Early stage cervical cancer: role of magnetic resonance imaging after conization in determining residual tumor

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Invasive Cancer of the Cervix: 2023 Update

Cervical cancer is a common gynecological malignancy worldwide. Cervical cancer is staged based on the International Federation of Gynecology and Obstetrics (FIGO) classification system, which was revised in 2018 to incorporate radiologic and pathologic data. Imaging plays an important role in pretreatment assessment including initial staging and treatment response assessment of cervical cancer. Accurate determination of tumor size, local extension, and nodal and distant metastases is important for treatment selection and for prognostication. Although local recurrence can be diagnosed by physical examination, imaging plays a critical role in detection and follow-up of local and distant recurrence and subsequent treatment selection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Clinical Epidemiology of Microinvasive Cervical Carcinoma in an Italian Population Targeted by a Screening Programme

Simple Summary

According to this population-based study, 3750 patients living in the Emilia-Romagna Region (northern Italy) were registered with cervical carcinoma between 1995–2016, including 2942 eligible patients. The likelihood of stage IA cervical carcinoma (n = 876, 29.8%) did not change over time, decreased with increasing patient age, and was lower for patients with adenocarcinoma and grade 3–4 disease. Three hundred and fifty (40.0%) patients had a conservative treatment, 317 (36.2%) had hysterectomy, 197 (22.5%) had hysterectomy with lymph node dissection (LND), and 12 (1.4%) had a conservative treatment with LND. The proportion of hysterectomy decreased from 70.6% in 1995–1999 to 46.9% in 2011–2016. The likelihood of hysterectomy increased above the age of 40. Among screening-aged (25–64 years) patients, the likelihood of hysterectomy did not differ between screen-detected and non-screen-detected ones. Hysterectomy was increasingly combined with LND. High tumour grade was the strongest determinant of LND during hysterectomy.

Abstract

(1) Background: This population-based study aimed at identifying the factors associated with the likelihood of detection of stage IA cervical carcinoma—versus the detection of stage IB through IV cervical carcinoma—and the patterns of surgical treatment. (2) Methods: Between 1995–2016, 3750 patients living in the Emilia-Romagna Region (northern Italy) were registered with cervical carcinoma, including 2942 eligible patients (median age, 53). Multivariate analysis was performed using binary logistic regression models. (3) Results: The likelihood of stage IA cervical carcinoma (n = 876, 29.8%) did not change over time, decreased with increasing patient age, and was lower for patients with adenocarcinoma and grade 3–4 disease. Three hundred and fifty (40.0%) patients had a conservative treatment, 317 (36.2%) had hysterectomy, 197 (22.5%) had hysterectomy with lymph node dissection (LND), and 12 (1.4%) had a conservative treatment with LND. The proportion of hysterectomy decreased from 70.6% in 1995–1999 to 46.9% in 2011–2016. The likelihood of hysterectomy increased above the age of 40. Among screening-aged (25–64 years) patients, the likelihood of hysterectomy did not differ between screen-detected and non-screen-detected ones. Hysterectomy was increasingly combined with LND. High tumour grade was the strongest determinant of LND during hysterectomy. (4) Conclusions: This study provided a multifaceted overview of stage IA cervical carcinoma over the last decades.

Useful MRI Findings for Minimally Invasive Surgery for Early Cervical Cancer

Simple Summary

Radical hysterectomy and lymph node dissection are extensive procedures with severe post-operative morbidities and should be avoided on patients with low risk of recurrence. Still, due to lack of good prognostic tools, radical surgery is performed on most patients with early stage cervical cancer, leading to overtreatment and unnecessary morbidities. The recent International Federation of Gynecology and Obstetrics (FIGO) staging system accepts the use of magnetic resonance imaging (MRI) in addition to physical examination. Currently, 3 Tesla (3T) MRI is available widely and, due to its high soft tissue contrast, can provide more useful information on precise estimation of tumor size and metastasis than can physical examination in patients with cervical cancer. Therefore, this imaging modality can help gynecologic oncologists to determine whether minimally invasive surgery is necessary and can be used for early detection of small recurrent cancers.

Abstract

According to the recent International Federation of Gynecology and Obstetrics (FIGO) staging system, Stage III cervical cancer indicates pelvic or paraaortic lymph node metastasis. Accordingly, the new FIGO stage accepts imaging modalities, such as MRI, as part of the FIGO 2018 updated staging. Magnetic resonance imaging (MRI) is the best imaging modality to estimate the size or volume of uterine cancer because of its excellent soft tissue contrast. As a result, MRI is being used increasingly to determine treatment options and follow-up for cervical cancer patients. Increasing availability of cancer screening and vaccination have improved early detection of cervical cancer. However, the incidence of early cervical cancers has increased compared to that of advanced cervical cancer. A few studies have investigated if MRI findings are useful in management of early cervical cancer. MRI can precisely predict tumor burden, allowing conization, trachelectomy, and simple hysterectomy to be considered as minimally invasive treatment options for early cervical cancer. This imaging modality also can be used to determine whether there is recurrent cancer following minimally invasive treatments. The purpose of this review is to highlight useful MRI features for managing women with early cervical cancer.

