Ultrasonography versus histopathology for diagnosing

cervical cancer metastasis to urinary bladder, which

one is more accurate?
dr. Andi Darma Putra. Sp. OG(K)

Division of Oncology, Department of Obstetrics and Gynecology

Faculty of Medicine Universitas Indonesia / Cipto Mangunkusumo Hospital, Jakarta

ABSTRACT
Introduction: Cervical cancer is one of the commonest gynecological cancer that causes
death among women in developing countries. It is commonly found in advanced state,
therefore it needs accurate diagnostic for better outcome. Cystoscopy is the approved method
for assessing involvement of bladder according to the International Federation of Gynecology
and Obstetrics (FIGO), but it may be missed if the tumors only involve the outer bladder wall
without any invasion of the mucosa. The recent various studies showed ultrasonography has
become increasingly useful for detecting invasion of urinary bladder in cervical cancer.
Objectives : To review and compare the effectiveness of ultrasonography and histopathology
for diagnosing bladder involvement in advanced cervical cancer patients.
Methods : A prospective study was conducted between January 2019 and March 2019 on 6
patients with advanced cervical cancer. These patients underwent both ultrasound and
cystoscopy to diagnose bladder involvement. Presence or absence of bladder involvement
was then confirmed with ultrasound and cystoscopy examination.
Results : In all the 6 patients that were studied, 5 patients showed clinical hematuria. On
these 5 patients, 1 patient showed bladder involvement on cystoscopy, while the others
showed no bladder involvement on cystoscopy. Whether for the remain 1 patient with clinical
non-hematuria, cystoscopy shows no bladder involvement. On the other hand, ultrasound
shows bladder involvement clearly in all these 6 patients. Therefore, in this study, ultrasound
was 100% sensitive in detecting bladder involvement for cervical cancer.
Conclusion : TVS is a more sensitive and accurate tool than cystoscopy for diagnosing
bladder invasion in advanced cervical cancer
INTRODUCTION
Cervical cancer is one of the major causes of death from cancer among women in
developing countries.1 In 2018, an estimated 569,847 new cases of cervical cancer were
diagnosed and 311,365 deaths occurred worldwide due to this malignancy.2 Indonesia is the
4th ranking country in South-East Asia, with the highest cervical cancer incidence after
Cambodia, Myanmar, and Thailand.3
Human Papillomavirus (HPV) causes 90% of cervical cancer with just two types, 16
and 18 that responsible for 70% of all cervical cancers.4,5 It commonly spreads through
sexual or skin-to-skin contact with an infected area of body.5
The treatment are determined on the degree of cancer metastasis based on The
International Federation of Gynecology and Obstetrics (FIGO).1,6 Invasion of the urinary
bladder is seen in about 6%-8% of all patients with cervical cancer and when present, it has
already been in advanced staging.1
FIGO has recommended IVP and cystoscopy for the staging of cervical cancer.7
However, previous studies have shown FIGO staging to be relatively inaccurate in 34–39%
of cases.8 Furthermore, it is difficult to obtain accurate information concerning invasion of
the bladder wall using cystoscopy, because infiltration extends inward from outer layer.6
Therefore, it is important to accurately stage the patients and diagnose bladder invasion.1,6
There are several alternative methods that have been commonly used for detecting
bladder infiltration, but they remain limited.9 Magnetic resonance imaging (MRI) was
reported to have better sensitivity and specificity than computed tomography (CT) in
assessing bladder wall infiltration, but both of them are expensive and lack of availability.1,9
Laparoscopy allows macroscopic inspection of tumor involvement as well as biopsy samples
from suspicious sites at the cervicovesical junction, but it is an invasive procedure.9
Transvaginal ultrasonography (TVS) appears to be a suitable alternative in diagnosing
bladder involvement, especially in this situation.1,6 Its validity has been shown in various
studies recently.1 TVS is a simple, non-invasive and low-cost technique.10 It was reported to
be useless in the pretreatment evaluation of invasive cervical cancer because of its low
contrast resolution.10 However, recent high-resolution TVS provides a relatively clear
demonstration of the tissue planes between the cervix and lower urinary tract.9,10
This case report will discuss the accuracy and effectiveness of ultrasound and
histology in diagnosing bladder involvement in cervical cancer patients.
Ultrasonography Versus Histopathology for Detecting Urinary Bladder Metastasis
in Cervical Cancer
Cystoscopy is the approved method for assessing involvement of the bladder
according to the International Federation of Gynecology and Obstetrics (FIGO).9 However, it
has only a limited role in the evaluation of infiltration or invasion of the bladder wall.9 In
short, bladder invasion may be missed during a cystoscopic examination if the tumors only
involves the outer bladder wall without any invasion of the mucosa.1 Several alternative
methods have been proposed for detecting bladder infiltration, such as CT-scan and MRI, but
they remain limited due to a lack of universal availability and patient affordability.1,9
TVS is a promising tool to diagnose bladder invasion due to its easy availability, non-
invasive, and lower cost.10 Both the inner and outer wall of the bladder can be clearly
distinguished and seen on TVS.10 Bladder invasion may easily be diagnosed on TVS by
identifying disruption, irregularity or tenting of the outer bladder wall (Figure 1).10
Ultrasound characteristics of bladder wall involvement are a tumor protuberance at
the junction of the cervix and the uterine corpus which adjoined and invaded the bladder in
the supratrigonal area, resulting in an elevation of the bladder wall and causing a tent like
appearance of the bladder wall on TVS.1,9 In addition, the inner bladder wall was found to be
heteroechoic with abnormal surface and echotexture.1 Areas of increased echogenicity or
hypoechoic areas with an irregular outline signify changes also compatible with cervical
carcinoma.11 Cervical carcinoma may exhibit an exophytic or an endophytic growth pattern.12
There are several reports that show TVS to be a promising tool to diagnose urinary
bladder invasion in cervical carcinoma.1 One recent study at 2017 showed that TVS is 100%
sensitive in diagnosing bladder invasion.1 This was confirmed both intra operatively and by
histopathologic examination of the excised specimens.1
Another study from Iwamoto K et al shows the similar results.6 In their study, the
diagnosis of bladder invasion was made by restricted mobility of the bladder wall over the
cervix upon moving the probe in anterior fornix.1,6 They also reported a relatively lower
accuracy of CT, MRI, or cytoscopic examination (76%, 86%, 80% respectively) than TVS
(95%) in detecting bladder invasion.6 TVS has many features that allow an accurate
diagnosis, including the possibility of real-time examination and superior image quality.6
Huang WC et al., also reported a 100% sensitivity of the TVS in diagnosing bladder
infiltration.9 The variables they measured on TVS to define bladder infiltration included
bladder wall thickness, less clear-cut bladder wall outline and morphological changes in the
inner bladder.9 Disruption of the endopelvic fascia without involvement of the inner bladder
wall was the initial stage of bladder wall invasion (stage I).9 Therefore, cystoscopy would not
reveal any abnormality of the bladder mucosa.9

