Carcinoma of the cervix is a malignancy arising from the cervix and is considered the third commonest gynaecologic malignancy.
It typically presents in younger women with the average age of onset at around 45 years.
- human papilloma virus - HPV (16 and 18) infection : for most types except for clear cell carcinoma of the cervix and mesonephric carcinoma of the cervix
- multiple sexual partners
- early age of first sexual intercourse
Presenting symptoms include
- vaginal bleeding
- vaginal discharge
- subclinical with an abnormality detected on Pap smear screening
Invasive cervical carcinoma is thought to arise from the transformation of cervical intraepithelial neoplasia (CIN).
The main histological types are
- squamous cell carcinoma of the cervix : accounts for the vast majority ( 80 - 90 %) of cases and is associated with exposure to human papilloma virus (HPV).
- adenocarcinoma of the cervix : rarer ( ~ 5 - 20 %) and can have several sub types which include 11,20
- small cell carcinoma of the cervix : rare (0.5 - 6%) 18,22
- adeno-squamous cell carcinoma of the cervix : rare
For a detailed overview - refer to
Cervical carcinoma arises from the squamo-columnar junction. This is situated on the ectocervix in younger patients though regresses into the endocervical canal with age. Hence cervical tumours tend to be exophytic in younger patients and endophytic with advancing age.
In order to be radiographically visible, tumours must be at least stage Ib or above (see staging). MRI is the imaging modality of choice to depict the primary tumour and assess local extent. Distant metastatic disease is best assessed with CT or PET where available.
Although the FIGO staging system is clinically based, the revised 2009 FIGO staging encourages imaging as an adjunct to clinical staging. MRI can stratify patients to the optimum treatment group of primary surgery or combined chemotherapy and radiotherapy. Tumours stage IIa and below are treated with surgery.
May be seen as a hypoechoic mass involving the cervix. Ultrasound does not play a role in the clinical assessment of suspected cervical carcinoma.
CT in general is not very useful in assessment of the primary tumour but can be useful in assessing advanced disease. It is performed primarily to assess adenopathy but also has roles in defining advanced disease, monitoring distant metastasis, planning the placement of radiation ports, and guiding percutaneous biopsy.
On CT, the primary tumour can be hypo-attenuating or iso-attenuating (~ 50 % 19) to normal cervical stroma after administration of intravenous contrast material.
PET - CT
PET-CT in conjunction with pelvic MRI is widely considered to be the optimum imaging strategy to stage cervical carcinoma.
A dedicated MRI protocol is often useful for optimal imaging assessment.
The normal low signal cervical stroma provides intrinsic contrast for the high signal cervical tumour.
- T1 : usually iso intense compared with pelvic muscles
- high signal relative to the low signal of the cervical stroma
- hyper intensity is thought to be present regardless of histological sub type 1
T1 C+ :
- contrast is not routinely used though maybe helpful to demonstrate small tumours considered for trachelectomy.
MRI reporting guidelines for carcinoma of the cervix
The tumour should be measured in 3 orthogonal planes. Tumours with a maximum diameter greater than 4 cm are usually not amenable to primary radical surgery.
The parametrium is the anatomical space lateral to the cervix. The reported accuracy of MRI in detecting parametrial invasion varies in the literature from 75 to 96%.
MRI does however have a high negative predictive value in excluding parametrial invasion. If the T2 low signal cervical ring is intact then parametrial invasion is excluded.
Replacement of the usual low signal vaginal wall with high signal tumour.
- invasion of the upper 2/3 of the vagina = stage IIa
- invasion of the lower 1/3 of the vagina = stage IIIa
Pelvic sidewall involvement or hydronephrosis
Extension to the pelvic sidewall and or hydronephrosis (unless due to another cause) is consistent with IIIb disease.
Bladder and rectal invasion
MRI has a high negative predictive value at excluding bladder and rectal involvement.
Bladder involvement can be seen on MRI as thickening of the posterior bladder wall and disruption of the low signal bladder musculature or a mass within the bladder.
Rectal involvement is less common and can be seen as loss of posterior fat planes and direct tumour extension.
Treatment and prognosis
Prognosis is affected by many factors which include
- tumour stage
- volume of the primary mass
- histologic grade
Five-year survival rates vary between 92 % for stage I disease and 17% for stage IV disease 18.
One of the keys roles of the radiologists is to accurately determine staging as this may lead to appropriate management pathway either with surgery or chemo-radiotherapy. At the time of writing stage II is considered as a important separator in deciding whether a case is operable or not.
