Imaging techniques for the evaluation of cervical cancer

Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO)

Cervical cancer continues to have a significant incidence, despite global efforts in HPV vaccination campaigns. Managing this condition involves a diverse team of healthcare professionals. Research in this field is undergoing a period of great revolution in multiple areas, and international guidelines will soon have to adapt to new scientific evidence. This could be true mainly in locally advanced stages, and it could also be true for minimal invasive surgery. This paper aims to summarize and compare the most recent recommendations published by international gynecological oncological societies for patients with cervical cancer. From their comparison, common aspects and disagreements emerged, especially in the diagnostic pathway and follow-up strategies. Several issues that remain to be debated in the literature were addressed and compared, highlighting similarities and differences, from the role of the sentinel lymph node in early stages to that of the adjuvant hysterectomy in locally advanced tumors. On the surgical side, for this last subset of patients, currently, a laparotomic approach is recommended. At the same time, the advent of immunotherapy has just opened up new and promising scenarios in systemic treatment for locally advanced cervical cancer, and international guidelines will soon introduce it into their algorithms.

Role of artificial intelligence applied to ultrasound in gynecology oncology: A systematic review

The aim of this paper was to explore the role of artificial intelligence (AI) applied to ultrasound imaging in gynecology oncology. Web of Science, PubMed, and Scopus databases were searched. All studies were imported to RAYYAN QCRI software. The overall quality of the included studies was assessed using QUADAS-AI tool. Fifty studies were included, of these 37/50 (74.0%) on ovarian masses or ovarian cancer, 5/50 (10.0%) on endometrial cancer, 5/50 (10.0%) on cervical cancer, and 3/50 (6.0%) on other malignancies. Most studies were at high risk of bias for subject selection (i.e., sample size, source, or scanner model were not specified; data were not derived from open-source datasets; imaging preprocessing was not performed) and index test (AI models was not externally validated) and at low risk of bias for reference standard (i.e., the reference standard correctly classified the target condition) and workflow (i.e., the time between index test and reference standard was reasonable). Most studies presented machine learning models (33/50, 66.0%) for the diagnosis and histopathological correlation of ovarian masses, while others focused on automatic segmentation, reproducibility of radiomics features, improvement of image quality, prediction of therapy resistance, progression-free survival, and genetic mutation. The current evidence supports the role of AI as a complementary clinical and research tool in diagnosis, patient stratification, and prediction of histopathological correlation in gynecological malignancies. For example, the high performance of AI models to discriminate between benign and malignant ovarian masses or to predict their specific histology can improve the diagnostic accuracy of imaging methods.

Staging by imaging in gynecologic cancer and the role of ultrasound: an update of European joint consensus statements

In recent years the role of diagnostic imaging by pelvic ultrasound in the diagnosis and staging of gynecological cancers has been growing exponentially. Evidence from recent prospective multicenter studies has demonstrated high accuracy for pre-operative locoregional ultrasound staging in gynecological cancers. Therefore, in many leading gynecologic oncology units, ultrasound is implemented next to pelvic MRI as the first-line imaging modality for gynecological cancer. The work herein is a consensus statement on the role of pre-operative imaging by ultrasound and other imaging modalities in gynecological cancer, following European Society guidelines.

Dose-dense neoadjuvant chemotherapy before radical surgery in cervical cancer: a retrospective cohort study and systematic literature review

OBJECTIVE

To evaluate the role of dose-dense neoadjuvant chemotherapy followed by radical hysterectomy in reducing adjuvant radiotherapy in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB1-IB2/IIA1 cervical cancer with disrupted stromal ring and as an alternative to concurrent chemoradiotherapy in FIGO 2018 stages IB3/IIA2.

METHODS

This was a retrospective cohort study including patients with FIGO 2018 stage IB1-IIA2 cervical cancer undergoing dose-dense neoadjuvant chemotherapy at the European Institute of Oncology in Milan, Italy between July 2014 and December 2022. Weekly carboplatin (AUC2 or AUC2.7) plus paclitaxel (80 or 60 mg/m2, respectively) was administered for six to nine cycles. Radiological response was assessed by Response Evaluation Criteria in Solid Tumours (RECIST) v1.1 criteria. The optimal pathological response was defined as residual tumor ≤3 mm. Kaplan-Meier curves were used to estimate survival rates. A systematic literature review on dose-dense neoadjuvant chemotherapy before surgery for cervical cancer was also performed.

RESULTS

A total of 63 patients with a median age of 42.8 years (IQR 35.3-47.9) were included: 39.7% stage IB-IB2/IIA1 and 60.3% stage IB3/IIA2. The radiological response was as follows: 81% objective response rate (17.5% complete and 63.5% partial), 17.5% stable disease, and 1.6% progressive disease. The operability rate was 92.1%. The optimal pathological response rate was 27.6%. Adjuvant radiotherapy was administered in 25.8% of cases. The median follow-up for patients who underwent radical hysterectomy was 49.7 months (IQR 16.8-67.7). The 5-year progression-free survival and overall survival were 79% (95% CI 0.63 to 0.88) and 92% (95% CI 0.80 to 0.97), respectively. Fifteen studies including 697 patients met the eligibility criteria for the systematic review. The objective response rate, operability rate, and adjuvant radiotherapy rate across studies ranged between 52.6% and 100%, 64% and 100%, and 4% and 70.6%, respectively.

CONCLUSIONS

Dose-dense neoadjuvant chemotherapy before radical surgery could be a valid strategy to avoid radiotherapy in stage IB1-IIA2 cervical cancer, especially in young patients desiring to preserve overall quality of life. Prospective research is warranted to provide robust, high-quality evidence.

Imaging evaluation of para-aortic lymph nodes in cervical cancer

BACKGROUND

In recent years, much literature has reported the diagnostic value of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT in para-aortic lymph node metastasis of cervical cancer.

PURPOSE

To compare and analyze the para-aortic lymph node presentations found in cervical cancer on different images in order to determine the best precise imaging method for identifying metastatic lymph nodes.

MATERIAL AND METHODS

PubMed, Web of Science, MEDLINE, and other databases were searched for the non-invasive detection of metastatic lymph nodes for a comprehensive comparison.

