0:34

All right, so, um, the objectives of today's hour are

0:38

to go over, um, uterine cancer imaging, specifically

0:41

focusing on cervical cancer and endometrial cancer.

0:44

Um, and what I want to do is go over, um, staging

0:47

of those cancers, how imaging plays a role

0:50

in the staging and treatment of those cancers,

0:52

and then, um, small updates about the treatment

0:54

of those cancers.

0:56

So, we're going to start right

0:57

off the bat with a question.

0:59

Um, so if you wouldn't mind pulling up question one.

1:01

Um, so question one, imaging is used for all of

1:04

the following except: is the answer cervical cancer

1:08

staging, cervical cancer treatment decisions, uterine

1:12

cancer staging, or uterine cancer treatment decisions.

1:16

All right.

1:16

So imaging is used for treatment decisions

1:20

for both cervical and uterine cancers,

1:22

um, and is only part of the staging system

1:25

for cervical cancer and only as of 2018.

1:28

So imaging is not technically part

1:30

of the staging system for uterine

1:32

cancers, but it is for cervical cancers.

1:34

And we'll go over all of this in detail, um, in the

1:37

10 cases that we're going to go through together.

1:39

So we'll jump into the first case.

1:41

This patient has neither

1:42

cervical nor endometrial cancer.

1:44

I'm showing you a normal uterus and cervix

1:46

aside from, um, a small, uh, cesarean

1:50

section scar here in the anterior myometrium

1:52

so we can go over the normal anatomy.

1:55

Um, so the normal endometrium is a thin T2 hyper

1:59

intense, um, line in the center of the uterine body.

2:04

Um, this is a postmenopausal patient and

2:05

so she has a very thin endometrial lining.

2:07

In a premenopausal patient, it can be

2:09

a little bit thicker, um, but it should

2:11

be homogeneous and T2 hyperintense.

2:13

Um, the myometrium, um, in a postmenopausal

2:17

patient is going to be more homogeneous.

2:20

In a premenopausal patient, you may see a T2

2:23

hypointense junctional zone and then T2, um,

2:26

intermediate kind of myometrial tissue around that.

2:29

The cervix is down here.

2:32

So the cervix, the endocervical canal will also be

2:34

T2 bright, um, and then on either side of that, we

2:37

have very T2 dark cervical stroma, um, so this is

2:42

what the endometrium and cervix normally look like.

2:46

In the axial view, um, there's one feature that

2:49

I want to point out, and this is a straight axial

2:51

view, this is not an oblique axial view, so it's not

2:53

really the best, um, way to look at the parametrium,

2:58

but we're going to do our best on this case.

3:00

Um, so the parametrium, the, the, parametrium,

3:03

um, is part of the cardinal ligament, which

3:06

is the lower part of the broad ligament.

3:08

And the cardinal ligament holds the vagina

3:10

and the cervix to the pelvic sidewalls.

3:13

There are two parts, um, to that.

3:16

There's the parametrium, which is above the ureters,

3:19

and the paracervix, which is below the ureters.

3:22

So if we look here on this axial and we follow,

3:25

this is the left ureter coming down here to the left

3:28

UVJ and the right ureter here on the other side.

3:32

All of this tissue on either side of the cervix above

3:36

the level of the UVJ, um, is the parametrium, which

3:40

becomes very important in cervical cancer staging.

3:42

Anything below the UVJ is paracervix.

3:49

So now that we've kind of gone over normal anatomy,

3:53

Um, I want to start talking about cervical cancer

3:56

specifically and make a couple of points about

3:58

cervical cancer before jumping into the next case.

4:01

Um, so cervical cancer is a heterogeneous, um, group

4:05

of cancers in that there are squamous subtypes, um,

4:09

adenocarcinoma subtypes, adenosquamous, clear cell, um,

4:13

the histologic, um, um, um, The histologic morphology,

4:17

um, doesn't really affect the grade, um, or the stage.

4:22

Staging is done based only on tumor

4:24

spread, um, not on histopathologic grading.

4:28

Um, but there are multiple types of

4:31

cancers that can arise in the cervix.

4:33

Um, the staging is assigned once all

4:35

of the, uh, clinical, radiologic, and

4:38

pathologic information is available.

4:40

So, um, typically like after surgery, if the

4:43

patient is going to be having surgery, um, and

4:46

then once that stage is assigned, it's fixed.

4:48

So even if the patient undergoes treatment

4:51

afterwards, um, their staging never changes, even

4:54

if they develop more distant disease later on.

4:57

Um, up until 2018, um, the FIGO staging

5:01

system did not incorporate imaging at all.

5:04

The staging was only done based on physical

5:06

examination, which often needed to be performed

5:09

under anesthesia in the operating room,

5:11

included a colposcopy, sometimes a cystoscopy.

5:15

Thankfully though, in the most recent update

5:17

in 2018, they started incorporating imaging

5:20

findings and pathology findings to the staging

5:23

system and started recommending imaging.

5:26

In any patient that has a clinically visible lesion

5:29

because those imaging findings really help to

5:32

make treatment decisions as to whether the patient

5:35

should go straight to surgery or be treated with

5:37

chemoradiation up front and so forth. The reason

5:42

that imaging is really helpful is that cervical

5:44

cancer spreads by direct extension. Um, so directly

5:47

out of the cervix to local regional nodes. And then

5:49

hematogenous metastases are a very late finding.

5:53

And so imaging can play a role, um, because the

5:57

local extent of disease is the first place that

5:59

you're going to see the cervical cancer, um, spread.

6:03

So any patient with a clinically visible

6:05

lesion, um, imaging is indicated.

6:07

Here in the States, that's typically done

6:09

by a pelvic ultrasound and then an MRI.

6:12

Um, you could skip right to the MRI, but

6:14

the MRI is really the gold standard for

6:16

evaluation of the extent of cervical cancer.

