UNIVERSITATEA DE MEDICIN I FARMACIE

IULIU HAIEGANUCLUJ-NAPOCA

COALADOCTORAL

REZUMATTEZDEDOCTORAT

Studiicomparativealemetodelor
imagisticenstadializarea
canceruluidecoluterin

DoctorandViorica,Varodi
ConductordedoctoratNicolae,Costin

CLUJNAPOCA2011

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Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

Mulumesc,
Dlui.prof.dr.NicolaeCostin,Dlui.conf.dr.AlexandruIrimie,
Dluidr.VasilePopi,Dlui.dr.OresteStraciuc,
Dnei.MarilenaCheptea
inunultimulrndfamilieimele,
pentrusprijinuliajutorulacordat.

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Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

CUPRINS

INTRODUCERE
13
STADIULACTUALALCUNOATERII

1.DATEGENERALEDEANATOMIEIHISTOLOGIEACOLULUIUTERIN 17
1.1.Anatomiacoluluiuterin
17
1.2.Histologiacoluluiuterin
19
1.3.Histogenezaneoplaziilorintraepitelialecervicale(CIN)icancerulinvaziv 21

2.EPIDEMIOLOGIACANCERULUIDECOLUTERIN

2.1.Incidenimortalitate
2.2.Dategeneraledespreepidemiologiacanceruluidecoluterin
2.3.Istorianaturalacanceruluidecoluterin
2.4.Factoriiderisciprognosticulcanceruluidecoluterin

3.METODEDIAGNOSTICENCANCERULDECOLUTERIN

3.1.Examenclinic
3.1.1.Simptomatologie
3.1.2.Examencuvalveitueuvaginal
3.2.Investigaiispecialendepistareaprecoceacanceruluidecoluterin
3.2.1.Citologieexfoliativ.ExamenBabePapanicolau
3.2.2.SistemBethesda
3.2.3.Biopsiacervical
3.2.4.Diagnostichistopatologic

4.STADIALIZAREACANCERULUIDECOLUTERIN

4.1.SistemuldestadializareFIGO
4.2.SistemuldestadializareM.D.Anderson
4.3.SistemuldestadializarepropusdeAmericanjointcommitteoncancer
4.4.SistemuldestadializareTNMalUICC
4.4.1.Corelareastadializriiclinicecuceachirurgical

5.PRINCIPIIDETRATAMENTNCANCERULDECOL
5.1.Urmrirepostterapeutic

CONTRIBUIAPERSONAL
1.IPOTEZDELUCRU
1.1.Obiectivegenerale
1.2.Obiectivespecifice

2.MATERIALIMETOD

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2.1.Metodologiageneral
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2.1.1.Limfografia
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2.1.1.1.Avantaje
52
2.1.2.Ecografia
52
2.1.2.1.Avantaje
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2.1.3.Tehnicaganglionuluisantinel(Limphaticmapping)
55
2.1.3.1.Avantaje
55
2.1.4.ComputerTomografia(CT)
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2.1.4.1.Avantaje
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2.1.5.Imagisticaprinrezonanmagnetic(IRM)
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2.1.5.1.Avantaje
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2.1.6.TomografiacuemisiedepozitroniTomografiecomputerizat(PETCT)64
2.1.6.1.Avantaje
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2.2.Metodologiaexaminarii
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2.2.1.Evaluareatumoriiprimare
2.2.2.Evaluareastaiilorganglionare
2.2.3.Evaluarearspunsuluilatratament

3.REZULTATE

3.1.Vrsta,mediuldeprovenien,niveleducaional,starecivil
3.2.Diagnostichistopatologic
3.3.Stadializare
3.4.Adenopatiilelomboaortice
3.5.Invaziaparametrelor

4.DISCUII

4.1.Vrsta
4.1.1.Concluziideetap
4.2.Mediuldeprovenien
4.2.1.Concluziideetap
4.3.Niveluleducaional,starecivil
4.3.1.Concluziideetap
4.4.Diagnostichistopatologic
4.4.1.Concluziideetap
4.5.Stadializare
4.5.1.Concluziideetap
4.6.Adenopatiilelomboaortice
4.6.1.Concluziideetap
4.7.Invaziaparametrelor
4.7.1.Concluziideetap
4.8.PETCT
4.8.1.Concluziideetap
4.9.Evaluareapostterapeutic
4.9.1.Cazuriclinice

5.CONCLUZIIGENERALE
6.ORIGINALITATEAICONTRIBUIILEINOVATIVEALETEZEI
6.1.Evaluareaautocriticatezei

7.ANEXE
8.REFERINE

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CUVINTE CHEIE: CANCER DE COL UTERIN, STADIALIZARE, TOMOGRAFIE

COMPUTERIZAT,REZONANMAGNETIC,PETCT

Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

REPERECONCEPTUALEALECERCETRII

Actualitatealucrrii:Canceruldecoluterinareunimpactmondialdeosebit,
ceeacelsitueazpeloculaldoileanrndulneoplaziilorlafemeiledintoatlumea,
estimnduse, n 2002, un numr de 493.000 de femei diagnosticate primar cu
neoplasm cervical, 274 000 care au decedat. Majoritatea cazurilor (83%) sunt
diagnosticate n rile n curs de dezvoltare, unde implementarea programelor de
screening citologic este defectuoas. Impactul social al cancerului de col uterin este
chiar mai mare dect sugereaz numrul de cazuri, deoarece cancerul de col uterin
afecteazfrecventfemeilerelativtinere,fiindocauzmajoramortalitiinrilen
cursdedezvoltare.
Descriereasituaieindomeniuldecercetareiidentificareaproblemelor
de cercetare. Incidena cea mai mare a cancerului de col uterin sa nregistrat n
Africa, sudestul Asiei i n America Latin, n timp ce n rile industrialiazate
incidenaestemultmairedus,cuvalorialerateistandardizatepevrstsub15cazuri
la100000.
nRomniasenregistreazceamaimareincidenimortalitateprincancer
de col uterin din Europa, dup date estimate de IARC (Agenia Internaional de
CercetareaCancerului)pentruanul2000.

2.2. Date generale despre epidemiologia cancerului de col

uterin

Cancerul de col uterin (CCU) reprezint o problem primordial de sntate

publicpemapamond,avndoincidenridicat.
n95%cazuriesteuncarcinomepidermoidinumain5%adenocarcinom.
Cancerul colului uterin totalizeaz 44% din totalul neoplaziilor genitale
feminine, fapt ce justific eforturile depuse pe plan naional i internaional pentru
studiereaacesteimaladii.

2.3.Istorianaturalacanceruluidecoluterin

Istoria natural a cancerului de col se bazeaza pe faptul c leziunile care

precedapariiaboliineoplazicepotevolua(nuobligatoriu)delaoleziunedisplazicala
uncancerinsituiapoictreoleziuneneoplazicinvazivCanceruldecoluterineste
otumormaligncaresedezvoltdinepiteliulcervicalobinuitdelanivelulzoneide
interferendintreepiteliulpavimentosexocervicalicelcilindric,deundeseextinde
din aproape n aproape n suprafa i profunzime, invadnd colul endocervical i
organeledinjurimetastazndpecalelimfatic

2.4.Factoriiderisciprognosticulcanceruluidecoluterin

Populaia cu risc crescut pentru cancerul de col uterin este infecia cu HPV
constituie principalul factor de risc al apariiei CINurilor. ADNul HPVului este
detectatn9599%dincazurilecucancereinfiltrativei90%dincazurileculeziunide
gradnaltlanivelcervical
PerioadamediedintreoleziuneHSILiapariiacanceruluiesteestimatla10
ani. Numeroase studii de cohort au evaluat riscul dezvoltrii CINurilor asociate cu
detectareaHPVuriloroncogene

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Ali factori de risc: viaa sexual precoce (sub 17 ani); parteneri multipli,
promiscuitate; numr mare de avorturi; multiparitatea; nivel socioeconomic i
cultural precar; maladii cu transmisie pe cale sexual; fumatul; boli
imunosupresive.Riscul de cancer al colului apare n adolescen i continu pn n
jurulvrsteide50deani.Aceastasugereazposibilitateacahormoniisfieimplicai
n carcinogeneza , dei sunt posibile i alte explicaii. Printre acestea, exist i
posibilitateacaanticoncepionaleleoralespoatinfluenacancerulgenital.
Majoritatea studiilor epidemiologice sunt unanime n a considera c
repartizarea cancerului cervical pe grupe de vrst urmeaz o curb ascendent
ncepndcudecada2029deani,cuunmaximumndecada4554 deani,dupcare
descretelent.
Anumite studii arat c modificrile genetice pot aprea mult naintea celor
histologice, ceea ce ar putea permite, teoretic, deplasarea precocitatii diagnosticului
pn la nivel subcelular cromosomial.n ultima vreme sa reuit s se stabileasc
fizionomia unor tipuri de populaie cu un risc crescut de mbolnvire (high risk
population), noiune de mare nsemntate pentru organizarea economic i eficace a
profilaxiei, depistrii i a diagnosticului precoce n cancerul colului uterin., A fost
remarcatofrecvenmairidicataneoplazieiintraepitelialecervicalelafemeilecare
auprimitmedicaieimunosupresivdupuntransplantrenal.
Human Papyloma Virus de tipul 6, 11, 16 i 18 este responsabil de apariia
canceruluidecoluterinn70%cazuri

