DOI: 10.1148/rg.251045047
RadioGraphics 2005;25:41-52
© RSNA, 2005
MR Imaging Appearances of the Female Pelvis after Trachelectomy1
Anju Sahdev, MRCP, FRCR,
Jonathan Jones, MRCP, FRCR,
John H. Shepherd, FRCR, FRCOG and
Rodney H. Reznek, FRCP, FRCR
1 From the Department of Radiology, Homerton University Hospital, Homerton Row, London E9 6SR, England (A.S.); the Department of Radiology, St Bartholomew’s Hospital, Barts and the London NHS Trust, London (J.J., R.H.R.); and the Department of Surgical Gynaecology, St Bartholomew’s Hospital, London (J.H.S.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received March 17, 2004; revision requested April 14 and received May 10; accepted May 13. All authors have no financial relationships to disclose. Address correspondence to A.S. (e-mail: anju.sahdev@homerton.nhs.uk).
 |
Abstract
|
|---|
Carcinoma of the cervix has a predilection for affecting young women. In recent years, surgical procedures that combine local radical surgery with maintenance of fertility potential in young women have been investigated. One such procedure is radical trachelectomy with pelvic lymphadenectomy, in which the corpus uteri is preserved, thus maintaining fertility potential. Magnetic resonance (MR) imaging is useful in the selection of suitable patients for trachelectomy and in postsurgical follow-up. The MR imaging findings in 45 patients who underwent trachelectomy at one institution between 1996 and 2004 were retrospectively reviewed. The uterovaginal anastomosis has variable appearances, with an end-to-end anastomotic appearance or a vaginal neofornix seen after surgery; suture artifacts can also occur. Possible changes affecting the vagina include diffuse wall thickening and hematomas, whereas lymphoceles and exaggeration of the pelvic venous plexuses can occur in the pelvis. Adenomyosis and endometriosis may be found incidentally in this patient group. Successful pregnancies after trachelectomy have been reported and should be treated as high-risk pregnancies. Knowledge of these MR imaging appearances will help radiologists distinguish between normal postsurgical variations, benign postsurgical changes, and recurrent disease in patients who have undergone trachelectomy.
© RSNA, 2005
|
Introduction
|
|---|
Carcinoma of the cervix is the third commonest gynecologic malignancy worldwide and is a disease with a predilection for young women. Approximately 30% of women with cervical cancer are less than 35 years of age (1). These cancers are mostly screening detected cancers and manifest as early disease. Cervical cancer is staged by using the Federation Internationale de Gynecologie et d’Obstetrique (FIGO) staging system (Table). For superficial invasive cervical cancer (stage IA), in women who want to preserve their fertility, conization of the cervix is an accepted form of treatment. For invasive cancer stage IA and up to and including stage IIA, the traditional treatment has been a Wertheim radical hysterectomy or radiation therapy. Advanced disease with parametrial invasion is treated by radiation therapy. These radical treatments have good survival results, but both modalities are associated with subsequent sterility. In recent years, surgical procedures have been explored combining radical local resection of the tumor while maintaining fertility in young women (2–4). This follows the belief that the traditional management represented overtreatment for a proportion of very early stage I tumors.
Radical trachelectomy with pelvic lymphadenectomy is a conservative but curative surgical procedure for early (stage IB1 or lower) carcinoma of the cervix. In 1994, Dargent and Mathevet (5) reported a significant advance in the use of conservative curative surgery by using a modified technique of radical vaginal trachelectomy and pelvic lymphadenectomy in 14 patients. In 1998, Shepherd et al (6) also reported excellent results with this procedure in 10 patients. The technique performed at our institution involves a proximal vaginotomy, cervical resection, and paracervical and paravaginal dissection. The cervix is resected, preserving the corpus uteri. An end-to-end anastomosis is performed, and a cerclage suture may be placed to maintain competency and therefore fertility potential (Fig 1). Bilateral pelvic lymphadenectomy is performed in all patients. Radical trachelectomy has been shown to have a lower mortality and morbidity but comparable curative rates to the more traditional hysterectomy (3,4). To date, approximately 200 cases have been described in the literature (2–4). There are six centers worldwide known to perform radical trachelectomy in significant numbers, and close communication exists between the centers. The updated number from these centers is closer to 350 cases (Shepherd JH, personal communication, 2004).
