 Hello everyone, I'm Priyankar. I will be speaking to you about staging of cervical cancer in this talk This is the last lecture of my series of talks on pelvic MRI imaging So this is going to be the flow of the talk, we'll touch briefly on the epidemiology, the role of MRI Staging using MRI, talk about precarious and fertility sparing surgery Cervical cancer is the first and fourth most common cancer in women worldwide and it is the second most common cancer in women in India. It accounts for about a quarter of all cases worldwide There is a steady decline in cases in the developed countries due to screening whereas in India the five years evaluation rate is still quite poor at almost 50%. Risk factors include HPV which is the main one. Smoking, perceptive use, multi-parity, multiple sex partners and sex at young age. It tends to happen in women between 35 to 60 years of age. Because of association of risk with HPV prevention is possible using HPV vaccines and HPV DNA based screening. In developed countries this used to be done with pap smears which has now been replaced with cervical screening test W2 has classified in cervical tumors into three separate epithelial tumors, subtypes. The most common one is cremesal carcinoma which accounts for about 80% of the cases remaining are adenocarcinomas with other rare varieties reported. For some reasons cremesal carcinoma has better prognosis and adenocarcinoma. Now these cremesal carcinoma tends to arise in the scrimo-columnal junction while the adenocarcinoma arises in the ecto cervix. The scrimo-columnal junction is in the ecto cervix in younger patients which regresses to the endoscopyte canal with age. Therefore we tend to see that younger women have an exorbitant mass whereas the older women will have an endophtic lesion. Clinically most of these women are asymptomatic or they might present with intramethyl vanishing or postmenopausal vanishing and other non-specific symptoms. Initial investigation is done using ultrasound and staging is done with MRI and PET CT scan. Staging is done using the FIGO method. Similar to endometrial cancers, FIGO and event division for cervical cancers is done which that stage 1B now has three separate subgroups and lymph nodes have been incorporated into the current FIGO staging in stage 3. Also similar to endometrial cancer previously radiology was not part of FIGO staging. So MRI is the method of choice for local regional extent. Now unlike endometrial cancers, dynamic contrasting and sequence is still a research tool. It can demonstrate invasion into the adjacent tissues better but is not recommended for staging of cervical cancer. So you can perform MRI without administering contrast. It can also help identify tiny tumors in women who are considering fertility-sparing surgery. Diffusion on the other hand is helpful and together with T280 it helps to linear the tumor better. So this image just shows how to protocol your scans. So the blue part is tumor in the cervix. Your axiom should be oriented perpendicular to the endosavial canal and your two coronals are going to be perpendicular to these. On MRI the tumor is going to be iso intense to cervical stroma on T1 sequence and it's going to be hyper intense compared to the cervical stroma on T2 sequences. If we do give contrast the tumor is going to be more enhancing than the adjacent cervical stroma and they tend to have a stick to diffusion. Here is an example. We have a normal cervix, MRI of a normal patient. You see the endosavial canal lining and this is the cervical stroma. In between we see the junctional zone as a low T2 signal and then the outer cervical stroma ring of low T2 signal. On axial we see a low T2 signal ring, then the cervical stroma, then the junctional zone and the hyper intense component of the center is the endometrial lining. Then the adjacent paramedical fat. Please note that we do have some vessels in the paramedic here. So when we do discuss tumor don't tend to call these as tumor extension to the paramedic because the paramedic fat is vascular and therefore does have some internal striations. This is just to show tumor endobis cervix which is on T2 is heterogeneous recycling hyper intense and demonstrates restricted diffusion. Now moving on to staging. Stage one cancer is strictly confined to the cervix. 1a is microscopic and therefore we're not going to see an MRI. Stage 1b tumor is still confined to the uterine cervix and has three separate sub types. Stage 1b1, 1b2 and 1b3. These sizes are going to be 1b1 is between 5 millimeters to 2 centimeters. 1b2 is between 2 and 1b3 is more than 4 centimeters and the size is the maximum dimension in any plane. This allows for risk stratification and identify patients who are candidates for fertility sparing surgery. With stage 1b1 and 2 there is a significantly increased risk of death which is almost double in stage 1b2. Therefore they are recommended to undergo pelvic lymphatic in radiotherapy whereas 1b1 can benefit from limited surgery. Here we've got an example. There's a tiny T2 hyper intense lesion in the ecto cervix. If we measure it's going to be small I know part of the remaining structures also pair hyper intense but this was the tumor and this is going to be a stage 1b1 disease. Another case we see a tumor which is to the left of the midline it does involve the endo cervix here. We have lost the internal inner rim of junctional zone and then it's involving the cervical stroma but the outer rim is still intact. So this is stage 1b2 tumor and on this one we see the tumor is right. It's causing expansion of the posterior cervical wall and it's going to be more than 4 centimeters in length as we measure here. This is stage 1b3. So there is not much to add for me here it's just that you have to identify the tumor which is going to be T2 hyper intense and it's going to have to stick to diffusion and measure to decide whether it's which stage of 1b it is. Moving on to stage 2 cancers these extend beyond the uterus but not to the lower third of vagina or the pelvic side wall. Now 2a is going to involve the upper two tones of vagina and again we've got subtype subgroups in the basal size. Stage 2b will extend into the paravigio in which you are going to lose the low signal rim of the cervical stroma and it's going to cause circulated and nodular outline of the tumor and paramedium interface. It might incase the paramedium vessels. Here we've got a tumor in the cervix there is going to be no difficulty in identifying this and then we