Fig. 47   Recurrent cervical cancer after hysterectomy. (a, b) T2w TSE images in sagittal and transverse orientation. (c, d) T1w TSE images in sagittal and transverse orientation 1 min after administration of Gd-DTPA. MRI after hysterectomy depicts a nodular lesion at the roof of the

vagina with enhancement on the postcontrast images (arrows). Note the unusually low signal intensity of the lesion (like a scar); however, tumor recurrence is indicated by the strong contrast enhancement. Gel filling of the vagina

to radiation. Numerous studies published in the last years have demonstrated that pretreatment DCE parameters of high relative signal intensity or peak enhancement are associated with better response to treatment (Zahra et al. 2009; Mayr et al. 1996, 2010). Similarly, other groups were able to demonstrate that mid-treatment ADC may be a useful surrogate biomarker of treatment response (Harry et al. 2008) and even patient’s survival (Somoye et al. 2012).

2.5.4\ Recurrent Cervical Cancer

Cervical cancer tends to recur within 2 years after the initial diagnosis. Recurrence is defined as the demonstration of renewed local tumor growth, development of nodal metastases, or hematogenous distant metastases after a tumorfree interval of at least 6 months. About 30% of patients with invasive cervical carcinoma die because of recurrent disease. Some guidelines recommend follow-up examinations at 3-month

Fig. 48  Recurrent tumor of the pelvic sidewall after hysterectomy. (a) T2w TSE image in transverse orientation. At the right pelvic sidewall, a solid, heterogeneous mass (arrows) is depicted that infiltrates the pelvic wall and extends to the iliac bone. Tumor adhesion

to the sigmoid colon. (b) T1w TSE image with FS transverse orientation

1 min after administration of Gd-DTPA. MRI depicts an enhancement on the postcontrast image and central necrosis

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b

intervals during the first 3 years, every 6 months during the next 2 years, and once a year thereafter. A survival advantage from inclusion in structured follow-up has not been demonstrated. The routine follow-up tests are merely clinical and comprise history taking, physical, and vaginal examination, which may be supplemented by colposcopy and cytology, and a transvaginal ultrasound examination. More extensive tests are performed in patients with clinically suspected locoregional tumor recurrence. Recurrence is suggested by the findings of the gynecologic follow-up examination or if the patient reports difficulties passing urine or stools or other suspicious symptoms. Recurrent tumor of the pelvic

Fig. 49  Recurrent tumor of the pelvic sidewall after hysterectomy. T2w TSE image in sagittal orientation. A solid, heterogeneous mass with irregular margins (arrows) and infiltration of muscle is seen anterior to the sciatic foramen

Fig. 50   Recurrent cervical cancer after radiochemotherapy. (a, b) T2w TSE images in sagittal and transverse orientation. Recurrent cervical cancer 6 months after primary radiochemotherapy. The high-signal-intensity mass (arrows) is located eccentrically on the right side of the cervix. Gel filling of the vagina. (c, d) T1w TSE images

with FS in sagittal and transverse orientation showing recurrent cervical cancer with slightly higher signal intensity. (e, f) T1w TSE images with FS in sagittal and transverse orientation 1 min after administration of Gd-DTPA. MRI depicts a moderate enhancement on the postcontrast image (arrows)

Fig. 51  Other tumors of the cervix. T2w TSE image in sagittal orientation. Cervical manifestation (asterisk) of endometrial cancer (arrow)

sidewall may manifest with pain due to nerve infiltration or leg edema due to obliteration of the lymphatics.

CT, MRI, and PET-CT are recognized techniques for the detection of recurrent cervical cancer. MRI is particularly accurate in detecting suspected local recurrence and for evaluation following radiation therapy. When the clinical symptoms suggest the presence of distant metastases either CT or PET-CT are preferable to MRI. For the assessment of lymph node metastases, PET-CT has a greater sensitivity and specificity than either MRI or CT.