RESULTS

Positive lymph nodes on CT are significantly related to the following factors: short axis ≥10 mm; and round or central necrosis. Positive lymph nodes on MRI are significantly related to the following factors: short axis ≥8 mm; inhomogeneous signal intensity; morphology: round, irregular edge, extracapsular invasion, central necrosis, loss of lymph node structure, burrs, or lobes; and ADC value decreases, combined with local actuality. On PET-CT examination, when the short axis of the lymph node is >5 mm, the SUV is >2.5, or the FDG uptake is greater than that of the surrounding tissue, it is a metastatic lymph node.

CONCLUSION

In conclusion, different imaging techniques show metastatic lymph nodes in different ways. Combining the patient's medical history with the symptoms of the aforementioned lymph nodes, together with one or more imaging techniques, is important to diagnose para-aortic lymph nodes in cervical cancer.

Diagnostic Value of Diffusion-Weighted Imaging with Background Body Signal Suppression (DWIBS) for the Pre-Therapeutic Loco-Regional Staging of Cervical Cancer: A Feasibility and Interobserver Reliability Study

(1) Background: cervical cancer is one of the leading causes of cancer-related deaths and the fourth most common cancer among women worldwide. Magnetic resonance imaging (MRI) is the modality of choice for loco-regional staging of cervical cancer in the primary diagnostic workup beginning with at least stage IB. (2) Methods: we retrospectively analyzed 16 patients with histopathological proven cervical cancer (FIGO IB1−IVA) for the diagnostic accuracy of standard MRI and standard MRI with diffusion-weighted imaging with background body signal suppression (DWIBS) for the correct pre-therapeutic assessment of the definite FIGO category. (3) Results: In 7 out of 32 readings (22%), DWIBS improved diagnostic accuracy. With DWIBS, four (13%) additional readings were assigned the correct major (I−IV) FIGO stages pre-therapeutically. Interobserver reliability of DWIBS was weakest for parametrial infiltration (k = 0.43; CI-95% 0.00−1.00) and perfect for tumor size <2 cm, infiltration of the vaginal lower third, infiltration of adjacent organs and loco-regional nodal metastases (k = 1.000; CI-95% 1.00−1.00). (4) Conclusions: the pre-therapeutic staging of cervical cancer has a high diagnostic accuracy and interobserver reliability when using standard MRI but can be further optimized with the addition of DWIBS sequences when reporting is performed by an experienced radiologist.

Study of T2 mapping in quantifying and discriminating uterine lesions under different magnetic field strengths: 1.5 T vs. 3.0 T

BACKGROUND

MRI is the best imaging tool for the evaluation of uterine tumors, but conventional MRI diagnosis results rely on radiologists and contrast agents (if needed). As a new objective, reproducible and contrast-agent free quantification technique, T2 mapping has been applied to a number of diseases, but studies on the evaluation of uterine lesions and the influence of magnetic field strength are few. Therefore, the aim of this study was to systematically investigate and compare the performance of T2 mapping as a nonenhanced imaging tool in discriminating common uterine lesions between 1.5 T and 3.0 T MRI systems.

METHODS

A total of 50 healthy subjects and 126 patients with suspected uterine lesions were enrolled in our study, and routine uterine MRI sequences with additional T2 mapping sequences were performed. T2 maps were calculated by monoexponential fitting using a custom code in MATLAB. T2 values of normal uterine structures in the healthy group and lesions (benign: adenomyosis, myoma, endometrial polyps; malignant: cervical cancer, endometrial carcinoma) in the patient group were collected. The differences in T2 values between 1.5 T MRI and 3.0 T MRI in any normal structure or lesion were compared. The comparison of T2 values between benign and malignant lesions was also performed under each magnetic field strength, and the diagnostic efficacies of the T2 value obtained through receiver operating characteristic (ROC) analysis were compared between 1.5 T and 3.0 T.

RESULTS

The mean T2 value of any normal uterine structure or uterine lesion under 3.0 T MRI was significantly lower than that under 1.5 T MRI (p < 0.05). There were significant differences in T2 values between each lesion subgroup under both 1.5 T and 3.0 T MRI. Moreover, the T2 values of benign lesions (71.1 ± 22.0 ms at 1.5 T and 63.4 ± 19.1 ms at 3.0 T) were also significantly lower than those of malignant lesions (101.1 ± 4.5 ms at 1.5 T and 93.5 ± 5.1 ms at 3.0 T) under both field strengths. In the aspect of differentiating benign from malignant lesions, the area under the curve of the T2 value under 3.0 T (0.94) was significantly higher than that under 1.5 T MRI (0.90) (p = 0.02).

CONCLUSION

T2 mapping can be a potential tool for quantifying common uterine lesions, and it has better performance in distinguishing benign from malignant lesions under 3.0 T MRI.

Vaginosonography versus MRI in Pre-Treatment Evaluation of Early-Stage Cervical Cancer: An Old Tool for a New Precision Approach?

This study aims to analyze the sensitivity of vaginosonography (VGS) and magnetic resonance imaging (MRI) in the preoperative local evaluation of early-stage cervical cancers and to assess their accuracy in the detection of tumors, size of the lesions and stromal invasion by comparing them with the final histopathology report. This single-center study included 56 consecutive patients with cervical cancer who underwent VGS and MRI from November 2012 to January 2021. VGS significantly overestimated the lesion size by 2.7 mm (p = 0.002), and MRI underestimated it by 1.9 mm (p = 0.11). Both MRI and VGS had a good concordance with the pathology report (Cohen’s kappa of 0.73 and 0.81, respectively). However, MRI had a false-negative rate (38.1%) that was greater than VGS (0%) in cases of cervical tumor size <2 cm. We found a good concordance between histology and VGS in the stromal infiltration assessment, with 89% sensitivity (95% CI 0.44−0.83) and 89% specificity (95% CI 0.52−0.86). VGS is a simple, inexpensive, widely available, and fast execution method that can complement ultrasound in particular cases and show a good correlation with MRI in the assessment of tumor dimensions, with a better performance in detecting small tumors (<2 cm).

