Cervical Cancer Staging:

A Resident’s Primer

Anish Raithatha, BSc, MBBS,1* Ioanna Papadopoulou, FRCR,1 Victoria Stewart, BMed Sci, BMBS,
MRCP, FRCR,1 Tara D. Barwick, MBChB, MSc, MRCP, FRCR,1,2 Andrea G. Rockall, BSc, MBBS,
MRCP, FRCR,1,2 Nishat Bharwani, BSc (Hon), MBBS, MRCP, FRCR1,2

1 Department of Radiology, Imperial College Healthcare NHS Trust, London, England

2 Department of Surgery and Cancer, Imperial College London, England

Presented as an education exhibit at the 2014 RSNA Annual Meeting – OBE117.

All authors have disclosed no relevant relationships.

Address correspondence to: Department of Radiology, Imperial College Healthcare NHS Trust, St
Mary’s Hospital, Praed Street, London W2 1NY, England (*email: anish.raithatha@gmail.com), Tel
020 3312 6666 ext 27616
 Learning Objectives
After viewing this online presentation, participants will be able to:
• Describe the International Federation of Gynecology and
Obstetrics (FIGO) staging of cervical cancer and the magnetic
resonance (MR) imaging appearances of each stage of the
primary tumor.
• Explain the appropriate role of each imaging modality in staging,
follow-up, and assessment of recurrent cervical cancer.
• Recognize potential imaging and interpretative pitfalls.

Abbreviations
Ax = axial, CECT = contrast-enhanced CT, Cor = coronal, CTPA = CT pulmonary angiogram, FIGO = International
Federation of Gynecology and Obstetrics, LFOV = large field of view, Obl = oblique, Sag = sagittal, SFOV = small field of
view, T1 = T1-weighted, T2 = T2-weighted
 Key Concepts
1. The use of cross-sectional imaging is important as a noninvasive means to
determine accurate staging in patients with cervical cancer.

2. MR imaging is the modality of choice to determine local-regional tumor

spread and is used to establish the FIGO stage prior to treatment.

3. Contrast material–enhanced computed tomography (CT) and fluorine 18

fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT are
used in locally advanced cervical cancer to assess the extent of distant
disease spread.

4. Imaging plays an important role in planning initial management and in

follow-up.

5. Accurate reporting of radiologic findings is dependent on knowledge of

common imaging and interpretive pitfalls.
 Introduction
• Cervical cancer is the fourth most common cancer
worldwide in women and the seventh most
common cancer overall.1
• Cervical cancer accounted for 7.5% of female cancer
deaths worldwide in 2012.1
• It is the most common cause of cancer-related death
in the younger than 35 age group.2
• Around 85% of cervical cancers occur in middle- and
low-income countries.2

1International Agency for Research on Cancer, 2 Cancer Research UK Web site (all accessed November 2015)
 Cervical Cancer: Risk Factors
Risk Factor Comment
Human papillomavirus - Associated with 99% of cases.1
(HPV 16 and 18) -While HPV infection is common, malignant transformation is
relatively rare.
Immunosuppression2 - Immunosuppressed and human immunodeficiency virus–
positive patients.
Smoking2 - Approximately twice the risk.
- Smoking is associated with high-risk behavior.
- Smoking weakens the immune system, allowing HPV to persist.
Early first pregnancy2 - Women who have their first full-term pregnancy before age 17
are twice as likely to develop cervical cancer.
Poverty2 - Associated with inadequate access to health services and
screening facilities.
Family history2 - Two to three times higher risk if mother or sister have been
diagnosed.

