DOI: 10.1148/rg.234035001
(Radiographics. 2003;23:969-981.)
© RSNA, 2003
Uterine Cervical Carcinoma after Therapy: CT and MR Imaging Findings1
Yong Yeon Jeong, MD,
Heoung Keun Kang, MD,
Tae Woong Chung, MD,
Jeong Jin Seo, MD and
Jin Gyoon Park, MD
1 From the Department of Diagnostic Radiology, Chonnam National University Medical School, 8 Hack-Dong, Dong-Ku, Gwang-Ju 501-757, Korea. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received January 2, 2003; revision requested January 24 and received February 21; accepted February 26. Address correspondence to Y.Y.J. (e-mail: yjeong@chonnam.ac.kr).
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Abstract
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Cervical carcinoma is one of the most frequent causes of death in women. Computed tomography (CT) and magnetic resonance (MR) imaging are the primary modalities for follow-up of treated cervical carcinoma. A normal vaginal cuff after hysterectomy appears as a smooth, low-signal-intensity muscular wall on T2-weighted MR images. Early (2–3 months after treatment) and significant decreases in the signal intensity and volume of the tumor at MR imaging indicate a good response to radiation therapy. Sites of recurrence are the pelvis, lymph nodes, and distant sites. Pelvic recurrence appears as a heterogeneously enhancing mass at contrast material–enhanced CT and often appears as a heterogeneous, high-signal-intensity mass at T2-weighted MR imaging. Lymph node recurrence ranges from scattered, minimally enlarged nodes to large, conglomerate nodal masses. Determination of neoplastic infiltration of lymph nodes is based on size; most researchers consider nodes greater than 1 cm in short-axis diameter to be metastatic. Distant metastases are usually due to recurrent disease and occur in the abdomen, thorax, and bone. Knowledge of the normal therapeutic changes and the spectrum of recurrent tumor in patients with cervical carcinoma is important for accurate interpretation of follow-up CT and MR images.
© RSNA, 2003
Index Terms: Uterine neoplasms, 854.32 • Uterine neoplasms, CT, 854.1211 • Uterine neoplasms, diagnosis, 854.39 • Uterine neoplasms, metastases, **.332 • Uterine neoplasms, MR, 854.1214 • Uterine neoplasms, therapeutic radiology, 854.47 • Uterine neoplasms, therapy, 854.451
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LEARNING OBJECTIVES FOR TEST 5
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After reading this article and taking the test, the reader will be able to:
- Identify the CT and MR imaging appearances of posttherapy changes in patients with cervical carcinoma.
- Discuss the complications of hysterectomy or pelvic irradiation performed for treatment of cervical carcinoma.
- Describe the imaging features of recurrent cervical carcinoma in the pelvis and lymph nodes and of distant metastases.
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Introduction
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Cervical carcinoma is the third most common gynecologic malignancy (1). Although patients now survive longer due to radiation therapy and more effective chemotherapy, cervical carcinoma is also one of the most frequent causes of death in women. The staging system of the International Federation of Gynecology and Obstetrics (FIGO) is widely used for treatment planning (2). The official FIGO staging method relies on pelvic physical examination and readily available diagnostic examinations such as intravenous urography, barium enema study, and chest radiography. Although FIGO staging plays an important role in determining the therapeutic strategy, there are significant inaccuracies in the FIGO staging system (2,3).
The treatment plan for patients with cervical carcinoma is shown in Table 1. The choice of treatment demands clinical judgment. Stage IA cervical carcinoma can be treated conservatively with conization in patients who desire fertility, but the standard of care remains simple hysterectomy. Patients with stage IB or IIA lesions may be treated with either surgery or radiation therapy, as these two approaches have an equivalent survival benefit. At many institutions, surgery for stage I and stage IIA disease is reserved for young patients, in whom preservation of ovarian function is desired and improved vaginal preservation is expected. Radiation therapy combined with chemotherapy is preferred for stage IIB, III, or IVA tumors (3–5).
Although advances in surgical techniques, radiation therapy, and chemotherapy have resulted in improved survival rates, approximately 30% of patients with invasive cervical carcinoma die as a result of recurrent or persistent disease (3). After primary treatment, patients are usually followed up with computed tomography (CT) or magnetic resonance (MR) imaging (Table 2) (6–11). Because additional radiation therapy or chemotherapy can improve the prognosis, early detection of recurrent cervical carcinoma is important.