Quality Requirements for gynecological ultrasound examinations of DEGUM level II - Recommendations of the Sections/Working Groups Gynecology and Obstetrics of DEGUM, ÖGUM and SGUM

Gynecological sonography is the central and most frequently used technical examination method used by gynecologists. Its focus is on the clarification of masses of the uterus and the adnexa, fertility diagnosis, clarification of bleeding disorders and chronic and acute pelvic problems, pelvic floor and incontinence diagnosis as well as the differential diagnosis of disturbed early pregnancy. The indication for diagnostic and therapeutic interventions, preoperative planning and postoperative controls are largely based on the findings of gynecological sonography. These examinations are particularly dependent on the experience of the examiner.Based on the proven multi-stage concept of obstetric diagnostics, gynecological sonography should primarily be performed by an experienced and specialized examiner in patients for whom the initial gynecological examinations have not yet led to a sufficient assessment of the findings. So that the expert status required for this has an objective basis, the Gynecology and Obstetrics Section of DEGUM in cooperation with ÖGUM and SGUM implemented the option of acquiring DEGUM Level II for gynecological sonography. The effectiveness of the care in the multi-level concept depends on the quality of the ultrasound examination at level I. Quality requirements for the basic examination and the differentiation between the basic and further examination have therefore already been defined by DEGUM/ÖGUM. The present work is intended to set out quality requirements for gynecological sonography of DEGUM level II and for the correspondingly certified gynecologists.Common pathologies from gynecological sonography and requirements for imaging and documentation are described.

The Application of Sonovaginography for Implementing Ultrasound Assessment of Endometriosis and Other Gynaecological Diseases

Sonovaginography is a way of assessing gynaecological diseases that can be described as cheap yet accurate and non-invasive. It consists of distention of the vagina with ultrasound gel or saline solution while performing transvaginal sonography to clearly visualize and assess a host of local cervical, as well as any vaginal, disorders. With endometriosis being a steadily growing gynaecological pathology affecting 8-15% of women of fertile age, transvaginal sonography (TVS) can be considered as one of the most accurate and comprehensive imaging techniques in its diagnosis. Nevertheless, the accuracy may vary depending on scan sites. The purpose of this narrative review is to assess the performance of sonovaginography in detecting endometriosis in those sites where TVS has a low sensitivity.

[Uterine Cervical Cancer: Emphasis on Revised FIGO Staging 2018 and MRI]

Uterine cervical cancer is a common gynecological cancer prevalent in Korea. Early detection, precise diagnosis, and appropriate treatment can affect its prognosis. Imaging approaches play an important role in staging, treatment planning, and follow-up. MRI specifically provides the advantage of assessing tumor size and disease severity with high soft tissue contrast. The revised version of the International Federation of Gynecology and Obstetrics (FIGO) staging system has been introduced in 2018, which incorporates subdivided primary tumor size and lymph node metastasis. In this review, the staging of uterine cervical cancer based on previous studies, the recently revised FIGO staging, and various post-treatment images are primarily described using MRI.

Implications of the new FIGO staging and the role of imaging in cervical cancer

International Federation of Gynecology and Obstetrics (FIGO) staging, which is the fundamentally important cancer staging system for cervical cancer, has changed in 2018. New FIGO staging includes considerable progress in the incorporation of imaging findings for tumour size measurement and evaluating lymph node (LN) metastasis in addition to tumour extent evaluation. MRI with high spatial resolution is expected for tumour size measurements and the high accuracy of positron emmision tomography/CT for LN evaluation. The purpose of this review is firstly review the diagnostic ability of each imaging modality with the clinical background of those two factors newly added and the current state for LN evaluation. Secondly, we overview the fundamental imaging findings with characteristics of modalities and sequences in MRI for accurate diagnosis depending on the focus to be evaluated and for early detection of recurrent tumour. In addition, the role of images in treatment response and prognosis prediction is given with the development of recent technique of image analysis including radiomics and deep learning.

Updated applications of Ultrasound in Uterine Cervical Cancer

Cervical cancer is a common gynecologic malignancy worldwide. It is the fourth for both incidence and mortality. For cervical cancer, imaging and pathology assessments are incorporated in the revised 2018 Federation of Gynecology and Obstetrics (FIGO) staging system. Uses of imaging techniques for the pre-treatment work-up of cervical cancer have been increasing. Among imaging techniques for the evaluation of cervical cancer, ultrasound is cheaper, faster and widely available than other imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI). Advanced technique in ultrasound, such as three-dimension (3D) ultrasound and color Doppler, have improved the clinical application of ultrasound in cervical cancer. Ultrasound may provide highly accurate information on detecting tumor presence and evaluating local tumor extent if performed by ultrasound-trained gynecologists; the experience of readers is also critical for correct pretreatment staging and assessment of response to treatment. Sonographic images could be useful to predict response of neoadjuvant chemotherapy, radiotherapy, chemotherapy and concurrent chemoradiotherapy in patients with cervical cancer. This review article attempted to present the most updated specific applications of ultrasound in cervical cancer.

Imaging modalities in fertility preservation in patients with gynecologic cancers

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.

Ultrasound Differential Diagnosis in Deep Infiltrating Endometriosis of the Urinary Tract

Endometriosis of the urinary tract is a rare condition that may lead to severe complications. At present, the major challenge appears to be the ultrasound differential diagnosis with diseases that can afflict the ureter and the bladder. Preoperative scan findings were compared with surgical and histologic records. Twenty-three cases were selected as being of interest, as they were referred for suspected endometriosis, whereas second-level ultrasound revealed a different disease in some cases. This case series aims to help in becoming familiar with the possible differential diagnosis of lesions of the urinary tract that resemble endometriosis.

Differential Diagnosis of Endometriosis by Ultrasound: A Rising Challenge

Ultrasound is an effective tool to detect and characterize endometriosis lesions. Variances in endometriosis lesions’ appearance and distorted anatomy secondary to adhesions and fibrosis present as major difficulties during the complete sonographic evaluation of pelvic endometriosis. Currently, differential diagnosis of endometriosis to distinguish it from other diseases represents the hardest challenge and affects subsequent treatment. Several gynecological and non-gynecological conditions can mimic deep-infiltrating endometriosis. For example, abdominopelvic endometriosis may present as atypical lesions by ultrasound. Here, we present an overview of benign and malignant diseases that may resemble endometriosis of the internal genitalia, bowels, bladder, ureter, peritoneum, retroperitoneum, as well as less common locations. An accurate diagnosis of endometriosis has significant clinical impact and is important for appropriate treatment.