PARTEASPECIALA

CONTRIBUIIPERSONALE

Introducere

Cancerul colului uterin este o malignitate extrem de frecvent, incidena

anualala100.000defemeifiindvariabil
n Romnia incidena cancerului de col uterin are tendine nefavorabile n
ultimiiani,attprinincidenaridicataboliictiprinfrecvenaridicatacazurilor
avansate.Acesta se datoreaz n principal politicilor sanitare din ultimii ani i
ineficieneiprogramelordescreening.
Diagnosticul cancerului de col uterin, stadializarea si monitorizarea post
terapeutic este facut n prezent dup criterii stabilite de ctre Federaia
InternaionaldeGinecologiesiObstetic(FIGO).CiteriileutilizatedeFIGOsuntnsa
limitate,nprincipalexamenulclinic.Stadializareaimagisticnuesterecunoscut,iar
explorrile imagistice recomandate inc sunt radiografia toracic, urografia
intravenoas(UIV)siclismabaritat.
Dac pentru stadiile incipiente examenul clinic si stadializarea clinic se pot
dovedi eficiente pentru un numr mare de cazuri, pentru stadiile mai avansate cu
invazielocalsaudeterminriganglionaresecundareevaluareaclinicestenmulte
cazuriineficient,iarutilizareametodelorimagisticesecionale(US,CT,IRM,PETCT)
oferdateexcelentepentruapreciereaextinderiibolii.nultimaperioad,chiardac
FIGOnurecunoatestadializareaimagistic,recomandtotuifolosireanunelecazuri

Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

aimagisticiisecionale.
Precizareacuexactitateaextinderiibolii,preterapeutic,esteesenialpentruo
conduit terapeutic corect. Opiunile terapeutice sunt dependentente de stadiul
bolii.
Scopullucrrii: Scopul tuturor cercetrilor n oncologie la constituit
ameliorareamijloacelordediagnosticdecarevadepindeconduitapracticdeviitor.

n mod particular, n cazul cancerului de col uterin, dup confirmarea

diagnosticului pozitiv, un rol esenial l constituie fixarea unei ct mai exacte
stadializri a bolii care devine esenial. La ndemnapracticianului rmne i astzi
efectuarea unei stadializri pe principii clinice la care se ncearc n a apela la
numeroase investigaii paraclinice ceau aprut dea luingul anilor (limfografia,
ecografia,CT,IRM,PET).

Cu toate progresele efectuate, stadializarea cancerului de col uterin comport

nc dificulti de ordin practic, tendina n ceea ce privete stadializarea este fie n
minus,fienexces,careintruncazinaltulesteriscant.

Tendinaactual,nvedereauneistadializrictmaicorecteacanceruluidecol
uterin,seimpuneafolosicelemaimoderneifiabilemetodeiinvestigaiiparaclinice,
nmodparticular,CT,IRMiPETCT.

Aceste metode iau dovedit fiabiliatea rednd un grad nalt de sensibilitate i

specificitateametodei.

nfunciedestadializareactmaiexact,depindefixareaetapelordetratament,
supravegherea acestuia, in modcutotul particularva depinde prognosticul bolii i
nu n ultimul rnd diagnosticul i supravegherea complicaiilor postchirurgicale i
postradioterapeutice. Scopul lucrrii de fa, const n a face un studiu comparativ a
numeroaselor investigaii imagistice corelate cu examenul clinic n vederea stabilirii
unei stadializri ct mai exacte de care va depinde prognosticul i tratamentul pe
termenscurtilungaacestorcauze.

Lucrareadefaconstituie unelementdepioneratnliteraturadespecialitate
peplannaional.

Finalitatea acestui studiu va constitui un excelent ghid de conduit pentru

medicul practician n formularea unui algoritm imagistic de investigaii pre i
postterapeutic.
Materialimetod:Amrealizatunstudiuretrospectivlongitudinal,avndla
dispoziieunlotde50depaciente,investigatecliniciimagisticnInstitutulOncologic
Prof.Dr.IonChiricuClujNapocanperioada01.06.200530.04.2009.Afostluate
n studiu un numr de 50 bolnave cu diagnosticul de cancer de col uterin confirmat
histopatologic.Pentrustudiusaufolositfoiledeobservaiedeundeaufostrecoltate
datelecliniceideinvestigaiiparaclinice.
Aufostinclusenstudiu(criteriideincludere):
pacientelecuvrstacuprinsntre1879deani
pacientelecuconfirmarehistologicdecarcinomdecoluterin.
Aufostexclusedinstudiu(criteriideexcludere):
pacientecuvrstapeste80deani
pacientelecuafeciunineoplazicenantecedente
pacientelecuneoplaziisincrone.
Examenulclinic,biopsiadiagnosticistadializareaaufostefectuatencadrul
InstitutuluiOncologicProf.Dr.IonChiricuClujNapoca(IOCN).

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Un grup de 8 paciente au fost investigate imagistic (PETCT) n Centrul de

Diagnostic Pozitron Oradea, constatrile examenului PETCT fiind analizate
comparativcuinvestigaiileCTsiIRManteriorefectuate.
Prelucrarea statistic a datelor sa realizat cu ajutorul programelor SPSS i
StatisticasubWindows.
Sau utilizat metode de statistic descriptiv i analitic (histograme pentru
distribuia valorilor, medii +/ deviaie standard, intervale de confiden, valori
minime/maxime),frecventeitestulHiptrat(Chisquare)testbidirecional.
Metodologia cercetrii tiinifice: n vederea unor analize semiologice a
leziunilor prin IRM (sau cu ajutorul IRM) a cancerului de col uterin sau utilizat
urmtoarelesecvene(etape):
Identificareaitopografialeziunii:
Cndleziuneadevinevizibil,semnalulaparemoderathiperintensimaimult
heterogen n ponderaia T2. n ponderaia T1, leziunea este izointens i crete
moderat dup injectarea de gadolinium n raport cu stroma i miometrul din
vecintate.
Suntobligatoriudemenionatlocalizareaendosauexocervicalaleziunii.
Msurareaideterminareavolumuluitumoral:
Sa demonstrat c elementele determinante la pacientele cu cancer de col
uterin sunt: volumul tumorii, gradul de extensie cervical sau parametrial i tipul
histologic. Utilizarea antenelor endovaginale au permis determinarea precis a
volumului tumoriiivaloareade 13cm3estepropuscalimitlacaresupravieuirea
la3aniesteapreciatde100%.
Invaziaparametrelor:
Constituie o etap foarte important n examinarea prin IRM a cancerului de
col uterin curmnerea inelului fibros care este hipointens. Dac acesta este integru
njurulleziuniiputemspunecnuestenicioinvaziestromal(FIGO1B).
Efraciafocal a inelului fibroscu extensie directatumorii este un semn de
invazie a parametrelor (FIGO2B). Injectarea cu gadolinium pe cale intravenoas
permiteaprecizaraporturileanatomicentreesutulsntosi tumorideasemenea
vizualizareaeventualelorzonedenecroztumoral.
Cnd tumora cuprinde toat grosimea stromei, constatm prinderea
parametrelorn73%dincazuri.
- Invaziavaginului:
Se poate afirma dac este o extensie directde la tumor la pereii vaginului
sauobliterareaparialafornixuluivaginal.Esteimportantdeaprecizastadializarea
zoneiinvadate(treimeasuperioarsaudoutreimiinferioare).
- Invaziavezical:
Este confirmat dac n T2 hiperintens al tumorii este nlocuit cu semnalul
hipointensalpereteluivezicaliapoitergereaplanuluigrsosceseparcoluluterin
de vezic. Este important de a diferenia o atingere a ntregului perete vezical de o
atingere limitat a musculaturii singure (n aceast situaie radioterapia poate fi
realizat).
- Infiltrarearectal:
Se confirm dac n T2 semnalul hiperintens al tumorii nlocuiete semnalul
hipointensalpereteluirectaliduptergereaplanuluigrsosceseparcoluluterin
derect.Injectareasubstaneidecontrastaduceomaibunvizualizareaimaginii.

Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

11

Invaziaureterelor:
Esteconfirmatdeextensiadirectatumoriisaucompresiuneaureterelorde
ctreaceastea.
SecveneleurograficenhiperponderaiaT2permitvizualizareanansamblua
ureteruluidilatatidemonstreazcupreciziesediulobstruciei.
Invaziapereteluipelvin:
Ea este definit prin prezena tumorii la mai puin de 3 mm de perete. Acest
estedefaptconstituitdemuchiiridictorianali,obturatoriinterniipiriformi.Invazia
direct este definit dedispariia plnului grsos paramuscular, prezena unui semnal
T2nmuchisauintensificareadupinjectareadegadoliniumninteriorulmuchiului
ncontinuitatedirectcutumora.
Invazialimfatic:
Diagnosticuladenopatiilorpelvinesauabdominalesebazeazpeurmtoarele
criterii: ganglioni deformoval a cruiaxmare estepeste uncm , sau ganglioni de
formrotunjitacruidiametruestedepeste8mm.Dinpunctdevederemorfologic
suntcercetateurmtoarelesemne:
- Neregularitateaconturuluiganglionilor
- Uoaracompoziiegrsoasperiganglionar
- Plcidenecrozmaimultsaumaipuinntinse
- Aspectheterogenalganglionilor
Se vor analiza sistematic ariile ganglionare: inghinale, parametriale, iliaci
comuni,iliaciinterni,externi,obturatori,presacrai,lomboaortici,bifurcaiailiacpn
deasupraveneirenale.
Studiul ganglionilor reprezint n mod sigur un timp capital al bilanului de
examinare.
Evaluarea tumorii primare: Criteriile CT si IRM utilizate pentru precizarea
limitriilacolatumoriiaufost:
delimitareanetaaprocesuluitumoral
absentamaseitumoralenlojeleparametriale
absenadensificariiparametriale
conservareaesutuluilipomatosperiuterin.
Pentru precizarea invaziei parametriale, criteriile CT i IRM utilizate, au fost
celestabilitedeVick:
neregularitateasaudelimitareaimprecisnplanlateralacoluluiuterin
infiltrareaesutuluiparametrial
obliterareagrsimiiperiuterine
prezenauneimasetisulareexcentrice
CriteriileCTutilizatepentruinvaziavezicalsaurectalaufost:
absenafocalaplanuluilipomatosperivezicalsauperirectal
prezena unei mase tumorale endoluminale, n continuitate cu tumora
primardelanivelulcoluluiuterin
Aspectul nodular al peretelui rectal sauvezical precum i demonstrarea unui
traiectfistulosaufostdeasemeneaurmrite.
Evaluarea staiilor ganglionare: Criteriile imagistice (CT si IRM) pentru
definireaadenopatiilortumoraleaufost:
criteriuldimensional:ganglionicudimensiunidepeste5mmngrupele
pelvineipeste10mmngrupeleabdominale

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criteriulstructural:hipodensitateafocalcentral(hipersemnalT2laIRM),
urmare a necrozei ganglionare a fost considerat criteriu cert al invaziei
tumoraleindiferentdedimensiunileganglionului.
Evaluarea rspunsului la tratament: Evaluarea imagistic postterapeutic
saefectuatpentrudeterminareagraduluideraspunslatratament,precumipentru
detectarearecidiveitumorale.
Rezultate:Referitorlavrstapacientelordinlotulcelor50careaubeneficiat
deevaluareimagisticiIRMsiCTamconstataturmtoarele:
mediavrsteiafostde4812ani,95%IC:4552;
medianavrsteiafostde49deani;
modulvrsteiafostde58deani;
vrstele pacientelor au fost cuprinse ntre valoarea minim de 18 ani i
valoareamaximde79deani;
distribuiavalorilorvrsteiafostuniform.

Figura44:IRMseciuniaxialenponderaieT1iT2,cuevideniereaunei
recidivetumoralepresacrateiaadenopatiilorlomboaorticeiiliacecomune

Figura45:PETCTseciuniaxialecupunereanevidenaamaseitumoralepresacrate
(recidivatumoral)iaadenopatiilortumoraleiliacecomunedrepte

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13

Datorit numrului redus de cazuri disponibile (8) cu CETPT nu am avut

posibilitatea efecturii unei analize statistice a rezultatelor i comparrii acestora cu
celeobinuteprininvestigareaIMRsauCT.

Vrsta
Concluziideetap:
1. nlegturcucorelaiavrstincidenacanceruluidecoluterinseconstat
interveniafactoruluihormonaliaproceselordeinvoluieisenescena
organelorgenitale.
2. Unrolmajornapariiacanceruluidecoluterinlareviaasexual:debutul
vieiisexualeiraporturilesexualecupartenerimultiplii.
3. O via sexual tumultoas i neprotejat va expune mult mai frecvent
femeiatnrlainfeciipericuloaseinprimulrndexpunerealainfecia
HIV.
4. Un rol important n apariia cancerului de col uterin l are numrul
naterilor,avorturiloriasisteneiobstetricaledeficitare.
5. Profilaxia cancerului de col uterin prin intensificarea screeningului
reprezintrolulprimordialnreducerealamaximaincideneiacesteiboli.

Mediul
Concluziideetap:
1. n legtur cu intervenia mediului n apariia cancerului de col uterin, se
poate face o corelaie cu factorii ce vizeaz condiiile de igien, rolul
parturiieiipracticilesexuale.
2. Incidenamaimareacazurilordecancerdecoluterinnmediulurbaneste
explicatdeodeplasareevidentapopulaieitinere,fertile,dinspremediul
ruralsprecelurban.

Niveluleducaional
Concluziideetap:
1. Creterea frecvenei cancerului de col uterin la persoanele cu studii
gimnaziale i medii, denot carene n ceea ce privete nivelul educaiei
medicale.
2. Acestaspectatrageateniaaupraroluluifactoruluifamilial,educaional i
social,ncretereaniveluluieducaieisanitarenrndulgeneraieitinere.
3. Se resimt n mod clar, deficineele de profilaxie n depistarea precoce a
canceruluidecoluterin,fiindbeneficobligativitateanviitoraexamenului
citologicivirusal.

Formelehistopatologice
Concluziideetap:
1. Din punct devedere a formelor histopatologice ponderea e reprezentat
deexistenacarcinoamelorcucelulescuamoasen72%dincazuri.
2. Prezena adenocarcinoamelor a fost diagnosticat ntrun numr mai
redusdecazuri,respectiv8paciente(16%dincazuri).

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3. n ceea ce privete distribuia cazurilor cu stadializare clinic versus

stadializare RMN se constat avantajul net al examenului RMN n
acurateeastadializriicanceruluidecol.

Adenopatiilelomboaortice
Concluziideetap:
1. Diagnosticuldeadenopatiepelvinsaulomboaorticpoatefipuscnd:un
gangliondeformovalprezintundiametru10mmsauunganglionde
formrotundprezintundiametru8mm.
2. n studiul aplicat pentru compararea rezultatelor obinute n urma
evalurii i evidenierii adenopatiilor lomboaortice se constat o
semnificaiestatisticaIRMfadeevaluareacliniciCT.

Invaziaparametrelor
Concluziideetap:
1. Stadiul IB este confirmat cnd tumora este complet nconjurat de bolta
fibroas intermediar (hipointens n ponderaie TII) i mai estimat n
plan axial transversal. Valoarea predictiv a acestui semn pentru invazia
parametruluiestede95%.
2. Stadiul IIB este sigur dac semnalul tumoral este direct vizualizat n
parametre. Un stadiul IIB poate fi evocat n cazul prinderii stromei
cervicale dup bolta fibroas intermediar fr semn macroscopic de
invazieaparametrului.
3. Prinderea parametrial va fi cu att mai probabil dac infiltrarea este
complet(FullThicknessStromalInvasion)idactumoraestemaimare:
invaziacompletastromeicuundiametrudepeste1cm,nseamn90%
probabilitateainvazieiparametriale.
4. Undiagnosticdeinvazievaginalsaurectalestepozitivcnd:

PETCT
Concluziideetap:
1. Diagnosticul precoce al tumorilor maligne (esut tumoral cu metabolism
activ) se bazeaz pe recunoaterea deformrilor maligne prin
metabolismulmaiaccentuatatuncicndnuestencvizibilomodificare
morfologic sau aceasta nu trezete suspiciuni. Aceasta o face o metod
imagisticunicndiagnosticareaprecoce.Datoritsensibiliicrescutea
metodei se pot recunoate i focare tumorale de 3 mm ce nu se pot
diagnosticaprinnicioaltmetodimagistic.
2. Identificarea dimensiunilor exacte tumorale i stabilirea conduitei
chimioterapeutice, limitarea interveniei chirugicale, aprecierea
volumuluiintaradioterapiei.
3. Estimarea neinvaziv a malignitii tumorale,. Tehnica PET, cu utilizarea
FDG este capabil s indice, in vivo, gradul malignitii tumorilor,
deoarece tumorile cu grad de malignitate mai crescut au o glicoliz mai
intens.Intensitateaglicolizeidepindedealimentareacusnge(oxigena
esutuluitumoral).Tumorilecugraddemalignitatemaicrescutprezint
zonecudescompunereanaerobaglucozei.

Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

15

4. Stabilirea zonei de biopsie. Examinarea PETCT poate fi de ajutor n

cazurile cu leziuni neomogene cnd aceast metod ne indic zona cu
metabolismulcelmaiactiv(exemplutumoricerebrale,limfoame).
5. Evaluarea eficacitii terapiilor oncologice aplicate (restaging).
Diagnosticul PETCT face posibil msurarea eficienei tratamentelor
oncologice,deoarecemetabolismulesutuluitumoralcuoreaciebunla
tratament scade n msur mai mare dect a esutului fr reacie sau
reacieparialpstrat.Graieacestuirspunssepoaterenunalaterapia
inutil,ialegeoalternativmaieficient.Dupterminareatratamentului
se verific dac n organism nu au rmas esuturi tumorale viabile. n
posesia procedeelor de chimio i radioterapie foarte eficiente, n terapia
oncologic, este o problem tot mai important minimizarea apariiei
efectelor secundare tardive induse pentru a pstra la un nivel ct mai
ridicatcalitateavieiipacientului.
6. Confirmarea sau excluderea recidivelor este un punct forte al
diagnosticuluiPETCT,deoareceestevorbadesprebolnaviidejatrataila
care n urma terapiilor aplicate (intervenii, chimio i radioterapie) au
aprut modificri anatomice (cicatrici, deformri) care scad exactitatea
diagnosticelor imagistice tradiionale. PETCTul poate recunoate cu
exactitaterecidivatumoral,sauexcludereaei.
Concluziifinale
1. Un rol major n apariia cancerului de col uterin l are viaa sexual:
debutulvieiisexualeiraporturilesexualecupartenerimultiplii.
2. Via sexual tumultoas i neprotejat va expune mult mai frecvent
femeiatnrlainfeciipericuloaseinprimulrndexpunerealainfecia
HIV.
3. Incidena mai mare a cazurilor de cancer de col uterin n mediul urban
esteexplicatdeodeplasareevidentapopulaieitinere,fertile,dinspre
mediulruralsprecelurban.
4. Se resimt n mod clar, deficineele de profilaxie n depistarea precoce a
cancerului de col uterin, fiind benefic obligativitatea n viitor a
examenuluicitologicivirusal.
5. Prezena adenocarcinoamelor a fost diagnosticat ntrun numr mai
redusdecazuri,respectiv8paciente(16%dincazuri).
6. n ceea ce privete distribuia cazurilor cu stadializare clinic versus
stadializare RMN se constat avantajul net al examenului RMN n
acurateeastadializriicanceruluidecol.
7. n studiul aplicat pentru compararea rezultatelor obinute n urma
evalurii i evidenierii adenopatiilor lomboaortice se constat o
semnificaiestatisticaIRMfadeevaluareacliniciCT.
8. Stadiul IB este confirmat cnd tumora este complet nconjurat de bolta
fibroas intermediar (hipointens n ponderaie TII) i mai estimat n
plan axial transversal. Valoarea predictiv a acestui semn pentru invazia
parametruluiestede95%.
9. Stadiul IIB este sigur dac semnalul tumoral este direct vizualizat n
parametre. Un stadiul IIB poate fi evocat n cazul prinderii stromei

VarodiViorica

16

cervicale dup bolta fibroas intermediar fr semn macroscopic de

invazieaparametrului.
10. Evaluarea eficacitii terapiilor oncologice aplicate (restaging).
Diagnosticul PETCT face posibil msurarea eficienei tratamentelor
oncologice,deoarecemetabolismulesutuluitumoralcuoreaciebunla
tratament scade n msur mai mare dect a esutului fr reacie sau
reacieparialpstrat.Graieacestuirspunssepoaterenunalaterapia
inutil,ialegeoalternativmaieficient.Dupterminareatratamentului
se verific dac n organism nu au rmas esuturi tumorale viabile. n
posesia procedeelor de chimio i radioterapie foarte eficiente, n terapia
oncologic, este o problem tot mai important minimizarea apariiei
efectelor secundare tardive induse pentru a pstra la un nivel ct mai
ridicatcalitateavieiipacientului.


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17

CURRICULUMVITAE

NUMEIPRENUME
VioricaVARODI
PRINII
Tatl:
GheorgheBRN
RaisaBRN
Mama:
STARECIVIL
cstorit
COPII
2(elevi)
ADRESAPROFESIONAL

SpitalulJudeeandeUrgen

Str.Ravensburg13
440192,SatuMare,Romnia
Tel.0261727050
ADRESA(DOMICILIUL)

Str.TraianVuianr.1
440033SatuMare,Romnia
DATAILOCULNATERII

12aprilie1974,Chiinu,RepublicaMoldova
NAIONALITATE

romn
LIMBAMATERN

romn
LIMBISTRINECUNOSCUTE

- rusa (abilitatea de a citi, abilitatea de a scrie, abilitatea de a participa la

conversaienivelexperimentat)
- franceza(abilitateadeaciti,abilitateadeascrie,abilitateadeaparticipa
laconversaienivelexperimentat)
- engleza(abilitateadeaciti,abilitateadeascrie,abilitateadeaparticipala
conversaienivelelementar)
STUDII
- promoia1991:LiceulMihaiEminescu,Chiinu,RepublicaMoldova
- promoia 1997: Facultatea de Medicin i Farmacie Iuliu Haieganu,
ClujNapocamedicingeneral
TITLURIDIPLOME/COMPETENE
1991:

Diplomadebacalaureat
1997:

Diplomademedic
2004:

Medicspecialistobstetricginecologie
2005:

Competennecografiaginecologiciobstetrical
2010prezent: Medicprimarobstetricginecologie
2011:
Atestatdestudiicomplementarencolposcopie

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VarodiViorica

POZIIAACTUAL
2004prezent: doctorand, nmatriculare la Universitatea de Medicin i
FarmacieIuliuHaieganuClujNapoca
2005prezent: medicprimarobstetricginecologie
ACTIVITATEPROFESIONAL
19992004:
medic rezident, specialitatea obstetricginecologie, Clinica
ginecologieII,ClujNapoca
20052010:
medic specialist, specialitatea obstetricginecologie,
Spitaluljudeeandeurgen,SatuMare
2010prezent: medic primar obstetricginecologie, Spitalul judeean de
urgen,SatuMare
STUDIIPOSTUNIVERSITARE

1998:

CursdeChirurgielaparoscopic,ClinicaChirurgieIII

ClujNapocaRomania
2005:

CompetenEcografiaobstetricaliginecologic

MinisterulSntii,Romnia

2006:

coalaeuropeanIanDonaldsecografiefetal3D4D

Budapesta,Ungaria
2007:
CursUltrasonografie3D/4Dversusultrasonografie2D
Universitatea de Medicin i Farmacie Iuliu Haieganu
ClujNapoca,Romnia
2010:
coalaeuropeandeoncoginecologie
MinisterulSntii
Chiinu,RepublicaMoldova
2011:
Curs Colposcopie integrat, actualiti n screeningul
oncologicgenital
UniversitateadeMediciniFarmacieGr.T.Popa,Iai
2011:
Atestatdestudiicomplementarencolposcopie
Ministerul Sntii Centrul de Perfecionare
PostuniversitaraMedicilor,Farmacitilor,altuipersonalcu
studiisuperioareiasistenilormedicali
2011:
CursChirurgielaparoscopic,parteaII
Universitatea de Medicin i Farmacie Iuliu Haieganu
ClinicaChirurgieIII
ClujNapoca,Romnia
PARTICIPRILAMANIFESTRITIINIFICENARISTRINTATE
2002:
ZileleOncologiceClujene
912octombrie2002,ClujNapocaRomania
2004:
AVxxxxxxxaConferindeGinecologieurologic

2830mai,PoianaBraov,Romnia
2005:
AlVleaCongresdeChirurgieAmbulatorie;Limfologie

2729octombrie,Timioara,Romnia
2005:
Conferinajudeeandeconsensndiagnosticul
citologicitratamentulginecologicooncological
leziunilorprecocealecoluluiuterin

25mai2005,ClujNapocaRomania


Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

19

2007:

2008:

2009:

AlIIleaCongresdeMedicinimagistic
89noiembrie,Chiinu,RepublicaMoldova
AlVleaCongresdeEndocrinologieginecologic
811martie,Veneia,Italia
ZileleInstitutuluiOncologicProf.Dr.I.ChiricuCluj
Napoca

80deanideluptmpotrivacancerului
13octombrie2009,ClujNapoca,Romnia
2009:
1st International Sympozium of Oncologic Imaging
FocusingonPET/CT
3031octombrie2009,Oradea(BileFelix),Romnia
2011:
The 4th Congress of the South East European Society
ofPerinatalMedicine

2021mai,Bucharest,Romania
2011:
ZileleUrologiceStmrene

1618iunie,SatuMare,Romnia
APARTENENALASOCIETIPROFESIONALE
SocietateaRomndeObstetricGinecologie
EuropeanSocietyofGinecologycalOncology
LUCRRITIINIFICE
extenso(primautor)
1. VioricaVarodi.Evaluareadiagnosticpreoperatorieacanceruluidecoluterin.
BuletinulAcademieidetiineaMoldovei(tiineMedicale)2006;3(7):278
287.
2. Viorica Varodi. Les tumeurs de l'utrus sous l'aspecte de l'IRM. Buletinul
AcademieidetiineaMoldovei(tiineMedicale)2007;5(14):291294.
3. Viorica Varodi. Intrt du staging IRM du cancer du col uterine. Buletinul
AcademieidetiineaMoldovei(tiineMedicale)2007;5(14):283286.
4.

