AJR 2003; 180:1621-1631
© American Roentgen Ray Society
Imaging in Oncology from The University of Texas M. D. Anderson
Cancer Center |
Diagnosis, Staging, and Surveillance of Cervical Carcinoma
Harmeet Kaur1,
Paul M. Silverman1,
Revathy B. Iyer1,
Claire F. Verschraegen2,
Patricia J. Eifel3 and
Chusilp Charnsangavej1
1 Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer
Center, 1515 Holcombe Blvd., Box 57, Houston, TX 77030.
2 Division of Medical Oncology, The University of Texas M. D. Anderson Cancer
Center, Box 401, Houston, TX 77030.
3 Division of Radiation Oncology, The University of Texas M. D. Anderson Cancer
Center, Box 97, Houston, TX 77030.
Received January 31, 2002;
accepted after revision October 9, 2002.
Address correspondence to H. Kaur.
Introduction
Cervical cancer is the third most common gynecologic malignancy. In the
United States, it is anticipated that 13,000 new cases of cervical cancer will
be diagnosed in 2002, and 4100 deaths will be attributed to the disease
[1].
In the past few decades, introduction of screening with the Papanicolaou
(Pap) smear has resulted in a declining incidence of and mortality from
invasive squamous carcinoma of the cervix
[1]. The relative incidence of
adenocarcinoma, on the other hand, has increased because it is less readily
detected by exfoliative cytology obtained with the Pap smear
[2]. Epidemiologic studies have
identified several potential risk factors in cervical cancer that include
early sexual activity, especially with multiple partners, cigarette smoking,
immunosuppression, and infection with human papillomaviruses 16 and 18
[3].
Pathology
Squamous carcinoma accounts for 85% of cervical cancers and adenocarcinoma,
for 15%. Several uncommon tumors such as adenoid cystic, small cell,
adenosquamous carcinoma, and lymphoma, to mention a few, may also affect the
cervix. The cervix is divided by the vagina into supravaginal and vaginal
regions. The vaginal portion, or portio vaginalis, is covered by stratified
squamous epithelium that meets the columnar epithelium of the endocervical
canal at the squamous–columnar junction over the external os. Squamous
tumors arise from metaplasia at this junction
(Fig. 1).
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Fig. 1. —Coronal illustration of uterus, cervix, and vagina depicts
vaginal portion of cervix or portio vaginalis (arrowhead) with small
tumor arising at external os invading cervical stroma (arrow).
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Cervical cancer can be subdivided into preinvasive (before transgression of
the basement membrane) and invasive lesions. Invasive carcinoma can present as
fungating, ulcerative, or infiltrative tumors. Cervical cancer spreads by
direct extension to contiguous structures (uterine corpus, vagina, and
parametrium) or through lymphatics to regional nodes and rarely by the
hematogenous route.
Clinical Staging and Prognostic Factors
The current system of staging for cervical cancer is based on the
International Federation of Gynecology and Obstetrics (FIGO) classification
[4]
(Appendix 1). This staging
system is a clinical approach based on findings from clinical assessment or
examination of patients under anesthesia, which may be supplemented by chest
radiography, excretory urography, cystoscopy, and proctoscopy. Cross-sectional
imaging is not included as a part of the initial staging because access to
this technology is not universally available. However, errors in clinical
staging have been reported in up to 22% of patients with stage I disease and
in up to 75% with stage III disease. These errors arise from failure to
recognize infiltration of the parametrium, the pelvic sidewall, or the bladder
or rectal wall and metastatic spread
[5]. Aside from the
inaccuracies of clinical staging, important prognostic factors such as lymph
node status, tumor size, and histologic grade are not included in the FIGO
staging system. The presence and extent of nodal involvement are the most
important prognostic factors in cervical cancer
[6]. In surgically treated
stages IB and IIA cervical cancer, survival rates decline from 85–90% to
50–55%, respectively, in the presence of nodes that are positive for
tumor [7,
8]. The significance of tumor
size is reflected by a decline in the 5-year survival rate from 84% to 66% in
tumors larger than 3 cm in diameter
[7]. In 1995, FIGO addressed
the issue of tumor size by subdividing stage IB into IB1 (4 cm or smaller) and
IB2 (larger than 4 cm) [4].
