Hysterography in cancer of the uterus

Hysterography

in Cancer

of the Uterus

By OLOF NORMAN, M.D.

H

YSTEROSALPINGOGRAPHY is still used mainly to demonstrate the patency or occlusion of the fallopian tubes in the investigation of female sterility. Hitherto, the method has been used by only a few workers for the investigation of cancer of the uterus. B&l&e was the first to apply hysterography routinely in the examination of patients with met0rrhagia.l At the University Hospital of Lund, hysterography has been used routinely since 1946 in the study of cancer of the uterus. Consequently, extensive experience has been gained in the radiologic diagnosis of uterine cancer, especially of the body. Hysterography is less vaIuable for cancer of the cervix since cervical tumors often encroach upon the external OS and prevent adequate filling. TECHNIQUE

Various-sized cervical cones must be available, since a close fit is indispensable. The nozzle of the cannula should project only a few millimeters beyond the cone; not only to prevent perforation, but also to avoid obscuring any pathologic changes in the cervix. Several iodized oils have been employed in hysterography, but none are truly suitable. Iodized oil is usually too opaque and does not delineate the fine details of a tumor, nor does it mix with the secretions often present in carcinoma. The risk of vascular backflow is also significant with the oily media. Consequently, water-soluble contrast media are now being used with increasing frequency. For the last 15 years we have used Perjodal-H-Viscous,* a diiodine pyridon to which dextran is added as a thickener. The examination must be carried out under fluoroscopic control. This permits the examiner to follow the passageof the contrast medium into the uterine cavity and to expose films in the appropriate positions and with optimal filling. ROENTGEN APPEARAR’CE

The radiologic signs of cancer of the uterine body and of the cervix vary widely from case to case. Infiltration of the uterine wall and a proliferative growth are common to the different forms of cancer. The surface facing the lumen, i.e., the contour that is seen at hysterography, may be irregular (often ragged) or smooth. Those with a smooth outline (Figs. 1, 7 and 9) can expand the uterus, although the attachment to the wall may be limited (Fig. 1). These tumors are generally histologically more anaplastic. The ragged type of tumor (Figs. 2, 4 and 11) usually shows a higher degree of differentiation. Hysterograms showing various intermediate forms between these two types are, of course, seen (Fig, 3). Tumors also vary in location and extent in the uterine cavity. OLOF NORMAN,M.D.: Lund,

Head,

Roentgen&agnostic

Department

II,

University

Hospital,

Sweden.

* Pharmacia, Sweden. 244

SEMINARS IN ROENTGENOLOGY, VOL. 4, No. 3 (JULY), 1969

HYSTEROGRAPHY

IN

CANCER

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Fig. 1 .-A smooth, well-outlined tumor bulging from the fundus and partly filling the uterine cavity. The attachment to the uterine wall is limited. Cancers of this appearance are usually lowly differentiated.

Fig. 2.-Diffuse cancer of the endometrium. The entire uterine cavity is occupied by an irregularly outlined, moderately exophytic mural growth. This type of cancer usually represents the more differentiated type of lesion.

DISCUSSION

It is not always possible, of course, to say whether a lesion is malignant or not. However, in only 2 of more than 1500 cases of cancer of the uterus did a later curettage show cancer in spite of a negative hysterogram. This justifies

the use of hysterography as the first line of investigation of metrorrhagia. Even if hysterography does not permit a secure diagnosis it can provide a valuable guide for subsequent curettage. If a cancer is clinically suspected but the biopsy is negative, one has a situation that strongly warrants hysterography. In about 10 per cent of our series, hysterography performed less than two months after a negative curettage gave a distinct picture of cancer.2 In more than half of these, the carcinoma was large. Occasionally, hysterography has been of special value in the differential diagnosis between hyperplasia and cancer (Fig. 4). Apparently the pathologist does not always receive curettings representative of the lesion.

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The anatomic information derived from hysterography can also help explain why a previous biopsy was negative. In most instances, the reason is one of topography: the tumor is in a location easily missed by the probing curette. Abnormal deviation of the uterus can also make it almost impossible for an instrument to reach the cavity of the corpus (Fig. 5).

Fig. S.-Partly smooth, partly irregular tumor. The right horn is elongated and expanded by a tumor showing a different appearance distally and centrally. The outline of the cornu is shaggy while the central part is smoothly outlined. This indicated anaplastic changes medially and more differentiation laterally, which was verified at microscopic examination.

Fig. 4.-Cancer vs. endometrial hyperplasia. Hysterography showsa uterine cavity

of normal size. In the fundus and along the left border, there are changes resembling hyperplasia. However, a hormonal influence on the endometrium should involve the entire wall and therefore, the roentgen diagnosiswas carcinoma, which was verified by a second biopsy.

