Introduction
Cervical cancer is the second most common cancer in India in women, accounting for 16.5% of all cancer cases in women and 8.35% death among all cancer cases in both men and women (Globocan 2018). FIGO Staging for carcinoma cervix is predominantly based on clinical examination. Precise staging is imperative for rendering appropriate therapy, with Concurrent chemo-radiation being the preferred choice of primary treatment for stages lB3 and above (NCCN version 5.2019). Clinical staging is subject to high inaccuracy with error rates ranging between 26 and 66%.1 Hence, for proper assessment of the size and the extent of tumour, examination under anaesthesia is required. Since there is muscle relaxation, the parametrium is better assessed under anaesthesia, which may not be feasible in a conscious patient due to discomfort. With the advent of imaging modalities like CT and MRI there have been claims of better assessment of stage. This study attempts to identify the concordance between clinical examination, examination under anaesthesia and CECT with respect to the various parameters involved in staging of carcinoma cervix and to define the relevance of EUA in the current scenario.
Materials and Methods
Total number of patients
90.
CECT abdomen and pelvis was taken for all patients. Results regarding tumour size, fornix and parametrium involvement were tabulated and analysed.
The EUA was performed under spinal anaesthesia. With patient in low lithotomy position, visual assessment of the tumour was done using speculum, followed by vaginal and combined rectovaginal examination. During visual assessment, site and size of the tumour assessed. The vaginal fornices are visualised and also felt during digital examination. Rectovaginal examination was done to assess for parametrium. If nodularity or shortening of uterosacral ligament are noted, then this likely represents tumour involvement. If there is no cancer free space between tumour and pelvic sidewall, stage lllB is assigned.
Results
Tumour size
In 21.2% (17/80) of patients who had bulky disease on EUA, CECT has reported tumour size as <4cm.
Based on tumour size 5/81(6.2%) patients were down-staged by EUA in comparison with clinical examination.
In 5% of patients (4/80) EUA upstaged tumour size in comparison with clinical examination.
Fornix
Clinical examination failed to identify fornix involvement in 8 out of the 83 patients who had fornix involvement on EUA (9.6%).
Parametrium
Out of 67 patients who had parametrium involvement on EUA, clinical examination failed to identify it in 5. (7.4%).
In 28.3% of patients (19/67) who had parametrium involvement on EUA, there was no parametrium involvement reported in CECT.
Among the 71 patients with parametrium involvement, 4 patients were identified only in CECT (5.6%).
Out of 16 patients who had parametrium involvement upto side wall on EUA, CECT had no HUN or lateral pelvic wall in 11 patients.(68%).
Clinical examination failed to identify parametrium involvement upto side wall in 11/16 patients stage lllB according to EUA (68%).
Discussion
Staging in carcinoma cervix is predominantly based on clinical examination. Examination under anaesthesia has been an integral part in staging of carcinoma cervix. The superiority of EUA to clinical examination has been proved by a number of studies, dating back to the works of J.R. Van Nagell et al, who stated that EUA increased overall staging accuracy from 54 to 74%.2 B Stefanon et al reported modification in clinical stage in 24.5% of patients and a 10% change in therapeutic decision after EUA.3 In our study there is 11.2% discrepancy between EUA and clinical examination with regards to tumour size. In the evaluation of parametrium, clinical examination failed to identify involvement in 7.4% of patients. There was a significant difference in identification of level of parametrial involvement, with clinical examination failing to identify sidewall involvement in 68% of patients.
With the advent of cross-sectional imaging modalities like CT and MRI, the staging accuracy has been reported to be improved when compared to clinical examination. Hricak H et al. reported that for the detection of advanced stage (> or = IIB), sensitivity of clinical staging is 29%, CT is 42%, and 53% for MRI.4
Ozsarlak et al. reported that the overall accuracy of staging for clinical examination, CT, and MRI to be 47, 53, and 86 per cent respectively when compared with surgical findings.5
Though the above mentioned studies reported better staging accuracy with CT there is significant disaggrement between CT and EUA in our study. CECT significantly understaged tumour size in 21.2% of patients in comparison to EUA.
CT has limitations in the depiction of cervical cancer. Upto 50 per cent of tumours are isodense to cervical stroma on contrast-enhanced CT and hence not discretely demonstrated.5 Hence there is significant discrepancy in the tumour size reported.
In the assessment of parametrial invasion, Hancke et al. reported that, results with CT and MRI were no better than with palpation (accuracy: CT 61% and 54%, MRI 61% and 56%, respectively).6 Whitley et al. also showed poor sensitivity by CT in diagnosing pelvic side wall invasion.7 Similar to their experience, in our study there was no parametrial involvement reported by CECT in 28.3% of patients who had parametrial involvement in EUA. The sensitivity for identifying side wall involvement is very low in CECT with 68% of patients identified to have disease extending upto side wall in EUA showed no HUN or definite lateral wall involvement. Similar low identification of pelvic sidewall involvement by CT was reported by T.V Prasad et al. who stated that clinical examination showed pelvic side wall invasion in 51 per cent patients whereas CT showed in 13.2 per cent patients only.8
There is no significant difference in identifying fornix involvement between EUA and clinical examination.
Since advanced carcinoma cervix is primarily treated with chemoradiation pathological confirmation was not available to identify the accuracy of CECT and clinical finding.
Conclusion
EUA offers undeniable advantage over clinical examination in staging of carcinoma cervix.
CECT does not reliably correlate with EUA, with significant percentage of understaging, especially with regards to tumour size and pelvic sidewall involvement. The role of CECT is in identification of lymphnode and distant metastasis.