However, because the FIGO classification remains a clinical staging system,
nodal status has still not been included. Given the limitations of clinical
staging, "extended" clinical staging is frequently used when the
technology is available. This staging system incorporates the results of
cross-sectional imaging into therapeutic planning for most tumors more
advanced than stage IA.
Radiologic Evaluation
Imaging modalities used to evaluate the extent of cervical cancer include
excretory urography, barium enema, lymphangiography, sonography, CT, MR
imaging, and positron emission tomography (PET). An important issue in the
staging of cervical cancer is distinguishing early disease (stages IA and IB)
that can be treated with surgical resection from more advanced disease that
requires radiation and possibly chemotherapy. Recent years have seen a decline
in the use of excretory urography, barium enema, and lymphangiography and an
increase in cross-sectional imaging, particularly CT. MR imaging, in spite of
its proven superiority over other techniques for staging and detection of
recurrent disease, remains underused.
MR Imaging
MR imaging with its superior soft-tissue resolution is the single best
modality for preoperative staging of cervical cancer. It has been found to be
cost-effective because it can replace multiple other tests, some of which are
invasive (barium enema, excretory urography, cystoscopy, and sigmoidoscopy).
MR imaging provides the most benefit in evaluating tumors greater than 2 cm at
clinical examination, endocervical lesions, possible parametrial extension,
and pregnant patients [9].
MR imaging of the pelvis for cervical cancer is preferably performed using
a torso phased array coil. One milligram of glucagon can be administered
intramuscularly before the examination to reduce artifacts from bowel
peristalsis. On a 1.5-T magnet, T1-weighted images can be obtained using a
spin-echo pulse sequence with a TR of 500–600 msec, a TE of 12 msec, and
a k-space matrix size of 256 x 192 in the axial and coronal planes. This
sequence is ideal for visualization of lymph nodes, and it also provides the
best tumor-to-parametrial tissue contrast
[10]
(Fig. 2A). Imaging should be
extended cranially to the kidneys for revealing retroperitoneal adenopathy and
hydronephrosis. T2-weighted fast spin-echo images are acquired with the
following parameters: TR range/TE, 4000–5000/130; and a matrix of 512
x 256 in the axial and sagittal planes. The following parameters are
common for both T1- and T2-weighted sequences: thickness of 6 mm with an
interslice gap of 2 mm, bandwidth of 16 kHz, field of view of 26 cm, and 2
signal averages. Respiratory compensation is used with all spin-echo sequences
and an anterior saturation band with fast spin-echo T2- and T1-weighted
sequences to reduce breathing artifacts. T2-weighted fast spin-echo images
provide the best tissue contrast among tumor, cervical stroma, and the rectal
and bladder walls (Fig. 2B) and
are superior to conventional spin-echo T2-weighted images. Fat suppression
does not provide any additional benefit in tissue contrast
[10].
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Fig. 2A. —38-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIB [4]). Axial
T1-weighted MR image shows excellent parametrial-to-tumor tissue contrast;
irregular parametrial-to-tumor interface (arrows) is noted
bilaterally.
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Fig. 2B. —38-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIB [4]). Axial
T2-weighted MR image shows tumor (arrow) as hyperintense. Tumor is
seen extending into parametrium and abutting parametrial vessels
(arrowhead).
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Oblique axial images obtained at a right angle to the endocervical canal
may provide a benefit in the depiction of parametrial spread and stromal
involvement [11] (Figs.
3A,
3B). Contrast-enhanced
T1-weighted imaging provides limited benefit because contrast enhancement
leads to overstaging of stromal, parametrial, and vaginal involvement
[12,
13], but this technique may
provide some benefit in detection of bladder wall invasion and the definition
of fistulas [13].
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Fig. 3A. —60-year-old woman with poorly differentiated carcinoma of
cervix (FIGO stage IIA [4]).
Axial T2-weighted MR image shows full-thickness stromal involvement and
questionable parametrial invasion (arrow) on left. Right ovarian cyst
(arrowhead) is incidentally noted.
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Fig. 3B. —60-year-old woman with poorly differentiated carcinoma of
cervix (FIGO stage IIA [4]).
Oblique axial T2-weighted MR image obtained perpendicular to endocervical
canal clearly shows left parametrial invasion abutting periuterine vessels
(arrow).
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Dynamic MR imaging reportedly improves tumor detection and depiction of the
depth of stromal and parametrial invasion. This is because small cervical
tumors enhance early (30–60 sec) compared with normal cervical stroma
and epithelium [14,
15] (Figs.
