(Radiographics. 2001;21:1155-1168.)
© RSNA, 2001
CT Evaluation of Cervical Cancer: Spectrum of Disease1
Harpreet K. Pannu, MD,
Frank M. Corl, MS and
Elliot K. Fishman, MD
1 From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md. Presented as an education exhibit at the 2000 RSNA scientific assembly. Received April 10, 2001; revision requested May 16 and received June 22; accepted July 2. Address correspondence to H.K.P., Department of Radiology, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: hpannu@jhmi.edu).
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Abstract
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Invasive cervical cancer is the third most common gynecologic malignancy. The prognosis is based on the stage, size, and histologic grade of the primary tumor and the status of the lymph nodes. Assessment of the stage of disease is important in determining whether the patient may benefit from surgery or will receive radiation therapy. The official clinical staging system of the International Federation of Gynecology and Obstetrics has led to errors of 65%–90% in stage III and IV disease; the result has been unofficial extended staging with cross-sectional imaging modalities such as computed tomography (CT). CT is useful in staging advanced disease and in monitoring patients for recurrence. The primary tumor is heterogeneous and hypoattenuating relative to normal stroma on contrast material–enhanced scans. Obliteration of the periureteral fat plane and a soft-tissue mass are the most reliable signs of parametrial extension. Less than 3 mm separation of the tumor from the pelvic muscles and vascular encasement are signs of pelvic side wall invasion. Lymphatic spread is along the external and internal iliac nodal chains and the presacral route to the paraaortic nodes. Distant metastases are seen with primary or recurrent disease and can involve the liver, lung, and bone.
Index Terms: Uterine neoplasms, CT, 854.12115 • Uterine neoplasms, diagnosis, 854.32 • Uterine neoplasms, metastases, **.332 • Uterine neoplasms, staging, 854.32
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LEARNING OBJECTIVES FOR TEST 3
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After reading this article and taking the test, the reader will be able to:
- Discuss the limitations of the FIGO clinical staging system for cervical cancer.
- Describe the signs of extracervical pelvic spread at CT.
- Describe the features of extrapelvic tumor recurrence at CT.
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Introduction
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Invasive cervical cancer is the third most common gynecologic malignancy (1). There were approximately 13,700 new cases and 4,900 deaths in 1998 with an estimated prevalence of 208,000 (2). Patients present with abnormal vaginal bleeding and can have pelvic pain from local spread of disease or inflammation (3). Eighty percent to 90% of cervical carcinomas are of squamous cell origin, and the tumors are exophytic or primarily endocervical (3). From the cervix, tumors spread to the lower uterine segment, vagina, and paracervical space along the broad and uterosacral ligaments (Fig 1) (3). Involvement of the pericervical tissues includes the bladder, rectum, pelvic lymph nodes, and pelvic side wall (3).
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Figure 1a. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Figure 1b. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Figure 1c. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Figure 1d. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Figure 1e. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Figure 1f. Drawings of the primary tumor and local spread. (a) Coronal drawing of the uterus shows tumor (arrow) confined to the cervix. (b) Coronal drawing of the uterus shows extension of the cervical cancer into the myometrium (arrow). (c) Coronal drawing of the uterus shows extension of the cervical cancer into the upper one-third of the vagina (arrow). (d) Axial drawing of the pelvis shows tumor extending beyond the cervix and encasing the right ureter, a sign of parametrial invasion. (e) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the muscles of the right pelvic side wall. (f) Axial drawing of the pelvis shows tumor extending beyond the cervix and involving the bladder and rectum.
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Factors that affect prognosis include tumor stage, volume of the primary mass, and histologic grade (4). There are four stages of disease as defined by the staging system of the International Federation of Gynecology and Obstetrics (FIGO) (Table 1), on which treatment is based (3). Patients can be treated with surgery or radiation, with surgery being reserved for those with tumors less than or equal to stage IIA (4). These patients with early-stage disease may undergo radical hysterectomy, radiation therapy, or both. On the other hand, patients with stage IIB or higher-stage disease are treated only with radiation (4). The important distinction in staging is therefore between stage IIA disease, in which there is no parametrial involvement, and stage IIB disease, in which there is parametrial involvement. Although not included in the official FIGO staging system, the presence of lymph node metastases is also an important prognostic factor (1,3,5). Nodal status is included in the TNM staging system for cervical cancer (Table 1). Other prognostic factors are the presence of unilateral versus bilateral parametrial and pelvic side wall disease (3).
