Workup/Staging Flashcards
What should be included in the workup for a cervical mass?
Pelvic mass workup: H&P, including HIV status, careful pelvic exam in the office, basic labs, pregnancy test, EUA with Bx, for any visible lesions, and pelvic imaging.
What are the areas at risk for local extension of cervical cancer?
Cervical cancer can spread locally to the uterine corpus, parametria, and vagina. These should be carefully assessed during a physical exam. Tumor size and parametrial involvement are better assessed by rectovaginal exam. Cervical tumors can also spread to the bladder anteriorly or rectum posteriorly.
Name 3 routes of lymphatic drainage from the cervix.
Routes of lymphatic drainage from the cervix:
Lat to the external iliac nodes via the round ligament
Post into common iliac and lat sacral nodes via the uterosacral ligament
Post–lat into internal iliac nodes
What imaging studies are included in FIGO staging of cervical cancer? What common imaging modalities are not allowed?
CXR, barium enema, and intravenous pyelogram data are included in FIGO staging of cervical cancer, as are procedures such as cystoscopy, proctoscopy, and hysteroscopy if there is concern for invasion. CT, PET, MRI, bone scan, lymphangiography, and laparotomy/laparoscopy data are not allowed to be used for staging but can be obtained for parametrial invasion, Tx decision making, and planning purposes (but do not influence FIGO staging of the pt).
What is the utility of PET scans in cervical cancer?
PET is generally fairly sensitive (85%–90%) and specific (95%–100%) for detection of para-aortic nodes in pts with locally advanced cervical cancer. Interpretation of the primary tumor at the cervix is not very reliable d/t the high excretion of FDG and the resultant high SUV in the bladder.
In what group of cervical cancer pts is evaluation of the urinary tract required?
Cervical cancer pts with more than stage IB1 Dz require imaging of the urinary tract. This can be performed with CT, MRI, or intravenous pyelogram.
What is the FIGO 2018 staging for cervical cancer?
Stage IA: microscopic Dz, with ≤5 mm DOI. It is further delineated into IA1 (tumors ≤3 mm depth) and IA2 (tumors >3 mm but ≤5 mm deep)
Stage IB: clinically visible tumor or >IA2, with IB1 ≤2 cm, and IB2 >2cm ≤4cm. 1B3 being bulky tumors >4 cm
Stage IIA: invades beyond uterus/cervix; involves the upper two-thirds of the vagina without parametrial invasion with IIA1 lesions ≤4 cm and IIA2 lesions >4 cm
Stage IIB: invades beyond uterus/cervix and into parametria but not into pelvic wall or lower 3rd of vagina
Stage IIIA: invades lower 3rd of vagina but no extension into pelvic wall
Stage IIIB: invades pelvic sidewall and/or causes hydronephrosis or nonfunctioning kidney
Stage IIIC1pelvic lymph node involvement. Stage IIIC2 PA lymph node involvement.
Stage IVA: invades beyond true pelvis or mucosa of bladder or rectum (must be Bx-proven); bullous edema of bladder or rectum does not count
Stage IVB: DMs
How does the AJCC version 8 (TNM) staging system for cervical cancer compare with the FIGO system?
In AJCC cervical cancer staging, the T stage corresponds to the FIGO stage, except for FIGO stage IVB. Positive regional LNs are not included in FIGO, but are N1 in AJCC; however they do not influence AJCC stage grouping. Para-aortic nodes are no longer considered M1 Dz in AJCC version 8.
What factors are predictive of pelvic nodal involvement in cervical cancer?
Factors that predict for nodal involvement in cervical cancer include DOI, FIGO stage, tumor size, and LVSI (10% without vs. 25% with). It is controversial whether histologic subtype is an independent predictor for nodal involvement, although some studies show adenocarcinomas having higher rates of DM.
Estimate the risk of pelvic LN involvement based on the following DOIs of a cervical cancer: <3 mm, 3–5 mm, 6–10 mm, and 10–20 mm.
Risk of pelvic nodal involvement by DOI:
≤3 mm: <1%
3–5 mm: 1%–8%
6–10 mm: 15%
10–20 mm: 25%
Estimate the risk of pelvic LN involvement based on the FIGO stage of cervical cancer.
Pelvic LN+ rates for cervical cancer based on the FIGO stage:
Stage IA1: 1%
Stage IA2: 5%
Stage IB: 15%
Stage II: 30%
Stage III: 50%
Stage IVA: 60%
Estimate the risk of P-A nodal involvement based on the FIGO stage of cervical cancer.
P-A LN+ rates for cervical cancer based on the FIGO stage:
Stage IA: 0%
Stage IB: 5%–8%
Stage IIA: ∼10%
Stage IIB: ∼15%
Stage III: 30%
Stage IVA: 40%
What are the 5-yr OS rates based on the FIGO stage?
5-yr OS based on FIGO stage:
Stage IA: 93%
Stage IB: 75%–80%
Stage IIA: 80%
Stage IIB: 65%–70%
Stage IIIA: 35%
Stage IIIB: 35%–40%
Stage IVA: 10%
Stage IVB: 0%
(AJCC 8th edition 2017)
Which key clinical factors are included in the nomogram by Rose et al.?
The Rose nomogram predicts 2-yr PFS, 5-yr OS, and pelvic recurrence using the prognostic factors of histology, race/ethnicity, PS, tumor size, FIGO stage, tumor grade, pelvic node status, and Tx with concurrent cisplatin. (Rose P et al., J Clin Oncol 2015)
