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

Imaging of cancer of the cervix

Cancer of the endometrium is the most common invasive gynecologic malignancy in North America. Although transvaginal sonography is often the initial imaging examination in women with dysfunctional uterine bleeding, MRI offers multifactorial assessment once the diagnosis of endometrial cancer has been established. Specifically, preoperative contrast-enhanced MRI alters the likelihood ratios for myometrial invasion, which in turn affects type and extent of surgery performed. This information also helps identify patients who would most benefit from referral to a tertiary care center for treatment by a gynecologic oncologist.

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.

Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: extended diagnostic evaluation for paraaortic node metastasis--a Gynecologic Oncology Group study

Three hundred twenty patients were entered into GOG Protocol 63, a clinical-pathologic study of stage IIB, III, and IVA cervical carcinoma. Following the completion of FIGO staging prerequisites, patients had computerized tomography (CT), a lymph-angiogram (LAG), and an ultrasound (US) of the aortic area. If any study was positive, a cytologic or histologic evaluation by fine-needle aspiration or selective paraaortic lymphadenectomy was performed. Paraaortic node dissection was mandated for patients with negative extended staging studies. Results of extended staging evaluations were compared with histologic or cytologic results. Two hundred sixty-four patients were eligible and evaluable. One hundred sixty-seven patients (63%) were stage IIB, 89 (34%) were stage III, and 8 (3%) were stage IVA. Positive paraaortic nodes occurred in 21% of stage IIB, 31% of stage III, and 13% of stage IVA. LAG sensitivity was 79% with a specificity of 73%. Sensitivity of CT and US was 34 and 19%, respectively, with specificities of 96 and 99%, respectively. The frequency of false-negative results with LAG for patients with stage IIB disease was 6%. This decrease is consistent with a stable sensitivity and specificity. These findings suggest that a negative LAG may be adequate to eliminate surgical staging in subgroups with low risk of metastasis to the aortic nodes. Until new noninvasive testing methods are developed, LAG appears to be the most reliable noninvasive examination to evaluate spread of cervical cancer to aortic nodes.

OC125 immunoscintigraphy in ovarian carcinoma: a comparison with alternative methods of assessment

The membrane bound, tumour associated antigen CA125 is recognized by the monoclonal antibody OC125 and may be detected in tumour tissue and serum in over 80% of patients with epithelial ovarian carcinomas. A total of 13 immunoscintigrams using 111 MBq 131I-OC125 have been performed in 11 patients. The results have been compared with clinical examination, CT and ultrasound scans, surgical findings and serum CA125 concentrations. Macroscopic disease was present at the time of scanning in 11 patients (less than 2 cm, eight patients, greater than 2 cm, three patients). Clinical examination and ultrasound were positive in three, CT scanning in four, immunoscintography in seven and serum CA125 in eight patients. This pilot study suggest that serum CA125 estimation is the most sensitive indicator of disease activity. However, immunoscintigraphy using this agent may localize residual disease when clinical examination and other radiological investigations fail.

Correlation of abdominal ultrasound and computed tomography scans with second- or third-look laparotomy in patients with ovarian carcinoma

To determine the best noninvasive means of evaluating response in patients with advanced ovarian carcinoma, 50 abdominal ultrasound (US) and computed tomography (CT) scans were performed in clinically disease-free ovarian cancer patients. The scans were correlated with the results obtained at a subsequent second- or third-look laparotomy. CT and US were not complementary, and only metastases larger than 2 cm were detected. The overall positive predictive value of nonconcordant scans was 57% compared with 100% for concordant CT and US (95% confidence limits: 18.4-90.1 and 29.2-100%, respectively). The corresponding negative predictive values were 45 and 47% (30.2-59.9 and 30.4-61.2%, respectively), if undetected microscopic disease was classified as a false-negative result. The negative predictive value of US and CT increased only to 60% in both cases, if undetected microscopic disease was registered as a true-negative result. Compared with the pelvic examination CT and US added positive information for 4 of 22 (18%) patients with macroscopic residual disease. In this study neither CT nor US was sensitive enough to preclude second-look laparotomy.