VioricaVarodi,NataliaRotaru.Diagnosticulimagisticcomplexalcanceruluide
coluterin.BuletinulAcademieidetiineaMoldovei(tiineMedicale)2008;
2(16):187195.

5. VioricaVarodi,NataliaRotaru.EvaluareastriiganglionilorlimfaticiprinIRM
n cancerul de col uterin. Buletinul Academiei de tiine a Moldovei (tiine
Medicale)2008;5(19):159162.
6. VioricaVarodi,L.Iaco.Ratanateriiprinoperaiecezarianifactoriicareo
influeneaz.BuletinulSocietiiOncologicedinRepublicaMoldova2011:25
32.

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VarodiViorica

extenso(coautor)
1. L. Iaco, N. Arapu, Viorica Varodi. Managementul parturientelor din grup de
riscdedezvoltareapatologieineurologicedobnditelaft.BuletinulSocietii
OncologicedinRepublicaMoldova,2011:3339.
rezumate/prezentri(primautor)
1. Viorica Varodi, R. Rotaru. Elaborare de algoritm imagistic n aprecierea
stadializrii cancerului de col uterin. Zilele Oncologiei Ieene, volum de
rezumate,2225noiembrie2011,pg:163164.
2. Viorica Varodi, R. Rotaru. Studii comparative ale metodelor imagistice i
stadializarea cancerului de col uterin. Zilele Oncologiei Ieene, volum de
rezumate,2225noiembrie2011,pg:165166.
rezumate/prezentri(coautor)
1. S.Ungureanu,VioricaVarodi.Importanavaccinriicametoddeprofilaxien
cancerul de col uterin. Mas rotund: Societatea de Obstetric i Ginecologie
dinRepublicaMoldova,volumderezumate,2225noiembrie2011,pg:815.


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21

U NIVERSITY OF MEDICINE AND PHARMACY IULIU HAIEGANUCLUJNAPOCA

DOCTORALSCHOOL

DOCTORALTHESISABSTRACT

Comparativestudiesofimagistic
methodsinstagingcervical
cancer

DoctorandViorica,Varodi
SupervisorNicolae,Costin

CLUJNAPOCA2011

22

VarodiViorica


Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

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CONTENTS
INTRODUCTION
OVERVIEW
1.ANATOMYANDHISTOLOGYOFUTERINCERVIX
2.CERVCALCANCEREPIDEMIOLOGY
3.CERVCALCANCERDIAGNOSTIC
4.STAGINGINCERVCALCANCER
5.TREATMETANDGUIDELINESINCERVCALCANCER

ORIGINALRESEARCHCONTRIBUTIONS
1.STUDYOBJECTIVES
1.1.Generalobjectives
1.2.Specificobjectives

2.PATIENTSANDMETHODS
2.1.Generalmethods
2.1.1.Limphography
2.1.1.1.Facillities
2.1.2.Ultrasonography
2.1.2.1.Facillities
2.1.3.Limphaticmapping
2.1.3.1.Facillities
2.1.4.ComputerTomography
2.1.4.1.Facillities
2.1.5.Magneticrezonance
2.1.5.1.Facillities
2.1.6.PETCT
2.1.6.1.Facillities
2.2.Methodologyofexamination
2.2.1.Evaluationofprimarysitetumour
2.2.2.Evaluationofthelymphnodes
2.2.3.Evaluationofthetreatmentresponse

3.RESULTS

3.1.Statisticalstudyofcervixcancerincidenceaccordingtogender,age,
environment,educationlevel
3.2.Histopathologicforms
3.3.Staging
3.4.Lomboaorticadenopathys
3.5.Invasionoftheparameters

4.DISCUSSION

4.1.Age
4.1.1.Stageconclusions
4.2.Environment
4.2.1.Stageconclusions
4.3.Educationlevel
4.3.1.Stageconclusions
4.4.Histopathologicforms

13

17
23
29
35
43

47
47
47

49
49
51
52
52
54
55
55
55
58
58
63
64
68
68
74
74
74

75
77
78
83
84

87
87
88
88
88
89
89
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24

4.4.1.Stageconclusions
4.5.Staging
4.5.1.Stageconclusions
4.6.Lomboaorticadenopathys
4.6.1.Stageconclusions
4.7.Invasionoftheparameters
4.7.1.Stageconclusions
4.8.PETCT
4.8.1.Stageconclusions
4.9.Posttherapeuticevaluation
4.9.1.Clinicalcase

5.GENERALCONCLUSIONS
6.ORIGINALITYOFTHEDOCTORALTHESIS
7.APENDIX
8.BIBLIOGRAPHY

KEYWORDS:CERVICALCANCER,STAGING,CT,IRM,PETCT

90
90
90
91
91
91
92
92
93
94
97

107
109
111
115

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25

CONCEPTUALLANDMARKSOFTHERESEARCH

Presentinterest:Cervicalcancerhasasignificantworldwideimpact,ranking
secondamongneoplasmsaffectingwomenthroughouttheworld;in2002ithasbeen
estimated that there were 493.000 women primarily diagnosed with cervical
neoplasm,amongwhich274.000died.Mostcases(83%)werediagnosedindeveloping
countries, where the implementation of cytological screening programs still needs
improvement.Thesocialimpactofcervicalcancerisevengreaterthanthenumberof
casessuggests,sincecervicalcancerfrequentlyaffectsrelativelyyoungwomenandisa
majorcauseofdeathindevelopingcountries.
State of the art in the field and identification of research questions. The
greatest incidence of cervical cancer has been recorded in Africa, southeast Asia and
Latin America, while in the industrialized countries its incidence is much lower, with
standardizedratevaluesoffewerthan15casesin100.000.
According to the estimated data provided by the IARC (International Agency
forResearchonCancer)in2000,thehighestincidenceofcervicalcancerinEuropehas
beenrecordedinRomania.

2.2.Generaldataontheepidemiologyofcervicalcancer
Cervical cancer (CC) is a primary public health issue worldwide, with a high
incidence.
In 95% of cases one encounters epidermal carcinoma, while Aden carcinoma
canonlybefoundin5%ofcases.
Cervical cancer represents 44% of all female genital neoplasia, justifying the
internationaleffortsinthestudyofthismalady.

2.3.Naturalhistoryofcervicalcancer
The natural history of cervical cancer is based on the fact that lesions
precedingtheonsetoftheneoplasticdiseasecandevelop(butnotnecessarily)froma
dysplastic lesion to in situ cancer and then to invasive neoplastic lesions. Cervical
cancer is a malign tumor that develops from the usual cervical epithelium at the
interference area between the exocervical pavement and cylindrical epithelia, from
where it gradually extends on both surface and in depth, invading the endocervical
neckandthenearbyorgans,producingmetastasesthroughthelymphaticsystem.

2.4.Riskfactorsandcervicalcancerprognosis
The population with high risk of cervical cancer consists of persons infected
withHPVandthisconstitutesthemainriskfactorintheapparitionofCINs.TheDNAof
theHPVisdetectedin9599%ofcasessufferingfrominfiltrationcancersand90%of
caseswithseverelesionsonthecervix.
TheaverageperiodbetweenaHSILlesionandtheonsetofcancerisestimated
at 10 years. Numerous cohort studies have evaluated the development risk of CINs
associatedwiththedetectionofoncogenousHPVs.
Otherriskfactors:earlystartofonessexlife(before17yearsofage);multiple
partners, promiscuity; numerous abortions; multiparity; precarious social, economic,
and cultural levels; sexuallytransmitted maladies; smoking; and immunosuppressive
diseases. The risk of cervical cancer features from adolescence until ca. 50. This

26

VarodiViorica

suggests the possibility that hormones might be involved in carcinogenesis, though

other explanations might apply as well. Among them, there is a possibility that oral
birthcontrolpillsmightinfluencegenitalcancer.
Mostepidemiologicalstudiesagreeinconsideringthattheagedistributionof
cervical cancer follows an upwards curve starting with the age group 2029, with a
peakinthedecade4554andthenslowlydecreases.
Certain studies indicate the fact that genetic modifications can appear much
beforehistologicalones;thismighttheoreticallypushtheearlydiagnosisdowntothe
chromosomalsubcellularlevel.Oneofthelatestachievementsinthefieldconsistsof
theidentificationofgroupsofhighriskpopulation;thetermissignificantlyusefulin
the economical and efficient organization of cervical cancer prophylaxis, its tracking
andearlydiagnosis.Ahigherfrequencyofcervicalintraepithelialneoplasiahasbeen
noted in women who had received immunosuppressive medication following kidney
transplants.
Human Papyloma Virus type 6, 11, 16 and 18 is responsible for the onset of
cervicalcancerin70%ofthecases.

