Female Pelvis: Malignant Diseases

Malignant Diseases of the Female Pelvis

Over the next 30 minutes,
we'll cover malignant diseases of the female pelvis
and we'll cover three topics, cervical
and endometrial and ovarian cancer.

Cervical Cancer

Let's start with cervical cancer.

Some facts and figures are important.
We know the magnitude of the problem.
It's the third most common gynecological cancer.
And in 2013 we had about 12,000 new cases
with about one third of patients dying.

There are many risk factors.
The most important one
to remember probably is HPV infection.
And the reason to remember that is that we have a vaccine
available nowadays.

Things that we can do to make the diagnosis PAP smear
and HPV co screening, again, Gardasil
and Ariix are the two vaccines
and they're being offered for young females
and males as well.

Most of those tumors would be squamous sonomas.
There are other types. Most
of the other ones would be adenocarcinomas.
Average age of a woman, about 50 years old.
And this patient may present with different symptoms,
sometimes even a symptomatic.
When they do present something, often it's related
to inter menstrual postal vaginal bleeding.

We will not do imaging to make the diagnosis
that's done by biopsy.
And imaging will be an adjunct too in the
assessment of these patients.

These patients are typically now seen by the,
the surgeons, the gynecological surgeons,
and they'll get a clinical staging done.
The figo is a clinical staging.
It doesn't involve imaging.
We have stage number one, a tumor
that is confined to the uterus.
Stage two, we have limited extra uterine extension.
It may involve the upper vagina or the tum.
That's important to remember.
We may have in a more advanced tumor.
Now we have involved with the lower vagina, pelvic sidewalls
and ureters leading to hydronephrosis.
And we may have then even more advanced tumor with bladder
and rectum involvement for instance.

Why does this matter? It matters
because it affects treatment and prognosis.
Treatment of a patient with a stage two B
is not surgical anymore.
Two B or greater patients will be treated
with radiation therapy and systemic therapy.
Patients that have less than that may,
may be treated with surgery.
It's a cutoff point in the way they
manage these patients.

Alright, what are the imaging indications?
Staging quotes, because it's a clinical stage,
but it does provide some information to the surgeon.
We want to detect
or confirm the parameter invasion,
which means the patient will undergo radiation
therapy rather than surgery.
And we wanna assess for pelvic sidewall invasion,
'cause that will also affect the prognosis.

How is the prognosis affected?
This is a five year survival
rate in patients with different stages.
Stage one, over 90%
of the patients will have five year survival when you drop
to 30, when you drop to about 30% in patients
with stage three, which is pelvic sidewall
involvement in Hy Nephrosis.

What are the key imaging features here?
We are gonna be looking for, masses
that are centered in the cervix that are iso to
hyperintense on T one, slightly hyperintense on T two.
Compared to the myometrium, they typically enhance less than
the adjacent cervix.
The cervix has a lot of fibrous tissue
and it tends to enhance a little bit later in the tumor
intense a little bit earlier, One
of the most important things to remember is this thoma ring.
The stroma ring is a, a dark line that surrounds the,
the, the cervical canal.
It's contiguous with the junctional zone.
When you're coming down on the sagittal plane,
this is it here on the axial plane.
We identify it right here.

Why does it matter?
It matters 'cause if this ring is preserved,
there's no way that the tumor that is arising here
has extended here.
You're looking for a preserved ring.
If the ring is there, you know,
there's no parameter extension.
Stage one, a microinvasive tumor,
it's not identified on MRI stage one B, macro invasive,
it's a preserved ring.
And then stage two B parametric extension,
you have a disrupted ring.
Not all disrupted rings are associated
with parametric extension, but it makes it more suspicious.