The official FIGO staging method relies on pelvic physical examination, which may be performed under anesthesia, and readily available diagnostic tests such as intravenous urography, barium enema study, and chest radiography (1). Nevertheless, unofficial extended clinical staging has developed by using computed tomography (CT) and magnetic resonance (MR) imaging (1). A survey of pretreatment diagnostic assessments found an increase in use of these tests from 1984 to 1990 with a decrease in use of the imaging tests outlined in the FIGO criteria (6). This trend is due to errors in clinical FIGO staging of approximately 25% in stage I and II disease and 65%–90% in stage III and IV disease (4). The inaccuracy of clinical staging with advancing stages accounts for the differences in survival seen between patients within one clinical stage. For example, in stage IB disease, the survival rate is 85%–95% for patients with negative nodes at surgery and 45%–55% for those with positive nodes (3). Errors occur due to underestimation of disease (4). Gynecologists have difficulty measuring the endocervical component of the tumor and evaluating extracervical spread into the uterine body, parametrium, pelvic side wall, and pelvic and extrapelvic lymph nodes (4).
These parameters can be evaluated with MR imaging and CT. The role of CT in staging is currently being reevaluated in the American College of Radiology Imaging Network (ACRIN) trial. Most prior studies of the accuracy of CT for staging were performed by using scanners with 1–3-second scanning times and 8–10-mm-thick sections (7). Visualization of the primary tumor has been limited; therefore, the role of CT currently is in staging cases of advanced disease (1). The accuracy of CT in assessment of stage IIIB–IVB disease is 92% (8). CT can demonstrate pelvic side wall extension, ureteral obstruction, advanced bladder and rectal invasion, adenopathy, and extrapelvic spread of disease (1). CT can also be used to guide biopsy of enlarged nodes, plan radiation therapy ports, and monitor patients for tumor recurrence (9,10).
For identification of stromal and parametrial invasion, MR imaging has been shown to be superior to CT (1). The role of CT when yet-to-be-determined optimized protocols are used on multi–detector row scanners is currently not known. The strengths of CT are rapid acquisition time, imaging during peak vascular (arterial or venous) enhancement, lack of bowel motion artifact, and fewer contraindications than MR imaging. Patient claustrophobia is also usually not a factor. CT is included in the recommended tests for cervical cancer according to the appropriateness criteria guidelines of the American College of Radiology. The limitations of CT have been lack of consistent visualization of the primary tumor and inaccuracies in detection of parametrial invasion. Whether these limitations are still true with multi–detector row CT is not known. The use of CT versus MR imaging is at the discretion of the referring physician. Patients may not undergo cross-sectional imaging prior to surgery or may undergo MR imaging for early-stage disease and CT for advanced tumors.
In this article, we present the spectrum of abnormalities of cervical cancer at CT. First, CT protocols for single– and multi–detector row scanners are described. Then, the appearances of the primary tumor, parametrial spread of disease, pelvic side wall disease, pelvic visceral disease, lymphatic spread of tumor, local recurrence of tumor, and distant metastases are illustrated.
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CT Protocols
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Single–Detector Row Spiral CT
A spiral scan is performed from the symphysis pubis through the iliac crest, followed by a scan to the diaphragm. Scanning is performed from caudal to cranial to image the uterus and cervix during the phase of maximal vascular enhancement. The patient ingests 750–1,000 mL of water-soluble oral contrast material, and 120 mL of nonionic contrast material is injected intravenously at 2 mL/sec. The oral contrast material is useful to distinguish bowel loops from tumor, especially in patients with recurrent disease, which may appear cystic. After a delay of 50 seconds, images are obtained with a collimation of 5 mm, table speed of 5 mm/sec, and reconstruction interval of 5 mm. Longer scanning delays may be used if necessary to distinguish nonenhanced vessels from nodes or to demonstrate the ureters for assessment of tumor encasement. According to the capability of the scanner, 3-mm-thick sections may be obtained to optimize visualization of the cervix and parametrial tissues.