Prospective validation of craniocaudal tumour size on MR imaging compared to histoPAthology in patients with uterine cervical cancer: The MPAC study

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Tumour extension on MRI was compared with histopathology using three methods.

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MRI visualises tumour extension within a margin of 10 mm compared to microscopy.

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The major source of measurement uncertainty is post-surgical change of organ.

Purpose

To determine the accuracy of MRI in detecting craniocaudal tumour extension, compared to histopathology, of the hysterectomy specimen in patients with early-stage uterine cervical cancer. Three complementary methods were investigated.

Materials and methods

Thirty-four patients with early-stage cervical cancer had pre-operative MRI, followed by radical hysterectomy or trachelectomy. 1) craniocaudal tumour extension was measured on MRI by two radiologists and compared to microscopy by a pathologist, 2) to compensate for changes in uterine shape between pre-operative MRI and the surgical specimen, craniocaudal tumour extensions were directly compared and appreciated as being a part of a 3-dimensional tumour by a radiation oncologist and resident, and 3) tumour size on MRI was compared macroscopically after digital non-rigid registration of the uterus, uterine cavity and tumour of both modalities.

Results

The craniocaudal tumour extension measured on histopathology minus MRI gives: 1) on average +3 mm difference when measured by a radiologist compared to the microscopic extension (range −13 to +15 mm), 2) −0.2 mm (range −11 to +6.0 mm) when evaluated on MRI by a radiation oncologist compared to the macroscopic tumour; 3) after non-rigid organ registration, a margin of 10 mm around the tumour on MRI would be needed to cover 95% of the tumour in 90% of the patients.

Conclusions

Results indicate that microscopic tumour extension towards the uterine fundus is within a margin of 10 mm around the visible tumour on MRI. The major source of measurement uncertainty is post-surgical change of organ shape and form.

Making the invisible visible: improving detectability of MRI-invisible residual cervical cancer after conisation by DCE-MRI

AIM

To determine whether dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) quantitative parameters increase the detectability of MRI-invisible residual cervical cancer after conisation.

MATERIALS AND METHODS

This retrospective study included 59 patients with MRI-invisible cervical cancer, but positive conisation pathology. Thirty-five patients were confirmed to have residual cervical cancer, and 24 patients showed non-residual cervical cancer. DCE-MRI quantitative parameters were calculated in the anterior or posterior cervix according to the conisation position. Receiver operating characteristic (ROC) analysis was used to find the threshold of DCE-MRI parameters in differentiate residual cervical cancer patients from non-residual cervical cancer patients after conisation.

RESULTS

For patients with residual cervical cancer, the K^trans and V_e values were significantly higher than in their counterparts with non-residual cervical cancer (0.610±0.395 versus 0.366±0.305/min, p=0.013; and 0.703±0.270 versus 0.540±0.280%, p=0.028; respectively). The K^trans showed the highest area under the ROC curve (AUC) of 0.705 (p=0.004) with a sensitivity of 67.6% and specificity of 68%.

CONCLUSION

DCE-MRI quantitative parameters increased the detectability of MRI-invisible residual cervical cancer after conisation.

Apparent diffusion coefficient for prediction of parametrial invasion in cervical cancer: a critical evaluation based on stratification to a Likert scale using T2-weighted imaging

PURPOSE

To evaluate the value of apparent diffusion coefficient (ADC) for determining parametrial invasion (PMI) in cervical cancer, by stratifying them into subgroups based on a Likert scale using T2-weighted imaging (T2WI).

MATERIALS AND METHODS

This retrospective study included 87 patients with FIGO stage IA2-IIB cervical cancer who underwent preoperative MRI followed by radical hysterectomy. Radiological PMI was assessed on T2WI using a six-point Likert scale and ADC values of the tumors were measured. MRI findings were compared between patients with and without PMI. Differences in ADC according to the Likert scale were also assessed.

RESULTS

19 (21.8%) patients had pathological PMI. The prevalence of PMI was significantly associated with Likert scale (P < 0.001). ADC values significantly differed according to Likert scale (P < 0.001). However, only tumors with a Likert score of 0 (MRI-invisible) had significantly greater ADC than others (P < 0.001) while no significant difference was observed among tumors with Likert scores of 1-5 (P = 0.070-0.889). Patients with PMI had significantly lower ADC values than those without PMI (P = 0.034). However, no significant difference was seen between patients with and without PMI within each Likert score group (P = 0.180-0.857).

CONCLUSION

T2WI-based Likert score for radiological PMI and ADC values of the tumor were significantly associated with pathological PMI. However, the apparent association seen between ADC values and PMI may be due to contribution of high ADC values of MRI-invisible tumors rather than reflecting their relationship.