{"id":5139,"date":"2015-12-18T12:21:02","date_gmt":"2015-12-18T12:21:02","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5139"},"modified":"2016-01-20T11:46:38","modified_gmt":"2016-01-20T11:46:38","slug":"imagistica-prin-rezonanta-magnetica-in-stadializarea-si-in-monitorizarea-cancerului-de-col-uterin","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/imagistica-prin-rezonanta-magnetica-in-stadializarea-si-in-monitorizarea-cancerului-de-col-uterin\/","title":{"rendered":"Imagistica prin Rezonan\u021b\u0103 Magnetic\u0103 \u00een stadializarea \u0219i \u00een monitorizarea cancerului de col uterin"},"content":{"rendered":"<p style=\"text-align: justify;\"><strong>Cancerul cervical <\/strong>se afl\u0103 pe pozi\u021bia a treia ca frecven\u021b\u0103 \u00een cadrul neoplaziilor ginecologice \u0219i are dou\u0103 v\u00e2rfuri de inciden\u021b\u0103: 30-44 ani, respectiv 75 ani.\u00a0 Folosirea metodelor de screening (examen ginecologic, examen Babe\u0219 Papanicolau) a dus la descoperirea \u0219i tratarea multor leziuni \u00een stadiul premalign. Primele simptome pot fi: s\u00e2ngerare vaginal\u0103, secre\u021bii vaginale anormale, durere pelvin\u0103, simptome urinare dar, de obicei, carcinomul <em>in situ<\/em> este asimptomatic \u0219i se descoper\u0103 la frotiu. Cancerul de col uterin \u00ee\u0219i are originea la nivelul zonei tranzi\u021bionale, situat\u0103 la v\u00e2rste tinere \u00een exocol, cu progresie endocervical\u0103 odat\u0103 cu v\u00e2rsta, ceea ce explic\u0103 \u0219i principalele pattern-uri de cre\u0219tere (exofitic la v\u00e2rsta t\u00e2nar\u0103, respectiv endocervical la v\u00e2rste mai \u00eenaintate).<\/p>\n<p style=\"text-align: justify;\">Cei mai importan\u021bi factori prognostici sunt: gradul histologic, volumul tumoral la momentul diagnostic\u0103rii, ad\u00e2ncimea invaziei stromale, invazia structurilor adiacente \u0219i prezen\u021ba adenopatiilor, ultimele patru fiind evaluate doar \u00een cadrul examin\u0103rilor imagistice. Leziunile preinvazive (care nu au traversat membrana bazal\u0103) pot fi tratate prin electrocoagulare, crioabla\u021bie, laser sau chirurgie local\u0103. Cancerele cervicale invazive sunt tratate chirurgical, prin radio- sau chimioterapie sau o combina\u021bie a acestor 3 metode, \u00een func\u021bie de stadiul tumorii.<\/p>\n<p style=\"text-align: justify;\"><strong>Sistemul FIGO de stadializare a cancerului cervical:<\/strong><\/p>\n<table>\n<tbody>\n<tr>\n<td width=\"36\">0<\/td>\n<td width=\"321\">carcinom <em>in situ<\/em><\/td>\n<td width=\"262\"><em>\u00a0<\/em><\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\" width=\"36\">I<\/td>\n<td rowspan=\"2\" width=\"321\">carcinom limitat la colul uterin<\/td>\n<td width=\"262\">IA: microscopic<\/td>\n<\/tr>\n<tr>\n<td width=\"262\">IB: vizibil clinic<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\" width=\"36\">II<\/td>\n<td rowspan=\"2\" width=\"321\">extensie dincolo de uter, dar nu la peretele pelvin<\/td>\n<td width=\"262\">IIA: extensie \u00een 2\/3 superioare ale vaginului<\/td>\n<\/tr>\n<tr>\n<td width=\"262\">IIB: extensie parametrial\u0103<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\" width=\"36\">III<\/td>\n<td rowspan=\"2\" width=\"321\">extensie \u00een 1\/3 inferioar\u0103 a vaginului sau la peretele lateral pelvin<\/td>\n<td width=\"262\">IIIA: extensie \u00een 1\/3 inferioar\u0103 a vaginului<\/td>\n<\/tr>\n<tr>\n<td width=\"262\">IIIB: invazia peretelui lateral pelvin \u0219i\/sau hidronefroz\u0103<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\" width=\"36\">IV<\/td>\n<td rowspan=\"2\" width=\"321\">extensie dincolo de peretele pelvin sau invazie de vezic\u0103 urinar\u0103 \u0219i\/sau rect<\/td>\n<td width=\"262\">IV A: mucoas\u0103 rectal\u0103 sau vezical\u0103<\/td>\n<\/tr>\n<tr>\n<td width=\"262\">IV B: metastaze la distan\u021b\u0103<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Sistemul de clasificare FIGO se bazeaz\u0103 pe evaluarea clinic\u0103 \u0219i nu \u00eencorporeaz\u0103 statusul ganglionar, \u00eens\u0103 ghidurile recente integreaz\u0103 rezonan\u021ba magnetic\u0103 \u00een sistemul de stadializare.