Imaging in Uterine and Cervical cancers

1. Carcinoma Uterus and Cervix
Dr. Yash Kumar Achantani
OSR

2. Endometrial Carcinoma

3. Endometrial carcinoma is the fourth most common female cancer and
the most common malignancy of the female reproductive tract.
Adenocarcinomas constitute 90% of endometrial cancers.
The remaining histologic types of endometrial carcinoma include
adenocarcinoma with squamous differentiation, adenosquamous
carcinoma, clear cell carcinoma, and papillary serous carcinoma.
The prognosis of women with endometrial carcinoma depends on a
number of factors, including stage, depth of myometrial invasion,
lymphovascular invasion, nodal status, and histologic grade

4. MRI Protocol
Patients are usually instructed to fast for 4–6 hours before the MRI
examination to limit artefact due to small-bowel peristalsis.
An antiperistaltic agent (hyoscine butyl bromide or glucagons) may be
administered to the patient before imaging as an alternative to fasting.
Patients are imaged in the supine position using a pelvic surface array
multichannel coil.
The basic MRI protocol includes
Axial T1-weighted spin-echo images with a large field of view to
evaluate the entire pelvis and upper abdomen for lymphadenopathy
and bone marrow changes.

5. T2-weighted fast spin-echo (FSE) images in the axial and sagittal
planes for the evaluation of the primary tumor.
Dynamic contrast enhanced T1-weighted images (small field of
view) in the sagittal and axial oblique planes to evaluate the extent
of myometrial and cervical involvement.
High-resolution T2-weighted FSE sequences perpendicular to the
long axis of the uterine corpus are favored for the evaluation of
primary tumor and myometrial invasion.
Sagittal and oblique axial multiphase IV contrast–enhanced 3D T1-
weighted fat-saturated sequences through the uterine corpus are
routinely used to improve staging accuracy.

6. The early enhancement phases (0 and 1 minute) allow identification
of the subendometrial zone, which enhances earlier than the bulk of
the myometrium and corresponds to the inner junctional zone.
Identification of this zone is especially important in detecting early
myometrial invasion because the junctional zone often becomes
indistinct in postmenopausal Women.
The equilibrium phase (2–3 minutes after injection) allows better
evaluation of deep myometrial invasion , whereas the delayed phase
(4–5 minutes) enables better evaluation of cervical stroma invasion.

8. MR Imaging Appearances
Endometrial cancer is isointense relative to hypointense normal
endometrium on unenhanced T1-weighted images and most
commonly shows heterogeneous intermediate signal intensity relative
to hyperintense normal endometrium on T2- weighted images.
Relative to normal myometrium, the tumor is mildly hyperintense on
T2-weighted images.
Endometrial cancer exhibits impeded diffusion compared with
surrounding tissue, manifesting with high signal intensity on
diffusion-weighted MR images and low signal intensity on ADC
maps, which provide a quantitative measure of water diffusion.

9. FIGO staging

10. Stage IA endometrial cancer in a 72-year-old woman.
(a) Axial oblique T2-weighted MR image demonstrates a hypointense tumor (*) that
appears to be confined to the endometrium. The junctional zone is relatively poorly
defined (arrow). A left ovarian fibroma (F) is incidentally noted.

11. (b) Sagittal T2-weighted MR image shows the hypointense tumor (*) in the endometrial
cavity. The junctional zone is poorly defined.
(c) On an axial oblique dynamic contrast-enhanced MR image obtained 4 minutes after
contrast medium injection, the endometrial tumor (*) is hypointense relative to the
hyperintense enhancing myometrium, with invasion of the inner layer of the myometrium
(arrows).

12. Stage IB endometrial cancer in a 53- year-old woman.
(a) Axial oblique T2-weighted MR image demonstrates a tumor (*) with invasion of the
myometrium. However, the depth of invasion is difficult to determine due to poor tumor-
to-myometrium contrast (arrow).

