Abdominopelvic computed tomography in the preoperative evaluation of early cervical cancer

Different imaging techniques for the detection of pelvic lymph nodes metastasis from gynecological malignancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the diagnostic performance of different imaging techniques and the corresponding diagnostic criteria for preoperative detection of pelvic lymph node metastasis from gynecological carcinomas.

METHODS

Six databases were systematically searched for retrieving eligible studies. Study inclusion, data extraction and risk of bias assessment were performed by 2 reviewers independently. STATA 14.0 was used to perform the meta-analysis.

RESULTS

Eighty eligible studies were collected. The pooled sensitivity, specificity, and area under curve (AUC) of CT, MRI and DWI were 47%, 93%, 0.7424; 50%, 95%, 0.8039 and 84%, 95%, 0.9523 respectively. As regards PET, PET-CT and US, the pooled sensitivity, specificity and AUC were 56%, 97%, 0.9592; 68%, 97%, 0.9363 and 71%, 99%, 0.9008 respectively. The summary receiver operating characteristic (SROC) curve indicated that the systematic diagnostic performances of PET, PET-CT, DWI were superior to other imaging modalities.

CONCLUSIONS

The present work demonstrated that DWI, PET, PET-CT were the top-priority consideration of imaging modalities for detecting metastatic pelvic lymph node in gynecological carcinoma. DWI was recommended as the first choice for metastasis exclusion and all the other imaging techniques including CT and MRI were suitable for metastasis conformation. However, for the early stage lymph node malignancy, PET or PET-CT could represent a better choice. More studies exploring the diagnostic efficacy of detailed criteria are required in the future.

CT and Ultra Low Field (0.02 T) MR Imaging of Uterine Cervical Carcinoma

Nineteen pelvic MR and 21 CT examinations were performed in 21 patients with uterine cervical carcinoma. The results were compared with clinical (FIGO) staging in all patients, and with the histopathologic results after operation in 8. In the evaluation of local tumor growth CT agreed with clinical staging in 29%, MR imaging with clinical staging in 47% and CT with MR in 53%. The greatest discrepancy between the imaging methods and clinical examination was in the evaluation of parametrial extension. From 8 Stage I tumors with surgical confirmation the local tumor growth was overestimated with CT in 3 cases, with clinical examination in 2 and with MR imaging in 2 cases. CT and MR imaging at 0.02 T did not differ in the evaluation of parametrial tumor growth. Clinical examination overestimated parametrial growth but was relatively accurate in detecting vaginal wall involvement. MR imaging at 0.02 T is a convenient, inexpensive and accurate method for the local staging of early uterine cervical carcinoma.

Diagnostic performance of computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with cervical cancer: meta-analysis

We performed a meta-analysis to compare diagnostic performances of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET or PET/CT), for detection of metastatic lymph nodes in patients with cervical cancer. We searched MEDLINE (PubMed), EMBASE and the Cochrane Review database in December 2007. All articles were independently reviewed and selected by three evaluators. We estimated a summary receiver operating characteristic (sROC) curve. The area under the curve (AUC), Q*, and pooled weighted estimates of sensitivity and specificity for each modality by patient-based and region- or node-based data analyses and conducted pair-wise comparisons between modalities using the two-sample Z-test. Forty-one of 768 initially identified studies were included in the meta-analysis. In a patient-based data analysis, PET or PET/CT showed the highest pooled sensitivity (82%) and specificity (95%), while CT showed 50% and 92%; and MRI, 56% and 91%, respectively. The AUC (0.9641) and Q* (0.9106) of PET or PET/CT were significantly higher than those of MRI (AUC = 0.8270; Q* = 0.7599), both P < 0.001. In region- or node-based data analysis, sensitivities of CT (52%) and PET or PET/CT (54%) were higher than that of MRI (38%), P < 0.02 and P < 0.001, respectively, while specificities of MRI (97%) and PET or PET/CT (97%) were higher than that of CT (92%), both P < 0.001. The AUC and Q* showed no significant difference among CT, MRI, and PET or PET/CT. PET or PET/CT had an overall higher diagnostic performance than did CT or MRI in detecting metastatic lymph nodes in patients with cervical cancer.

Cervical carcinoma with full-thickness stromal invasion: relationship between tumor size on T2-weighted images and parametrial involvement

PURPOSE

The purpose of this work was to investigate the relationship between tumor size on T2-weighted images and parametrial involvement by cervical carcinoma with full-thickness stromal invasion and to evaluate whether the size of the tumor on T2-weighted images is a useful index of parametrial involvement.