Let's look at a couple of examples.
This is a very large tumor,
which is expanding the cervix.
This higher signal intensity,
but surrounding it we identify this thin dark line
and that's the stroma ring.
If the stromal ring is preserved,
there's no parametric extension.
However, here we have a, again, large tumor,
we can follow this stroma ring
and all of a sudden it disappears.
And we have obviously a big finger
of tumor extending into the parum.
This is stage two B.
Another one large tumor stroma ring is preserved stage one B
two other examples, gross involvement.
But just to illustrate the ring, we have half
of the ring here, the other half is gone
and we have tumor that's beyond the circum,
the expected circumference
of the cervix parameter extension.
And then another one, which the only amount
of the cervical ring we see,
the stromal ring we see is this part here.
Large tumor involved the tum.
This patient will be treated radiation therapy.

Stage two A that's involvement
of the upper thirds of the vagina.
We can identify again increased signal
with thickening of the vagina.
And it's very nice that we see this now we call,
they're gonna call to say yeah,
there is involvement of the vagina.
And then they look, yeah, I know 'cause I palpated it.
They don't really care about this here,
but they really care about is the
involvement, the parameter extension.
They can do a good physical examination, palpate the air,
suspect it, but when it's small, we'll be able to tell them
and they will not be able to palpate stage three B.

Now we're talking about parametal, I mean,
pelvic sidewall involvement.
We can identify the very, very large tumor.
This tumor here is involving the pelvic sidewall on the
right side and it's causing hydronephrosis on the left.
But you can imagine that a tumor can be very large
and not be involving the sidewall or causing hydronephrosis.
Size doesn't matter.
It could be still a very large two B
tumor in this case here.
Three B, there's loss of the fat plane between the tumor
and the muscles on the side
and there is a little bit of a higher signal than expected.
And then hydronephrosis.
This is just an example on a Corona imaging CT
to show the hy nephrosis on the right side
on the very, very large tumor.
Cervical cancer, this is part of the ureter here.
And another one, hydro Nero on the left side,
very large mass in the pelvis and the ureter stage three B.

And in stage four,
this is just an example of bladder invasion.
Now obviously this tumor has now eaten
through the bladder wall.
We can identify the bladder wall.
Now it's disrupted over here.
It comes back, there's a big mass.
This patient had gross hematuria.
Now an easy diagnosis, we have to remember lymphatic spread.
It's not part of the staging system,
but it will affect prognosis.
And now this is just,
a large tumor we can now identify here in the sagittal
plane, cervical tumor, there's parameter extension.
This is the, the,
the endometrial cavity is dilated and occluded.
This is the same patient.
Now, on a pet ct we can identify lymphadenopathy,
peric, lymphadenopathy.

I would like to mention a, a slightly different type
of tumor, which is adenoma malignant.
It's a variant of, of cervical cancers
and it's typically well differentiated that presents
with dysfunctional bleeding.
One of the clinical features that's classical
for this tumor is water or discharge.
The tumor is very cystic.
And the sort of multicystic appearance,
which may be confused with nebulin cysts, it may present
with solid components and it's often associated, not often,
but it may be associated with mucinous tumors of the ovary.
If you have a larger maxo mass, that looks like an epithelial neoplasm
and you identify a cervix that has all those cystic lesions,
think at no malignant and it's also ger.

Endometrial Cancer

Let's move on to endometrial cancer.
Again, I would like to first start with some, stats about, it's the fourth most common cancer now not
gynecological cancer, but cancer
with about 50,000 new cases in 2013
and the eighth cause of death, by cancer with about,
8,000 deaths in last year.

Risk factors, estrogen expo exposure,
is the main thing to remember.
And all those things here end up being related
to estrogen exposure in one way or the other.
Maybe not Lynch syndrome, obviously. That's genetic.

90% of those tumors will be adenocarcinomas.
Again, there might be some variants,
but that's, those are the last common, the typical age,
slightly older than the patient with cervical cancer.
And the minority of patients.
Younger patients can have endometrial cancer.
They, those may be associated
with polycystic ovarian tumor.
Those are exceptions, not the rule.
Most of those patients would be presented
with postmenopausal bleeding,
or irregular vaginal bleeding.

And again, the diagnosis is not based on imaging results.
We don't really do this to diagnose when we suspect MI
cancer patients undergo biopsy imaging is done again
as an adjunct tool.

