Computerized tomography applied to gynecologic oncology CCY
J.
PHOTOPULOS,
WILL.lAM
H.
LESLIE
A.
EDW,4RD Clmfwl
Hill,
M.D.
MCCARTNEY,
WALTON, V. STAAB,
6nrth
M.D.
M.D. M.D.
Cnrolincr
Forty patients on the gynecologic oncology service at the University of North Carolina were evaluated with CT scans. Accuracy and clinical benefit of these scans were compared to those of manual clinical examinations. The CT scans were generally superior and had fewer (9) verified errors in the regions of the pelvic wall and para-aortic area than did the manual examinations(l7). Both the CT and bimanual examinations had the same number of verified errors (3) in the central pelvic region. The authors found the CT scans to be beneficial in evaluation of pelvic wall and para-aortic regions for treatment planning of either primary or recurrent cancer. (AM. J. OBSTET. GYNECOL.
135:381,
1979.)
COMPUTERIZED TOMOGRAPHY (CT)has enhanced the diagnostic evaluation of space-occupying lesions. Many reports have discussed the technique, application, and potential.‘-‘j Few reports, however, have discussed its application in problems of gynecologic cancer. We considered that CT could be used to define the size, extent, and anatomic site of pelvic tumors. In addition, detection of metastatic tumor to pelvic and para-aortic lymph nodes was considered possible as described by Marshal1 and colleagues’ for lymphoma and seminoma. This paper reports our evaluation of the first year’s experience with CT in the study of patients with gynecologic malignancy at the University of North Carolina.
Material and methods All from The area were
records of patients undergoing CT evaluation May, 1977, through April, 1978, were reviewed. requests for CT evaluation and designation of the to be examined, i.e., pelvis and para-aortic area, made at the discretion of the clinician responsible From the Depurtrnent,s Radiolog?r, Unizwrsity Received
for publication
Retcised Septembrr .4ccr$ted
of ObstPtrics and Gynecology ofNorth Carolina.
,Vovnnber
and
July 6. 1978.
5, 197X. 13, 1978.
Reprint reqwsts: Dr. Guy J. Photojndos, Division of Gynecologic Oncology, 800 Madison Ave., Memphis. Tenneswe 38163. 0002-997R/7411Y0381+03$00.30/0~
1979The
C.V.
Mosby Co.
for the patient’s care on the gynecologic oncology service and not by random selection. Forty patients with gynecologic malignancies were evaluated with pelvic CT scans and 19 of these also had para-aortic CT scans. The majority of the patients had carcinoma of the cervix and endometrium. The CT studies were carried out under the direction of the Division of Imaging in the Department of Radiology. Computerized tomography images were obtained with an Ohio-nuclear Delta 50 M’hole Body Scanner, requiring approximately 2 minutes to produce a pair of 1 cm thick body section images (256 by 256 matrix). Scans were typically performed after intravenous administration of 50 ml of radiographic contrast material to enhance visualization of the bladder and ureters. If only the pelvis was selected for imaging. the study was started at the iliac crest and terminated at the symphysis pubis. Studies requiring evaluation of para-aortic nodes scanned from the upper renal margins to the symphpsis pubis. In 17 patients a needle aspiration biopsy was directed by CT scanning of pelvic or para-aortic masses by the technique previously reported.x The accuracy of the CT scans was verified where possible by either exploratory surgery, cytologic diagnosis of malignancy via needle aspiration biopsy. or the concurrence of other tests including lymphography, venography, and gallium scan. Presence of’ tumor was considered verified if at least two of these tests demonstrated the tumor mass at the same site and of essen381
382
Photopulos
et al.
PELVICWALL
PARA-MMTIC
Table II. Needle biopsies directed at the sites suspected of cancer Region y?f biopsy sate
No. qf biojxirc
Central pelvis External iliac Common iliac Para-aortic Total
CENTRALPELVIS
by rhr (1 I irn;lg:c
No. rorth CNUC~,
4 9 3
I 6 2
-2 19
2 II
Table III. Comparison* of the over-all benefit patient care of the CT and manual pelvic examinations in the management of each patient
to
No.
Fig. 1. For each region
that the CT and manual evaluations could be verified by surgery, needle biopsy, or concurrence of two other diagnostic studies, the results are recorded as either demonstrating tumor or not demonstrating tumor and are contrasted to the true or verified result (vertical column) for accuracy.
Table I. The number of patients evaluated for either suspected recurrent cancer or primary evaluation prior to treatment* Cancer Cervix Ovary Endometrium Other Total
site
No.
