Stage IB cervical carcinoma: comparison of clinical, MR, and pathologic staging

In patients with stage IB cervical carcinoma (carcinoma confined to the cervix), accurate staging is essential in order to determine the best treatment strategy--that is, whether to use surgery alone or surgery in combination with pre- or postsurgical radiation therapy. Currently, decisions regarding the management of patients are made on the basis of clinical staging that has an error rate of 34-39% (when surgical staging is used as the standard). To investigate the value of MR in staging patients with IB cervical cancer, we performed prospective MR examinations in 27 patients who had cervical carcinoma. Of these, 10 were clinically staged as having IB cervical carcinoma and underwent radical hysterectomy, providing specimens for pathologic correlation. In six of these 10 patients, the extent of disease had been underestimated during clinical examination under anesthesia. These six patients would have received radiation therapy before surgery had the MR information been used at the treatment-planning stage. MR imaging correlated better with surgical pathology than did clinical examination under anesthesia in determining the location and extent of tumor. MR imaging should be used in conjunction with clinical staging to determine appropriate therapy in patients with stage IB cervical carcinoma.     

Magnetic resonance imaging in the measurement of clinical stage IB cervical carcinoma

MRI can accurately define the extension of cervical carcinoma to the parametria. However, in patients with cervical carcinoma clinical stage IB, the definition of the dimensions of the tumour, prior to surgery, may also modify the treatment procedure. Recently pre-operative neoadjuvant chemotherapy has been proposed for patients with bulky tumours. Multiple factors may influence the prognosis of clinical stage IB and survival varies greatly among these patients. In particular the maximum dimensions of the tumour seem to have a prognostic relevance. The aim of this paper is to evaluate the potential of MRI to measure tumour size, in order to discriminate between patients needing surgery alone or pre-operative therapy followed by surgery. In 20 patients with clinical stage IB cervical carcinoma we performed MRI to measure the radius of the cervix, the radius of the tumour and their ratios. The measurements obtained have been compared with the corresponding data from histopathology of the operative specimens. The close correspondence between these linear measurements allows us to propose MRI as a reliable method to define tumour size in clinical stage IB patients before surgery.     

Stage IB Endometrial Cancer

BACKGROUND: The role of surgical lymph node dissection and adjuvant radiation therapy (RT) in early stage endometrial cancer is no longer clearly defined. The increased appreciation of lymphadenectomy and the absence of survival advantage from adjuvant RT rise controversies how patients should adequately be treated in stage IB endometrial cancer. The aim of this review is to rule out the validity of either treatment option and determine which preference provides the best therapeutic benefit. METHODS: Reports of relevant studies obtained from a search of PubMed and studies referenced in those reports were reviewed. RESULTS: Based on the available data in the literature, for stage IB grade 1 or 2, the risk of pelvic relapse is considered too low to justify pelvic RT. However, intravaginal RT (IVRT) should be recommended for those >or= 60 years old or with lymphovascular invasion (LVI). For patients with stage IB grade 3 (and IC all grades), the treatment recommendation is mainly based on whether surgical lymph node staging was performed. These patients have--without surgical lymph node staging--a high risk of pelvic recurrence and should therefore primarily undergo relaparotomy for lymphadenectomy or pelvic RT as second choice. If these patients had a surgical lymph node staging, then IVRT alone is a reasonable alternative to pelvic RT. CONCLUSION: Overall survival may not be the only ideal endpoint for stage IB endometrial cancer since causes of death are mostly other than endometrial cancer. Conventional pelvic RT may be overtreatment in some patients, in particular in those patients with a large number of negative lymph nodes after lymphadenectomy. However, negative surgical staging should not be understood as adjuvant RT can be omitted in all patients.     

18F-FDG PET in stage IB/IIB cervical adenocarcinoma/adenosquamous carcinoma

Purpose  

The diagnostic and prognostic value of ¹⁸F-FDG PET in cervical adenocarcinoma/adenosquamous carcinoma (AC/ASC) is unclear. The aim of this study was to assess the value of PET in the management of cervical AC/ASC.     