Figo staging now, figo staging now is not clinical,
now it's a surgical staging system.
Patients will have a biopsy,
they'll have, you know, the whole assessment.
They'll take the patient to er, they'll look at everything
and then they'll come up with a stage.
But we can now
before that, provide them some information
that will help them to treat those patients as well.

Figo stage one is one that's confined
to the uterus and about 75% of those, are confined.
Then we can subdivide us.
You can have a stage one A
or a stage, one B stage one A is when the milometer invasion is less
than half of the thickness of the omera.
This one is stage one A. There's no TER invasion.
This one is one with milometer invasion,
but not reaching 50% of the thickness if it goes
beyond 50% of the thickness.
Now it's stage one B. And why does that matter?
Well, millimeter invasion is associated with increased risk
of lymphadenopathy, but even more if 50%
or more of the omera is involved.
Deep millimeter invasion, greater than 50%, about 30%
of the patients will represent with lymphadenopathy.
And that obviously will have an effect on the
patient's survival as well.

F igo stage two, now we have something that's confined
to the uterus but extending into the cervix.
Stage three we may have, involvement
through the cis involving ovaries, uterus, and vagina
and external iliac lymph nodes.
If those lymph nodes now go beyond external, i, iliac nodes involving the INGO lymph node.
It's stage four. It's distant metastasis obviously.
And again, involvement of adjacent organs.
Just to point out again, that that has an implication.
95% survival with stage one,
15% survival with stage four.
And obviously this is a, a progressive change.

What are the imaging indications?
We're gonna try to detect nodal metastasis.
We can look for them directly
and try to say this is likely malignant.
We know we don't do well. We can use size criteria,
we can use morphological criteria
and in some cases we can actually tell them very likely
there is metastatic disease to nodes.
But now we all know
that we don't, we don't do great with that.
But indirectly we can detect millimeter invasion,
tell them this patient has a higher risk
and that will lead to changes in management.
They may do a more through assessment, of the lymph nodes following surgery for instance.
They might dissect more
and, more thoroughly the lymph nodes
or they may extend lymph node dissection
at the time of the procedure.
And in some cases they, if,
if this is really clear then may then
just start with radiation therapy.

As a general rule, ultrasound will be the first technique
to assess and confirm an abnormality.
Postmenopausal patient comes with bleeding,
gets a transvaginal ultrasound, we identify the thickening
with suspecting endometrial cancer.
Patient will undergo biopsy,
but it's not reliable to assess extent of disease.
That's when we can do cross-section imaging.
CT and MRI often performed after treatment again
because it's not part of their surgical staging system.
Luckily at UCSF, a lot of the patients will get imaging
before,
but it's not following their guideline junctional zone.

Again, I would like to go back to
that 'cause that's also important.
This is the T two sagittal view of the uterus.
Another one here, two different patients.
We can follow the junctional zone.
If I do identify a preserved junctional zone,
there's no manometer invasion
'cause it has to go through that.
It is part of the, it has to disrupt that to, to to,
to be involving in the omera.
Here we can follow the, the junctional zone.
Now it's gone now maybe a little bit here,
gone again and coming back here.
This patient does have nanometer invasion.

On the T two 80 they may showed you
before a gadolinium image.
We can do that with gadolinium as well.
Well if you're worried about in the T two way you're not
quite sure, go to the the GAD and try to identify it.
But the T two can also be very helpful.

Imaging features tend to be ISO to hyperintense on T one,
slightly hyperintense on T two compared to the adjacent ome.
Typically we enhance a little bit less than
the adjacent ome.
This is a GAD image Post GAD image Corona.
And again just showing a very large tumor disrupts
that smooth contour involves the myometrium
deep myometrial invasion.
This is more than the 50% of the thickness
stage one, again preserve junctional zone.
That's the same case I just showed you.
This is less than 50%
by meter invasion in the post GA image.
That smooth contour is gone.
Now this is irregular ill-defined.
The tumor is coming all the way here, less than 50%
grossly disrupted junctional zone.
Greater than 50% of the depth
of the TER involved by the tumor.
Deep TER invasion Stage two.
We have tumor involving the cervix,
the junction zones preserved here,
expanding the cervical canal.
This is where it is in the post cat image.

