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116 Ultrasonography in Gynaecological Cancers
Figure 4. Tumour identification. A squamous cell cancer is characterized as a hypoechogenic, richly vascularized tumour (A-C), while
adenocancer is manifested as a iso- or hyperechogenic, highly perfused structure contrasting with healthy residual cervical stroma (D-F).
Local Staging in Patients With Early-Stage patients with histologically confirmed early-stage cancer
Disease (27). Results of a study published in 2013 are presented
in Table 2. The diagnostic agreement between ultrasound
One of the largest prospective studies comparing the and pathology was significantly better at detecting
diagnostic accuracy of ultrasound and MRI in the local residual tumour and parametrial invasion than MRI
staging of cervical cancer was published by Fischerova (p<0.001). A surprising finding was the maintenance
et al. in 2008 and included 95 patients with early-stage of diagnostic accuracy of ultrasound in the detection of
disease (25). The study showed a significantly higher residual tumour after cone biopsy, where it is difficult to
accuracy of ultrasound when compared with MRI in distinguish post-inflammatory and reparative changes
tumour identification and identification of residual after the procedure from the presence of residual tumour.
tumour after previous biopsy (93.7% vs. 83.2%, p ≤0.006) The study results also showed the comparable accuracy
and in the measurement of tumours including small of both imaging techniques in the size assessment and in
tumours ≤1 cm3 (90.5% vs. 81%, p≤0.049) (Figure 1). the evaluation of deep stromal invasion.
Achieving these results was made possible by a significant
improvement in the technical quality of the ultrasound Parameters for Individualised Surgical
device, which included the ability to detect an enhanced Treatment
perfusion within a tumour assessed by a sensitive colour
Doppler in the majority of cases (98% of cases). The In addition to evaluation of the local extent of disease
data also showed the insignificantly higher accuracy it was necessary to verify whether ultrasound is also
of ultrasound in the evaluation of parametrial spread able to reliably determine the parameters necessary for
compared to MRI (99% vs. 95%, p ≤0.219). the individualisation of surgical treatment –different
radicality of parametrial resection, fertility sparing
Promising data was confirmed a year later in a study surgery (FSS) and others.
by Testa et al. on 75 patients with early-stage disease
(26). Ultrasound detected the presence of a tumour, deep The precise assessment of lateral tumour-free margin
stromal tumour invasion, infiltrated parametria and allows a side-differentiated extension of parametrial
other monitored parameters with an accuracy at least resection as demonstrated in Figure 5 followed by less
similar to, or greater than MRI. significant side effects at the site where autonomn nerves
remain uninjured (28, 29). The lateral tumour-free
The verification of previous study results in a multi- margin is evaluated as the minimum thickness between
center prospective study was crucial for the general the tumour and pericervical fascia at the point where
acceptance of ultrasound in the staging of cervical cancer. ventral, lateral and dorsal parameteria attached to the
A European multi-centre trial initiated by Epstein et al. cervix. The proximal extent of tumour (a cranial tumour-
ran from 2007 to 2010 and consequently included 182 free margin) is of major interest for fertility-sparing