CT is an effective diagnostic tool for detection of recurrent cervical carcinoma because of its advantages of rapid acquisition time, lack of bowel motion artifact, and fewer contraindications than MR imaging (8,9). However, with CT, it may be difficult to differentiate recurrence from postoperative and postirradiation fibrosis (6,7).
MR imaging is useful for making the diagnosis of tumor recurrence. A recurrent lesion shows increased signal intensity on T2-weighted images. The extent of vaginal recurrence and involvement of the pelvic floor muscles is better shown at MR imaging than at CT (13–15). The disadvantages of MR imaging compared with CT are its high cost and long imaging time.
CT and MR imaging have become pivotal for evaluating postoperative complications prior to radiologic intervention and for determining the presence of recurrent tumors and their response to radiation therapy (8–13). The purpose of this article is (aA to illustrate treatment-related changes in the pelvis, that is, anatomic changes resulting from surgery and those changes induced by radiation therapy; (b) to illustrate treatment-related complications; and (c) to review the imaging features of recurrent disease at CT and MR imaging.
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Posttherapy Changes
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Appearance after Surgery
Surgery is indicated for most patients with FIGO stage IB or IIA cancer of the cervix. The classic surgical approach is the Wertheim-Meigs operation. It consists of a total abdominal hysterectomy including resection of the upper third of the vagina, excision of parametrial and paravaginal tissue including the sacrouterine ligaments, and dissection of pelvic and paraaortic lymph nodes (2).
The CT and MR imaging appearances of the central pelvis are similar after radical hysterectomy. In addition to absence of the uterus, the vaginal fornix typically forms a linear soft-tissue configuration at CT and MR imaging following hysterectomy (8). Relative to CT, sagittal-plane MR imaging is useful for demonstrating the normal vagina wall. It is confirmed by visualizing a smooth, low-signal-intensity muscular wall on T2-weighted MR images (Fig 1). In some cases, however, fibrotic scar tissue is present at the vaginal vault. The scar demonstrates medium to low signal intensity on T2-weighted MR images (16,17). Metallic clips along the pelvic side wall can be detected at the site of lymph node dissection with CT (Fig 2). At MR imaging, metallicclips after radical hysterectomy may appear as low-signal-intensity foci.
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Figure 1a. Normal vaginal cuff after hysterectomy in a 46-year-old woman with stage IIA cervical carcinoma. (a) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/8) obtained through the vaginal cuff shows linear low signal intensity of the vaginal fornices (arrows). (b) Axial T2-weighted fast spin-echo MR image (3,500/78) obtained at the same level as a shows low signal intensity of the normal muscularis of the vagina (arrows). (c) Sagittal T2-weighted MR image (3,500/78) shows low signal intensity of the muscular layer of the vagina and high signal intensity of the vaginal mucosa. The uterus is absent.
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Figure 1b. Normal vaginal cuff after hysterectomy in a 46-year-old woman with stage IIA cervical carcinoma. (a) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/8) obtained through the vaginal cuff shows linear low signal intensity of the vaginal fornices (arrows). (b) Axial T2-weighted fast spin-echo MR image (3,500/78) obtained at the same level as a shows low signal intensity of the normal muscularis of the vagina (arrows). (c) Sagittal T2-weighted MR image (3,500/78) shows low signal intensity of the muscular layer of the vagina and high signal intensity of the vaginal mucosa. The uterus is absent.
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Figure 1c. Normal vaginal cuff after hysterectomy in a 46-year-old woman with stage IIA cervical carcinoma. (a) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/8) obtained through the vaginal cuff shows linear low signal intensity of the vaginal fornices (arrows). (b) Axial T2-weighted fast spin-echo MR image (3,500/78) obtained at the same level as a shows low signal intensity of the normal muscularis of the vagina (arrows). (c) Sagittal T2-weighted MR image (3,500/78) shows low signal intensity of the muscular layer of the vagina and high signal intensity of the vaginal mucosa. The uterus is absent.
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Figure 2. Metallic attenuation after lymphadenectomy in a 48-year-old woman with stage IB cervical carcinoma. Contrast material-enhanced CT scan shows areas of metallic attenuation (arrows) in both internal iliac lymph node chains.