<\/p>\n<p style=\"text-align: justify;\"><strong><em>Rolul imagisticii \u00een evaluarea cancerului cervical:<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\">Metodele imagistice CT\/IRM sunt folosite pentru stadializarea local\u0103 a tumorile detectate clinic cu diametru &gt; 2 cm. Examinarea <strong>IRM<\/strong> este metoda de elec\u021bie \u00een stadializarea, \u00een stabilirea conduitei terapeutice a cancerului cervical \u0219i \u00een evaluarea r\u0103spunsului la radioterapie (reducerea \u00een dimensiuni a tumorii, reducerea intensit\u0103\u021bii semnalului). Examinarea IRM este superioar\u0103 pentru planning-ul radioterapiei datorit\u0103 posibilit\u0103\u021bii de vizualizare direct\u0103 a tumorii \u0219i de determinare corect\u0103 a \u201dvolumului \u021bint\u0103\u201d. Cancerul cervical debuteaz\u0103 \u00een canalul cervical \u0219i invadeaz\u0103 progresiv stroma colului uterin. \u00cen cazurile avansate pot fi implicate uterul, vaginul \u0219i\/sau structurile adiacente. \u00a0Prin IRM se pot evalua cu fiabilitate crescut\u0103 dimensiunile tumorii (multe dintre leziuni sunt descoperite la dimensiuni mici, dar se \u00eent\u00e2lnesc \u00eens\u0103 \u0219i cazuri cu mase tumorale voluminoase).<\/p>\n<p style=\"text-align: justify;\"><strong>CT<\/strong> se folose\u0219te pentru detec\u021bia adenopatiilor \u0219i pentru evaluarea bolii avansate (metastaze la distan\u021b\u0103), precum \u0219i pentru ghidajul biopsiei percutante \u0219i \u00een planning-ul radioterapeutic. <strong>PET\u2013CT<\/strong> este folosit \u00een cazul cancerelor avansate, pentru evaluarea disemin\u0103rilor tumorale la distan\u021b\u0103 (de ex. ganglioni cervicali sau mediastinali).<\/p>\n<p style=\"text-align: justify;\">\u00cen stabilirea conduitei terapeutice \u0219i \u00een evaluarea prognosticului individual sunt esen\u021biale informa\u021biile oferite de examin\u0103rile imagistice privind sediul tumorii, dimensiunile \u0219i volumul s\u0103u, prezen\u021ba\/absen\u021ba invaziei parametriale (stadiu IIB), invaziei organelor adiacente \u0219i prezen\u021ba metastazelor ganglionare.<\/p>\n<p style=\"text-align: justify;\">O examinarea IRM corect\u0103 presupune preg\u0103tirea prealabil\u0103 a pacientei (examinare <em>a jeun<\/em>, cu administrare de medica\u021bie antiperistaltic\u0103 pentru reducerea artefactelor date de mi\u0219c\u0103rile intestinului) \u0219i trebuie s\u0103 includ\u0103 urm\u0103toarele secven\u021be (protocol de examinare):<\/p>\n<ul style=\"text-align: justify;\">\n<li>Secven\u021be <strong>T2 ponderate<\/strong> achizi\u021bionate \u00een cel pu\u021bin 2 planuri &#8211; axial \u0219i sagital (sunt cele mai utile pentru patologia colului uterin), op\u021bional coronal, cu FOV mic, respectiv rezolu\u021bie crescut\u0103 pentru evaluarea uterului, colului uterin, vaginului \u0219i a parametrelor. Este secven\u021ba cheie pentru\u00a0 diagnosticul de cancer cervical prin vizualizarea masei solide \u00een <u>hipersemnal<\/u>. Se prefer\u0103 secven\u021ba <strong>T2 ponderat\u0103 paraaxial\u0103<\/strong> (perpendicular\u0103 pe axul lung al colului uterin), \u00een special pentru evaluarea invaziei parametriale.