Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

Abstract

MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Endometrial cancer (EC) is the most common malignant tumor of the female genital tract in Western countries. EC patients are divided into risk categories based on histopathological tumor type, grade, and myometrial invasion depth. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) system. Since FIGO (2009) stage correlates with prognosis, preoperative staging is essential for tailored treatment. MRI reveals myometrial invasion depth, which correlates with tumor grade and lymph node metastases, and thus correlates with prognosis. Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. The FIGO Gynecologic Oncology Committee recently revised its CC staging guidelines, allowing staging based on imaging and pathological findings when available. The revised FIGO (2018) staging includes node involvement and thus enables both therapy selection and evaluation, prognosis estimation, and calculation of end results. MRI can accurately assess prognostic indicators, e.g., tumor size, parametrial invasion, pelvic sidewall, and lymph node invasion. Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Awareness of mimics that can simulate both cancers is critical. With careful application, functional MRI with DWI and DCE sequences can help establish a correct diagnosis, although it is sometimes necessary to perform biopsy and histopathological analysis.

Keywords: Cervical cancer; Diffusion; Endometrial cancer; Lymph nodes; Magnetic resonance.

Fig. 1

MRI technique artifacts. a Axial oblique T2WI. b, c DWI (b: 1000 and ADC map). Right hip prostheses and rectal air prevent detection of a small cervical tumor. d–f Axial oblique T2WI and DWI. After rectal air removal and change of phase direction, a tiny cervical cancer tumor is visible (arrows)

Fig. 2

Planning of MRI sequences in endometrial (a) and cervical (b) cancers. Yellow line indicates the coronal plane, red line indicates the axial oblique plane

Fig. 3

FIGO IA endometrial tumor (arrows) with myometrial invasion of < 50% is isointense in T2WI images (a) and well-delineated in fused T2WI-DWI images (b)

Fig. 4

Uterus of postmenopausal woman exhibits myomas and FIGO IA endometrial cancer. Endometrial tumor is not delineated on axial oblique T2WI images (a) and is well-defined on DWI (b = 1000, ADC map) (arrows) (b)

Fig. 5

FIGO IB tumor exhibiting left cornual extension. a Axial oblique T2WI. b Coronal T2WI. c Fused T2WI-DW images show endometrial tumor (arrow), which was difficult to delineate on individual images

Fig. 6

Endometrial cancer with endometrial cavity distension. a Axial oblique T2WI. b DCE and parametric map. Disruption of the endometrial–myometrial zone (arrows) indicates myometrial invasion

Fig. 7

Endometrial cancers visualized by sagittal T2WI. a No cervical invasion; cervical stromal is preserved (white arrow). b Direct cervical invasion; cervical stroma is invaded (red arrow)

Fig. 8

Synchronous endometrial and ovarian cancer. Visualization by sagittal T2WI (a) and axial oblique T2WI (b) reveals a large multicystic ovarian mass (white arrow) and endometrial cancer (red arrow). c, d DCE imaging shows heterogeneous uptake in the ovarian mass (white arrow) and hypoenhancement in the endometrial mass (red arrow)

Fig. 9

Small cell neuroendocrine tumor with myometrium and cervical invasion visualized by sagittal T2WI (a) and sagittal DCE (b). Vaginal and pubic metastasis are much better delineated in the DCE sequence (arrows)

Fig. 10

Endometrial hyperplasia visualized by sagittal T2WI (a) and axial oblique T2WI (b). Both images show intracavitary endometrial proliferation that is hyperintense relative to the myometrium. In panel c, there is no diffusion restriction on b = 1000

Fig. 11

Endometrial-based tumor visualized with sagittal T2WI (a) and sagittal T2WI+DWI (b) was found to be a carcinosarcoma mimicking endometrial carcinoma. c–e In another patient, an endometrial stromal sarcoma mimicking cervical cancer is visualized by sagittal T2WI (c), axial T2WI+DWI (d), and DCE (e), revealing a cervical-centered mass with parametrial invasion and adenopathies (arrows in d)

Fig. 12

Pregnant woman with biopsy-confirmed cervical cancer that is not detectable on T2WI (a), but is delineated (white arrows) on DWI images (b, c)

Fig. 13

a, b Sagittal and axial oblique T2WI with vaginal gel, revealing a cervical carcinoma with vaginal infiltration, seen as disruption of the hypointense anterior wall (arrow)