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Appearance after Radiation Therapy
The definition of primary healing after radiation therapy is a cervix covered with normal epithelium or obliteration of the vaginal vault without evidence of ulceration or discharge (2). After completion of radiation therapy, clinical treatment (physical examination combined with evaluation of tumor markers) as well as imaging studies such as MR imaging are primarily intended for early detection of recurrent cervical carcinoma.
An early (2–3 months) and significant decrease in the signal intensity and volume of the tumor indicates a positive response to radiation therapy and a high probability of complete remission (11). MR imaging is more effective than CT for determining the effect of radiation therapy (Table 2). Hricak et al (13) reported that the findings of reconstitution of the normal zonal anatomy of the cervix and the presence of homogeneous low-signal-intensity cervical stroma at MR imaging are reliable indicators of a tumor-free postirradiation cervix (Fig 3).
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Figure 3a. Complete response of cervical carcinoma after radiation therapy. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/90) shows a large high-signal-intensity mass (arrows) in the uterine cervix. (b) Follow-up T2-weighted fast spin-echo MR image (3,500/90) obtained 4 months later shows a complete response with reconstitution of the zonal anatomy of the cervix. Fatty replacement changes are seen in the pelvic bone marrow.
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Figure 3b. Complete response of cervical carcinoma after radiation therapy. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/90) shows a large high-signal-intensity mass (arrows) in the uterine cervix. (b) Follow-up T2-weighted fast spin-echo MR image (3,500/90) obtained 4 months later shows a complete response with reconstitution of the zonal anatomy of the cervix. Fatty replacement changes are seen in the pelvic bone marrow.
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Complications of Treatment
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Complications of Surgery
The major complications of radical hysterectomy are ureteral fistula, lymphocele, pelvic infection, and hemorrhage (Fig 4). The prevalence of these complications is decreasing steadily to below 4% (2). CT is useful for evaluating surgical complications (Table 2). Lymphoceles are bothersome postoperative complications and have been reported in up to 30% of cases of lymphadenectomy performed because of gynecologic malignancy (18). Most lymphoceles are small and asymptomatic. They do not require treatment and eventually resolve spontaneously. However, symptomatic lymphoceles may become quite debilitating and may necessitate surgical or less invasive intervention, including simple aspiration, percutaneous catheter drainage (Fig 5), or percutaneous catheter drainage with sclerotherapy (19,20).
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Figure 4. Lymphoceles and hematoma in a 39-year-old woman after hysterectomy. Contrast-enhanced CT scan shows bilateral large lymphoceles (L) in the pelvic cavity and an oval hematoma (arrows) with internal high attenuation in the lower abdominal wall. The urinary bladder (UB) filled with contrast medium is seen in the central portion of the pelvic cavity.
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Figure 5a. Percutaneous drainage of a lymphocele. (a) Contrast-enhanced CT scan shows a large bilobulated lymphocele (arrows) with an enhancing wall in the pelvic cavity, an appearance suggestive of infection. (b) Follow-up CT scan obtained 4 days after percutaneous drainage without sclerotherapy shows a marked decrease in the size of the lymphocele.
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Figure 5b. Percutaneous drainage of a lymphocele. (a) Contrast-enhanced CT scan shows a large bilobulated lymphocele (arrows) with an enhancing wall in the pelvic cavity, an appearance suggestive of infection. (b) Follow-up CT scan obtained 4 days after percutaneous drainage without sclerotherapy shows a marked decrease in the size of the lymphocele.
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Complications of Radiation Therapy
Over the past century, radiation therapy has emerged as a notable alternative to radical surgery, primarily because of continued technical improvements. Late complications of radiation therapy include rectovesical fistula (Fig 6), sigmoiditis (Fig 7), rectal stricture, ureteral stricture, and sacral insufficiency fracture (2,21). In the evaluation of these complications, conventional imaging studies, such as barium study or excretory urography, are initially used. In the diagnosis of sacral insufficiency, MR imaging is an effective diagnostic modality. At contrast-enhanced MR imaging, presumed insufficiency fractures parallel the sacral side of the sacroiliac joint, are most prominent or initially seen anteriorly, and have ill-defined margins with all imaging sequences. Insufficiency fractures of the sacrum in the post–radiation therapy patient can mimic metastases (21).
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Figure 6a. Rectovesical fistula in a 55-year-old woman who underwent radical hysterectomy and radiation therapy. (a) Contrast-enhanced CT scan shows a fistulous tract (arrow) between the urinary bladder (UB) and rectosigmoid junction (R). (b) Lateral image from a barium enema examination clearly shows the fistulous tract (arrows). (c) Contrast-enhanced CT scan obtained caudad to a shows a recurrent mass (arrows) in the vaginal stump.