4A,
4B). Large tumors are
frequently necrotic and may or may not enhance on dynamic images but are often
surrounded by an enhancing rim that facilitates tumor definition (Figs.
5A,
5B,
5C). Many techniques are used
for dynamic MR imaging. One method is to obtain sagittal dynamic gradient-echo
images with the following parameters: TR range/TE, 120–150/minimum; flip
angle, 80°; matrix, 256 x 128; 1 signal average; thickness, 6 mm
with a gap of 2 mm; field of view, 26 cm; and bolus injection, 0.1 mmol/kg of
gadopentetate dimeglumine. Images can be obtained at 30, 60, and 90 sec.
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Fig. 4A. —56-year-old woman with papillary squamous carcinoma of cervix
(FIGO stage IB [4]). Sagittal
T2-weighted MR image shows hyperintense endocervical tumor invading posterior
cervical lip (arrow).
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Fig. 4B. —56-year-old woman with papillary squamous carcinoma of cervix
(FIGO stage IB [4]). Dynamic
sagittal MR image obtained at 30 sec shows early enhancement of tumor
(small arrow) in contrast to nonenhancing cervical stroma (large
arrow).
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Fig. 5B. —40-year-old woman with squamous cell carcinoma of cervix.
Sagittal dynamic MR images obtained at 30 (B) and 90 (C) sec
show minimal early enhancement of tumor. Enhancing rim (arrows)
facilitates definition of tumor.
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Fig. 5C. —40-year-old woman with squamous cell carcinoma of cervix.
Sagittal dynamic MR images obtained at 30 (B) and 90 (C) sec
show minimal early enhancement of tumor. Enhancing rim (arrows)
facilitates definition of tumor.
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In terms of the utility of contrast medium, a distinction must be made
between routine T1-weighted contrast-enhanced images that can overestimate
stromal and parametrial invasion and dynamic images that are reportedly
superior to T2-weighted images in the detection of stromal and parametrial
invasion [14,
15].
On T2-weighted images, fibrotic cervical stroma appears hypointense and the
vascular parametrium, hyperintense. Cervical tumors are hyperintense on
T2-weighted images and are accurately identified in 91% of cases of invasive
disease [16].
MR imaging is superior to clinical evaluation in the assessment of tumor
size; measurements are within 0.5 cm of the surgical size in 70–90% of
cases [11,
16,
17]. The accuracy of MR
imaging for parametrial invasion ranges from 77% to 96%
[12,
16,
18,
19,
20]. The highest accuracy is
seen in small tumors, in which preservation of an intact dark stromal ring has
a negative predictive value of 94–100% in excluding parametrial invasion
[16,
18]
(Fig. 6). Accuracy is seen to
fall to 74% if only stage IIA and more advanced tumors are considered
[16]. With larger tumors, the
entire thickness of the cervical stroma may be hyperintense on T2-weighted
images. This can lead to overstaging because edema cannot be distinguished
from tumor or under-estimation of early parametrial involvement (Figs.
7A,
7B). In such circumstances, a
focal disruption of the stromal ring or protrusion of tumor is a more reliable
sign of parametrial invasion (Figs.
3A,
3B). For tumors located in the
supravaginal cervix, the presence of an irregular margin or abutment or
encasement of periuterine vessels suggests parametrial spread (Figs.
8A,
8B). If the tumor is confined
in the vagina, parametrial invasion is suggested by the disruption of the
vaginal wall [21]. In spite of
its limitations in evaluating larger tumors, the use of MR imaging improves
staging accuracy from 53% to 73% in comparison to the clinical examination
when only tumors more advanced than stage IIA are considered
[16].
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Fig. 7B. —27-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IB2 [4]). Axial
T2-weighted MR image shows hyperintense mass (arrowhead) with no
normal stroma identified. Note round left obturator node (arrow)
negative for tumor at pathology.
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Fig. 8A. —48-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIB [4]). Coronal
illustration of stage IIB shows tumor involving vaginal and supravaginal
cervix with parametrial invasion on left.
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Fig. 8B. —48-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIB [4]). Axial
T2-weighted MR image shows hyperintense mass replacing cervix, with bilateral
parametrial invasion, and tumor abutting parametrial vessels
(arrows). Small parametrial node (arrowhead) is seen on
left.