View larger version (94K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a. Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.
|
|
View larger version (88K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b. Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.
|
|
View larger version (101K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1c. Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.
|
|
Magnetic resonance (MR) imaging has been used preoperatively for patient selection (7) and also for postoperative follow-up. Within the world literature, individual complications, pregnancy rates, recurrence rates, and modifications to the technique of trachelectomy have been described (3,8). To our knowledge, there has been no review of the MR imaging appearances of the pelvis in women following trachelectomy. In this article, we discuss the postoperative pelvic appearances following a trachelectomy to aid radiologists not familiar with this technique. We will include features that are normal and related to postsurgical changes that may serve as a pitfall for the diagnosis of recurrent disease. We also discuss postoperative surgical complications, concurrent pelvic disease processes, and appearances of pregnancy. Finally, although it is rare, we demonstrate the appearances of recurrent disease in this group of patients.
|
Materials and Methods
|
|---|
At our institution, 94 women have undergone a trachelectomy and pelvic lymphadenectomy. The pre- and postoperative MR images of 45 patients were available for review. As our institution is a tertiary referral center, several patients underwent the pre- or postoperative follow-up MR imaging at the referring centers. The imaging was performed preoperatively and at 3 and 6 months after surgery. Longer follow-up with MR imaging was performed if clinically required. Each patient’s MR images were retrospectively reviewed by two of the authors (A.S., J.J.).
At our institution, MR imaging was performed with a 1.5-T superconducting magnet (Signa; GE Medical Systems, Milwaukee, Wis). Pulse sequences performed were axial, sagittal, and oblique T2-weighted fast spin-echo sequences (5,000–6,000/119 [repetition time msec/echo time msec], 7-mm section thickness, 2-mm gap) and an axial T1-weighted spin-echo sequence (500/10, 7-mm section thickness, 2-mm gap). A 24 x 24-cm field of view was used for the axial and oblique sequences, and a 32 x 32-cm field of view was used for the sagittal sequences. A matrix of 256 x 192 or 516 x 256 was used with two or three signals acquired. All sequences were performed with use of a phased-array pelvic coil. The axial T1-weighted sequence included the abdomen and pelvis, but the T2-weighted sequences were confined to the pelvis.
|
Normal Appearances of the Pelvis
|
|---|
Appearances of the Uterus
End-to-End Anastomotic Appearance.—
With the resection of the cervix, the expected surgical appearance is that of an end-to-end anastomosis between the corpus uteri and the vaginal vault. Figure 1 illustrates the surgical procedure. In our cohort of patients, the end-to-end anastomotic appearance was seen in 20 of 45 women (44%) (Fig 2).
View larger version (166K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2. End-to-end anastomotic appearance after trachelectomy. Sagittal T2-weighted image shows the corpus uteri anastomosed to the upper vaginal vault (arrow). On the basis of the surgical details, this is the expected postoperative appearance of the residual uterus and vagina. Twenty patients (44%) demonstrated this appearance.
|
|
Neofornix of the Vagina.—
The appearance of the anastomosis can vary. In 25 of 45 women (56%), there was a posterior extension of the vaginal wall appearing as a neo–posterior vaginal fornix (Figs 3, 4). MR imaging appearances of recurrent disease include the presence of a soft tissue mass at the site of the uterovaginal anastomosis. Therefore, it is important to recognize this normal variant in order to differentiate it from recurrent disease. In our experience, anastomotic appearances do not alter with time and follow-up images obtained up to 2 years after surgery retain the original postoperative appearances. Correlation of these MR imaging findings with the surgical procedures suggests that these appearances are a combination of the healing process of the vagina and the closure of the lateral fornices formed at the time of anastomosis. During healing, it is assumed that the lateral fornices come to lie posteriorly and are seen on MR images as the neofornix.