Multi–Detector Row Spiral CT
The injection parameters, scanning delay, and scanning direction are the same as for a single–detector row scanner. The section collimation is 2.5 mm, the table speed is 12.5 mm per rotation, and the reconstructed section width is 3–5 mm with the scan reconstructed every 3–5 mm.
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Primary Tumor
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The normal cervix has a variable enhancement pattern and shows diffuse enhancement on images that are delayed by several minutes (11). The primary tumor can be hypoattenuating or isoattenuating to normal cervical stroma after administration of intravenous contrast material. Fifty percent of stage IB cancers have been described as isoattenuating to normal parenchyma (1). When the primary tumor is visible, it has low-attenuation areas due to necrosis, ulceration, or reduced vascularity (Fig 2) (9). Necrosis or prior biopsy can result in gas within the mass (12). The cervix is enlarged to greater than 3.5 cm, and an anteroposterior size of the cervix greater than 6 cm at CT correlates with a poorer outcome (7,8). The tumor arises from the cervical canal and has variable degrees of extension peripherally into the cervical stroma. The cervix usually has a smooth, well-defined margin if the tumor is confined to it (12).
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Figure 2a. Clinical and imaging stage IIIB cervical cancer in a 37-year-old woman with hydronephrosis at diagnosis. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) Arterial-dominant phase image shows a cervical cancer as a hypoattenuating mass (solid arrow) with diminished enhancement when compared with the normal stroma (open arrow) of the cervix and myometrium. Minimal gas is present and is compatible with necrosis. (b) Delayed image obtained 9 minutes later still shows the hypoattenuating tumor (arrow), but the margin cannot be clearly separated from normal parenchyma. (c) Arterial-phase image obtained 2 months later shows an increase in the size of the tumor (arrow). Myometrial extension can be appreciated when this image is compared with a.
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Figure 2b. Clinical and imaging stage IIIB cervical cancer in a 37-year-old woman with hydronephrosis at diagnosis. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) Arterial-dominant phase image shows a cervical cancer as a hypoattenuating mass (solid arrow) with diminished enhancement when compared with the normal stroma (open arrow) of the cervix and myometrium. Minimal gas is present and is compatible with necrosis. (b) Delayed image obtained 9 minutes later still shows the hypoattenuating tumor (arrow), but the margin cannot be clearly separated from normal parenchyma. (c) Arterial-phase image obtained 2 months later shows an increase in the size of the tumor (arrow). Myometrial extension can be appreciated when this image is compared with a.
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Figure 2c. Clinical and imaging stage IIIB cervical cancer in a 37-year-old woman with hydronephrosis at diagnosis. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) Arterial-dominant phase image shows a cervical cancer as a hypoattenuating mass (solid arrow) with diminished enhancement when compared with the normal stroma (open arrow) of the cervix and myometrium. Minimal gas is present and is compatible with necrosis. (b) Delayed image obtained 9 minutes later still shows the hypoattenuating tumor (arrow), but the margin cannot be clearly separated from normal parenchyma. (c) Arterial-phase image obtained 2 months later shows an increase in the size of the tumor (arrow). Myometrial extension can be appreciated when this image is compared with a.
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Obstruction of the endocervical canal leads to distention of the endometrial cavity with blood, serous fluid, or pus (7). This finding is not uncommon in patients treated with radiation therapy (13). The cervical cancer can also grow into the myometrium (Fig 3) and vagina (Fig 4). Tumor extension into the body of the uterus is associated with a higher prevalence of distant metastases (3). Multiplanar reformation can be used to display the superior and inferior extents of the tumor in the sagittal and coronal planes. It is hypoattenuating to the myometrium and distends the vagina. Exophytic cervical cancer can protrude into the vagina without invading it.
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Figure 3. Tumor extension into the uterus in a 50-year-old woman with initial clinical stage IB cervical cancer diagnosed 4 years earlier; she had not undergone prior imaging. The patient was noncompliant with treatment, and there was growth of the tumor over time. Axial CT image of the pelvis obtained with intravenous contrast material shows infiltration of the myometrium by the tumor (solid arrow). The tumor surrounds a uterine fibroid (open arrow) and also extends beyond the myometrium (*).
