Diagnostic Imaging Pathways - Cervical Cancer (Staging)
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This pathway provides guidance on the staging of cervical cancer.
Date reviewed: October 2013
Date of next review: 2017/2018
Published: April 2013
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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 | Medium | 5-10 mSv |
 | High | >10 mSv |
Teaching Points
Teaching Points
- The diagnosis of cervical cancer requires histological confirmation
- Staging is performed according to the FIGO system of classification, which is largely based on clinical examination (often under anaesthesia by an experienced examiner). It may include inspection, palpation with rectovaginal examination, cystoscopy and proctoscopy
- PET and PET/CT provides better assessment of extra pelvic metastases. It is increasingly being used in the detection of residual or recurrent disease
intro
Cervical Cancer (Staging)
- The incidence and mortality from cervical cancer has decreased significantly over the last 10 years in most developed countries due to a regular screening programme 1
- The life time risk of cervical cancer in Victoria (Australia) in 1994 was 1:80,and this had decreased to 1:250 by 2002 1
- Carcinoma of the uterine cervix grows locally and may extend to the paracervical tisues and to the pelvic organs,spread to regional lymph nodes, and occasionally spread by haematogenous dissemination to distant structures 2
- Squamous carcinoma and adenocarcinoma are the most common histological subtypes 2
Confirmation of diagnosis
- Requires histological confirmation and review by gynaecological pathologists
- If a definitive diagnosis of invasive cancer cannot be made on office biopsy, then an excisional biopsy or cold knife cone biopsy will be required 5,6
The FIGO system of staging
Main features- Used to assess the extent of disease and to determine therapeutic approach
- Clinical staging (not surgical or radiological staging) is used as most patients are treated with primary radiotherapy and resource poor countries may not have access to advanced imaging modalities
- The FIGO system of staging is largely based on clinical examination (often under anaesthesia by an experienced examiner) which may include inspection, palpation with rectovaginal examination, cystoscopy and proctoscopy
- The FIGO system of staging allows Chest Radiograph examination of the lungs and skeleton, intravenous urography and blood tests (liver and renal function tests) to exclude distant metastases 2
- However optional imaging (CT/MRI/PET) may be performed. This may aid to guide treatment decisions but does not affect FIGO staging except if hydronephrosis, lung or bony metastases are detected 1-4
- If there is doubt as to the stage, the earlier stage is chosen. Once clinically decided, the stage cannot be changed 2
- Please refer to the new 2010 International Federation of Gynaecology and Obstetrics(FIGO) classification and Tumour Node Metastasis(TNM) classification for Cervical Cancer 2
clinical
Clinical Presentation
- Abnormal pap smear
- Abnormal vaginal bleeding
- Vaginal discharge
- Pelvic pain
- Other rare presentations include ureteric obstruction/hydronephrosis
Examination and Biopsy
- Physical examination including palpation of supraclavicular and groin nodes
- Speculum examination to look for cervical lesion and vaginal involvement
- Pelvic and rectal examination to asses size of cervix and extracervical spread
- Biopsy should be performed for any obvious macroscopic cervical lesion
- If normal looking cervix,then colposcopy +biopsy +/-endocervical curettage
ct
Computed Tomography (CT) Chest / Abdomen / Pelvis
- CT Chest is considered to be superior to plain chest radiograph to identify lung metastases 4,10
- CT/MRIs have replaced the use of intravenous urography to assess urinary tract as they also provide additional information about disease in retroperitoneum and upper abdomen 4,10,15
- For women with clinically apparent metastatic disease, contrast CT chest, abdomen and pelvis is more appropriate than MRI 4,10
- However for women with contraindications to MRI, CT is more appropriate 4,7
mri
Magnetic Resonance Imaging (MRI)
- MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer 28
- It is considered more accurate than CT as well as clinical examination for assessment of cervical cancer. 4,7,8,9,28 The assessment accuracy of MRI ranges from 75%-96% whereas that of CT ranges from 32%-80% 10
- MRI is considered better than CT in the assessment of the primary tumour volume, 4,7,11,12 parametrial involvement, 8,13 vaginal involvement, 14 and bladder and rectal involvement 8
- It has a slightly higher sensitivity than CT to detect nodal disease (60% vs 43%) but similar specificity (92%) 8,16
- Findings on MRI or CT can not be used to change the stage of disease (exceptions: see - FIGO system of staging cervical cancer)
pet
Positron Emission Tomography (PET) / Computed Tomography (CT)
- PET and PET/CT provides better assessment of extra pelvic metastases (nodal status and systemic spread). 17,18,19 It is increasingly being used in the detection of residual or recurrent disease. 3,9,10,20-25
- Integrated PET/CT is considered to be more sensitive than PET alone or MRI for detection of nodal metastases, especially within pelvic lymph nodes 26,27
- Patients not suitable for surgery should be considered for a PET scan as these patients are statistically more likely to have nodal or metastatic disease as compared to those amenable to surgery and thus can benefit from chemo radiotherapy if found positive nodal disease 4