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Fig. 5.-Widespread cancer in the left anterior portion of the corpus. The uter-

us is markedly flexed, which may explain why curettage failed to provide the diagnosis.

Fig. 6.-A well-demarcated cancer in the right horn of a bicornuate uterus. The first curettage wasnega-

tive, probably because only the left horn was explored.

We have a number of casesin which a carcinoma was localized to one of the horns of a bicornuate uterus and apparently only the horn without the lesion was explored by the curette (Fig. 6). In some patients, a cervical myoma has prevented the passageof the curette. It is also known that malignant growth is often located in one of the recessesat the border of a myoma and therefore is difficult to reach with an instrument. In all such casts, hysterography can provitle vital information.

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SOHhIAN

Hysterography is also an excellent complementary method for evaIuating patients referred for radiotherapy. For localizing tumors, it is superior to intrauterine instrumental palpation. In endocervical tumor, if it is technically possible to perform hysterography, as much information can be derived as in cancer of the body (Figs. 7 and 8). Hysterography will demonstrate the topography of adjacent structures, which is essential to the therapist in treatment planning and in deciding whether effective radium packing is possible (Fig. 9) and if so, in what manner the capsules should be packed. It is sometimes difficult to determine by instrumental palpation spread of the tumor in relation to the internal OS,particularly if the cancer is predominantly reveal even uniIatera1 at the isthmus (Fig. IO). Hysterography will, however,

Fig. cancer,

7.-Well-demarcated

endocervical

In cancer of the cervix, hysterography is often unsuccessful because the portio vaginalis is commonly involved, blocking the cervical canal.

Fig. &-Extensive carcinoma, The uterus is en-

larged by a c&.&r, cuffformed cancer involving the major part of the uterus, leaving only the fundus and the distal part of the cervix free. Roentgenologically this should be classified as cancer of the corpus and cervix. Clinically, however, it was considered to be a cancer of the cervix.

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such a small overgrowth and be useful in tumor staging and thereby is of importance in the choice of treatment. Hysterography enables the radiotherapist to evaluate the effect of treatment (Fig. 11). Any decrease in tumor size will be shown; such information is important in deciding whether the patient should be operated upon.

Fig. 9.-Extensive uterine carcinoma. The lIterus is enlarged ;md

the body and the upper half of the cervix are filled by an exophytic, smoothly outlined tumor. Curettage yielded ample curettings from the cervix but instrumental exploration of the corpus was impossible.Hysterography gives the explanation. The patient was operated Itpon kvithout ludium therapy.

Fig. lO.-Unilateral uterine carcinoma with continuous growth of

cancer from the left horn down to the upper part of the cervix. Hysterography shows the relationship to the isthmus better than instrum~?ntalexamination.

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Fig. IL-Carcinoma of the corpus. A. Initial hysterography shows an enlarged uterine cavity almost filled with cancer. B. Three weeks after intracavitary radium treatment, hysterography shows good regression. C. Five weeks after the second treatment, the cancer has disappeared and the uterus is reduced to normal size.

Fig. 12.-Instrumental perforation of the uterus. The uterus deviates to the right. A cylindrical canal is seen as a continuation of the cervix. This is characteristic of perforation through the uterine wall. From the top of the canal, corresponding to the outer surface of the uterine wall, contrast is seen to pass into the veins.

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UTERUS

COMPLICATIONS

The risk of instrumental injury attending hysterography in cancer is not great. On the other hand, hysterography will reveal a preexisting perforation. The radiographic picture of such a lesion is characteristic: a cylindrical canal extends through the wall of the uterus more or less in the direction of the cervix (Fig. 12). Such spontaneous perforations are common in uterine cancer cases (10 to 15 per cent), but usually do not cause serious complications. Nevertheless, it is necessary to be familiar with their roentgen appearance, especially when the uterus is to be packed with radium. If a perforation is suspected or demonstrated, the position of the capsules must be repeatedly checked. The possibility of disseminating cancer cells during hysterography is often used as an argument against employment of this procedure. Such spread has never been proved, and in a recent follow-up of the patients in our series, nothing was observed to substantiate such an assumption, Local infection is a fairly common accompaniment of cancer of the uterus, but has not been regarded as a contraindication to hysterography. The risk of infection from hysterography is no greater in uterine carcinoma than it is in noncancerous disease. In several patients, hysterography was performed shortly after drainage of a pyometra. Moderate temperature elevations for a day or two were noted in a few patients, but it was never necessary to postpone packing because of an inflammatory complication of hysterography. REFERENCES 1. Bi?cl&re, Salpingographie. 2. Norman,

C., and Fayolle, G.: L’hystkroParis, Masson & Cie, 1961. 0.: Hysterography in cancer

of the corpus of Suppl. 7911, 1950.

the

uterus.

Acta

Radiol.