Figure 1c: Images show uterine cervical cancer at CT versus MRI. Most cervical cancers are diagnosed in low-resource settings where options such as modern cross-sectional and functional imaging (eg, CT, MRI, PET/CT), brachytherapy, and on-site pathologic analysis are either constrained or not accessible at all. Radiographics. 2003;180 (6): 1621-31. With the inclusion of lymph node involvement in the updated 2018 FIGO staging, cross-sectional imaging-and in particular, fluorodeoxyglucose PET/CT-has an increasing role in the depiction of nodal disease. Viewer, https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf, https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/survival.html, 2018 FIGO Staging Classification for Cervical Cancer: Added Benefits of Imaging, Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies, MRI for Radiation Therapy Planning in Human Papillomavirus–associated Gynecologic Cancers, Utility of PET/CT to Evaluate Retroperitoneal Lymph Node Metastasis in High-Risk Endometrial Cancer: Results of ACRIN 6671/GOG 0233 Trial, FDG PET/CT Pitfalls in Gynecologic and Genitourinary Oncologic Imaging. 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. 8. In June 2009 the FIGO committee introduced the revised staging [5] of cervical carcinoma updating the previous staging of 1988 (Tables 1 and 2). 2. 2007;188 (6): 1577-87. 1. Choice of modality depends on the technology available within the practice setting (Table 2). Patient was staged as IIIC2 based on PET/CT. tases (22). Springer Verlag. Enter your email address below and we will send you the reset instructions. Most of these metastases (ie, thoracic lymphadenopathy, pulmonary nodules <1 cm, and bone metastases) are not depicted with pelvic MRI and chest radiography, the recommended alternative modalities if PET/CT is unavailable (62). Stage IIIC1 corresponds to nodal metastases confined to the pelvis and stage IIIC2 to para-aortic nodal metastases. However, clinical implementation of PET/MRI would require that the challenges posed by attenuation correction be better solved, especially in the abdomen and pelvis. (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. Dissemination of the advantages of imaging for cervical cancer staging lies within the domain of global health development efforts. CT should be of diagnostic quality but use of iodinated contrast material is optional. Cervical carcinoma is staged at clinical examination because many tumors are inoperable at the time of patient presentation. 106, No. Staging can be based on the TNM or FIGO system. (Adapted, under a CC BY license, from reference 1.). Although the revised FIGO staging system does not include imaging in the staging of cervical cancer, for the first time the committee encourages the use of imaging techniques, if available, to assess the 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. 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. 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. Although imaging is already a part of pretreatment planning in some high-resource settings, its incorporation into assigning stage is a new development. 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. Until 2018, CC was clinically staged based on the FIGO 2009 classification. Figure 3: Image shows uterine cervical cancer with parametrial involvement. 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. (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, 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. (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. The derived apparent diffusion coefficients offer an opportunity for quantitative imaging but have yet to be incorporated into clinical examination protocols (45). Figure 1a: Images show uterine cervical cancer at CT versus MRI. However, in patients with lymphadenopathy, surgery alone does not cure and 10%–30% of patients with early stage disease harbor lymph node metastases (22). MR imaging of the uterine cervix: imaging-pathologic correlation. To be considered a candidate for this procedure, the woman must be considered to have stage I (ie, tumor confined to the cervix) and not stage II (ie, tumor growth into the upper third of the vagina or the parametria) disease. American Joint Committee on Cancer - Cervix Uteri Cancer Staging. 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. Mediastinal lymphadenopathy, unlike retroperitoneal or supraclavicular lymphadenopathy, does not result from direct drainage of the primary tumor; instead, it would suggest underlying pulmonary metastases. (b) Sagittal MRI after gadolinium-based contrast agent administartion shows that tumor (arrows) extends into uterine corpus and measures 4.8 cm, corresponding to stage IB3. Consequently, we routinely include diffusion-weighted imaging with b values of 0 and 1000 sec/mm2 to facilitate lesion detection (42). If PET/CT is unavailable, then CT or MRI is a second-line alternative with both modalities demonstrating similar diagnostic performance (28,60). Choice of imaging for staging is also modified to reflect this variability. 4, Magnetic Resonance Imaging Clinics of North America, Vol. PET/CT is the most sensitive imaging examination for detection of lymphadenopathy. MRI is preferred over CT or pelvic examination for measuring primary tumor size. 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. 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) ovarian cancer staging system was first published in 1973 and was revised in 1988 and 2014 [1, 2]. Chest radiography in posterior-anterior and lateral views is performed in patients with local-regionally advanced disease to evaluate for pulmonary metastases. Revised FIGO staging of cervical carcinoma 2018 8 FIGO no longer includes Stage 0 (Tis) I:confined to cervix uteri (extension to the corpus should be disregarded) 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. Staging of cervical cancer can either be based on the TNM or FIGO system. ). The false-positive rate was also low, but was higher for MRI (8%) than for US (2%; P < .001) (Table 3) (52). 