Gastric Cancer: Сlinical Implementation of Artificial Intelligence, Synergeti...
Imaging in diagnosis and treatment of carcinoma cervix
1. Role of Imaging
in
Diagnosis and Treatment
of
Carcinoma Cervix
Presenter : Jagadesan Pandjatcharam
Moderators : Assoc.Prof. D.N. Sharma
: Assoc.Prof. Sanjay Thulkar
Dr.BRA IRCH, AIIMS, New Delhi, 2009
2. Introduction
• Cancer cervix is the second most common cancer in the
world among females [Globocan 2002]
• Commonest Cancer in females in most part of India
• It ranks second in Delhi [NCRP]
• Highest incidence in Chennai
• 30-50 years
* Global Cancer Statistics,CA Cancer J Clin 2005;55;74-108
** National Cancer Registry Programme,India 2005
4. Risk Factors
• Human Papillomaviruses-Types16,18,31,33
• Young age at first intercourse (<16 years)
• Multiple sexual partners
• High parity
• Low socioeconomic status
• Poor Sexual Hygiene
» Eur J Gynaecol Oncol. 1990;11(1):51-6
5. Prognostic factors
Tumor size
Lymph node metastases
Stromal invasion
Lympho-Vascular space invasion
Hemoglobin status
6. Stages FIGO Staging [1994]
Confined to cervix – microscopic (1A) or clinical (1B)
I
I A1 Less than 3 mm depth of invasion, <7 mm horizontal spread
I A2 3-5 mm depth of invasion
I B1 >5 mm depth of invasion, macroscopically visible
I B2 > 4 cm of primary tumor size
Invasion of upper vagina (2A) or parametrium (2B)
II*
Invasion of lower vagina (3A), pelvic wall/ hydronephrosis (3B)
III
Invasion of UB/ rectum (4A) or distant metastases (4B)
IV
*modified in FIGO 2010
7. Errors in FIGO Staging
FIGO staging Errors in comparison to
surgical staging
I
20-30%
II 23%
III 65-90%
IV
-Obs&Gyn,1995;86((1):43-5
-Vidaurreta J et al Gynecol Oncol 1999;75:366–71
8. FIGO Imaging tests
• IVP
• Barium enema
• Chest x-ray
• Cross sectional imaging is not mentioned, but
it is increasingly used in the form of
– USG / CT / MRI
13. Computed Tomography
• Advantages
– Detection of parametrial extension, local organ
invasion, metastases, renal abnormality
– Replace IVP
• Disadvantages
– Primary tumor may not be seen
15. Computed Tomography
• Parametrial invasion
– Streakiness
– Extension of mass
– Encasement of ureter
– Thickening of uterosacral
ligament
16. Computed Tomography
• Pelvic wall invasion*
– Tumor within 3 mm from
muscles
– Invasion of muscles, bone
– Vascular encasement
• Invasion of UB/ rectum
– Loss of fat planes
– Wall thickening, irregularity
*H.K. Pannu, RadioGraphics, 2001;21:1155-1168
33. Positron Emission Tomography
• Scanning of the radioisotope activity in the
body from the head to mid-thighs
• Functional scan as it reflects the amount of
function related to the substance to which the
isotope is tagged
• Commonly used 2-F18-Fluoro,2-Deoxy Glucose
34. Positron Emission Tomography
• Advantages
– Pelvic and Para-aortic nodes
– Distant visceral metastases
– SUV*
• Disadvantages
– Poor local tumor description
– Poor visibility of local extension
– Longer scanning time
Kidd EA, Cancer. 2007 Oct 15;110(8):1738-44
40. PET Fusion
Sensitivity Specificity
PET-CT 44.1% 93.9%
PET-MR 54.2% 92.7%
79 pts had lymphadenectomy
Kim SK et al, Eur J Cancer. 2009 Aug;45(12):2103-9.
41.
42. Prognostic use of PET
• 20 patients of II and III were studied for pre
treatment SUVmax of the primary tumor
• Responses were related to the uptake
• There is a trend of poor response to standard
therapy with increasing SUV.
