To compensate for these shortfalls, treatment planning for invasive cervical cancer in much of the developed world has included modern cross-sectional and functional imaging such as CT, MRI, and fluorine 18 fluorodeoxyglucose, or FDG, PET (10,11). The new staging adds Stage IIIC1 for pelvic lymph node metastasis and IIIC2 for aortic lymph node metastasis, similar to the FIGO staging of lymph nodes in endometrial cancer. Figure 5b: Images show uterine cervical cancer with thoracic metastases. Historically, Federation of Gynecology and Obstetrics (FIGO) staging was based mainly on clinical examination in consideration of the prevalence of cervical cancer in low-income populations with limited access to advanced technology. Online supplemental material is available for this article. A prospective multicenter trial demonstrated that, in patients with early stage tumor intended for curative surgery, sensitivity of MRI versus clinical examination to help detect parametrial extension was 53% versus 29% (53). 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. Cervical cancer, MRI and PET/CT for triaging stage IB clinically operable cervical cancer to appropriate therapy: decision analysis to assess patient outcomes, Multidisciplinary perspectives on newly revised 2018 FIGO staging of cancer of the cervix uteri, Validation of the 2018 FIGO cervical cancer staging system, Vaginal radical trachelectomy: a valuable fertility-preserving option in the management of early-stage cervical cancer—a series of 50 pregnancies and review of the literature, Radical vaginal trachelectomy as a fertility-sparing procedure in women with early-stage cervical cancer-cumulative pregnancy rate in a series of 123 women, The performance of magnetic resonance imaging in early cervical carcinoma: a long-term experience, Fertility-sparing surgery in early-stage cervical cancer: indications and applications, Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic lymphadenectomy: prospective multicenter study of 100 patients with early cervical cancer, FDG-PET-based prognostic nomograms for locally advanced cervical cancer, PET/CT imaging to guide cervical cancer therapy. PET/CT is best used to evaluate for hydronephrosis (stage IIIB), retroperitoneal lymphadenopathy (stage IIIC), and distant metastases (stage IVB). 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). With the FIGO 2018 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 (Table 1) (1). Often, large field-of-view anatomic images (eg, gradient-echo T1-weighted or echo planar T2-weighted images) from the level of the renal hilum through the pelvic floor are also obtained in the axial plane to evaluate for hydronephrosis (stage IIIB) and lymphadenopathy (stage IIIC). Tumor size (stage IB and IIA), cervical stromal invasion (stage IA), and lack of parametrial spread (stage IIB) are assessed well with MRI but poorly with CT. MRI affords a larger field of view than does US and greater tissue contrast than does CT. 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). Until 2018, CC was clinically staged based on the FIGO 2009 classification. Chest CT findings of metastases are pulmonary nodules or involvement of the supraclavicular nodes, a station in the drainage pathway of the primary tumor (31). The 2018 FIGO cervical cancer staging system now enables identification and upstaging of these patients based on pretreatment lymph node imaging, thereby sparing them unnecessary surgery and long-term morbidity (12,23). Table 2: Choice of Imaging Based on Resource Availability for Staging of Patients with Uterine Cervical Cancer. Stage predicts patient prognosis and guides treatment planning. Patients with pelvic and/or para-aortic lymph node metastases are designated as having stage IIIC disease, irrespective of primary tumor size or local pelvic spread. With the FIGO 2018 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 (Table 1) (1). 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). However, in patients with lymphadenopathy, surgery alone does not cure and 10%–30% of patients with early stage disease harbor lymph node metastases (22). 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. ■ Both US and MRI accurately measure the primary tumor and assess parametrial spread better than does CT or physical examination. Staging of cervical cancer can either be based on the TNM or FIGO system. In this context, PET/CT is preferred as the imaging modality because it also enables depiction of occult distant metastases, another factor in staging. 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. Negative rather than positive oral contrast material is used to minimize attenuation-correction artifact. Springer Verlag. AJR Am J Roentgenol. 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. Gynecologic cancers are staged according to the International Federation of Gynecology and Obstetrics (FIGO) system (1). 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. Instead, they are triaged to one or the other curative, and far less morbid, options (12). 1. human papillomavirus (HPV) 16 and 18 infections: for most types except for clear cell carcinoma of the cervix and mesonephric carcinoma of the cervix 2. multiple sexual partners or a male partner with multiple previous or current sexual partners 3. young age at first intercourse 4. high parity 5. immunosuppression 6. certain HLA subtypes 7. oral contraceptives 8. nicotine/smoking (except for cervical adenocarcinom… Table 3: US versus MRI for Tumor Size and Parametrial Spread. Methods: This study is based on a database cohort of 1282 patients newly diagnosed with cervical cancer from 1997 to 2019. Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. Additionally, the revision calls for a more precise description of primary tumor size, which should be measured with MRI, especially for trachelectomy planning. Note.— Data in parentheses are primary ratios. (a) Coronal maximal intensity projection PET image in a patient staged as IB following clinical examination and normal chest x-ray (not shown) shows hypermetabolic foci in left upper (arrow) and right middle (arrowhead) thorax corresponding to (b) left supraclavicular lymphadenopathy (arrow) and (c) cavitary right lung nodule (arrowhead), respectively. Role of PET/MRI in Staging of Cervical Cancer Under the Newly Updated FIGO Staging System, The International Federation of Gynecology and Obstetrics (FIGO) Cancer Report 2019: An Imaging Update on Cervical Cancer Staging and Beyond, Pseudoprogression with Immunotherapy Treatment, Locally advanced, metastatic prostate adenocarcinoma. If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. The International Federation of Gynecology and Obstetrics (FIGO) system, last revised in 2009, is the most widely used staging system for cervical carcinoma (Table 3.3) [].The FIGO staging of cervical carcinoma is clinical and does not rely on either surgical or pathologic findings. M1: Distant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal or para-aortic lymph nodes, lung, liver or bone). 7. (a) Coronal maximal intensity projection PET image in a patient staged as IB following clinical examination and normal chest x-ray (not shown) shows hypermetabolic foci in left upper (arrow) and right middle (arrowhead) thorax corresponding to (b) left supraclavicular lymphadenopathy (arrow) and (c) cavitary right lung nodule (arrowhead), respectively. Patient was staged as IIIC2 based on PET/CT. 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). (b, c), On concurrent contrast-enhanced CT images, hypermetabolic abdominal lymph nodes measure less than 1 cm in short axis and are morphologically normal. Note.—Adapted, with permission, from reference 59. PET/CT, MRI, and CT are the imaging options. The 2018 FIGO cervical cancer staging system keeps the backbone of staging clinical, while incorporating results from imaging and pathology. Diffusion-weighted imaging, when added to conventional MRI sequences, improves lesion detection (35–42). Cervical cancer is a significant cause of morbidity and mortality worldwide despite advances in screening and prevention. Because of its sensitivity in depicting lymph node metastases, PET and PET/CT are a strong predictor of disease-specific survival (15,63). *Complete description is available in reference 53. ). Robbins SL, Kumar V, Abbas AK et-al. 5. Cervical Carcinoma and Updated FIGO Staging: What Should Radiologists Know in 2019? 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). Thus, distant metastases depicted with PET/CT should be confirmed with biopsy, because a designation of stage IVB is associated with a significant change in treatment strategy. 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. MR imaging of the uterine cervix: imaging-pathologic correlation. *Indicates stages that are new from the 2009 FIGO system. Multiplanar fast spin-echo T2 images help evaluate for tumor invasion into the parametria (stage IIB) and pelvic sidewall (stage IIIB), and images after gadolinium-based contrast agent administration help assess for peritoneal, nodal, and bone metastases (10,32). 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). The standards for image acquisition and interpretation are summarized with cases illustrating potential pitfalls. ); and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (M.A. 6. Figure 3: Image shows uterine cervical cancer with parametrial involvement. Diagnosis, staging, and surveillance of cervical carcinoma. ■ Torso (chest, abdomen, and pelvis) PET CT reveals unsuspected distant metastases (eg, chest, peritoneum, bone, etc) that changes the stage, prognosis, and treatment plan in 14% of women with local-regionally advanced (ie, clinically suspected FIGO stage IB3, IIA2, ≥IIB) cervical cancer. Lymphadenopathy assessed at cross-sectional imaging is a major prognostic factor for survival and an important determinant in treatment planning (20,21). Table E1 (online) is a representative protocol for image acquisition. The revisions introduced in the 2018 FIGO staging system are intended to address the gap between the staging formalism and ongoing clinical practice and to explicitly acknowledge the role that advanced imaging has come to play in the care of women with invasive uterine cervical cancer (13). Another prospective multicenter trial showed that the false-negative rate with US and MRI for parametrial extension was comparable and very low (ie, <3%). 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. 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). 2003;180 (6): 1621-31. If PET/CT is unavailable, then chest radiography is recommended as first-line imaging modality for thoracic imaging. The International Federation of Gynecology and Obstetrics (FIGO) staging system is widely used for treatment planning but more often for standardization of epidemiologic and treatment results (,Table 1) (,2,,3). Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) … If PET/CT is unavailable, then CT or MRI is a second-line alternative with both modalities demonstrating similar diagnostic performance (28,60). Patients with tumors less than 2 cm (ie, stage IB1) demonstrate a nearly twofold lower risk of cervical cancer death compared with patients with tumors measuring 2–4 cm (ie, stage IB2). MR imaging is the modality of choice for staging with CT having relatively low specificity (especially for myometrial invasion 5). Choice of modality depends on the technology available within the practice setting. Figure 4b: Images show uterine cervical cancer lymphadenopathy at fluorodeoxyglucose PET/CT versus CT. (a) Coronal maximum intensity projection PET image in a patient clinically staged as IB shows hypermetabolic foci in pelvis (arrowheads) and abdomen (arrows), which at fusion PET/CT (not shown) correspond to retroperitoneal lymphadenopathy. Table 2 TNM (8 th … Fusion of the PET signal with the anatomic CT images helps to address the limited special resolution and soft-tissue contrast of PET. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Patient was staged as IIIC2 based on PET/CT. MRI is preferred over CT or pelvic examination for measuring primary tumor size. With a simple physical and pelvic examination, it is possible to ascertain if the cervix cancer is localised and would be amenable to surgical resection. Cervical carcinoma is staged at clinical examination because many tumors are inoperable at the time of patient presentation. Other features such as density, shape, and the presence or absence of the fatty hila have been suggested as important but consensus guidelines are silent on how they should be applied. At MRI, this is best seen on fast spin-echo T2 long-axis oblique views of the cervix where the isointense tumor extends beyond the dark stromal ring of the cervix. The International Federation of Gynecology and Obstetrics Federation (FIGO) staging system of cervical cancer was introduced in 1958 and most recently revised in 2018, reflecting an increased knowledge of cancer biology and prognostic factors, and … Unable to process the form. American Joint Committee on Cancer - Cervix Uteri Cancer Staging. All underwent standard clinical examination and whole-body FDG-PET. However, in 2018, the FIGO Gynecologic Oncology Committee made revisions to allow stage assignment based on imaging and pathological findings, when available . (2010) ISBN:1416031219. 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 2010;30 (5): 1251-68. Note.—Imaging is appropriate in women with tumor invasive to a depth greater than or equal to 5 mm. Neerja B, Jonathan SB, Mauricio CF et-al. The patient is asked to void before scanning to decrease bladder volume. Axial oblique fast spin-echo T2-weighted image in a woman clinically staged as IB shows tumor that extends beyond dark stromal ring of cervix into adjacent parametria (arrows) corresponding to stage IIB. (a) Contrast--enhanced CT, (b) axial fast spin-echo T2-weighted MRI, and (c) axial T1 images after gadolinium-based contrast agent administration through pelvis of a woman with stage IB2 cervical cancer (arrows). In June 2009 the FIGO committee introduced the revised staging [5] of cervical carcinoma updating the previous staging of 1988 (Tables 1 and 2). As with CT, lymph nodes are evaluated not only based on size, but also for abnormal signal and/or shape. Imaging routinely encompasses the skull base through the proximal thighs. Data in parentheses are 95% confidence intervals. To be considered a candidate for this procedure, the woman must be considered to have stage I (ie, tumor confined to the cervix) and not stage II (ie, tumor growth into the upper third of the vagina or the parametria) disease. The size and extent of local spread of the primary tumor in the central pelvis can now be assessed by using clinical examination, imaging, or pathologic measurement. Thus, early detection of stage IVB disease significantly impacts patient treatment and represents an opportunity to decrease treatment-related morbidity. For these women, the modern cross-sectional and functional imaging introduced into the 2018 FIGO staging system is unlikely to prove beneficial. Check for errors and try again. Patient was staged as IVB based on PET/CT and lymph node biopsy that showed metastases at pathologic analysis. 28, No. Whereas FIGO staging of most gynecologic cancers relies on surgery and pathologic analysis, uterine cervical cancer is unusual among the gynecologic cancers in that it is staged clinically with pelvic examination, often under anesthesia with bladder cystoscopy and colposcopy, in combination with imaging. Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. Radiographics. CT evaluation of cervical cancer: spectrum of disease. Although surgery is more sensitive, imaging is less morbid in avoiding the short- and long-term complications of lymphadenectomy (57). This new primary tumor size cutoff value of 2 cm also corresponds to the eligibility criteria for radical trachelectomy, a fertility-sparing treatment for cervical cancer in which the uterine cervix, parametria, and the vaginal cuff are resected (15,16). 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. Accurate staging of cervical carcinoma is crucial to patient management. Magnetic resonance imaging is the imaging modality of choice for staging the primary cervical … 9. Cervical carcinoma is the third most common gynecologic malignancy, with an average patient age at onset of 45 years (,1,,2). Assessment of abdominopelvic retroperitoneal lymph nodes in cervical cancer staging was introduced with the 2018 update and was not in any previous versions of the FIGO system.
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