METHOD

T2-weighted images of 33 patients with cervical carcinoma showed full-thickness stromal invasion. Three-dimensional diameters (transverse, anteroposterior, and craniocaudal) of the primary tumor were measured on T2-weighted images. The area and volume of the tumor were also calculated.

RESULTS

There were statistically significant differences between the patients with parametrial involvement and those without parametrial involvement for each tumor size. The criteria that showed the best accuracy for each tumor size were determined.

CONCLUSION

The tumor size on T2-weighted images is considered to be a useful index for evaluating parametrial involvement by cervical carcinoma with full-thickness stromal invasion.

Biology of cervical carcinoma

Cervical cancer is generally a locoregional disease. The endopelvic fascia envelops the cervix in anterior-posterior fashion and serves as a natural barrier. Thus, cervical cancer preferentially grows to the parametria and involves the ureters before it infiltrates the bladder or rectum. Disease stage, grade, cell type, tumor volume, depth of stromal invasion, vascular space invasion, and lymph node status are common prognostic indicators. Irregular vaginal bleeding and discharge are the two most frequent complaints. Although cervical cancer is still staged clinically, data continue to accumulate favoring a conversion to surgical staging to improve accuracy and treatment outcome.

Applications of computed tomography in gynecologic diseases

Computed tomography (CT) has evolved to play a significant role in the assessment of gynecologic diseases, primarily gynecologic malignancies. The cross-sectional display provides clear depiction of the female pelvic organs, viscera, and their surrounding fat planes. In the evaluation of certain pelvic malignancies, CT has become a fundamental study in the initial staging and subsequent follow-up of patients undergoing chemotherapy and radiation treatment. This manuscript describes and illustrates the role of CT in evaluating a spectrum of gynecologic pathology.

Diagnostic imaging of gynecological diseases: the clinician's view

The introduction of ultrasonography, computerized tomography, and magnetic resonance imaging has led to tremendous progress in the diagnostic evaluation of gynecologic diseases. Refinements in these techniques have allowed the gynecologist to diagnose unsuspected pathology, define disease and its extent, and select the most appropriate treatment despite limitations in specificity experience and cost. Practically the most appropriate imaging modalities are: ultrasonography for adnexal masses, computerized tomography for advanced cervical cancers, and magnetic resonance imaging for corpus cancers and selected cervical cancers.

Advances in gynecologic imaging and intervention

Advances in diagnostic imaging of the female genital tract facilitate characterization of many pelvic masses. Preoperative assessment of gynecologic malignant tumors provides information that may alter the surgical approach or timing of radiation therapy. Image-guided biopsy accurately confirms recurrent malignant lesions. Transcervical techniques have improved diagnostic assessment of infertile couples; thus, effective and inexpensive treatment options can be offered. Postoperative complications of gynecologic procedures can be detected with imaging, and many can be treated with image-guided techniques.

Computed tomography in the evaluation of clinical stage IB carcinoma of the cervix

A retrospective analysis of 47 cases of clinical stage IB cervical carcinoma radiologically staged with computed tomography (CT) was undertaken. There were no cases where CT provided information which altered staging. In 5 cases, CT suggested extension of disease beyond the cervix which was not confirmed surgically or with other staging procedures. In 3 cases, one or more normal-sized obturator or internal iliac nodes with metastatic disease were discovered at surgery, but the high common iliac and periaortic nodes were disease free. We conclude that routine use of CT in patients with clinical stage IB cervical carcinoma is not warranted unless the patient's body habitus precludes accurate physical examination.

Hysterectomy with extended surgical staging and radiotherapy versus hysterectomy alone and radiotherapy in stage I endometrial cancer: a comparison of complication rates

Extended surgical staging (ESS) has been added to total hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) in patients with clinical Stage I endometrial cancer in order to better define patterns of metastatic spread and the response to treatment. Adjuvant radiotherapy has a demonstrated efficacy in decreasing central recurrence in Stage I disease. The combined use of radical surgery and pelvic radiotherapy for cervical cancer patients results in an increased incidence of complications. This study compares major complication rates in Stage I endometrial cancer patients who underwent either TAHBSO with ESS or TAHBSO alone followed by adjuvant external beam radiotherapy (RT). Records of 52 patients with clinical stage I endometrial cancer were reviewed. Thirty-two patients underwent TAHBSO plus ESS and 20 patients had TAHBSO alone. All patients received postoperative, whole pelvis external radiotherapy. Four patients suffered complications potentially related to treatment which required rehospitalization, and all 4 were in the group which had undergone ESS. A comparison of complication rates between the ESS + RT group (4/37 or 10.8%) and TAHBSO + RT group (0/20) suggested a trend toward significance (P less than 0.10). Treatment protocols using extended surgical staging prior to adjuvant radiotherapy in Stage I endometrial cancer should examine complications potentially related to this combination, to further define treatment risks and benefits.