The Role of 2D/3D Ultrasound to Assess the Response to Neoadjuvant Chemotherapy in Locally Advanced Cervical Cancer

INTRODUCTION

Different imaging techniques were introduced to improve preoperative clinical staging of locally advanced cervical cancer (LACC) with transvaginal ultrasound (TV-US) or transrectal ultrasound (TR-US) representing a promising staging technique in the evaluation of the local extension of the disease for invasive tumors. The aim of this study was to evaluate the response to neoadjuvant chemotherapy (NACT) in LACC by 2D/3D ultrasound examination.

MATERIALS AND METHODS

We prospectively enrolled patients affected by histologically and clinically confirmed LACC. All patients were scheduled for 3 cycles of platinum-based NACT followed by radical surgery. The ultrasound examination was performed at every cycle and within 10 days before surgery. The parameters evaluated were: the volume (automatically computed by the VOCAL software) and the mass vascularization.

RESULTS

From March 2010 to March 2019, 157 women were recruited. Among these patients, 12 of them were excluded: 6 for the presence of distant metastases, 4 for rare histology, and 2 for severe comorbidities not allowing the protocol treatment. Seventeen patients after NACT were excluded because they were not amenable to radical surgery. Thus, 128 were considered for the final analysis of whom 106 (83%) were considered responders to NACT by histology. The sensibility and specificity of ultrasound with regard to the response to chemotherapy compared to histological specimen were 94 and 82%, respectively, with an accuracy of 92%. The positive predictive value and negative predictive value were 96 and 75%, respectively. Finally, we found that nonetheless there was a trend towards a continuous response to chemotherapy among patients who were considered responders to NACT at pathological examination; the major volume and vascularization index (VI) reduction were observed during the first 2 cycles (74, 71% and 47, 63%, respectively). On the contrary, non-responders showed an initial reduction of the VI (4.86 consisting of 33%, 95% CI 0.79-8.92, p = 0.013), but no significant modification in tumour volume along NACT.

CONCLUSION

2D/3D ultrasound is useful in assessing early response to NACT in patients with LACC.

Revised FIGO Staging for Cervical Cancer - A New Role for MRI

Cervical cancer is still the fourth most common malignancy in women worldwide and has a high mortality rate. The prognosis as well as the therapy depends largely on the extent of the tumor at the time of initial diagnosis. This shows the importance of correct staging of cervical cancer. In order to promote a globally uniform approach, staging of cervical cancer in the past was based on widespread examinations such as exam under anesthesia, histology from cervical conization or biopsy, systematic lymphadenectomy, cystoscopy, proctoscopy, i. v.-pyelogram and chest X-ray. However, as the primary tumor stage was often underestimated, the 2018 revised FIGO classification now permits cross-sectional imaging techniques and pathological findings to be incorporated into disease staging or an already existing stage to be adapted based on radiological findings. Thanks to its excellent soft tissue contrast, magnetic resonance imaging (MRI) is the method of choice for local-regional staging of cervical cancer, evaluating the response to treatment, detecting tumor recurrence and for follow-up examinations. It is important that radiologists interpreting pelvic MRI in case of suspected cervical cancer are familiar with the current FIGO staging system. This is the only way to determine the tumor stage as precisely as possible and thus lay the foundation for the success of therapy for patients. The aim of this review is to present the changes of the revised FIGO classification as well as to show the importance of MRI as the method of choice for local-regional tumor staging as a complement to clinical examination. KEY POINTS::   · Cervical cancer is still the world's fourth most common female cancer and has a high mortality rate.. · The FIGO classification for staging cervical cancer in the past was based on clinical and widespread examinations.. · The primary tumor stage has often been underestimated with the FIGO staging system since 2018.. · Since 2018, cross-sectional imaging techniques have been incorporated into disease staging.. · MRI is the method of choice for local-regional tumor staging, evaluation of the response to treatment, detection of tumor recurrence and possible complications.. CITATION FORMAT: · Merz J, Bossart M, Bamberg F et al. Revised FIGO Staging for Cervical Cancer - A New Role for MRI. Fortschr Röntgenstr 2020; 192: 937 - 944.

Measurement of tumor size in early cervical cancer: an ever-evolving paradigm

The major tenets in accurately assessing tumor size in patients with early stage cervical cancer currently include physical examination, imaging studies, and pathologic evaluation. It is estimated that when comparing clinical stage based on physical examination and final pathology, the concordance diminishes as stage increases: 85.4%, 77.4%, 35.3%, and 20.5% for stage IB1, IB2, IIA, and IIB, respectively. Vaginal involvement and larger tumor diameter are considered the main causes of stage inaccuracy. When considering imaging studies, magnetic resonance imaging (MRI) provides the highest level of accuracy in the assessment of cervical tumor size. Its accuracy in determining tumor location within the cervix is approximately 91% and in predicting tumor size 93%. MRI imaging is also significantly more accurate in measuring tumor size, delineating cervical tumor boundaries, and local tumor extension when compared with computed tomography (CT) scan. When comparing with pelvic ultrasound, the accuracy of both imaging techniques (MRI and pelvic ultrasound) in the assessment of tumor size in small versus large tumors is comparable. Pertaining to pathology, the depth of invasion should be measured by convention from the nearest surface epithelium, which equates to tumor thickness. In the setting where tumor is found both in the conization and hysterectomy specimen, the horizontal extent should be measured by summing the maximum horizontal measurement in the different specimens and the depth of invasion measured as the maximum depth in either specimen. A new pattern-based classification for endocervical adenocarcinomas recommends the description of patterns of invasion for human papillomavirus (HPV)-related adenocarcinomas as this is associated with differing risks of lymph node involvement.

Multimodality Imaging of Uterine Cervical Malignancies

OBJECTIVE. In this article, we provide an updated review on the role of imaging in initial staging, treatment monitoring, and follow-up of cervical cancer with a focus on the role of MRI and FDG PET/CT. In addition, the 2018 International Federation of Gynecology and Obstetrics staging system and its implication on management of cervical cancer are explored. CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases.