13. (b) Sagittal T2-weighted MR image shows a large iso- to hypointense endometrial tumor
(*) with poor tumor-to-myometrium contrast (arrow).
(c) Axial oblique dynamic contrast-enhanced MR image obtained 4 minutes after
contrast medium injection shows tumor enhancement (*) with invasion of the outer half
of the myometrium (arrow).

14. Stage II endometrial cancer in a 64-year-old woman. (a) Sagittal T2-weighted MR image
shows distention of the endometrial cavity by a tumor (*) that extends into the cervix
(arrow). (b) Sagittal dynamic contrast-enhanced MR image obtained 2 minutes after
contrast medium injection shows extension of the endometrial tumor (*) into the cervix.
Invasion of the cervical stroma is present posteriorly (arrow) and is better appreciated
than on the T2-weighted image.

15. Stage IIIA endometrial cancer in a 65-year-old woman.
(a) Sagittal T2-weighted MR image shows a large endometrial tumor (*). The depth of
myometrial invasion is difficult to determine owing to poor tumor-to-myometrium
contrast (arrow). In addition, the uterus is distorted by two leiomyomas (L), whose
presence is a commonly reported pitfall in staging.
(b) On a sagittal diffusion-weighted MR image (b = 500 sec/mm2), the tumor (*) has high
signal intensity with deep myometrial invasion (arrow).

16. (c) On a sagittal dynamic contrast-enhanced MR image obtained 2 minutes after
contrast medium injection, the tumor (*) is hypointense relative to the hyperenhancing
myometrium, with deep myometrial invasion (arrow). L = leiomyoma.
(d) Axial oblique T2-weighted MR image shows extension of the endometrial tumor (*)
into both fallopian tubes (arrows). The tumor is isointense relative to the adjacent
myometrium. L = leiomyoma.

17. (e) Axial oblique dynamic contrast-enhanced MR image obtained 4 minutes after
contrast medium injection shows enhancement of the tumor extension into the fallopian
tubes (arrows). The primary (endothelial) tumor (*) enhances less than the adjacent
myometrium.
(f) Axial oblique diffusion-weighted MR image (b = 800 sec/mm2) shows hyperintense
tumor extension into the left fallopian tube and adnexa (arrowhead). The primary tumor
(*) is bright relative to the adjacent myometrium. O = right ovary.

18. Stage IIIB endometrial cancer in an 80-year-old woman with chronic renal failure. (a)
Sagittal T2-weighted MR image shows a large, isointense endometrial tumor (*) with
extension into the upper aspect of the vagina (arrow). (b) On a sagittal diffusion-
weighted MR image (b = 500 sec/mm2), the tumor (*) is hyperintense with invasion of the
upper aspect of the vagina (arrow).

19. (c) On a sagittal ADC map, the tumor (*) is hypointense due to impeded diffusion.
Posterior vaginal invasion (arrow) is also noted. Although intravenous contrast medium
was not administered in this case due to renal impairment, diffusion-weighted MR
imaging was adequate for disease staging.

20. Stage IIIC1 endometrial cancer in a 66-year-old woman. (a) Axial T2-weighted MR
image shows a bulky endometrial tumor (*) with poor tumor-to-myometrium contrast
(arrow). An enlarged right external iliac lymph node (N) is also present. (b) On an axial
dynamic contrast-enhanced MR image obtained 4 minutes after contrast medium
injection, the node (N) demonstrates avid enhancement.

21. (c) On an axial diffusion-weighted MR
image (b = 800 sec/mm2), the node (N)
demonstrates high signal intensity.

22. Stage IIIC2 endometrial cancer in a 74-year-old woman. (a) Axial FIESTA (axial fast
imaging employing steady-state acquisition image shows a large nodal mass (N)
surrounding the inferior vena cava. (b) Axial dynamic contrast-enhanced MR image
obtained 2 minutes after contrast medium injection demonstrates significant
enhancement within the nodal mass (N).

