNETOM Verio 3.0T (True Form) Avanto 1.5T T2WI TSE: TR/TE=4000/89, TSE: TR/TE=4000/76, (axial,sagittal) Matrix= 512/307, Matrix= 320/320, FOV=200x200, ETL=19, FOV=250x250, ETL=7, slice thickness=3mm slice thickness=3mm T1WI SE: TR/TE=450/12, (axial) Matrix= FOV=200x200, DWI EPI: TR/TE=7200/80, (axial) Matrix= FOV=300x300, TSE: TR/TE=519/8.7, 320/192, Matrix= 256/256, FOV=200x200, ETL=2, slice thickness=3mm slice thickness=3mm EPI: TR/TE=4000/70, 128/94, Matrix= FOV=320x320, 128/128, slice thickness=4.5mm slice thickness=7.0mm b=0, 800 b=0, 500, 1000 SPACE TR/TE=2700/287, (axial) Matrix= FOV=250x250, 256/256, slice thickness=1.0mm flip angle mode=t2 var HASTE TR/TE=2000/88, (coronal) Matrix= FOV=280x280, 3D-VIBE TR/TE=3000/64, 320/240, Matrix= FOV=250x100, 256/256, slice thickness=5mm slice thickness=4mm TR/TE=3.74/1.38, FA=11, TR/TE=6.0/2.19, FA=12, Page 8 of 31

9 Dynamic scan Matrix= FOV=250x200, 256/256, Matrix= FOV=250x200, 256/179, (pre,60,120,180) slice thickness=1.0mm slice thickness=1.2mm Gd-Fat sat-t1wi SE: TR/TE=550/12, TSE: TR/TE=500/9, (sagittal) Matrix= FOV=250x250, 256/256, Matrix= FOV=250x250, slice thickness=3mm ETL=2, thickness=3mm 320/224, slice Images for this section: Page 9 of 31

10 Fig. 1: Case 1a. Uterine corpus cancer with cervical stromal invasion Relative high intensity mass invaded to the cervical stromal tissue on T2WI.(arrow) Page 10 of 31

11 Fig. 2: Case 1b. Uterine corpus cancer with cervical stromal invasion Relative high intensity mass invaded to the cervical stromal tissue but did not extend to the parametrium. Page 11 of 31

12 Fig. 3: Case 1c. Uterine corpus cancer with cervical stromal invasion Relative low intensity mass was obtained clearly on enhanced fat sat T1WI.(arrow) Page 12 of 31

13 Fig. 4: Case 1d. Uterine corpus cancer with cervical stromal invasion Resected uterus. The corpus cancer is arising from lower uterine body and invading cervical stroma. Stage II Page 13 of 31

14 Fig. 5: Case 1d. Uterine corpus cancer with cervical stromal invasion. Stage II Page 14 of 31

15 Fig. 6: Case2a Uterine corpus cancer, Stage IA Small abnormal signal polypoid mass was observed. Page 15 of 31

16 Fig. 7: Case2 Uterine corpus cancer, Stage IA Thickend uterine endometrium showed relative low intensity. JZ is clearly determined. Page 16 of 31

17 Fig. 8: Case2 Uterine corpus cancer, Stage IA. Histopathologically, this case had small amount of myometrial invasion. Former staging system classified this case as Stage IB, but now, FIGO 2008 classifies Stage IA. Page 17 of 31

18 Fig. 9: Case 3a Carcinosarcoma, stage II (following FIGO2008 system of uterine corpus cancer). The bulky tumor extends to the uterine cervix. Uterine body showed hematometra on T2WI. Page 18 of 31

19 Fig. 10: Case 3a Carcinosarcoma, stage II (following FIGO2008 system of uterine corpus cancer). The bulky tumor does not destroy the parametrium on Gd-Dynamic T1WI (FS). Page 19 of 31

20 Fig. 11: Case 3a Carcinosarcoma, stage II (following FIGO2008 system of uterine corpus cancer). The bulky tumor shows very high intensity on DWI. Page 20 of 31