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Figure 4a. Tumor extension into the vagina in a 50-year-old woman with clinical stage IIIB and imaging stage IIIA cervical cancer. Axial (a), sagittal (b), and coronal (c) CT images of the pelvis obtained with oral and intravenous contrast material show a low-attenuation mass in the cervix (solid arrow), which represents the primary tumor. The vagina (open arrow) is expanded by the tumor (*) growing into it from the cervix. The tumor involves the lower one-third of the vagina, a finding consistent with stage III disease.
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Figure 4b. Tumor extension into the vagina in a 50-year-old woman with clinical stage IIIB and imaging stage IIIA cervical cancer. Axial (a), sagittal (b), and coronal (c) CT images of the pelvis obtained with oral and intravenous contrast material show a low-attenuation mass in the cervix (solid arrow), which represents the primary tumor. The vagina (open arrow) is expanded by the tumor (*) growing into it from the cervix. The tumor involves the lower one-third of the vagina, a finding consistent with stage III disease.
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Figure 4c. Tumor extension into the vagina in a 50-year-old woman with clinical stage IIIB and imaging stage IIIA cervical cancer. Axial (a), sagittal (b), and coronal (c) CT images of the pelvis obtained with oral and intravenous contrast material show a low-attenuation mass in the cervix (solid arrow), which represents the primary tumor. The vagina (open arrow) is expanded by the tumor (*) growing into it from the cervix. The tumor involves the lower one-third of the vagina, a finding consistent with stage III disease.
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Parametrial Spread of Disease
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The parametrium is the connective tissue between the leaves of the broad ligament (12). Medially, it abuts the uterus, cervix, and proximal vagina. Laterally, it extends to the pelvic side wall. Inferiorly, it is contiguous with the cardinal ligament (12). The parametrium consists primarily of fat, through which run uterine vessels, nerves, fibrous tissues, and lymphatic vessels (12).
The distal ureter is in the parametrium as it passes from the pelvic side wall to the bladder approximately 2 cm lateral to the margin of the cervix (12). When cervical cancer extends into the parametrium, the ureter can be encased by tumor (1,12). Encasement of the ureter and a parametrial soft-tissue mass are specific signs of parametrial invasion (Figs 5, 6) (9,12). If there is hydronephrosis, the patient has stage IIIB disease. Hydronephrosis, hydroureter, and the site of obstruction can be demonstrated with CT (Fig 7), avoiding the need for intravenous urography (14).
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Figure 5a. Parametrial soft-tissue mass in a 30-year-old woman with clinical stage IIIB and imaging stage IIB cervical cancer. Axial spiral CT images of the pelvis were obtained with intravenous and oral contrast material and a scanning delay of 50 seconds after injection. (a) A low-attenuation mass (arrow) is present in the cervix, and the attenuation of the parametrium is increased bilaterally. (b) Image obtained superior to a shows a mass of soft-tissue attenuation (arrow) in the left parametrium. At surgery, tumor was present in the parametrium bilaterally.
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Figure 5b. Parametrial soft-tissue mass in a 30-year-old woman with clinical stage IIIB and imaging stage IIB cervical cancer. Axial spiral CT images of the pelvis were obtained with intravenous and oral contrast material and a scanning delay of 50 seconds after injection. (a) A low-attenuation mass (arrow) is present in the cervix, and the attenuation of the parametrium is increased bilaterally. (b) Image obtained superior to a shows a mass of soft-tissue attenuation (arrow) in the left parametrium. At surgery, tumor was present in the parametrium bilaterally.
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Figure 6. Obliteration of the periureteral fat plane in a 50-year-old woman with progression of initial clinical stage IB cervical cancer; she had not undergone prior imaging. Axial CT image of the pelvis obtained with intravenous contrast material shows a mass in the cervix and stranding of the parametrium. The fat plane around both ureters has been obliterated (arrows), a finding compatible with parametrial invasion by the tumor.
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Figure 7. Ureteral obstruction secondary to adenopathy in a 67-year-old woman with clinical stage IIB cervical cancer diagnosed 2 years earlier; she had not undergone prior imaging. Axial CT image of the abdomen obtained with oral and intravenous contrast material shows retroperitoneal adenopathy (arrow), which encases the right ureter (arrowhead). Stents are present in both ureters.
