MRI in Cervix and Endometrial Cancer

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1 28th Congress of the Hungarian Society of Radiologists RCR Session Budapest June 2016 MRI in Cervix and Endometrial Cancer DrSarah Swift St James s University Hospital Leeds, UK

2 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!!

3 Carcinoma of the Cervix Traditionally FIGO Staging System based on clinical examination Introduced in 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%

4 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

5 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 SubakL et al. ObstetGynecol 1995;86:43-39 Cost effective HricakH et al. Radiology 1996;198:

6 2009 FIGO Staging Stage I Tumour confined to cervix IA Micro invasive IB Clinically invasive Stage II tumour extension beyond cervix but not to pelvic sidewall IIA involvement of upper 2/3rds of vagina IIB parametrial invasion

7 MRI and Gynaecological malignancy Inherent soft tissue contrast of T2W MRI See intrinsic anatomy of uterine body and cervix Identify pathology

8 MRI and Carcinoma of the Cervix 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

9 MRI and Carcinoma of the Cervix 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

10 MRI and Carcinoma of the Cervix Squamous carcinoma occurs at the squamocolumnar junction Pre-menopausal women at the level of the ectocervix Tumours often exophytic

11 MRI and Carcinoma of the Cervix Post menopausal status Junction migrates up the endocervical canal Tumours grow superiorly into the uterine body May obstruct the endometrial cavity

12 MRI and Carcinoma of the Cervix Post menopausal status Junction migrates up the endocervical canal Tumours grow superiorly into the uterine body May obstruct the endometrial cavity

13 What information is needed from MRI in Cervical Cancer?

14 ? Surgery -1 Is the disease confined to the cervix? Avoid inappropriate surgery for advanced disease Not deny suitable patients curative surgical option

15 ? Surgery -1 Is the disease confined to the cervix? Is there an intact stromal ring?

16 ? Surgery -1 Intact stromal ring Negative predictive value Intact stromal ring has a high (95%) negative predictive value for parametrial invasion SubekLL et al, Obstet Gynecol 1995

17 Tumour size? Independent poor prognostic factor Failure of local disease control with increasing tumour size Perez CA et al. Cancer; 1992: MRI can give an accurate assessment of tumour dimensions and volume? Surgery -2

18 ? 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

19 ? Surgery -3 Are there nodal metastases? Not included in FIGO staging Profound influence on treatment strategy Poor prognostic factor

20 Nodal disease MRI = CT Accuracies ~ 85 90% Low sensitivity 43 73% Inability to identify metastases in normal sized nodes

21 Nodal disease Size Other features Extracapsular extension Central necrosis Obstruction

22 Nodal disease Size Other features Extracapsular extension Central necrosis Obstruction PET CT

23 Non-surgical management Chemo-radiotherapy Concurrent chemotherapy and external beam radiotherapy 3 x intracavitary brachytherapy

24 Non-surgical management Aim to deliver a tumouricidaldose of radiation to a well defined target volume Spare surrounding normal tissue Curative or palliative intent

25 Radiotherapy Volumes CTV GTV PTV

26 CTV GTV PTV Irradiated Volume

27 External Beam Radiotherapy

28 What does the Radiation Oncologist Anatomical detail want to know -1 Where exactly is the tumour? Accurate delineation of the GTV CT planned Need bony and tissue electron density information

29 What does the Radiation Oncologist Tumour size want to know -2 Particularly craniocaudal extent Planning intracavitary treatment

30 What does the Radiation Oncologist Tumour size want to know -2 Particularly craniocaudal extent Planning intracavitary treatment

31 What does the Radiation Oncologist Is there vaginal involvement want to know -3 What is the inferior extent? Affects RT volumes GTV and CTV

32 What does the Radiation Oncologist Is there vaginal involvement want to know -3 What is the inferior extent? Affects RT volumes GTV and CTV

33 What does the Radiation Oncologist 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

34 MRI and Carcinoma of the Cervix 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

35 MRI and Endometrial Cancer More contentious than the use of MRI in Cervical Cancer Grade 1& 2, stage 1A disease Hysterectomy Surgery is the primary treatment modality Extent of surgery depends on pathology and tumour stage Grade 3 all stages and Grade 1 & 2 stage >1B Lymphadenectomy

36 MRI and Endometrial Cancer Why? Stage disease Select patients who at risk of relapse for more radical surgery Plan adjuvant treatment Avoid over treating lowrisk patients

37 MRI and Endometrial Cancer Depth of myometrial invasion Prognostic information Correlates Tumour grade Cervix involvement Likelihood of nodal metastases

38 How good is MRI for assessing depth of Radiology literature reports accuracy between 55 77% for T2W images invasion? 85 91% for dynamic contrast enhanced images KinkelK et al Radiology 1999 FreiK et al Radiology 2000

39 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

40 Peritoneal disease Not a contraindication to surgery Identify preoperatively Need chemotherapy

41 Uterine Dimensions Assess suitability for laparoscopicallyassisted vaginal hysterectomy (LAVH)

42 Limitations of MRI Myometrialthinning by bulky tumours Cornual regions Coexisting benign pathology Difficult to assess depth of invasion

43 Coexisting benign pathologies Adenomyosis

44 Coexisting benign pathologies Cystic Adenomyosis

45 Coexisting benign pathologies Leiomyomata Distort uterine anatomy

46 What do wewant the Surgeons and Heterogeneous polypoidmass on T2W images Progressive enhancement post contrast Oncologists to know?! Think sarcoma

47 What do we want the Surgeons and Oncologists to know?! Lesions which prolapse down into the cervix and vagina Uterine inversion Think sarcoma

48 MRI for Cervix and Endometrial Demonstrates and stage the disease Cancers Can answer the questions that are needed to plan patient management

49 Thank you

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