Table Of ContentAtlas of Staging in Gynecological Cancer
J. Richard Smith • Jeremiah Healy • Giuseppe Del Priore (Eds)
Atlas of Staging in Gynecological Cancer
J. Richard Smith, MB, ChB, MD, FRCOG Jeremiah Healy, MRCP, FRCR
Consultant Gynaecological Oncologist Consultant Radiologist
West London Gynaecological Cancer Centre Chelsea and Westminster Hospital
,
Hammersmith & Q ueen Charlottes Hospital London
London UK
UK
Giuseppe Del Priore, MD, MPH
Vice President Research
New York Downtown Hospital
New York
USA
British Library Cataloguing in Publication Data
Atlas of staging in gynecological cancer
(cid:49). Generative organs, Female – Cancer – Atlases (cid:50). Tumors – Classification
I. Smith, J. Richard II. Healy, Jeremiah III. Del Priore, Giuseppe
(cid:32)(cid:32)(cid:32)(cid:32)(cid:54)(cid:49)(cid:54)(cid:46)(cid:57)(cid:169)(cid:57)(cid:52)(cid:54)(cid:53)(cid:32)(cid:32)
ISBN-(cid:49)(cid:51)(cid:58)(cid:57)(cid:55)(cid:56)(cid:45)(cid:49)(cid:45)(cid:56)(cid:52)(cid:54)(cid:50)(cid:56)(cid:45)(cid:52)(cid:51)(cid:51)(cid:45)(cid:53) e-ISBN-(cid:49)(cid:51)(cid:58)(cid:57)(cid:55)(cid:56)(cid:45)(cid:49)(cid:45)(cid:56)(cid:52)(cid:54)(cid:50)(cid:56)(cid:45)(cid:52)(cid:51)(cid:52)(cid:45)(cid:50)
Printed on acid-free paper
© Springer-Verlag London Limited (cid:50)(cid:48)(cid:48)(cid:56)(cid:32)
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this
publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic
reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the
publishers.
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws
and regulations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective
user must check its accuracy by consulting other pharmaceutical literature.
(cid:57)(cid:32)(cid:32)(cid:56)(cid:32)(cid:32)(cid:55)(cid:32)(cid:32)(cid:54)(cid:32)(cid:32)(cid:53)(cid:32)(cid:32)(cid:52)(cid:32)(cid:32)(cid:51)(cid:32)(cid:32)(cid:50)(cid:32)(cid:32)(cid:49)
Springer Science+Business Media
springer.com
Contents
Acknowledgements vii
..........................................................................................................................................................................................................................................................................................................................................................................................................
Editors and Contributors ix
..........................................................................................................................................................................................................................................................................................................................................................................................................
Cervical Cancer J.A. Lacombe, G. Del Priore and J. Hillier 1
..................................................................................................................................................................................................................................................................................
Vaginal Cancer M.K. Guess and A. Sohaib 6
.............................................................................................................................................................................................................................................................................................................................
Vulval Carcinoma S. Ghaem-Maghami, A. McIndoe, E. Moskovic and A. Sohaib 9
.........................................................................................................................................................................................................................
Endometrial Cancer A. Wang, K.M. Hartzfeld and M. Hughes 15
..................................................................................................................................................................................................................................................................................
Ovarian Cancer S. Shahabi and A. Sohaib 20
................................................................................................................................................................................................................................................................................................................................
Gestational Trophoblastic Disease K. Sieunarine, J.R. Smith, A. Aylwin and A. Mitchell 25
...................................................................................................................................................................................................................................................
v
Acknowledgements
The FIGO staging system (†) is reproduced by courtesy of the International Federation of
Gynecology and Obstetrics, previously published in the International Journal of Gynecology
and Obstetrics, Vol. 83, Sup. 1, October 2003.