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Figure 6b. Rectovesical fistula in a 55-year-old woman who underwent radical hysterectomy and radiation therapy. (a) Contrast-enhanced CT scan shows a fistulous tract (arrow) between the urinary bladder (UB) and rectosigmoid junction (R). (b) Lateral image from a barium enema examination clearly shows the fistulous tract (arrows). (c) Contrast-enhanced CT scan obtained caudad to a shows a recurrent mass (arrows) in the vaginal stump.
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Figure 6c. Rectovesical fistula in a 55-year-old woman who underwent radical hysterectomy and radiation therapy. (a) Contrast-enhanced CT scan shows a fistulous tract (arrow) between the urinary bladder (UB) and rectosigmoid junction (R). (b) Lateral image from a barium enema examination clearly shows the fistulous tract (arrows). (c) Contrast-enhanced CT scan obtained caudad to a shows a recurrent mass (arrows) in the vaginal stump.
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Figure 7a. Sigmoiditis in a 77-year-old woman after radiation therapy. (a) Contrast-enhanced CT scan shows concentric edematous wall thickening of the sigmoid colon with preservation of colonic layering (arrows). There is proliferation and linear infiltration of the prerectal fat plane. (b) Frontal image from a barium enema examination shows tapered narrowing of the sigmoid colon (arrows).
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Figure 7b. Sigmoiditis in a 77-year-old woman after radiation therapy. (a) Contrast-enhanced CT scan shows concentric edematous wall thickening of the sigmoid colon with preservation of colonic layering (arrows). There is proliferation and linear infiltration of the prerectal fat plane. (b) Frontal image from a barium enema examination shows tapered narrowing of the sigmoid colon (arrows).
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Tumor Recurrence
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A recurrence is defined as local tumor regrowth or the development of distant metastases at least 6 months after the treated lesion has regressed. Risk factors for recurrence of cervical carcinoma include the histologic features of the tumor, tumor size, the depth of stromal invasion, and the nodal status at presentation (2,4). The most frequent site of recurrence is the pelvis (22,23).
Therapeutic options for recurrent tumor include surgery, radiation therapy, and chemotherapy, depending on the primary tumor therapy and the location and extent of the recurrence (2,4). Determination of the extent of recurrence with CT and MR imaging may provide clinical assistance in selection of the optimal therapy. Locally recurrent disease can be treated with either radiation after radical hysterectomy or pelvic exenteration after primary radiation therapy (Table 3). Exenteration in appropriately selected patients yields 5-year survival rates up to 82% with low complication rates (4). With recurrent disease outside the initial treatment field, irradiation is frequently successful in providing local control and symptomatic relief (2).
Although there is little information in the literature concerning the usefulness of MR imaging compared with CT for diagnosis of recurrent cervical carcinoma, MR imaging may be superior to CT for delineating residual tumor because of its high contrast resolution (10,24,25). There is evidence to suggest that tumor recurrence can be differentiated from radiation fibrosis at MR imaging (12,13). Residual tumor may be recognized on CT scans obtained with intravenous contrast material, on which it may appear as a soft-tissue mass with diminished enhancement compared with that of normal cervical tissue. Residual tumor has high signal intensity on T2-weighted images, similar to the corresponding primary tumor (Fig 8) (6,8).
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Figure 8a. Persistent disease 4 months after radiation therapy. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/75) shows an inhomogeneous high-signal-intensity mass (arrows) in the uterine cervix and invasion of the posterior wall of the urinary bladder. (b) Sagittal T2-weighted fast spin-echo MR image (3,500/75) obtained 2 months later shows that the mass (arrows) has the same signal intensity.
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Figure 8b. Persistent disease 4 months after radiation therapy. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/75) shows an inhomogeneous high-signal-intensity mass (arrows) in the uterine cervix and invasion of the posterior wall of the urinary bladder. (b) Sagittal T2-weighted fast spin-echo MR image (3,500/75) obtained 2 months later shows that the mass (arrows) has the same signal intensity.