21 Fig. 12: Case 3a Carcinosarcoma, stage II (following FIGO2008 system of uterine corpus cancer). Page 21 of 31

22 Fig. 13: Case 4a Uterine cervical cancer stage IIA2. The bulky tumor (>4cm) protrudes from uterine cervix to the vagina. The upper portion of the vagila is invaded by the tumor. Page 22 of 31

23 Fig. 14: Case 4a Uterine cervical cancer stage IIA2. The bulky tumor (>4cm) protrudes from uterine cervix to the vagina. The upper portion of the vagila is invaded by the tumor on Gd-dynamic FS T1WI. Page 23 of 31

24 Fig. 15: Case 4a Uterine cervical cancer stage IIA2. The bulky tumor (>4cm) protrudes from uterine cervix to the vagina. The upper portion of the vagila is invaded by the tumor. Page 24 of 31

25 Fig. 16: Case 4a Uterine cervical cancer stage IIA2. The bulky tumor (>4cm) protrudes from uterine cervix to the vagina. The upper portion of the vagila is invaded by the tumor. Page 25 of 31

26 Fig. 17: Case5a Endometrial stromal sarcoma, Stage IB. Pedunculated heterogeneous signal mass overgrow from myometrium to the uterine cervix on T2WI. The tumor limited to the uterus. Page 26 of 31

27 Fig. 18: Case5a Endometrial stromal sarcoma, Stage IB. Pedunculated heterogeneous signal mass enhanced irregularly with necrosis on Gd-enhanced T1WI(FS). The tumor limited to the uterus. Page 27 of 31

28 Fig. 19: Case5c Endometrial stromal sarcoma, Stage IB. Pedunculated heterogeneous signal mass overgrow from myometrium to the uterine cervix. Page 28 of 31

29 Fig. 20: Case5d Endometrial stromal sarcoma, Stage IB. Pedunculated heterogeneous signal mass overgrow from myometrium to the uterine cervix on T2WI. The tumor limited to the uterus. Page 29 of 31

30 Conclusion New FIGO staging system has major changes and diagnostic radiologists should know accurately and try to avoid confusion between old and new staging system. Personal Information References 1. Ballester M, Koskas M, Coutant C, et al. Does the use of the 2009 FIGO classification of endometrial cancer impact on indications of the sentinel node biopsy? BMC Cancer 2010; 10: D'Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010; 116: Hancke K, Heilmann V, Straka P, Kreienberg R, Kurzeder C. Pretreatment staging of cervical cancer: is imaging better than palpation?: Role of CT and MRI in preoperative staging of cervical cancer: single institution results for 255 patients. Ann Surg Oncol 2008; 15: Hricak H, Gatsonis C, Chi DS, et al. Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network 6651-Gynecologic Oncology Group 183. J Clin Oncol 2005; 23: Koyama T, Tamai K, Togashi K. Staging of carcinoma of the uterine cervix and endometrium. Eur Radiol 2007; 17: Mariani A, Dowdy SC, Podratz KC. New surgical staging of endometrial cancer: 20 years later. Int J Gynaecol Obstet 2009; 105: Orezzoli JP, Sioletic S, Olawaiye A, Oliva E, del Carmen MG. Stage II endometrioid adenocarcinoma of the endometrium: clinical implications of cervical stromal invasion. Gynecol Oncol 2009; 113: Ozsarlak O, Tjalma W, Schepens E, et al. The correlation of preoperative CT, MR imaging, and clinical staging (FIGO) with histopathology findings in primary cervical carcinoma. Eur Radiol 2003; 13: Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009; 105: Page 30 of 31

31 10. Prat J. FIGO staging for uterine sarcomas. Int J Gynaecol Obstet 2009; 104: Sala E, Wakely S, Senior E, Lomas D. MRI of malignant neoplasms of the uterine corpus and cervix. AJR Am J Roentgenol 2007; 188: Zivanovic O, Leitao MM, Iasonos A, et al. Stage-specific outcomes of patients with uterine leiomyosarcoma: a comparison of the international Federation of gynecology and obstetrics and american joint committee on cancer staging systems. J Clin Oncol 2009; 27: Page 31 of 31