Staging of cervical cancer can either be based on the TNM or FIGO system. Moreover, radical trachelectomy, an emerging fertility-preserving technique in which the uterine corpus is anastomosed to the vagina to treat the many women diagnosed during their reproductive years, was not a consideration with these older systems. {"url":"/signup-modal-props.json?lang=gb\u0026email="}. (2019) International Journal of Gynecology & Obstetrics. In lower-resource settings, analogous modalities are pelvic US and chest radiography. Other features such as density, shape, and the presence or absence of the fatty hila have been suggested as important but consensus guidelines are silent on how they should be applied. 106, No. Similarly, intrauterine tumor growth, lymph node metastases, and peritoneal carcinomatosis are more reliably depicted with diffusion-weighted imaging than with conventional noncontrast sequences (37, 43, 44). We aim to explore the reasonability and limitations of stage IIIC-r and try to explore the potential reasons. FIGO = International Federation of Gynecology and Obstetrics. (Adapted, under a CC BY license, from reference 1.). Online supplemental material is available for this article. Tumor size (stage IB and IIA), cervical stromal invasion (stage IA), and lack of parametrial spread (stage IIB) are assessed well with MRI but poorly with CT. The updated FIGO staging gives added importance to MRI as a method of accurately measuring tumor size and depicting the presence of parametrial involvement. Pannu HK, Corl FM, Fishman EK. The 2018 FIGO cervical cancer staging system keeps the backbone of staging clinical, while incorporating results from imaging and pathology. Presence of distant metastases (stage IVB) confers a substantially poorer prognosis and indicates that local-regionally–directed therapies, such as surgery and radiation therapy, will not be sufficient for cure (49,50). Distant metastases noted at PET/CT should be confirmed with pathologic analysis, because this finding significantly impacts patient prognosis and treatment (49,50). ). For diagnosing lymphadenopathy based on morphology, there is variability in the literature on the acceptable size of cutoff value, which ranges between 0.8 cm and 1.0 cm in short-axis measurements (29,30). However, because tumor is usually homogeneously enhancing similar to normal cervical tissue, CT is usually suboptimal for assessing tumor extent of central pelvic spread and accurate measurement of the tumor (Fig 1) (28). Chest CT findings of metastases are pulmonary nodules or involvement of the supraclavicular nodes, a station in the drainage pathway of the primary tumor (31). † Examination should include small field-of-view images tailored for soft-tissue evaluation of the central pelvis and large field-of-view images of the abdomen and pelvis to evaluate retroperitoneal lymph nodes and the renal collecting system. From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114 (S.I.L. 6. The false-positive rate was also low, but was higher for MRI (8%) than for US (2%; P < .001) (Table 3) (52). (a) Contrast--enhanced CT, (b) axial fast spin-echo T2-weighted MRI, and (c) axial T1 images after gadolinium-based contrast agent administration through pelvis of a woman with stage IB2 cervical cancer (arrows). Administration of intravenous iodinated contrast material is optional but can aid in the evaluation of solid organs (eg, uterine corpus, liver, kidneys). ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Okamoto Y, Tanaka YO, Nishida M et-al. Until 2018, CC was clinically staged based on the FIGO 2009 classification. However, the limited field of view and soft-tissue contrast of US can impede accurate assessment of bulky tumors (Fig 2) and precludes evaluation of retroperitoneal lymph nodes. The authors would like to thank Mitchell D. Schnall, MD, PhD, and Gillian M. Thomas, MD, for their unfailing support of gynecologic cancer imaging trials. Mediastinal lymphadenopathy, unlike retroperitoneal or supraclavicular lymphadenopathy, does not result from direct drainage of the primary tumor; instead, it would suggest underlying pulmonary metastases. Tumor size (stage IB and IIA), cervical stromal invasion (stage IA), and lack of parametrial spread (stage IIB) are assessed well with MRI but poorly with CT. The International Federation of Gynecology and Obstetrics (FIGO) ovarian cancer staging system was first published in 1973 and was revised in 1988 and 2014 [1, 2]. Son H, Kositwattanarerk A, Hayes MP et-al. This revision is based on observational data that define two clinically distinct patient populations (14). To compensate for these shortfalls, treatment planning for invasive cervical cancer in much of the developed world has included modern cross-sectional and functional imaging such as CT, MRI, and fluorine 18 fluorodeoxyglucose, or FDG, PET (10,11). Kaur H, Silverman PM, Iyer RB et-al. ■ Retroperitoneal lymphadenopathy in the abdomen and pelvis, also new to the 2018 FIGO revision, can be diagnosed at imaging alone or with pathologic analysis. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. In June 2009 the FIGO committee introduced the revised staging [5] of cervical carcinoma updating the previous staging of 1988 (Tables 1 and 2). If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. The International Federation of Gynecology and Obstetrics (FIGO) system, last revised in 2009, is the most widely used staging system for cervical carcinoma (Table 3.3) [].The FIGO staging of cervical carcinoma is clinical and does not rely on either surgical or pathologic findings. During the operation, a cerclage is sutured across the isthmus to ensure uterine competence for future pregnancy. Radiologists must familiarize themselves with the new FIGO staging system and understand its relevance to patient management. 1994-1997 FIGO Committee on Gynecologic Oncology. Most common are lung nodules, although pleural effusions or masses can also be seen. Diagnostic-quality imaging requires a system greater than or equal to 1.5 T and intravenous contrast material administration. AJR Am J Roentgenol. For oncologists, the use of modern imaging will enable them to stage more accurately, to counsel on prognosis with greater certainty, and to tailor treatment to be curative but less morbid. The examination offers “one-stop staging” by assessing the pelvic tumor with MRI and evaluating the entire body for retroperitoneal nodal and distant metastases. Thus, MRI best delineates tumor spread into the uterine corpus, pelvic sidewalls, and adjacent viscera such as bladder and bowel. Stage predicts patient prognosis and guides treatment planning. 2. (1). The revisions introduced in the 2018 FIGO staging system are intended to address the gap between the staging formalism and ongoing clinical practice and to explicitly acknowledge the role that advanced imaging has come to play in the care of women with invasive uterine cervical cancer (13). In this article, we review the 2018 FIGO staging system for cervical cancer and the new additions relevant to radiologists. The maximal cross-sectional tumor diameter visualized in any plane is measured both at imaging and at pathologic analysis. PET/CT is indicated and is the preferred examination for whole-body staging in patients with local-regionally advanced cancer at pelvic examination (ie, clinical stage IB3, IIA2, >IIB) and in patients in whom radiography, CT, or MRI indicates extrauterine spread of the primary tumor. With the FIGO 2018 staging system for uterine cervical cancer, imaging is formally incorporated as a source of staging information and as a supplement to clinical examination (ie, pelvic examination, cystoscopy, and colposcopy) to obtain an accurate description of tumor spread (Table 1) (1). 4. 5. Patients and methods: This prospective multicenter clinical study was conducted by the American College of Radiology Imaging Network and the Gynecologic Oncology Group from March 2000 to November 2002; 25 United States health centers enrolled 208 consecutive patients with biopsy-confirmed cervical cancer of FIGO stage > or = IB who were scheduled for surgery based on clinical assessment. If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. AJR Am J Roentgenol. FDG = fluorodeoxyglucose, FIGO = International Federation of Gynecology and Obstetrics. Nx: Regional lymph nodes cannot be assessed. (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. However, in patients with lymphadenopathy, surgery alone does not cure and 10%–30% of patients with early stage disease harbor lymph node metastases (22). Given this, oncologists have stratified management of cervical cancer according to the resource intensity of the practice setting (51). Table 4: CT versus PET/CT in Detecting Abdominal Retroperitoneal Metastases in Uterine Cervical Cancer. *PET and CT images acquired in a hybrid scanner and interpreted with inclusion of fusion imaging. If MRI is unavailable, then US with an endovaginal or endorectal probe is an alternative in women when the clinical examination suggests early stage disease. 4 Cervical carcinoma is staged at clinical examination because many tumors are inoperable at the time of patient presentation. Treatment will involve systemic chemotherapy with local-regional therapy modified to play a less aggressive role. 2003;180 (6): 1621-31. Although imaging is already a part of pretreatment planning in some high-resource settings, its incorporation into assigning stage is a new development. To evaluate the diagnostic potential of diffusion kurtosis imaging (DKI) functional maps with whole-tumor texture analysis in differentiating cervical cancer (CC) subtype and grade. Table 1: 2018 FIGO Staging System for Uterine Cervical Cancer, Note.