23. Stage IVA endometrial cancer in a 72-year-old woman. (a) Sagittal T2-weighted MR
image shows a large endometrial tumor (*) with invasion of the sigmoid colon as
evidenced by loss of the normal fat plane between the tumor and colon (arrow). (b) Axial
dynamic contrast-enhanced MR image obtained 2 minutes after contrast medium
injection shows invasion of the sigmoid colon (arrows) by the enhancing tumor, a finding
that was confirmed at histopathologic analysis.

24. Uterine Sarcomas

25. Uterine sarcomas are a rare heterogeneous group of tumors of
mesenchymal origin, accounting for approximately 8% of uterine
malignancies.
These malignancies may originate from the
1. Smooth muscle in myometrium (leiomyosarcoma),
2. Endometrial stroma (endometrial stromal sarcoma [ESS] and
undifferentiated endometrial sarcoma [UES])
3. Or both (adenosarcoma)
Leiomyosarcoma is the most common histological variant of uterine
sarcomas and is considered an aggressive tumor associated with poor
prognosis, ESS is relatively indolent and UES has a very aggressive
behavior and poor prognosis, Adenosarcomas are rare mixed tumors with
relatively low malignant potential and slow-growth pattern.

26. Leiomyosarcoma
On MRI, leiomyosarcomas commonly manifest as large infiltrating
myometrial mass of heterogeneous hypointensity on T1-weighted
images, with irregular and ill-defined margins.
On T2-weighted images, they usually show intermediate-to-high
signal intensity, with central hyperintensity indicative of extensive
necrosis.
Hemorrhage is common, and foci of calcifications may be present.
Post contrast study shows early heterogeneous enhancement.

27. Distinction from degenerating leiomyomas is difficult sometimes but
the presence of irregular margins, necrosis, and rapid growth are most
suggestive features of malignancy.
DWI may limit misdiagnosis of uterine sarcomas as benign
leiomyomas, and should be the first criterion to help radiologists
characterize a unique uterine tumor.
ADC value- Malignant tumor < Leiomyoma < Myometrium

29. Leiomyosarcoma in a 52-year-old woman. Sagittal T1-weighted image (a), T2-weighted
image (b), show marked uterine enlargement due to a heterogeneous myometrial
tumor. The lesion demonstrates central hyperintensity on T1-weighted image (a)
attributable to extensive hemorrhage, a central area of high signal on T2-weighted
image (b) representing cystic necrosis. Endometrial cavity is pushed anteriorly by the tumor

30. Gadolinium-enhanced T1- weighted image with fat suppression show early
intense enhancement in solid areas of the tumor , as compared with normal
myometrium. Irregular central zones of low signal intensity suggest extensive
tumor necrosis.

31. Leiomyosarcoma in a 54-year-old
woman. Axial DWI on b1000 (a)
demonstrates a hyperintense mass.
The mass appears hypointense on
ADC map (b), with the normal
myometrium seen as an area of
hyperintensity (arrows).

32. Endometrial stromal sarcoma
ESS more frequently appears as polypoid endometrial mass, with low
signal on T1-weighted images and heterogeneously increased high
T2 signal.
After contrast administration, enhancement is moderate and
commonly heterogeneous.
It typically shows myometrial involvement, either sharply demarcated
or in a more diffuse and destructive manner (the latter is far more
common with UES).
Having a tendency for lymphatic and vascular invasion, it shows worm-
like extension bands of low signal intensity within areas of myometrial
involvement on T2-weighted images (“bag of worms”), corresponding
to preserved bundles of myometrium.

33. Endometrial stromal sarcoma in an 82-year-old woman. Sagittal T2-weighted image (a)
and sagital T1-weighted image with fat suppression, after contrast administration (b)
show a very large lesion centered at cervix region, infiltrating uterine body superiorly and
superior half of the vagina inferiorly. The tumor shows multiple foci of hyperintense
signal on T2-weighted image due to extensive necrosis, as well as moderate and mildly
heterogeneous contrast enhancement.

34. Sagittal (a) and axial (b) T2-weighted images show an endometrial stromal sarcoma in a
64-year-old woman. The lesion shows heterogeneous signal with extensive nodular
invasion into the myometrium and marked marginal irregularity and nodularity
(attributable to tumor extension along vessels and lymphatics).