The American Joint Committee on Cancer surgical staging system (‡) is used with the
permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois, USA. The
original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002),
edited by F.L. Greene, D.L. Page, I.D. Fleming et al, published by Springer New York,
www.springer.com
Illustrations by courtesy of Health Press Ltd., Abingdon, UK, taken from the publications Fast
Facts Gynaecological Oncology,Fast Facts Breast Cancer, and Patient Pictures Breast Cancer.
vii
Editors Contributors
J.R. Smith, MB, ChB, MD, FRCOG Anthony Aylwin, MRCP, FRCR A. McIndoe PhD, FRCS, FRCCOG
Consultant Gynaecological Oncologist Consultant Radiologist Consultant Gynaecological Oncologist
West London Gynaecological Cancer Centre Charing Cross Hospital Hammersmith and Queen Charlotte’s Hospital
Hammersmith & Queen Charlotte’s Hospital London, UK London, UK
London, UK
S. Ghaem-Maghami, PhD, MRCOG Adam Mitchell, FRCS, FRCR
J. Healy, MRCP, FRCR Consultant Gynaecological Oncologist Consultant Radiologist
Consultant Radiologist Hammersmith & Queen Charlotte’s Hospital Charing Cross Hospital
Chelsea & Westminster Hospital London, UK London, UK
London, UK
Marsha Guess, MD E. Moskovic, FRCP, FRCR
Giuseppe Del Priore, MD, MPH Yale University School of Medicine Consultant Radiologist
Vice President Research Connecticut, USA Royal Marsden Hospital
NY Downtown Hospital London, UK
NY-Presbyterian Healthcare Kimberly M. Hartzfeld, MD
New York, USA New York Downtown Hospital Shohreh Shahabi, MD
New York, USA Montefiore Medical Center
New York, USA
Julia Hillier, MRCP, FRCR
Consultant Radiologist Aslam Sohaib, MRCP, FRCR
Chelsea & Westminster Hospital Consultant Radiologist
London, UK Royal Marsden Hospital
London, UK
Michael Hughes, MRCP, FRCR
Consultant Radiologist K. Sieunarine, MRCOG
Charing Cross Hospital Research Fellow
London, UK Chelsea & Westminster Hospital
London, UK
Julia A. Lacombe, MD
University of Vermont Andrea S. Wang, MD
College of Medicine Columbia University
Vermont, USA College of Physicians & Surgeons
New York, USA
ix
CERVICAL CANCER
J.A. Lacombe, G. Del Priore and J. Hillier
Introduction Staging Imaging studies and cervical cancer
Approximately 12 000 women were newly Because the majority of the cases of cervical generally carries an extremely good prognosis. Lymphangiography can be used to assign
diagnosed with cervical cancer in the USA in cancer worldwide are in women living in However, these distinctions are of extreme staging in the FIGO system. A computed
2003.1 Although cervical cancer remains a underdeveloped countries, staging systems for importance in the determination of which tomography (CT) scan, MRI and a PET scan
leading killer of women worldwide, the cervical cancer have been clinically based. patients can be treated conservatively cannot be included in the FIGO staging
incidence in the USA represents a significant Staging procedures have accordingly been versus those who require more aggressive procedure, but certainly change treatment
decrease, mainly attributable to the geared towards technologies available within treatment.5,6 decisions when available. These imaging
widespread implementation of Pap test these countries. The American Joint Committee on Cancer studies are useful in accurately determining the
screening. The Pap smear is designed for The International Federation of Gynecology (AJCC) has established a TNM (tumour, node, extent of disease spread in order to tailor
detecting pre-invasive disease of the cervix. and Obstetrics (Federation Internationale metastasis) classification system based on the treatment for patients with cervical cancer.
