Methods: Guidelines for uterine cervical cancer … For diagnosing lymphadenopathy based on morphology, there is variability in the literature on the acceptable size of cutoff value, which ranges between 0.8 cm and 1.0 cm in short-axis measurements (29,30). 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) Figure 1c: Images show uterine cervical cancer at CT versus MRI. Cervical Carcinoma and Updated FIGO Staging: What Should Radiologists Know in 2019? Nx: Regional lymph nodes cannot be assessed. Lungs, peritoneum, supraclavicular and thoracic lymph nodes, and bones represented the involved sites in the order of prevalence. FIGO staging of cervix cancer is simple and practical. Detection of lymphadenopathy that extends beyond the pelvis into the para-aortic region is clinically significant, not only because it upstages the patient, but it also expands the fields for radiation therapy. In this article, we review the 2018 FIGO staging system for cervical cancer and the new additions relevant to radiologists. To be consistent with consensus guidelines for solid tumor measurement, we report tumor involvement as “likely” if the lymph node measures greater than or equal to 1.0 cm and as “almost certainly” if it measures greater than or equal to 1.5 cm in short axis (30). 6. Two conventional curative treatment options for invasive cervical cancer are radical hysterectomy with lymphadenectomy in early stage disease (IA, IB1, and IIA1) or radiation therapy with concurrent platinum-based chemotherapy for patients with local-regionally advanced disease (tumor >4 cm, stage IIB or greater). {"url":"/signup-modal-props.json?lang=gb\u0026email="}. It is largely based on the clinical assessment of the extent of cancer growth in anatomical compartments. Preoperative MR imaging criteria are not formally included in the revised FIGO staging system because cervical carcinoma is most prevalent in developing countries, where imaging resources are limited. Figure 1b: Images show uterine cervical cancer at CT versus MRI. *Reference standard is pathologic analysis. † Stage IIIC should be annotated with r (radiology) or p (pathologic analysis) to indicate the method used to allocate this stage. However, in patients with lymphadenopathy, surgery alone does not cure and 10%–30% of patients with early stage disease harbor lymph node metastases (22). Staging of cervical cancer can either be based on the TNM or FIGO system. Table 2 TNM (8 th … 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. The 2018 FIGO cervical cancer staging system keeps the backbone of staging clinical, while incorporating results from imaging and pathology. 1994-1997 FIGO Committee on Gynecologic Oncology. ■ PET CT is more sensitive than is CT or MRI in depicting metastases to the retroperitoneal lymph nodes. Figure 5c: Images show uterine cervical cancer with thoracic metastases. 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. The 2018 International Federation of Gynecology and Obstetrics (FIGO) staging guideline for cervical cancer includes stage IIIC recognized by preoperative radiology (IIIC-r) to state there are lymph nodes metastases (LNM) identified by imaging tools. 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. Olivetti L, Grazioli L. Imaging of Urogenital Diseases, A Color Atlas. Robbins and Cotran pathologic basis of disease. International Federation of Gynecology and Obstetrics, European Journal of Nuclear Medicine and Molecular Imaging, International Journal of Radiation Oncology*Biology*Physics, Vol. Image Acquisition and Interpretation by Modality With the FIGO 2018 staging system for uterine cervical can- Pannu HK, Corl FM, Fishman EK. Because of its sensitivity in depicting lymph node metastases, PET and PET/CT are a strong predictor of disease-specific survival (15,63). 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). Table 4: CT versus PET/CT in Detecting Abdominal Retroperitoneal Metastases in Uterine Cervical Cancer. (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. (2009) ISBN:8847013437. … Lymph node status is to be assigned based on imaging and/or pathologic analysis and the methodology is to be recorded. Choice of imaging for staging is also modified to reflect this variability. Enter your email address below and we will send you the reset instructions. The revision calls for a more precise measurement of primary tumor size, best assessed with imaging. If PET/CT is unavailable, then CT or MRI is a second-line alternative with both modalities demonstrating similar diagnostic performance (28,60). Figure 3: Image shows uterine cervical cancer with parametrial involvement. 21 (5): 1155-68. 