Figure 1. TVS image of a patient with bladder involvement showing tenting of the
bladder wall.

MATERIALS AND METHODS

A single retrospective study was conducted at Cipto Mangunkusumo Hospital,
Jakarta, Indonesia between January 2019 and March 2019. Study subjects consisted of all
women with a diagnosis of advanced stage (Stage IIIB, IVA and IVB) cervical cancer. All
patients were examined with TVS and cystoscopy by an oncologist to detect invasion of the
urinary bladder.
TVS was performed with patients in the supine position using Toshiba SSA-260A
(Tokyo, Japan) or Toshiba Power Vision 6000 (Tokay, Japan) scanners or a Voluson 730
scanner (GE Medical Systems, Zipf, Austria). During the TVS procedure, the probe was
placed in the anterior fornix with focus on the cervico-vesical junction and images were
obtained in multiple planes to identify structural changes suggestive of bladder invasion,
include tenting of the bladder wall and loss of integrity of the bladder-cervix interface
(Figure 2). This procedure was performed by a single oncologist who is also an expert in
radiology to eliminate any interobserver variations.
Figure 2. A transvaginal transducer is inserted into the anterior fornix of the vagina and used
to study the bladder wall in the sagittal plane. UT = uterus; CX= cervix, T=transducer.

RESULTS
Few minutes were required to do ultrasound and cystoscopy examination. The
average ages of the subjects were between 37 – 64 years. Four of the six women in the study
group were postmenopausal. One of the women had a history of post hysterectomy and
radiotherapy.
All tumors were squamous cell carcinomas. The initial clinical staging for the study
group was stage IVA in five cases (Cases 1, 2, 3, 5, 6) and stage IVB in one case (Case 4).
In these cases, subject 5 had significant finding of bladder involvement on cystoscopy
(17%). However, in the remain cases, they showed no significant findings of bladder
involvement on cystoscopy (83%). On the other hand, TVS showed bladder involvement in
all 6 cases (100%).
Ultrasound
Clinical Cystoscopy Cystoscopy primary site
(bladder
(Hematuria +/-) endometrium (bladder involvement)
involvement)
Case 1 + + - +
Case 2 + + - +
Case 3 + + + +
Case 4 + + - +
Case 5 - + - -
Case 6 + + - +

Figure 3. Ultrasonography and cystoscopic findings in study group

LIMITATION
The subjects in the present study, were relatively little, need to be confirmed by trials with
larger sample size.

CONCLUSION
Accurate clinical evaluation of cervical cancer is crucial to have a successful
treatment that leads to a better outcome. The recent introduction of high-resolution vaginal
probes showed ultrasonography has become increasingly useful for detecting invasion of
urinary bladder in cervical cancer.9
Even though cystoscopy is the approved method for assessing involvement of the
bladder according to the FIGO, it has only a limited role in the evaluation of infiltration or
invasion of the bladder wall. Bladder invasion may be missed during a cystoscopic
examination if the tumors only invades the outer bladder wall without the mucosa.
On the other hand, both the inner and outer wall of the bladder can be clearly
distinguished and seen on TVS. Bladder invasion may easily be diagnosed on TVS by
identifying disruption, irregularity or tenting of the outer bladder wall. Several studies also
have shown that TVS is more sensitive and accurate than CT, MRI, or cystoscopy for
diagnosing of bladder invasion in advanced cervical cancer. Therefore, TVS is a highly
sensitive and better tool than cystoscopy for diagnosing bladder invasion in advanced cervical
carcinoma.
References

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