This allows treatment to be initiated prior to Gynecologique Obstetrique or FIGO) along same clinical staging information as FIGO. Advances in imaging could improve the
the development of cancer.2 with the World Health Organization last According to the AJCC, the T stages accuracy of staging cervical cancer by
Human papillomavirus (HPV) is a sexually revised its staging system in 1995.4 The correspond to the FIGO stages. The AJCC facilitating the detection of lymph node and
transmitted virus associated with cervical FIGO staging (Table 2.1) system is based upon recommends that surgical and pathologic distant organ metastases. This procedure is
dysplasia and invasive cancer. Low-risk HPV a thorough clinical examination, chest X-ray, findings be recorded as a final pathologic rarely used when the modern alternatives
types, such as 6 and 11, are associated with intravenous pyelogram, cystoscopy, proctoscopy (TMN) disease stage, but should not change described below are available because it is
cervical intraepithelial neoplasia (CIN) I and and barium enema as indicated. The physical the clinical FIGO stage. painful and operator dependent leading to
condyloma. High-risk types of HPV, such as examination should include abdominal, Controversy exists regarding surgical questionable reliability.9
types 16, 18, 31, 33 and 35, are observed in pelvic, rectovaginal and lymph node staging for cervical cancer. In 1980 the
association with high-grade dysplasia or examinations. Examination under anaesthesia Gynecologic Oncology Group (GOG) Lymphangiography
cervical cancer. HPV DNA can be detected in is strongly recommended because of the added reported a greater than 30% risk of Lymphangiography involves injecting a
close to 100% of patients with invasive benefits of muscular relaxation and para-aortic lymph node metastasis in patients contrast dye into the lymphatic system prior to
cervical cancer. Although the prevalence of inter-examiner correlation.5 If up-to-date with locally advanced cervical cancer, i.e. X-ray imaging. Normal lymph nodes appear
HPV in some populations approaches imaging methods are available such as stages IB2–III.7Many authors have advocated opaque and lymph nodes with neoplastic cells
30–90%, only a small number of these women magnetic resonance imaging (MRI) and lymphadenectomy in cervical cancer for do not. The cervix has predictable drainage to
go on to develop cervical cancer.2 positron emission tomography (PET) scanning, prognostic information as well as to assist in local lymph nodes and is well suited to
The overwhelming majority of cervical an examination under anaesthesia EUA may the planning of radiation fields.5,8The advent lymphangiography.
carcinomas have historically been of not be needed for treatment planning. of laparoscopy has made this procedure less The dorsal pedal lymphaticsare identified using
squamous cell histology. However, with According to the FIGO staging guidelines, a morbid, thereby renewing interest in surgical a visible blue dye. The identified lymphatic
improvement in the diagnosis and treatment of major distinction exists between micro-invasion staging.8 However, a consistent survival channels are then canalized and radiographic
pre-invasive cervical cancer the percentage stage IA disease versus macroscopic stage benefit has not been demonstrated.5 contrast injected with direct observation of the
of adenocarcinomas has steadily risen from IB disease. Micro-invasive disease is further pelvic nodes at risk. The reported sensitivities
the 1970s to the present. In 1996 24% of delineated as stage IA1, with stromal are in the range of 28–83% and the specificities
diagnosed cervical cancer was adenocarcinoma invasion less than 3 mm in depth with a are in the rangeof 47–100%.9
representing a twofold rise in incidence from maximum horizontal spread of 7 mm and
1973.3 The diagnosis, treatment and stage IA2, defined as stromal invasion up to Computed tomography
prognosis of both histological subgroups 5 mm with the same horizontal spread up to CT scans are completed with the use of a 360°
appear to be similar. 7 mm on a single histology slide. Micro- X-ray beam and computer reproduction of
invasive cervical cancer is generally diagnosed images. These scans allow for multiplanar
upon cone biopsy following an abnormal Pap cross-sectional and three-dimensional views of
smear and colposcopy. Stage IA disease body organs and tissues.
1
Staging in Gynaecological Cancer
Imaging studies and cervical cancer continued Treatment
In the staging of cervical cancer, CT may be Positron emission tomography The treatment of cervical cancer is individualized women interested in retaining the possibility
unofficially substituted for an intravenous Through the use of labelled isotopes, to each patient based upon her stage and of childbearing, a radical trachelectomy appears
pyelogram in the evaluation of ureteral 2-[F-18]flouro-2-deoxy-D-glucose(18 FDG PET) concomitant medical problems. Treatment to be both a safe and effective treatment. This
obstruction. In addition, CT scans may scanning provides a functional assessment of may include surgery, radiation, chemotherapy can be performed abdominally or vaginally.