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MR imaging findings that are suggestive of pelvic sidewall involvement
include tumor within 3 mm of or abutment of the internal obturator, levator
ani, and pyriform muscles and the iliac vessels
[21,
22]. Loss of normal
parametrial signal intensity and increased signal intensity in pelvic
musculature on T2-weighted images are other suggestive findings. Involvement
of the vagina is suggested by disruption of the normal low-signal-intensity
wall on T2-weighted images (Figs.
9A,
9B). Overall accuracy for
vaginal invasion is 86–93%
[16,
18]. Accuracy is lower in
bulky tumors because stretching of vaginal fornices may suggest tumor
infiltration, even if vaginal fornices are not involved.
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Fig. 9A. —27-year-old woman with poorly differentiated squamous cell
carcinoma of cervix (FIGO stage IIIA
[4]). Coronal illustration
depicts stage IIIA with tumor extending into lower third of vagina.
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Fig. 9B. —27-year-old woman with poorly differentiated squamous cell
carcinoma of cervix (FIGO stage IIIA
[4]). Sagittal T2-weighted MR
image shows hyperintense mass invading anterior and posterior vaginal fornices
(large arrows) with extension into lower third of vagina (small
arrow).
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Some authors have reported that MR imaging has a high accuracy in assessing
bladder invasion [23]. The
criteria described include focal obliteration of the hypointense bladder wall
and high signal intensity along the anterior aspect of the posterior bladder
wall on T2-weighted images and, in advanced cases, nodular masses that project
into the bladder (Figs. 10A,
10B) or a vesicovaginal
fistula (Fig. 11). Although
preservation of a hypointense bladder wall, perivesical fatty layer, and
vesicouterine ligament excludes bladder involvement, the positive predictive
value of increased signal intensity on T2-weighted images within these same
structures is low. This is because an edematous response in these structures
can mimic tumor infiltration. This limitation has led to the assessment of the
role of dynamic MR imaging. A recent study evaluated dynamic imaging with
pharmacokinetic analysis. This technique derives pharmacokinetic parameters
from dynamic data such as the exchange rate constant and amplitude of
enhancement. In 16 patients with surgically confirmed stage IV disease,
dynamic MR imaging improved accuracy in assessing bladder involvement in
comparison with T2-weighted images alone
[20].
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Fig. 10B. —39-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IB2 [4]). Sagittal
T2-weighted MR image shows large hyperintense mass arising from cervix with
involvement of anterior and posterior vaginal fornices (large solid
arrow). Note extension into vesicovaginal septum (small solid
arrow) and invasion of posterior bladder wall (open arrow).
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Fig. 11. —74-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IVA [4]) leaking
urine through vagina. Sagittal T2-weighted MR image shows fluid containing
fistulous tract extending from bladder to vagina (small arrow). Fluid
is seen within vaginal lumen (arrowhead). Hyperintense tumor seen
involving vesicovaginal septum and extending posterior to urethra (large
arrow).
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Sonography
Transabdominal sonography can be used to reveal the presence of
hydronephrosis, but otherwise this procedure has a limited role in staging
cervical cancer. Endoluminal probes have been used in the assessment of local
disease spread but are inadequate for detection of nodal and pelvic sidewall
involvement. Endorectal sonography has been used in revealing parametrial
involvement with a reported accuracy of 87–95%, and transvaginal
sonography has been used in assessing bladder invasion
[24,
25,
26]. Preservation of mobility
of the bladder over the cervical tumor as seen on transvaginal sonography has
a reported accuracy of 95% in detecting bladder involvement in comparison with
76% for CT and 80% for MR imaging
[26].
CT
CT differs from sonography and MR imaging in that CT is inaccurate in the
detection of local disease because 50% of tumors are isodense to cervical
stroma on contrast-enhanced CT
[27]. CT is performed
primarily to assess adenopathy. CT also has a role in defining advanced
disease, monitoring distant metastasis, planning the placement of radiation
ports, and guiding percutaneous biopsies.
Scans are obtained using oral, IV, and rectal contrast materials. A tampon
may be used to outline the vaginal canal. Scanning from below the inferior
aspect of the pubic bone to the diaphragm enables imaging of the uterus and
cervix during the phase of maximal enhancement. An initial scanning delay of
40 sec followed by a 4- to 5-min delay for definition of the ureters and
bladder can be obtained.