Fig. 14

Tumor visualization with axial oblique T2WI (a), DWI-ADC map (b), and DCE imaging (c) reveals loss of the hypointense cervical rim on the right lateral aspect of the cervix, with an irregular interface between the tumor and the parametrium (arrow). ADC map shows diffusion restriction, and DCE imaging reveals enhancement of the right lateral wall indicating early parametrial invasion (arrows)

Fig. 15

FIGO IB2 cervical cancer, with post-biopsy cervical edema. Biopsy was performed 2 days before MRI. a Axial oblique T2WI shows cervical cancer with apparent parametrial invasion (arrows). b DWI (b = 1000/ADC map) reveals a delineated tumor (arrows), without parametrial invasion

Fig. 16

MRI reveals FIGO IIIB cervical cancer in a 38-year-old woman with adenomyosis and endometriosis in the left ovary. Visualization by coronal T2WI (a), axial FS T1WI (b), and sagittal T2WI (c) reveals a mass extending to the left parametrium and involving the left ureter (red arrows) below the endometrioma (E), with a subsequent hydronephrosis. d, e DWI (b = 1000/ADC map) reveals diffusion restriction of the cervical mass, with extension to the left ureter. f DCE sequence shows enhancement of the cervical mass and ureter wall

Fig. 17

FIGO Stage IVA cervical cancer with bladder invasion. Visualization by sagittal T2WI (a) and coronal T2WI (b) reveals cervical cancer invading the bladder mucosa (red arrow) and rectouterine space (white arrow)

Fig. 18

Cervical cancer. a Axial oblique T2WI shows a cervical mass (arrow), with hematometra and ureteral invasion (arrowhead) (IIIB). b Sagittal T2WI shows loss of the hypointense rim of the posterior bladder wall suggesting invasion (arrows). c T2WI+DWI reveals no invasion of the bladder wall (arrow)

Fig. 19

Cervical cancer treated with chemotherapy and radiotherapy. a Axial oblique T2WI at diagnosis shows a cervical mass. b, c, d A post-treatment residual mass (arrows) is detected on the right posterior aspect of the cervix by axial oblique T2WI (b), DCE and a type 3 time-intensity curve (c) and PET/CT (d). e Axial oblique T2WI at 6 months after treatment establishes cervical and right parametrium fibrosis (red arrow) and shows no residual mass

Fig. 20

Tunnel clusters visualized by axial oblique T2WI (a), coronal T2WI (b), sagittal T2WI (c), and DWI-ADC map (d). Clustered cystic spaces have a round or oval appearance, an absence of invasion of the deep cervical stroma, and no diffusion restriction (arrow in d)

Fig. 21

Adenoma malignum visualized by axial oblique T2WI (a), coronal T2WI (b), sagittal T2WI (c), and DCE (d). Multicystic lesions extend from the endocervical glands to the deep cervical stroma with solid components, forming a mass (arrows)

Fig. 22

Transitional bladder cancer invading the cervix (star), visualized by sagittal T2WI (a), axial oblique T2WI (b), and T2WI+DWI (c)

Fig. 23

Vaginal vault mass after surgery for cervical carcinoma (white arrows) visualized by sagittal T2WI (a), axial oblique T2WI (b), DWI (b = 1000, ADC map) (c), and DCE (d). Imaging reveals diffusion restriction and early contrast uptake. Biopsy and histopathology indicated granulation tissue

Fig. 24

Axial oblique T2W (a) and DWI images (b, c) showing stage IIIC 1 endometrial cancer (white arrow) with metastatic left obturatory lymph node (red arrow)

Fig. 25

a, b MRI of a 48-year-old woman with known adenomyosis, a previous cesarean section, and FIGO IA1 cervical cancer diagnosed in an outpatient clinic, including sagittal T2WI (a) and axial oblique T2WI (b). No anomalies are visible in the cervix. The cystic image in the right obturator space (arrow in b) was interpreted as a right ovary with a small follicle. The patient underwent simple extrafascial hysterectomy with ovarian removal. Post-surgical histology confirmed FIGO stage IA1 (high-grade squamous cell carcinoma), without LVSI and with a clear surgical margin. c, d MRI was performed 6 months after surgery, including axial oblique T2WI (c) and coronal MIP-DCE sequence imaging (d). The right obturator cystic lesion increased in size and in contact with right iliac vessels (arrows). Images also show medial displacement of the right pelvic peritoneal fascia (red arrowhead) indicating an extraperitoneal origin of the cystic lesion. e ¹⁸F-FDG PET-CT shows avid enhancement of the cystic mass. Lymphadenectomy was performed. Histological analysis showed metastatic adenopathy of cervical cancer