Malignant Tumors of the Cervix and Uterus

Invasive cervical carcinoma is the third most common malignancy of the female genital tract. Early detection of cervical carcinoma due to gynecologic examination and the Pap smear has led to a significant reduction in mortality. At histology, squamous cell carcinoma is found in over 90% of cases. Imaging is not used for tumor detection, but for staging of cytologically proven disease. Transvaginal ultrasound is usually the first imaging modality employed. Additional cross-sectional imaging is especially useful if the tumor volume is large. MRI was shown to be superior to CT in the local staging of cervical carcinoma.

T2-weighted MR sequences are most helpful for local staging of cervical disease. The tumor presents with high signal intensity compared with the low intensity cervical stroma. Stage-IB International Federation of Gynecology and Obstetrics (FIGO) carcinoma is restricted to the cervix and presents on T2-weighted images with a fully preserved hypointense rim of normal cervical stroma surrounding the tumor (Fig. 9), whereas in patients with parametrial invasion (stage FIGO IIB), i.e., one of the most important criteria influencing therapeutic decision making, the normal stroma is disrupted. Contrast-enhanced sequences are not routinely used for the staging of cervical carcinoma. They may be useful in selected cases with suspected invasion of the bladder or rectum.

In patients with endometrial carcinoma proven by fractional abrasion, MRI is the imaging modality of choice for preoperative staging. It is used to assess the depth of myometrial invasion and to identify invasion of the cervix or extrauterine spread. It was shown to be especially helpful in the subpopulation of patients in whom the extent of tumor growth may alter the surgical approach or in patients in whom concomitant lesions, such as leiomyomas, make clinical assessment difficult.

Signal intensities of small endometrial tumors are similar to that of normal endometrium on T2-weighted sequences, limiting the ability of tumor delineation, whereas larger tumors result in the widening of the endometrial cavity. It should be kept in mind that endometrial hyper-plasia and endometrial polyps are benign entities also resulting in a thickened endometrium that have therefore to be distinguished from endometrial carcinoma (Fig. 10).

A disruption of the junctional zone by a hyperintense

Fig. 8. Focal adenomyosis (T2-weighted images). Enlarged uterus with diffusely thickened junctional zone with multiple hyperin-tense foci indicative of adenomyoma. A small leiomyoma can also be seen (arrow)

Fig. 9. Cervical carcinoma stage FIGO IB. a Sagittal T2-weighted MR image. b Axial oblique T2-weighted MR image. Although the tumor volume is rather large, the cervical stroma (arrows) is not disrupted

endometrial tumor is indicative of myometrial invasion. The junctional zone, however, cannot always be delineated in postmenopausal women, which makes correct imaging interpretation difficult in these cases. Deep my-ometrial invasion is suggested by the presence of hyper-intense tumor in the outer half of the myometrium. Intravenous administration of gadolinium compounds is helpful for MR staging of endometrial carcinoma, with the cancer demonstrating less pronounced contrast-enhancement compared with the surrounding tissues. Contrast-enhanced images further improve the differentiation of vital tumor from necrosis or hematometra.

Fig. 10. Endometrial Carcinoma stage FIGO IA (sagittal T2-weight-ed MR Image). The endometrial stripe is thickened due to the presence of tumor, while the junctional zone (arrow) remains intact

Most uterine tumors are adenocarcinomas; other histologic subtypes like leiomyosarcoma or endometrial stro-mal tumors are rare.

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