Single-detector helical CT scans are generally obtained using 5- to
7-mm-thick contiguous cuts. As far as multidetector CT (MDCT) is concerned,
optimized imaging protocols and the potential role of MDCT are still being
evaluated. A suggested technique is a section collimation of 2.5 mm and a
table speed of 12.5 mm/sec with reconstructed sections of 3–5 mm. The
data can be used to reconstruct images in the coronal and sagittal planes
[28].
On CT, the cervix appears as a soft-tissue attenuation structure surrounded
by parametrial fat containing uterine vessels and lymphatics. The cardinal
ligaments are occasionally seen as triangular structures, extending laterally
from the cervix. The reported accuracy of contrast-enhanced CT in revealing
parametrial invasion is 76–80%
[17,
27,
29]. The primary limitation of
CT is its inability to distinguish tumor from the normal parametrial
structures, leading to overestimation of early parametrial involvement
[27,
30]. Advanced parametrial
invasion is more easily assessed; the signs include obliteration of
periureteral fat planes, eccentric parametrial mass
(Fig. 12), and encasement of
periuterine vessels [31]. CT
has an accuracy of 92% in the depiction of advanced disease—that is,
stages IIIB and higher [30].
The criteria include tumor abutment of pelvic sidewall musculature and vessels
or tumor within 3 mm of the pelvic sidewall and a nodular or eroded bladder
and rectal wall. Early involvement of the bladder wall and the vagina is not
reliably defined on CT.
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Fig. 12. —70-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIIB [4]). Axial
contrast-enhanced CT scan shows necrotic hypodense tumor extending into right
parametrium (arrowheads).
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Imaging of Lymph Node Involvement
Lymphatic spread from cervical tumors is initially to the parametrial nodes
followed by extension primarily along three pathways
(Fig. 13). The lateral route
is to the external iliac nodes, the hypogastric route is to the internal iliac
or hypogastric nodes that lie along the internal iliac vessels, and the
posterior route is along the uterosacral ligaments to the lateral sacral and
sacral promontory nodes (Fig.
14). Nodes along the external iliac vessels can be classified into
lateral, middle, and medial chains (Fig.
15). Medial chain nodes are located posteriorly and medially to
the external iliac vessels. These nodes are the first to be involved in the
lateral route of spread. They are in close proximity to and frequently
inseparable from obturator nodes. All nodal groups drain to the common iliac
nodes (Fig. 16) and then to
the paraaortic nodes [32].
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Fig. 14. —40-year-old woman treated with radiation for squamous
carcinoma of cervix who presented with recurrent disease. Axial CT scan of
pelvis shows enlarged lateral sacral node (arrowhead) medial to
internal iliac vessels (arrow).
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Fig. 15. —27-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IB2 [4]). Axial
T2-weighted MR image shows enlarged left medial chain external iliac node
found to be reactive at biopsy (large arrow). Note benign fatty
bilateral lateral chain external iliac nodes (small arrows).
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Fig. 16. —45-year-old woman who presented with right hip pain 1 year
after radiation treatment for cervical cancer. Axial contrast-enhanced CT scan
shows right necrotic common iliac node (small black arrow) that abuts
lumbar nerve roots in this region and necrotic left junctional node (large
black arrow). Gonadal vessels are identified bilaterally (white
arrows).
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CT and MR imaging have comparable accuracies for detecting nodal
involvement: 83–85% for CT and 88–89% for MR imaging
[27,
33]. This is because both
techniques rely on nodal enlargement of at least 1 cm or rounded nodes as the
criterion for suggesting malignant adenopathy. In some studies, MR imaging has
a slight edge in accuracy, partly because of the greater ease in
discriminating lymph nodes from ovaries and adjacent vessels and its
multiplanar capability [27].
However, the limitation of both techniques is a low sensitivity of
24–70% because of their inability to detect metastasis in normal-sized
nodes. Although neither technique can differentiate hyperplastic inflammatory
nodes from malignant nodes, specificity is reportedly high—between 89%
and 93% [27,
33].
A recent report [33]
described a 17–27% incidence of necrotic adenopathy with cervical
cancer, depending on whether MR imaging or CT was used
(Fig. 17). This finding has a
high specificity [33].
However, these nodes can have an appearance similar to that of the ovaries,
and care must be taken in distinguishing these structures. The definition of
the gonadal vessels occasionally proves helpful in defining the ovaries (Figs.
18A,
18B).