1WHO Web site, 2www.cancer.org (Accessed March 2015)

 Cervical Cancer: Screening
• Screening involves cervical sampling and examination of
samples with microscopy to identify dyskaryotic changes.
• Dyskaryosis describes the microscopic appearance of
abnormal squamous epithelial cells characterized by
hyperchromatic nuclei or irregular nuclear chromatin.
United
United Kingdom Screening
States Screening Program
Program: 2 1:

Age
Age groupFrequency
group Frequency of screening
of screening
2521 First screening
First screening visit visit
Normal Papanicolaou test
21–30 EveryEvery
25-49 3 years
3 years staining.3
50-64
30–65 EveryEvery
5 years
3-5 years
65+
65+ Only Only
if notifscreened after age
patient does not 50 or recent
meet criteria for
abnormal results
adequate prior testing

• If moderate or severe dyskaryosis is found, colposcopy and

formal biopsy are performed to rule out malignancy.
• If the histologic findings of the biopsy confirm invasive
cervical cancer, the disease in the patient will require
staging before choosing an appropriate management plan. Papanicolaou stain
1NHS
demonstrating atypical cells.3
Cervical Screening Programme, 2U.S. Preventative Services Task Force, 3Courtesy of Roberto Dina, MD
 Cervical Cancer: FIGO Staging
• The most widely used staging system for cervical cancer is the
FIGO staging system, which was revised in 2009.
• The FIGO system is based on clinical examination and
inspection to allow uniform classification of patients
worldwide, as the disease is prevalent in countries with
limited access to imaging.
• However, the 2009 revision encourages the use of cross-
sectional imaging where it is available to assess prognostic
factors such as parametrial or pelvic sidewall invasion and
nodal involvement, which are not easily evaluated clinically.

Pecorelli (2010)
FIGO Staging of Cervical Cancer (2009)
Stage I: The carcinoma is confined strictly to the cervix.
IA: invasive carcinoma that can only be diagnosed with
microscopy and is less than 7 mm in width.

Image taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/
 FIGO Staging of Cervical Cancer (2009)
Stage I: The carcinoma is confined strictly to the cervix.
IB: clinically visible tumor confined to the cervix.
IB1: 4 cm or less in greatest dimension.
IB2: greater than 4 cm in greatest dimension.

Image taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/
 Stage I: Confined to the Cervix
• Stage IA tumors are only diagnosed with microscopy
and are not clinically visible.
• Stage IB tumors are subclassified on the basis of their
size (smaller or larger than 4 cm).

Stage IB1: The intermediate-signal-intensity Stage IB2: A 4.3-cm tumor is visualized at

tumor (*) can be visualized within the low- the anterior cervical lip (*) projecting into
signal-intensity cervical stroma (arrow) and but not involving the anterior vaginal
measures less than 4 cm in diameter. fornix.

*
* *
*
T2 Sag T2 Ax Obl T2 Sag T2 Ax Obl
 FIGO Staging of Cervical Cancer (2009)
Stage II: The carcinoma invades beyond the uterus but
spares the lower third of the vagina and pelvic sidewall.
IIA: with upper vaginal involvement IIB: involving the parametrium.
but no parametrial invasion. The parametrium is defined as
IIA1: less than 4 cm in greatest “connective tissue that extends laterally
dimension from the cervix between the layers of the
IIA2: greater than 4 cm in greatest broad ligament.”
dimension

Images taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/
 Stage II: Beyond the Cervix
No involvement of the pelvic sidewall or lower third of the vagina.
• Stage IIA1: <4 cm • Stage IIB:
• Stage IIA2: >4 cm Parametrial invasion

T2 Sag T2 Ax
Stage IIA2: The primary cervical tumor (*)
Stage IIB: There is loss of the normal T2-
measures more than 4 cm in maximal
hypointense cervical stroma surrounding
dimension and involves the upper third of
the majority of the tumor, a finding
the vagina (arrow), in keeping with FIGO
suggestive of parametrial invasion.
stage IIA2. The T2-weighted low-signal-
intensity cervical stromal ring is intact, and
there is no evidence of parametrial
invasion.
Pearls and Pitfalls–Parametrial Invasion
• While an intact ring of hypointense cervical
stroma surrounding the tumor excludes
parametrial invasion…

• Complete loss of the low-signal-intensity

ring does not always confirm parametrial
invasion. T2 Ax
T2 Ax

This appearance may also represent Complete preservation of the low 

Loss of the low signal intensity ring of cervical stroma 
signal cervical stromal ring,
complete involvement of the cervical … ?Parametrial invasion
excuding parametrial invasion.
stroma without invasion into the
parametrium.
Learning point: Look for extension beyond the
cervical contour to confirm parametrial
involvement.
Normal cervical contour
Site of parametrial invasion T2 Ax
Pearls and Pitfalls–Postbiopsy Change
When examining the patient preoperatively, it is important
to take into consideration the timing of MR imaging.

