Fig.21  Stage IIA. (a) T2w TSE image in sagittal orientation. High-signal-intensity cervical cancer with ulceration (open arrow) of its posterior portion and infiltration of the posterior vaginal fornix (arrow). (b) T1w TSE image in

sagittal orientation. Following administration of Gd-DTPA, a low-signal intensity (hypovascularized) cervical cancer with ulceration and tumor infiltration of the posterior vaginal fornix is seen. Gel filling of the vagina

Fig.22  Stage IIA. (a) T2w TSE image in sagittal orientation. Cervical cancer seen as a high-signal-intensity mass of the anterior cervix (arrow) with infiltration of the proximal vagina (open arrow)

2.3.4.8  Stage IVB

Stage IVB cervical cancer is characterized by hematogenous dissemination.

2.3.5\ Lymph Node Staging

Following invasion of the dense network of lymphatic vessels in the parametria, cervical cancer can spread to the pelvic and para-aortic lymph nodes. The presence of lymph node metastases affects treatment planning and survival. Although several studies have shown that the presence of nodal metastases is among the most important prognostic factors in patients with cervical cancer, the nodal status is not taken into account by the FIGO classification. The earliest tumor stage associated with lymph node metastasis is IB (20%) and the risk increases with tumor size and stage (see Sects. 1.7 and 1.9). The risk of metastatic lymph nodes is increased in tumor recurrence and in patients with adenocarcinoma as compared with squamous cell carcinoma. Lymphatic spread usually first affects the primary

Fig.23  Stage IIA. (a) T2w TSE image in sagittal orientation. Cervical cancer seen as a high-signal-intensity mass of the anterior proximal cervix (arrow) with infiltration of the upper two-thirds of the vagina (open arrow). (b) T1w

TSE image with FS in sagittal orientation. Following administration of Gd-DTPA, a hypovascularized cervical cancer is depicted

lymph node stations in the parametrium, along the internal and external iliac arteries, from where the tumor spreads to the secondary, presacral lymph nodes along the common iliac artery and to the para-aortic lymph nodes (Figs. 33, 34, 35, and 36).

Finally, there may be spread to extra-abdomi- nal lymph nodes. These are primarily the supraclavicular lymph nodes in the venous angle (Fig. 37), at the termination of the azygos and hemiazygos veins into the superior vena cava, besides the less commonly affected parabronchial and axillary lymph node stations. The morphologic changes caused by nodal metastases range from slight increases in size of ­isolated nodes to large lymph node conglomerates.

Surgical lymphadenectomy remains the gold standard in the diagnosis of nodal metastases. However, despite dramatic advantages in ­minimally invasive surgical techniques and technologies, surgical lymphadenectomy remains a potential source of severe complications. For this reason, in recent years, a great research effort has been directed at identifying imaging techniques able to reliably assess the nodal status in a noninvasive manner. Historically, radiologic

evaluation of the lymph nodes is based on merely morphologic criteria including size and shape. A parametrial node is considered suspicious when its short axis is 5 mm or longer. A pelvic or para-aortic lymph node with a short axis longer than 10 mm and oval in shape or with an axis longer than 8 mm and round shape is interpreted as a potentially metastatic lymph node at MRI and CT (Scheidler et al. 1997; Kim et al. 1994). Other morphologic criteria are an irregular contour, inhomogeneous contrast enhancement and central necrosis. Intravascular contrast medium administration­ is especially useful to differentiate vascular structures and identify necrotic areas. While traditional size criteria display a specificity of almost 90% to exclude lymph node metastasis in early-stage cervical cancer patients, reported sensitivity rates are limited by the inability of merely morphological imaging techniques to detect lymphatic metastasis in normal-sized and -shaped nodes (Klerkx et al. 2010). Diffusionweighted MR imaging (DWI), a sequence that provides functional information about the integrity of cell membranes and tissue consistency, has been proposed to improve the distinction between normal and metastatic lymph nodes by means of

Fig. 24  Stage IIB. (a, b) T2w TSE images in sagittal and transverse orientation. Cervical cancer (asterisks) with infiltration of the posterior vagina (open arrow). Posterior disruption of the cervical stroma and a solid tumor extending in a posterior direction (arrows) are seen as signs of parametrium infiltration. (c) T1w TSE image with FS in transverse orientation 1 min after administration of Gd-DTPA showing a moderately hypervascularized cervical cancer with hypovascularized cervical stroma and hypervascularized lateral parametrial tissue

a

b

c

Fig. 25  Stage IIB. (a, b) T2w TSE images in sagittal and transverse orientation. Cervical cancer (asteriks) with infiltration of the posterior vaginal fornix. Clearly seen are parametrium tumor extensions (arrows) in a posterior direction and to the right without infiltration of the pelvic

sidewall or of the rectum. (c, d) T1w TSE images in sagittal and transverse orientation 1 min after administration of Gd-DTPA. Heterogeneous hypervascularized cervical cancer (asterisks) with hypovascularized, necrotic portions. Accessory finding: cervical cysts

differences in signal intensity quantified as the apparent diffusion coefficient (ADC). In recent years, numerous studies have demonstrated that DWI is able to distinguish metastatic from benign lymph nodes in cervical cancer patients. Chen

et al. (2011) reported that DWI with ADC measurements could differentiate metastatic from hyperplastic nodes with a sensitivity of 83.3%, specificity of 74.7%, and accuracy of 78.4%. By using the minimum ADC (≤0.881 × 10−3 mm2/s)

Fig.26   Stage IIB. (a, b) T2w TSE images in sagittal and transverse orientation. Cervical cancer with infiltration of the uterine corpus and hematometra (asterisk) due to tumorous stenosis of the cervical canal. Large solid tumor portions extend into the parametria posteriorly (open

arrow) but do not infiltrate the rectum. Also seen are nodal metastases of the internal obturator group, along the internal iliac artery, and of pararectal nodes on the left. (c, d) T1w TSE images in sagittal and transverse orientation 1 min after administration of Gd-DTPA

as a cutoff, Liu et al. reported a sensitivity and specificity for ­differentiating metastatic from nonmetastatic nodes of 95.7% and 96.5%, respectively (Liu et al. 2011). In a recent meta-analysis, Shen et al. reported pooled estimates of 0.86 (95% CI, 0.84–0.89) for sensitivity and 0.84 (95% CI, 0.83–0.86) for specificity, suggesting that DWI

could be beneficial in the assessment of pelvic nodal metastases in patients with cervical cancer (Shen et al. 2015).

Another modality, whole-body FDG-PET (5-fluor-odesoxyglucosis-positron emission tomography), can be used as a supplementary test for lymph node staging in follow-up (Reinhardt

Fig.28  Stage IIIB. (a, b) T2w TSE images in sagittal and transverse orientation. (c) HASTE TSE image in coronal orientation. (d) T1w TSE image in transverse orientation 1 min after administration of Gd-DTPA. Cervical cancer

with right lateral parametrial infiltration and infiltration of the right ureter, which is distended as a consequence (arrows)