Stage I and II cervical carcinoma. Study with magnetic resonance and transrectal echography

Twenty-five patients with histologically-proven cervical carcinoma (clinical stages I and II according to FIGO classification system) were studied by means of transrectal US (TRUS) and MR imaging (MRI) at 1.5 T, to evaluate the primary tumor and measure its size. Stage Ib cancers were divided into small 4 (less than 4 cm) and large (greater than 4 cm). The patients with large Ib and those with stage II lesions were administered preoperative radiation therapy. All the patients underwent TRUS, MRI, and clinical examination under sedation; they were subsequently operated. Stage Ia and small Ib patients underwent therapeutic surgery, while large Ib and stage II cases had surgical exploration for pathologic staging. The tumor was correctly identified and measured in 22 patients with MRI, and in 20 cases with TRUS. Tumoral involvement of parametria and uterine ligaments was demonstrated in 75% of cases by MRI and in 62.5% of patients by TRUS. Vaginal involvement was demonstrated by MRI in 77.8% of cases and by TRUS in 66.6% of patients. Tumor size could be evaluated more accurately than with clinical examination under sedation, while the results were poorer in the demonstration of tumor spread into uterus and parametria.     

MR imaging of cervical carcinoma: a practical staging approach.

Cervical carcinoma is the third most common gynecologic malignancy and is typically seen in younger women, often with serious consequences. The International Federation of Gynecology and Obstetrics (FIGO) staging system provides worldwide epidemiologic and treatment response statistics. However, there are significant inaccuracies in the FIGO staging system, and magnetic resonance (MR) imaging, although not included in that system, is now widely accepted as optimal for evaluation of important prognostic factors such as lesion volume and metastatic lymph node involvement that will help determine the treatment strategy. MR imaging examination obviates the use of invasive procedures such as cystoscopy and proctoscopy, especially when there is no evidence of local extension. Brachytherapy and external beam therapy are optimized with MR imaging evaluation of the shape and direction of lesion growth. In general, T2-weighted MR imaging more clearly delineates cervical carcinoma and is preferred for evaluation of the lymph nodes. Dynamic gadolinium-enhanced T1-weighted imaging may help identify smaller tumors, detect or confirm invasion of adjacent organs, and identify fistulous tracts. MR imaging staging, when available, is invaluable for identifying important prognostic factors and optimizing treatment strategies.     

Stage IV endometrial carcinoma: a 10 year review of patients.

Stage IV endometrial cancer is uncommon, often occurs in elderly patients and has a poor prognosis, which makes the choice of treatment difficult. 18 patients with stage IV endometrial cancer presenting over a 10 year period, between 1987 and 1997, were reviewed with regard to mode of treatment and response. The mean age was 65 years. Five had disease confined to the pelvis and 13 had extra pelvic disease. 15 of 18 patients had a total abdominal hysterectomy (TAH). One patient received radiotherapy alone and five received post-operative radiotherapy. Overall freedom from pelvic symptoms was achieved in seven of 18 patients. All seven had undergone TAH and two had received post-operative radiotherapy. Progestogens were given to 13 patients. Six received progestogens alone, without radiotherapy or chemotherapy. Of these, two responded, one for 9 months and one with verified lung metastases, who had a complete response, is still alive at 6.5 years. Eight patients received chemotherapy, with single agent cisplatin or carboplatin AUC 6. Three patients responded, one for 4.5 years. The overall median survival was 12 months from diagnosis. Actuarial 5 year survival was 15% (CI 3-36). There was no significant survival difference for, hormone therapy or chemotherapy. Stage IV endometrial cancer has a poor prognosis but durable response can be achieved in some patients.     

Development of a clinical chart audit programme

Radiation oncology charts containing medical information and treatment details are the major methods of communication between the various personnel involved in delivering radiation therapy to the patient. It is paramount to good patient care for this communication to be clear, precise and accurate in detail. A regular chart audit should be a part of the quality assurance programme of every radiation oncology department. The primary aim of this study was to develop and assess an objective and quantitative programme for reviewing radiation oncology charts, thereby improving the quality of communication and hence patient management. A secondary aim was to compare the charts of radically treated patients with those treated palliatively. A pilot study using a new chart review tool, developed at the Perth Radiation Oncology Centre, was carried out over an 8-month period. A sample of charts, representing 25% of our treatment group, were assessed using the tool on a monthly basis. A total of 156 charts were reviewed during this time period. Fifty-six per cent were radical treatments and 44% were palliative. The overall mean chart scores significantly improved over the time of this study (P < 0.001). The individual radiation oncologists' scores were also seen to improve during the study period. The alpha coefficients for intra-rater and inter-rater reliability were 0.99 and 0.88, respectively. The chart review programme was found to be an easy-to-use and a reliable tool by both medical and non-medical reviewers. It appeared to have a positive influence on the standard of radiation oncology charts in our department.     