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Pelvic Recurrence
Recurrence of tumor in the pelvis is either central or at the side wall (23). Central pelvic recurrence of cervical carcinoma may be located in the preserved cervix (Fig 9) or the vaginal cuff (26,27). Images in the sagittal and axial planes are helpful in tumor detection, and the combination of T1- and T2-weighted images often allows tissue characterization. Central pelvic recurrence with anterior extension may lead to ureteral obstruction by direct encasement of the ureter or by tumor infiltration of the bladder wall, which results in obstruction at the ureteral orifice (Fig 10). In some instances, central pelvic recurrences may extend posteriorly to involve the rectum with development of a rectovaginal fistula or extend laterally to involve the pelvic side wall (23). The treatment for rectovaginal fistula with recurrence is pelvic exenteration, which is required to divert the fecal stream. The presence of pelvic side wall invasion makes the patient ineligible for curative exenteration (Table 3) (2).
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Figure 9a. Central pelvic recurrence of cervical carcinoma in a 78-year-old woman 10 years after radiation therapy. (a) Contrast-enhanced CT scan shows a ringlike enhancing recurrent mass (arrows) in the uterine cervix. (b) Sagittal multiplanar reformatted image shows severe hydrometra (H).
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Figure 9b. Central pelvic recurrence of cervical carcinoma in a 78-year-old woman 10 years after radiation therapy. (a) Contrast-enhanced CT scan shows a ringlike enhancing recurrent mass (arrows) in the uterine cervix. (b) Sagittal multiplanar reformatted image shows severe hydrometra (H).
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Figure 10a. Central pelvic recurrence of cervical carcinoma in a 46-year-old woman after surgery. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/90) shows an ill-defined inhomogeneous mass (arrows), which has high signal intensity relative to that of back muscle. Loss of low signal intensity in the wall of the urinary bladder is indicative of invasion. (b) Axial contrast-enhanced gradient-echo MR image (120/1.5) shows a central recurrent mass with an irregular, thick, enhancing wall and invasion of the right pelvic side wall (arrow). (c) Axial T2-weighted fast spin-echo MR image (4,000/104) obtained at the renal hilum shows moderate right hydronephrosis.
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Figure 10b. Central pelvic recurrence of cervical carcinoma in a 46-year-old woman after surgery. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/90) shows an ill-defined inhomogeneous mass (arrows), which has high signal intensity relative to that of back muscle. Loss of low signal intensity in the wall of the urinary bladder is indicative of invasion. (b) Axial contrast-enhanced gradient-echo MR image (120/1.5) shows a central recurrent mass with an irregular, thick, enhancing wall and invasion of the right pelvic side wall (arrow). (c) Axial T2-weighted fast spin-echo MR image (4,000/104) obtained at the renal hilum shows moderate right hydronephrosis.
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Figure 10c. Central pelvic recurrence of cervical carcinoma in a 46-year-old woman after surgery. (a) Sagittal T2-weighted fast spin-echo MR image (3,500/90) shows an ill-defined inhomogeneous mass (arrows), which has high signal intensity relative to that of back muscle. Loss of low signal intensity in the wall of the urinary bladder is indicative of invasion. (b) Axial contrast-enhanced gradient-echo MR image (120/1.5) shows a central recurrent mass with an irregular, thick, enhancing wall and invasion of the right pelvic side wall (arrow). (c) Axial T2-weighted fast spin-echo MR image (4,000/104) obtained at the renal hilum shows moderate right hydronephrosis.
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Recurrent tumor may appear as a heterogeneous soft-tissue mass with variable degrees of necrosis at postcontrast CT and MR imaging (Fig 11). Pelvic recurrence may have a cystic appearance with minimal soft-tissue masses (12). When there is recurrence within the preserved cervix after radiation therapy, obstruction of the cervical os may occur and may result in hydrometra (Fig 9). At T2-weighted MR imaging, recurrent tumor often demonstrates heterogeneous high signal intensity. After contrast material administration, recurrent tumor shows varying degrees of enhancement (15,28). CT has high sensitivity and specificity for detection of recurrent tumor and can be used to monitor patients (6,7). However, MR imaging is superior to CT for delineating recurrent tumor because it provides superior soft-tissue contrast. MR imaging may be more accurate than CT for evaluating tumor invasion of the bladder and rectum (15,29).
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Figure 11. Pelvic recurrence of cervical carcinoma in a 42-year-old woman after surgery. Contrast-enhanced CT scan shows a heterogeneously enhancing mass in the pelvic cavity with invasion of the left posterolateral pelvic wall (arrows) and destruction of the sacrum.