provide information regarding tumour size, glycolytic activity within a patient’s body. In or a combination of all three modalities. The advent of minimally invasive surgery has
lymph node enlargement and the presence of this way, FDG-PET is a non-invasive method brought about interest in a variant of the
distant metastases. CT and MRI have of detecting metastatic disease in cancer. Its Surgical management classic Shauta procedure, where a radical
comparable accuracies in determining lymph utility due to a high specificity and sensitivity Because the risk of nodal involvement in early vaginal hysterectomy can be performed with
node metestases in cervical carcinoma of 85- has been demonstrated in cancers of the lung, micro-invasive cervical cancer (stage IA1) is laparoscopic lymph node dissection. In
95%.10 Meta-analysis of published studies head and neck and oesophagus. The use of less than 1%, patients with stage IA1 disease addition, a total laparoscopic radical
confirmed that CT and MRI performed to a PET scanning in cervical cancer is thought to can be treated simply with a total abdominal hysterectomy has also been developed.17
similar degree of accuracy in the detection of be more accurate for the detection of lymph hysterectomy performed via the abdominal, A small percentage of women with
lymph node metestases and slightly better node spread than CT scanning or MRI. The vaginal or laparoscopic route.16 In young recurrent cervical cancer may be candidates
than lymphangiography.11 A finding of sensitivity of PET scanning for lymph node patients with a desire to preserve fertility, a for pelvic exenteration. Total exenteration
enlarged lymph nodes on CT scanning has a status in cervical cancer has been shown to be cone biopsy may be considered therapeutic. involves surgical resection of the pelvic viscera
specificity of 93%, but a positive predictive between 75 and 90%. Most importantly, the However, even with stromal invasion of including the bladder and rectosigmoid colon.
value of only 39%.9,10 negative predictive value is over 90%.9,14,15 ≤3 mm, a patient must be counselled as to her This procedure carries with it a high morbidity
Enlarged lymph nodes or evidence of The role of PET scanning in the diagnosis of small but real risk of residual disease after a and mortality rate and a 5-year survival rate of
metastatic disease on a CT scan warrant further recurrent cervical cancer and, specifically, the cone biopsy. In addition, many practitioners approximately 20–65%. Patient selection and
investigation with other imaging or biopsy. determination of appropriate candidates for would recommend total hysterectomy at the pre-operative counselling are crucial to the
total pelvic exenteration is currently under completion of childbearing.5,16,17 success of this operation.18
Magnetic resonance imaging investigation and appears promising. With stromal invasion of up to 5 mm (stage
MRI employs radio frequency pulses as Evolving technologies have combined PET IA2) the risk of lymph node metastasis Radiation therapy
opposed to ionizing radiation for mapping scanning with CT scanning or MRI in order to increases to 6–7%.16 This is generally felt to Patients with advanced stage (stages IIB, III
internal structures. Although MRI and CT combine an anatomical image with the be an unacceptably high risk and simple and IVA) cervical cancer are generally not
scanning are comparable in their ability for functional PET scanning result. Further hysterectomy an under-treatment. Radical considered to be surgical candidates. These
determining lymph node status, MRI is far investigation is needed into specific uses for hysterectomy with pelvic and para-aortic patients have been traditionally treated with
superior to CT scanning in soft tissue contrast this novel technology. lymph node dissection is the recommended external pelvic irradiation and brachytherapy
resolution. MRI provides a detailed survey of surgical procedure for patients who are combined with chemotherapy sensitization.5,16
pelvic anatomy and has proven useful for Lymphatic mapping medically stable with disease confined to the In addition, post-surgical patients with
determining tumour size, the depth of invasion Sentinal lymph node identification is a cervix and upper vagina (stages IA2, IB and high-risk features on their final pathology
and parametrial involvement and identifying technique that involves a peri-tumoral IIA).5 Radical hysterectomy allows for should receive radiation therapy and/or
bladder and rectal extension. Several authors injection of a short-lived radioactive substance sampling and removal of the cervix, uterus, chemotherapy. The combined modalities of
have demonstrated the accuracy of MRI for and/or a blue dye that is then transported by parametrial and paracervical tissues and upper surgery and radiation lead to an increase in
pre-treatment staging to be greater than the lymphatic channels to the sentinel lymph vagina. Tumour volume may be used as a morbidity that may be unacceptably high. An
90%.5,9–13 The primary use of MRI appears node. This modality has been routinely used in determinant of surgical respectability. The ongoing GOG trial is investigating whether
to be in assisting in the determination of a melanoma, breast cancer, penile cancer and formula for calculation of the volume of a patients with bulky local tumours (stage IB2)
patient’s operability. vulvar cancer. Larger trials need to be cervical tumour is D3xπ/ (5) should be treated up front with radiation
3 .