MR staging of clinical stage I and IIa cervical carcinoma: a reappraisal of efficacy and pitfalls

The purpose of this study was to evaluate the diagnostic efficacy and pitfalls of magnetic resonance (MR) imaging in preoperative staging of cervical cancer. MR imaging was performed to determine the tumor staging for 31 patients with cervical carcinoma emphasizing tumor size, parametrial invasion, vaginal invasion and lymph node metastases. Tumor size was 3.23+/-1.75 cm (mean+/-standard deviation) at MR imaging compared with 2.79+/-1.76 cm at surgical-pathologic evaluation. The discrepancy between the tumor size determined by MR imaging and the measured surgical specimens was consistent in tumors larger than 1 cm. In assessing parametrial invasion, vaginal invasion and lymph node metastases, MR imaging had an accuracy of 96.7 and 87%. In determining stage of disease and differentiating operable (< or =stage IIA) from advanced disease (> or =stage IIB), MR imaging had an accuracy of 83.8 and 96.7%. Pitfalls leading to staging errors included difficulties in differentiating cancer foci from surrounding tissue edema and excluding vaginal invasion in the presence of large cervical cancer. In conclusion, MR imaging is accurate in the evaluation of parametrial invasion and useful in the differentiation of operable from advanced disease. The ability of MR imaging to exclude vaginal invasion in the presence of large cervical cancer and differentiate cancer foci from surrounding tissue edema is not as reliable.     

A 12 month clinical audit of cervical spine imaging in multiply injured and intubated patients

Previous work has questioned how plain films should be used when imaging the cervical spine of trauma patients. The authors wanted to identify whether the National Institute for Clinical Excellence (NICE) guidelines were being followed with respect to the imaging of patients presenting with cervical spine injury over a 1 year period. Data retrieved from the Electronic Digital Information Service (EDIS) computerised database records of all patients presenting with a triage code 1 or 2 between 1 September 2007 and 31 August 2008 were used to conduct a retrospective audit that identified multiply injured and intubated patients who did not undergo CT of the cervical spine and to highlight the use of plain films when the patient was to undergo CT of the head and cervical spine. A clinical record search identified 52 patients with a mean age of 32 years, of whom 73% were males, who had been admitted with multiple traumas and had undergone imaging of the cervical spine. Although no patient was intubated without undergoing CT of the cervical spine or head, seven patients had plain films when it was clear that they were to undergo CT. In conclusion, the audit emphasised the excellent work of emergency department and radiology staff in identifying and imaging multiple trauma patients, as all patients requiring CT of the cervical spine received this investigation. However, careful thought should be given to ordering plain films before CT, as some patients who clearly required CT of the cervical spine underwent unnecessary lateral plain films in the emergency department, delaying their progression to definitive care.Studies suggest that 2–3% of patients who present to the emergency department with blunt trauma undergo some kind of imaging, be it plain radiography or CT. It is worth considering that only 1.5% of patients who present with trauma suffer injury to the cervical spine. Selective use of an appropriate cervical spine imaging modality is vital. If a cervical spine fracture is missed, the long-term neurological outcome is of high consequence, as it is estimated that, historically, up to 29% of patients who have a delayed diagnosis of cervical spine injury suffer full paralysis [1]. One must also consider the institutional cost of missed cervical spine injury as a result of inadequate imaging. A study in the USA found that, although the estimated costs of plain cervical radiography and CT were $120 and $329, respectively, the reduction in litigation costs as a result of missed injury rendered the difference insignificant. It found that the average cost of the investigation, once litigation for paralysis by a missed injury had been taken into account, was $2022 for plain films and $553 for CT — a fourfold decrease [2]. For these and other reasons, the threshold for CT of the cervical spine in blunt trauma remains low. Guidelines aim to reduce unnecessary imaging, in turn reducing costs, waiting times and patient radiation. UK-developed National Institute for Clinical Excellence (NICE) guidelines state that, when a patient presents with a head injury and has any of the following, the cervical spine should be immobilised:

• Glasgow Coma Scale (GCS) score <15 on presentation.
• Neck pain or tenderness.
• Focal neurological deficit.
• Paraesthesia in the extremities.
• Any other clinical indication of cervical spine injury [3].

The patient''s cervical spine should remain immobilised until it can be cleared clinically or by imaging.Currently, plain cervical spine radiography is the investigation of choice for most patients presenting with possible injury of the cervical spine. However, if any of the following occur, then CT of the cervical spine is indicated:

• GCS <13 on initial assessment.
• The patient has been intubated.
• Plain film was inadequate, suspicious or definitely abnormal (C7/T1 junction cannot be demonstrated).
• Continued clinical suspicion of injury despite normal radiograph.
• Patient is being scanned for multiregional trauma [3].