Revised 2018 International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging: A review of gaps and questions that remain

Recently the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system for cervical cancer was published. In this most recent classification, imaging modalities and pathologic information have been added as tools to determine the final stage of the disease. Although there are many merits to this new staging for cervical cancer, including more detailed categorization of early-stage disease as well as information on nodal distribution, the classification falls short in clarifying areas of controversy in the staging system. Many unanswered questions remain and, as such, a number of gaps lead to further debate in the interpretation of relevant clinical data. Factors such as measurement of tumor size, definition of parametrial involvement, ovarian metastases, lower uterine segment extension, lymph node metastasis, and imaging modalities are explored in this review. The goal is to focus on items that deserve further discussion and clarification in the most recent FIGO staging for cervical cancer.

Prospective intra/inter-observer evaluation of pre-brachytherapy cervical cancer tumor width measured in TRUS and MR imaging

BACKGROUND

Ultrasound (US) imaging has been proved as an excellent diagnostic tool in gynecology and, due to its wide availability and limited cost, is under intense investigation as base for dose adaptation in cervical cancer brachytherapy. Purpose of this work is to test inter/intra-observer uncertainties between magnetic resonance (MR) and trans-rectal ultrasound (TRUS) imaging in defining maximum tumor width before first brachytherapy (BT) application in a prospective cohort of cervical cancer patients undergoing image-guided adaptive brachytherapy (IGABT).

METHODS

One hundred ten consecutive cervical cancer patients treated between 2013 and 2016 were included. Before the first BT implant patients underwent MR and TRUS scan with no applicator in place. Images were independently analyzed by three examiners, blinded to the other's results. With clinical information at hand, maximum tumor width was measured on preBT TRUS and MR. Quantitative agreement analysis was undertaken. Intra-class correlation coefficient (ICC), Passing-Bablok and Bland Altman plots were used to evaluate the intra/inter-observers measurement agreement.

RESULTS

Average difference between tumor width measured on MR (HRCTV_MR) and TRUS (HRCTV_TRUS) was 1.3 ± 3.2 mm (p <  0.001); 1.1 ± 4.6 mm (p = 0.01) and 0.7 ± 3 mm (p = 0.01). The error was less than 3 mm in 79, 82 and 80% of the measurements for the three observers, respectively. Intra-observer ICC was 0.96 (CI95% 0.94-0.97), 0.93 (CI95% 0.9-0.95) and 0.96 (CI95% 0.95-0.98) respectively. Inter-observer ICC for HRCTV_MR width measures was 0.92 (CI95% 0.89-0.94) with no difference among FIGO stages. Inter-observer ICC for HRCTV_TRUS was 0.86 (CI95% 0.81-0.9). For FIGO stage I and II tumors, ICC HRCTV_TRUS values were comparable to respective HRCTV_MR ICC values. For larger tumors HRCTV_TRUS inter-observer ICC values were lower than respective HRCTV_MR although remaining acceptable.

CONCLUSIONS

Our results suggest that TRUS is equivalent to MR in assessing preBT tumor maximum width in cervical cancer FIGO stage I/II. In more advanced stages TRUS seems to be slightly inferior to MR although maintaining a good agreement to gold standard imaging.

What Is the Role of Imaging at Primary Diagnostic Work-Up in Uterine Cervical Cancer?

PURPOSE OF REVIEW

For uterine cervical cancer, the recently revised International Federation of Gynecology and Obstetrics (FIGO) staging system (2018) incorporates imaging and pathology assessments in its staging. In this review we summarize the reported staging performances of conventional and novel imaging methods and provide an overview of promising novel imaging methods relevant for cervical cancer patient care.

RECENT FINDINGS

Diagnostic imaging during the primary diagnostic work-up is recommended to better assess tumor extent and metastatic disease and is now reflected in the 2018 FIGO stages 3C1 and 3C2 (positive pelvic and/or paraaortic lymph nodes). For pretreatment local staging, imaging by transvaginal or transrectal ultrasound (TVS, TRS) and/or magnetic resonance imaging (MRI) is instrumental to define pelvic tumor extent, including a more accurate assessment of tumor size, stromal invasion depth, and parametrial invasion. In locally advanced cervical cancer, positron emission tomography-computed tomography (PET-CT) or computed tomography (CT) is recommended, since the identification of metastatic lymph nodes and distant metastases has therapeutic consequences. Furthermore, novel imaging techniques offer visualization of microstructural and functional tumor characteristics, reportedly linked to clinical phenotype, thus with a potential for further improving risk stratification and individualization of treatment. Diagnostic imaging by MRI/TVS/TRS and PET-CT/CT is instrumental for pretreatment staging in uterine cervical cancer and guides optimal treatment strategy. Novel imaging techniques may also provide functional biomarkers with potential relevance for developing more targeted treatment strategies in cervical cancer.

MRI of cervical cancer with a surgical perspective: staging, prognostic implications and pitfalls

LEARNING OBJECTIVES

Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) 2018 clinical staging of cervical cancer. It is imperative that radiologists are familiar with the imaging appearance of the different stages of cervical cancer as well as the post-treatment changes and imaging pitfalls given the respective clinical manifestations, treatment regimens, and prognosis of an accurate diagnosis. In addition to the different stages of cervical cancer, we address the imaging techniques for diagnosis, staging and treatment implications as well as the changes of the new FIGO staging system.

BACKGROUND

The use of MRI to diagnose and stage cervical cancer is steadily increasing and the new FIGO stagi ng system, previously based on clinical examination, now allows the staging or change of staging based on the imaging findings. MRI can evaluate the extent of disease because of its excellent contrast resolution for pelvic tissues and organs, high accuracy and detailed elaboration of the cervical/uterovaginal anatomy.

