Patterns of Recurrent Disease in Cervical Cancer

Abstract

Uterine cervical cancer is one of the most common causes of cancer-related deaths among women worldwide. Patients with cervical cancer are at a high risk of pelvic recurrence or distant metastases within the first few years after primary treatment. However, no definitive agreement exists on the best post-treatment surveillance in these patients. Imaging may represent an accurate method of detecting relapse early, right when salvage treatment could be effective. In patients with recurrent cervical cancer, the correct interpretation of imaging may support the surgeon in the proper selection of patients prior to surgery to assess the feasibility of radical surgical procedure, or may help the clinician plan the most adaptive curative therapy. MRI can accurately define the extension of local recurrence and adjacent organ invasion; CT and 18F-FDG PET/CT may depict extra-pelvic distant metastases. This review illustrates different patterns of recurrent cervical cancer and how imaging, especially MRI, accurately contributes towards the diagnosis of local recurrence and the assessment of the extent of disease in patients with previous cervical cancer. Normal post-therapy pelvic appearance and possible pitfalls related to tissue changes for prior treatments will be also illustrated.

Keywords: CT; MRI; cervical cancer; personalized approach; recurrence.

Figure 1

(a) Sagittal FSE T2-weighted image shows soft tissue with high signal intensity consistent with a cervical tumor extended to the vagina (arrows). (b) Sagittal FSE T2-weighted image shows reconstitution of the normal T2-weighted hypointense cervical stroma (arrows), with disappearance of the tumoral mass after chemoradiation therapy.

Figure 2

A 42-year-old patient with history of cervical cancer treated with chemoradiation therapy. (a) Sagittal and (b) axial FSE T2-weighted images show a nodular hyperintense lesion in the anterior aspect of the cervix, causing interruption of the hypointense cervical stroma, consistent with recurrence (arrows). (c) Axial diffusion-weighted image demonstrates restricted diffusion of the lesion (arrowhead).

Figure 3

A 32-year-old woman who underwent previous chemoradiation therapy for cervical cancer. (a) Coronal and (b) axial FSE T2-weighted images show a soft-tissue mass in the right parametrium (black arrows). Note the contact with the right ureter embedded by the lesion (arrowhead). (c) Diffusion-weighted image shows focus of hyperintense signal into the lesion (white arrow). The finding was confirmed to be recurrence at surgery.

Figure 4

A 57-year-old patient who underwent radical hysterectomy with bilateral salpingo–oophorectomy for cervical cancer. (a) Sagittal and (b) axial FSE T2-weighted images show a nodular hyperintense lesion in the vaginal cuff (arrows), consistence with relapse. (c) Diffusion-weighted image demonstrates highly restricted diffusion of the lesion (arrowhead) in relation to hypercellularity.

Figure 5

A 65-year-old woman who underwent chemoradiation therapy for cervical cancer. (a) Sagittal and axial (b) FSE T2-weighted image show an anterior pelvic recurrence, characterized by a soft-tissue mass infiltrating the posterior bladder wall extending into the bladder lumen (white and black arrow). (c) The lesion appears hyperintense on diffusion-weighted images (arrowhead).

Figure 6

(a,b) A 46-year-old patient who underwent chemoradiation therapy for recent cervical cancer. (a) Sagittal and (b) axial FSE T2-weighted images show a soft-tissue mass in the cervix, extended posteriorly to the rectal wall (white arrow), causing luminal narrowing (black arrow). Note the bullous oedema of the posterior bladder wall mucosa (arrowhead). (c) A 58-year-old patient who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. Axial post-contrast CT image shows a nodular mass in the right pelvis infiltrating the distal sigma (arrow).

Figure 7

(a,b) A 36-year-old patient who underwent radical hysterectomy with bilateral salpingo–oophorectomy (BSO) and chemoradiation therapy for cervical cancer. Axial post-contrast CT images show pathological tissue infiltrating the left piriform muscle, the left internal obturator muscle (solid white arrow in (a,b)) and the external iliac vein (white arrowhead in (b)). Note the infiltration of the anterior rectal wall (black arrowhead in (b)), the bladder and the left ureteral orifice (with the ureteral stent) (open arrow in (b)). (c) A 58-year-old who underwent radical hysterectomy with BSO for cervical cancer. Axial post-contrast CT image shows pathological tissue infiltrating the left sacral promontory (black arrow).

Figure 8

A 55-year-old patient who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. (a) Coronal and (b) axial FSE T2-weighted images show multiple pelvic bilateral lymphadenopathies, with heterogenous signal intensity (arrows). Note the recurrent lesion in the vaginal cuff extended to the left parametrium (arrowhead in (a)). (c) The lymphadenopathies demonstrate restriction on diffusion-weighted image (open arrows).

Figure 9

(a) A 40-year-old patient who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. Axial post-contrast CT image shows left axillary lymph nodal relapse (solid arrow). (b,c) A 44-year-old patient who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. (b) Axial and (c) sagittal post-contrast CT images show pathological mediastinal soft tissue infiltrating the vertebral soma (open arrows).

Figure 10

(a,b) A 56-year-old patient who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. (a) Axial FSE T1 weighted and (b) axial FSE T2-weighted fat-sat images show osseous metastases in the sacrum, characterized by hypointense T1 and hyperintense T2 signal intensity (solid arrows). (c,d) A 41-year-old patient who underwent previous chemoradiation therapy for cervical cancer. (c) Axial FSE T1 weighted and (d) axial FSE T2-weighted fat-sat images show osseous metastases in the ischio–pubic right branch (open arrow in c). Note the oedema in the adjacent soft tissue and muscles (arrowheads in (b,d)).

Figure 11

A 38-year-old woman who underwent radical hysterectomy with BSO and chemoradiation therapy for cervical cancer. (a) Axial FSE T2-weighted and (b) axial T1 weighted fat-sat post-contrast images show heterogeneous nodular lesion in the soft tissue of the left gluteal region (arrows). This finding was confirmed to be metastasis at histology.