Possible recurrence
Pti?7Ul~ evaluation
Pelvic radiation
19 6 9
17 5 6
2 1 3
17 0 6
s 40
4 3’L
4 8
3 26
Hysterectomy 3t 5 5 3 Is
*Because of the importance of distinguishing a central cancer from radiation fibrosis or from a uterus, the numbers of patients with prior irradiation and hysterectomy are also shown. tTwo had had radical oophorectomy.
hysterectomy
and bilateral
salpingo-
tially the same size as the CT scan. Central pelvic disease was verified by a conventional biopsy and clinical follow-up. The CT scans were individually reviewed by one author (W. M.), who knew only the patient’s gynecologic diagnosis and whether or not a hysterectomy had been done. Although clinical signs and symptoms as well as surgical and hi&logic information were withheld to avoid bias, the findings of the reviewer were not significantly different from the primary reports. The clinical records were reviewed by one author (G. P.) simultaneously with the review of the CT scans. In addition to entering all required information on a
13 4 17 -5 40
CT bettel Manual better Equal No decision Total *This comparison one author (C. P.).
is subjective;
it reflects
the judgment
of
specially designed code sheet, a retrospective clinical judgment was made of the relative merits of the CT and bimanual examination as they contributed to over-all patient care. This necessarily subjective evaluation was intended to take into account not only the relative accuracy but also contributions to planning radiation therapy, determining need for surgery, monitoring chemotherapy, etc.
Results Forty patients had CT evaluations, the majority to evaluate possible recurrent malignancy (Table I). Twenty-six of the patients had received pelvic radiation therapy and 16 had undergone hysterectomy. Seventeen patients had one or more biopsies directed by the CT image. The biopsy site and number revealing cancer are shown in Table II. There were no complications from the biopsies. Pathology confirmation of regional or distant metastases eliminated the need for surgical exploration in six patients. These biopsies were also used to verify CT and clinical impressions in this study. Pelvic bone metastases were identified in three patients. The presence or absence of tumor mass in the central pelvis, lateral pelvis (pelvic wall), and para-aortic area as demonstrated by CT and clinical bimanual examination are compared to the verified results in those patients where verification was possible (Fig. 1). The clinical bimanual evaluation and CT examinations were each incorrect on three occasions in 32 ver-
Computerized
ified evaluations of the central pelvis. At the pelvic wall the CT was incorrect in five, as compared to nine incorrect evaluations by clinical examinations. In the paraaortic area, the CT was incorrect in four, as compared to eight by clinical assessment. A retrospective judgment of the clinical merit of the CT pelvic evaluation as compared to the bimanual evaluation reported in the patient’s record was made by one author (C. P.) (Table III).
Comment In several clinical situations, CT may aid in evaluation and ultimately in the management of gynecologic oncology patients. Identification of pelvic wall and para-aortic tumor involvement, frequently confirmed by directed needle biopsy, permitted better selection of radiation treatment fields to include regions with matastatic tumor. In addition, patients suspected of having recurrent pelvic cancer may not require surgical exploration if nodal matastases are confirmed. In these situations, important therapeutic decisions may be made without the need of surgical exploration. Our impression concurs with the conclusion of Carter and colleagaes” that the CT scan provides valuable information for differential diagnosis and clarifies relationships between soft tissue and bone structure. It may also be beneficial in distinguishing pelvic radiation fibrosis from tumor as well as distinguishing conglomerate bowel from tumor. It is anticipated that faster scanning techniques will provide even better results with less artifact and clearer definition of bowel and
REFERENCES
1. Paxton, T. R., and Ambrose, J.: The EMI scanner. A brief review of the first 650 patients, Br. J. Radiol. 47:530, 1974. 2. Sheedy, P. F., Stephens, B. H.. Hattery, R. R., Muhm, J. R., and Hartman, G. W.: Computed tomography of the body: Initial clinical trial with the EMI prototype, Am. J. Roentgenol. 127:23, 1976. 3. Evans, R. G.: New frontier of radiology: Computed tomography, Am. J. Roentgenol. 126:1117, 1976. 1. Ambrose, J. R., and Hounsfeld, G.: Computerized transverse axial tomography: Description of a System, Br. J. Radiol. 46:148, 1973. 5. Brooks. R. A., and Dichiro, G.: Theory of image reconstruction in computed tomography, Radiology 117:561, 1975. 6. Chernak, A. S., Rodriquez-Amtunez. A., Jelden, G. L.,