- Findings on PET can not be used to change the stage of disease. (exceptions: see FIGO system of staging cervical cancer)
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Allen D, Narayan K. Managing advanced-stage cervical cancer. Best Pract Res Clin Obstet Gynaecol. 2005;19(4):591-609. (Review article)
- Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL,Trotti A. AJCC cancer staging manual. 2010:7th Ed. (Consensus guidelines)
- Practice guidelines cervical cancer. PET Professional Resources and Outreach Source. 2008. (Level I evidence)
- Management of cervical cancer. A National Clinical Guideline. Scottish Intercollegiate Guidelines Network. 2008. (Level I evidence)
- Greer B,Koh W, Abu-Rustum N, Apte S, Bookman M, Bristow R, et al. The NCCN clinical practice guidelines in oncology-cervical cancer. National Comprehensive Cancer Network. 2010;1. (Level I evidence)
- Vries C Sd, Africa M, Gebremariam FA, Rensburg J, Otto F, Potgieter HF. The imaging of stab injuries. Acta Radiol. 2010;51(1):92-106. (Review article)
- Hricak H, Gatsonis C, Chi DS, Amendola MA, Brandt K, Schwartz LH, et al. Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network. Gynecologic Oncology Group 183. J Clin Oncol. 2005;23(36):9329-37. (Level II evidence)
- Bipat S, Glas AS, Velden Jvd, Zwinderman AH, Bossuyt PMM, Stoker J. Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol. 2003;91(1):59-66. (Level I evidence)
- The ACOG Committee on Practice Bulletin. Diagnosis and treatment of cervical carcinomas. Obstet Gynecol. 2002;99(5 Pt 1):855-67. (Review article)
- Scoutt L, Andreotti R, Lee S, Allison SD, Horrow M, Javitt M, et al. ACR appropriateness criteria: staging of invasive cancer of the cervix. American College of Radiology. 2008. (Consensus guidelines)
- Hricak H, Yu K. Radiology in invasive cervical cancer. AJR Am J Roentgenol. 1996;167(5):1101-8. (Review article)
- Sheu M, Chang C, Wang J, Yen M. Preoperative staging of cervical carcinoma with MR imaging: a reappraisal of diagnostic accuracy and pitfalls. Eur Radiol. 2001;11(9):1828-33. (Level II evidence)
- Hricak H, Powell CB, Yu KK, Washington E, Subak LL, Stern JL, et al. Invasive cervical carcinoma: role of MR imaging in pretreatment work-up, cost minimization and diagnostic efficacy analysis. Radiology. 1996;198(2):403-9. (Level III evidence)
- Togashi K, Nishimura K, Sagoh T, Minami S, Noma S,Fujisawa I, et al. Carcinoma of the cervix:staging with MR imaging. Radiology. 1989;171(1):245-51. (Level II evidence)
- Masad LS, Calvello C, Gilkey SH, Abu-Rustum NR. Assessing disease extent in women with bulky or clinically evident metastatic cervical cancer: yield of pretreatment studies. Gynecol Oncol. 2000;76(3):383-7. (Level III evidence)
- Scheidler J, Hricak H, Yu K, Subak L, Segal M. Radiological evaluation of lymph node metastases in patients with cervical cancer: a meta-analysis. JAMA. 1997;278(13):1096-101. (Level I evidence)
- Lin W, Hung Y, Yeh L, Kao C, Yen R, Shen Y. Usefulnes of (18) F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings. Gynecol Oncol. 2003;89(1):73-6. (Level II evidence)
- Yen T, Ng K, Ma S, Chou H, Tsai C, Hsueh S, et al. Value of dual-phase 2-fluoro-2-deoxy-d-glucose positron emission tomography in cervical cancer. Clin Oncol. 2003;21(19):3651-8. (Level II evidence)
- Reinhardt M, Ehritt-Braun C, Vogelgesang D, Ihling C, Hogerle S, Mix M, et al. Metastatic lymph nodes in patients with cervical cancer: detection with MR imaging and FDG PET. Radiology. 2001;218(3):776-82. (Level II evidence)
- Wolfson A. Magnetic resonance imaging and positron-emission tomography imaging in the 21st century as tools for the evaluation and management of patients with invasive cervical carcinoma. Semin Radiat Oncol. 2006;16(3):186-91. (Review article)
- Kumar R, Chauhan A, Jana S, Dadparvar S. Positron emission tomography in gynecological malignancies. Expert Rev Anticancer Ther. 2006;6(7):1033-44. (Review article)
- Rajendran J, Greer B. Expanding role of positron emission tomography in cancer of the uterine cervix. J Natl Compr Canc Netw. 2006;4(5):463-9. (Review article)
- Sironi S, Buda A, Picchio M, Perego P, Moreni R, Pellegrino A, et al. Lymph node metastasis in patients with clinical early-stage cervical cancer: detection with integrated FDG PET/CT. Radiology. 2006;238(1):272-9. (Level II evidence)
- Rose P, Adler L, Rodriguez M, Faulhaber P, Abdul-Karim F, Miraldi F. Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study. J Clin Oncol. 1999;17(1):41-5 (Level III evidence).
- Havrilesky L, Kulasingam S, Matchar D, Myers E. FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol. 2005;97(1):183-91. (Review article)
- Loft A, Berthelsen A, Roed H, Ottosen C, Lundvall L, Knudsen J, et al. The diagnostic value of PET/CT scanning in patients with cervical cancer: a prospective study. Gynecol Oncol. 2007;106(1):29-34. (Level II evidence)
- Choi H, Roh J, Seo S, Lee S, Kim J, Kim S, et al. Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymphnode metastases in patients with uterine cervical carcinoma: a prospective study. Cancer. 2006;106(4):914-22. (Level II evidence)
- Balleyguier C, Sala E, Da Cunha T, Bergman A, Brkljacic B, Danza F, et al. Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology. Eur Radiol. 2011;21(5):1102-10. (Consensus guidelines)
Special Thanks:
Professor Yee Leung, Consultant Gynaecologist, King Edwards Memorial Hospital, Perth, Western Australia.
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