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In patients who have received radiation therapy, distinguishing radiation fibrosis from recurrent tumor can be difficult and biopsy may be necessary. Recent studies indicate that dynamic contrast-enhanced T1-weighted MR imaging may be helpful in making this important distinction, with accuracies of 82%–83% (14,28). In addition, serial or follow-up MR imaging is useful for distinguishing recurrent disease from radiation-induced fibrosis, as the latter is expected to remain stable or diminish in prominence over time (11).
Lymph Node Recurrence
Lymphatic involvement in cervical cancer has traditionally been separated into primary and secondary nodal groups (Fig 12). The primary group consists of the paracervical, parametrial, external and internal iliac (hypogastric), and obturator nodes, whereas the secondary group includes the sacral, common iliac, inguinal, and paraaortic nodes (2). In general, paracervical and parametrial lymph nodes are involved first, followed by the obturator nodes, the remaining external iliac nodes, and the internal iliac nodes (2,26,30). When the secondary nodal group is involved, the prognosis worsens. Multiple extrapelvic and extraabdominal nodal sites of recurrence, including the parabronchial, supraclavicular, and axillary nodes, have been reported but are less frequently involved than the primary and secondary groups (21,30).
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Figure 12. Lymphatic pathways of spread of cervical carcinoma. Coronal (left) and sagittal (right) drawings of the abdomen and pelvis show the primary nodes (blue) and secondary nodes (green).
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The prevalence of lymphatic involvement by tumor varies with the histologic type of the tumor (30). Drescher et al (31) reported that tumor involvement of the primary nodal group occurred in 75% of patients with adenocarcinoma versus 61% of patients with squamous cell carcinoma. Similarly, tumor was identified in paraaortic nodes in 62% of patients with adenocarcinoma versus 30% of patients with squamous cell carcinoma.
The findings of nodal metastasis range from scattered, minimally enlarged lymph nodes to large, conglomerate nodal masses at CT and MR imaging (Fig 13). The reported accuracy rate of CT for detecting pelvic node metastasis in patients with uterine cervical carcinoma is 73%–83%, whereas the rate for MR imaging is 76%–100% (32,33). Recently, Yang et al (34) reported that CT and MR imaging show similar accuracy in evaluation of pelvic lymph nodes in patients with cervical carcinoma. Although CT and MR imaging cannot help distinguish reactive from neoplastic lymph nodes, they are useful for detecting enlarged nodes. Determination of metastatic infiltration of lymph nodes with CT and MR imaging is based on their size. Although the size criterion for metastatic lymph nodes is currently debatable, most authors agree that nodes greater than 1 cm in short-axis diameter are considered to represent metastatic lymph node involvement with accuracy rates of 75%–88% (14,33,35). Central lymph node necrosis is a helpful finding for differentiating metastatic nodes from nonmetastatic and hyperplastic nodes. When central necrosis is detected in a lymph node, the positive predictive value for malignancy is 100% (34).
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Figure 13a. Lymph node metastases. (a) Obturator node metastasis in a 32-year-old woman who underwent radical hysterectomy. Contrast-enhanced CT scan shows a peripherally enhancing low-attenuation mass (arrows) attached to the left ilium. (b) Paraaortic node metastases in a 55-year-old woman who underwent radiation therapy. CT scan shows conglomerate enlarged lymph nodes (arrows) in the portacaval space.
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Figure 13b. Lymph node metastases. (a) Obturator node metastasis in a 32-year-old woman who underwent radical hysterectomy. Contrast-enhanced CT scan shows a peripherally enhancing low-attenuation mass (arrows) attached to the left ilium. (b) Paraaortic node metastases in a 55-year-old woman who underwent radiation therapy. CT scan shows conglomerate enlarged lymph nodes (arrows) in the portacaval space.
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Extrapelvic lymph nodes, including the supraclavicular, paraaortic, and inguinal, are common sites of distant metastasis (Fig 13b). The prevalence of recurrence at extrapelvic lymph nodes is higher in patients treated with radiation therapy or those with pelvic side wall extension than in those who undergo surgery; this is probably because this tumor stage is generally more advanced (2). CT is useful for detecting clinically unsuspected extrauterine metastases and lymph node metastases (36).
Distant Metastases
Distant metastases from cervical carcinoma are usually due to recurrent disease and are seen in the abdomen, thorax, and bone, in decreasing order of frequency. After the pelvis and lymph nodes, the solid organs of the abdomen are the most frequent sites of involvement of recurrent cervical carcinoma.