View larger version (186K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Posterior neofornix of the vagina. (a) Sagittal T2-weighted image shows an apparent posterior vaginal fornix (arrow). (b) Axial T2-weighted image shows the neofornix as an apparent mass posterior to the anastomosis (arrow). It is important to diagnose this finding as a normal variant of the surgical appearance and not as a recurrent mass lesion. This appearance was seen in 25 patients (56%).
|
|
View larger version (196K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Posterior neofornix of the vagina. (a) Sagittal T2-weighted image shows an apparent posterior vaginal fornix (arrow). (b) Axial T2-weighted image shows the neofornix as an apparent mass posterior to the anastomosis (arrow). It is important to diagnose this finding as a normal variant of the surgical appearance and not as a recurrent mass lesion. This appearance was seen in 25 patients (56%).
|
|
Suture Artifacts.—
Suture artifacts arise from two sources: the anastomotic sutures and the cerclage suture (Fig 1c), which is placed around the corpus uteri to preserve competence during pregnancy. The artifacts are most pronounced with the sagittal and axial fast spin-echo T2-weighted sequences.
Suture susceptibility artifacts were present in 10 of 45 patients (22%). The artifacts are usually minor and in our review did not hinder diagnostic interpretation in nine of 10 cases (Figs 5, 6). In one patient (Fig 7), the artifacts from the cerclage suture were quite conspicuous and could have obscured a small recurrent mass at the anastomosis.
View larger version (160K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5. Suture artifacts. Sagittal T2-weighted image shows susceptibility artifacts produced by the cerclage and anastomotic sutures (arrow). These artifacts were seen in 10 patients (22%) but did not limit interpretation of the MR images in nine of these patients.
|
|
View larger version (162K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7. Suture artifacts. Sagittal T2-weighted image shows prominent susceptibility artifacts from the cerclage suture at the anastomotic site. Pronounced susceptibility artifacts were seen only in this patient; therefore, direct visualization by means of clinical examination was performed to exclude a small recurrent mass.
|
|
Isthmic Stenosis.—
Isthmic stenosis occurred in one patient (2%) in our study (Fig 8). This was detected on MR images acquired 3 months after surgery as a routine follow-up. This complication of trachelectomy has been previously reported in the literature (8). Schlaerth et al (3) also reported two cases in their study of 10 patients. These patients presented with secondary amenorrhea following trachelectomy.
View larger version (202K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8. Isthmic stenosis. Sagittal T2-weighted image shows stenosis at the anastomotic site (arrow) with resultant dilatation of the endometrial cavity. This finding was seen in one patient (2%), who presented with secondary postsurgical amenorrhea.
|
|
Appearances of the Vagina
Diffuse Wall Thickening.—
Radical trachelectomy requires the dissection of paravaginal and parametrial tissue in order to mobilize the proximal vagina and cervix prior to resection. Consequently, postsurgical changes can be present in the residual vaginal wall at MR imaging. In our experience, there was diffuse vaginal wall thickening in three of 45 women (7%). This was most apparent on the postsurgical images obtained 3 and 6 months after trachelectomy (Fig 9). At 3 months, biopsy of the vaginal walls was performed to exclude infiltrative recurrent disease. The thickening slowly resolved by 1 year after surgery. The signal intensity on T2-weighted images of this diffuse thickening cannot be differentiated from and therefore can be confused with recurrent disease affecting and infiltrating the vaginal wall.
View larger version (175K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9. Thickening of the vaginal wall. Sagittal T2-weighted image shows diffuse thickening of both the anterior and posterior vaginal walls (arrows). These changes were seen in three patients and persisted for up to 6 months after trachelectomy. Biopsy of the diffusely thickened wall demonstrated only benign changes, but the changes in signal intensity mimic infiltrative recurrent disease.
|
|
Hematomas.—
In addition to diffuse involvement of the vaginal wall, focal postsurgical hematomas were present in two patients (4%) (Figs 10, 11). Both hematomas resolved slowly, persisting for up to 1 year after surgery.