performed in order to assess the sensitivity, Novel surgical procedures for early stage because of their likelihood of requiring
specificity and safety of sentinel node detection cervical cancer are available and may in the post-operative radiation.19 In addition,
in cervical cancer.16 future change the standard of care. In young patients of any stage whose medical conditions
2
Cervical Cancer
References
preclude surgery should be referred for 1. Cancer Facts and Figures. The American 13.Kerr IG et al.Positron emission tomography
radiation therapy. Cancer Society; 2003. for the evaluation of metastases in patients
2. Cannistra S, Niloff JM. Cancer of the uterine with carcinoma of the cervix: a retrospective
Chemotherapy cervix. N Engl J Med1996; 334:1030–7. review. Gynecol Oncol2000; 81:477–80.
In 1999 two large randomized prospective 3. Smith HO et al. The rising incidence of 14.Grisbey PW, Herzog TJ. Current management
studies concluded that chemotherapy adenocarcinoma relative to squamous cell of patients with invasive cerivical carcinoma.
administered along with radiation significantly carcinoma of the uterine cervix in the United Clin Obstetr Gynecol2001; 44:531–7.
improved survival compared to radiation States – a 24 year population-based study. 15.Herzog TJ. New approaches for the
alone.16,20 As a result the standard of care Gynecol Oncol2000; 78:97–105. management of cervical cancer. Gynecol
has shifted to treatment involving concurrent 4. Creaseman WT. New gynecologic cancer Oncol2003; 90:S22–7.
chemotherapy with radiation therapy.15 staging. Gynecol Oncol1995; 58:157. 16.Disai PJ, Creasman WT. Clinical Gynecologic
Patients with poor performance status, 5. Hoskins W, Perez CA, Young RC. Principles Oncology. 2002.
co-morbid medical conditions or metastatic and Practice of Gynecologic Oncology.2000. 17.Disai P, Kellner JR. Protocol GOG-0201:
disease need to be evaluated on a case-by-case 6. Creasman WT. Stage IA cancer of the cervix: treatment of patients with stage IB2
basis as to the additional benefits of radiation. finally some resolution of definition and carcinoma of the cervix: a randomized
Chemotherapy is indicated in the treatment of treatment. Gynecol Oncol1999; 74:163–4. comparison of radical hysterectomy and
metastatic (stage IVB) and extra-pelvic 7. Lagasse LD et al.Results and complications tailored chemo-radiation. 2003.
recurrences of cervical cancer. Although of operative staging in cervical cancer: 18.Rose PG et al. Concurrent cisplatin-based
multiple chemotherapeutic regimens have experience of the Gynecologic Oncology radiotherapy and chemotherapy for locally
shown activity against cervical cancer with Group. Gynecol Oncol1980; 9:90. advanced cervical cancer. N Engl J Med
initial response rates as high as 80%, the 8. Sonoda Y et al. Prospective evaluation of 1999; 340:1144–53.
response rates are generally in the order of surgical staging of advanced cervical cancer
20% in previously treated patients.5 via a laparoscopic extraperitoneal approach.
Gynecol Oncol2003; 91:326–31.
Follow Up 9. Follen M et al.Imaging in cervical cancer.
Patients are reviewed 3–4 monthly for 2 years Cancer 2003; 98(9 Suppl): 2028–38.
and then 6 monthly for the next 3 years. Most 10.Kim SH et al.Preoperative staging of uterine
practitioners will then undertake annual cervical carcinoma: comparison of CT and
review thereafter. Review should comprise MRI in 99 patients.J Comput Assist Tomogr
examination and vaginal vault cytology. 1993; 17:633–40.
11.Subak LL et al.Cervical carcinoma: computed
tomography and magnetic resonance imaging
for preoperative staging. Obstet Gynecol
1995; 86:43–50.
12.Narayan K et al.A comparison of MRI and
PET scanning in surgically staged loco-
regionally advanced cervical cancer: potential
impact on treatment. Int J Gynecol Cancer
2001; 11:263–71.
3