6:19

So we're going to jump into the next case here.

6:21

So this is a 76-year-old woman who had a friable

6:24

cervix on her annual physical examination.

6:26

A pap smear was done and was markedly

6:28

abnormal, and then a colposcopy showed

6:30

invasive adenocarcinoma of the cervix.

6:33

So we know that we're finding, we're going

6:34

to be looking for an invasive adenocarcinoma,

6:36

so let's go find it in the images.

6:38

So I always start with the sagittal T2

6:40

in the pelvis, the T2 non-fat-sat images.

6:43

The sagittal is the plane in which the uterus and

6:47

cervix, I think, are best assessed in kind of a 30,

6:50

000-foot overview, because you see them in long axis.

6:54

And with the T2-weighted images that are not

6:56

fat-suppressed, we see the nice T2 hypointense

7:00

muscular tissue of the uterus and cervix

7:02

outlined by the peritoneal fat, which is bright.

7:06

So I always start here.

7:07

I'll then move on to axials and go

7:09

through all the other images in sequence.

7:11

Um, so the abnormalities in the anterior

7:14

cervical wall here, so this very T2 dark

7:17

posterior cervical wall is our normal cervix.

7:20

There are a couple of Nabothian, a couple of Nabothian

7:22

cysts here in the cervix, just simple Nabothian cysts.

7:25

Um, but if we contrast the appearance of the anterior

7:28

cervical wall, there's a T2 hyperintense mass in

7:31

the anterior cervix, and this is our cervical cancer.

7:35

Um, cervical cancers are going to be T2

7:37

bright relative to the normal cervical stroma.

7:42

If we then transition and look on an A1

7:45

axial oblique image.

7:47

So a short-axis axial as opposed to a straight axial.

7:51

These are done, um, after a radiologist has given the

7:55

technologist the long and short axis of the tumor.

7:58

Um, so we're getting a down-the-barrel

7:59

look of the cervix as opposed to just

8:01

a straight axial through the pelvis.

8:03

Um, so again, just in case we missed it on

8:05

the sagittal, the posterior cervical wall

8:08

T2 hypointense normal anterior cervical

8:10

wall has this T2 hyperintense mass in it.

8:12

That's abnormal.

8:13

So if we switch to the axial oblique images, again, we

8:17

see normal T2 hypointense posterior cervical wall, and

8:21

then this T2 hyperintense mass in the anterior cervix.

8:24

Um, when we're evaluating cervical cancers, um, we

8:28

always want to know whether the mass is confined to

8:30

the cervix or not, and that gets to the parametrium.

8:34

So the normal, um, parametrium, the normal border

8:38

of the cervix should be a T2 hypointense

8:41

line such as this, um, that, and then here on

8:45

the other side, um, that, uh, is maintained.

8:49

If you see a tumor, uh, break this T2 hypointense

8:53

border and extend into the parametrial tissues around,

8:56

um, that is what parametrial invasion looks like.

8:59

So in this case, we don't have parametrial invasion.

9:02

This mass is confined to the cervix.

9:04

We'll see an example of parametrial invasion later.

9:07

Um, the next, um, data point to collect when you're

9:11

staging a cervical cancer is the size of the lesion.

9:14

And these are measured, um, in any plane in

9:17

the longest, uh, longest axis that you can measure.

9:20

So this tumor happens to be longest in the coronal

9:23

plane here, and if I measure it, it's up to 3.

9:26

3 centimeters, okay?

9:28

So tumors that are confined to the

9:30

cervix are considered stage one disease,

9:34

um, and then stage one is broken down.

9:37

Based on size.

9:39

Um, there's a two-centimeter cutoff

9:43

and then a four-centimeter cutoff.

9:45

And these two- and four-centimeter

9:46

cutoffs, um, are important for prognostic

9:49

information and also for treatment.

9:51

So, um, if we could go to question two,

9:54

so a tumor like this, that's confined

9:56

to the cervix is going to be treated

9:58

how? With surgery, chemo radiation could be either.

10:01

It depends on patient age or could

10:03

be either, depends on tumor size.

10:06

Okay, great.

10:06

So, um, we have a couple different

10:09

answers, but one of you got it right.

10:10

So, um, it could be either.

10:12

It actually depends on the tumor size.

10:14

So, in the pre-2018 treatment algorithm, um, these

10:18

patients would always be treated with surgery.

10:20

So, um, whoever got it wrong, don't feel bad

10:22

because you wouldn't have been wrong two years ago.

10:25

Um, after 2018, they updated the treatment

10:29

algorithm such that a 4-centimeter mass is the

10:32

new cutoff that they, that gynecologists use

10:36

to differentiate whether a patient should be

10:38

treated with surgery or with chemo radiation.

10:41

And the reason that they changed that rule is

10:43

because they were finding that so many patients with

10:45

tumors greater than 4 centimeters were requiring

10:48

adjuvant radiation after surgery, and the morbidity

10:51

of that adjuvant radiation was so high that it

10:53

made surgery up front really not the way to go.

10:56

Um, and so now, even stage 1 tumors that are

10:59

confined to the cervix, um, or stage 2, um, tumors,

11:03

um, they, if they're greater than 4 centimeters,

11:08

um, they will treat those patients with chemo

11:09

radiation rather than with surgery, um, because

11:12

of the morbidity of the adjuvant treatment.

11:14

Okay, so going back to this lesion, um, this

11:19

lesion is less than 4 centimeters, um, so this patient

11:22

is going to be treated with, um, surgery, um, 2

11:26

centimeters as a cutoff is the differentiation between

11:31

whether trachelectomy can be offered to the patient.

11:35

So a trachelectomy is basically like a partial

11:37

cervical resection, um, which they can do if the

11:40

cervical cancer is in the lower portion of the cervix.

11:42

They basically resect the lower portion of the

11:44

cervix, leave the upper portion of the cervix.

