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It typically presents in younger women with an average age of onset at around 45 years.
multiple sexual partners or a male partner with multiple previous or current sexual partners
young age at first intercourse
certain HLA subtypes
nicotine/smoking (except for cervical adenocarcinoma 26)
Presenting symptoms include:
subclinical: an abnormal cervical cancer screening test
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 papillomavirus (HPV)
adenocarcinoma of the cervix: rarer (5-20%) and can have several subtypes which include 11,20
small cell carcinoma of the cervix: rare (0.5-6%) 18,22
For a detailed overview, refer to:
Cervical squamous cell carcinoma arises from the squamocolumnar junction while adenocarcinomas arise from the endocervix. The squamocolumnar junction is situated on the ectocervix in younger patients though regresses into the endocervical canal with age. Hence cervical tumors tend to be exophytic in younger patients and endophytic with advancing age.
In order to be radiographically visible, tumors must be at least stage IB or above (see staging). MRI is the imaging modality of choice to depict the primary tumor and assess the 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. Tumors stage IIA and below are treated with surgery.
hypoechoic, heterogeneous mass involving the cervix
may show increased vascularity on color Doppler
although cervical cancer is staged clinically, ultrasound can be a useful adjunct by showing
size (<4 cm or >4 cm)
tumor invasion into the vagina
tumor invasion into adjacent organs
hydronephrosis: implies stage IIIB tumor
CT, in general, is not very useful in the assessment of the primary tumor, but it can be useful in assessing advanced disease. It is performed primarily to assess lymphadenopathy, 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 tumor can be hypoenhancing or isoenhancing to normal cervical stroma (~50% 19).
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 tumor.
T1: usually isointense compared with pelvic muscles
hyperintense relative to the low signal of the cervical stroma
hyperintensity is thought to be present regardless of histological subtype 1
T1 C+ (Gd)
contrast is not routinely used, though it may be helpful to demonstrate small tumors considered for trachelectomy
on contrast-enhanced T1-weighted images, tumor presents as a high signal relative to the low signal of the cervical stroma 24
For further information, see the article: MRI reporting guidelines for cervical cancer.
PET-CT in conjunction with pelvic MRI is often used as an imaging strategy to stage cervical carcinoma.
Treatment and prognosis
Prognosis is affected by many factors which include:
the volume of the primary mass
Five-year survival rates vary between 92% for stage I disease and 17% for stage IV disease 18.
One of the key roles of the radiologist is to help determine staging, as this may lead to appropriate management pathway either with surgery or chemo-radiotherapy. At the time of writing stage IIA vs IIB is considered as an important separator in deciding whether a case is operable or not.
For a mass involving the cervix consider:
invasion of the cervix from
adenoma malignum: often considered a subtype of mucinous carcinoma of the cervix
cervical ectopic pregnancy: consider with women of childbearing age with a high βHCG
MRI T2-weighted imaging to assess parametrial invasion (stage IIB) is crucial to determine if the patient is candidate for surgery or not
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