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Perivascular invasion and thickening of the uterosacral ligaments may also be seen with parametrial invasion. Less specific signs are increased attenuation and stranding of the parametrial fat and an ill-defined cervical margin (Fig 8) (9,12). The lower specificity of these signs is due to the parametrial inflammation without tumor extension that occurs in patients with cervical cancer (8,12). Parametrial inflammation is due to instrumentation, ulceration and infection of the cervical tumor, and prior pelvic surgery (12). The nodularity of pelvic endometriosis can also be a confounding factor when assessing the parametrium (15).
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Figure 8a. Irregular cervical margin, parametrial stranding, and a parametrial mass in an 81-year-old woman with clinical and imaging stage IVA cervical cancer due to the presence of bladder invasion. The tumor occurred in a cervical stump 25 years after supracervical hysterectomy. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) A low-attenuation cervical mass (solid arrow) is present with irregular margins and thick parametrial soft-tissue strands (open arrow). (b) Image obtained superior to a shows a parametrial mass (arrow).
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Figure 8b. Irregular cervical margin, parametrial stranding, and a parametrial mass in an 81-year-old woman with clinical and imaging stage IVA cervical cancer due to the presence of bladder invasion. The tumor occurred in a cervical stump 25 years after supracervical hysterectomy. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) A low-attenuation cervical mass (solid arrow) is present with irregular margins and thick parametrial soft-tissue strands (open arrow). (b) Image obtained superior to a shows a parametrial mass (arrow).
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A pitfall of CT is misdiagnosis of normal parauterine and paracervical ligaments and vessels as evidence of parametrial tumor (9,12). These structures can appear as soft-tissue strands but are thinner than abnormal tumor or inflammatory strands, which tend to be greater than 3–4 mm in thickness (12). Contrast material–enhanced scans and thinner sections have been suggested to avoid this error (16).
False-positive diagnoses account for the low 30%–58% accuracy of CT for diagnosis of parametrial tumor (7). The probability of parametrial disease is 28% for tumors that are greater than 2 cm in diameter (1).
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Pelvic Side Wall Disease
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Invasion of the pelvic side wall is diagnosed when the wall cannot be separated from the tumor at rectal examination (3). At imaging, invasion is diagnosed when the tumor is less than 3 mm from the side wall (1). With frank invasion, the piriformis and obturator internus muscles are enlarged and can demonstrate an enhancing soft-tissue mass (Fig 9) (9). The iliac vessels are encased and narrowed by tumor, and destruction of the pelvic bones occurs by direct extension (1,17). With extensive disease, the soft tissues of the pelvis can be diffusely infiltrated by tumor.
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Figure 9a. Muscle and sacral invasion in a 44-year-old woman with clinical and imaging stage IV cervical cancer. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) There is an enhancing necrotic mass (solid arrow) that enlarges the cervix. The mass extends into the right sciatic notch and invades the piriformis and gluteus muscles (open arrow). (b) Image obtained superior to a shows erosion of the right side of the sacrum (arrow) by the mass.
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Figure 9b. Muscle and sacral invasion in a 44-year-old woman with clinical and imaging stage IV cervical cancer. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) There is an enhancing necrotic mass (solid arrow) that enlarges the cervix. The mass extends into the right sciatic notch and invades the piriformis and gluteus muscles (open arrow). (b) Image obtained superior to a shows erosion of the right side of the sacrum (arrow) by the mass.
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Pelvic Visceral Disease
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Bladder or rectal involvement constitutes stage IVA disease and occurs by local extension of tumor. Invasion is confirmed with cystoscopy or proctoscopy and biopsy (3). CT signs of invasion are loss of the perivesical or perirectal fat plane, asymmetric nodular thickening of the bladder or rectal wall, an intraluminal mass, and formation of a fistula with air in the bladder (Figs 10, 11) (7). The sensitivity of CT is low for mucosal invasion of the bladder diagnosed with cystoscopy (18). A positive predictive value of 60% was reported in a small series (19). Therefore, cystoscopy is helpful in patients with bulky disease (18). Bladder involvement has been reported in patients with other evidence of disseminated disease, such as a pelvic side wall tumor or distant metastases (18).
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Figure 10. Invasion of the bladder and ureteral encasement in a 41-year-old woman with initial clinical stage IB cervical cancer with local progression. Axial CT image of the pelvis obtained with intravenous contrast material shows a necrotic mass (solid arrow) in the cervix. There is invasion of the bladder (open arrow) with wall thickening. The right ureter has a stent and is also encased by the tumor.
