Fig.29  Stage IVA. (a, b) T2w TSE images in sagittal and transverse orientation. (c, d) Tlw TSE images in sagittal and transverse orientation 1 min after administration of Gd-DTPA. Cervical cancer with infiltration of the posterior parametria. Rectal infiltration (arrows) is seen as

hyperintense tumor extension disrupting the anterior rectal wall, which is of low signal intensity before and of intermediate signal intensity after CM administration. Tumor is also seen in the posterior vaginal wall (asterisks)

51.2%) for FDG-PET/CT compared to DWI (Kitajima et al. 2012).

2.3.6\ Distant Metastases

Distant metastases are characteristic of stage IVB cervical cancer. In the FIGO classification, metastases of the para-aortic lymph nodes count as distant metastases. Hematogenous dissemination occurs late in cervical cancer or typically in

patients with local tumor recurrence. Organ metastases most commonly affect the lungs and are less frequent in the liver, peritoneum, and skeleton. Systemic staging for the exclusion of distant metastases is indicated in stage III and IV cervical cancer. In Germany, an additional helical CT scan of the chest, abdomen, and pelvis including the supraclavicular region, with oral opacification and IV bolus administration of contrast

Fig.30  Stage IVA. (a, b) T2w TSE images in sagittal and transverse orientation showing cervical cancer with infiltration of the urinary bladder. Disruption of the hypointense bladder wall and intravesical tumor growth are seen

(arrows). In addition, there is infiltration of the left lateral parametria and the left ureter, which is distended as a consequence (open arrow)

medium, is recommended (Schmidt-Matthiesen and Wallwiener 2005).

Autopsy studies found pulmonary metastases in about 35% of patients with recurrent cervical cancer. The probability of lung metastases is similar for squamous cell carcinoma and adenocarcinoma of the cervix. Solitary or multiple nodular pulmonary metastases may occur and are comparable to pulmonary metastases from other primaries in that clinical symptoms occur late. Chest CT is recommended as the first-line modality for exclusion of pulmonary metastases. Alternatively, routine chest radiography performed before therapy for assessment of the cardiopulmonary status can likewise be used to exclude pulmonary metastases but is less sensitive than CT. Pulmonary metastases are associated with mediastinal or hilar lymphadenopathy in 30% of cases and with pleural metastases in about 27% (autopsy studies). A slightly higher risk of pleural metastases has been reported for cervical adenocarcinoma. Rare findings are pericardial metastases, bronchial spread with endobronchial obstruction (5%), and pulmonary lymphangiosis carcinomatosa (3%) (Choi et al. 2000).

Liver metastases occur in about 30% of patients with recurrent cervical carcinoma (Drescher et al. 1989) (Fig. 37). They are identified by ultrasound as multiple focal lesions of low echogenicity and as focal lesions with heterogeneous contrast medium uptake on CT and MRI. MRI has the highest sensitivity in detecting liver metastases, especially when performed with administration of a liver-specific contrast medium (Hamm et al. 1997). Metastases in the peritoneum (Fig. 38), major omentum, or mesentery were identified at autopsy studies in 5–27% of cases (Nicolet et al. 2000; Sahdev et al. 2007). Clinical symptoms occur late and comprise abdominal pain and an increase in abdominal circumference. Metastases in these locations are sensitively identified by MRI and CT (Outwater et al. 1996; Low et al. 1997). MRI is performed with contrast-enhanced fat-saturated T1-weighted sequences, optionally supplemented by oral opacification. Characteristic signs of peritoneal metastases are a wavy contour of the liver resulting from impressions by the focal lesions, nodular­ peritoneal masses, and irregular peritoneal thickening. Ascites is unspecific but may indicate peritoneal metastases (Badib et al. 1968).

Recurrent cervical cancer is associated with bone metastases (Fig. 38) in 15–29% of patients at autopsy (Badib et al. 1968). Typical locations are the bony pelvis as well as the lumbar and other vertebral bodies. Bone metastases in the ribs and extremities

are less common. Skeletal metastases typically have an osteolytic character and originate from locally advanced or recurrent tumor in the pelvic sidewall or arise through retrograde tumor spread in patients with para-aortic lymph node metastasis.

Fig. 31  Stage IVA. (a) T2w TSE image in sagittal orientation. Cervical cancer with infiltration of the vesicouterine ligament and of the low-signal-intensity posterior bladder wall (arrow). Tlw TSE image with FS transverse

Fig. 32  Lymph node staging. Stages of metastatic spread to the lymph nodes in cervical cancer. (a) Parametrial nodes. (b) Nodes along the external and common iliac arteries. (c) Presacral nodes. (d) Para-aortic nodes (regarded as distant metastases) (from Wittekind et al. 2005)

orientation 1 min after administration of Gd-DTPA. (b) After CM administration, a hypervascularized tumor (transverse image) is seen in the posterior bladder wall (arrow) (from Nicolas et al. 2005)

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