1. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS S TAGE IV I NVASION OF THE M UCOSA OF B LADDER, R ECTUM OR B OTH ; I NVASION E XTENDING B EYOND THE T RUE P ELVIS ; OR B OTH ■ IV A  Invasion of the mucosa of bladder, rectum, or bladder and rectum; invasion extending beyond the true pelvis; or both Imaging findings suggesting bladder invasion: - Focal or diffuse disruption of the normal hypointense posterior bladder wall - Nodular or irregular bladder wall - Mass protruding into the lumen - Presence of bullous edema Rectal invasion is rare, its appearance is: - Segmental disruption of the hypointense rectal wall - Segmental thickened rectal wall - Prominent strands between the tumor and the rectal wall Both of them show abnormally high signal intensity on T2-weighted imaging

2. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS S TAGE IV I NVASION OF THE M UCOSA OF B LADDER, R ECTUM OR B OTH ; I NVASION E XTENDING B EYOND THE T RUE P ELVIS ; OR B OTH ■ IV A  Invasion of the mucosa of bladder, rectum, or bladder and rectum; invasion extending beyond the true pelvis; or both Uterus Rectum (R) Bladder (B) Ureter Vagina B T Tumor (T)

3. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS S TAGE IV I NVASION OF THE M UCOSA OF B LADDER, R ECTUM OR B OTH ; I NVASION E XTENDING B EYOND THE T RUE P ELVIS ; OR B OTH ■ IV A  Invasion of the mucosa of bladder, rectum, or bladder and rectum; invasion extending beyond the true pelvis; or both Sagittal T2-weighted MR images show heterogeneous mass (T) arising from cervix with involvement of anterior and posterior vaginal fornices. Note nodular and irregular posterior bladder wall (arrow); bladder invasion was confirmed in cistoscopy. B T BT B T B T

4. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS S TAGE IV I NVASION OF THE M UCOSA OF B LADDER, R ECTUM OR B OTH ; I NVASION E XTENDING B EYOND THE T RUE P ELVIS ; OR B OTH ■ IV A  Invasion of the mucosa of bladder, rectum, or bladder and rectum; invasion extending beyond the true pelvis; or both B ULLOUS E DEMA Sagittal T2-weighted MR image: hyperintense bullous thickening of the bladder wall (arrow). This finding is not a direct sign of tumor extension but may indicate inflammation or microscopic invasion.

5. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS S TAGE IV I NVASION OF THE M UCOSA OF B LADDER, R ECTUM OR B OTH ; I NVASION E XTENDING B EYOND THE T RUE P ELVIS ; OR B OTH ■ IV A  Invasion of the mucosa of bladder, rectum, or bladder and rectum; invasion extending beyond the true pelvis; or both ■ IV B  Spread to distant organs

6. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS A BOUT THE L YMPH N ODES ■ Although pelvic node metastases are not included and don’t change the FIGO stage, paraaortic or inguinal node metastases are classified as stage IV B. ■ Lymph node involvement has two important implications: - Suggests a poor prognosis, with an important decrease in survival rates -Is an important factor in the choice of adjuvant radiation therapy ■ Surgical lymph node assessment is the gol standard for the diagnosis of lymph node metastases, but preoperative evaluation of them is very important, because lymphadenectomy carries a high risk of complications.

7. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS A BOUT THE L YMPH N ODES ■ The highest problem with MRI is that it rely on size criteria, which results in a low sensitivity due to the inability to identify metastasis in normal-size lymph nodes. The development of lymph node-specific MRI contrast agents can solve this limitation in the future. ■ The most widely accepted size criteria for lymph node malignancy is a transverse diameter greater than 10 mm ■ A slightly hyperintense ring flow artifact is often found in the iliac veins and should not be confused with adenopathy.

8. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS A BOUT THE L YMPH N ODES Axial T1-weighted MR image and T1-weighted MR image obtained after intravenous injection of contrast material show enlarged bilateral external iliac nodes (arrow)

9. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS R ECURRENT D ISEASE ■ Recurrence is defined as local tumor regrowth or the development of distant metastasis discovered 6 months or more after complete regression of the treated lesion ■ Recurrence is most common in the first few years after diagnosis (90 % within 5 years) and most of them are within the pelvis (74%). The most common sites of recurrent disease are the vaginal cuff, cervix, parametrium and pelvic sidewall. ■ Manifestations of recurrent disease in cervical carcinoma can be characterized as typical and atypical. 

10. IMAGING FINDINGS R ECURRENT D ISEASE ■ Typical  Involvement the pelvis and lymph nodes Pelvis recurrences: - May be observed as masses involving the cervix an uterus, vagina or vaginal cuff, parametria, bladdder, ureters, rectum or ovaries - May result in fistula formation or hydronephrosis MRI appearance of vaginal vault recurrence: - Loss of the low-signal-intensity lineal configuration of the vaginal vault - Associated soft-tissue mass of high signal intensity on T2-weighted images Nodal recurrence: - May be identified as enlarged pelvic and retroperitoneal nodes UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES

11. IMAGING FINDINGS R ECURRENT D ISEASE ■ Typical  Involvement the pelvis and lymph nodes UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES Patient treated with radical hysterectomy. Axial (A), sagittal (B) and coronal (C) T2- weighted images show hyperintense recurrent mass in right side of vaginal cuff (R). R R R A B C

12. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS R ECURRENT D ISEASE ■ Typical  Involvement the pelvis and lymph nodes Patient treated with radical hysterectomy. Sagittal (A) and coronal (B) fat-saturated T1-weighted MR image obtained after dynamic intravenous injection of gadopentetate dimeglumine: the recurrent mass in right side of vaginal cuff (R) shows an important homogeneously enhancement. A R B R

13. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS R ECURRENT D ISEASE ■ Atypical: These manifestations may involve: -Solid organs of the abdomen (focal masses) -Peritoneum, mesentery and omentum (implants) -Gastrointestinal tract (obstruction, fistula formation, ischemia) -Chest (lunch parenchyma, pleura and pericardium) -Bones (destructive lesions, most frecuently in vertebral bodies) -Other sites (skin, subcutaneous tissues, brain, meninges…) Intrabdominal solid organ most commonly affected  LIVER The next most commonly involved intraabdominal solid organ is the adrenal gland The prevalence of these less typical manifestations are increased, due to the use of intensive pelvic radiation therapy, the evolution of improved imaging techniques and the more frequent use of imaging as a means of surveillance 

14. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS R ECURRENT D ISEASE ■ The critical issue is distinguishing postradiation changes from recurrent tumor. ■ Initial studies with MR imaging had suggested that it was possible to distinguish radiation fibrosis from tumor 6 months or more after completion of radiation therapy. The criteria used to define recurrent tumor were the presence of a mass hyperintense on T2-weighted images, but benign conditions as edema, inflammation and necrosis may also cause increase T2 signal. ■ Dynamic MR imaging improves specificity by identifying rapidly enhancing masses seen between 45 and 90 sec as malignant. ■ Follow-up MR imaging is useful too, because radiation-induced fibrosis is expected to remain stable or diminish in prominence over time. ■ Early radiation change continues to pose a problem because it may show early enhancement. CT-guided biopsies of the areas in question and PET scanning are usefull in theses cases.

15. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS T HERAPEUTIC R ESPONSE ■ Respond of tumors treated with radiation therapy:  Decrease in size  Decrease signal intensity on MR imaging ■ The response may be immediate (3-6 months) or, in larger tumors, delayed (6-9 months) ■ Dynamic MR imaging supplemented by pharmacokinetic analysis has the potential to distinguish tumors that will respond to radiation from those that will be resistant. If these results are proven, it may be possible to identify patients who will benefit from more aggressive therapy

16. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS T HERAPEUTIC R ESPONSE Sagittal (A/B) and axial oblique (C) T2-weighted images: exophytic heterogeneous mass (T) involving anterior lip of cervix T A T B T C

17. UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES IMAGING FINDINGS T HERAPEUTIC R ESPONSE 10 months after radiotherapy and chemoteraphy Sagittal T2-weighted images show that cervical mass has disappeared after treatment.

18. IMAGING FINDINGS ■ Adenoma Malignum: Special subtype of mucinous adenocarcinoma of the cervix Poor prognosis MR Imaging: Multicystic lesions that extend from the endocervical glands to the deep cervical stroma with solid components Differential diagnosis: Deep nabothian cysts, florid endocervical hyperplasia, well differentiated adenocarcinoma Differentiation of these lesions with MR imaging is controversial It is associated with Peutz-Jeghers syndrome UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES O THER R ARE H ISTOLOGIC T YPES

19. IMAGING FINDINGS ■ Neuroendrocrine Tumors: Small cell carcinoma: - Similar to pulmonary small cell carcinoma - Contains neuroendocrine granules Carcinoid: - Rare tumor arising in the uterine cervix Their imaging findings are not particularly different from those of squamous cell carcinoma ■ Malignant Melanoma: It usually develops in the vaginal mucosa and occasionally involves the uterine cervix Tipically, it shows high signal intensity on both T1-weighted and T2-weighted images because of their melanin concentration, but these characteristics can change according to different causes UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES O THER R ARE H ISTOLOGIC T YPES

20. IMAGING FINDINGS UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ 85-90% Squamous cell carcinoma ■ FIGO staging system is based on surgical and pathologic findings alone; imaging, although useful in preoperative assessment of tumor stage, is not recognized as a method for definitive staging. ■ T2-weighted images are the best to see cervical tumors ■ Tumor is seen as an intermediate/hiperintense mass on T2-weighted images and fibrous cervical stroma as a hipointense ring sorrounding it. ■ If the hipointense ring is intact, there is no parametrial invasion. ■ Differentiate between stage IIB and IIA (parametrial invasion or not) that determines the treatment (surgery and radiation/chemotherapy respectively). T EACHING P OINTS : KEEP THEM IN MIND

21. IMAGING FINDINGS UTERINE CERVICAL CARCINOMA BASIC MRI PRINCIPLES ■ Although lesion volume and nodal metastases are not included in the FIGO staging system, they are the most important prognosis factors and their evaluation is crucial in determining appropriate therapy. ■ Recurrence is most common in the first few years after diagnosis and most of them are within the pelvis. ■ Intrabdominal solid organ most commonly affected  LIVER T EACHING P OINTS : KEEP THEM IN MIND