Anatomy

The cervix is the lower part of the uterus, providing a connection between the uterine cavity and the vaginal canal. It communicates with the uterine cavity via the internal os and with the vaginal canal via the external os. The cervix is composed of the portio, which protrudes into the cranial aspect of the vaginal vault and the supravaginal portion. The endocervical canal has a length of approximately 3 cm.

Arterial supply of the cervix is from a branch of the uterine artery and venous drainage is to the uterine vein, then to the internal iliac vein. Lymphatic drainage is to the iliac and sacral nodes.

The external os of the cervix is covered by non-keratizing, stratified squamous epithelium and the endocervical canal is lined by simple columnar epithelium. Squamous cell carcinoma arises from the squamo-columnar junction following squamous metaplasia of the columnar epithelium, whereas adenocarcinoma arises from the endocervical canal. 

Fig. 1: Normal anatomy of the uterus and cervix
References: http://www.jaypeedigital.com

Cervical carcinoma is typically seen in younger women with an age of onset of approximately 45. 

Squamous cell carcinoma is the most common carcinoma of the cervix, accounting for approximately 85% of cases, followed by adenocarcinoma (15%). Rarer histologic subtypes such as adenoid cystic, small cell, adenosquamous carcinoma and lymphoma can also affect the cervix.

The incidence of squamous cell carcinoma of the cervix has seen a decrease in incidence with the introduction of the Papanicolaou smear, however adenocarcinoma has started increasing in relative incidence as it is less easily diagnosed using the cytology obtained at smear.

Prognosis of the disease is based on the stage, size, histologic stage of the primary and the status or regional and distant lymph nodes. The stage of carcinoma is used in determining the further management.

Multiparametric MR Imaging Protocol

• Prior to undergoing MRI evaluation for cervical carcinoma, the patient should be fasting for at least 3 hours and should receive an intravenous anti-peristaltic agent such as glucagon or hyoscine butylbromide to reduce motion artefact and increase image quality. A phased array surface coil is used to increase the Signal-to-Noise Ratio.
• Small field of view (FOV) T2-weighted images in three orthogonal planes should be obtained followed by large FOV T1-weighted images in the axial plane.
• Diffusion weighted imaging of the tumour is standard.
• Optional sequences include dynamic contrast enhanced MRI.

Normal MRI anatomy

T2-weighted imaging is used in the evaluation of the zonal anatomy of the uterus and cervix.
The cervix demonstrates distinct zones on T2W MR Imaging:

1. Central hyperintense mucous
2. Hyperintense endocervical mucosa
3. Hypointense fibrous stroma which is contiguous with the junctional zone of the uterus
4. Outer smooth muscle layer demonstrates intermediate signal 

Fig. 2: T2 weighted sagittal MRI: normal uterine and cervical anatomy. a. endocervical mucus b. fibrous stroma c. muscularis propria d. endometrium e. junctional zone f. myometrium
References: Department of Radiology, University Hospital Waterford

Cervical cancer staging 

Staging of cervical cancer can be based on the FIGO or the AJCC TNM staging systems.

Cervical carcinoma demonstrates lymphatic spread to the parametrial nodes, followed by the obturator and finally the iliac chain nodes. PET/CT is used in the evaluation of lymphatic or distant metastatic disease prior to surgical management.

Cases

Case 1

55 year old patient with invasive squamous cell carcinoma of the cervix. T2-weighted MR imaging demonstrates bilateral parametrial involvement, bilateral pelvic sidewall and groin lymphadenopathy. 

Biopsy: squamous cell carcinoma 

Stage: T2bN1

Fig. 3: T2W axial image shows bilateral parametrial involvement (arrow), resulting in a T2b stage
References: Department of Radiology, University Hospital Waterford

Fig. 4: T2W coronal images of the pelvis show bilateral parametrial involvement (double arrow) and pelvic sidewall adenopathy (arrow).
References: Department of Radiology, University Hospital Waterford

Case 2

A 33 year old patient presented with irregular PV bleeding. Imaging showed a T2 hypointense cervical lesion with bilateral parametrial involvement without extension into the lower third of the vagina. Bilateral pelvic sidewall adenopathy is also noted. 

Biopsy: squamous cell carcinoma. 

StageT2bN1

Fig. 5: T2W sagittal image of the pelvis shows a hypointense mass lesion of the cervix without extension into the lower third of the vagina. No evidence of bladder or bowel wall involvement.
References: Department of Radiology, University Hospital Waterford

Fig. 6: T2 axial image shows bilateral parametrial involvement.
References: Department of Radiology, University Hospital Waterford

Fig. 7: Diffusion weighted imaging demonstrates restricted diffusion within the mass lesion.
References: Department of Radiology, University Hospital Waterford

Case 3

A 51year old patient presented with PV bleeding. Imaging showed bilateral parametrial involvement with a presacral deposit. Both the cervical mass and the presacral deposit demonstrated diffusion restriction. 

Biopsy: Endocervical adenocarcinoma. 

Stage:T2bN1

Fig. 8: T2W sagittal imaging through the pelvis shows a heterogeneous cervical soft tissue mass with bilateral parametrial involvement. A presacral deposit is noted (arrow).
References: Department of Radiology, University Hospital Waterford

Fig. 9: T2W axial imaging of the presacral deposit (arrow)
References: Department of Radiology, University Hospital Waterford

Fig. 10: The cervical mass lesion demonstrates restricted diffusion on diffusion weighted imaging.
References: Department of Radiology, University Hospital Waterford

Case 4

A 53 year old female presenting with intermittent postmenopausal bleeding. Examination revealed a large, bleeding cervical mass. Imaging showed a multilobulated soft tissue mass extending from the cervix into the lower 1/3 of the vagina and to the pelvic sidewall bilaterally. Associated pelvic sidewall lymphadenopathy was also noted. 