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Figure 11. Invasion of the rectum and bladder in an 81-year-old woman with clinical and imaging stage IVA cervical cancer arising from a cervical stump 25 years after supracervical hysterectomy. Axial CT image of the pelvis obtained with oral and intravenous contrast material shows a heterogeneously enhancing cervical mass (solid arrow). The mass extends to the rectum (open arrow) and also involves the bladder at the right uretero-vesical junction. This invasion of pelvic organs is consistent with stage IV disease.
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Lymphatic Spread of Tumor
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Nodes greater than 1 cm in short-axis diameter are considered to be abnormal (1,5). Suggested upper limits of normal for specific sites are 7 mm for the internal iliac nodes, 9 mm for the common iliac nodes, and 10 mm for the external iliac nodes (20). The nodes in the parametrium are the first to be involved by tumor (9). There are three lymphatic pathways of drainage for the cervix through which tumor can spread. The lateral route is along the external iliac vessels, the hypogastric route is along the internal iliac vessels, and the presacral route is along the uterosacral ligament (Fig 12, Table 2) (21). All three routes lead to the common iliac nodes, from where tumor can involve the paraaortic nodes.
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Figure 12. Lymphatic pathways of spread of cervical cancer. Sagittal drawing of the pelvis shows that the tumor can spread through the external iliac, hypogastric, or presacral nodal pathway to the paraaortic nodes. a. = artery.
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More specifically, in the lateral route, tumor first involves the medial external iliac chain, then the middle and lateral external iliac chains, and finally the common iliac chain (Fig 13) (21). The medial chain of nodes is medial and posterior to the external iliac vein and accepts lymph from the deep inguinal nodes. The middle chain is between the external iliac artery and vein, and the lateral chain is lateral to the external iliac artery. The common iliac nodal group also has medial, middle, and lateral chains. The medial chain is in the area between the common iliac arteries and includes the nodes anterior to the sacral promontory (21). The middle chain nodes are bounded by the common iliac vessels anteriorly, the psoas muscle laterally, and the spine medially, whereas the lateral chain is lateral to the common iliac artery (21).
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Figure 13a. Lymphatic spread along the lateral pelvic nodal pathway in a 54-year-old woman with recurrent cervical cancer (clinical stage unknown) 14 years after a hysterectomy. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) A soft-tissue mass is present at the vaginal cuff (white arrow). There are enlarged nodes (black arrow) medial to the right external iliac vessels, a finding compatible with tumor spread along the lateral pelvic pathway. (b) Image obtained superior to a shows an enlarged node in the lateral external iliac chain (solid arrow) as well as the enlarged node in the medial chain (open arrow). There is also superior extension of the vaginal cuff mass (arrowhead).
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Figure 13b. Lymphatic spread along the lateral pelvic nodal pathway in a 54-year-old woman with recurrent cervical cancer (clinical stage unknown) 14 years after a hysterectomy. Axial CT images of the pelvis were obtained with intravenous contrast material. (a) A soft-tissue mass is present at the vaginal cuff (white arrow). There are enlarged nodes (black arrow) medial to the right external iliac vessels, a finding compatible with tumor spread along the lateral pelvic pathway. (b) Image obtained superior to a shows an enlarged node in the lateral external iliac chain (solid arrow) as well as the enlarged node in the medial chain (open arrow). There is also superior extension of the vaginal cuff mass (arrowhead).
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In the hypogastric route, tumor spreads along the branches of the internal iliac artery and then involves the junctional nodes, which lie between the internal and external iliac vessels (Fig 14) (21). Subsequent extension is to the common iliac nodes. In the presacral route, the lymphatic plexus anterior to the sacrum and coccyx is involved, followed by disease in the medial and middle chains of the common iliac nodes (Fig 15) (21).
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Figure 14a. Lymphatic spread along the hypogastric pelvic nodal pathway in a 56-year-old woman with clinical stage IVA cervical cancer. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) An enlarged node (arrow) is seen along the visceral branches of the right internal iliac artery. The cervix is enlarged secondary to a tumor. (b) Image obtained superior to a shows an enlarged junctional node (arrow) between the external and internal iliac vessels secondary to tumor drainage along the hypogastric route.
