Journal List > J Korean Soc Radiol > v.77(2) > 1087885

Yoon and Kim: MR Imaging for Staging of Cervical Carcinoma: Update


Uterine cervical cancer is globally the third most common cancer among women, and shows high mortality with invasive cervical carcinoma. Early detection of the disease, its correct staging, and treatment are therefore of great importance. The staging system updated in 2009 by the International Federation of Gynecology and Obstetrics (FIGO), is commonly used for planning the treatment. However, there are significant inaccuracies in the FIGO staging system. Accurate tumor staging is very important to decide the treatment strategy. Although not included in the staging system, magnetic resonance (MR) imaging is a valuable tool for local staging of the disease, and is useful in assessing the spread of the tumor and metastatic lymph nodes, thereby becoming a more accurate substitute for clinical staging of cervical carcinoma. In addition, it is capable of assessing the disease response to surgery or chemoradiation. This review briefly describes the role of MR imaging and the basic MR scanning protocol in evaluating cervical carcinoma. The MR findings with staging, and MR evaluation of treatment response, are further addressed.


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Fig. 1.
Axial oblique T2-weighted MR image. A. Sagittal T2-weighted MR image shows a heterogeneous, intermediate signal intensity mass in the uterine cervix. Lines indicate scan direction of oblique axial images, which are obtained perpendicular to the long axis of cervix. B. Axial T2-weighted image shows that parametrial invasion is not clear in the anterior aspect of the cervix (arrow). C. Oblique axial T2-weighted image clearly excludes the extension to the parametria, which provides more accurate assessment of stromal and parametrial invasion, as compared with T2-weighted image.
Fig. 2.
Stage IB1 cervical carcinoma in a 59-year-old woman. A, B. Sagittal (A) and axial (B) T2-weighted MR images show no abnormal signal intensity lesions in the uterine cervix. C. Axial contrast-enhanced T1-weighted MR image shows a small enhancing tumor (arrow) in the cervix. D. A photograph of gross specimen of the uterine cervix reveals a small nodular mass (arrow) within the endocervix, which is staged as IB1 disease after radical hysterectomy.
Fig. 3.
Stage IVA cervical carcinoma in a 58-year-old woman. A. Sagittal T2-weighted MR image shows a bulky tumor (arrow) with invasion to the posterior wall of the bladder. B. Sagittal contrast-enhanced T1-weighted MR image clearly demonstrates an enhancing mass with fistulous tract (arrow) between the urinary bladder (UB) and vagina (V), a finding indicative of vesicovaginal fistula.
Fig. 4.
Stage IB1 cervical carcinoma in a 51-year-old woman. A, B. Sagittal (A) and axial oblique (B) T2-weighted MR images show an exophytic hyperintense mass (arrows) arising from external os of the uterine cervix, without parametrial invasion. Stage IB1 cervical carcinoma in a 51-year-old woman. C-E. Axial DWI (C) and ADC (D, E) maps show a hyperintense mass (white arrow) with diffusion restriction (black arrow) and decreased mean ADC value (1.070 × 10-3 mm2/s). F. A photograph of the gross specimen of the uterine cervix demonstrates a polypoid mass with exophytic growing from external os of the uter-ine cervix (arrow). ADC = apparent diffusion coefficient, DWI = diffusion-weighted imaging
Fig. 5.
Stage IIA2 cervical carcinoma in a 63-year-old woman. A. Sagittal T2-weighted MR image shows a hyperintense exophytic growing mass with extension to the upper half of the anterior vaginal wall (arrow). B. A photograph of the gross specimen of the uterine cervix reveals an ill-defined, infiltrative mass (4.5 × 2 cm) with extension to the upper anteri-or vagina (arrow), after radical hysterectomy.
Fig. 6.
Stage IIB cervical carcinoma in a 63-year-old woman. Axial T2-weighted MR image shows an intermediate signal intensity mass with focal disruption of hypointense stromal ring in the left side (arrow), a finding indicative of stromal invasion.
Fig. 7.
Stage IIB cervical carcinoma in a 77-year-old woman. A. Sagittal T2-weighted MR image shows a relatively ill-defined, hyperintense mass (arrow) in the cervix. B, C. Axial oblique (B) T2-weighted MR image shows disruption of hypointense ring and spiculated tumor-parametrial interface, a finding con-sistent with parametrial invasion (arrow). This finding is also clearly seen on coronal (C) T2-weighted MR image (arrow).