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Hematoma of the vaginal wall. (a) Sagittal T2-weighted image shows a high-signal-intensity fluid collection along the posterior wall of the vagina. (b) Axial T1-weighted image obtained with fat saturation shows that the fluid collection has high signal intensity. The signal intensity properties suggest that there is blood within the fluid collection. The fluid collection was seen on postoperative follow-up images for 1 year after surgery.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Hematoma of the vaginal wall. (a) Sagittal T2-weighted image shows a high-signal-intensity fluid collection along the posterior wall of the vagina. (b) Axial T1-weighted image obtained with fat saturation shows that the fluid collection has high signal intensity. The signal intensity properties suggest that there is blood within the fluid collection. The fluid collection was seen on postoperative follow-up images for 1 year after surgery.
|
|
View larger version (148K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11. Hematoma of the vaginal wall. Sagittal T2-weighted image shows a small hematoma in the anterior vaginal wall (arrow). The typical layering of blood products seen in hematomas is demonstrated in this case.
|
|
|
Pelvic Changes
|
|---|
Lymphoceles
Radical trachelectomy includes the resection of lymph nodes in the obturator and iliac chains bilaterally. Lymphoceles are a common consequence of nodal resection. In our cohort of patients, lymphoceles were present in 12 patients (27%). These were bilateral in eight patients and unilateral in four (Figs 12, 13). In our study, lymphoceles occurred most commonly in the external iliac distribution. In our experience, all lymphoceles were slow to resolve: After several years of routine follow-up, four patients had persistent lymphoceles, all of which were gradually decreasing in size. Similar natural histories of pelvic lymphoceles have been reported following lymphadenectomy with prostatectomy and after renal transplantation in the pelvis (9,10).
View larger version (164K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Bilateral pelvic lymphoceles. (a) Axial T2-weighted image shows large lymphoceles in the external iliac distribution (arrows). (b) Axial T1-weighted image shows uniform low signal intensity within the lymphoceles (arrows). The lymphocele on the right side contains debris and is thick walled. The lymphoceles were unchanged on follow-up MR images for 2 years.
|
|
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Bilateral pelvic lymphoceles. (a) Axial T2-weighted image shows large lymphoceles in the external iliac distribution (arrows). (b) Axial T1-weighted image shows uniform low signal intensity within the lymphoceles (arrows). The lymphocele on the right side contains debris and is thick walled. The lymphoceles were unchanged on follow-up MR images for 2 years.
|
|
View larger version (166K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13. Bilateral pelvic lymphoceles. Axial T2-weighted image shows lymphoceles in the right deep femoral and left external iliac distributions (arrows). The ovaries are also seen (arrowheads), and there is free fluid posterior to the uterus.
|
|
Exaggeration of the Pelvic Venous Plexuses
In six women (13%), there was an unexplained, asymptomatic exaggeration of the parametrial and pelvic venous plexuses after trachelectomy (Fig 14). In these women, the increase in size of the veins appears irreversible, as two women have undergone MR imaging over 2 years and the postoperative venous appearances remain unchanged.
View larger version (188K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Exaggeration of the parametrial venous plexus. (a) Axial T2-weighted image shows the parametrial venous plexus before trachelectomy (arrows). (b) Axial T2-weighted image shows the parametrial venous plexus 3 months after trachelectomy (arrows). The uterine veins are dilated and engorged. The patient was asymptomatic. This appearance was unchanged 6, 9, and 18 months after trachelectomy.
|
|
View larger version (187K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Exaggeration of the parametrial venous plexus. (a) Axial T2-weighted image shows the parametrial venous plexus before trachelectomy (arrows). (b) Axial T2-weighted image shows the parametrial venous plexus 3 months after trachelectomy (arrows). The uterine veins are dilated and engorged. The patient was asymptomatic. This appearance was unchanged 6, 9, and 18 months after trachelectomy.
|
|
|
Incidental Findings
|
|---|
Women undergoing trachelectomy are of childbearing age, and other common gynecologic conditions seen in this age group are included in our review. The radiologist should be alert to the MR imaging appearances of these concurrent and unrelated findings to avoid raising suspicion of recurrent disease.