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Figure 14b. Lymphatic spread along the hypogastric pelvic nodal pathway in a 56-year-old woman with clinical stage IVA cervical cancer. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) An enlarged node (arrow) is seen along the visceral branches of the right internal iliac artery. The cervix is enlarged secondary to a tumor. (b) Image obtained superior to a shows an enlarged junctional node (arrow) between the external and internal iliac vessels secondary to tumor drainage along the hypogastric route.
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Figure 15. Lymphatic spread along the presacral pelvic nodal pathway in a 40-year-old woman with cervical cancer (clinical stage unknown). Axial CT image of the pelvis obtained with oral and intravenous contrast material shows the middle chain nodes (arrow), which are bounded by the common iliac vessels anteriorly, the psoas muscle laterally, and the spine medially. There is also destruction of the vertebral body.
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Patients with cervical cancer can have secondary infection that results in adenopathy (10). Enlarged malignant and hyperplastic nodes cannot be distinguished at CT (9). Conversely, tumor may be present in normal-sized nodes, giving CT a sensitivity of 44% for malignancy (1). Enhancement of benign and malignant nodes is similar on arterial- and venous-phase images after administration of intravenous contrast material (22). However, if central necrosis is detected in a node, the positive predictive value for malignancy is 100% (22). The accuracy of CT is between 65% and 80% for detection of metastatic involvement, and biopsy of suspicious nodes is necessary for confirmation (5,9). Laparoscopic ultrasonography and node resection have been suggested to detect metastatic nodes without delaying radiation therapy (23). The probability of malignant nodes is 18.6% for tumors that are less than or equal to stage IIB and 44.3% for higher-stage tumors (5). Overall, 14.8% of patients across all stages have paraaortic nodes that are positive for tumor (5). A meta-analysis of the literature on the usefulness of CT in identifying lymph node metastases showed that detection of normal-sized nodes reduces the probability of metastatic disease (5). On the other hand, if enlarged nodes are seen, the probability of tumor is only moderately increased. There was no significant difference between CT, MR imaging, and lymphangiography.
Patients with enlarged pelvic nodes at CT have a lower 5-year disease-free survival rate due to development of distant metastases (24). CT detection of enlarged pelvic nodes is equivalent to FIGO stage IIIB disease with pelvic side wall extension (7). Diagnosis of enlarged paraaortic or inguinal nodes is equivalent to FIGO stage IVB disease.
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Local Recurrence of Tumor
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A recurrence is defined as tumor that develops at least 6 months after the treated lesion has regressed (25). Recurrence of tumor in the pelvis is either central or at the side wall (25). The mass is at the vaginal cuff or cervix in cases of central recurrence. Similar to a primary tumor, it can grow anteriorly, posteriorly, or laterally to involve the bladder, rectum, or side wall (25,26). The likelihood of recurrence depends on the tumor stage, histologic findings, and treatment efficacy. Thirty percent of deaths are due to recurrent or persistent tumor (25).
CT has a high sensitivity and specificity for detection of recurrent tumor and can be used to monitor patients (7). In a study of 39 patients with recurrent disease, 85% of local recurrences were correctly diagnosed with CT (26). A soft-tissue mass with variable degrees of necrosis is present in the pelvis (Fig 16) (7,25). Pelvic recurrences may have a cystic appearance with minimal soft tissue (27). These can be differentiated from postsurgical collections because recurrent tumor generally occurs more than 6 months after surgery (27). Evaluation of possible invasion of the adjacent organs and the side wall is important if pelvic exenteration is planned (26). In patients who have received radiation therapy, distinguishing radiation fibrosis from recurrent tumor can be difficult and biopsy may be necessary (7).
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Figure 16a. Local recurrence in a 61-year-old woman in whom clinical stage IB cervical cancer was diagnosed 12 years earlier and treated with hysterectomy. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) A necrotic mass (arrow) with a hypoattenuating center and an enhancing wall is present superior to the vaginal cuff. This finding is compatible with local tumor recurrence. (b) Image obtained superior to a shows a necrotic right obturator node (arrow). There is also thickening of bowel loops from radiation therapy.