tomography
in gynecologic
oncology
383
normal anatomic structures. Indeed, one false-negative para-aortic scan resulted from motion artifact that obscured detail in that region. False-negative SC;IIIS generally were attributed to small matast‘lses. Falscpositive scans resulted from inadequate resolution od normal or fibrotic tissue. In addition to faster. scms. Gastrografin (diatrizoate meglumine and diatrizoate sodium) is now being used to better distinguish bowel and to improve tissue definitions in se1ectt.d patients, particularly in postradiation problems requiring dif ferentiation of possible tumor mass fl-cm radiation fibrosis or “conglomerate bowel pseudoma~s.” Clinical bimanual exam with Papanicolaou c.ytolog\. and selected biopsies is the preferred method of evaluating the central pelvis. Bimanual pelvic wall ancl para-aortic evaluation, however, is sev~rcl! limited by fibrosis subsequent to radiation therapv anti 1-)\ adipose tissue. If cancer is demonstrated by CT a~ the pcAlvic wall OI para-aortic region, and confirned by aspiration biops! or open biopsy, treatment of primar! or recurrerrt cancer is usually quite different from what it would bt, if no tumor were present. CT has proved h~lpf’ul in WI preliminary experience for better evaluation of these regions. The number of situations requiring the dclmonstration of tumor presence, size, and location in gynecologic oncology provide excellent applications tor (17 scanning. Further study with faster scanning met hods will be necessary to better establish this new diagnostic mode in problems of pelvic cancer.
Dhaliwal, R. W., and Lavik, P. S.: The use of computed tomography for radiation therap!, treatment planning. Radiology 117:613. 1975. 7. Marshall, H. W., Jr., Bruman, R. S., Harell. C;. S., Glatstein. E., and Kaplan, H. S.: Computed tomography of abdominal para-aortic lymph node disease: Preliminary observation with a six second scanner. .\m. J. Roentgenol. 128:759, 1977. 8. Jaques, P., Staab, E., Richey, W., Photopulos. G., and Swanton, M.: CT assisted pelvic and abdominal aspiration biopsies in gynecological malignancy. Radiologv 128:651, 1978. 9. Carter, B. L., Kahn, P. C., Wolpert. M. S.. Hammerschlag, S. B., Schwartz. A. M., and Scott, R. M.: L’llusual pelvic masses: A comparison of computerized tomographic scanning and ultra scintography. Radiology 121:3X3. 1976.
J.
PHOTOPULOS,
WILL.lAM
H.
LESLIE
A.
EDW,4RD Clmfwl
Hill,
M.D.
MCCARTNEY,
WALTON, V. STAAB,
6nrth
M.D.
M.D. M.D.
Cnrolincr
Forty patients on the gynecologic oncology service at the University of North Carolina were evaluated with CT scans. Accuracy and clinical benefit of these scans were compared to those of manual clinical examinations. The CT scans were generally superior and had fewer (9) verified errors in the regions of the pelvic wall and para-aortic area than did the manual examinations(l7). Both the CT and bimanual examinations had the same number of verified errors (3) in the central pelvic region. The authors found the CT scans to be beneficial in evaluation of pelvic wall and para-aortic regions for treatment planning of either primary or recurrent cancer. (AM. J. OBSTET. GYNECOL.
135:381,
1979.)
COMPUTERIZED TOMOGRAPHY (CT)has enhanced the diagnostic evaluation of space-occupying lesions. Many reports have discussed the technique, application, and potential.‘-‘j Few reports, however, have discussed its application in problems of gynecologic cancer. We considered that CT could be used to define the size, extent, and anatomic site of pelvic tumors. In addition, detection of metastatic tumor to pelvic and para-aortic lymph nodes was considered possible as described by Marshal1 and colleagues’ for lymphoma and seminoma. This paper reports our evaluation of the first year’s experience with CT in the study of patients with gynecologic malignancy at the University of North Carolina.
Material and methods All from The area were
records of patients undergoing CT evaluation May, 1977, through April, 1978, were reviewed. requests for CT evaluation and designation of the to be examined, i.e., pelvis and para-aortic area, made at the discretion of the clinician responsible From the Depurtrnent,s Radiolog?r, Unizwrsity Received
for publication
Retcised Septembrr .4ccr$ted
of ObstPtrics and Gynecology ofNorth Carolina.
,Vovnnber
and
July 6. 1978.
5, 197X. 13, 1978.
Reprint reqwsts: Dr. Guy J. Photojndos, Division of Gynecologic Oncology, 800 Madison Ave., Memphis. Tenneswe 38163. 0002-997R/7411Y0381+03$00.30/0~
1979The
C.V.
