1. DON`T LET UTERINE CERVICAL CARCINOMA DRIVE YOU CRAZY: BASIC MRI PRINCIPLES M. Gamo P. Ramos E. Diez E. Barcina P. Quintana

2. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ Breast, uterine cervical and endometrial carcinomas are the most frequent gynecologic neoplasms ■ Cervix carcinoma is the fifth neoplasm on women and the third most common gynecologic malignancy ■ Incidence: Increase from 20 years old. Average patient age at onset of 45 years (maximum from 45 to 55) ■ Two categories: Epithelial Neoplasms Nonepithelial Neoplasms - 85-90% are squamous cell carcinoma - 5-15% are adenocarcinoma - Other rare histologic types (carcinoid tumor, malignant melanoma) I NTRODUCTION - Lymphoma, leiomyoma D UE TO THE HIGH FREQUENCY OF SQUAMOUS CELL CARCINOMA, WE WILL FOCUS ON IT FOR THE REST OF THIS PRESENTATION

3. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ The cervix consists of two different types of epithelium: squamous epithelium and mucinous epithelium. Squamous cells cover the epithelial surface of the portio continuing from the vagina, and columnar cells cover the mucinous epithelium of the endocervical gland, which produces mucin. With age, squamous cells grow back to cover the columnar cells. This transitional area is the squamocolumnar junction (SCJ). ■ Carcinoma of the cervix develops almost exclusively within the transformation zone that extends between the original SCJ and the physiologic SCJ. CORPUS CERVIX VAGINA Tubo-endometrial epithelium Squamous epithelium SCJ Mucinous epithelium A NATOMY

4. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ Most cervical squamous cell carcinomas grow at the SCJ (transitional area between squamous cells from the vagina and columnar cells) by metaplasia of squamous epithelium ■ Classification:  Preinvasive lesion  before transgression of the basement membrane Dysplasia or Carcinoma in situ (-CIN-)  STAGE 0  Invasive lesion, three patterns of growth:- Fungating - Ulcerative - Infiltrative ■ Younger women (< 35 years old): - The SCJ is located outside the external uterine os - The tumor tends to grow outward (exophytic growth pattern) ■ Elderly women (> 35 years old): - The SCJ is located within the cervical canal - The tumor tends to grow inward along the cervical canal (endophytic growth pattern) P ATHOLOGY

5. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ Signs and symptoms: - Vaginal bleeding (menorrhagia) ■ Routes of dissemination:  Direct extension to contiguous structures  uterine corpus, vagina and parametrium  Lympathics nodes  Hematogenous route (lung, liver… ) Lymphatic spread from cervical tumors is initially to the parametrial nodes, followed by extension primarily along three pathways: -Lateral route  to external iliac nodes -Hypogastric route  to the internal iliac or hypogastric nodes -Posterior route  along the uterosacral ligaments to the lateral saccral and sacral promontory nodes All nodal groups drain to the common iliac nodes and then to the paraaortic nodes P ATHOLOGY

6. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES Abdominal Aorta Paraaortic nodes Lateral sacral nodes Hypogastric nodes Presacral nodes Obturator nodes External iliac nodes Junctional nodes External iliac artery P ATHOLOGY L YMPHATIC S PREAD FROM C ERVICAL T UMOR

7. BACKGROUND UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ Prognostic Factors: - Lymph node status  MOST IMPORTANT - Tumor size - Depth of invasion - Histologic grade - Stage  Five-year survival: between 92% for stage I to 17% for stage IV ■ Diagnosis: Papanicolau smear and biopsy [This test has declined incidence of and mortality from invasive squamous carcinoma of the cervix, but adenocarcinoma is less readily detected with it, because of this,its incidence has increased] ■ Risk factors:  Early sexual activity, especially with multiple partners  Cigarette smoking  Immunosupression  Infection with human papilomaviruses 16 and 18 P ATHOLOGY

8. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES BACKGROUND S TAGING ■ The current system of staging for cervical cancer is based on the International Federation of Gynecology and Obstetrics (FIGO) classification ■ This staging system is a clinical approach based on findings from: Physical examination (genital exploration, lymph nodes evaluation) Examination of patients under anesthesia Colposcopy and lesion biopsy ( conization if it is necessary) ■ It may be supplemented by some complementary techniques: Chest/bone radiography, barium enema, intravenous urography Cystoscopy Proctoscopy Histeroscopy

9. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES BACKGROUND S TAGING ■ MR imaging examination obviates the use of invasive procedures (such as cystoscopy and proctoscopy), especially when there is no sign of local extension. ■ Cross-sectional imaging is not included as a part of the initial staging, because access to this technology is not universally available, neither are included significant prognosis factors like lesion volume and nodal metastases. ■ The greatest difficulties in the clinical evaluation of patients with cervical cancer are the assessment of parametrial and pelvic sidewall invasion; accurate estimation of tumor size, especially if the tumor is primarily endocervical in location; and evaluation of lymph node metastases.

10. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES BACKGROUND ■ The most important issue in staging of cervical cancer is to distinguish early disease (stages I and IIA) that can be treated with surgery from advanced disease (stage IIB or greater) that requires radiation and possibly chemotherapy. ■ Because the combination of radical surgery and irradiation has greater morbidity compared with either modality alone, accurate preoperative assessment is crucial to minimize the need for both treatments. ■ Given the limitations of clinical staging, “extended” clinical staging is frecuently used when the tecnology is availabe. MR imaging is now widely accepted as optimal for evaluation of the main prognostic factors and selection of therapeutic strategy. S TAGING

11. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES TNMFIGODescription T1ICarcinoma confined to the cervix T1aIAInvasive carcinoma identified only microscopically T1a1IA1Stromal invasion no greater than 3 mm in depth and no wider than 7 mm T1a2IA2Stromal invasion greater than 3 mm but less than 5 mm in depth and no wider than 7 mm T1bIBClinically invasive disease T1b1IB1Clinical lesions no larger than 4 cm T1b2IB2Clinical lesions larger than 4 cm T2IIExtension beyond cervix and involvement of the upper vagina (but not the lower vagina) T2aIIANo parametrial invasion T2bIIBParametrial invasion T3IIIInvasion of the lower third of the vagina, to the pelvic sidewall, or both T3aIIIAInvasion of the lower third of vagina T3bIIIBExtension to the pelvic wall or hydronephrosis (or both) T4IVTumor extends outside pelvis or invades bladder or rectal mucosa T4aIVAInvasion of the mucosa of bladder, rectum or bladder and rectum; invasion extending beyond the true pelvis; or both M1IVBDistant metastasis BACKGROUND

12. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES BACKGROUND T REATMENT ■ IA  Surgery or pelvis irradiation with intracavitary treatment  IA1  Simple hysterectomy (removing of only the uterus, not the parametrial and uterosacral ligaments)  IA2  Radical hysterectomy (resection of the uterus, upper vagina, parametrium and pelvic lymph nodes) ■ IB1 and IIA  Either radiotherapy or surgery  Pathologic risk factors positive (nodal metastasis, surgical margin within 3 mm of the tumor)  adjuvant radiotherapy  Poor prognostic factors (nodal involvement, tumor largher than 4 cm or adenocarcinoma)  Surgery is not the treatment of choice ■ IB2, IIB-IVA, IB1 or IIA with adverse prognostic factors  Combined external pelvis radiation and brachytherapy with concurrent administration of chemotherapy. Neoadjuvant chemotherapy before radiation has not improved survival in patients with locally advanced cervical cancer

13. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES BACKGROUND T REATMENT ■ Stage O and IA  Conization ■ Stage I-IIA  Surgery, radiotherapy or both ■ Stage IIB-IVB  Radiotherapy + Brachitherapy + Chemotherapy IMPORTANT!!! Differentiate between IIA stage and IIB stage PARAMETRIAL INVASION 