What about this one here? Just
to show you again the use of gadolinium.
There's a very large tumor
endometrial cavity, it's very hard.
This tumor could be just be expanding the endometrial
cavity, not necessarily involving the myometrium.
On this T two, it's very hard to say anything.
I mean look at the gad, the red arrow is point
to a smooth transition, a smooth transition
between the tumor and endometrial cavity.
It's not involved there. The white arrows,
however, showing this more irregular,
more ill-defined interface, that's
where the manometer invasion is.
And when they're very, very stretched,
the manometer is thin, it can be hard to determine how much
of this millimeter is actually involved.

Again, why does it matter?
It matters because it affects treatment.
Stage two lymph node sampling,
stage three lymph node dissection.
Now we may not be telling them
what the final stage will be,
but we're improving, the results of their surgery
to get a more accurate staging following treatment.

Ovarian Cancer

Let's move on to the next, 10 minutes or so
and talk about and ovarian cancer, you can see
that ovarian cancer is sort of low in the list.
When you look at the list of tumors,
it's like cutting the bottom.
Only 3% of the patients have ovarian cancer.
But when you look at the death, it's actually pops up
and it's almost twice as many patients.
5% compared to the other ones, right?
That means a lot of those patients are dying.
Even though not many patients have ovarian cancer,
when they do have typically the prognosis bat, so about 63%
of the patients will die of disease.

This is an interesting graph.
This is, and we probably can get a new one,
but this is from 1930 to 2010.
All those lines represent the mortality
of different types of cancer
and how they have changed over time.
No gastric cancer has decreased,
lung has increased maybe because of smoking here and so on.
Now this is the ovary line here. Let's follow this line.
And it doesn't really change at all.
It's sort of a flat line in this last 80 years here.
And this is in spite of improving diagnosis,
improving treatment.
And not, I actually put a line I didn't remember that,
but easier to see there now.
This is not something that we're doing great yet.

What are the different types of ovarian neoplasms?
Most of them are surface epithelial neoplasm.
Those are the serious misuse.
Endometrioid clear cell types of tumor, about two thirds.
But we can have germ cell, we can have sex tro
and obviously no patients may present
with metastatic disease to the ovaries.

On the radiologist side, what can we do?
We can try to use imaging to characterize something
that's benign versus malignant
or we can again try to use this for, for staging purposes.
Why does it matter?
Well now that will affect treatment planning and prognosis.
Again, we can identify the size
and location of implants, maybe lymph nodes.
It's important to remember
that you're not looking only at the ovary
but you're looking now adjacent to the liver,
the lesser sac, no fissures of the liver, pelvis,
pericolic, gutters, et cetera.
The size of the implants matter as well.
If you have a patient with way too many implants
and large implants, this patient might be better managed
with debulking, chemotherapy prior to surgery.
The reason is surgery might not be able
to do adequate debulking.
The location matters.
If you have an implant in the superior recess
of the lessor sac, the surgeon needs
to know about it 'cause they won't see it.
They have to go there. If you have subdiaphragmatic
implants, they do go to the subdiaphragmatic space,
but if they know that there will be a tumor there for sure,
they'll actually be very careful when, you know,
trying to get this out.
You have to describe that,
in a very clear way to them.

We'll talk about an approach to to
to assess those lesions now.
We'll, we'll start with cystic ovarian masses here.
And there are some benign imaging features of cystic masses.
And the enhancement tends to be just peripheral
because you know, we're not expecting neuro nodules.
They may have citations,
but they shouldn't have really large internal components
and they're typically not hypervascular masses.

This is now an example of something
that has more benign features.
Once you, you're looking cystic mass, we're thinking
of low signal intensity on on T one,
high signal intensity on T two
and we're thinking epithelial neoplasms,
which may be benign or malignant.

Here's an example of a immune cyst.
Another thing I wanna mention. There's a lot of overlap.
This is a general guide
and no gynecological oncological surgeon will say,
well you told me this is benign,
I'm not gonna do anything about it.
This patient will have this over resected.
Again, it's the mindset
of the surgeon when they're thinking about the surgeon,
what they will do, which is what we're trying to help.

