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MR imaging in cervical cancer: seeing is believing

The 2004 Mackenzie Davidson Memorial Lecture

¹ Cancer Imaging, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE and ² Department of Clinical Radiology, Homerton University Hospital, Homerton Row, London E9 6SR, UK

View larger version (21K): [in a new window]   Figure 1. Variation in TNM stage with age group for cervical cancer cases in the West Midlands. Cancers diagnosed 1991–1995. (Cancer Research UK [34]). * indicates total number of cases in each age group.

View larger version (13K): [in a new window]   Figure 2. The relationship of incidence and mortality of cervical cancer against social deprivation score. (Cancer Research UK [34]).

View larger version (87K): [in a new window]   Figure 3. (a) T2 weighted sagittal fast-spin-echo scan showing a large cervical tumour with high T2 signal. The oblique scan line demonstrates the plane that is required to obtain a true axial representation of the cervix as in Figure 3b. (b) Oblique T2 weighted fast-spin-echo scan. There is preservation of the normal low T2 signal intensity of the cervical stoma (arrows). The preservation of this line has a negative predictive value exceeding 96 for parametrial invasion.

View larger version (76K): [in a new window]   Figure 4. (a) T2-weighted sagittal fast-spin-echo scan demonstrating an endocervical tumour (arrow). (b) T2 weighted oblique scan demonstrating the loss of the normal low T2 cervical stroma on the right side (arrow) indicating parametrial invasion.

View larger version (72K): [in a new window]   Figure 5. (a) T2 weighted sagittal fast-spin-echo scan demonstrating a large endocervical and exophytic tumour. The exophytic component of the tumour extends into the proximal vagina and is surrounded by the vaginal wall. (b) T2 weighted oblique scan at the level of the proximal vagina and the exophytic component of the cervical tumour (dashed scan line). The vaginal walls surrounding the cervical tumour have low signal intensity on T2 weighted images (arrows). These can be misinterpreted as cervical stroma and careful correlation of oblique scans against sagittal T2 weighted scans is recommended to avoid this pitfall. (c) T2 weighted oblique scan at the level of the cervix (continuous scan line) demonstrating the loss of normal cervical stroma suggesting parametrial extension (arrows). (d) Pathological specimen orientated in a longitudinal plane, demonstrating the large central cervical tumour extending into the proximal vagina but also extending into the parametrium.

View larger version (86K): [in a new window]   Figure 6. (a) T2 weighted oblique fast-spin-echo scan showing a small carcinoma in the anterior lip of the cervix (star). Anteriorly there is apparent extension of tumour into the fat space between the cervix and bladder wall (arrow). (b) T2 weighted sagittal fast-spin-echo scan shows the cervical cancer (star). The anterior wall of the vagina is folded and collapsed resulting in the appearance of extracervical tumour.

View larger version (135K): [in a new window]   Figure 7. T2 weighted fast-spin-echo sagittal scan showing a large exophytic mass occupying the entire cervix. The appearances are indistinguishable from cervical cancer but histologically this was endometriosis with a small focus of carcinoma.

View larger version (162K): [in a new window]   Figure 8. T2 weighted axial fast-spin-echo scan showing a large cervical tumour with full thickness bladder wall and mucosal invasion.

View larger version (159K): [in a new window]   Figure 9. T2 weighted axial fast-spin-echo scan showing an extensive infiltrative cervical tumour. There is invasion of the left utero-sacral ligaments and invasion of the rectal wall (arrows).

View larger version (58K): [in a new window]   Figure 10. (a) T2* weighted axial scan showing a 10 mm external iliac lymph node (arrows) prior to the administration of ultra small iron oxide particles (USIOPs). (b) T2* weighted axial scan following administration of USIOPs showing the 10 mm left external iliac node losing all central signal after administration of the USIOPs (arrow). The capsule of the node (arrowhead) and hilum (curved arrow) are clearly seen. (c) Histological specimen of the same lymph node showing normal macrophages through out the node without evidence of metastatic tumour deposits.

View larger version (130K): [in a new window]   Figure 11. (a) T2* weighted axial scan prior to the administration of USIOP showing a 5 mm external iliac lymph node. (b) T2* weighted axial scan following USIOPs administration showing the node in Figure 11a with persistent high signal suggesting a nodal metastases and the absence of normal iron laden macrophages. (c) Axial non-contrast enhanced CT scan. A fine-needle aspiration of the lymph node demonstrated in Figure 11a was performed under CT guidance. This confirmed nodal metastases from cervical cancer.

View larger version (100K): [in a new window]   Figure 12. (a) T2 weighted sagittal fast-spin-echo sequence demonstrating recurrent disease in the posterior lip of the cervix after primary radiotherapy (arrow). (b) T2 weighted sagittal fast-spin-echo sequence demonstrating early central recurrence (arrow) after hysterectomy and bilateral salphingo-oopherectomy.

View larger version (148K): [in a new window]   Figure 13. T2 weighted axial fast-spin-echo sequence showing a large recurrent mass (arrows) within the right iliacus muscle extending into the right sacral neural foraminae.

View larger version (168K): [in a new window]   Figure 14. T2 weighted fast-spin-echo sagittal sequence showing a recurrent perineal mass outside the field of radiotherapy. The cervix and uterus are atrophic in keeping with radiotherapy changes.

View larger version (119K): [in a new window]   Figure 15. Sagittal short tau inversion recovery (STIR) sequence demonstrating a vesico-vaginal fistula (arrow). Within the vaginal walls there is irregular thickening (star). Biopsy of these areas and in the site of the fistula showed recurrent cervical cancer.

View larger version (90K): [in a new window]   Figure 16. (a) T2 weighted sagittal fast-spin-echo scan demonstrating a very large cervical cancer invading the posterior bladder wall (arrow). (b) T2 weighted sagittal scan demonstrating a very large vesico-vaginal fistula which developed after radiotherapy at the site of the patient's primary cervical cancer. Bullous oedema is also noted affecting the bladder wall (star). Multiple biopsies of the vaginal wall and bladder revealed no recurrent disease.

View larger version (64K): [in a new window]   Figure 17. (a) Schematic diagram showing the region of the cervix resected during trachelectomy. (b) After removal of the tumour-bearing cervix, the uterus and vagina are re-anastamosed. (c) Sagittal view post-trachelectomy showing the location of the cerclage suture (arrow).

View larger version (175K): [in a new window]   Figure 18. T2 weighted sagittal fast-spin-echo scan demonstrating a soft tissue posterior to the anastamosis. This is normal vaginal wall and represents a "neo-fornix".

View larger version (90K): [in a new window]   Figure 19. (a) T2 weighted sagittal scan with the anterior (midway through the pubic symphysis) and posterior (S2/3 intervertebral joint) radiotherapy limits marked as solid lines. There is a large tumour in the cervix and based on the normal lateral fields, the tumour would be under treated as the uterine fundus lies outside the anterior field. (b) T2 weighted sagittal scan with the anterior and posterior radiotherapy limits marked as solid lines. The tumour-bearing cervix lies centrally and the lateral margins can be narrowed to avoid radiation to vital pelvic structures without under treating the cervical cancer.

View larger version (81K): [in a new window]   Figure 20. (a) Non-contrast CT scan of the pelvis at the site of the cervical cancer. The estimated gross tumour volume map has been drawn in white. (b) T2 weighted axial fast-spin-echo scan with the gross tumour volume map drawn in yellow. (c) The CT and MRI scans are co-registered and show the two gross tumour volume maps are significantly different. Radiotherapy, usually based on the CT map, appears to have overestimated the gross tumour volume.