11:47

That allows those patients to still have

11:48

childbearing potential after their cervical

11:51

cancer treatment, should they want that.

11:53

Um, and then, although, again, the

11:55

tumor has to be in the lower part of

11:56

the cervix, less than two centimeters.

11:58

It's a very specific, um, patient population

12:00

that they're able to offer that in.

12:02

They've also found that patients, um, that

12:05

patients with tumors greater than two centimeters,

12:08

but less than four, um, have higher rates of,

12:12

um, cancer-related death, um, and are more

12:17

likely higher grade squamous cell carcinomas

12:19

as opposed to lower grade adenocarcinomas.

12:21

So the prognosis of having a tumor greater

12:24

than two centimeters versus less than two

12:25

centimeters is worse, um, because it's associated

12:29

with factors beyond just the tumor size.

12:32

If we look at other imaging features of this

12:35

tumor, so here we're going to be looking at

12:37

the DWI, um, so we can see the tumor itself

12:40

is very bright on DWI and very dark on ADC.

12:45

So it restricts diffusion, is

12:47

expected, it's a malignancy.

12:49

Um, and then if we look at the enhancement

12:53

pattern of the tumor, so the tumor, which is here,

12:56

has this kind of peripheral hyperenhancement,

12:59

but itself is predominantly hypoenhancing

13:02

relative to the myometrium in the venous phase.

13:05

This coronal was the most delayed phase.

13:07

The dynamics were done in the axial phase.

13:09

And this is pretty typical for a cervical

13:11

cancer that they're going to be hypoenhancing

13:12

to the myometrium on the delayed phase.

13:15

All right.

13:16

So this next case is a 60-year-old woman

13:18

who presented with five months of vaginal

13:20

bleeding and progressive pelvic pain.

13:22

Um, a speculum examination could not be performed

13:24

because she had a mass in the superior vagina.

13:27

Um, and when a biopsy of that mass was

13:29

performed, she was found to have moderately

13:31

differentiated squamous cell carcinoma.

13:34

Um, so let's look at her imaging.

13:36

So this was done at an outside institution.

13:38

Their protocol is a little bit different from ours.

13:40

I know that it's different right away because

13:42

she has vaginal gel in place and we happen to not

13:44

use vaginal gel here, um, although I wish we did.

13:48

Um, so the abnormality is here.

13:51

Um, if we think about our normal

13:55

anatomy, this is our myometrium.

13:58

It's very expanded.

13:59

There's a lot of T2 hyperintense fluid here.

14:02

Um, we see a T2 hypointense junctional zone

14:05

immediately around this expanded endometrial cavity.

14:08

And then we really don't.

14:09

see a normal cervix hardly at all here.

14:12

Um, there's just this T2 hyperintense kind of evil

14:15

gray tissue, um, that has near replaced the cervix.

14:18

And also for those of you who are

14:20

looking carefully, extends along the

14:22

posterior wall of the vagina back here.

14:25

So now that we're done with the sagittals,

14:27

let's look and see what this is on the axials.

14:30

So again, a very expanded endometrial

14:32

cavity, kind of heterogeneous.

14:36

We have a mass.

14:38

that is kind of near replacing the cervix.

14:40

The T2 character here is a

14:42

little bit brighter than usual.

14:44

And if we go down to the level of the vagina, um,

14:46

we can nicely see how that tumor extends along

14:49

the vagina from the five o'clock to say the ten

14:53

o'clock, um, station around the vagina here.

14:56

If we look, so this is one, if we

14:59

look at, um, her parametrium though,

15:01

up higher, her parametria are intact.

15:05

This tumor is growing out of the cervix

15:07

and down into the vagina, into the vaginal

15:10

wall, but not outside of the cervix.

15:13

Because this is a straight axial, not an

15:15

axial oblique, it's really not the most ideal

15:18

plane for evaluation of the parametrium.

15:20

But if you humor me and trust me, this

15:24

mass invades the vagina and not the parametrium.

15:28

So, stage two disease is

15:31

when we have invasive cancer.

15:33

And so, because it's not confined to the

15:35

cervix anymore, it is considered invasive disease.

15:38

Stage 2A disease is disease that invades

15:42

the upper portion of the

15:43

vagina, but not the parametrium.

15:45

So, this is another instance where

15:47

if the tumor is less than four centimeters,

15:50

the patient will be treated surgically.

15:51

If the tumor is greater than four centimeters, the

15:54

patient will be treated with chemoradiation therapy.

15:58

If we look at the post-contrast appearance of

16:01

this again, we're seeing a hypo-enhancing tumor

16:05

here in the cervix and in the posterior vaginal

16:07

wall relative to the myometrium and then all of

16:10

this fluid that is stuck in the endometrial cavity

16:14

because of this obstructing cervical mass is non-

16:17

enhancing, and so that helps us to center the tumor

16:21

in the cervix as opposed to in the endometrium.

16:25

So, case four, I'm trying to move quickly, is a 58-year-

16:30

old woman, who presented with yellowish discharge

16:34

and bleeding for several months before she came to see me.

16:37

She saw a doctor.

16:38

A Pap smear showed atypical squamous cells

16:42

of uncertain significance and was HPV positive.

16:45

Then, a colposcopy showed a two-

16:47

centimeter cauliflower-like lesion at the

16:49

cervical os, and biopsies of that showed

16:53

poorly differentiated squamous cell carcinoma

16:55

involving the full thickness of the biopsy.

16:57

And so, because she had a clinically

16:59

visible lesion, she went on to MRI for staging.

17:02

So, this is her sagittal T2 non-FATSAT first.

17:06

She has a couple of uterine fibroids

17:07

that are really T2 dark here.

17:09

This little bright stripe here

17:10

is her endometrial cavity.

17:12

We see kind of normal heterogeneous myometrium.

17:15

And then really no cervix anymore.