can see this is the posterior vaginal phonics and anterior vaginal phonics and there is tumor extending into the upper vagina. So this is stage 2a. How do you decide whether tumor is in the upper vagina or lower vagina? You can draw a line through the base of bladder through the neck of the bladder and see where it intersects the vagina. Whatever you have above it which is here that's going to be the upper vagina and whatever you have below is going to be the lower vagina. In this case this is an axial small field of view through axial through the cervix. We see the tumor involving most of these cervix and then we see these additional striations into the paramedium and then nodular outline. Also we cannot appreciate the low signal rim of the cervical stroma. So this is extension into the paramedium and this is stage 2b disease. Stage 3 tumor is going to extend into the lower third of vagina. Appearances are going to be similar to what I showed for stage 2a which is that it is going to go below the line through the bladder pains. It can extend to the pelvic side wall and the definition of pelvic side wall is similar to endometrial cancer which is going to be less than 3 millimeters distance between tumor and the true pelvic fold. Please don't overcall based on peritumoral enhancement or fat strengthening. So it has to be distance between the actual tumor and this pelvic side wall. Stage 3c is going to be pelvic lymph node involvement or parietal lymph node involvement and these again are similar to what we have already discussed in endometrial ca stage 3. Stage 4 again is identical to ca endometrial. Tumor extends beyond the true pelvis and involves the mucosa bladder and rectum. So tumor touching the bladder wall is not stage 4. It has to involve the mucosa for either the bladder or the rectum. Stage 4b is distant metastasis. Here we've got a case of cervical tumor. This is an image I've taken off the internet. It is extending into the bladder wall very clearly and the coronal views again we can see there is tumor seen within the urinary bladder. So this is the tumor. In some cases as I said we may see tumor touching the cirrhosis margin that may not be tumor stage 4a. In those cases we can look at contrast enhanced sequences if there is an enhancing tumor seen within the bladder or sometimes a fused image of T2 weighted sequence and diffusion imaging might help and if you do not see any activity or any restricted diffusion within the bladder wall then it might not feed bladder wall invasion. Lymph nodes. There is not much which is different in lymph nodes staging of cervical cancer for metamethyl cancer. These signs you can take as 1 cm or 0.8 and 1 cm as discussed previously. Now MRI has limited sensitivity in detecting beta-sided disease in normal sized lymph nodes but this can be resolved with PET CT scan and this is recommended for most patients who have higher grade of cervical tumor. So what you do not see on MRI should be picked up on PET CT scan. Therefore PET CT is recommended for anyone who has stage 1B2 or above disease. So this is going to be how we plan treatment. We perform an MRI if patient has a low grade disease and is not a candidate for fertility sparing then patient undergoes surgery and that's curative for patients who have higher stage disease. They need to undergo PET CT scan. If there is pelvic lymph load involvement these patients have to go for pelvic radiation and chemotherapy. If there is distant metastasis they go for chemotherapy and radiation and in pariotic lymph load involvement they have to undergo pelvic and pariotic radiation and chemotherapy. So recurrence is going to have similar appearance as primary cancer. MRI is the modernity of choice unlike MRI that we perform for staging primary cancer contrast enhanced sequences to have a role here and this is to differentiate inflammatory tissue and fibrosis from tumor recurrence. So recurrence is going to enhance in early and late phase of this scan whereas fibrosis will fully enhance and inflammation might enhance to some degree and they both can have receptor diffusion so that does not have much of a role in recurrence. On PET CT scan there's a possibility that there'll be some metabolic activity that you see for up to three to six months post treatment and that's probably related to information so please do not over call that and for doubtful cases maybe review together with the clinical presentation and MRI and PET CT scan findings. If patient underwent radiotherapy for management of primary cancer then they have to undergo radical surgery now for recurrence whereas if they did not have radiotherapy for primary cancer management they can now undergo chemotherapy for management of recurrence. Briefly touching upon fertility sparing surgery so the eligibility criteria for that is any histological subtype tumor stage one be one or less tumor is at least one centimeters away from the internal loss there is less than 50 percent enrollment of the cervical stroma and there is no nodal disease. If the patient does decide to go for this surgery then MRI is recommended for these patients to be done first to be done at six months and then to be done annually. Now sometimes we see tumors from endometrium extending down to the cervix and there can be a bulky cervical mass and it's important to distinguish whether it's a primary and endometrial cancer or primarily a cervical cancer which is a management is very different so there are findings which can help if we see bulk of tumor to be centered in cervix then it is going to be a cervical cancer whereas if bulk of tumor is in the endometrium then it is going to be an endometrial cancer also endometrial cancers tend to distend the endometrial cavity whereas cervical cancers might just extend upwards but not distend. I'm sorry for this age don't get confused because this is just to show that the tube can look similar but if we pay attention to the features that I've just described we will be able to differentiate the two. Worst case scenario biopsy will be helpful to decide which one it is. So in summary cervical cancer MRI is the standard of care for staging and you do not necessarily need to give contrast for primary staging MRI. PET CD scan is indicated for patients who've got higher grade or stage disease assess the patient for possibility of fertility spanning surgery and also assess if the patient is a surgical candidate for management. That will be all thank you so much for listening I hope you enjoyed the talk.