Post treatment imaging in patients with local advanced cervical carcinoma

Abstract

Cervical cancer (CC) is the fourth leading cause of death in women worldwide and despite the introduction of screening programs about 30% of patients presents advanced disease at diagnosis and 30-50% of them relapse in the first 5-years after treatment. According to FIGO staging system 2018, stage IB3-IVA are classified as locally advanced cervical cancer (LACC); its correct therapeutic choice remains still controversial and includes neoadjuvant chemo-radiotherapy, external beam radiotherapy, brachytherapy, hysterectomy or a combination of these modalities. In this review we focus on the most appropriated therapeutic options for LACC and imaging protocols used for its correct follow-up. We explore the imaging findings after radiotherapy and surgery and discuss the role of imaging in evaluating the response rate to treatment, selecting patients for salvage surgery and evaluating recurrence of disease. We also introduce and evaluate the advances of the emerging imaging techniques mainly represented by spectroscopy, PET-MRI, and radiomics which have improved diagnostic accuracy and are approaching to future direction.

Keywords: MRI; cervical cancer; gynecologic malignancies; gynecology; oncology.

Figure 1

45- year-old woman. Sagittal T2W and axial DWI MR images show an invasive CC with parametrial invasion and extension of the upper 2/3 of the vagina (A, B). Stable disease (C, D) after CCRT, CC is changed in morphology and size; however, infiltration of the vaginal fornix, upper 2/3 of the vagina, and both parameters remain.

Figure 2

48- year-old woman. Sagittal T2W and axial DWI MR images show an invasive CC extending from the uterine isthmus to the external uterine orifice, laterally infiltrating both vaginal fornices, and extending beyond the stromal ring with extensive infiltration of the parameters. (A, B). Partial response (C, D) approximately 30% reduction of cervical heteroplastic tissue.

Figure 3

37- year-old woman. Sagittal T2W and axial DWI MR images show CC infiltrating both parameters, the upper 1/3 of the vaginal canal, the uterine body, and the left ureter (A, B). Complete response (C, D) significant post-CHT reduction of heteroplastic tissue (around 90%).

Figure 4

67- year-old woman. Sagittal T2W and axial DWI MR images show an invasive CC (A, B). Progression disease (C, D) CC infiltrates the uterine body, lower 1/3 of the vaginal canal, mesorectum, anterior wall of the rectum, and posterior wall of the bladder.

Figure 5

41- year-old woman. Sagittal and axial T2W (A, B) and axial DWI MR images with ADC map (C, D) show an invasive CC extending to the upper third of the vaginal canal and anterior rectal wall with focal parametrial infiltrations. Sagittal and axial T2W (E, F) and axial DWI MRI images with ADC map (G, H) shows a complete response after CCRT.