17:18

There's a little bit of posterior

17:19

cervical wall that kind of ekes by here.

17:21

But there's this massive, T2 heterogeneous, kind of iso-intense, but more of a different sort

17:26

of character, more homogeneous in places than the

17:29

heterogeneous myometrium, mass in the cervix.

17:35

In this protocol, we do have axial

17:39

obliques, through the short axis

17:41

of the cervix, which is very helpful.

17:43

Because in this case, we have an

17:45

example of a parametrium that is not intact.

17:48

So, if we look here, this is

17:54

kind of a representative image showing a level

17:56

where the parametrial invasion can be seen.

17:58

And so, I'm going to ask question three here.

18:01

So, where in this case do we

18:02

see the parametrial invasion?

18:04

Is it invading anteriorly, along the right

18:07

wall, posteriorly, or along the left wall?

18:10

Okay, so the parametrial invasion can be seen

18:13

here along the right aspect of the cervix.

18:15

So, there is no parametrium

18:17

anteriorly and posteriorly.

18:18

Those were kind of bogus answers.

18:20

You will only see parametrial invasion

18:21

either on the right or on the left.

18:23

And in this case, we see the kind of normal

18:26

parametrial vessels and fat on the left side.

18:30

But here on the right side, you can

18:31

see there's this lip of tumor that extends

18:33

out of the right parametrium here, out

18:36

of the right cervix into the parametrium.

18:38

If we look at the coronal obliques for the

18:42

same finding, we can again see that parametrial

18:45

invasion here on the right side, and see

18:48

how the tumor is insinuating amongst the

18:51

normal vasculature of the parametrium.

18:55

If we see how this tumor is enhancing,

18:57

we see that it's a hypo-enhancing

18:59

mass relative to the myometrium.

19:02

Um, the parametrial component is kind of nodular,

19:06

hypo-enhancing with some surrounding, um, enhancement.

19:09

And as in the other cases, if I don't blind you,

19:14

you can see that the mass is very, very restricting.

19:17

Um, so this is a stage 2b tumor.

19:20

Um, when we saw the earlier one that invaded

19:22

the vagina, but not the parametrium, that's 2a.

19:25

This is 2b.

19:26

Where we have parametrial invasion, um,

19:28

that remains in the center portion of the

19:29

pelvis, not up to the pelvic side wall.

19:32

Alright, so moving on to the next case,

19:33

and upwards in our staging system.

19:36

Uh, this is a 67-year-old woman who had a

19:38

history of carcinoma in situ on a pap smear

19:40

16 years prior, had multiple repeat pap smears

19:43

after that, which showed no concerning findings.

19:45

And so went for the last five years without having

19:48

any pap smear at all because she got reassured.

19:51

Um, she has had six months of intermittent

19:54

post-menopausal bleeding with Valsalva,

19:56

um, which has recently gotten worse.

19:58

Um, and so she presented to her doctor,

20:01

um, for evaluation of that finding.

20:04

Um, she had a pelvic ultrasound, which showed

20:06

hematocolpos, meaning blood in the endometrial cavity.

20:10

Um, and friable cervix with an irregular

20:14

growth of tissue encompassing the cervix.

20:16

Um, a biopsy showed moderately differentiated

20:19

squamous cell carcinoma, and so imaging

20:21

was performed to stage her disease.

20:23

So if we start with our T2,

20:26

um, our T2 nonfat-saturated

20:29

sagittal images.

20:31

Um, we can see the endometrial cavity, which

20:33

is, um, expanded here, um, in keeping with

20:36

the, uh, blood products that they saw in

20:38

the endometrial cavity on her ultrasound.

20:41

And then her cervix is, uh, replaced with this T2 hypo-

20:45

intense, um, irregular mass here invading the cervix.

20:50

Um, if we look at the axial obliques,

20:54

uh, we see that tumor again, um, We don't

20:58

see a really nice T2 hypo-intense line.

21:02

Um, so there is parametrial invasion here on the left.

21:05

Um, and most importantly, uh, here at the level of

21:08

this parametrial invasion, we see this structure.

21:11

So this is actually her left ureter, um, which

21:14

when you come down is obstructed by the parametrial

21:18

extension of tumor on the left side here.

21:22

Um, so, this is right at the border of

21:25

the parametrium versus the paracervix,

21:27

which is below the level of the ureter.

21:29

Um, so this is parametrial invasion on the left.

21:31

So when we see pelvic sidewall involvement

21:34

and/or hydronephrosis as a result of the

21:37

parametrial invasion, this increases the stage

21:40

of the tumor from a stage two to a stage three.

21:44

Um, so, this is an example of stage 3B disease, um,

21:50

where the ureter is obstructed by the mass.

21:55

If we look to see, um, the other imaging features

21:58

of this tumor, um, it restricts diffusion here

22:02

on the, uh, ADCs, and like the others, um,

22:10

is going to be kind of centrally hypo-enhancing here.

22:13

Okay.

22:13

With peripheral hyper-enhancement, um,

22:16

relative to the myometrium, which is a

22:17

little bit harder to see here on this case.

22:20

And then on the pre, you can see that the stuff in

22:23

the endometrial cavity is intrinsically T1 bright.

22:26

Um, that's in keeping with

22:27

the hematocolpos blood products.

22:29

From the cervical obstruction by the mass.

22:33

As we continue to move upwards in our staging

22:35

algorithm, we're now going to meet a 36-year-old woman

22:38

who had a few months of heavy menstrual bleeding.

22:41

Um, she was found to have a four-centimeter

22:43

tumor, um, occupying the posterior portion

22:46

of her cervix on physical examination.

22:48

Um, and a biopsy showed moderately

22:50

differentiated squamous cell carcinoma.

22:52

So since she had a clinically visible

22:54

lesion, an MRI was ordered for staging.

22:56

Um, this is not the, some of these images

22:58

are not the most awesome quality, but

23:00

I think we can see what we need to see.