SPECIALPART

PERSONALCONTRIBUTIONS

Introduction

Cervical cancer is a highly frequent malighty; its annual incidence among

100.000womenvaries.
In Romania, the incidence of cervical cancer had negative tendencies during
thelastyears,boththroughthehighincidenceofthediseaseandthehighfrequencyof
advanced cases. This is mainly due to recent sanitary policies and the inefficiency of
screeningprograms.
The diagnosis ofcervicalcancer, its staging,and posttherapymonitoringare
mainly performed, at present, according to criteria established by the International
Federation for Gynecology and Obstetrics (FIGO). The criteria FIGO employs are
neverthelesslimited,especiallyinrelationtoclinicalexamination.Imagisticstagingis
not recognized, and imagistic exploration still recommended consists of thoracic
radiography,intravenousurography(UIV),andbariumclysmata.
Ifclinicalexaminationandstagingcanproveefficientfortheearlystagesina
large number of cases, for advanced stages with local invasions and secondary
ganglionic determinations clinical evaluation is in most cases inefficient, while the
employmentof sectional imagistic methods(US, CT, IRM, PETCT)provides excellent
dataforevaluatingtheextensionofthedisease.EventhoughFIGOdoesnotrecognize
imagisticstaging,sectionalimagisticsisrecentlyrecommendedinsomecases.
Anexactpretherapyidentificationoftheextensionofthediseaseisessential
for a correct therapeutic behavior. Therapeutic options depend on the stage of the
disease.
Aim:Theaimofallresearchinthefieldofoncologyhasbeentheimprovement
ofdiagnosismeansonwhichfuturepracticalbehaviordepends.

Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

27

Inthecaseofcervicalcancerinparticular,establishingthe exactstageofthe
diseaseplaysanessentialroleaftertheconfirmationofthediagnosis;theexactstaging
of the disease thus becomes essential. Practitioners still turn to staging according to
clinicalprinciples,tryingtousenumerousparaclinicalinvestigationsdevelopedover
theyears(lymphography,echography,CT,IRM,andPET).
Despitetheprogressmade,thestagingofcervicalcancerstillinvolvesseveral
practical difficulties; staging tends to be of either too little or too much importance,
bothrisky.

Theactualtendencytowardsthecorrectstagingofcervicalcancerimposesthe
use of the most modern and viable methods and paraclinical investigations,
particularlytheCT,IRM,andPETCT.
These methods have proven efficient, rendering an elevated degree of
sensibilityandspecificitytothemethod.

Staging, established with the maximum precision possible, determines the

establishmentoftreatmentstages,treatmentsupervision,theprognosisofthedisease
in particular, and, not least, the diagnosis and supervision of postsurgery and post
radiotherapy complications. The present paper aims at performing a comparative
study of the numerous imagistic investigations correlated to clinical examinations in
order to establish the staging, with the maximum precision possible, on which short
andlongtermprognosisandtreatmentofthesecausesdepend.
The present paper is a pioneering element in the national specialized
bibliographyonthetopic.

Thisstudywillconstituteanexcellentbehaviorguideforpractitionerdoctorsin
theformulationofanimagisticpreandposttherapyalgorithm.

Source material and method: I performed a longitudinal retrospective study

onasampleof50patients,clinicallyandimagisticallyinvestigatedattheProf.Dr.Ion
ChiricuOntologicalInstituteinClujNapocabetween01.06.2005and30.04.2009.50
female patients diagnosed with cervical cancer (confirmed through histopathology)
wereselected.AssourcematerialIusedtheirobservationcharts,extractingtheclinical
dataandparaclinicalinvestigations.
Inclusioncriteria:
patientsagedbetween18and79
patientswithhistologicallyconfirmedcervicalcarcinoma.
Exclusioncriteria:
patientsolderthan80
patientswithpreviousneoplasticdiseases
patientswithsynchronicneoplasia.
Clinicalexaminations,diagnosticbiopsies,andstaginghavebeenpreformedat
theProf.Dr.IonChiricuOncologicalInstituteinClujNapoca(IOCN).Agroupof8
patientswereimagisticallyinvestigated(PETCT)atthePozitronDiagnosisCenterin
Oradea;thePETCTexamobservationswereanalyzedincomparisontothepreviously
performedCTandIRMinvestigations.
The statistical analysis of the data was performed with the computer
programsSPSSandStatisticsunderWindows.
Methods of descriptive and analytical statistics have been employed
(histogramsforthedistributionofvalues,average+/standarddeviation,confidence

28

VarodiViorica

intervals,minimal/maximalvalues),frequenciesandtheChisquaretestbidirectional
test.
Scientific research methodology: The following sequences (stages) were
usedin thesemiologicanalysisofcervicalcancerlesionsthroughIRM(orwiththeaid
ofIRM).:
Identificationandtopographyofthelesion:
Whenlesionsbecomevisible,thesignalappearsashyperintensivelymoderate
and more heterogeneous in T2 balance. In T1 balance, the lesion is isointense and
grows moderately after injecting the gadolinium as compared to the neighboring
stromaandmiometer.
Onemustmentiontheendoorexocervicallocationofthelesion.
Measuringanddeterminingthetumoralvolume:
It has been proven that the following elements are determinant in cervical
cancer patients: the tumors volume, the degree of cervical or parametrial extension,
and the histological type. The employment of endovaginal antennas allowed for a
preciseidentificationofthetumorsvolume;ithasbeensuggestedthatavolumeof13
square centimeters is the limit at which survival to 3 years is considered to be of
100%.

Invasionoftheparameters:
This is a very important step in the IRM examination of cervical cancer, by
following the fiber ring that is hypointense. If the ring is integral around the lesion,
onecanstatethereisnostromainvasion(FIGO1B).
Thefocaleffractionofthefiberringwithadirectextensionofthetumorisa
sign of invasion of parameters (FIGO2B). The intravenous injection of gadolinium
allowsonetoidentifytheanatomicalproportionbetweenhealthytissueandthetumor
andtovisualizetheareasoftumoralnecrosis(ifsuchbethecase).
Whenthetumorincludestheentirethicknessofthestroma,onecanobservein
73%ofthecasesthattheparametersarecaughtup.
- Invasionofthevagina:
A direct extension from the tumor to the vagina walls or the partial
obliteration of the vaginal fornex can be determined. It is important that one
determinesthestagingoftheinvadedarea(upperthirdortwolowerthirds).
- Invasionofthebladder:
This is confirmed if in T2the tumors hyperintense signal is replaced by the
hypointense signal of the bladder wall and then by the erasing of the fat plane that
separatesthecervixfromthebladder.Itisimportantonemakethedifferencebetween
theaffectedentirebladderwallandthelimitedaffectofthemusclesalone(inthelatter
caseradiotherapycanbeperformed).
- Rectalinfiltration:
Rectal infiltration is confirmed if in T2 the hyperintense signal of the tumor
replacesthehypointensesignaloftherectalwallandaftertheerasingofthefatplane
thatseparatesthecervixfromtherectum.Injectingacontrastsubstancecontributesto
abettervisualizedimage.
Invasionoftheurethras:
Theinvasionoftheurethrasisconfirmedbythedirectextensionofthetumor
orbyitcompressingtheurethras.
Urological sequences in T2 allow one to visualize an overview image of the

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29

dilatedurethraandprove,withallcertainty,thelocationoftheobstruction.
Invasionofthepelvicwall:
Theinvasionofthepelvicwallisdefinedbythepresenceofthetumorlessthat
3mm.awayfromthewall.ThelatterinfactconsistsoftheLevatorani,innerobturator
muscles, and the piriformis. Direct invasion is defined by the disappearance of the
paramuscularplane,thepresence ofaT2signalinthemusclesortheintensification
aftergadoliniumwasinjectedinsidethemuscleindirectcontinuationofthetumor.
Lymphaticinvasion:
The diagnosis of pelvian or abdominal adenopathy is based on the following
criteria: ovalshaped ganglia with large axes of over 1 cm. or roundshaped ganglia
withdiametersexceeding8mm.Fromamorphologicalperspective,thefollowingsigns
aresearchedfor:
- Irregularcontouroftheganglia
- Slightlyfatperiganglionarycomposition
- Moreorlessextendednecrosisplaques
- Heterogeneousaspectoftheganglia.
The following ganglionary areas are to be thoroughly inspected: inguinal,
parametrial, common iliacs, inner iliacs, external, obturators, presacral, lomboaortic,
andtheiliacforkuntilabovetherenalvein.
Thestudyofthegangliaiscertainlyamainstageintheexaminationsurvey.
Evaluation of the primary tumour: The following CT and IRMcriteria have
beenemployedintheidentificationoftumorslimitedtothecervix:
acleardelimitationofthetumoralprocess
theabsenceoftumoralmassintheparametrialcavity
theabsenceofparametrialdensification
theconservationofperiuterinelipomatoustissue.
VicksCTandIRMcriteriahavebeenusedinthedefinitionof theparametrial
invasion:
theirregularityorimpreciselateraldelimitationofthecervix
theinfiltrationoftheparametrialtissue
theobliterationoftheperiuterinefat
thepresenceofaneccentrictissularmass.
TheemployedCTcriteriaforbladderorrectalinvasionwere:
thefocalabsenceofthelipomatoseperibladderorperirectalplane
thepresenceofanendoluminaltumoralmass,incontinuitywiththeprimary
tumoronthecervix.
I was also looking for the nodular aspect of the rectal and bladder wall and
demonstratingafistulartrajectory.
Evaluating ganglia stations: The imagistic criteria (CT and IRM) for the
definitionoftumoraladenopathywerethefollowing:
dimension:gangliameasuringover5mm.inthepelvinegroupsandover10
mm.intheabdominalgroups
structure:centralfocalhypodensity(T2hypersignalattheIRM),causedby
ganglia necrosis was considered a certain criterion of tumoral invasion
independentoftheganglionssize.
Evaluation of treatment response: Posttherapy imagistic evaluation was
performedinordertodeterminethedegreepatientsrespondedtotreatmentsandto