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). The FIGO staging systems are determined by the International Federation of Gynaecology and Obstetrics (Fédération Internationale de Gynécologie et d’Obstétrique). Thus, early detection of stage IVB disease significantly impacts patient treatment and represents an opportunity to decrease treatment-related morbidity. These should be routinely acquired if a PET/CT or an abdominopelvic CT is not planned. Table 2 TNM (8 th … (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. Endovaginal or endorectal US with a high-frequency (eg, 7–9 MHz) transducer is used to measure the primary tumor and to assess for local spread into the uterine cervical stroma (stage IB) or parametria (stage IIB) in patients suspected of having early stage disease. Role of PET/MRI in Staging of Cervical Cancer Under the Newly Updated FIGO Staging System, The International Federation of Gynecology and Obstetrics (FIGO) Cancer Report 2019: An Imaging Update on Cervical Cancer Staging and Beyond, Pseudoprogression with Immunotherapy Treatment, Locally advanced, metastatic prostate adenocarcinoma. Nx: Regional lymph nodes cannot be assessed. International Federation of Gynecology and Obstetrics, Revised FIGO staging for carcinoma of the cervix, FIGO staging for carcinoma of the vulva, cervix, and corpus uteri, Utilization of diagnostic studies in the pretreatment evaluation of invasive cervical cancer in the United States: results of intergroup protocol ACRIN 6651/GOG 183, The staging of cervical cancer: inevitable discrepancies between clinical staging and pathologic findinges, Tumor size evaluated by pelvic examination compared with 3-D quantitative analysis in the prediction of outcome for cervical cancer, ACR Appropriateness Criteria® pretreatment planning of invasive cancer of the cervix, Clinical Practice Guideline in Oncology. With the 2018 International Federation of Gynecology and Obstetrics 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. 3, Journal of Magnetic Resonance Imaging, Vol. 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. Administration of intravenous iodinated contrast material is optional but can aid in the evaluation of solid organs (eg, uterine corpus, liver, kidneys). Gynecologic cancers are staged according to the International Federation of Gynecology and Obstetrics (FIGO) system (1). Cervical carcinoma is the third most common gynecologic malignancy, with an average patient age at onset of 45 years (,1,,2). Note.—Adapted, with permission, from reference 59. 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. Cervical Carcinoma and Updated FIGO Staging: What Should Radiologists Know in 2019? The most recent revision of the FIGO staging system was announced in 2018 (Table 1). Note.— Data in parentheses are primary ratios. 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). Distant metastases noted at PET/CT should be confirmed with pathologic analysis, because this finding significantly impacts patient prognosis and treatment (49,50). The 2018 FIGO cervical cancer staging system keeps the backbone of staging clinical, while incorporating results from imaging and pathology. Objective: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. The updated FIGO staging gives added importance to MRI as a method of accurately measuring tumor size and depicting the presence of parametrial involvement. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. 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). 9. Imaging modalities for staging in a range of high- to low-resource practice settings are presented. In addition, patient table times with the current scanners are long (ie, ≥1.0 h), which would represent a relative contraindication in many patients. (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. In high-resource settings, pelvic MRI (to assess tumor size and central pelvic spread) and torso fluorodeoxyglucose PET/CT (to assess lymphadenopathy and distant metastases) are used to assign stage and to plan therapy. Choice of modality depends on the technology available within the practice setting. (2009) ISBN:8847013437. MRI affords a larger field of view than does US and greater tissue contrast than does CT. 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). Patients with pelvic and/or para-aortic lymph node metastases are designated as having stage IIIC disease, irrespective of primary tumor size or local pelvic spread. 3. Neerja B, Jonathan SB, Mauricio CF et-al. In general, there are five stages: stage 0: carcinoma in situ (common in cervical, vaginal, and vulval cancer) stage I: confined to the organ of origin PET/CT evaluation of cervical cancer: spectrum of disease. Staging of cervical cancer can either be based on the TNM or FIGO system. 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. Most common are lung nodules, although pleural effusions or masses can also be seen. Figure 5a: Images show uterine cervical cancer with thoracic metastases. In this context, PET/CT is preferred as the imaging modality because it also enables depiction of occult distant metastases, another factor in staging. Lymph node status is to be assigned based on imaging and/or pathologic analysis and the methodology is to be recorded. Sala E, Wakely S, Senior E et-al. For patients suspected of having stage IB (invasive cancer ≥5 mm) disease or greater, imaging is indicated to assign stage (see Fig E1 [online]). 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). (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. In 2018, this practice was revised by the FIGO Gynecologic Oncology Committee to allow imaging and pathologic findings, where available, to assign the stage. Fusion of the PET signal with the anatomic CT images helps to address the limited special resolution and soft-tissue contrast of PET. 52, No. Imaging modality or pathologic technique should also be documented. The 2018 FIGO cervical cancer staging system now enables identification and upstaging of these patients based on pretreatment lymph node imaging, thereby sparing them unnec-essary surgery and long-term morbidity (12,23). Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) … Diagnosis, staging, and surveillance of cervical carcinoma. Because of its sensitivity in depicting lymph node metastases, PET and PET/CT are a strong predictor of disease-specific survival (15,63). 