MD Thesis of Jagadesan P, Jun 2009 under Dr D.N.Sharma
43. SUV comparisons between different responses
FIGO stage No. of patients Complete Partial Responders(4)
responders(16)
IIa 0
Mean 7.90 9.96
IIb 8 Minimum 2.90 5.40
IIIa 0 Maximum 12.60 22.40
Standard ±3.02 ±8.30
IIIb 12
deviation
44. Stages Revised FIGO Staging - w.e.f Jan 2009
Confined to cervix – microscopic (1A) or clinical (1B)
I
I A1 Less than 3 mm depth of invasion, <7 mm horizontal spread
I A2 3-5 mm depth of invasion
I B1 >5 mm depth of invasion, macroscopically visible
I B2 > 4 cm of primary tumor size
Invasion of upper vagina (2A) or parametrium (2B)
II
II A1 Mass ≤ 4.0cm involving upper 2/3 vagina
II A2 Mass ≥ 4.0cm involving upper 2/3 vagina
Invasion of lower vagina (3A), pelvic wall/ hydronephrosis (3B)
III
Invasion of UB/ rectum (4A) or distant metastases (4B)
IV
46. Can MRI/CT replace endoscopic evaluation?
• CT and MRI have good sensitivity and
specificity in detecting local invasion into
bladder
• NPV of 100% with MR as well as CT imaging
47. AIIMS - IRCH Attribute All patients Patients with
on CT scan
Patients with
bladder invasion bladder invasion
on Cystoscopy
study No. of patients
Median age (yrs)
305
50
43 [14.1%]
45
17 [5.6%]
48
Age range (yrs) 25-85 30-77 30-75
IB 36 2 0
Distribution of bladder IIA 9 0 0
IIB 65 3 1
invasion in cervical cancer
IIIA 10 2 1
patients IIIB 139 26 11
Effectiveness of CT scan in IVA 17 6 4
IVB
detecting bladder invasion 9 1 1
Unknown 20 3 0
Histopathology- 283 39 15
Squamous
Adeno 14 4 2
Others 8 0 0
Grade- Well differentiated 71 5 1
Mod. differentiated 130 8 4
Poorly differentiated 84 25 11
Unknown 20 5 1
52. Early stage
– Ia1, Ia2 • Wertheim’s hysterectomy
– Ib1, Ib2 Type III hysterectomy
– IIa • TAH+BSO
• Pelvic lymphadenectomy
• ± Para-aortic LN sampling
53. Advanced stages
• IB2 • Concurrent Radiation
• Bulky IIA [>4cm] with chemotherapy
• II B to IV A – EBRT plus CISPLATIN
– Intra-cavitary
brachytherapy
Palliation with chemotherapy and/or radiation in late metastatic disease
56. Fluoroscopy
Demarcate the
target areas in
relation to bony
anatomy
Borders of the field
varies according to
the involved levels
of lymph node
stations
60. MRI
• Better target delineation
• Need to fuse with CT to obtain
Dosimetric Info.
• USPIO [Ultrasmall Super-
Paramagnetic Iron Oxide ]
used to identify involved
nodes*
*Dinniwell et al, IJROBP, 2009 Jul 1;74(3):844-51
61. PET
Better sensitivity in
detection of pelvic
and para-aortic nodes
Being tried in
treatment planning*
*Mutic S et aI, Int J Radiat Oncol Biol Phys. 2003 Jan 1;55(1):28-35
62. Brachytherapy- ICRT
• CT
• MRI
– GEC-ESTRO guidelines for
image based brachytherapy
– Helps in accurate description
of OARs [organ at risk]
• PET*
*Int J Radiat Oncol Biol Phys. 2007 Jan 1;67(1):91-6
71. Image guided brachytherapy - EBM
• 35 patients underwent catheter insertion
• CT imaging confirmed accurate placement within the uterine canal
in all cases[100%] {perforation rate of 10% with unaided insertions}
• Visualizing patient anatomy during insertion altered the selection of
tandem length and angle in 49% of cases, resulting in improved
applicator matching to anatomy.
• Average insertion time significantly decreased from 34 to 26
minutes (p=0.01)
• Requests for assistance from gynecologic surgical oncology declined
from 38% to 5.7% of procedures
Davidson MT et al, Brachytherapy. 2008 Jul-Sep;7(3):248-53
72. Conclusions
• Though cervical cancer is a clinically staged disease, imaging plays
an important role in deciding its management
• Imaging is helpful in describing local disease extent and nodal
involvement which are important prognostic factors
• CT scan is a good imaging modality for pre-treatment evaluation as
it is relatively easily available with good sensitivity and specificity
• MRI is the best option, presently available in evaluating cervical
cancer
• PET scan is useful in detecting nodal spread
73. Conclusions
• Image-Guided methods
– It is needed for disease assessment, provisional treatment
planning ("pre-planning"), applicator placement and
reconstruction
• Image BASED processes
– contouring, definitive treatment planning and quality control of
dose delivery
• Image-Guided and Image-Based radiation treatments are
aimed at better target localization and effective sparing of
organs at risk [OAR].