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Fig. 17. —68-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IIB [4]). Axial
contrast-enhanced CT scan shows bilateral medial chain external iliac nodes
(arrows). Node on right is necrotic. Large isodense cervical mass and
right parametrial nodes (arrowheads) are also noted.
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Fig. 18A. —48-year-old woman with poorly differentiated adenocarcinoma
of cervix (FIGO stage IB2 [4]).
Sagittal T2-weighted MR image shows endocervical mass (black arrow)
with large peritoneal implant (white arrow).
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Fig. 18B. —48-year-old woman with poorly differentiated adenocarcinoma
of cervix (FIGO stage IB2 [4]).
Axial T2-weighted MR image shows tumor implant on left ovary (arrow)
and gonadal vessel entering ovary (arrowhead). Gonadal vessel helps
to distinguish ovary from external iliac node.
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Lymphangiography differs from cross-sectional imaging modalities in that it
does not rely on nodal size as a criterion for determining metastatic disease.
Instead, filling defects in opacified nodes show replacement of the node by
metastatic tumor (Fig. 19).
However, lymphangiography is invasive, requiring cannulation of lymphatics and
injection of oil-based contrast medium. Few centers now perform
lymphangiography, resulting in inexperience in both its performance and
interpretation.
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Fig. 19. —36-year-old woman with squamous cell carcinoma of cervix
(FIGO stage IB2 [4]).
Radiograph obtained 24 hr after bipedal lymphangiogram shows filling defect
consistent with metastatic tumor in left external iliac nodes
(arrow).
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FDG used for PET studies is taken up by 91% of cervical tumors
[34]. In comparison with MR
imaging, the use of PET improved sensitivity in detection of lymph node
metastasis from 50–73% to 83–91%
[35,
36]. Small nodes of less than
1 cm in maximal diameter and micrometastasis remain a problem even with PET
scanning [35]. The positive
predictive value of PET is 90–100%
[35,
36]. Consequently, a possible
approach to noninvasively evaluate for nodal disease is to supplement CT and
MR imaging with PET scanning (Figs.
20A,
20B). Positive PET findings
showing pelvic and paraaortic nodes should, in view of the high positive
predictive value of PET, obviate surgical intervention. Negative PET findings,
however, would require nodal dissection
[35].
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Fig. 20A. —49-year-old woman with treated carcinoma of cervix. Follow-up
CT scan (A) reveals solitary paraaortic node (arrow) that
shows increased uptake of FDG on coronal positron emission tomography image
(B) (arrowhead). (Courtesy of Kim E, Houston, TX)
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Fig. 20B. —49-year-old woman with treated carcinoma of cervix. Follow-up
CT scan (A) reveals solitary paraaortic node (arrow) that
shows increased uptake of FDG on coronal positron emission tomography image
(B) (arrowhead). (Courtesy of Kim E, Houston, TX)
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Imaging of Recurrent Disease
Recurrence is most common in the first few years after diagnosis, with 60%
of patients developing recurrent disease within 2 years and 90% within 5 years
[37]. In cervical cancer, 74%
of recurrences are within the pelvis
[38]. The most common sites of
recurrent disease are the vaginal cuff, cervix, parametrium, and pelvic
sidewall (Figs. 21A,
21B). Early detection and
accurate characterization of the extent of disease are important in
identifying patients who might be candidates for curative pelvic
exenteration.
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Fig. 21A. —38-year-old woman with adenocarcinoma of cervix (FIGO stage
IB1 [4]) treated with radical
hysterectomy. Axial T2-weighted MR image shows hyperintense recurrent mass in
vaginal cuff (arrowhead).
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Fig. 21B. —38-year-old woman with adenocarcinoma of cervix (FIGO stage
IB1 [4]) treated with radical
hysterectomy. Axial T2-weighted MR image shows right recurrent mass in pelvic
sidewall abutting external iliac vessels (arrow) and sacral nerve
roots. Normal exiting sacral nerve roots are clearly identified on left side
(arrowhead).
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|
The critical issue is distinguishing postradiation changes from recurrent
tumor. Early CT studies evaluating recurrent disease reported an accuracy of
83–84% [39,
40]. However, these studies
evaluated advanced disease, with the average tumor size ranging from 4 to 7
cm. Walsh and Goplerud [30]
subsequently reported that in 60% of patients who were evaluated, CT could not
distinguish posttreatment change from recurrent tumor. Although widely used
for the detection of recurrent disease, CT remains limited in this regard.