— Imaging and pathologic analysis, where available, can be used to supplement clinical findings for all stages. Seventy-six patients with CC were enrolled. A lymph node is considered positive for metastasis when it is within the anatomic nodal drainage pathway for the primary tumor and demonstrates tracer uptake greater than that of a clearly a normal node elsewhere on the scan (48). Historically, Federation of Gynecology and Obstetrics (FIGO) staging was based mainly on clinical examination in consideration of the prevalence of cervical cancer in low-income populations with limited access to advanced technology. ■ Both US and MRI accurately measure the primary tumor and assess parametrial spread better than does CT or physical examination. CT should be of diagnostic quality but use of iodinated contrast material is optional. If performed as an alternative to pelvic MRI, then intravenous contrast material should be administered for soft-tissue contrast to aid in distinguishing tumor from the normal uterine and other pelvic tissues. Although this revision acknowledges the progress that the developed countries have made in incorporating imaging for cervical staging to treat patients more effectively and with less morbidity, it also highlights the stark disparities in the care of patients with cervical cancer worldwide. The current system of staging for cervical cancer is based on the International Federation of Gynecology and Obstetrics (FIGO) classification [] ().This staging system is a clinical approach based on findings from clinical assessment or examination of patients under anesthesia, which may be supplemented by chest radiography, excretory urography, cystoscopy, and proctoscopy. Often, large field-of-view anatomic images (eg, gradient-echo T1-weighted or echo planar T2-weighted images) from the level of the renal hilum through the pelvic floor are also obtained in the axial plane to evaluate for hydronephrosis (stage IIIB) and lymphadenopathy (stage IIIC). American Joint Committee on Cancer - Cervix Uteri Cancer Staging. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Figure 3: Image shows uterine cervical cancer with parametrial involvement. The following amendments to the staging classification of carcinoma of the cervix uteri were made by the FIGO Committee for Gynecologic Oncology in 2018: Allowing the use of any imaging modality and/or pathological findings for allocating the stage. PET/CT is the most sensitive imaging examination for detection of lymphadenopathy. The main applications of 2-[18 F]-fluoro-2-deoxy-d-glucose (FDG) PET/CT in gynaecological oncology are the staging of cervical cancer and detection of recurrent ovarian, cervical and endometrial cancer. Tumor, both primary and metastatic, is of intermediate signal intensity (ie, lower than fat but higher than myometrium or cervical stroma) on fast spin-echo T2-weighted images and enhances homogeneously or heterogeneously but less avidly than the normal myometrium in the venous phase of the contrast material bolus (Fig 1) (33,34). In this context, PET/CT is preferred as the imaging modality because it also enables depiction of occult distant metastases, another factor in staging. 3, Journal of Magnetic Resonance Imaging, Vol. Saunders Company. Other option for nodal evaluation is surgical and includes lymphadenectomy or sentinel node biopsy, the latter limited to sites where the necessary surgical and pathologic expertise are available (55,56). (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. Figure 2a: Images show uterine cervical cancer size at US versus MRI. The revision calls for a more precise measurement of primary tumor size, best assessed with imaging. Accurate staging of cervical carcinoma is crucial to patient management. ‡ Abnormalities should be further evaluated with chest CT. § PET and CT images should be acquired with hybrid scanner and analysis should include fusion imaging. Tumor size (stage IB and IIA), cervical stromal invasion (stage IA), and lack of parametrial spread (stage IIB) are assessed well with MRI but poorly with CT. Table E1 (online) is a representative protocol for image acquisition. ║ Abnormalities should be confirmed with pathologic analysis. Although surgery is more sensitive, imaging is less morbid in avoiding the short- and long-term complications of lymphadenectomy (57). Patient was staged as IIIC2 based on PET/CT. Figure 4c: Images show uterine cervical cancer lymphadenopathy at fluorodeoxyglucose PET/CT versus CT. (a) Coronal maximum intensity projection PET image in a patient clinically staged as IB shows hypermetabolic foci in pelvis (arrowheads) and abdomen (arrows), which at fusion PET/CT (not shown) correspond to retroperitoneal lymphadenopathy. A prospective trial of 189 women with FIGO stage IA2–IIA cervical cancer (ie, invasive tumors <4 cm) showed that maximal tumor dimension measured with US agreed with those obtained with MRI or pathologic analysis (Table 3) (52). Cancer staging is a fundamental principle and one of the first and most important steps used to predict patient outcome as well as to plan the most appropriate treatment. ); and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (M.A. (2009) ISBN:8847013437. With the FIGO 2018 staging system for uterine cervical cancer, imaging is formally incorporated as a source of staging information and as a supplement to clinical examination (ie, pelvic examination, cystoscopy, and colposcopy) to