23:02

So, um, we see a normal anterior cervical wall

23:06

here with a T2 hypointense cervical stroma.

23:08

And then in the posterior cervix,

23:10

we see this T2 hyperintense mass.

23:12

We see a little bit of T2 dark stroma

23:14

there, and then the lower portion of it.

23:16

And then the posterior portion of the

23:17

cervix is kind of by this large lesion.

23:20

Um, if we look at the axials, um, we

23:26

again can see normal anterior wall and

23:29

then obliteration of the posterior wall

23:31

of this cervix by this T2 hypointense mass.

23:34

And on the T2 images, it's actually a little,

23:37

um, misleading how much tumor she has.

23:40

Um, if we look at the, um, diffusion-weighted

23:44

images, um, and we jump to our highest B value,

23:50

we can see that there's

23:50

actually a lot of tissue around.

23:52

So this is our cervix.

23:54

This is our cervical lumen right here.

23:56

This was the mass in the posterior cervix.

23:58

And then if you look at all of the tissue around the

24:00

cervix, um, all of that is restricting diffusion.

24:04

Um, and if we look at the post-contrast images,

24:08

um, maybe we'll, these are subtractions.

24:13

If we look at the post-contrast images, we can

24:14

see that all of that tissue is also enhancing.

24:17

And so all of that is actually disease.

24:19

Um, the T2, uh, images were falsely reassuring.

24:24

What is going to upstage her though, is, on her

24:29

DWI, if we look at her lymph nodes, she has a very

24:33

large pelvic sidewall lymph node on the right here.

24:37

So when patients have cervical cancer and positive

24:40

nodal disease, um, this upgrades them to stage 3C.

24:44

So stage 3C indicates nodal disease.

24:48

Um, this is a new, completely new, um, staging.

24:53

Um, this is a completely new stage as of the

24:55

2018 criteria, um, because this is made based on

24:59

radiologic findings, um, in the preoperative setting.

25:03

Um, so stage 3C.

25:07

So all of the following, uh, can we get to question 4?

25:12

When we're thinking about nodal drainage of

25:14

these cervical cancers, um, all of the following

25:17

are considered part of the direct drainage

25:19

pathway of the cervix, except for which?

25:21

External iliac lymph nodes, obturator nodes,

25:24

internal iliac nodes, or para-aortic nodes.

25:27

Okay, so, the cervix will drain to external iliac

25:31

nodes, obturator nodes, and internal iliac nodes.

25:34

And so this external iliac node is considered,

25:36

um, part of the primary, um, or first

25:39

stage nodal drainage pathway of the cervix.

25:41

Para-aortic nodes are not part of the cervical cancer

25:45

drainage pathway, but can be a part of a uterine

25:48

endometrial cancer drainage pathway, particularly

25:51

if the tumor arises from the uterine fundus.

25:53

So the fundus of the uterus will drain upwards to

25:56

those para-aortic nodes, um, the lower part of the

25:59

uterus and the cervix drain to the pelvic sidewalls.

26:02

Uh, before we go to the next

26:03

case, let's go to question five.

26:05

So which imaging modality is most accurate

26:07

for the detection of lymph node and distant

26:09

metastases in patients with cervical cancers?

26:12

Is it CT, chest, abdomen, pelvis, a PET, CT, or MRI?

26:17

Great.

26:17

So you guys are absolutely correct.

26:19

PET, CT is the way to go.

26:20

It has 75 percent sensitivity and 98 percent

26:24

specificity, um, as opposed to CT and MRI, which

26:28

both clock in at about 58 percent sensitivity

26:31

and specificities in the lower 90 percent range.

26:34

CT is great for normal.

26:36

That's greater than a centimeter.

26:37

Um, they have a four to 15 percent false negative rate.

26:41

Um, so we can say, um, based on MRI, that a node

26:47

is likely involved, um, with disease, um, if it's

26:51

greater than one centimeter in short axis, is

26:54

almost certainly involved if it's greater than 1.5

26:56

centimeters in short axis.

26:58

Um, we expand, when we're thinking about

27:01

rectal cancers, the criteria of abnormal nodes

27:04

to include, um, um, abnormal morphology, um,

27:08

heterogeneous density, um, we'll sometimes

27:11

talk about a rounded shape of the lymph node.

27:13

Um, those things we don't really know how, um,

27:17

there aren't specific guidelines as to how those

27:19

specific criteria, um, play into the likelihood

27:22

of malignancy in cervical cancer specifically.

27:25

Um, but based on MRI, if we know that the node is

27:28

greater than a centimeter, it's probably metastatic.

27:31

Okay.

27:33

Alright, so moving on to the next case here, um,

27:37

this is a 54-year-old woman who had a few months of

27:40

vaginal bleeding, lower abdominal pain, and cramping.

27:44

Um, on physical exam, she had a mass involving

27:47

her entire vagina, originating near the cervix and

27:50

extending all the way down to near her urethra.

27:53

So she had an MRI, um, to, to, uh,

27:58

evaluate the extent of her disease.

28:00

And this is her cervix here.

28:02

Um, for the most part intact, the, uh, T2 hypo

28:06

intense cervical stroma for the most part looks okay.

28:09

There are a couple of T2 hyperintense Nabothian cysts

28:11

here in the cervix, um, but if we look at the anterior

28:15

portion of the cervix and, um, the anterior kind of

28:18

fornix of the vagina, um, there's abnormal T2 hypo

28:21

intense tissue that is involving the anterior portion

28:24

of the cervix and the very cervical os down here and

28:27

then extending down the anterior wall of the vagina.

28:30

And also the sidewall of the vagina over here.

28:33

So if we look at this on the axial T2s, um, again, we

28:39

see this very, very large T2 hyperintense or evil gray

28:43

mass, um, mostly involving the vagina all the way down.

28:46

This is her urethra anteriorly down here.