Biopsy: Moderately differentiated squamous cell carcinoma. 

Stage: T3bN1

Fig. 11: T2W sagittal image illustrates a multilobulated soft tissue mass of the cervix with preserved fat planes between the urinary bladder and the rectum. The mass extends into the lower 1/3 of the vagina.
References: Department of Radiology, University Hospital Waterford

Fig. 12: T2W axial image shows bilateral parametrial involvement with extension to the pelvic sidewall bilaterally, resulting in a T3b radiologic stage.
References: Department of Radiology, University Hospital Waterford

Case 5

A 43 year old patient with an abnormal examination. MR Imaging showed a T2 hypointense soft tissue mass replacing the cervix with bilateral parametrial involvement. The mass extended into the lower uterine segment, however there was no vaginal extension. A left ureteric obstruction was also noted. 

Biopsy: Poorly differentiates cervical adenocarcinoma or adenosquamous carcinoma.

Stage: T3bN

Fig. 13: T2W sagittal image demonstrating a T2 hypointense cervical mass with extension into the lower uterus. Bilateral parametrial involvement.
References: Department of Radiology, University Hospital Waterford

Fig. 14
References: Department of Radiology, University Hospital Waterford

Fig. 15: T2W axial imaging of the pelvis shows a left sided hydroureter (arrow), resulting from a tumoral ureteric obstruction.
References: Department of Radiology, University Hospital Waterford

Fig. 16: Postcontrast T1W axial images show avid enhancement of the cervical mass.
References: Department of Radiology, University Hospital Waterford

Case 6

A 77 year old woman presented with profound weight loss. A pelvic mass was noted at sonography. MRI demonstrates a diffuse cervical tumoral infiltration with tumour extending into the inferior 1/3 of the vagina. There is invasion of the bladder wall and the mass extends inferiorly along the urethra. Right lateral rectal wall involvement is also noted along with direct pelvic sidewall involvement with invasion into the right levator ani.

Biopsy: Squamous cell carcinoma 

Stage: T4 disease

Fig. 18: T2W axial image shows tumour involvement of the anterolateral rectal wall (arrow) and extension to the right lateral pelvic sidewall.
References: Department of Radiology, University Hospital Waterford

Fig. 19: T2W axial image showing invasion into the posterior bladder wall (arrow), resulting in a stage T4 tumour.
References: Department of Radiology, University Hospital Waterford

Case 7 

A 53 year old patient presented with an acute lower limb DVT on a background of menorrhagia. MR imaging showed a cervical mass lesion with bilateral parametrial involvement and extension to the pelvic sidewall bilaterally. Bladder wall infiltration with a vesicovaginal fistula was also noted. Bilateral ureteric obstruction secondary to the cervical mass. Pelvic sidewall lymphadenopathy. Followup restaging imaging showed direct extension of the pelvic mass into the lumbar spine.

Biopsy: Squamous cell carcinoma. 

Stage: T4 disease

Fig. 20: T2W sagittal image shows a large, heterogeneous pelvic mass, extending into the lower 1/3 of the vagina and involving the posterior bladder wall (star) with a resultant vesicovaginal fistula (arrow). The tumour also extends inferiorly along the urethra (double arrow).
References: Department of Radiology, University Hospital Waterford

Fig. 21: T2W axial imaging of the upper pelvis demonstrates bilateral hydronephosis secondary to ureteric obstruction (star).
References: Department of Radiology, University Hospital Waterford

Fig. 22: Axial and sagittal T2W images show paravertebral extension of the mass lesion (arrow)
References: Department of Radiology, University Hospital Waterford

Fig. 23: Follow-up restaging CT demonstrates progression of the cervical mass with retroperitoneal extension and direct invasion into the lumbar spine.
References: Department of Radiology, University Hospital Waterford

Case 8

A 73 year old patient presented with a 1 week history of postmenopausal bleed. Following imaging, she underwent a TAH and BSO. MRI shows a T2 hyperintense and markedly heterogeneous lesion arising from the endocervical canal and extending into the uterus. The lesion demonstrates avid postcontrast enhancement. 

Pathology: high grade sarcoma.

Fig. 24: T2W sagittal image shows a T2 hyperintense, necrotic cervical mass extending from the endocervical canal into the uterine cavity. Imaging findings are atypical for squamous cell carcinoma of the cervix, which is typically T2 hypointense.
References: Department of Radiology, University Hospital Waterford

Case 9

59 year old patient post radiotherapy for a squamous cell carcinoma of the cervix. We can note post treatment uterine atrophy with distension of the endometrial cavity, likely secondary to post treatment stenosis of the endocervical canal. An anterior vaginal and posterior bladder wall defect is noted, in keeping with a vesicovaginal fistula, secondary to radiotherapy.

No residual disease was identified.

Fig. 25: T2W sagittal images show an anterior vaginal and posterior bladder wall defect (arrow), consistent with a vesicovaginal fistula. Note the unusual high signal fluid within the vaginal cavity (star).
References: Department of Radiology, University Hospital Waterford