obtain an accurate description of tumor spread (Table 1) (1). The most recent revision of the FIGO staging system was announced in 2018 (Table 1). Additional inclusion criteria specify that the tumor cannot extend into the uterine corpus or must be a specific distance from the internal cervical os at MRI, and that the pelvic lymph nodes must be evaluated surgically and deemed negative for metastases (17–19). Detection of lymphadenopathy that extends beyond the pelvis into the para-aortic region is clinically significant, not only because it upstages the patient, but it also expands the fields for radiation therapy. (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. *Complete description is available in reference 53. Figure 4b: Images show uterine cervical cancer lymphadenopathy at fluorodeoxyglucose PET/CT versus CT. (a) Coronal maximum intensity projection PET image in a patient clinically staged as IB shows hypermetabolic foci in pelvis (arrowheads) and abdomen (arrows), which at fusion PET/CT (not shown) correspond to retroperitoneal lymphadenopathy. 8. Figure 1a: Images show uterine cervical cancer at CT versus MRI. Source.—References 8 and 9. However, in 2018, the FIGO Gynecologic Oncology Committee made revisions to allow stage assignment based on imaging and pathological findings, when available . Diagnosis, staging, and surveillance of cervical carcinoma. Chest radiography in posterior-anterior and lateral views is performed in patients with local-regionally advanced disease to evaluate for pulmonary metastases. These should be routinely acquired if a PET/CT or an abdominopelvic CT is not planned. Check for errors and try again. Understanding the radiologic techniques used, the literature supporting them, and common imaging pitfalls ensures accurate staging … MRI affords a larger field of view than does US and greater tissue contrast than does CT. Table 2 TNM (8 th … The correlation of preoperative CT, MR imaging, and clinical staging (FIGO) with histopathology findings in primary cervical carcinoma | springermedizin.de Skip to main content ■ PET CT is more sensitive than is CT or MRI in depicting metastases to the retroperitoneal lymph nodes. Preceding versions of the staging system included imaging with chest and skeletal radiography, intravenous pyelography, and barium enema (4–6). The primary drainage of uterine cervical cancer is to the pelvic sidewall (ie, external iliac, obturator, and internal iliac) and the supraclavicular lymph nodes (23,47). Stage IIIC1 corresponds to nodal metastases confined to the pelvis and stage IIIC2 to para-aortic nodal metastases. MR imaging of the uterine cervix: imaging-pathologic correlation. Whereas FIGO staging of most gynecologic cancers relies on surgery and pathologic analysis, uterine cervical cancer is unusual among the gynecologic cancers in that it is staged clinically with pelvic examination, often under anesthesia with bladder cystoscopy and colposcopy, in combination with imaging. Preoperative staging of cervical cancer: is 18-FDG-PET/CT really effective in patients with early stage disease? MRI is preferred over CT or pelvic examination for measuring primary tumor size. Note.—Imaging is appropriate in women with tumor invasive to a depth greater than or equal to 5 mm. (a) Coronal maximal intensity projection PET image in a patient staged as IB following clinical examination and normal chest x-ray (not shown) shows hypermetabolic foci in left upper (arrow) and right middle (arrowhead) thorax corresponding to (b) left supraclavicular lymphadenopathy (arrow) and (c) cavitary right lung nodule (arrowhead), respectively. Staging of cervical cancer can either be based on the TNM or FIGO system. Negative rather than positive oral contrast material is used to minimize attenuation-correction artifact. The patient is asked to void before scanning to decrease bladder volume. The International Federation of Gynecology and Obstetrics (FIGO) staging system is widely used for treatment planning but more often for standardization of epidemiologic and treatment results (,Table 1) (,2,,3). Figure 5b: Images show uterine cervical cancer with thoracic metastases. 23 (2): 425-45. Axial oblique fast spin-echo T2-weighted image in a woman clinically staged as IB shows tumor that extends beyond dark stromal ring of cervix into adjacent parametria (arrows) corresponding to stage IIB. Table 2 shows the revised staging (FIGO 2018) and TNM (8th Edition) classifications [26, 31]. These small field-of-view images are optimized for high-spatial-resolution and soft-tissue contrast imaging of the central pelvis. It is usually performed as part of a PET/CT examination or as an alternative to abdominopelvic MRI if the latter examination is contraindicated or unavailable. As with CT, lymph nodes are evaluated not only based on size, but also for abnormal signal and/or shape. Thus, distant metastases depicted with PET/CT should be confirmed with biopsy, because a designation of stage IVB is associated with a significant change in treatment strategy. Cervical cancer