Fig. 8.
Stage IB2 cervical carcinoma in a 46-year-old woman. A. Sagittal T2-weighted MR image shows a lobulated hyperintense mass (arrow) in the endocervix. B. Axial T2-weighted MR image shows irregular and spiculated tumor-parametrial interface (arrow), suggestive of clinical stage IIB disease. How-ever, this lesion was overstaged and proven stage IB2 after radical hysterectomy.
Fig. 9.
Stage IIIA cervical carcinoma in a 64-year-old woman. Sagittal T2-weighted MR image shows a hyperintense mass and extension to anterior upper and lower vaginal wall (arrows), which is a favorable finding of vaginal invasion. However, hypointense posterior wall of the blad-der is intact.
Fig. 10.
Stage IIIB cervical carcinoma in a 75-year-old woman. A, B. Axial (A) and coronal (B) T2-weighted MR images show intermediate signal intensity mass in the cervix, extending into the right lower ure-ter (arrows). C. Axial T2-weighted MR image obtained at the renal hilar level shows hydronephrosis (arrow) in the right kidney.
Fig. 11.
Stage IVA cervical carcinoma in a 48-year-old woman. Sagittal T2-weighted MR image shows tumor extension into the posterior wall of the bladder and anterior wall of the rectosigmoid colon, findings con-sistent with bladder and rectal invasion (arrows).
Fig. 12.
Stage IVA cervical carcinoma in a 52-year-old woman. A, B. Axial T2-weighted (A) and contrast-enhanced T1-weighted (B) MR images show an intermediate signal intensity mass with extension to the uterosacral ligament (arrow) posteriorly. C. Coronal T2-weighted MR image shows tumor invasion to the posterior wall of the bladder as well as the uterosacral ligament (arrow).
Fig. 13.
Total hysterectomy for stage IA1 cervical carcinoma in a 73-year-old woman. Sagittal T2-weighted MR image shows absence of the uter-us with no abnormal signal intensity mass in the vaginal cuff and nor-mal appearing smooth, low signal intensity vaginal wall (arrow).
Fig. 14.
Complete response after radiation treatment for stage IIB cervical carcinoma in a 67-year-old woman. A, B. Pre-treatment sagittal (A) and axial (B) T2-wighted images show an intermediate signal intensity mass (arrows) with invasion to the upper vagina and parametrium, a finding indicative of stage IIB disease. C, D. Following radiation treatment, sagittal (C) and axial (D) T2-wighted images show diffuse, homogeneous low signal intensity cervical stro-ma, and reconstitution of the normal zonal anatomy in the uterine cervix (arrows), a finding consistent with complete response.
Fig. 15.
A 42-year-old woman with a recurrent cervical cancer after surgical treatment. A, B. Following radical hysterectomy, sagittal (A) and axial (B) T2-weighted MR images show intermediate signal intensity mass in the vaginal cuff (arrows). C. Post-contrast T1-weighted MR image shows good enhancement of the mass in the vaginal cuff (white arrow), a finding consistent with a re-current cancer. D, E. Axial DWI (D) and ADC (E) maps show a hyperintense mass (white arrow) with diffusion restriction (black arrow) in the corresponding area. ADC = apparent diffusion coefficient, DWI = diffusion-weighted imaging
Table 1.
Revised FIGO Staging of Cervical Carcinoma
Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)
IA Invasive carcinoma diagnosed only by microscopy
IA1 Measured stromal invasion of ≤ 3 mm in depth and extension of ≤ 7 mm
IA2 Measured stromal invasion of > 3 mm and not > 5 mm with an extension of not > 7 mm
IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA
IB1 Clinically visible lesion ≤ 4 cm in greatest dimension
IB2 Clinically visible lesion > 4 cm in greatest dimension
Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
IIA Without parametrial invasion
IIA1 Clinically visible lesion ≤ 4 cm in greatest dimension
IIA2 Clinically visible lesion > 4 cm in greatest dimension
IIB With parametrial invasion
Stage III The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney
IIIA Tumor involves lower third of the vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV
IVA Spread of the growth to adjacent organs
IVB Spread to distant organs

FIGO = International Federation of Gynecology and Obstetrics

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