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Figure 16b. Local recurrence in a 61-year-old woman in whom clinical stage IB cervical cancer was diagnosed 12 years earlier and treated with hysterectomy. Axial CT images of the pelvis were obtained with oral and intravenous contrast material. (a) A necrotic mass (arrow) with a hypoattenuating center and an enhancing wall is present superior to the vaginal cuff. This finding is compatible with local tumor recurrence. (b) Image obtained superior to a shows a necrotic right obturator node (arrow). There is also thickening of bowel loops from radiation therapy.
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Distant Metastases
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Distant metastases from cervical cancer are usually due to recurrent disease and are seen in the liver, lung, bone, and extrapelvic nodes (25). Liver metastases are present in one-third of patients and appear as solid masses with variable enhancement (Fig 17) (25). Adrenal metastases are usually from cervical adenocarcinomas and are present in approximately 15% of patients (25). Peritoneal metastases appear as soft-tissue masses and ascites and are present in 5%–27% of cases in autopsy series (25).
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Figure 17. Liver metastasis in a 43-year-old woman with clinical stage IB cervical cancer in whom recurrence occurred 3 years after diagnosis. Axial CT image of the abdomen obtained with oral and intravenous contrast material shows a hypoattenuating mass (arrow) in the left lobe of the liver with central low attenuation, which likely represents necrosis. These findings are compatible with a liver metastasis.
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Thoracic metastases manifest most commonly as multiple pulmonary nodules and occur in 33%–38% of patients (25,28). Cavitation occurs in a minority of cases (28). Lymphangitic carcinomatosis is seen in less than 5% of patients and appears as diffuse interstitial lung disease (28,29). Mediastinal or hilar adenopathy and pleural lesions or effusions are present in approximately one-third of patients with metastatic disease to the chest (Fig 18) (28). Adenopathy is usually seen with pleural or parenchymal disease (28). Rarely, the pericardium and myocardium may be involved (30,31). Tumor spreads from the paraaortic nodes to the pericardium and an effusion can develop (30). Patients with cervical adenocarcinoma are more likely to have evidence of thoracic metastases than those with squamous cell carcinoma (28).
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Figure 18a. Mediastinal adenopathy and pericardial effusion in a 43-year-old woman with clinical stage IB cervical cancer who presented with a cough 3 years after treatment. Axial CT images of the chest were obtained with intravenous contrast material. (a) There is adenopathy (solid arrow) in the prevascular and precarinal regions and the aortopulmonary window. A seroma (open arrow) in the left chest wall was secondary to mediastinoscopy. (b) Image obtained inferior to a shows a small pericardial effusion (arrow). Cytologic analysis of the fluid was positive for squamous cell carcinoma.
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Figure 18b. Mediastinal adenopathy and pericardial effusion in a 43-year-old woman with clinical stage IB cervical cancer who presented with a cough 3 years after treatment. Axial CT images of the chest were obtained with intravenous contrast material. (a) There is adenopathy (solid arrow) in the prevascular and precarinal regions and the aortopulmonary window. A seroma (open arrow) in the left chest wall was secondary to mediastinoscopy. (b) Image obtained inferior to a shows a small pericardial effusion (arrow). Cytologic analysis of the fluid was positive for squamous cell carcinoma.
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Large necrotic psoas metastases that simulate abscesses have usually been reported in women infected with human immunodeficiency virus, in whom cervical cancer has a more aggressive course (32). Osseous lesions usually occur secondary to direct extension from adjacent nodes and most commonly involve the lumbar spine (25). There is destruction of the vertebral body with an accompanying soft-tissue mass (17). This appearance is in contrast to that of radiation necrosis, in which a soft-tissue mass is absent and blastic changes may be present in the bone (33).
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Summary
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CT can aid in the staging and follow-up of patients with advanced cervical cancer. The primary tumor is heterogeneous and hypoattenuating to normal stroma on contrast-enhanced scans. Obliteration of the periureteral fat plane and a soft-tissue mass are the most reliable signs of parametrial extension. Less than 3 mm separation of the tumor from the pelvic muscles and vascular encasement are signs of pelvic side wall invasion. Lymphatic spread of tumor is along the external and internal iliac nodal chains and the presacral route and eventually involves the paraaortic nodes. Distant metastases are seen with recurrent disease and can involve the liver, lung, and bone.
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Footnotes
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**. Multiple body systems 
Abbreviation: FIGO = International Federation of Gynecology and Obstetrics
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Abstract
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