 MR imaging was performed fewer than 4 days after

cone biopsy of a 6-mm tumor.
What is the local-regional staging at imaging?
* - Is there parametrial involvement (yellow arrow)?
- Does the disease involve the right pelvic sidewall
(blue arrow)?
- Do the left pelvic sidewall lymph nodes (red arrow)
represent metastatic spread?
T2 Ax
Pathologic findings demonstrated no residual tumor;
Note also gas in the cervical canal (*). there are fibrosis and granulation changes only. The
nodes are likely to have been reactive. FIGO stage IA1.

Learning point: Be aware of postbiopsy inflammatory changes.

Perform MR imaging at least 7–10 days after biopsy.
 FIGO Staging of Cervical Cancer (2009)
Stage III: The tumor extends to the pelvic wall and/or
involves the lower third of the vagina and/or causes
hydronephrosis or nonfunctioning kidney.
IIIA: Involvement of the lower third of IIIB: Hydronephrosis or extension to the
the vagina. pelvic sidewall.

Images taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/
Stage III: Involvement of the Lower Vagina
and/or Pelvic Sidewall
Stage IIIA: Extension to the lower
* third of the vagina.
#
Note the large mass (#) centered on the cervix that is
obstructing the endometrial canal, resulting in fluid
accumulation within the endometrial cavity (*) and
extending to involve the lower vagina (arrow).

T2 Sag
Stage IIIB: Extension to the
pelvic sidewall.
Figure A: The primary cervical tumor (*) with
evidence of parametrial invasion.
Figure B: Right-sided hydronephrosis and an
* enlarged aortocaval lymph node (arrow). The
dilated ureter could be traced to the level of the
tumor, in keeping with right pelvic sidewall
Fig A: T2 Sag Fig B: T2 Ax involvement.
Pearls and Pitfalls: Vaginal Involvement
Learning point: An arbitrary line extending posteriorly from
the point of insertion of the urethra into the urinary bladder
divides the vagina into its upper two-thirds and lower third.
Normal study: Cervical cancer:

Upper ⅔

Patient 1: T2 Sag Patient 2: T2 Sag

Lower ⅓
Stage IIA2 Stage IIIA
T2 Sag
 FIGO Staging of Cervical Cancer (2009)
Stage IV: The tumor extends beyond the true pelvis or
there is biopsy-proven involvement of the bladder or rectal
mucosa.
IVA: Spread of tumor to the adjacent IVB: Distant spread of disease.
organs.

Images taken with permission from the patient information Web site of Cancer Research UK: http://www.cancerresearchuk.org/about-cancer/
 Stage IV Disease
• Stage IVA: Extension to adjacent organs or invasion
through the rectal or bladder wall to involve mucosa.
• Stage IVB: Distant disease.
FDG PET

T2 Ax

T2 Sag T2 Sag

Stage IVA: Rectosigmoid Stage IVA: Bladder wall Stage IVB: FDG PET
involvement (arrow). involvement. Note image shows bone and
hydroureter (arrows). pulmonary metastases.
 The Role of Imaging
• The clinically based FIGO (2009) staging system results in
understaging of cervical cancer in 20%–30% of stage IB
patients and up to 64% of stage IIIB patients.1
• Imaging modalities such as MR imaging, contrast-
enhanced CT, and FDG PET/CT can improve preoperative
staging and influence treatment decisions and the
accuracy of radiotherapy fields.
• MR imaging is suitable for local-regional staging of
biopsy-proven cancers, while contrast-enhanced CT and
FDG PET/CT are well suited to provide information on
disease extent.
• The American College of Radiology (ACR)
Appropriateness Criteria can be used to guide choice of
imaging modality.