CT demonstration of peritoneal metastases after intraperitoneal injection of contrast media

Thirty-three patients with ovarian carcinoma who had no evidence of metastases or ascites demonstrated on computed tomography (CT) with and without contrast agent were examined with CT after injection of approximately 3000 cc of a 2.4% solution of nonionic contrast media into the peritoneum. After intraperitoneal injection with CT (IPC CT), 22 were diagnosed as having intraperitoneal metastases. Of these, 19 were found to be true positives and 3 false negatives. Three other patients diagnosed as normal were found to have metastases. In all patients the peritoneum was well outlined and generally any metastases smaller than 1 cm were demonstrated. It was possible to identify compartmentalization of the peritoneum and to determine the location of the lesion to be in the peritoneum or the extraperitoneal space. This information is necessary in the planning of chemotherapy, particularly endoperitoneal chemotherapy. Tiny metastases to the omentum or adherent loops of small bowel could not be seen well.

Ovarian carcinoma. Advances in diagnosis, staging, and treatment

While major strides have occurred in the field of oncology and tumor biology, the basic problems of tumor heterogeneity, and mutational resistance to therapy continue to thwart progress in the diagnosis and treatment of patients with ovarian carcinoma. It is hoped ongoing clinical research using the above modalities will unfold ways to circumvent these and other major obstacles to the early diagnosis and treatment of patients with ovarian malignancies.

The impact of computed tomography and ultrasonography on the management of patients with carcinoma of the ovary

We have carried out a prospective study on the impact of computed tomography (CT) and ultrasonography (US) on the management of patients with carcinoma of the ovary. Seventy-eight CT and 88 US scans were performed on 94 patients. Clinicians decided patient management prospectively at the time the CT and/or US was ordered. Clinical assessment differed from the result obtained by CT or US in 45% of cases (35/78 and 40/88, respectively). CT and US altered patient management in only a minority of cases (14/78, 18% and 9/88, 10% respectively). Even when the scan and clinical assessments differed, management was only altered on 14/35 (40%) occasions after CT and on 9/40 (23%) occasions after US, a difference which was not significant. In patients with clinically undetectable disease, management was altered by CT on 17% of occasions and by US on 10%. We conclude that in patients with carcinoma of the ovary CT and US alters patient management in a minority of cases. In view of current financial restrictions in health care, clinicians should be more selective in the use of these imaging techniques. Furthermore, we recommend that similar prospective studies are performed for other clinical situations.

Magnetic resonance imaging determination of myometrial invasion in endometrial carcinoma

Fifteen patients with FIGO stage I biopsy confirmed endometrial adenocarcinoma underwent preoperative pelvic magnetic resonance imaging (MRI) to evaluate the presence and depth of myometrial invasion. Imaging was performed with a Diasonics superconducting imaging system operating at 0.35 T (15 MHz); multislice multi-spin-echo pulse sequences were used exclusively, with 5-mm contiguous sections. All patients then received primary therapy consisting of abdominal hysterectomy and bilateral salpingo-oophorectomy. Imaging findings were then compared with the uterine specimen histopathology. MRI was accurate in predicting the presence or absence of invasion in 13 of 15 cases (87%) and was able to discriminate superficial from deep invasion in 9 of 11 cases (82%). Based on our findings, we conclude that MRI appears to be an excellent technique for determining myometrial invasion, and that it may play a significant role in the preoperative planning of a thorough search for lymphatic spread in those patients considered to be at high risk by virtue of myometrial invasion.

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%).

Vaginal adenocarcinoma developing in residual pelvic endometriosis: a clinical dilemma

The clinical history of a patient with pelvic adenocarcinoma arising in residual endometriosis is reported. Detailed literature review fails to outline an optimal treatment strategy; however, thoughts concerning staging and treatment are presented.