CONTENT

Relevant anatomy, including normal MRI appearance of the cervix, parametria and pelvic ligaments; different stages of cervical cancer on MRI with prognostic and therapeutic implications; MRI sequences, other imaging modalities used in the staging and follow-up, treatment of different stages and the appearance of the cervix and cervical cancer post-treatment. Since clinical implications and therapeutic strategies for cervical cancer treatment vary tremendously according to degree of tumor extension, familiarity with relevant MRI techniques and findings is essential for radiologists. It is important that radiologists interpreting pelvic MRI are aware with the different stages of cervical cancer to provide useful information regarding treatment and prognosis. Pitfalls regarding the interpretation of tumor extension can interfere with an accurate diagnosis and have significant therapeutic implications.

The effect of modulated electro-hyperthermia on local disease control in HIV-positive and -negative cervical cancer women in South Africa: Early results from a phase III randomised controlled trial

BACKGROUND

The global burden of cervical cancer remains high with the highest morbidity and mortality rates reported in developing countries. Hyperthermia as a chemo- and radiosensitiser has shown to improve treatment outcomes. This is an analysis of the local control results at six months post-treatment of patients enrolled in an ongoing study investigating the effects of the addition of modulated electro-hyperthermia (mEHT) to chemoradiotherapy for the treatment of HIV-positive and -negative cervical cancer patients in a low-resource setting.

METHODS

This ongoing Phase III randomised controlled trial, conducted at a state hospital in Johannesburg, South Africa, was registered with the appropriate ethics committee. After signing an informed consent, participants with FIGO stages IIB to IIIB squamous cell carcinoma of the cervix were randomised to receive chemoradiotherapy with/without mEHT using a secure online random-sampling tool (stratum: HIV status) accounting for age and stage. Reporting physicians were blind to treatment allocation. HIV-positive participants on antiretroviral treatment, or with a CD4 count >200cell/μL were included. mEHT was administered 2/weekly immediately before external beam radiation. The primary end point is local disease control (LDC) and secondary endpoints are toxicity; quality of life analysis; and two year survival. We report on six month LDC, including nodes visualised in the radiation field on 18F-FDG PET/CT (censored for six month survival), and six month local disease free survival (LDFS) (based on intention to treat). Trial status: Recruitment closed (ClinicalTrials.gov: NCT03332069).

RESULTS

271 participants were recruited between January 2014 and November 2017, of which 210 were randomised for trial and 202 were available for analysis at six months post-treatment (mEHT: n = 101; Control: n = 101). Six month LDFS was higher in the mEHT Group (n = 39[38.6%]), than in the Control Group (n = 20[19.8%]); p = 0.003). LDC was also higher in the mEHT Group (n = 40[45.5%]) than the Control Group (n = 20[24.1%]); (p = 0.003).

CONCLUSION

Our results show that mEHT is effective as a chemo-radiosensitiser for cervical cancer, even in high risk a patients and resource-constrained settings.

The role of para-aortic nodal irradiation in cervical cancer

The current standard of care for locally advanced cervical cancer is whole pelvis and para-aortic radiation when indicated, delivered concomitantly with chemotherapy and brachytherapy. Para-aortic node involvement is a predictor of survival in locally advanced disease but presence of metastases is difficult to determine because the currently available imaging methods lack enough sensitivity to be able to detect accurately para-aortic metastases when surgical staging is not feasible. The objective of this review is to describe the current status of para-aortic lymph node irradiation in locally advanced cervical cancer. It includes analysis of the diagnostic imaging and surgical approaches for assessment of para-aortic lymph node dissemination, together with indications for radiotherapy and radiotherapeutic techniques.

The Potential Value of MRI in External-Beam Radiotherapy for Cervical Cancer

The reference standard treatment for cervical cancer is concurrent chemoradiotherapy followed by magnetic resonance imaging (MRI)-guided brachytherapy. Improvements in brachytherapy have increased local control rates, but late toxicity remains high with rates of 11% grade ≥3. The primary clinical target volume (CTV) for external-beam radiotherapy includes the cervix and uterus, which can show significant inter-fraction motion. This means that generous margins are required to cover the primary CTV, increasing the radiation dose to organs at risk and, therefore, toxicity. A number of image-guided radiotherapy techniques (IGRT) have been developed, but motion can be random and difficult to predict prior to treatment. In light of the development of integrated MRI linear accelerators, this review discusses the potential value of MRI in external-beam radiotherapy. Current solutions for managing pelvic organ motion are reviewed, including the potential for online adaptive radiotherapy. The impacts of the use of MRI in tumour delineation and in the delivery of stereotactic ablative body radiotherapy (SABR) are highlighted. The potential role and challenges of using multi parametric MRI to guide radiotherapy are also discussed.

Discriminating Performance of Early Uterine and Cervical Artery Pulsatility and Resistivity In Pre-Invasive Cervical Lesions

Objectives:

The aim of the present study was to investigate the diagnostic effectiveness of uterine and cervical vascularity alone or in combination with human papillomavirus (HPV) DNA testing and with cytology.

Methods:

Data were prospectively collected from 129 patients in an outpatient clinic of a secondary setting. Routine liquid-based cervical cytology and HPV-DNA testing were obtained. An abnormal result of any of these high-risk types was viewed as positive. Pulsatility (PI) and resistance (RI) indices of uterine (UA) and cervical (CA) arteries were assessed by Doppler sonography. Pathological diagnosis was considered as the gold standard for assessment. Diagnostic efficiency of alone and joint screening of the three indices for discriminating cervical intraepithelial neoplasia (CIN-I) or above from below was assessed.

Results:

UA-RI and CA-RI were significantly lower in the HPV (+) group than in the controls (p=0.02 and p=0.03, respectively). In subsequent sub-analysis among patients with positive HPV-DNA, UA-PI was significantly higher in the HPV-16 (+) group than in the HPV-18 (+) group (p=0.04). High-risk HPV (Hr-HPV) testing had the highest sensitivity compared with Doppler and cytology (76.5%, 64.7%, and 58.5%, respectively). Combining CA-RI with cytology or Hr-HPV significantly reduced the sensitivity (23.5% and 29.4, respectively) but improved the specificity from 54.4% to 69.8% and 40.9% to 70.7%, respectively. Combining UA-PI with Hr-HPV slightly increased the positive predictivity when compared with testing Hr-HPV alone (36.1% vs. 33.3%).