1Lagasse et al (1980)
 ACR Appropriateness Criteria
• The ACR Appropriateness Criteria provide guidance to supplement a clinician’s
judgment as to whether a patient is a reasonable candidate for an imaging study.
• Guidance is based on the initial tumor staging:
FIGO Stage IB1 FIGO Stage IB2 FIGO Stage >IB

MR imaging, pelvis Usually appropriate Usually appropriate Usually appropriate

with and without
contrast material
FDG PET/CT, whole Usually appropriate Usually appropriate Usually appropriate
body
CT, abdomen/pelvis May be appropriate May be appropriate Usually appropriate
with contrast
material

CT, thorax with - - Usually appropriate

contrast material

Chest radiography May be appropriate May be appropriate -

ACR Appropriateness Criteria (http://www.guideline.gov/content.aspx?id=43887). Accessed November 2015.

 MR Imaging Protocol
Sequence Plane Field of Reason Tumor
View Characteristics

T1 Axial Large Identify pelvic Isointense

weighted (renal hila to lymph nodes; compared with
symphysis
assess bone pelvic muscles Ax T2 LFOV
pubis)
marrow
T2 Axial Large Overview of pelvic High signal
weighted (renal hila to sidewalls; assess intensity relative to
symphysis
for hydronephrosis low-signal-
pubis)
intensity cervical
stroma
T2 Sagittal Large Assess tumor
weighted position and
invasion of vagina T2 Sag LFOV

and/or adjacent
tissues
T2 Oblique Small Assess for
weighted (perpendicular parametrial
to long axis of invasion
cervix)
Diffusion- Axial or Large Tumor assessment Tumor or nodes
T2 Ax Obl SFOV
weighted oblique axial and an aid in demonstrate
LFOV: large field of view
imaging detection of local restricted diffusion SFOV: small field of view
(DWI) lymph nodes
 MR Imaging Protocol
• DWI can be useful in detection of cervical cancers to help
differentiate normal cervical tissue from cervical cancer, particularly
with small tumors.

• A cervical tumor typically will retain high signal intensity at high b

values and demonstrate low signal intensity on the corresponding
apparent diffusion coefficient (ADC) map, in keeping with reduced
diffusivity within the lesion.
DWI (high b value) ADC map
Fig 1: High-b-value DWI
sequence demonstrates the
hyperintense cervical tumor
(arrow).

Fig 2: Corresponding ADC

map confirms restricted
diffusion (arrow).
Fig 1 Fig 2
 CT Imaging
• Contrast-enhanced CT plays an important role in determining
disease extent in locally advanced cervical cancer.
• Patients with positive para-aortic lymph nodes have a poor
prognosis, with an overall survival of less than 20%–30% at 5
years.1
• Evaluation of lymph node status has an effect on radiotherapy
planning and dose escalation to the affected areas.

T2 Sag T2 Ax
Ax CT
MR images demonstrate a large cervical tumor CT image in the same patient
(*), with upper vaginal extension and enlarged demonstrates a single aortocaval
external iliac lymph nodes (arrows). lymph node (arrow) that
measures 8 mm in the short axis.
1Herrera and Prior (2013)
 FDG PET/CT
• FDG PET/CT does not play a role in cervical cancer screening or in
accurate T staging of the primary tumor because MR imaging is the
optimal modality for delineating local tumor extension.
• However, the degree of FDG activity of the primary tumor at
diagnosis, measured by the maximum standardized uptake value, is
a predictive biomarker of lymph node status and disease
outcome.1
• In locally advanced tumors (>stage IB1), the overall staging
accuracy is higher with FDG PET/CT than with standard MR
imaging or CT.2
Indications for PET/CT3,4
- Determining the extent of disease in locally advanced
cervical cancer (>stage IB1), where the patient is being
considered for radical chemoradiation therapy.
- Assessment of disease extent for patients being considered
for pelvic exenteration surgery.
1 Grigsby et al (2001), 2 Choi et al (2010), 3 RCR Recommendations (2014), 4NCCN (2015)
 FDG PET/CT
Case B: Stage IIIB at MR imaging (not
shown) with left pelvic sidewall
extension and pelvic and retroperitoneal
nodes. FDG PET/CT (maximum intensity
projection [MIP] and axial fused) images
demonstrate active primary tumor (blue
arrows) and pelvic and retroperitoneal
(pink arrows) and mediastinal and left
supraclavicular (orange arrows) nodal
A: T2 Ax B: CT Ax involvement.