28:49

So it goes almost all the way to the vaginal introitus,

28:52

um, but involving circumferentially, but predominantly

28:55

the left wall of the vagina and a little bit of

28:57

the cervix, the very distal portion of the cervix.

29:00

Um, so on pathology, this was found to be a

29:04

moderately differentiated, um, papillary squamous

29:07

cell carcinoma, um, that originated in the cervix.

29:09

There was some debate, um, before the biopsy

29:12

came back about whether this was going to be

29:13

a vaginal primary or a cervical primary, um,

29:16

and it ended up being a cervical primary.

29:18

And it helps to make the point that cervical

29:19

cancers, um, tend to, the majority of cervical

29:24

cancers arise, um, at the Squamous-columnar junction.

29:28

So the outer portion of the cervix is going to have

29:31

a squamous epithelium, and the inner portion of

29:35

the cervix is going to have a columnar epithelium.

29:37

And the junctional zone where the two meet,

29:40

between the squamous cell ectocervix and

29:43

the columnar cell endocervix, is where

29:45

cervical cancers usually arise from.

29:48

So this one kind of took a turn and went

29:50

outside instead of inside, um, which is a little

29:52

strange, but we do see involvement of the very

29:55

outer portion of the cervical os here, which

29:57

is where this tumor happened to originate.

30:01

Like the others, if we look, um, at our ADC,

30:05

uh, the tumor is restricting diffusion here.

30:08

It's very T2 dark, um, the mass is hypo-enhancing

30:17

centrally and kind of hyper-enhancing peripherally.

30:21

The feature of her disease that is going to

30:23

determine her staging, um, is this right here.

30:26

So this mass is invading the

30:28

lower portion of the vagina.

30:30

But also invading the bladder.

30:32

So when we see cervical cancers that are

30:34

directly invading the bladder or directly

30:37

invading the rectum, um, this, um, this

30:41

upgrades it to stage IV-A disease.

30:44

If there's disease outside of the pelvis

30:46

altogether, so distant hematogenous spread

30:48

metastatic disease, that's stage IV-B.

30:51

Um, but this also is stage IV because of the

30:53

direct, uh, invasion of the adjacent organ.

31:01

Okay.

31:01

So that was all I wanted to say about

31:04

cervical cancers.

31:06

So now we're going to transition

31:07

to talk about endometrial cancers.

31:10

Um, and I'm going to go back to our normal

31:12

anatomy case just to again remind ourselves of

31:15

what the normal endometrial cavity looks like.

31:18

So, the normal endometrial cavity is a very thin T2 hyper

31:21

intense, um, line, um, that should be homogeneous.

31:27

Endometrial cancers are the most common

31:30

gynecologic cancer in women, um, the fourth

31:32

most common cancer overall in women in North

31:35

America, um, and there are a couple of different

31:38

subtypes of endometrial cancers, as there are a

31:40

couple of different subtypes of cervical cancers.

31:43

So if we could get question six now, please.

31:46

So, which histologic subtype of endometrial

31:49

cancer is typically associated with

31:50

the least aggressive form of disease?

31:52

Is it endometrioid adenocarcinoma, serous

31:56

adenocarcinoma, mucinous adenocarcinoma,

31:58

or clear cell adenocarcinoma?

32:00

And I didn't even include the other two

32:02

subtypes of which there are many.

32:04

So, endometrioid adenocarcinoma is correct.

32:06

So, um, there are two broad

32:09

types of endometrial cancer.

32:11

There is type 1, which is grade 1, histologic grade

32:14

1, or histologic grade 2 endometrioid adenocarcinoma.

32:18

So, these are the cancers that are seen in

32:20

women with, um, a lot of estrogen production.

32:23

So, women, um, with, uh, overweight women with a

32:28

high BMI, um, women greater than 40, um, these are

32:32

the cancers that arise in a background of atypical

32:36

hyperplasia and are very estrogen sensitive.

32:39

Um, these cancers are associated with a better

32:41

prognosis and slower rate of growth and invasion.

32:45

Type 2 endometrial cancers include

32:48

grade 3 endometrioid adenocarcinoma.

32:51

So, endometrioid, but with a little bit more

32:53

histologic atypia, um, or other histologies,

32:57

including serous adenocarcinoma, clear cells,

32:59

mucinous, and all the other cell types.

33:02

Um, those types of endometrial cancers are typically

33:04

seen in older women in their sixties to seventies.

33:07

Um, they arise in the setting of an atrophic

33:10

endometrium, as opposed to a hyperplastic endometrium.

33:13

Um, they're not as hormone sensitive and they're

33:16

usually diagnosed late, um, and are more aggressive.

33:20

And so those patients do, uh,

33:22

worse, um, in the long run.

33:25

So as we mentioned at the beginning of the lecture,

33:28

endometrial cancers are staged surgically, technically,

33:32

um, based on the surgical, um, the surgical specimen.

33:37

Um, imaging will play a role in how the

33:41

gynecologic oncologist thinks about treating

33:43

the patient, um, but isn't technically part

33:45

of the staging algorithm according to FIGO.

33:49

Um, like cervical cancer, endometrial cancer spreads

33:53

through local regional nodes with direct drainage.

33:56

And as we had mentioned before, the

33:57

direct drainage pathway of the endometrium

34:00

includes para-aortic lymph nodes as well.

34:02

Um, and so if it's an endometrial primary, um, think

34:06

about those lower para-aortic nodes as being direct

34:09

drainage, um, and can spread, um, into the peritoneal

34:13

cavity, particularly if it's a type 2 endometrial

34:15

cancer, um, or hematogenously, um, although those are,

34:19

uh, not seen until, uh, later stages of the disease.

34:23

Okay, so jumping into cases, um, this is a 28

34:26

year-old female, actually, very sad story, um,

34:29

had a long history of menstrual irregularities.