Parametrial invasion of uterine cervical cancer assessed by transrectal ultrasonography: preliminary report

Transrectal ultrasonographic examinations were performed on 30 patients with uterine cervical cancer to assess parametrial invasion. The findings were compared with data obtained by manual rectal examination. Forty-six parametria in 23 patients were histologically examined following surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy of transrectal ultrasonography and rectal examination were 1.0 and 0.25 (P less than 0.05), 0.9 and 0.93, 0.5 and 0.25, 1.0 and 0.93, and 0.91 and 0.87, respectively. Therefore, transrectal ultrasonography may prove to be a useful diagnostic tool to determine the preoperative staging of uterine cervical cancer.

Preoperative CT study of lymph nodes in cervical cancer--its correlation with histological findings

A study was conducted to retrospectively evaluate the accuracy of abdominopelvic computed tomography (CT) in the diagnosis of paraaortic and pelvic lymph node metastases from carcinoma of the uterine cervix. Seventy patients with a diagnosis of invasive carcinoma of the cervix had preoperative CT of abdomen and pelvis and subsequently underwent a radical hysterectomy with pelvic lymph node dissection and paraaortic lymph node biopsy or an exploratory laparotomy with paraaortic lymph node biopsy. Five of six patients with metastatic paraaortic lymph nodes larger than 15 mm in diameter on the histologic slides were diagnosed by CT scan to have enlarged nodes. CT diagnosis was true-positive in five of seven patients with paraaortic lymph node metastases (71.4%). Two patients with false-positive paraaortic lymph nodes had clusters of small lymph nodes less than 10 mm in diameter on the histologic slides. In contrast, only a small number of the metastatic pelvic nodes were diagnosed by CT as enlarged nodes. CT diagnosis was true-positive in 5 of 11 sites with pelvic lymph node metastases (45.5%).

Predictive value of computerized tomography in the presurgical evaluation of primary carcinoma of the cervix

To determine the predictive value of abdominal-pelvic CT scan in assessing pelvic and paraaortic node metastases in untreated cervical carcinoma, the preoperative CT scans of 61 patients were compared with the gross and microscopic surgical findings. Although 75% of enlarged pelvic nodes on CT contained metastases, and 97% of patients with negative pelvic nodes had negative CT scans (specificity = 97%), histologically positive pelvic nodes were often missed on CT scan (sensitivity = 25%). For paraaortic nodes the CT scan had a specificity of 100% and a sensitivity of 67%. No paraaortic nodes were enlarged in stages I-IIA (0/51). CT scans are recommended for routine evaluation of paraaortic nodes in stages II-IV, but are not warranted in pretreatment evaluation of the pelvic nodes in stage I.

Changing pattern of cervical carcinoma: a report of 709 cases of invasive carcinoma treated in 1970-1974

Seven hundred and nine new cases of carcinoma of the uterine cervix were treated by surgery, radiotherapy, or both at Helsinki University Central Hospital between 1970 and 1974. Of these, 241 (34.0%) died of the disease during the 5-year follow-up period. Three hundred and eighty-three (53.9%) of the patients were operated on and in 112 (29.3%) of them the stage of the disease had been underestimated preoperatively. This was mainly due to the undetected lymph node involvement observed first at operation in 72 cases (18.8%). In 237 of the patients carcinoma was confined to the cervix according to findings at operation but in 24 (10.1%) of them a relapse or metastasis was observed within 5 years. Comparison of the results for 1970-1974 with those from the same hospital for 1926-1969 revealed a reversal in the steady improvement in the total 5-year survival rates. It is concluded that, even if the incidence of cervical carcinoma in Finland is to decrease, the prognosis for the disease may become poorer. This is mainly due to a shift in the peak incidence of cervical carcinoma to older age groups. Also a mass screening program is likely to decrease the relative number of slowly growing, less aggressive type of the disease.

The use of ultrasound and computed tomography scanning in the management of gynecologic cancer patients

The contribution of abdominal-pelvic computed tomography (CT) and ultrasound scanning to the management of gynecologic malignancy patients was assessed retrospectively in 62 scans that were performed immediately preceding laparotomy. A total of 55.5% CT and 71.4% ultrasound scans were found to be helpful. Diagnostic problem areas included the detection of lymph node metastases, peritoneal implants, omental metastases, and parametrial extension. An additional 75 scans performed in patients not undergoing laparotomy were received to assess any alteration in management resulting from the scans. It is concluded that clinicians should be more discriminating in their requests for scanning procedures and that appropriate communication between the clinician and the radiologist may avoid unproductive scans.