C: Fused Ax FDG PET/CT D: Fused Ax FDG PET/CT

Case A: Staging with FDG PET/CT in a patient with pelvic nodes

seen on MR image (A) and nonenlarged para-aortic lymph nodes
seen on contrast-enhanced CT image (B). FDG PET/CT images (C,
D) demonstrate that these are metabolically active (arrows). The
patient required extended-field retroperitoneal radiotherapy. MIP and fused Ax FDG PET/CT
 Prognostic Factors
• The clinical stage is an important predictor of
progression-free interval and survival.

• Other important prognostic factors include:

Tumor size Histologic Performance

grade status
Lymph
Histologic node
subtype status

Barwick et al (2013)
 Lymph Node Status
• Lymph node metastases are not a component of FIGO staging;
however, lymph node involvement is known to have an adverse
effect on survival.1

Learning point: Confirmation of the extent of nodal disease is

important as it may alter patient management.
CT and MR • Sensitivity 55.5%–57.5%2
Imaging • Specificity 92.3%–93.3%2

• Sensitivity 74.7%1
FDG PET • Specificity 97.6%1

• FDG PET/CT is therefore recommended for assessment of locally

advanced cervical cancer for stages greater than IB1, where there
is a higher pretreatment risk for lymph node involvement.3-5
1 Herrera and Prior (2013), 2Choi et al (2010), 3 NCCN (2015), 4RCR Recommendations (2014), 5SIGN guidelines (2008)
 Nodal Involvement
• Currently, nodal assessment at imaging relies on size and morphologic
criteria.
• In locally advanced tumors, FDG PET/CT is useful in identifying metastatic
disease, which can substantially alter patient management.

Size criteria
Node morphology
• >10 mm short
axis • Irregular
• >8 mm short contour
axis for round • Heterogeneous
T2 Ax
nodes T2 signal
intensity
*
T2 Ax
• Necrosis
Left pelvic lymph node
• Signal intensity (arrow) has an irregular
similar to that of posterior contour and has
primary tumor similar signal intensity to that
of the primary tumor (*).

FDG PET/CT Ax
MR and PET/CT images demonstrate a large necrotic right pelvic lymph node (pink arrow) and a
homogeneous rounded intermediate-signal-intensity left-sided node (blue arrow). Both show
increased tracer uptake at FDG PET/CT. RCR Recommendations (2014)
 Early Stage

Stage IA1 Stage IA2 Stage IB1

Recommended Hysterectomy and Hysterectomy and

Hysterectomy pelvic pelvic
treatment lymphadenectomy lymphadenectomy

Cone biopsy or Radical

Fertility-sparing large loop excision Radical trachelectomy* and
option of transformation trachelectomy pelvic
zone lymphadenectomy

*Only offered if the tumor maximal diameter is less than 2 cm1

Late Stage: IB2–IVA
- Parametrial invasion substantially increases the risk for lymph node involvement and
distal spread.
- A combination of chemotherapy and radiotherapy should be used.
- Radiotherapy includes:
- External beam radiotherapy (conformal or intensity modulated)
- Internal brachytherapy
1SIGN guidelines (2008)
Posttreatment Imaging Appearances
After extended cone biopsy
Large cone-shaped defect in the cervix is seen
on sagittal (Fig 1) and coronal (Fig 2) T2-
weighted images. The tumor was completely
excised with good margins and confirmed to
be stage IA1. Note some postbiopsy
irregularity (arrows), which is frequently seen
if the biopsy was recent.
Fig 1 Fig 2

Trachelectomy
This fertility-sparing procedure involves
excision of the cervix as well as
surrounding parametrial tissues and local
lymph nodes, with formation of a
uterovaginal anastomosis.