34:33

Eventually, because of her menstrual

34:34

irregularities, had a D&C, which showed grade

34:38

1 endometrioid adenocarcinoma in a background

34:41

of extensive atypical endometrial hyperplasia.

34:44

So, this is our classic type 1 endometrial cancer,

34:47

except that it's in a relatively skinny younger woman.

34:49

Um, so this is her sagittal image here.

34:58

I'll show you her axial here,

35:04

and just to convince you that

35:05

there really is something there.

35:07

I'll show you her.

35:11

And we can see how dark that tissue is on the ADC.

35:17

So can we get question seven, please?

35:21

The depth of myometrial invasion, which

35:23

distinguishes stage 1A from stage 1B disease is what?

35:27

Any amount of invasion, 25 percent invasion, 50 percent

35:32

myometrial invasion, or 75 percent myometrial invasion?

35:36

Um, so the answer is 50 percent invasion,

35:39

um, so 50 percent myometrial invasion as

35:42

measured from the uterine serosa is what

35:45

distinguishes stage 1A from stage 1B disease.

35:48

Um, so the question when we got this MRI was

35:52

whether this tumor invades the myometrium

35:54

greater than 50 percent or doesn't.

35:57

If it invades the myometrium a little bit,

35:58

but not quite 50%, that's the same as if

36:00

it doesn't invade the myometrium at all.

36:02

Um, so this is a stage 1 cancer.

36:05

There was a question of whether there

36:06

was focal myometrial invasion here.

36:09

Um, but again, it was definitely not greater

36:11

than 50%, and so it's kind of a moot point.

36:14

Um, she staged the same way and treated the same way.

36:17

Um, so this is an example of

36:19

stage 1A endometrial cancer.

36:21

Um, thank goodness we had the, um, D&C

36:26

results because otherwise it would be

36:27

a little bit difficult to interpret.

36:29

Um, you know, is this an endometrial cancer or

36:31

is this, um, hyperplastic tissue that's

36:34

restricting, um, or a blood clot that's restricting?

36:38

Um, but in this case, it's not.

36:39

Uh, we know that it's, uh, Type 1 low

36:42

grade endometrioid adenocarcinoma.

36:46

This is the lowest grade type of endometrial

36:47

cancer that we'll see on imaging.

36:50

Um, this is a 60-year-old woman who had

36:53

several episodes of postmenopausal bleeding.

36:55

Um, because of her postmenopausal bleeding,

36:58

she had an endometrial biopsy, which

37:00

showed Grade 1 endometrioid adenocarcinoma.

37:03

So another example of Type 1 cancer.

37:07

Um, so she has a big uterine fibroid here

37:14

on her sagittal, um, which makes it a

37:16

little bit difficult to see her endometrium.

37:19

But if we follow the endocervical canal up, we can see

37:23

this is her endometrial cavity kind of off to the side.

37:26

And if we look at this image right here, there's

37:29

a little nodule that is surrounded by T2 hyper

37:33

intense endometrial cavity on either side.

37:38

which is suspicious for an endometrial polyp.

37:40

Kind of hard to see.

37:42

If we look at our coronal oblique images here,

37:47

we can see this endometrial cavity pushed off

37:49

to the left by this large uterine fibroid,

37:53

and then this T2 hypo intense structure.

37:56

That's filling the lower, uh, the

37:58

lower uterine segment, the endometrial

37:59

cavity of the lower uterine segment.

38:01

Um, so this polyploid sort of looking lesion is what

38:05

corresponded to her endometrioid adenocarcinoma.

38:08

So this is her cancer here.

38:11

Um, on surgical pathology, um, this tumor was

38:16

invasive of the myometrium greater than 50%.

38:19

I think it's a little bit hard to see

38:21

on the MRI, um, because of her, uh,

38:25

fibroids that are getting in the way.

38:27

Um, but here you can see the hypo

38:29

enhancing, uh, hypo enhancing mass, um,

38:34

that is her endometrial cancer here.

38:36

Um, in the next case, we'll look at a really beautiful

38:39

example of very obvious, um, myometrial invasion

38:44

that'll hopefully make it a little bit easier to see.

38:47

Um, but I wanted to show you guys

38:48

another example of stage 1 disease.

38:50

Um, so can we go to question eight?

38:54

All patients with stage one disease

38:55

are treated with surgery alone.

38:57

Is this true or false?

39:00

So absolutely.

39:01

So this is false.

39:02

Um, so if a patient has stage 1B disease or higher,

39:07

um, they will get a hysterectomy and a lymphadenectomy,

39:11

um, but if a patient has stage 1B disease or if a

39:17

patient has, um, even a stage 1A tumor but their

39:22

lymph nodes were not evaluated, so for example

39:24

they had a simple hysterectomy performed for other

39:27

reasons and they happened to find, um, they happened

39:30

to find type 2 endometrial cancer, um, if those

39:33

patients didn't have their lymph nodes assessed.

39:36

They will go on to adjuvant radiation.

39:38

So there are select indications in which

39:40

patients will require adjuvant therapy after

39:44

um, definitive, after surgery, even though

39:47

the disease was confined to the uterus.

39:51

All right.

39:51

So let's move on.

39:52

So this will be our last case, case 10.

39:57

Um, so this is a 65-year-old woman who had intermittent

40:00

heavy vaginal bleeding of two years' duration.

40:03

Um, she had a cervical mass that

40:04

was seen on physical examination.

40:07

Um, and a biopsy showed grade

40:09

2 endometrioid adenocarcinoma.

40:12

Um, which histology, uh, showed to have

40:15

originated in the endometrium, not in the cervix.

40:19

Um, so I will say that when masses span both

40:23

the endometrial cavity and the cervix, um, it's

40:26

very difficult for us as radiologists to tell

40:29

whether it was of endometrial or cervical primary.