The value of CT scanning in the management of patients with gynecologic malignancies

The management of gynecologic malignancies is exceedingly complex, requiring thoughtful coordination of surgery, radiation therapy and chemotherapy. Despite the fact that the natural history and clinical course of these cancers are generally well understood, the scarring caused by surgery and/or radiation, and the marked limitations of pelvic examination make clinical staging and evaluation of limited value and known inaccuracy in following women with ovarian, cervical, uterine, vulvar and vaginal cancers. Understandably, the development of computerized axial tomography (CT), and its ability to visualize the abdomen and pelvis, lead to rapid acceptance of CT scans in defining extent of cancer and following patient response to various therapeutic interventions (Chen et al. 1980; Feigen et al. 1987; Photopoulos et al. 1977). Authors have compared the accuracy of CT findings with physical examination, surgical findings, lymphography, conventional radiography or ultrasound (Clarke-Pearson et al. 1986; Vercamb et al. 1987; Amendola 1981; Kerr-Wilson et al. 1984). However, little has been written on the effect of CT scanning on patient management. If we define and accept the accuracy of CT scanning in detecting pelvic and abdominal disease, can we show a benefit in patient management? Or, does CT scanning provide us with expensive information, or misinformation, which fails to translate into better patient care. Do complex imaging modalities compliment thorough examination and experienced clinical judgement, or only duplicate findings and provide extraneous information? To answer these questions, eighty-one months experience in using CT scanning in managing patients with gynecologic malignancies was reviewed.

The use and abuse of imaging in gynecologic cancer

The radiologic detection in staging of gynecologic malignancies comprises a variety of noninvasive and invasive procedures. In the last few years, the emergence of the cross-sectional imaging techniques such as ultrasonography (US), computerized tomography (CT), and more recently, magnetic resonance imaging (MRI) have enabled the radiologist to determine more accurately the entire degree and extent of pathologic processes both within the pelvis and spread of disease outside the pelvis. The radiologist has also become more involved in invasive procedures such as percutaneous biopsies, aspirations of fluid collections, and transcatheter intraarterial infusion and occlusions. Although the newer imaging modalities will be emphasized, an attempt will be made to point out both their strengths and weaknesses relative to the older modalities. The discussion will concentrate on ovarian and cervical cancers while the other cancers of the female genital tract will be superficially discussed. The thrust of the presentation will emphasize the workup of gynecologic patients, that the workup may be quick, thorough, and as practical as possible.

Pitfalls in interpretation of computed tomography prior to second-look laparotomy in patients with ovarian cancer

Fifty-seven patients with ovarian cancer were assessed with computed tomography (CT) prior to undergoing second-look laparotomy. All patients were clinically free of disease following chemotherapy. Patients were scanned from the top of the liver to the symphysis pubis using oral, rectal and intravenous contrast medium. Tumour was correctly identified on CT scan in nine of 25 patients who had visible evidence of cancer at laparotomy. However, in the remaining 16 patients peritoneal studding was present and was not detected. Tumours smaller than 1.5 cm in size were not found by CT scanning. Computed tomography showed abnormality in eight of 32 patients subsequently found to be free of disease. Fine-needle aspiration cytology, bolus contrast injection and repeat scanning with additional oral contrast medium could have assisted in these circumstances. As persistent disease is by definition, a contraindication to second-look laparotomy, aggressive pre-operative assessment will spare some patients unnecessary surgery. However, CT cannot detect the small nodules often present in ovarian cancer, and thus, normal scans cannot replace surgical restaging.

Computed tomography in evaluation of gynecologic malignancies: a retrospective analysis

The results of preoperative computed tomography and operative findings were assessed retrospectively in 52 patients with cervical, uterine, and ovarian neoplasms. Overall sensitivity and specificity for all disease states was 57% and 79%, respectively. Overall diagnostic accuracy was 69%. The use of computed tomography was felt to be helpful in evaluation of lymphadenopathy due to cervical cancer and in patients with suspected ovarian neoplasms. In uterine neoplasms, however, computed tomography did not add useful information.

Gynecologic masses: value of magnetic resonance imaging

Forty-two women with gynecologic abnormalities were studied with the use of magnetic resonance imaging. Magnetic resonance imaging correctly assessed the origin of the pelvic mass in all patients. In the evaluation of leiomyoma, magnetic resonance imaging accurately depicted the number, size, and location of the lesion. In the evaluation of endometrial carcinoma, magnetic resonance imaging depicted the location of the lesion, the presence of cervical extension, and the depth of myometrial penetration in the majority of the cases. In the analysis of adnexal cysts, magnetic resonance imaging was sensitive in localizing the lesion and was able to distinguish serous from hemorrhagic fluid. This preliminary report indicates that magnetic resonance imaging may become a valuable imaging modality in the diagnosis of gynecologic abnormalities.