Note the intermediate-signal-intensity

cervical tumor on the initial study (arrow)
Initial study After trachelectomy and the appearance after trachelectomy.
 Follow-up
• In a study of 993 patients with FIGO stage IB disease, reviewed after primary
surgery or chemotherapy, 13% developed recurrent disease.1 In another study,
70% of recurrences occurred within the 1st year after treatment. 2

• Recurrent disease may not become symptomatic until a late stage, and cervical
cytologic sampling has not proven effective in detecting recurrence.

• Contrast-enhanced CT, FDG PET/CT, or MR imaging are more accurate in detection

of recurrent disease than examination alone.
– MR imaging or contrast-enhanced CT should be considered initially to assess
suspected clinical recurrence.
– FDG PET/CT should be performed prior to pelvic exenteration.

Patients treated with surgery Patients treated with radiotherapy

• MR imaging at 6, 12, and 24 • MR imaging at 3, 12, and 24

months following surgery.3 months.3
• FDG PET/CT at 3 months to assess
metabolic response, particularly if
MR findings are equivocal.4
1SIGN guidelines (2008), 2Babar et al (2007), 3LCA Gynaecological Cancer Clinical Guidelines (2014), 4Schwarz et al (2007)
 Recurrent Disease

*
*

T2 Sag T2 Sag T2 Sag T2 Ax

An intermediate-T2 The patient completed a

Posttreatment Two years later, the
Initial Study

signal-intensity mass is
demonstrated within
the cervix (*). The
posterior margin of the
mass abuts the sigmoid
colon.
Follow-up
course of patient reported clear
chemoradiotherapy, and vaginal discharge. Pelvic
a repeat MR image T2 MR image
demonstrates a demonstrates a large
substantial response recurrent intermediate-
with no definite residual signal-intensity mass (*)
tumor visible. centered on the cervix,
with involvement of the
posterior bladder wall
and evidence of a
vesicovaginal fistula
(arrow).
 Management of Recurrent Disease
• The reported 5-year survival rates for patients with recurrent
cervical cancer are between 3.2% and 13%1.
• Therapeutic options are:
Pelvic exenteration
Chemotherapy Palliation
surgery
• This is the only • Cisplatin is the standard • If surgery or
potentially curative agent used, despite a chemotherapy are
option in women with poor response rate.1 considered
relapsed disease • Addition of paclitaxel inappropriate.
confined to the central shows a significantly • If the patient declines
pelvis. better response rate further management.
• FDG PET/CT is advisable and disease-free
prior to surgery to interval.2
exclude any distant • Clinical trials
metastases and avoid
futile surgery.1

1Lai (2004) 2Peiretti et al (2012)

 Case 1
• 26-year-old woman
• Routine Papanicolaou test positive
(high-grade dyskaryosis). 26mm

• Histologic findings from

colposcopy demonstrate poorly
differentiated squamous cell
carcinoma.
T2 Sag
T2 Ax
Results from CT of the thorax, abdomen, and
pelvis did not show evidence of metastatic
disease.
Staging pelvic MR imaging was performed.
…What is the local-regional stage? DWI (b = 1000) ADC map

A T2-weighted intermediate-signal-intensity tumor is seen along the posterior lip of

