Zehra Nihal Dolgun, Ahmet Salih Altintas, Cihan Inan, Petek Balkanli Comparison of Preoperative Magnetic Resonance Imaging Results with Postoperative Pathologic Results in Early Stage Uterine Cervical Cancer Zehra Nihal Dolgun, Ahmet Salih Altintas, Cihan Inan, Petek Balkanli Trakya University, Faculty of Medicine, Department of Obstetrics and Gynecology, Edirne

Uterine cervical cancer is the second most common cancer in women after breast cancer. Despite routine follow-up protocols, it is still the most fatal gynecologic cancer worldwide. The International Federation of Gynecology and Obstetrics (FIGO) describes cervical cancer staging clinically. Although imaging modalities may apply for detection of pelvic wall and parametrium invasion, they do not change the clinical staging . American Cancer Society: Cancer Facts & Figures. Atlanta, Georgia, 2014 Pecorelli S. Int J Gynaecol Obstet, 2009

FIGO Cervical Cancer Staging

Preoperative evaluations should include the level of tumor extension towards external os, the prediction of tumor size and tumoral stromal invasion to plan the appropriate treatment. Pelvic examination, cervical biopsy and optical imaging (colposcopy, cystoscopy, intravenous pyelogram or proctoscopy, e.g.) are generally used before treatment. Pecorelli S, et al. Int J Gynaecol Obstet, 2009

There are some limitations in FIGO clinical staging There are some limitations in FIGO clinical staging. Parametrial or sidewall invasions, metastases to pelvic and paraaortic lymph nodes can be difficult to determine accurately. For this reason, some additional imaging modalities such as abdominal/pelvic computed tomography (CT), positron emission tomography (PET), pelvic magnetic resonance imaging (MRI) are used in preoperative period. Imaging tests can be performed in addition to colposcopy, punch biopsy, cervical conization, cystoscopy, and colonoscopy, which FIGO currently presents as methods for determining the stage of cervical cancer. Although imaging tests like computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), PET/CT (1C) or surgical staging are not included in the methods that FIGO acknowledges for the staging of cervical cancer, these can be selectively performed in order to decide the direction of treatment. Cystoscopy and colonoscopy are performed for stage IB2 or higher lesions, particularly when invasive cancer to the bladder or colon is suspected. There is insufficient evidence that PET/CT is more sensitive than CT or MRI to predict pelvic or para-aortic lymph node metastasis. PET/CT shows discrepant results in terms of sensititivity in selected studies for meta-analysis. As per the study protocol, CT, MRI, and PET/CT have different sensitivity, specificity, negative predictive value and positive predictive value [12,13]. Overall, when metastases are not identified in the CT or MRI scans or when the results are uncertain, PET/CT could be helpful in predicting pelvic or aortic lymph node metastasis. Lee SI, et al. J Nucl Med, 2015

Material and Methods Aim To compare the preoperative MRI findings of early stage cervical cancer patients with their postoperative hystopathologic results. Material and Methods This is a retrospective study of 30 women who were diagnosed, operated and had preoperative MRI examinations in our institution.

Material and Methods Medical charts of the patients were examined. Demographic data, clinical FIGO staging of tumors, MRI examination results and postoperative pathologic results were recorded. MR images were analyzed for presence of cervical tumor, tumor stage, tumor size in three dimensions, invasion depth within cervix, the presence of parametrial and vaginal infiltration, lymph node involvement, vesical and rectal invasion.

Material and Methods The correlation of preoperative clinical FIGO and MRI stagings with postoperative histological staging, preoperative MRI examination accordances with pathological results and preoperative–postoperative histopatologic consistencies were evaluated.

Results   Pathological staging (n) Clinically correct staging (n) Correct staging by MRI (n) 1a 2 1 1b1 9 6 1b2 3 2a 5 4 2b 11 7 TOTAL 30 20 Correct staging of MRI and clinical evaluation according to pathological staging

Histopathological Staging Comparison of different stagings Results   Histopathological Staging TOTAL 1a 1b1 1b2 2a 2b Clinically FIGO Staging (n) 1 3 4 6 5 18 7 MRI 2 9 8 11 30 Comparison of different stagings

Staging accuracy of Magnetic resonance imaging Results MRI Stages Sensitivity Specificity PPV NPV 1a 1 0.93 0.50 0.92 1b1 0.66 0.84 0.33 0.87 1b2 0.96 2a 0.89 0.57 0.95 2b 0.63 0.85 Staging accuracy of Magnetic resonance imaging

MRI sensitivity in correct tumor size detection 0.68 Results Tumor size <4cm 17 patients MRI 8 patients Tumor size ≥ 4cm 13 patients MRI 9 patients MRI sensitivity in correct tumor size detection 0.68

Results   MRI Pathology Tumoral characteristics Present on MRI Present in MRI and Pathology Present Absent Cervical ring invasion (n) 17 13 20 10 Parametrium invasion (n) 8 7 11 19 Pelvic lymph node invasion (n) 3 9 21 Paraaortic lymph node invasion (n) 30 17 tane hasta için MRI, servikal ring invazyonu var dedi. Bunların 13 tanesi patolojik olarak da gerçekten tutuluydu. Magnetic resonance imaging and pathology findings of tumor invasion

Conclusions MRI staged 20 out of 30 patients (66.6%) correctly Only 7 patients (23.3%) were staged correctly with clinical examination. MRI overstaged 10% and understaged 23% of the cases. MRI staging is superior to clinical staging even in early stages of cervical cancer.

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