35. Compared to endometrial carcinoma, ESS usually shows larger size,
more contrast enhancement, irregular margin, nodular extension into the
myometrium, and marginal nodularity due to tumor extension along
vessels and lymphatics.
Rarely, ESS can appear as a myometrial mass mimicking intramural
leiomyoma with cystic degeneration.
In these cases, intramyometrial ESS can be differentiated based on their
rapid and invasive growth, lower degree of enhancement, lymphatic and
vascular invasion, higher incidence of necrosis, peripheral hypointense
rim on T2-weighted images, and enhanced marginal irregularity.

36. Undifferentiated endometrial
sarcoma
UES typically appears as a large polypoid mass in an expanded
endometrial cavity.
Shows heterogeneous signal intensity on both T1- and T2-weighted
images due to the high frequency of hemorrhage and necrosis within
the tumor.
Infiltrates the myometrium in a more destructive and extensive manner
than ESS, due to marked vascular and lymphatic invasion.
Contrast enhancement is generally heterogeneous, and iso- or
hyperintense when compared with normal myometrium, allowing
differentiation from endometrial carcinoma.

37. Hyperenhancement, the presence of irregular margins, multiple
marginal tumor nodules, intramyometrial worm-like extension, and
multiple nodular mass formation, are more frequently seen in UES than
ESS.

38. Undifferentiated endometrial sarcoma in a 36-year-old woman. Sagittal T2- weighted
image (a) and T1-weighted image after gadolinium administration (b) show marked
uterine enlargement due to a large polypoid heterogeneous tumor, with some nodular
marginality (arrow). The lesion shows intense and heterogeneous contrast uptake
(uncommon for endometrial carcinoma), with a hypointense area (asterisk) suggestive of
necrosis.

39. Adenosarcoma
Adenosarcoma is typically seen as a large well-demarcated polypoid
mass arising within the endometrial cavity and protruding through the
cervical os, causing marked enlargement of the uterus with a thin
myometrium.
This polypoid mass usually shows a multiseptated cystic appearance,
with multiple heterogeneous solid components that fill the endometrial
cavity, and may mimic the appearance of gestational trophoblastic
disease.

40. On T2-weighted images, small hyperintense foci may be seen
scattered within the mass, representing glandular epithelial
components or necrosis.
After administration of gadolinium, there is heterogeneous
enhancement, with solid components of the mass showing
enhancement similar to that of the myometrium.

41. Adenosarcoma in a 76-year-old woman. Sagittal T2-weighted image (a) and oblique
coronal T1-weighted image with fat suppression, after contrast administration (b) show a
very large polypoid mass with heterogeneous high signal intensity arising within the
endometrial cavity and protruding into the cervical os (arrow), causing marked
enlargement of the uterus. The tumor demonstrates a multicystic appearance, with solid
areas demonstrating enhancement similar to myometrium.

44. Ca Cervix

45. Magnetic Resonance Imaging (MRI) is the preferred imaging modality
because of its ability to assess soft tissue in detail, permitting there by
better identification of stromal and parametrial invasion.
MRI tells us the exact volume, shape, and direction of the primary
lesion, local extent of the disease, and nodal status accurately, which
helps the clinician in treatment planning.
Tumor behaviour to chemoradiation is also better evaluated with MRI.
FIGO staging system is used to stage cervical cancer on MRI.

46. MRI protocol
Patient is instructed to fast for 4 h before examination to reduce small
bowel peristalsis artifacts.
Axial T1W images are obtained from the kidney to perineum, This is
optimal for evaluation of the pelvis and lower abdomen for
lymphadenopathy and hydronephrosis.
High-resolution T2W images of pelvis are acquired in axial, sagittal,
and coronal planes for the evaluation of primary tumor spread.
It allows the evaluation of tumor extension to the body of uterus,
vagina, parametrium, rectal wall, and urinary bladder wall.