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). In addition, patient table times with the current scanners are long (ie, ≥1.0 h), which would represent a relative contraindication in many patients. PET/CT is indicated and is the preferred examination for whole-body staging in patients with local-regionally advanced cancer at pelvic examination (ie, clinical stage IB3, IIA2, >IIB) and in patients in whom radiography, CT, or MRI indicates extrauterine spread of the primary tumor. For an imaging pathway on the best modalities in accurate staging of cervical cancer: see reference 9. Figure 2a: Images show uterine cervical cancer size at US versus MRI. However, in 2018, the FIGO Gynecologic Oncology Committee made revisions to allow stage assignment based on imaging and pathological findings, when available . Unable to process the form. 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. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. Another prospective multicenter trial showed that the false-negative rate with US and MRI for parametrial extension was comparable and very low (ie, <3%). 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 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. 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). One of the major changes in the updated staging system is that stage IB disease (ie, invasive carcinoma limited to the cervix) now includes three, rather than two, subgroups based on tumor size measured in its maximal dimension. (Adapted, under a CC BY license, from reference 1.). 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). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. These small field-of-view images are optimized for high-spatial-resolution and soft-tissue contrast imaging of the central pelvis. The maximal cross-sectional tumor diameter visualized in any plane is measured both at imaging and at pathologic analysis. Seventy-six patients with CC were enrolled. Patient was staged as IIIC2 based on PET/CT. Diagnostic-quality imaging requires a system greater than or equal to 1.5 T and intravenous contrast material administration. Moreover, stage IB1 tumors are more likely to be adenocarcinoma with low-grade histologic features, whereas stage IB2 tumors are more likely to be squamous cell carcinoma with high-grade histologic features (14). Table 3: US versus MRI for Tumor Size and Parametrial Spread. (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. All underwent standard clinical examination and whole-body FDG-PET. In this context, PET/CT is preferred as the imaging modality because it also enables depiction of occult distant metastases, another factor in staging. Cervical cancer is a significant cause of morbidity and mortality worldwide despite advances in screening and prevention. *Complete description is available in reference 53. At US, tumor is typically homogeneously solid and hypoechoic relative to the uterine cervical stroma (24–27). Until 2018, CC was clinically staged based on the FIGO 2009 classification. However, clinical implementation of PET/MRI would require that the challenges posed by attenuation correction be better solved, especially in the abdomen and pelvis. Radiographics. The new system introduces retroperitoneal lymphadenopathy as a factor and specifies that cross-sectional imaging, ideally PET/CT, be used to assess nodal status. MR imaging is the modality of choice for staging with CT having relatively low specificity (especially for myometrial invasion 5). Some tumors, especially after cone biopsy, may be of too small a volume to be seen at MRI. Source.—References 8 and 9. Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Although surgery is more sensitive, imaging is less morbid in avoiding the short- and long-term complications of lymphadenectomy (57). Dissemination of the advantages of imaging for cervical cancer staging lies within the domain of global health development efforts. Other option for nodal evaluation is surgical and includes lymphadenectomy or sentinel node biopsy, the latter limited to sites where the necessary surgical and pathologic expertise are available (55,56). Although a parallel TNM system for gynecologic cancers has been described by the American Joint Committee on Cancer, the FIGO system continues to predominate worldwide in clinical practice and for cancer database reporting (2). 2003;180 (6): 1621-31. 2. Staging of cervical cancer can either be based on the TNM or FIGO system. Aside from staging, if radiation therapy is anticipated, then pelvic MRI is the preferred examination for treatment planning because it best defines the geometry of tumor growth in the central pelvis (54). CT should be of diagnostic quality but use of iodinated contrast material is optional. Son H, Kositwattanarerk A, Hayes MP et-al. Patient was staged as IIIC2 based on PET/CT. Table 1: 2018 FIGO Staging System for Uterine Cervical Cancer, Note.