Four patients (9%) had adenomyosis with widening of the junctional zone and high-signal-intensity foci on T2-weighted images in the myometrium of the residual corpus uteri. In two patients, these junctional zone changes were not appreciated at preoperative MR imaging (Fig 15).
View larger version (185K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15a. Adenomyosis. (a) Sagittal T2-weighted image shows small foci of high signal intensity in the myometrium. (b) Sagittal T2-weighted image shows a widened junctional zone in the residual corpus uteri. Susceptibility artifact from the cerclage suture is also noted (arrow). Concurrent adenomyosis was seen in four patients (9%). These appearances were observed only after surgery.
|
|
View larger version (157K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15b. Adenomyosis. (a) Sagittal T2-weighted image shows small foci of high signal intensity in the myometrium. (b) Sagittal T2-weighted image shows a widened junctional zone in the residual corpus uteri. Susceptibility artifact from the cerclage suture is also noted (arrow). Concurrent adenomyosis was seen in four patients (9%). These appearances were observed only after surgery.
|
|
Three patients (7%) were noted to have either unilateral or bilateral endometriomas (Fig 16). In two patients, the endometriomas were evident at postoperative MR imaging only.
View larger version (181K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16a. Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.
|
|
View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16b. Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.
|
|
View larger version (141K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16c. Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.
|
|
|
Pregnancy
|
|---|
In our patients, 13 women attempted to conceive after trachelectomy. After 1 year, eight (62%) were pregnant (Fig 17). There was a total of 14 pregnancies and nine live births. There were seven premature deliveries (50%) and one late miscarriage (7%). Six of the preterm births and the late miscarriage were associated with prelabor spontaneous rupture of membranes in the third trimester (11). As in our series, Bernardini et al (12) report preterm rupture of membranes as the primary cause of preterm delivery. Successful pregnancies after trachelectomy have been reported by other centers, and the overall recommendation is to treat these as high-risk pregnancies (13,14).
View larger version (163K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17a. Appearances of the residual uterus during pregnancy. (a) Axial T2-weighted image shows an intrauterine pregnancy. A left external iliac lymphocele is also present (arrowhead). (b) Sagittal T2-weighted image shows the gravid uterus. The cervical anastomosis is noted (arrow) with a cerclage suture maintaining competency during the pregnancy.
|
|
View larger version (175K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17b. Appearances of the residual uterus during pregnancy. (a) Axial T2-weighted image shows an intrauterine pregnancy. A left external iliac lymphocele is also present (arrowhead). (b) Sagittal T2-weighted image shows the gravid uterus. The cervical anastomosis is noted (arrow) with a cerclage suture maintaining competency during the pregnancy.
|
|
|
Recurrent Disease
|
|---|
There were two women (4%) with recurrent cervical cancer after radical trachelectomy. In both women, the initial recurrence was local and at the anastomotic site (Figs 18, 19a). Both patients received chemo- and radiation therapy for the recurrent disease. One patient continued to demonstrate disease progression with development of para-aortic lymphadenopathy (Fig 19b), while the second patient remains in disease remission.
View larger version (154K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18a. Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.
|
|
View larger version (159K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18b. Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.
|
|
View larger version (80K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18c. Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.
|
|
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19a. Local and distant recurrence of cervical carcinoma. (a) Axial T2-weighted image shows a mass at the left lateral margin of the anastomosis (arrow). Despite chemotherapy and radiation therapy, the recurrent disease progressed. (b) Axial T1-weighted image shows left para-aortic lymphadenopathy (arrow).
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19b. Local and distant recurrence of cervical carcinoma. (a) Axial T2-weighted image shows a mass at the left lateral margin of the anastomosis (arrow). Despite chemotherapy and radiation therapy, the recurrent disease progressed. (b) Axial T1-weighted image shows left para-aortic lymphadenopathy (arrow).
|
|
Review of the literature shows that the recurrence rate after trachelectomy varies from 0% to 25% (2–4,15). Dargent et al (15) demonstrated that tumors larger than 2 cm had a recurrence rate of 19% and tumors larger than 2 cm with a depth of invasion greater than 1 cm had the highest recurrence rate of up to 25%.