the cervix that demonstrates restricted diffusion (arrows), measuring 26 mm in
maximal length. There is preservation of the T2 low-signal-intensity cervical stromal
ring. There is no vaginal involvement.
… Pelvic MR imaging appearances are in keeping with stage IB1.
The patient was treated with radical hysterectomy and pelvic lymph node dissection.
This confirmed a poorly differentiated squamous cell tumor confined to the cervix
and without parametrial invasion.
• 42-year-old woman Case 2
• The patient opted for an alternative treatment, and a repeat
• Staging CT did not
demonstrate any MR study was obtained The patient
• after thenwhen
6 months optedshe returned
for medical care. for chemoradiotherapy.
extrapelvic disease
Follow-up MR and After chemoradiotherapy MR imaging:
Pretreatment MR imaging: There has been substantial
restaging CT:
T2 Sag
What interval
is the locoregional stage
T2 enlargement of the
for the
Sag
T2 Sag
The pretreatment
findings MRcervical
MR image
at pretreatment imaging?tumor (*) with
demonstrates a large cervicalextension
tumor to the lower
There has been
* (*) with extension into the third of the vagina.
myometrium Left-sided parametrial interval
* and upper vagina.
reduction in the
There is definite parametrial invasion is once again
noted. size of the
invasion demonstrated on the axial
cervical tumor;
image (arrow) with sparing atCTthe image
8– demonstrates
T2 Ax Obl
new left-sided however, a large
T2 Ax 9 o’clock position.
(arrow)residual mass
T2 Ax
There is no involvement of the hydronephrosis
lower
and multiple para-aorticremains. Note
third of the vagina and no evidence
the left JJ stent
of pelvic sidewall spread. (PA) lymph nodes
* (indicated). within the
… Pelvic MR image appearances are
CECT Ax urinary bladder
in keeping with stage IIB.
…Pelvic MR image (arrow).
appearances are in keeping
with stage IIIB with
positive PA lymph nodes.
 Case 3
• 54-year-old woman presented to the
emergency room acutely short of
breath and was found to have multiple *
central pulmonary emboli (arrows on
CT pulmonary angiogram). Ax CTPA Sag CECT
• Contrast-enhanced CT performed to
rule out occult malignancy.

This demonstrates a large cervical

mass lesion (*). No enlarged # *
*
abdominopelvic lymph nodes were
identified.
Staging
A stagingMRMRimaging:
study was the cervical T2 Sag T2 Ax
mass (*) extends
performed. Whatinto thestage
is the uterus with
restricted diffusion.
according There is no
to MR imaging?
obvious parametrial invasion, but
# *
there is abnormal tissue related to the # *
right ovary (#) that is of similar signal
intensity to the primary tumor and
also demonstrates restricted diffusion.
DWI (b = 1000) ADC map
FIGO staging - stage IIA with ovarian
involvement.
 Case 3 (continued)
In view of the local disease
extent, FDG PET/CT was
performed…

MIP PET

Fused Ax PET/CT

FDG PET/CT images show that

the cervical mass (*) and right
ovarian lesion (#) are
metabolically active. In
addition, there are multiple
Fused Ax PET/CT intensely avid pelvic and
retroperitoneal lymph nodes
that were below size criteria.

The patient completed a

# * course of extended field
radiotherapy and
brachytherapy and had a
Fused Ax PET/CT
complete response.
 Summary
• The FIGO (2009) staging system provides a clinical basis
to guide patient management in cervical cancer.
• MR imaging provides useful staging information that
cannot be determined from clinical examination alone.
• FDG PET/CT plays a role in locally advanced disease and
has good sensitivity and high specificity for detecting
lymph node metastases that are indicative of a poorer
prognosis.
• Regular posttreatment follow-up imaging is important
to ensure that recurrent disease is identified early and
further management options can be considered
promptly.
 Suggested Readings
1. Freeman SJ, Aly AM, Kataoka MY, Addley HC, Reinhold C, Sala E. The revised FIGO system
for uterine malignancies: implications for MR imaging. RadioGraphics 2012; 32(6):1805-
1827.
2. Herrera FG, Prior JO. The role of PET/CT in cervical cancer. Front Oncol 2013; Feb 26;3:34.
3. Sahdev A. Cervical tumors. Semin Ultrasound CT MR 2010; 31(5): 399-413.
4. Sala E, Rockall AG, Freeman SJ, Mitchell DG, Reinhold C. The added role of MR imaging in
treatment stratification of patients with gynecologic malignancies: what the radiologist
needs to know. Radiology 2013; 266(3):717-740.
5. Testa AC, Di Legge A, De Blasis I, et al. Imaging techniques for the evaluation of cervical
cancer. Best Pract Res Clin Obstet Gynaecol 2014; 28(5): 741-768.

Acknowledgments
The authors thank Cancer Research UK for their permission to use the line diagrams in this presentation.