Conclusion:

The potential of the Doppler indices of UA and CA was doubtful in discriminating CIN-I or above lesions in the early period. In addition, RI of UA and CA differed with regard to the presence of HPV infection, whereas CA-RI differed in high-risk HPV cases.

Imaging and cancer of the cervix in low- and middle-income countries

Cervix cancer is the fourth most common cancer globally but the second most cancer in women in resource-limited countries. It has remained a clinically-staged neoplasm as per the International Federation of Gynecology and Obstetrics staging classification. As the imaging machines are becoming more available worldwide, the resource-stratified guidelines recommended the inclusion of imaging whenever possible to guide treatment planning. In this report, the utility of imaging in low- and middle-income countries for diagnosis and treatment of cancer of the cervix will be reviewed.

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Imaging should be included to guide diagnosis and treatment planning.

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Role of ultrasound and computerized tomography in LMIC was reviewed.

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Cross-sectional imaging is important in planning for radiotherapy.

PRospective Imaging of CErvical cancer and neoadjuvant treatment (PRICE) study: role of ultrasound to assess residual tumor in locally advanced cervical cancer patients undergoing chemoradiation and radical surgery

OBJECTIVE

To determine the diagnostic performance of two-dimensional (2D) ultrasound parameters, three-dimensional (3D) power Doppler and contrast-enhanced indices in detecting residual disease in locally advanced cervical cancer patients triaged to neoadjuvant treatment followed by radical surgery.

METHODS

Between October 2010 and June 2014, we screened 108 women with histologically documented locally advanced cervical cancer Stage IB2-IVA, of whom 88 were included in the final analysis. 2D ultrasound parameters, 3D power Doppler and contrast-ultrasound parameters were assessed 5 weeks after the end of neoadjuvant chemoradiation therapy. The pathological response was defined as complete (absence of any residual tumor after treatment) or partial (including microscopic and/or macroscopic residual tumor at pathology examination). The two response groups were compared and receiver-operating characteristics (ROC) curves generated to determine the best cut-off value of sonographic tumor diameter to predict residual disease. Histology was considered as reference.

RESULTS

Complete pathological response to chemoradiation was observed in 40 (45.5%) patients and partial response in 48 (54.5%). The presence of residual disease, as confirmed at pathology examination, was detected by 2D grayscale ultrasound with a sensitivity of 64.6% and specificity of 65%. Color Doppler examination in the cases with lesions visualized on grayscale imaging detected the presence of residual disease, confirmed at pathology, with a sensitivity of 87.1% and specificity of 21.4%. The best area under the ROC curve (0.817) was for the detection of pathological residual disease of at least 6 mm in diameter, using a cut-off value of 12 mm for the largest tumor diameter assessed using 2D grayscale ultrasound (sensitivity, 95%; specificity, 70.6%). Neither 3D vascular indices nor contrast-ultrasound parameters obtained for lesions suspected at ultrasound following chemoradiation differed significantly between patients with histological complete and those with partial response.

CONCLUSIONS

Our results show that grayscale and color Doppler ultrasound have a low level of diagnostic performance in detecting residual disease after neoadjuvant chemoradiation in patients with locally advanced cervical cancer. The best performance was achieved in detection of macroscopic (≥ 6 mm) residual disease. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Effect of age and cone dimensions on cervical regeneration: an Italian multicentric prospective observational study

OBJECTIVES

To evaluate cervical regeneration at 6 months following excisional treatment for high-grade cervical intraepithelial neoplasia (CIN), and to investigate the effect of cone dimensions, age of patients and technique of excision on the efficacy of the regeneration process.

DESIGN

Prospective observational multicentric study.

SETTING

Three tertiary care and research centres.

PARTICIPANTS

Among the 197 eligible women of childbearing age, older than 25 years of age, undergoing for the first time a loop electrosurgical excision procedure or carbon dioxide laser cervical excision for a high-grade CIN at the colposcopy-directed cervical punch biopsy, and with a final diagnosis of high-grade CIN, 165 completed the 6-month follow-up and were included in the analysis.

PRIMARY OUTCOME MEASURES

The cervical length and volume regeneration (%) after 6 months from procedure were determined by three-dimensional ultrasound, and the correlation of regeneration with cone dimensions, age and excision technique was evaluated.

RESULTS

The mean±SD cervical length regeneration at 6 months was 89.5%±6.3% and the mean±SD cervical volume regeneration was 86.3%±13.2%. At the multivariate analysis, a significant and independent inverse correlation between excised cone length and cervical regeneration emerged (r=-0.39, P<0.001). A significantly negative trend in length regeneration at 6 months from procedure with an increasing class of cone length was found (P<0.001). No significant association was found in relation with patient age at the time of procedure or with the technique of excision.

CONCLUSIONS

Cervical length regeneration at 6 months from excisional treatments is negatively affected by an increasing cone length but not from the age of the patient or the technique of excision. While still achieving equal clinical efficacy, it is crucial to contain cone dimensions, in order to favour a greater length regeneration, reducing the cervical harm and the potential future obstetric complications.

Predicting Parametrial Invasion in Cervical Carcinoma (Stages IB1, IB2, and IIA): Diagnostic Accuracy of T2-Weighted Imaging Combined With DWI at 3 T

OBJECTIVE

The objective of our study was to retrospectively evaluate the efficacy of combined analysis of T2-weighted imaging and DWI in the diagnosis of parametrial invasion (PMI) in cervical carcinoma.

MATERIALS AND METHODS

The clinical records of 192 patients with cervical carcinoma who met the study requirements were reviewed for this retrospective study. The signal intensities of suspicious PMI tissue were assessed on T2-weighted images, DW images, and apparent diffusion coefficient maps independently by two experienced radiologists. The radiologist observers predicted the presence of PMI by scoring T2-weighted imaging alone and then by scoring T2-weighted imaging and DWI combined. The results were compared with histopathologic findings.