47. Fat-suppressed sequences can be useful for the evaluation of
parametrial involvement.
Post-contrast images are obtained in axial, coronal, and sagittal
planes, and are useful to identify bladder and rectal wall invasion,
fistulas, and in the detection of recurrent tumor.
Dynamic images obtained 30-60 seconds after gadolinium injection
are helpful for the assessment of smaller tumors which are not visible
on T2W images as they show increased early contrast enhancement
relative to the cervical stroma.

48. Normal cervix
The cervix is divided into supravaginal and vaginal portions by
fornices; the supravaginal portion is lined by columnar cells and the
vaginal portion by squamous cells.
MRI anatomy of the cervix is best delineated on T2W image as it
outlines the four major zones of cervix.
From center to periphery
 High signal intensity- endocervical canal.
 Intermediate signal intensity - plicae palmatae.
 Low signal intensity - fibrous stroma.
 Intermediate signal intensity - outer smooth muscle.

49. Normal cervix.
The four major zones are very well depicted on T2W images.
High signal intensity endocervical canal- white arrow,
Intermediate signal intensity plicae palmatae- black arrow,
Low signal intensity fibrous stroma- white arrow-head,
Intermediate signal intensity outer smooth muscle- black arrow-head

50. MRI findings
Tumors generally originate from the squamocolumnar junction, and
this is why, exophytic masses are common in younger females whereas
endocervical masses are common in older females.
T2W images play a crucial role in identification of the primary tumor
and assessment of its extent.
These masses show intermediate to high signal on T2W images.
Early tumor can be identified on dynamic contrast-enhanced images.
Diffusion-weighted images have some role in making the diagnosis.
Tumor tissue has significantly low apparent diffusion coefficient
value as compared to non-tumor tissue.

51. FIGO staging for carcinoma of cervix

52. Stage I
Carcinoma is strictly confined to cervix (extension to the corpus would
be disregarded)
IA Invasive carcinoma diagnosed by microscopy with the deepest
invasion ≤5 mm and the largest extension ≥7 mm (Not visible on MRI)
IA1 Stromal invasion of ≤3 mm in depth and extension of ≤7 mm
IA2 Stromal invasion between 3 and 5 mm and extension of not more
than 7 mm
IB Clinically visible lesions limited to cervix or preclinical cancer
greater than stage IA (Peripheral T2 hypointense stroma is
maintained)
IB1 Clinically visible lesion ≤4 cm in the greatest dimension
IB2 Clinically visible lesion >4 cm in the greatest dimension

53. A 50-year-old female with squamous cell carcinoma of cervix (stage IB1). Axial
and sagittal T2W images reveal hyperintense mass confined to cervix (white
arrows in A and B)

54. A 39-year-old female with carcinoma cervix (stage IB2).
Polypoidal cervical mass is seen extending in endometrial cavity (black arrow in
B). Preserved peripheral hypointense stromal ring (white arrow in A) is well seen
on T2W sequence

55. Stage II
Carcinoma invades beyond the uterus but not to the pelvic wall or to
the lower-third of the vagina.
IIA Without parametrial invasion
IIA1 Clinically visible lesion ≤4 cm in the greatest dimension
IIA2 Clinically visible lesion >4 cm in the greatest dimension
IIB With obvious parametrial invasion.
Involvement of the upper two-third of the vagina is seen as segmental
loss of the normally seen T2-hypointense vaginal wall.
In stage IIB, the tumor disrupts the normally seen hypointense
peripheral stroma on T2W images and extends in the parametrium

56. A 49-year-old female with adenocarcinoma of uterine cervix (stage IIA). Sagittal and
axial T2W images show ill-defined hyperintense mass in the cervix (white arrow in
A) and extending into upper third of the vagina along the the anterior and posterior
walls (black arrows in A and B)

57. Squamous cell carcinoma in a 40-year-old female (stage IIB).
Mass in cervix causing disruption of outer T2-hypointense stromal ring (white arrow
in A) with extension into parametrium and abutting the parametrial vessels (black
arrow in B)