And so this was an example of a musoma,
very large inocular mass.
This is post GAD image. See just very little enhancement.
The periphery benign appearing mass.
This is another one, with a few more septations now,
but no large neuro nodule malignant features.

We all have heard of it.
They tend to have more irregular walls.
They're more nodules.
The walls are thick.
Here's an example of neuro nodule.
This is a much uler mass here.
Very heterogeneous with internal components
and these tend to be more of an arterial enhancement,
earlier enhancement than the other ones.
This was a mucin assist adenocarcinoma.
The T one signal was intermediate
and when you have that, it's not
a hundred percent specific for malignancy,
but you have to consider malignancy more likely if you have,
if you don't have a low signal intensity one
but more of an intermediate signal intensity.

Now I think mucinous tumors and metastasis.
And then this one had a very large,
solid component associated with it.
This was however, a serious borderline tumor.

This is a borderline tumor.
It is a malignant tumor, but a lower malignant potential.
We often see it in the younger patients,
and often they look very benign.
You look at them and they just look like a little 60 you
call it's more likely benign.
They come back. Well it was borderline.
This one is one that looks a little bit more,
malignant than, than benign.

Here's an example.
One that has just those very large tumor, just a few SEPTA
as the mucin cyst adenoma that I showed you before.
But this was a borderline tumor.
And the good news is that they have very good,
survival,
long-term survival with most
of them being stage one at the time of diagnosis,
which is not the rule, for ovarian cancer.

And this is the another image of that same tumor.
Now sagittal T two 80 image.
Very, very large tumor with septations in the center.

Solid ovarian masses. Solid ovarian masses.
You have to think metastasis first.
They're typically gonna be bilateral heterogeneous.
You may have areas of necrosis, most commonly GI tumors,
but can be anywhere.
Just to mention berg tumors, people always talk, oh,
berg tumors gi then some people say berg tumors stomach.
And the reality is this is a histological assessment
'cause you're find mu secreting signaling cells in that.

Here's an example of a T one, low signal intensity
T two low signal, not as low
as the fibroma that I showed you before.
It's a little bit no higher signal than that fibroma.
And then the post GAD showing very
heterogeneous enhancement.
This was colon cancer.

This was a gastric adenocarcinoma.
Much larger tumors, bilateral lesions,
very necrotic on the T one post GAD
and very ugly on the T two.

They're predominantly solid mass is very heterogeneous
metastasis, however not all
of them will be metastasis is an example of lymphoma.
T one, low signal similar to the myometrium low
T two, again not as low as the fibroma.
Typically those patients already have a diagnosis
established, but then created OMA is also the
differential diagnosis.

Very low signal on T two. Low signal on T one.
It will follow the enhancement al
before they typically enhance avidly.
Look for a connection. Look for the bridging vessels.
Look for the separate ovary.
If there is a separate ovary, it cannot be ovarian.

This is the fibroma.
You can see that the signal 10 T two is much lower than
those of the meta metastasis that I showed you.
And it's also very low on T one
classical appearance of fibroma.
You can think of fibroma also in patient that may syndrome
with a little bit of ple effusion on the sitis.
They're typically older patients,
postmenopausal more commonly, this is one
of the most common benign tumors of the ovaries.

Summary

In summary, M imaging is a very good technique
for gynecological oncological assessment.
When you're thinking
of a patient when assessing the patient's cervical cancer,
the main thing that you have to remember is that you want
to assess for parameter extension.
If you wanna describe one thing,
is there a parameter extension, yes or no?

And endometrial cancer, you're now thinking more
of the myometrial invasion.
Is there deep myometrial invasion, which is 50%
or more of the thickness junctional zone.
Post contrast images can help you to determine that.

Ovarian masses, at the very least we had to try to say,
to the surgeon, if this is more likely benign or malignant.
If you may know this is malignant,
very certain this is malignant.
Then remember the location, the size
of the peritoneal implants, the disease burden,
those are very important for management of those patients.

And with that, I want to thank you.