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). Table 2: Choice of Imaging Based on Resource Availability for Staging of Patients with Uterine Cervical Cancer. Additionally, the revision calls for a more precise description of primary tumor size, which should be measured with MRI, especially for trachelectomy planning. The revision calls for a more precise measurement of primary tumor size, best assessed with imaging. 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). 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). ■ Torso (chest, abdomen, and pelvis) PET CT reveals unsuspected distant metastases (eg, chest, peritoneum, bone, etc) that changes the stage, prognosis, and treatment plan in 14% of women with local-regionally advanced (ie, clinically suspected FIGO stage IB3, IIA2, ≥IIB) cervical cancer. Although the choice of b values for nodal detection for gynecologic cancer has not been standardized, most studies use maximum b values of 800–1000 sec/mm2 (35–41). Data in parentheses are 95% confidence intervals. … Negative rather than positive oral contrast material is used to minimize attenuation-correction artifact. † Stage IIIC should be annotated with r (radiology) or p (pathologic analysis) to indicate the method used to allocate this stage. Such pretreatment imaging spared many women the particularly toxic combination of surgery, followed by concurrent chemotherapy and radiation therapy. Following the attenuation-correction CT, we acquire the PET images in the caudocranial direction to minimize the interval for bladder filling and bowel peristalsis that could cause misregistration between the CT and PET images (47). As radiologists now a play an active role in assigning stage, we should turn our attention to arriving at consensus standards and criteria for image acquisition, interpretation, and reporting to achieve optimum quality in the care of uterine cervical cancer. All underwent standard clinical examination and whole-body FDG-PET. International Federation of Gynecology and Obstetrics, European Journal of Nuclear Medicine and Molecular Imaging, International Journal of Radiation Oncology*Biology*Physics, Vol. For an imaging pathway on the best modalities in accurate staging of cervical cancer: see reference 9. Seventy-six patients with CC were enrolled. The standards for image acquisition and interpretation are summarized with cases illustrating potential pitfalls. At US, tumor is typically homogeneously solid and hypoechoic relative to the uterine cervical stroma (24–27). ║ Abnormalities should be confirmed with pathologic analysis. Stage predicts patient prognosis and guides treatment planning. As with CT, lymph nodes are evaluated not only based on size, but also for abnormal signal and/or shape. M1: Distant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal or para-aortic lymph nodes, lung, liver or bone). (2010) ISBN:1416031219. When compared with the conventional T1- or T2-weighted sequences, the diffusion-restricted tumor is more conspicuous against the normal tissue and is especially useful when gadolinium-based contrast agent cannot be administered. Figure 5b: Images show uterine cervical cancer with thoracic metastases. With a simple physical and pelvic examination, it is possible to ascertain if the cervix cancer is localised and would be amenable to surgical resection. Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Unable to process the form. The first staging system put forth by FIGO around the turn of the 20th century applied to carcinoma of the uterine cervix, at the time the most common cancer among women in the developed world (3). FDG = fluorodeoxyglucose, FIGO = International Federation of Gynecology and Obstetrics. 6, © 2021 Radiological Society of North America, History of the FIGO cancer staging system, FIGO staging of gynecologic cancer. The choice of imaging for staging is modified based on the availability of the technology and expertise (Table 2). 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. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Pelvic MRI visualizes the primary tumor and evaluates tumor spread into the soft tissues of the central pelvis. A basic overview of pelvic anatomy is important for staging cervical cancer because an understanding of pelvic ligaments, vessels, peritoneal reflections, and pelvic lymph node stations is vital in evaluating cross-sectional computed tomography (CT) and MRI. 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). Methods: Guidelines for uterine cervical cancer … Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. The size and extent of local spread of the primary tumor in the central pelvis can now be assessed by using clinical examination, imaging, or pathologic measurement. It typically presents in younger women with an average age of onset at around 45 years. 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). Check for errors and try again. From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114 (S.I.L. AJR Am J Roentgenol. ‡ Abnormalities should be further evaluated with chest CT. § PET and CT images should be acquired with hybrid scanner and analysis should include fusion imaging. Revised FIGO staging for carcinoma of the cervix uteri. Fluorine 18 FDG PET/MRI, in which MRI and PET data are acquired simultaneously in a single scanner, demonstrates promise to be an important tool in FIGO cervical cancer staging (42). Source.—References 8 and 9. Invasive uterine cervical cancer is a disease that primarily afflicts women who lack access to preventive health care, such as Papanicolaou test screening and the human papilloma virus vaccine. Patients with tumors less than 2 cm (ie, stage IB1) demonstrate a nearly twofold lower risk of cervical cancer death compared with patients with tumors measuring 2–4 cm (ie, stage IB2). Table E1 (online) is a representative protocol for image acquisition. 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. 23 (2): 425-45. The new system introduces retroperitoneal lymphadenopathy as a factor and specifies that cross-sectional imaging, ideally PET/CT, be used to assess nodal status. 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).
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