Mosby Co.
for the patient’s care on the gynecologic oncology service and not by random selection. Forty patients with gynecologic malignancies were evaluated with pelvic CT scans and 19 of these also had para-aortic CT scans. The majority of the patients had carcinoma of the cervix and endometrium. The CT studies were carried out under the direction of the Division of Imaging in the Department of Radiology. Computerized tomography images were obtained with an Ohio-nuclear Delta 50 M’hole Body Scanner, requiring approximately 2 minutes to produce a pair of 1 cm thick body section images (256 by 256 matrix). Scans were typically performed after intravenous administration of 50 ml of radiographic contrast material to enhance visualization of the bladder and ureters. If only the pelvis was selected for imaging. the study was started at the iliac crest and terminated at the symphysis pubis. Studies requiring evaluation of para-aortic nodes scanned from the upper renal margins to the symphpsis pubis. In 17 patients a needle aspiration biopsy was directed by CT scanning of pelvic or para-aortic masses by the technique previously reported.x The accuracy of the CT scans was verified where possible by either exploratory surgery, cytologic diagnosis of malignancy via needle aspiration biopsy. or the concurrence of other tests including lymphography, venography, and gallium scan. Presence of’ tumor was considered verified if at least two of these tests demonstrated the tumor mass at the same site and of essen381
382
Photopulos
et al.
PELVICWALL
PARA-MMTIC
Table II. Needle biopsies directed at the sites suspected of cancer Region y?f biopsy sate
No. qf biojxirc
Central pelvis External iliac Common iliac Para-aortic Total
CENTRALPELVIS
by rhr (1 I irn;lg:c
No. rorth CNUC~,
4 9 3
I 6 2
-2 19
2 II
Table III. Comparison* of the over-all benefit patient care of the CT and manual pelvic examinations in the management of each patient
to
No.
Fig. 1. For each region
that the CT and manual evaluations could be verified by surgery, needle biopsy, or concurrence of two other diagnostic studies, the results are recorded as either demonstrating tumor or not demonstrating tumor and are contrasted to the true or verified result (vertical column) for accuracy.
Table I. The number of patients evaluated for either suspected recurrent cancer or primary evaluation prior to treatment* Cancer Cervix Ovary Endometrium Other Total
site
No.
Possible recurrence
Pti?7Ul~ evaluation
Pelvic radiation
19 6 9
17 5 6
2 1 3
17 0 6
s 40
4 3’L
4 8
3 26
Hysterectomy 3t 5 5 3 Is
*Because of the importance of distinguishing a central cancer from radiation fibrosis or from a uterus, the numbers of patients with prior irradiation and hysterectomy are also shown. tTwo had had radical oophorectomy.
hysterectomy
and bilateral
salpingo-
tially the same size as the CT scan. Central pelvic disease was verified by a conventional biopsy and clinical follow-up. The CT scans were individually reviewed by one author (W. M.), who knew only the patient’s gynecologic diagnosis and whether or not a hysterectomy had been done. Although clinical signs and symptoms as well as surgical and hi&logic information were withheld to avoid bias, the findings of the reviewer were not significantly different from the primary reports. The clinical records were reviewed by one author (G. P.) simultaneously with the review of the CT scans. In addition to entering all required information on a
13 4 17 -5 40
CT bettel Manual better Equal No decision Total *This comparison one author (C. P.).
is subjective;
it reflects
the judgment
of
specially designed code sheet, a retrospective clinical judgment was made of the relative merits of the CT and bimanual examination as they contributed to over-all patient care. This necessarily subjective evaluation was intended to take into account not only the relative accuracy but also contributions to planning radiation therapy, determining need for surgery, monitoring chemotherapy, etc.
Results Forty patients had CT evaluations, the majority to evaluate possible recurrent malignancy (Table I). Twenty-six of the patients had received pelvic radiation therapy and 16 had undergone hysterectomy. Seventeen patients had one or more biopsies directed by the CT image. The biopsy site and number revealing cancer are shown in Table II. There were no complications from the biopsies. Pathology confirmation of regional or distant metastases eliminated the need for surgical exploration in six patients. These biopsies were also used to verify CT and clinical impressions in this study. Pelvic bone metastases were identified in three patients. The presence or absence of tumor mass in the central pelvis, lateral pelvis (pelvic wall), and para-aortic area as demonstrated by CT and clinical bimanual examination are compared to the verified results in those patients where verification was possible (Fig. 1). The clinical bimanual evaluation and CT examinations were each incorrect on three occasions in 32 ver-
Computerized
ified evaluations of the central pelvis. At the pelvic wall the CT was incorrect in five, as compared to nine incorrect evaluations by clinical examinations. In the paraaortic area, the CT was incorrect in four, as compared to eight by clinical assessment. A retrospective judgment of the clinical merit of the CT pelvic evaluation as compared to the bimanual evaluation reported in the patient’s record was made by one author (C. P.) (Table III).