However, CT is useful in the detection of recurrence in the presence of
baseline posttreatment scanning by identifying new areas of disease.
Initial studies with MR imaging had suggested that it was possible to
distinguish radiation fibrosis from tumor 6 months or more after completion of
radiation therapy. The criteria used to define recurrent tumor were the
presence of a mass or nodule on T1-weighted images that appeared hyperintense
relative to muscle and fat on heavily T2-weighted images
[41,
42]. Subsequent studies have
concluded that T2-weighted images have a high sensitivity (90–91%) but a
low specificity (22–38%) for recurrent disease
[43,
44]. This is because benign
conditions such as edema, inflammation, and necrosis may also cause increased
T2 signal. Dynamic MR imaging improves specificity by identifying rapidly
enhancing masses seen between 45 and 90 sec as malignant. The use of dynamic
MR imaging improved accuracy with T2-weighted images from 64–74% to
82–83% and improved specificity from 22–38% to 67%
[43,
44,
45]. Although this technique
has improved specificity, early radiation change continues to pose a problem
because it may show early enhancement
[44]. Frequently, CT-guided
biopsies of the areas in question are required to confirm recurrence. PET
scanning for recurrent disease has shown a high sensitivity and an improved
specificity over CT. If the initial promise of PET scanning is proven, a
negative finding on PET may obviate biopsy and surgical intervention
[46].
Therapeutic Options
In patients with stage IA cervical cancer, surgery or pelvic irradiation
with intracavitary treatment is equally efficacious
[47]. For patients with stage
IA1 disease, a simple hysterectomy that involves removal of only the uterus
(parametrial and uterosacral ligaments are not resected) is usually
sufficient. For patients stage IA2 disease, a radical hysterectomy is
indicated, which involves resection of the uterus, upper vagina, parametrium,
and pelvic lymph nodes.
Patients with stage IB1 and IIA cervical cancer can be safely treated with
either radiotherapy or surgery. In the presence of pathologic risk factors
such as nodal metastasis or a surgical margin within 3 mm of the tumor,
adjuvant radiotherapy is recommended. Because the combination of radical
surgery and irradiation has greater morbidity compared with either modality
alone, accurate preoperative assessment is crucial to minimize the need for
both treatments. In patients with poor prognostic factors such as nodal
involvement, tumor larger than 4 cm, or adenocarcinoma, surgery is not the
treatment of choice [48].
The standard treatment for patients with stage IB2, IIB–IVA, IB1, or
IIA with adverse prognostic factors is combined external pelvic radiation and
brachytherapy with concurrent administration of chemotherapy
[49]. Neoadjuvant chemotherapy
before radiation has not improved survival in patients with locally advanced
cervical cancer.
Therapeutic Response
Tumors treated with radiation therapy respond with a decrease in size and
signal intensity on MR imaging (Figs.
22A,
22B). The response may be
immediate (3–6 months) or in larger tumors delayed (6–9 months)
[50]. Dynamic MR imaging
supplemented by pharmacokinetic analysis has the potential to distinguish
tumors that will respond to radiation from those that will be resistant. If
these initial results are proven, it may be possible to identify patients who
will benefit from more aggressive therapy
[51].
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[in this window]
[in a new window]
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|
Fig. 22A. —40-year-old woman with squamous cell carcinoma of cervix FIGO
stage IB2 [4] before and after
treatment with 45 Gy of radiation. Sagittal T2-weighted MR image obtained
before patient underwent radiation shows exophytic hyperintense mass
(arrow). Note thinned but uninvolved hypointense vaginal fornix
(arrowhead).
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View larger version (192K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 22B. —40-year-old woman with squamous cell carcinoma of cervix FIGO
stage IB2 [4] before and after
treatment with 45 Gy of radiation. Sagittal T2-weighted MR image shows that
mass (arrow) after treatment is smaller and hypointense.
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|
Conclusion
MR imaging represents the single most effective modality for detection of
primary tumor and local spread. In revealing nodal involvement, CT and MR
imaging are equally effective. If clinically available, PET scanning improves
the specificity and sensitivity of these techniques. MR imaging is also the
best modality for showing recurrent disease and monitoring therapeutic
response. The addition of dynamic MR imaging improves specificity and provides
prognostic information.
Acknowledgments
We would like to extend our appreciation to Tara Blaylock for her efforts
in the preparation of this manuscript.
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Introduction
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