For a mass involving the cervix consider
- cervical lymphoma
- adenoma malignum : often considered a sub type of mucinous carcinoma of the cervix
- cervical leiomyoma
- metastases to the cervix
- invasion of the cervix from
- cervical ectopic pregnancy : consider with women of childbearing age with a high beta HCG
- 1. Pannu HK, Corl FM, Fishman EK. CT evaluation of cervical cancer: spectrum of disease. Radiographics. 21 (5): 1155-68. Radiographics (full text) - Pubmed citation
- 2. Nicolet V, Carignan L, Bourdon F et-al. MR imaging of cervical carcinoma: a practical staging approach. Radiographics. 20 (6): 1539-49. Radiographics (full text) - Pubmed citation
- 3. Hricak H, Yu KK. Radiology in invasive cervical cancer. AJR Am J Roentgenol. 1996;167 (5): 1101-8. AJR Am J Roentgenol (citation) - Pubmed citation
- 4. Rezvani M, Shaaban A. Imaging of cervical pathology. Clin Obstet Gynecol. 2009;52 (1): 94-111. doi:10.1097/GRF.0b013e31819617f1 - Pubmed citation
- 5. Kim SH, Choi BI, Lee HP et-al. Uterine cervical carcinoma: comparison of CT and MR findings. Radiology. 1990;175 (1): 45-51. Radiology (abstract) - Pubmed citation
- 6. Subak LL, Hricak H, Powell CB et-al. Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging. Obstet Gynecol. 1995;86 (1): 43-50. - Pubmed citation
- 7. Mezrich R. Magnetic resonance imaging applications in uterine cervical cancer. Magn Reson Imaging Clin N Am. 1994;2 (2): 211-43. - Pubmed citation
- 8. Son H, Kositwattanarerk A, Hayes MP et-al. PET/CT evaluation of cervical cancer: spectrum of disease. Radiographics. 2010;30 (5): 1251-68. doi:10.1148/rg.305105703 - Pubmed citation
- 9. Chiang SH, Quek ST. Carcinoma of the cervix: role of MR imaging. Ann. Acad. Med. Singap. 2003;32 (4): 550-6. - Pubmed citation
- 10. Zand KR, Reinhold C, Abe H et-al. Magnetic resonance imaging of the cervix. Cancer Imaging. 2007;7 : 69-76. doi:10.1102/1470-7330.2007.0011 - Free text at pubmed - Pubmed citation
- 11.Hiromura T, Tanaka YO, Nishioka T et-al. Clear cell adenocarcinoma of the uterine cervix arising from a background of cervical endometriosis. Br J Radiol. 2009;82 (973): e20-2. doi:10.1259/bjr/75304693 - Pubmed citation
- 12. Jena A, Oberoi R, Rawal S et-al. Parametrial invasion in carcinoma of cervix: role of MRI measured tumour volume. Br J Radiol. 2005;78 (936): 1075-7. doi:10.1259/bjr/36116150 - Pubmed citation
- 13. Babar S, Rockall A, Goode A et-al. Magnetic resonance imaging appearances of recurrent cervical carcinoma. Int. J. Gynecol. Cancer. 17 (3): 637-45. doi:10.1111/j.1525-1438.2007.00849.x - Pubmed citation
- 14. Gold MA. PET in cervical cancer--implications for 'staging,' treatment planning, assessment of prognosis, and prediction of response. J Natl Compr Canc Netw. 2008;6 (1): 37-45. - Pubmed citation
- 15. Epstein E, Di legge A, Måsbäck A et-al. Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix. Ultrasound Obstet Gynecol. 2010;36 (4): 512-6. doi:10.1002/uog.7638 - Pubmed citation
- 16. Okamoto Y, Tanaka YO, Nishida M et-al. MR imaging of the uterine cervix: imaging-pathologic correlation. Radiographics. 23 (2): 425-45. doi:10.1148/rg.232025065 - Pubmed citation
- 17. Jeong YY, Kang HK, Chung TW et-al. Uterine cervical carcinoma after therapy: CT and MR imaging findings. Radiographics. 23 (4): 969-81. doi:10.1148/rg.234035001 - Pubmed citation
- 18. Sala E, Wakely S, Senior E et-al. MRI of malignant neoplasms of the uterine corpus and cervix. AJR Am J Roentgenol. 2007;188 (6): 1577-87. doi:10.2214/AJR.06.1196 - Pubmed citation
- 19. Kaur H, Silverman PM, Iyer RB et-al. Diagnosis, staging, and surveillance of cervical carcinoma. AJR Am J Roentgenol. 2003;180 (6): 1621-31. AJR Am J Roentgenol (full text) - Pubmed citation
- 20. Shreve P. Clinical PET-CT. Springer Verlag. (2010) ISBN:0387489002. Read it at Google Books - Find it at Amazon
- 21. Levine DA, Santos JF, Fleming GF. Handbook for Principles and Practice of Gynecologic Oncology. Lippincott Williams & Wilkins. (2010) ISBN:0781778484. Read it at Google Books - Find it at Amazon
- 22. Yang DH, Kim JK, Kim KW et-al. MRI of small cell carcinoma of the uterine cervix with pathologic correlation. AJR Am J Roentgenol. 2004;182 (5): 1255-8. AJR Am J Roentgenol (full text) - Pubmed citation
- 23. Dallenbach-Hellweg G, Doeberitz MV, Trunk MJ. Color Atlas of Histopathology of the Cervix Uteri. Springer Verlag. (2010) ISBN:3642064337. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
|Synonyms or Alternative Spelling||Include in Listings?|
|Cancer of the cervix||✗|
|Uterine cervical cancer||✗|
|Uterine cervical carcinoma||✗|
|Carcinoma of cervix||✗|
|Carcinoma of the uterine cervix||✗|
|Carcinoma of uterine cervix||✗|