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VarodiViorica

detecttumoralrelapse.
Results:Asfortheageofpatientsinthelotof50whobenefitedfromimagistic
evaluation,IRM,andCT,thefollowingaspectshavebeennoted:
ageaveragewasbetween48and12,95%IC:4552;
agemedianwasof49years;
agemodewasof58years;
the patients age was in the interval between the minimum value of 18 and
themaximumvalueof79;
agevaluedistributionwasuniform.

DuetothesmallnumberofAVAILABLE(8)caseswithCETPT,Iwasnotgiven
theopportunityotoperformastatisticalanalysisoftheresultsandcomparethemwith
thoseobtainedthroughIRMorCTinvestigations.

Figure44:IRMaxialsectionsinT1andT2pondering,stressingapresacraltumoralrelapseand
lomboaorticandcommoniliacadenopathys.

Figure45:PETCTaxialsectionsstressingthepresacraltumoralmass(thetumoralrelapse)and
commonrightiliactumoraladenopathys.

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31

Age
Stageconclusions:
6. As for the correlation between age and the incidence of cervical cancer,
one can observe the intervention of the hormonal factor and of the
involutionandsenescenceofthegenitalorgans.
7. Sexual life plays a major role in the onset of cervical cancer: the start of
sexlifeandsexualcontactswithmultiplepartners.
8. A tumultuous and unprotected sex life often exposes young women to
dangerousinfectionsandforemost,totheHIVinfection.
9. Thenumberofbirths,abortions,andfaultyobstetricalassistancealsoplay
importantrolesintheonsetofcervicalcancer.
10. Cervicalcancerprophylaxisthroughtheintensificationofscreeningplays
aprimaryroleinthemaximumreductionoftheincidenceofthisdisease.

Environment
Stageconclusions:

3. Asfortheroleoftheenvironmentintheapparitionofcervicalcancer,one
canestablishacorrelationwithfactorsenvisaginghygieneconditions,the
roleofparturition,andofsexualpractices.
4. The higher incidence of cervical cancer cases in the urban milieu can be
explainedbyanobviousmovementoftheyoung,fertilepopulationfrom
theruralmilieutotheurbanone.

Educationlevel
Stageconclusions:
4. Theincreasedfrequencyofcervicalcanceramongpersonswithprimary
and highschool education indicates lacunas in the level of medical
education.
5. Thisaspectstressestheeducationalandsocialroleofthefamilyin
increasingthelevelofsanitaryeducationamongtheyoung.
6. Onecannoteobviousprophylacticdeficienciesintheearlydiagnosisof
cervicalcancer;amandatorycytologicalandvirusexaminationsmightbe
usefulinthefuture.

Histopatologicalforms
Stageconclusions:
4. From the point of view of histopatological forms, the proportion is
representedbytheexistenceofcarcinomawithsquamosecellsin72%of
thecases.
5. The presence of Aden carcinoma was diagnosed in a smaller number of
patients,i.e.8(representing16%ofthecases).
6. As forthe distribution of cases with clinical staging versus RMN staging,
onenotestheclearadvantageoftheRMNexamintheprecisestagingof
cervicalcancer.

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VarodiViorica

Lomboaorticadenopathys
Stageconclusions:
3. One can decide upon a diagnosis of pelvine or lomboaortic adenopatys
when: an ovalshaped ganglion measures 10mm in diameter or a
roundshapedganglionmeasures8mmindiameter.
4. Inthepracticalstudyforcomparingtheresultsoftheevaluationandthe
stressingoflomboaorticadenopathys,onenotesastatisticalsignificance
oftheIRMascomparedtoclinicalevaluationandCT.

Invasionoftheparameters
Stageconclusions:
5. The IB stage is confirmed when the tumor is completely surrounded by
the intermediary fiber vault (hypointense in TII pondering) and more
estimatedinatransversalaxialplane.Thepredictivevalueofthissignfor
theinvasionoftheparameterisof95%.
6. Stage IIB is certain if the tumoral signal is visualized directly on the
parameters.StageIIBcanbeidentifiedifthecervicalstromaiscaughtup
behind the fiber vault with no macroscopic sign of the invasion of the
parameter.
7. Theparametrialinvasionisallthemorelikelyinthecaseoffullthickness
stromalinvasionandifthetumorislarger:fullthicknessstromalinvasion
measuring more than 1 cm. in diameter indicates a 90% possible
parametrialinvasion.
8. Adiagnosisofvaginalorrectalinvasionispositivewhen:

PETCT
Stageconclusions:
7. The early diagnosis of malign tumors (tumoral tissue with active
metabolism)isbasedontherecognitionofmaligndeformationsthrough
the accented metabolism when no morphological modification is still
visibleoritdoesnotraiseanysuspicion.Thismakesitauniqueimagistic
methodinearlydiagnosis.Duetotheincreasedsensibilityofthemethod,
one can also identify 3 mm. tumoral centers that cannot be diagnosed
throughanyotherimagisticmethod.
8. The identification of a tumors exact dimensions and the establishing of
chemotherapeutical conduct, limiting surgical interventions, evaluating
thetargetvolumeofradiotherapy.
9. Thenoninvasiveestimationofthetumorsmalignity.ThePETtechnique,
with the employment of FDG, is capable of indicating, in vivio, the
malignitydegreeoftumors,sincetumorswithahighdegreeofmalignity
haveamoreintenseglycolisis.Theintensityoftheglycolisisdependson
blood irrigation (oxygen of the tumoral tissue). Tumors with a higher
degreeofmalignityshowareasofanaerobedecomposingoftheglucose.
10. Establishing the biopsy area. The PETCT examination can be useful in
caseswithnonhomogenouslesions,whenthismethodindicatesthearea
withthemostactivemetabolism(forex.Braintumors,lymphoma).

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33

11. Restaging the efficacy of applied oncologtical therapies. The PETCT

diagnosisallowsonetomeasuretheefficiencyofoncologicaltreatments
since the metabolism of the tumoral tissue that reacts well to the
treatmentdecreases morethan that of nonreactive tissue orthose with
partiallypreservedreaction.Onthebasisofthisresponse,uselesstherapy
canbesetasideandamoreefficientalternativecanbeselected.Afterthe
treatmentiscompleted,onechecksforthepresenceofstillviabletumoral
tissue in the organism. In oncological therapy, in possession of very
efficient chemo and radiotherapy, minimizing the installment of late
inducedsecondaryeffectsisanincreasinglysignificantissue,in orderto
maintainapatientshighestpossiblelifequality.
12. The confirmation or exclusion of relapses is one of PETCT diagnosis
strongestpoints,sinceitisthecasewithpatientspreviouslytreatedwho
show anatomical changes (scars, deformities) after applied therapies
(interventions,chemoandradiotherapy)thatmaketraditionalimagistic
diagnoses less exact. The PETCT can recognize with precision tumoral
relapsesortheirabsence.