76. Role of imaging
• Image-Guidance
– It is needed for disease assessment, provisional treatment planning
("pre-planning"), applicator placement and reconstruction
• Image BASED processes
– contouring, definitive treatment planning and quality control of dose
delivery
• MRI in staging primary - IB and above
• PET-CT in staging the Nodes
• CT is a cheap alternative to MRI and PET-CT
78. GEC-ESTRO guidelines for reporting
IGBT
• DVH parameters for GTV, HR CTV and IR CTV are the minimum dose
delivered to 90 and 100% of the respective volume: D90, D100.
• The volume, which is enclosed by 150 or 200% of the prescribed dose
(V150, V200), is recommended for overall assessment of high dose
volumes.
• V100 is recommended for quality assessment only within a given
treatment schedule.
• For Organs at Risk (OAR) the minimum dose in the most irradiated tissue
volume is recommended for reporting: 0.1, 1, and 2 cm3; optional 5 and
10 cm3.
80. Recurrent disease
• Most common within two years
• Sites
– Vaginal vault
– Lymph nodes
– Liver/ lung metastases
• Imaging
– MRI is preferred
– High sensitivity, poor specificity
• Early RT changes/ infection can not be
differentiated from tumor
82. Selectron OT, Dr.BRA IRCH, Department of Radiation
Oncology (Radiotherapy), AIIMS
83. Dose reduction to normal structures
Rectal dose (of Pt A) Bladder dose (of Pt A)
ICRT 60-70% 70-80%
Interstitial 20-25% 20-25%
Practised in Department of Radiation
Oncology, AIIMS
Notas do Editor
Lymphatic metastases were found in 34% of women; 13% had common iliac nodal metastases, and 9% had paraortic nodal metastases. Early invasive cervical cancer: MRI and CT predictors of lymphatic metastases in the ACRIN 6651/GOG 183 intergroup studyGynecologic OncologyVolume 112, Issue 1, January 2009, Pages 95-103
Cross-sectional imaging provide the tumor size and the lymph node status which are important prognostic factors
Figure 6a. Stage IIb cervical carcinoma. Sagittal (a) and axial (b)T2-weighted MR images show that the cervix is almost entirely replaced by a slightly hyperintense mass. The tumor protrudes into the parametrium bilaterally (arrowheads in b); however, it does not reach the pelvic wall. Hydrometra, which is caused by the obstructed internal cervical os, is also noted (arrow in a)
Figure 7b. Stage IIIa cervical carcinoma. (a)Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid mass that extends along the anterior vaginal wall and reaches the lower one-third of the vagina (arrow). (b) Axial T2-weighted MR image shows that the low signal intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty tissue between the mass and the posterior bladder wall has disappeared. However, the mass does not infiltrate the vesical mucosa.
Figure 8b. Stage IIIb cervical carcinoma. (a)Sagittal T2-weighted MR image shows a slightly hyperintense, large, solid mass that extends from the uterine cervix to the lower part of the uterine body. It also extends to the lower one-third of the anterior vaginal wall (arrow). (b) Axial T2-weighted MR image shows that the tumor also reaches the left posterior wall of the bladder, although the thinned vesical muscular layer remains (arrowheads)
Figure 9. Stage IVa cervical carcinoma. Sagittal T2-weighted MR image shows a hypointense mass that occupies the uterine cervix and invades the vaginal wall anteriorly. At the level of the vaginal extension, the tumor reaches the mucosa of the posterior vesical wall (arrows).
Figure 10a. Stage IVb cervical carcinoma. (a)Sagittal T2-weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and hematogenous hepatic metastases (c). These findings are classified as stage IVb disease
![Introduction
• Cancer cervix is the second most common cancer in the
world among females [Globocan 2002]
• Commonest Cancer in females in most part of India
• It ranks second in Delhi [NCRP]
• Highest incidence in Chennai
• 30-50 years
* Global Cancer Statistics,CA Cancer J Clin 2005;55;74-108
** National Cancer Registry Programme,India 2005](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)