Usually follow-up MRI is not indicated during the first 6 months after completion of primary therapy due to its limitations in differentiating recurrent tumor from acute perior postoperative changes (Hricak et al. 1993). As with primary staging, follow-up MRI should be performed by using sagittal and transverse T2-weighted sequences as well as a respiratory-gated T1-weighted abdominal PACE sequence and a T1-weighted pelvic sequence for lymph node staging. In contrast to pretreatment MRI, the follow-up examination

should always comprise a contrast-enhanced T1-weighted sequence. These are always performed in combination with an unenhanced T1-weighted examination in identical orientations. Ideally, the contrast-enhanced images should allow differentiation of recurrent tumor, which shows early and pronounced enhancement, from scar tissue. If there is extension to the pelvic floor, this basic protocol can be supplemented by T2-weighted sequences in coronal orientation. If hydronephrosis is suspected, an additional coronal T2-weighted sequence or contrast-enhanced MR urography is indicated. Besides the standard anatomical sequences, the use of diffusionweighted imaging (DWI) is becoming more and more common in both European and American centers. In a recently published study the addition of DWI to T2-weighted sequences considerably improved the accuracy of MRI (92.1% vs. 80%) in the detection of cervical cancer recurrence (Lucas et al. 2015).

Recurrent cervical cancer has a variable appearance at MRI. The tumor may have a nodular appearance with a blurred contour and extension into surrounding tissue, which may lead to fixation of bowel loops. The irregular contour is due to tumor extension and desmoplastic reactions. Alternatively, a recurrent tumor may show diffuse growth. In this case, the absence of a circumscribed mass makes the tumor especially difficult to distinguish from a postoperative scar. By clinical examination, both scar and recurrent tumor may appear indurated. Recurrent cancer can be differentiated from scar tissue and muscle by its higher signal intensity on T2-weighted images as well as earlier and more pronounced enhancement on dynamic contrast-enhanced T1-weighted images. Regressive tumor portions may be identified by lack of enhancement. In contrast, scar tissue resembles muscle, with a low signal intensity on T1and T2-weighted images. Moreover, scars show only little and late enhancement if MRI is performed not earlier than 6 months after the end of therapy.

Despite the short examination time and absence of artifacts caused by bowel motion, CT has little use in differentiating post-therapeutic changes and recurrent tumor in the true pelvis.

Fig. 52  Nabothian cysts. (a) T2w TSE image in sagittal orientation. Cystic lesions in the cervical stroma (arrows). (b) H&E-stained specimen of the cervix with intrastromal cystic lesions (arrows). Also seen are cervical glands (open arrow)

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However, CT of the chest, abdomen, and pelvis after oral opacification and IV contrast medium administration can be used in the follow-up of cervical cancer to exclude distant metastases and postoperative complications.

Recurrent tumor after surgery is most frequently seen in the operative bed, primarily the vaginal stump, and at the resection margins, in particular the pelvic sidewalls. After radical hysterectomy, most tumors show supravaginal recurrence (20%) at the roof of the vaginal stump and in the rectovaginal space, typically between the bladder and the rectum. An occasional patient may develop fibrotic scar tissue at the roof of the vaginal stump, which is characterized by moderate to low signal intensity on T2-weighted and T1-weighted images. When recurrent tumor is

identified, its relationship to the vaginal stump should be described and ­infiltration of the urinary bladder and rectum should be excluded (Figs. 10 and 48).

Posterior tumor growth leads to infiltration of the presacral space and sacral bone or of the perirectal space and rectum. Recurrent cervical cancer is associated with rectal infiltration in about 17% of cases. The most common site is the rectosigmoid junction. Laterally, recurrent tumor may extend to the pelvic sidewall. If the recurrent local tumor grows anteriorly along the peritoneal fold, there will be infiltration of the urinary bladder. Advanced recurrent cervical cancer may involve the remaining colon or the small intestine, is typically associated with adhesion of bowel loops, and may cause intestinal obstruction.