Comment In several clinical situations, CT may aid in evaluation and ultimately in the management of gynecologic oncology patients. Identification of pelvic wall and para-aortic tumor involvement, frequently confirmed by directed needle biopsy, permitted better selection of radiation treatment fields to include regions with matastatic tumor. In addition, patients suspected of having recurrent pelvic cancer may not require surgical exploration if nodal matastases are confirmed. In these situations, important therapeutic decisions may be made without the need of surgical exploration. Our impression concurs with the conclusion of Carter and colleagaes” that the CT scan provides valuable information for differential diagnosis and clarifies relationships between soft tissue and bone structure. It may also be beneficial in distinguishing pelvic radiation fibrosis from tumor as well as distinguishing conglomerate bowel from tumor. It is anticipated that faster scanning techniques will provide even better results with less artifact and clearer definition of bowel and
REFERENCES
1. Paxton, T. R., and Ambrose, J.: The EMI scanner. A brief review of the first 650 patients, Br. J. Radiol. 47:530, 1974. 2. Sheedy, P. F., Stephens, B. H.. Hattery, R. R., Muhm, J. R., and Hartman, G. W.: Computed tomography of the body: Initial clinical trial with the EMI prototype, Am. J. Roentgenol. 127:23, 1976. 3. Evans, R. G.: New frontier of radiology: Computed tomography, Am. J. Roentgenol. 126:1117, 1976. 1. Ambrose, J. R., and Hounsfeld, G.: Computerized transverse axial tomography: Description of a System, Br. J. Radiol. 46:148, 1973. 5. Brooks. R. A., and Dichiro, G.: Theory of image reconstruction in computed tomography, Radiology 117:561, 1975. 6. Chernak, A. S., Rodriquez-Amtunez. A., Jelden, G. L.,
tomography
in gynecologic
oncology
383
normal anatomic structures. Indeed, one false-negative para-aortic scan resulted from motion artifact that obscured detail in that region. False-negative SC;IIIS generally were attributed to small matast‘lses. Falscpositive scans resulted from inadequate resolution od normal or fibrotic tissue. In addition to faster. scms. Gastrografin (diatrizoate meglumine and diatrizoate sodium) is now being used to better distinguish bowel and to improve tissue definitions in se1ectt.d patients, particularly in postradiation problems requiring dif ferentiation of possible tumor mass fl-cm radiation fibrosis or “conglomerate bowel pseudoma~s.” Clinical bimanual exam with Papanicolaou c.ytolog\. and selected biopsies is the preferred method of evaluating the central pelvis. Bimanual pelvic wall ancl para-aortic evaluation, however, is sev~rcl! limited by fibrosis subsequent to radiation therapv anti 1-)\ adipose tissue. If cancer is demonstrated by CT a~ the pcAlvic wall OI para-aortic region, and confirned by aspiration biops! or open biopsy, treatment of primar! or recurrerrt cancer is usually quite different from what it would bt, if no tumor were present. CT has proved h~lpf’ul in WI preliminary experience for better evaluation of these regions. The number of situations requiring the dclmonstration of tumor presence, size, and location in gynecologic oncology provide excellent applications tor (17 scanning. Further study with faster scanning met hods will be necessary to better establish this new diagnostic mode in problems of pelvic cancer.
Dhaliwal, R. W., and Lavik, P. S.: The use of computed tomography for radiation therap!, treatment planning. Radiology 117:613. 1975. 7. Marshall, H. W., Jr., Bruman, R. S., Harell. C;. S., Glatstein. E., and Kaplan, H. S.: Computed tomography of abdominal para-aortic lymph node disease: Preliminary observation with a six second scanner. .\m. J. Roentgenol. 128:759, 1977. 8. Jaques, P., Staab, E., Richey, W., Photopulos. G., and Swanton, M.: CT assisted pelvic and abdominal aspiration biopsies in gynecological malignancy. Radiologv 128:651, 1978. 9. Carter, B. L., Kahn, P. C., Wolpert. M. S.. Hammerschlag, S. B., Schwartz. A. M., and Scott, R. M.: L’llusual pelvic masses: A comparison of computerized tomographic scanning and ultra scintography. Radiology 121:3X3. 1976.