— Imaging and pathologic analysis, where available, can be used to supplement clinical findings for all stages. Figure 1a: Images show uterine cervical cancer at CT versus MRI. ). Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. First-order texture features of the whole tumor were extracted from DKI and DWI functional maps, including apparent kurtosis coefficient averaged over all directions (MK), … A meta-analysis of 72 studies involving 5042 women found that PET demonstrates a higher sensitivity (75%) and comparable specificity (98%) to MRI (sensitivity of 56% and specificity of 93%) and CT (sensitivity of 58% and specificity of 92%) (58). Source.—References 8 and 9. 106, No. *PET and CT images acquired in a hybrid scanner and interpreted with inclusion of fusion imaging. Moreover in patients with cervical cancer, the measurement of ADC values could be an important factor for assessing response to chemoradiotherapy , . PET/CT evaluation of cervical cancer: spectrum of disease. Imaging routinely encompasses the skull base through the proximal thighs. Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Distant metastases noted at PET/CT should be confirmed with pathologic analysis, because this finding significantly impacts patient prognosis and treatment (49,50). Cervical cancer can manifest with tumor beyond the pelvic soft tissues and the retroperitoneal lymph nodes. 6, © 2021 Radiological Society of North America, History of the FIGO cancer staging system, FIGO staging of gynecologic cancer. Older systems did not include assessment of lymph node metastases, an important determinant for prognosis and treatment planning. Understanding the radiologic techniques used, the literature supporting them, and common imaging pitfalls ensures accurate staging … The current staging system for cervical carcinoma is based on the International Federation of Gynecology and Obstetrics (FIGO) classification. 2007;188 (6): 1577-87. Given this, oncologists have stratified management of cervical cancer according to the resource intensity of the practice setting (51). 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. ■ The 2018 International Federation of Gynecology and Obstetrics (FIGO) uterine cervical cancer staging system introduces a new primary tumor size cutoff value of 2 cm (ie, stage IB1 vs IB2), used to evaluate patients for fertility-sparing radical trachelectomy and to estimate prognosis. Int J Gynecol Cancer 5:319, 1995) The tumor prognosis, as well as the choice and success of therapy, depends on accurate clinical staging and volume assessment of the tumor. Gynecologic cancers are staged according to the International Federation of Gynecology and Obstetrics (FIGO) system (1). Although imaging is already a part of pretreatment planning in some high-resource settings, its incorporation into assigning stage is a new development. Consensus guidelines state that radiography, not CT, is the initial choice for chest imaging if PET/CT is not performed (10,11). In a prospective cohort study of 560 patients at a single center, the risk of recurrent disease was shown to increase incrementally on the basis of the most distant level of lymph node involvement at PET, with a hazard ratio of 2.40 (95% confidence interval: 1.63, 3.52) for pelvic, 5.88 (95% confidence interval: 3.80, 9.09) for para-aortic, and 30.27 (95% confidence interval: 16.56, 55.34) for supraclavicular involvement (63). Objective: To compare FIGO 2009 and FIGO 2018 cervical cancer staging criteria with a focus on stage migration and treatment outcomes. Consequently, we routinely include diffusion-weighted imaging with b values of 0 and 1000 sec/mm2 to facilitate lesion detection (42). Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Radiologists, among other physicians, should continue to participate in ongoing efforts to improve access to advances in medical technology and expertise in low-resource settings (65,66). The standards for image acquisition and interpretation are summarized with cases illustrating potential pitfalls. AJR Am J Roentgenol. Diagnosis, staging, and surveillance of cervical carcinoma. Administration of intravenous iodinated contrast material is optional but can aid in the evaluation of solid organs (eg, uterine corpus, liver, kidneys). Table E1 (online) is a representative protocol for image acquisition. 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. These low-technology choices reflected the demographic reality that nearly 85% of invasive cervical cancer is diagnosed in low-resource settings where advanced imaging modalities are unavailable. If MRI is unavailable, then US with an endovaginal or endorectal probe is an alternative in women when the clinical examination suggests early stage disease.
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