RESULTS

Histopathologic findings revealed PMI in 24 of 192 study subjects. In positively predicting the presence of PMI, T2-weighted imaging and DWI combined scored significantly better than T2-weighted imaging alone, as proven by high sensitivity (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 75.0% vs 83.3% [p = 0.477]; observer 2, 66.7% vs 91.7% [p < 0.05]), high specificity (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 84.5% vs 98.8% [p < 0.001]; observer 2, 85.7% vs 98.8% [p < 0.001]), and high accuracy (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 83.3% vs 96.9% [p < 0.001]; observer 2, 83.3% vs 97.9% [p < 0.001]). The area under the ROC curve was also significantly higher for T2-weighted imaging and DWI combined (observer 1, 0.911; observer 2, 0.952) than for T2-weighted imaging alone (observer 1, 0.798; observer 2, 0.762). Although the interobserver agreement was good for T2-weighted imaging (κ = 0.695) and excellent for T2-weighted imaging and DWI combined (κ = 0.753), the improvement failed to achieve statistical significance (p = 0.28).

CONCLUSION

Combined analysis of T2-weighted imaging and DWI enhances the accuracy of diagnosing PMI in patients with cervical cancer compared with T2-weighted imaging alone.

Prise en charge du cancer du col de l’utérus métastatique et/ou en rechute

METASTATIC OR RECURRENT CERVICAL CANCER/TREATMENT

The prognosis of metastatic or recurrent cervical cancer remains dismal. The poor chemosensitivity of this tumor- is an issue, especially in case of recurrence in irradiated fields. Still, chemotherapy has shown some efficacy, and mostly consists in platinum-based doublets. The addition of bevacizumab to chemotherapy has been recently validated. However, most of these patients present with complex clinical situations and the treatment strategy has to be discussed in multidisciplinary tumor boards.

Preoperative MR staging of cervical carcinoma: are oblique and contrast-enhanced sequences necessary?

Background

As the choice of treatment in patients with cervical carcinoma depends on cancer stage at diagnosis, accurate staging is essential.

Purpose

To compare three different combinations of magnetic resonance (MR) sequences for preoperative staging.

Material and Methods

Fifty-seven consecutive patients with biopsy proven cervical carcinoma underwent MR imaging (MRI) staging followed by primary surgical treatment. Thirty-two of 57 patients had had a cone biopsy prior to MRI. Three MR pulse sequence combinations were retrospectively reviewed by two experienced radiologists. The first imaging protocol consisted of pre-contrast sagittal and transverse images (protocol A), the second protocol included additionally oblique high-resolution T2-weighted (T2W) MR images of the cervix (protocol A+B), and the third included also contrast-enhanced sequences (protocol A+B+C). The imaging findings in the three steps (A, A+B, A+B+C) were recorded. The TNM stage was used for comparison between preoperative imaging and histopathology. Histopathology, together with surgical findings, served as gold standard.

Results

In 4/57 (7%) patients, the MR assessment of tumor stage (mrT) was altered when oblique sequences were added to the standard two plane imaging protocol (A+B). The mrT stage was altered in 1/57 (2%) patient when contrast-enhanced sequences were added to standard and oblique sequences (protocol A+B+C). The correlation between visible tumor on MRI and presence of tumor in the resected specimen did not change by adding oblique or contrast-enhanced images.

Conclusion

It is not necessary to perform oblique and contrast-enhanced sequences in small cervical carcinomas, i.e. without parametrial invasion. To avoid erroneous interpretation, information on previous cone biopsy is essential.

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

Three-Dimensional Transvaginal Sonography and Magnetic Resonance Imaging for Local Staging of Cervical Cancer: An Agreement Study

OBJECTIVES

To evaluate the agreement of clinical examination, 2-dimensional (2D) sonography, and 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) for local staging of cervical cancer.

METHODS

We conducted a prospective study including women with a diagnosis of carcinoma of the cervix. All women were staged clinically and underwent 2D and 3D transvaginal sonography and MRI before treatment for assessing tumor size and parametrial, bladder, and rectal involvement using the examiner's subjective impression. Agreement between sonography and MRI was assessed by calculating the κ index and percentage of agreement.

RESULTS

Forty women were included (mean age ± SD, 46.6 ± 11.4 years). Eleven had early-stage (IA and IB1) disease, and 29 had advanced-stage (IB2-IVB) disease. A significant correlation for tumor size estimation was found between MRI and pelvic examination (r = 0.754; P < .001), MRI and 2D sonography (r = 0.649; P < .001), and MRI and 3D sonography (r = 0.657; P< .001). Agreement for parametrial infiltration between MRI and pelvic examination was fair (κ = 0.26; 95% confidence interval [CI], 0.10-0.54; 62.5% agreement), between MRI and 2D sonography was moderate (κ = 0.41; 95% CI, 0.15-0.66; 70.0% agreement), and between MRI and 3D sonography was good (κ = 0.60; 95% CI, 0.35-0.85; 80.0% agreement). Agreement for bladder involvement between MRI and pelvic examination was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), between MRI and 2D sonography was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), and between MRI and 3D sonography was very good (κ = 0.84; 95% CI, 0.55-1.0; 97.5% agreement). Agreement for rectal involvement was not calculated because of the very small number of cases.

CONCLUSIONS

Three-dimensional sonography showed good agreement with MRI for assessing parametrial infiltration and bladder involvement in cervical cancer.

Current imaging strategies for the evaluation of uterine cervical cancer

Uterine cervical cancer still remains an important socioeconomic issue because it largely affects women of reproductive age. Prognosis is highly depended on extent of the disease at diagnosis and, therefore, accurate staging is crucial for optimal management. Cervical cancer is clinically staged, according to International Federation of Gynecology and Obstetrics guidelines, but, currently, there is increased use of cross sectional imaging modalities [computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT)] for the study of important prognostic factors like tumor size, parametrial invasion, endocervical extension, pelvic side wall or adjacent/distal organs involvement and lymph node status. Imaging indications also include cervical cancer follow-up, evaluation of tumor response to treatment and selection of suitable candidates for less radical surgeries like radical trachelectomy for fertility preservation. The preferred imaging method for local cervical cancer evaluation is MRI; CT is equally effective for evaluation of extrauterine spread of the disease. PET-CT shows high diagnostic performance for the detection of tumor relapse and metastatic lymph nodes. The aim of this review is to familiarize radiologists with the MRI appearance of cervical carcinoma and to discuss the indications of cross sectional imaging during the course of the disease in patients with cervical carcinoma.