Figure 1 outlines a pathway published on the NHS library that incorporates the Canadian and the National Emergency X-ray Utilization Study cervical spine rules.Open in a separate windowFigure 1Incorporation of Canadian and NEXUS criteria in both stable and unstable patients, enabling decisions about imaging to be clearer. However, for this study, patients were already intubated and a trauma referral (right arm) was already made. NHS Library; Cervical Spine Guidelines; Dr. Song-Seng Liau; May 2005 (http:\\www.library.nhs.uk\SpecialistLibrarySearch\download.aspx?resID = 83269). ED, emergency department; C-spine, cervical spine. GCS, Glasgow Coma Scale; P, pulse; RR, respiratory rate; ATLS, advanced trauma and life support; XR, X-ray.The Canadian rule appears more sensitive and specific than the NEXUS rule; however, the implementation of either rule has been avoided in some centres owing to the morbidity and mortality of a missed injury [4].     

Medical audit of mammography: a simplified alternative.

Assessing radiologists' mammographic interpretation and performing a complete audit of a mammographic practice are notoriously difficult and time consuming. The authors propose a simplified method for accomplishing a satisfactory medical audit. A search of the 1987 pathological reports of St. Michael's Hospital in Toronto yielded 153 patients who underwent excisional biopsy of the breast and for whom preoperatively obtained mammograms were available. The medical records of the patients were reviewed to obtain demographic data, as well as information as to whether the excised lesions had been palpable and the stage of the tumour. The mammograms of the patients were categorized retrospectively by four independent observers. The findings were correlated with the results of the pathological examinations and analysed with receiver-operating characteristic (ROC) curves. Forty-five nonpalpable and 121 palpable lesions were identified, of which 70 were malignant and 96 benign. The positive predictive value of mammography for the nonpalpable lesions was 20%. Three of the 9 nonpalpable cancers and 35 of the 56 palpable ones had metastasized to the axillary lymph nodes. The area under the ROC curves for the four radiologists ranged from 0.84 to 0.89. This audit method in inexpensive and easily applied.     

Difference in prognostic factors between stage IB and II uterine cervical carcinoma patients treated with radical hysterectomy and postoperative radiation therapy

PURPOSE: The purpose of the current study was to evaluate the difference in prognostic factors between stage IB and II uterine cervical carcinoma patients treated with postoperative radiation therapy. PATIENTS AND METHODS: Between May 1988 and May 1998, a total of 94 patients including 47 patients with stage IB and 47 patients with stage II uterine cervical carcinoma were treated with postoperative radiation therapy at Tokyo Metropolitan Komagome Hospital. All patients were treated with 10 MV X-rays using an anterior-posterior parallel opposed field which covered the whole pelvis. Fractionation was 2 Gy per day, five fractions per week, to a total dose of 50 Gy. RESULTS: The 5-year overall survival rates of stage IB and II were 89.4% and 79.3%, respectively. In multivariate analysis for all patients, lymph node status, histology, and surgical margin status were recognized as prognostic factors. Limited to stage IB patients, lymph node status was the only independent prognostic factor. However, for stage II patients, tumor histology was also an independent prognostic factor. CONCLUSIONS: The prognostic factors of stage IB and II were different. Tumor histology was only associated with stage II patients. These findings suggested that tumor histology might have played a different role as tumor stage progressed. However, further studies with large numbers of patients will be required to confirm these results.     

Colorectal carcinoma: a radiologic and clinical review

A profusion of imaging techniques is currently used for evaluating patients with suspected or known colorectal carcinoma. In most institutions, the combination of flexible sigmoidoscopy and a well-performed barium enema study should be retained as a more cost-effective, safe, and complete method of examination than colonoscopy. Endosonography appears to be promising for evaluating preoperatively the local extent of rectal carcinoma. CT is being challenged by MR imaging as the most sensitive modality for detecting liver metastases, but CT currently remains the technique of choice for evaluating recurrent disease and its extent. The diversity of available modalities will ensure that the radiologist remains at the forefront in the clinical investigation of colorectal carcinoma.     

Lung metastases in cervical and endometrial carcinoma.

Carcinoma of the cervix or endometrium was evaluated in 1,021 patients at the Joint Center for Radiation Therapy, Boston, between July 1968 and December 1977. The patients were retrospectively evaluated for the presence of lung metastases, appearing initially or during their disease course. On chest radiography, 42 patients were found to have metastases. Lung metastases were seen in 5.1% of patients with carcinoma of the cervix and in 3.6% of patients with carcinoma of the endometrium. Median time from initial disease staging to detection of lung metastases was 12 months. Once pulmonary spread was discovered, 80% of patients expired within 1 year. Lung nodules varied greatly in size. In 11 patients they were solitary; five patients had pleural effusions; three had mediastinal or hilar adenopathy; and none had excavation.