<\/li>\n<li>Secven\u021ba<strong> T1 ponderat\u0103<\/strong> achizi\u021bionat\u0103 \u00een plan axial, cu FOV (field of view) mare pentru scanarea \u00eentregului pelvis, cu aten\u021bie deosebit\u0103 pentru detec\u021bia adenopatiilor paraaortice joase, inghinale, respectiv evaluarea structurilor osoase din c\u00e2mpul de examinare pentru detec\u021bia eventualelor determin\u0103ri secundare;<\/li>\n<li><strong>DCE T1 GE dinamic<\/strong> \u2013 folosirea contrastului paramagnetic care aduce informa\u021bii suplimentare \u00een special atunci c\u00e2nd suspicion\u0103m invazie la nivelul organelor adiacente (vezica urinar\u0103, rect, anse intestinale etc) sau eventuale fistule.<\/li>\n<li><strong>Difuzia IRM (DWI)<\/strong> \u2013 tehnic\u0103 func\u021bional\u0103 inclus\u0103 recent \u00een protocolul complet de evaluare a tumorilor pelvine care permite, prin m\u0103surarea h\u0103r\u021bilor ADC (Apparent Diffusion Coeficient), evaluarea ponten\u021bialului malign al unei leziuni; este util\u0103 \u00een special \u00een diagnosticul diferen\u021bial benign-malign pentru cazurile echivoce, pentru aprecierea r\u0103spunsului la tratament (radio\/chimioterapic), pentru diferen\u021bierea recidiv\u0103 local\u0103 versus modific\u0103ri posttratament, dar \u0219i pentru decelarea leziunilor maligne oculte pelvine (determin\u0103ri secundare osoase, ganglionare etc.) inaparente pe secven\u021bele conven\u021bionale. Determin\u0103rile secundare apar pe DWI \u00een hipersemnal pe imaginile cu <em>b value<\/em> crescute (<em>b<\/em> 800), dat de restric\u021bia apei \u00een interiorul structurilor tumorale ce manifest\u0103 hipercelularitate. Pentru leziunile maligne osoase, studiile au ar\u0103tat o sensibilitate a DWI similar\u0103 cu cea a scintigrafiei\/PET CT. Cre\u0219terea valorilor ADC intratumoral se coreleaz\u0103 cu un r\u0103spuns bun la tratamentul adjuvant radio\/chimioterapic. Valorile reduse local pe h\u0103r\u021bile ADC se coreleaz\u0103 cu probabilitate mare de recidiv\u0103 tumoral\u0103.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Secven\u021bele op\u021bionale<\/strong>, dar incluse \u00een protocolul examin\u0103rilor pelvine efectuat la <strong>MED<\/strong>INST pentru a cre\u0219te acurate\u021bea diagnosticului \u0219i precizia stadializ\u0103rii, sunt urmatoarele:<\/p>\n<ul style=\"text-align: justify;\">\n<li>Secven\u021be<strong> T2 ponderate isometrice<\/strong> (achizi\u021bie volumetric\u0103, cu sec\u021biuni sub\u021biri 1mm), realizate \u00een plan sagital, cu posibilitate de reconstruc\u021bie multiplanar\u0103, utile \u00een cazurile echivoce pentru detec\u021bia dep\u0103\u0219irii seroasei sau a invaziei parametriale;<\/li>\n<li>Secven\u021bele <strong>T2 FAT SAT\/STIR<\/strong> care cresc contrastul dintre miometrul normal \u0219i \u021besutul tumoral;<\/li>\n<li>Se pot ad\u0103uga secven\u021be suplimentare <strong>T1 FAT SAT <\/strong>pentru vizualizarea componentelor hemoragice\/gr\u0103soase intra- sau perilezionale sau secven\u021ba <strong>T2*<\/strong>, care are o susceptibilitate crescut\u0103 la produ\u0219ii de degradare ai hemoglobinei sau la calciu (mai utile \u00eens\u0103 pentru studiul endometriozei).