The second most common site of recurrence is the pelvic sidewall, which is the preferred site of nodal metastasis (Figs. 49 and 50). An important issue is their topographic relationship to the bony pelvis and the iliac vessels because of its implications for the surgical technique. Regarding the iliac vessels, infraand peri-iliac metastases should be distinguished; regarding the bones, a distinction should be made between ischiopubic, acetabular, iliosacral, and sacrococcygeal ­metastases. Further progression may lead to destruction of the bony pelvis.

Pelvic tumor recurrence typically leads to external ureteral obstruction through encasement of the ureters and their orifices, which manifests as hydronephrosis. Follow-up MRI enables evaluation of both the etiology and the site of the obstruction.

Local recurrence after primary radiochemotherapy is characterized by the development of a new tumor in the cervix or infiltration of the vagina (Fig. 51). Alternatively, there may be recurrence in the parametria with lateral extension at the level of the cervix and vagina (Choi et al. 2000). A large recurrent tumor with a mass effect within the cervix may obstruct the internal os with development of hydrometra or pyometra. Alternatively, the cervix can be obstructed by radiation-induced stenoses. This is depicted by CT and MRI as a symmetrically enlarged uterine corpus containing nonenhancing fluid.

Patients with central pelvic tumor recurrence are operated on with curative intention if possible. Curative pelvic exenteration is more difficult when the pelvic wall is infiltrated. Hence, recurrent tumor of the pelvic wall is typically treated by radiochemotherapy, which can be performed with a curative dose in patients not having undergone irradiation before. Local control of recurrence in the pelvic wall is poorer and has a more unfavorable prognosis than central pelvic recurrence. Specific surgical procedures and possibly reduced radiotherapy are available for patients having been irradiated before. These aggressive measures are, however, associated with considerable side effects. Lymph node metastasis is typically treated by radiotherapy and hematogenous distant metastasis by chemotherapy.

2.6\ Role of Other Diagnostic

Modalities

2.6.1\ Ultrasound

While ultrasonography has a role in endometrial cancer, it is of little use in detection and staging of cervical cancer. Ultrasonography does not allow reliable demonstration of parametrial infiltration. Direct imaging of cervical cancer in controlling tumor response to radiochemotherapy by 3D ultrasound is under evaluation. The sonographic evaluation of the pelvic and para-aortic lymph nodes is limited due to their location at the pelvic wall or retroperitoneally and due to overlying bowel gas (Mamsen et al. 1995). Transabdominal or transrectal ultrasound is routinely used in pretherapeutic staging, typically to exclude liver metastases and at follow-up, above all to exclude ureteral obstruction (Innocenti et al. 1992; Magee et al. 1991). Ultrasonography is limited by its dependence on the examiner and the equipment used and lacks adequate documentation and reproducibility of the findings.

2.6.2\ PET/CT

In recent years, 18F-fluorodeoxyglucose (FDG) positron emission tomography—computed tomography (PET/CT) has gained acceptance in the initial evaluation of disease extent of patients with locally advanced cervical cancer, especially in the assessment of lymph node status and distant metastasis. Furthermore, FDG-PET/CT has been used for image-guided radiation therapy and for the detection of distal, extrapelvic recurrent tumor after therapy (Balleyguier et al. 2011; Herrera and Prior 2013).

2.7\ Other Malignant Tumors

of the Cervix

2.7.1\ Metastasis

Most metastases to the cervix are from endometrial cancer (Fig. 52) (or by tumor infiltration per continuitatem), less commonly from other primary tumors of the ovaries, breast, or stomach. On imaging, it is virtually impossible to differentiate a metastasis from a primary carcinoma.