Abdominal metastasis occurs in the peritoneal cavity and solid organs such as the liver and adrenal gland (26,37,38). The CT and MR imaging findings of metastases to the peritoneal cavity include ascites, implants scalloping the liver contour, peritoneal thickening with nodularity, and soft-tissue masses. The abdominal solid organ most commonly involved is the liver (31). CT and MR imaging permit detection of small liver metastases. Hepatic metastasis of cervical carcinoma usually appears as multiple focal masses with variable enhancement (Fig 14a). Therefore, the CT and MR imaging findings of hepatic metastasis in recurrent cervical carcinoma are indistinguishable from those of involvement by other primary malignancies (26,39). Involvement of another abdominal solid organ, such as the adrenal gland, spleen, kidney, pancreas, or gastrointestinal tract, is rare and in almost all cases occurs as widespread metastasis involving other organs as well (2,31).
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Figure 14a. Distant metastases. (a) Hepatic metastases in a 64-year-old woman who underwent radiation therapy. Portal venous phase CT scan shows multiple variably enhancing masses in the liver. (b) Lung metastases in a 41-year-old woman who underwent radiation therapy. Chest CT scan shows multiple nodular lesions (arrows) in the right lower lung. (c) Bone metastases in a 35-year-old woman who underwent radical hysterectomy. Contrast-enhanced CT scan shows multiple conglomerate lymph nodes (arrows) in the paraaortic space and irregular destruction (arrowhead) of the lumbar spine. There is marked hydronephrosis in the left pelvocaliceal system with cortical thinning.
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Figure 14b. Distant metastases. (a) Hepatic metastases in a 64-year-old woman who underwent radiation therapy. Portal venous phase CT scan shows multiple variably enhancing masses in the liver. (b) Lung metastases in a 41-year-old woman who underwent radiation therapy. Chest CT scan shows multiple nodular lesions (arrows) in the right lower lung. (c) Bone metastases in a 35-year-old woman who underwent radical hysterectomy. Contrast-enhanced CT scan shows multiple conglomerate lymph nodes (arrows) in the paraaortic space and irregular destruction (arrowhead) of the lumbar spine. There is marked hydronephrosis in the left pelvocaliceal system with cortical thinning.
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Figure 14c. Distant metastases. (a) Hepatic metastases in a 64-year-old woman who underwent radiation therapy. Portal venous phase CT scan shows multiple variably enhancing masses in the liver. (b) Lung metastases in a 41-year-old woman who underwent radiation therapy. Chest CT scan shows multiple nodular lesions (arrows) in the right lower lung. (c) Bone metastases in a 35-year-old woman who underwent radical hysterectomy. Contrast-enhanced CT scan shows multiple conglomerate lymph nodes (arrows) in the paraaortic space and irregular destruction (arrowhead) of the lumbar spine. There is marked hydronephrosis in the left pelvocaliceal system with cortical thinning.
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Thoracic metastases manifest most commonly as multiple pulmonary nodules (Fig 14b). Mediastinal or hilar adenopathy and pleural lesions or effusions are present in approximately one-third of patients with metastatic disease to the chest. Rare findings include endobronchial obstruction and lymphangitic carcinomatosis (26,27).
Bone metastasis occurs secondary to direct extension from adjacent lymph nodes and most commonly involves the lumbar spine, followed by the pelvis, ribs, and extremities (2,31). CT and MR imaging show destruction of the vertebral body with an accompanying soft-tissue mass (Fig 14c). This appearance is in contrast to that of radiation necrosis, in which a soft-tissue mass is absent (27).
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Conclusions
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CT and MR imaging are the primary modalities in staging and follow-up of patients with cervical cancer. Effective use of these imaging modalities in posttreatment evaluation of patients with cervical carcinoma requires familiarity with the common spectrum of posttreatment findings and the typical sites of tumor recurrence. Meticulous interpretation of CT and MR images obtained during the follow-up period after treatment permits these commonly involved sites to be accurately evaluated for evidence of posttreatment change or tumor recurrence.
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Acknowledgments
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We thank Bonnie Hami, MA, for her editorial assistance in the preparation of the manuscript.
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Footnotes
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2**. Multiple body systems 
See the commentary by Siegelman
following this article.
Abbreviation: FIGO = International Federation of Gynecology and Obstetrics
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