<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Caracterele de semnal ale cancerului cervical \u00een examin\u0103rile IRM:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong><\/p>\n<ul style=\"text-align: justify;\">\n<li>este<strong> izointens<\/strong> cu stroma cervical\u0103 pe secven\u021bele T1 ponderate, acestea fiind improprii pentru caracterizarea extensiei tumorii, fiind folosite mai mult pentru evaluarea ganglionilor pelvini\/inghinali;<\/li>\n<li>pe secven\u021bele T2 ponderate (cele mai utile pentru descrierea \u0219i stadializarea tumorilor cervicale deoarece ofer\u0103 un contrast natural pentru vizualizarea arhitecturii zonale locale) cancerul cervical apare ca mas\u0103 \u00een<strong> hipersemnal<\/strong> \u00een stroma cervical\u0103 \u00eenconjur\u0103toare care apare \u00een hiposemnal;<\/li>\n<li>\u00een cancerele cervicale limitate la strom\u0103, se vizualizeaz\u0103 un inel periferic complet intact \u00een hiposemnal T2, ce \u00eenconjoar\u0103 masa tumoral\u0103;<\/li>\n<li>\u00een caz de invazie pe toat\u0103 grosimea stromei, hiposemnalul normal este \u00eenlocuit complet de hipersemnal tumoral; o interfa\u021b\u0103 net\u0103 tumor\u0103-parametru exclude invazia parametrial\u0103;<\/li>\n<li>distrugerea inelului stromal cu semnal tumoral nodular sau neregulat extins spre parametru indic\u0103 invazie parametrial\u0103.<\/li>\n<li>pe secven\u021bele T1 postcontrast tumorile cervicale demonstreaz\u0103 \u00eenc\u0103rcare variabil\u0103 cu contrast paramagnetic. Examin\u0103rile cu substan\u021b\u0103 de contrast sunt utile \u00een stadiile avansate pentru detec\u021bia invaziei organelor adiacente sau a peretelui pelvin.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Diagnosticul diferential al tumorilor cervicale:<\/strong><\/p>\n<p style=\"text-align: justify;\">Chist Naboth \u2013 chist epitelial superficial, cu dimensiuni variabile; are semnal lichidian, f\u0103r\u0103 priz\u0103 (captare) de contrast;<\/p>\n<p style=\"text-align: justify;\">Poplipul cervical benign \u2013 nu invadeaz\u0103 stroma cervical\u0103. Este imposibil de diferen\u021biat imagistic de un cancer cervical f\u0103r\u0103 invazie de strom\u0103 cervical\u0103;<\/p>\n<p style=\"text-align: justify;\">Adenoma malignum \u2013 col uterin m\u0103rit, cu multiple forma\u021biuni chistice \u201e\u00een ciorchine\u201d situate intrastromal;<\/p>\n<p style=\"text-align: justify;\">Limfom sau metastaze cervicale \u2013 implicarea difuz\u0103 a stromei cervicale; canalul cervical este intact.<\/p>\n<p style=\"text-align: justify;\">Echipa Medicala\u00a0MEDINST Diagnostic<br \/>\nRom\u00e2no-German<\/p>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945.jpg\" rel=\"attachment wp-att-4113\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-4113\" src=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945-300x90.jpg\" alt=\"MADinst\" width=\"300\" height=\"90\" srcset=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945-300x90.jpg 300w, https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945.jpg 800w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p style=\"text-align: justify;\"><strong>Medinst Diagnostic Rom\u00e2no-German func\u021bioneaz\u0103 din anul 1997 \u00een cadrul Institutului Na\u021bional de Neurologie \u0219i Boli Neurovasculare Bucure\u0219ti.<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Cancerul cervical se afl\u0103 pe pozi\u021bia a treia ca frecven\u021b\u0103 \u00een cadrul neoplaziilor ginecologice \u0219i are dou\u0103 v\u00e2rfuri de inciden\u021b\u0103: 30-44 ani, respectiv 75 ani.\u00a0 Folosirea metodelor de screening (examen [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":5243,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[33,429],"tags":[442],"class_list":["post-5139","post","type-post","status-publish","format-standard","has-post-thumbnail","category-articole","category-ginecologie","tag-medinst"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Imagistica prin Rezonan\u021b\u0103 Magnetic\u0103 \u00een stadializarea \u0219i \u00een monitorizarea cancerului de col uterin<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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