58. Stage III
Tumor extends to the pelvic wall and/or involves lower-third of the
vagina and/or causes hydronephrosis or non-functioning kidney.
IIIA Tumor involves lower-third of the vagina with no extension to the
pelvic wall
IIIB Extension to the pelvic wall and/or hydronephrosis or non-
functioning kidney , infiltrates the obturator internus,
pyriformis, and levator ani muscles, encases the iliac vessels,
and destroys the pelvic bones

59. A 65-year-old
female with poorly
differentiated
squamous
cell carcinoma
(stage III A).
Hyperintense mass
infiltrating the
vaginal fornices
and extending
caudally to lower
third of the vagina
along the anterior
and posterior
vaginal walls (white
arrow).
Collection in
endometrial cavity
is seen as
hyperintensity
(black arrow)

60. Cancer of uterine cervix in a 65-year-old female (stage IIIB).
Axial and coronal T2W images show intermediate signal intensity cervical tumor
with parametrial invasion and involvement of distal ureters bilaterally (white
arrows in A and B)

61. Stage IV
Carcinoma has extended beyond the true pelvis or has involved (biopsy
proven) the mucosa of bladder or rectum. A bulbous edema does not
permit a case to be allotted to stage IV.
IVA Spread of cancer to adjacent organs
IVB Spread to distant organs
Bladder and rectal invasion is suggested by the presence of focal or diff
use disruption of the normally seen T2-low signal intensity wall,
irregular or nodular wall, and presence of an intraluminal mass.
Accuracy of MRI for bladder and rectal wall invasion increases with
contrast-enhanced images as compared to T2W images

62. Sagittal T2W image shows a large mass arising
from the cervix and involving the uterine
myometrium (white arrow in A) with invasion in
the rectum demonstrated as loss of T2-low
signal intensity rectal wall (black arrow in A). Also
note the infiltration in posterior bladder wall (white
arrow-head in A), better seen in the second
patient on T2 and post-gadolinium image (white
arrow heads in B and C)
Squamous cell
carcinoma in two
different
patients (stage
IVA).

63. Bulbous edema sign, which is hyperintense thickening of the bladder
mucosa on T2W images, is an indirect sign of invasion and should be
evaluated with care for associated tumor nodule.
Recurrent mass infiltrating left posterolateral bladder wall with hyperintense
thickening of the bladder mucosa on T2W images, typically called bulbous edema
sign (white arrows in A and B). Note the infiltration of mesorectal fascia and
extension in the mesorectum (black arrow in A)

64. Squamous cell
carcinoma
(stage IVB).
Sagittal (A), axial (B), and coronal (C) T2W
images reveal cervical mass infiltrating the
corpus and upper vagina and adherent to
the bladder and rectal wall (white arrows in
A and B). Nodular peritoneal deposits are
demonstrated on axial and coronal images
(black arrows in B and C). Note the
enlarged lymph node along left internal
iliac vessels (white arrow-head in B)

66. Lymph Node Involvement
Lymph node metastasis initially occurs to pelvic nodes, which then
subsequently spreads to retroperitoneal and supraclavicular nodes.
Although pelvic lymph node metastasis is not considered in FIGO
staging, it is one of the important prognostic factors and presence of a
positive node indicates poor prognosis in each stage.
Presence of metastatic para-aortic or inguinal node is classified as stage
IVB disease.
A lymph node having transverse diameter >10 mm is abnormal.
Morphological criteria that indicate pathological lymph node are border
irregularity, heterogeneity of signal on T2W images, and presence of
necrosis.

67. Post-treatment Appearance
After surgery, one can observe the normal lower two-third of the
vagina, seen as low signal intensity muscular wall on T2W images.
Sometimes, a fibrotic scar is present.
Post-radiation, the cervix loses its normal zonal anatomy and exhibits
homogeneously low signal intensity stroma on T2W images which is a
reliable indicator of tumor-free cervix.

68. Hyperintense mass in the cervix and upper vagina on pre-treatment. T2W sagittal
image (white arrow in A) in a 42-year-old female.
Homogeneous T2-hypontense stroma in the same patient treated with radiotherapy
(white arrow in B)