The Papanicolaou smear histopathologic slides (slide 6) were kindly contributed by Roberto Dina, MD,
consultant histopathologist, Imperial College Healthcare NHS Trust, London, England.
•
References
American College of Radiology Appropriateness Criteria (http://www.guideline.gov/content.aspx?id=43887).
Accessed November 12, 2015.
• Babar S, Rockall A, Goode A, Shepherd J, Reznek R. Magnetic resonance imaging appearances of recurrent
cervical carcinoma. Int J Gynaecol Cancer 2007; 17(3): 637–645.
• Barwick TD, Taylor A, Rockall A. Functional imaging to predict tumor response in locally advanced cervical cancer.
Curr Oncol Rep. 2013 Dec;15(6):549-558.
• Cancer Research UK. Lifetime risk of cervical cancer. www.cancerresearchuk.org/cancer-
info/cancerstats/incidence/risk. Accessed May 13, 2015.
• Cancer Research UK. Cervical cancer stages. www.cancerresearchuk.org/about-cancer/type/cervical-
cancer/treatment/cervical-cancer-stages. Accessed May 13, 2015.
• Cervical Cancer 2015. www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-risk-factors.
Accessed May 13, 2015.
• Choi HJ, Woong J, Seung KM, Yeol K. Diagnostic performance of computer tomography, magnetic resonance
imaging, and positron emission tomography or positron emission tomography/computer tomography for
detection of metastatic lymph nodes in patients with cervical cancer: meta-analysis. Cancer Science 2010; 101;
6:1471–1479.
• Final Recommendation Statement, Cervical Cancer: Screening March 2012.
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-
cancer-screening. Accessed May 13, 2015.
• Grigsby PW, Siegel BA, Dehdashti F. Lymph node staging by positron emission tomography in patients with
carcinoma of the cervix. J. Clin. Oncol 2001;19:3745–3749.
• Guidelines for cervical cancer. National Comprehensive Cancer Network (NCCN).
http://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf. Accessed May 13, 2015.
• Herrera FG, Prior JO. The role of PET/CT in cervical cancer. Front Oncol 2013; Feb 26;3:34.
• Lai C. Management of recurrent cervical cancer. Chang Gung Med J. 2004 Oct;27(10):711-717.
 References
• Lagasse LD, Creasman WT, Shingleton HM, Ford JH, Blessing JA. Results and complications of operative staging in
cervical cancer: experience of the Gynecologic Oncology Group. Gynecol. Oncol 1980; 9: 90–98.
• LCA Gynaecological Cancer Guidelines, July 2014. London Cancer Alliance.
• NHS Cervical Screening Programme Annual Review 2012.
http://www.cancerscreening.nhs.uk/cervical/publications/cervical-annual-review-2012.pdf. Accessed May 13,
2015.
• Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix and endometrium. Int J Gynaecol Obstet 2010;
Feb; 108(2):176.
• Peiretti M, Zapardiel I, Zanagnolo V, Landoni F, Morrow CP, Maggioni A. Management of recurrent cervical cancer:
a review of the literature. Surgical Oncology 2012; e1-e8.
• Rockall A, Sohaib A, Sala E. Carcinoma of the cervix, vagina and vulva. In: Nicholson T (ed). Recommendations for
cross-sectional imaging in cancer management, 2nd ed. London: The Royal College of Radiologists, 2014. Accessed
May 13, 2015.
• Royal College of Radiologists. Recommendations for cross-sectional imaging in cancer management, second
edition, lymph nodes, 2014. https://www.rcr.ac.uk/sites/default/files/publication/BFCR(14)2_4_Lymph.pdf.
Accessed March 8, 2016.
• Schwarz JK, Siegel BA, Dehdashti F, Grigsby PW. Association of posttherapy positron emission tomography with
tumor response and survival in cervical carcinoma. JAMA 2007;298:2289–2295.
• SIGN. Management of cervical cancer: a national clinical guideline. SIGN Guideline 99, January 2008.
• WHO GLOBOCAN Cervical Cancer Estimated Incidence, Mortality and Prevalence Worldwide in 2012.
http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp. Accessed May 13, 2015.
• World Health Organization. Immunization, vaccines and biologicals. www.who.int/immunization/topics/hpv/en.
Accessed March 8, 2016.