is a significant cause of morbidity and mortality worldwide despite advances in screening and prevention. Figure 2b: Images show uterine cervical cancer size at US versus MRI. Radial spread of tumor out of the uterine cervix into the parametria correlates with stage IIB disease and triages the patient away from primary surgery to concurrent chemotherapy and radiation therapy (Fig 3). Pelvic MRI visualizes the primary tumor and evaluates tumor spread into the soft tissues of the central pelvis. Older systems did not include assessment of lymph node metastases, an important determinant for prognosis and treatment planning. Some tumors, especially after cone biopsy, may be of too small a volume to be seen at MRI. A prospective multicenter trial demonstrated that, in patients with early stage tumor intended for curative surgery, sensitivity of MRI versus clinical examination to help detect parametrial extension was 53% versus 29% (53). Note.— Data in parentheses are primary ratios. If PET/CT is unavailable, then CT or MRI is a second-line alternative with both modalities demonstrating similar diagnostic performance (28,60). International Federation of Gynecology and Obstetrics, European Journal of Nuclear Medicine and Molecular Imaging, International Journal of Radiation Oncology*Biology*Physics, Vol. 21 (5): 1155-68. Magnetic resonance imaging is the imaging modality of choice for staging the primary cervical … … Abdominopelvic CT is performed to evaluate for retroperitoneal lymphadenopathy (stage IIIC). The new staging adds Stage IIIC1 for pelvic lymph node metastasis and IIIC2 for aortic lymph node metastasis, similar to the FIGO staging of lymph nodes in endometrial cancer. Dissemination of the advantages of imaging for cervical cancer staging lies within the domain of global health development efforts. Patient is clinically suspected to have low-stage disease (ie, less than International Federation of Gynecology and Obstetrics [FIGO] stage IIA). In a prospective cohort study of 560 patients at a single center, the risk of recurrent disease was shown to increase incrementally on the basis of the most distant level of lymph node involvement at PET, with a hazard ratio of 2.40 (95% confidence interval: 1.63, 3.52) for pelvic, 5.88 (95% confidence interval: 3.80, 9.09) for para-aortic, and 30.27 (95% confidence interval: 16.56, 55.34) for supraclavicular involvement (63). Because of its sensitivity in depicting lymph node metastases, PET and PET/CT are a strong predictor of disease-specific survival (15,63). If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. This new primary tumor size cutoff value of 2 cm also corresponds to the eligibility criteria for radical trachelectomy, a fertility-sparing treatment for cervical cancer in which the uterine cervix, parametria, and the vaginal cuff are resected (15,16). Evaluation for abdominopelvic retroperitoneal lymphadenopathy, either with imaging alone or with pathologic analysis, is now also part of staging. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. In patients suspected of having advanced disease, transabdominal US can be used to evaluate for hydronephrosis (stage IIIB) if cross-sectional imaging with CT, MRI, or PET/CT—usually performed for retroperitoneal nodal evaluation—is not performed. Staging according to the old systems (ie, FIGO cervical staging systems from 1999, 2009, and 2014) was inaccurate, with 20%–40% of stage IB–IIIB cancers understaged and up to 64% of stage IIIB cancers overstaged (7–9). Data in parentheses are 95% confidence intervals. FIGO staging of gynecologic cancers, cervical, and vulva. FDG PET/CT examination should be performed in a single sitting in a hybrid scanner in accordance with parameters defined by society guidelines (46). ■ The 2018 International Federation of Gynecology and Obstetrics (FIGO) uterine cervical cancer staging system introduces a new primary tumor size cutoff value of 2 cm (ie, stage IB1 vs IB2), used to evaluate patients for fertility-sparing radical trachelectomy and to estimate prognosis. (a) Sagittal endovaginal US image in a woman presenting with abnormal uterine bleeding shows 2.3-cm solid mass (arrows), pathologically diagnosed as invasive adenocarcinoma and initially staged as IB2. In a paired comparison, a multicenter prospective trial of 153 women showed that PET/CT is more sensitive than is CT alone, especially in depicting lymph nodes in the para-aortic stations (Fig 4, Table 4) (59). 28, No. In 2018, this practice was revised by the FIGO Gynecologic Oncology Committee to allow imaging and pathologic findings, where available, to assign the stage. MR imaging is the modality of choice for staging with CT having relatively low specificity (especially for myometrial invasion 5). Although FIGO staging system does not include imaging in the staging of cervical cancer, in the revised FIGO system imaging techniques are encouraged to assess the important prognostic factors and imaging is now complimentary to the clinical assessment.
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