Finalconclusions
11. Sexuallifeplaysamajorroleintheonsetofcervicalcancer:thebeginning
ofonessexlifeandsexualcontactwithmultiplepartners.
12. A tumultuous and unprotected sex life more frequently exposes young
womentodangerousinfections,HIVinparticular.
13. The higher incidence of cervical cancer cases in the urban milieu is
explainedbyanobviousmovementoftheyoung,fertilepopulationfrom
theruralmilieutotheurbanone.
14. Onecanobviouslynotetheprophylaxisdeficienciesintheearlydetection
of cervical cancer; mandatory cytological and virus examinations will be
usefulinthefuture.
15. The presence of Aden carcinoma was diagnosed in the case of a smaller
numberofcases,i.e.8patients(representing16%ofthecases).
16. As for the distribution of cases with clinical staging vs. those with RMN
staging,onecanobservetheclearadvantageoftheRMNexaminationin
anaccuratestagingofcervicalcancer.
17. IRMshowsstatisticalsignificanceincomparisontoclinicalevaluationand
the CT in the applied study for comparing the results obtained through
evaluationandstressinglomboaorticadenopathys.
18. The IB stage is confirmed when the tumor is completely surrounded by
the intermediate fiber vault (hypointense in TII pondering) and more
estimated in transversal axial plane. The predictive value of this sign in
theinvasionoftheparamentisof95%.
19. Stage IIB is certain if the tumoral signal is visualized directly on the
parameters. Stage IIB can be identified if cervical stroma is caughtup
behind the fiber vault with no macroscopic sign of the invasion of the
parameter.
20. Restaging the efficacy of applied oncologtical therapies. The PETCT
diagnosisallowsonetomeasuretheefficiencyofoncologicaltreatments

VarodiViorica

34

since the metabolism of the tumoral tissue that reacts well to the
treatment decreases more than that of nonreactive tissue or of those
with partially preserved reaction. On the basis of this response, useless
therapycanbesetasideandamoreefficientalternativecanbeselected.
After the treatment is completed, one checks for the presence of still
viable tumoral tissue in the organism. In oncological therapy, in
possession of very efficient chemo and radiotherapy, minimizing the
installmentoflateinducedsecondaryeffectsisanincreasinglysignificant
issue,inordertomaintainapatientshighestpossiblelifequality.


Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

35

NAME
PARENTS

CURRICULUMVITAE
VioricaVARODI

Fathersname:GheorgheBRN
Mothersname:RaisaBRN
MARITALSTATUS:married
2
CHILDREN:
WORKADDRESS

ObstetricsGynecologyHospital/HealthCareMaternityHospital
Ravensburgstreet13
440192,SatuMare,Romnia
Tel.0261727050
HOMEADDRESS

TraianVuiastreet1
440033SatuMare,Romnia
DATEANDPLACEOFBIRTH

12Aprilie1974,Chiinu,RepublicofMoldavia
NATIONALITY: romanian
MOTHERTONGUE:romanian

FOREIGNLANGUAGES
- Russian(reading,writing,speakingexperiencedlevel)
- French(reading,writing,speakingexperiencedlevel)
- English(reading,writing,speakingintermediatelevel)
EDUCATION
- Class of 1991, Mihai Eminescu High school, Chiinu, Republic of
Moldavia
- Class of 1997, Faculty of Medicine, Iuliu Haieganu University of
MedicineandPharmacy,ClujNapoca
DEGREESANDCERTIFICATES
1991:baccalaureatedegree
1997:undergraduatedegreeinmedicine
2004:certificateofspecialistdoctorinobstetricsandgynecology
2005:competenceinobstetricalandgynecologicalultrashonograpgy
2010:obstetricsgynaecologyprimaryphisician
2011:certificateofcomplementarystudiesincolposcopy
CURRENTPOSITION
2004 the present: doctoral students, Faculty of Medicine, Iuliu Haieganu
UniversityofMedicineandPharmacy,ClujNapoca,Romania
2005 the present: obstetricsgynaecology primary phisician, obstetrics and
gynaecology watch, specialty interventions: caesarean operations,
hysterectomy, birth assistance, obstetrics and gynaecology ultrasound scans;
laparoscopic surgery; colposcopy examinations. ObstetricsGynecology
Hospital/HealthCareMaternityHospital,SatuMare,Romania.

36

VarodiViorica

WORKEXPERIENCE
19992004:rezidency,obstetricsandgynecologyatGynecologycal(II)
Hospital,ClujNapoca,Romania
20052010:obstetricsgynaecologyprimaryphisicianatObstetrics
GynecologyHospital/HealthCareMaternityHospital,Satu
Mare,Romania
POSTGRADUATECOURSES
1998:
CourseinLaparoscopicSurgery,3rdSurgicalClinic,

ClujNapoca,Romania
2005:
Beginning of PhD studies PhD candidate; Subject: Comparative
Paraclinic Studies in the Screening/ Diagnosing and Treatment of
UterineCervixDiseases
IuliuHaieganuUniversityofMedicineandPharmacy,
ClujNapoca,Romania
2005:
Obstetricsandgynaecologyscancompetence
Ministry of Health Romania Center for the Postgraduate
TrainingofMedicalDoctors,Pharmacists,OtherHigherEducation
StaffandNurses
2006:
EuropeanSchoolIanDonaldsfetalultrashonography3D4D

Budapest,Hungary
2007:
CourseUltrashonography3D/4Dversusultrashonography2D
IuliuHaieganuUniversityofMedicineandPharmacy,
ClujNapoca,Romania
2010:
European School of Oncology Surgery for Eastern European
Countries
MinistryofHealth
Chiinu,RepublicofMoldavia
2011:
IAN DONALDS European School of Perinatology, 3rd edition,
Bucharest,Romania
2011:
Course Inbuilt colposcopy, news reel in gynaecological oncology
screening
UniversityofMedicineandPharmacyGr.T.Popa,Iai
2011:
Certificateofcomplementarystudyincolposcopy
Ministry of Health Romania Center for the Postgraduate
TrainingofMedicalDoctors,Pharmacists,OtherHigherEducation
StaffandNurses
CourseinLaparoscopicSurgery,3rdSurgicalClinic,secondpart
2011:

UniversitateadeMediciniFarmacieIuliuHaieganu
ClujNapoca,Romania
NATIONALANDINTERNATIONALCONFERENCESANDCONGRESSESATTENDED
2002:
ClujOncologicalDays
ClujNapoca,Romania
2004:
Conferenceofgynaecologicalurology

PoianaBraov,Romania


Studiicomparativealemetodelorimagisticenstadializareacanceruluidecoluterin

37

2005:

2005:

2007:

2008:

2009:

2009:
2011:

2011:

MEMBEROF

The5thCongressofsurgicalambulatory;limphology.
Timioara,Romania
RegionalconsensusConferenceintheCytologicalDiagnosisand
GynaecologicalOncologyTreatmentofEarlyUterineCervix
Lesions
ClujNapoca,Romania
ThesecondCongressofradiodiagnosticsmedicalimaging
Chiinu,RepublicofMoldavia
Congressofgynaecologicalendocrynology
Venice,Italy
The Days ofthe Prof. Dr. I. Chiricu Institute of Oncology, Cluj
Napoca
80YearsofFightingCancer
ClujNapoca,Romania
1st International Sympozium of Oncologic Imaging Focusing on
PET/CT
Oradea(BileFelix),Romania
The4thCongressoftheSouthEastEuropeanSocietyofPerinatal
Medicine
Bucharest,Romania
TheDaysofurologyinSatuMare
SatuMare,Romania

TheRomanianSocietyofObstetricsandGynaecology
TheEuropeanSocietyofGynaecologycalOncology
SCIENTIFICACTIVITY
extenso(primauthor)
1. VioricaVarodi.Evaluareadiagnosticpreoperatorieacanceruluidecoluterin.
BuletinulAcademieidetiineaMoldovei(tiineMedicale)2006;3(7):278
287.
2. Viorica Varodi. Les tumeurs de l'utrus sous l'aspecte de l'IRM. Buletinul
AcademieidetiineaMoldovei(tiineMedicale)2007;5(14):291294.
3. Viorica Varodi. Intrt du staging IRM du cancer du col uterine. Buletinul
AcademieidetiineaMoldovei(tiineMedicale)2007;5(14):283286.
4.

VioricaVarodi,NataliaRotaru.Diagnosticulimagisticcomplexalcanceruluide
coluterin.BuletinulAcademieidetiineaMoldovei(tiineMedicale)2008;
2(16):187195.

5. VioricaVarodi,NataliaRotaru.EvaluareastriiganglionilorlimfaticiprinIRM
n cancerul de col uterin. Buletinul Academiei de tiine a Moldovei (tiine
Medicale)2008;5(19):159162.

38

VarodiViorica

6. VioricaVarodi,L.Iaco.Ratanateriiprinoperaiecezarianifactoriicareo
influeneaz.BuletinulSocietiiOncologicedinRepublicaMoldova2011:25
32.
extenso(coauthor)
1. L. Iaco, N. Arapu, Viorica Varodi. Managementul parturientelor din grup de
riscdedezvoltareapatologieineurologicedobnditelaft.BuletinulSocietii
OncologicedinRepublicaMoldova,2011:3339.
abstract/oralpresentation(primauthor)
1. Viorica Varodi, R. Rotaru. Elaborare de algoritm imagistic n aprecierea
stadializrii cancerului de col uterin. Zilele Oncologiei Ieene, volum de
rezumate,2225noiembrie2011,pg:163164.
2. Viorica Varodi, R. Rotaru. Studii comparative ale metodelor imagistice i
stadializarea cancerului de col uterin. Zilele Oncologiei Ieene, volum de
rezumate,2225noiembrie2011,pg:165166.
abstract/oralpresentation(coauthor)
1. S.Ungureanu,VioricaVarodi.Importanavaccinriicametoddeprofilaxien
cancerul de col uterin. Mas rotund: Societatea de Obstetric i Ginecologie
dinRepublicaMoldova,volumderezumate,2225noiembrie2011,pg:815.