Diagnosis and Staging work Up

Routine clinical, laboratory, and radiological examinations for gynaecological malignancies are performed for the purpose of tumor detection, diagnosis, and accurate staging, so as to enable optimal treatment planning. Specific radiologic examinations for each malignancy depend on the site, histology, grade, and pattern and extent of spread based on clinical evaluation.

Investigations and Work-up for Cervical Cancer

Pre- treatment evaluation / Investigations

• Complete physical and gynaecological examination.
• CBC, Biochemistry and urine analysis, Chest X ray
• Ultrasonography or CT Scan / MRI of abdomen and pelvis.
• Biopsy- punch, knife, colposcopy guided or conization
• Cystoscopy / Barium enema / sigmoidoscopy / IVU - if bladder, rectal or ureteric involvement is suspected

Staging of Carcinoma of cervix

Stage 0

Pre-invasive carcinoma/ carcinoma in situ

Stage I

Tumour confined to cervix.

Stage IA1

Micro-invasive (diagnosed only under microscopy), no greater than 3 mmdepth and no wider than 7 mm.

Stage IA2

5mm below the basement membrane (BM) and > 7mm in transverse dimension.

Stage IB

5mm below BM and >7mm wide invasive lesion but limited to cervix only.

Stage IB1

4 cm in size

Stage IB2

4 cm in size

Stage II

Tumour beyond uterus but not the lower 1/3 of vagina or up to the pelvic side walls.

Stage IIA

without Parametrial invasion.

Stage IIB

with Parametrial invasion.

Stage III

Tumour extending upto pelvic wall, lower 1/3 vagina, hydro-nephrosis or non-functioning kidney.

Stage IIIA

No extension to pelvic wall but involved lower 3rd vagina.

Stage IIIB

Extension to pelvic side wall, hydronephrosis or non-functioning kidney.

Stage IV

Stage IVA

Invasion of bladder and/or rectum.

Stage IVB

Disease outside pelvis. Para-aortic nodes are regarded as distant metastasis.

Investigations and Work-up for Ovarian Cancer

Clinical examination

• Haematological and biochemical investigations
• Ultrasonography of abdomen & pelvis (transabdominal + transvaginal) with colour doppler in selected cases
• Imaging modalities for abdomen & pelvis to document extent of spread e.g. CT scan, MRI
• Tumour markers e.g. CA-125, beta HCG, AFP and CEA.
• Others Cytological examination of ascitic / pleural fluid if present
• Fine needle aspiration cytology of the mass, only if the disease is stage III & above and primary surgery not contemplated in view of clinically unresectable disease (to achieve cytological diagnosis prior to neo- adjuvant chemotherapy)

Staging: Ovarian carcinoma is a surgico-pathologically staged cancer. It requires a laparotomy with a thorough examination of the abdominal cavity. If disease appears confined to the ovary, biopsy of the diaphragmatic peritoneum, paracolic gutters, pelvic peritoneum, para-aortic and pelvic nodes, infracolicomentum are required in addition to peritoneal washings. In the event the patient receives chemotherapy prior to surgery, clinical staging is followed. However, every effort must be made to stage the disease as accurately as possible by imaging studies or laparoscopic evaluation.

Stage I: Growth limited to the ovaries

1A: Growth limited to one ovary; no tumour on the external surface; capsule intact; no ascites.

1B: Growth limited to both ovaries; no tumour on the external surface; capsule intact; no ascites

IC: IA or IB but with tumour on the surface of one or both ovaries; rupture of capsule; malignant ascites or positive peritoneal washings

Stage II: Growth involving ovaries with pelvic extension

IIA: Extension/metastases to uterus and or tubes

IIB: Extension to the pelvis.

IIC: IIa or lIb but with tumour on the surface of one or both ovaries; rupture of capsule; malignant ascites or positive peritoneal washings

Stage III: Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal lymph nodes. Superficial liver metastases equals stage

III. Tumour is limited to true pelvis but with histologically verified malignant extension to small bowel or omentum

IlIA: Tumour grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces"

IIIB: Tumour of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Nodes negative.

IIIC: Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes

Stage IV: Growth involving one or both ovaries with distant metastases. If pleural effusion is present, cytological test results must be positive to allot a case to stage IV. Parenchymal liver metastases equals stage IV.