40:34

Um, where the bulk of the tumor resides, um, in studies

40:39

has shown to be the greatest, um, the single factor

40:43

with the greatest predictive value of whether it's

40:47

tend to be uterine or cervical, um, which intuitively

40:50

makes sense, um, and other things that people have

40:53

looked at, like the degree of restricted diffusion,

40:55

the enhancement pattern, um, kind of second-order

40:59

diffusion characteristics, those things have, in kind

41:02

of multivariate analyses, turned into, uh, complex,

41:08

uh, complex algorithms that do an okay job of predicting,

41:13

but there's no clean and easy way other than

41:16

where's the bulk of the tumor, um, to differentiate

41:19

a lower endometrial segment from the cervical mass.

41:22

Um, so we really are reliant on our pathology

41:24

colleagues, um, and their histologic stainings,

41:27

um, to tell us, uh, where the mass is coming from.

41:31

So in this case,

41:33

we have a mass that is involving the lower

41:35

uterine segment and the cervix, which is why I

41:37

went on this long explanation about how it can be

41:39

difficult to tell the difference between the two.

41:41

If we look up here at the uterine fundus, we

41:43

see a little bit of normal uterus, so T2 hyper

41:46

intense endometrial cavity, T2 hypo intense

41:49

junctional zone, um, and subendometrial tissue.

41:53

And then in the lower uterine segment, we

41:54

start getting into this kind of T2 hyper

41:57

intense equal gray tissue that extends.

42:00

And really obliterates the whole cervix

42:01

and even extends into the vagina.

42:04

So a pretty extensive tumor in this patient.

42:06

If we look on the axial T1s, it's all

42:10

kind of isointense to the myometrium.

42:14

If we look at the axial T2s, um, we can see

42:19

our distended endometrial cavity, um, with

42:22

some, uh, material in it because it's blocked.

42:25

And then we get into our tumor, which we can see

42:29

here kind of circumferentially involves the vagina.

42:33

And this is our cervix here, which the normal anatomy

42:37

of the cervix is really pretty obliterated by the mass.

42:40

If we look at the post-contrast images on the

42:43

sagittal, we can see that this tumor is hypo-enhancing.

42:47

So just like the cervical tumors, our endometrial

42:49

cancers are going to be relatively hypo

42:51

enhancing to the myometrium in the venous phase.

42:54

Um, we can see the endometrial cavity is non-enhancing.

42:58

Um, and, uh, when we're looking into myometrial

43:02

invasion, things that we're looking for.

43:04

Are, um, this subendometrial stripe of enhancement

43:09

here, um, that as you can see in this picture,

43:12

we can follow that subendometrial stripe

43:14

of enhancement in the normal portions of the

43:16

uterus, and then where the tumor invades the

43:18

myometrium, we lose that subendometrial stripe.

43:22

Okay, so loss of the subendometrial stripe

43:24

is going to be one thing that you look for.

43:26

When you're trying to evaluate for myometrial

43:28

invasion, um, the other thing that you're going

43:30

to look for is disruption of the junctional zone.

43:33

Um, so we see the T2 hypointense junctional

43:36

zone, and then we lose the junctional

43:39

zone where the tumor starts invading.

43:41

So junctional zone, junctional

43:42

zone, junctional zone, tumor.

43:45

So that's how you can assess for myometrial invasion.

43:52

So this is an example of stage three endometrial

43:56

cancer, which is more invasive than stage two.

44:00

So stage three A disease is going to

44:03

involve the serosa of the uterus.

44:05

Stage three B is going to involve

44:07

the vagina or parametrium.

44:09

Stage three C disease is when we start

44:12

seeing, um, nodal drainage, um, as

44:17

with, uh, cervical cancers, PET/CT

44:20

is much more sensitive and specific.

44:23

Um, MRI does an okay job, um, but is less sensitive.

44:28

Um, and then similar to cervical cancer is we get

44:31

into stage four when there's bladder or bowel invasion

44:34

or when it's outside of the pelvis altogether.

44:37

Um, so if we can go to question nine.

44:41

So patients with distant

44:43

metastatic disease are treated how?

44:45

Surgery alone, chemoradiation alone,

44:49

or chemoradiation and surgery?

44:52

Great, so you guys actually got the answer correct.

44:54

So it's chemoradiation and

44:55

surgery, if they need the surgery.

44:57

So the chemoradiation is the

44:59

treatment for their cancer.

45:01

The surgery that they will sometimes do is a

45:05

palliative hysterectomy, um, and that's because

45:08

these endometrial cancers often bleed, um, and

45:12

so they will do palliative hysterectomies, um, to

45:16

basically debulk the worst of the tumor, um, and to

45:19

prevent these, to stop these patients from bleeding.

45:22

Um, because they can bleed, um, quite

45:24

extensively and require transfusion if you

45:26

don't, uh, remove the uterus altogether.

45:29

Um, so chemotherapy is the staple, but

45:32

palliative surgery can sometimes be performed.

45:36

Um, okay, so those are all of the kind of

45:39

major teaching points that I wanted to make

45:41

in the cases that I wanted to show you.

45:43

Are there any questions about

45:45

endometrial cancer imaging,

45:47

endometrial cancer staging and endometrial cancer

45:50

treatment from the radiologist's perspective?

45:53

All right, thanks so much

45:54

everybody and don't be overwhelmed.

45:56

The staging system, um, can seem overwhelming.

45:59

I keep a macro in my PowerScribe, um,

46:03

so that I can kind of directly drag in the FIGO

46:06

stage, um, based on the imaging features.

46:09

Um, the staging systems are very detailed,

46:13

um, and so it's okay to need to look it up.

46:15

Um, the important thing is to be able to

46:17

recognize the findings on the MR, um, so that

46:19

when you correlate what you see on the images

46:22

to the stage, you're doing that accurately.

46:24

But don't, uh, feel ashamed if you need a

46:27

macro, because I still use one to help me.

46:31

Thank you everybody.