|
Conclusions
|
|---|
Trachelectomy is now an established curative surgical procedure designed to retain fertility in young women with carcinoma of the cervix. MR imaging has an important role in selecting patients suitable for trachelectomy. MR imaging is also used in the postsurgical follow-up of patients, and early detection of recurrent disease allows further curative treatment to be instituted promptly. In our review, we have highlighted several pitfalls in the diagnosis of recurrent disease that relate specifically to trachelectomy.
|
References
|
|---|
- Covens A, Rosen B, Murphy J, et al. Changes in the demographics and perioperative care of stage IA(2)/IB(1) cervical cancer over the past 16 years. Gynecol Oncol 2001; 81:133-137.[CrossRef][Medline]
- Burnett AF, Roman LD, O’Meara AT, Morrow CP. Radical vaginal trachelectomy and pelvic lymphadenectomy for preservation of fertility in early cervical carcinoma. Gynecol Oncol 2003; 88:419-423.[CrossRef][Medline]
- Schlaerth JB, Spirtos NM, Schlaerth AC. Radical trachelectomy and pelvic lymphadenectomy with uterine preservation in the treatment of cervical cancer. Am J Obstet Gynecol 2003; 188:29-34.[CrossRef][Medline]
- Covens A, Shaw P, Murphy J, et al. Is radical trachelectomy a safe alternative to radical hysterectomy for patients with stage 1A-B carcinoma of the cervix? Cancer 1999; 86:2273-2279.[CrossRef][Medline]
- Dargent D, Mathevet P. Schauta’s vaginal hysterectomy combined with laparoscopic lymphadenectomy. Baillieres Clin Obstet Gynaecol 1995; 9:691-705.[CrossRef][Medline]
- Shepherd JH, Crawford RA, Oram DH. Radical trachelectomy: a way to preserve fertility in the treatment of early cervical cancer. Br J Obstet Gynaecol 1998; 105:912-916.[Medline]
- Peppercorn PD, Jeyarajah AR, Woolas R, et al. Role of MR imaging in the selection of patients with early cervical carcinoma for fertility-preserving surgery: initial experience. Radiology 1999; 212:395-399.[Abstract/Free Full Text]
- Selo-Ojeme DO, Ind T, Shepherd JH. Isthmic stenosis following radical trachelectomy. J Obstet Gynaecol 2002; 22:327-328.
- Carbone JM, Nadler RB, Bullock AD, Basler JW. Delayed infection of a pelvic lymphocele following pelvic lymphadenectomy. Urology 1996; 47:140-142.[CrossRef][Medline]
- Khauli RB, Stoff JS, Lovewell T, Ghavamian R, Baker S. Post-transplant lymphoceles: a critical look into the risk factors, pathophysiology and management. J Urol 1993; 150:22-26.[Medline]
- Shepherd JH, Mould T, Oram DH. Radical trachelectomy in early stage carcinoma of the cervix: outcome as judged by recurrence and fertility rates. BJOG 2001; 108:882-885.[CrossRef][Medline]
- Bernardini M, Barrett J, Seaward G, Covens A. Pregnancy outcomes in patients after radical trachelectomy. Am J Obstet Gynecol 2003; 189:1378-1382.[CrossRef][Medline]
- Roy M, Plante M. Pregnancies after radical trachelectomy for early stage cervical cancer. Am J Obstet Gynecol 1998; 179:1491-1496.[CrossRef][Medline]
- Rodriguez M, Guimares O, Rose PG. Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation and subsequent pregnancy in the treatment of early invasive cervical cancer. Am J Obstet Gynecol 2001; 185:370-374.[CrossRef][Medline]
- Dargent D, Franzosi F, Ansquer Y, Martin X, Mathevet P, Adeline P. Extended trachelectomy relapse: plea for patient involvement in the medical decision. Bull Cancer 2002; 89:1027-1030.[Medline]
This article has been cited by other articles:
|
|
|
|
 
N. Hindman, G. M. Israel, and G. A. Krinsky
Case 114: Radical Trachelectomy
Radiology,
June 1, 2007;
243(3):
898 - 900.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
