Radiological imaging of the uterine cervix diseases.

Dr/ ABD ALLAH NAZEER. MD.

The uterine cervix is composed of the portio, which protrudes into the vagina, and the supravaginal part of the cervix.Squamous cells cover the epithelial surface of the portio continuing from the vagina. With age, they grow back to cover the columnar cells of the endocervical gland. This transitional area is called the squamocolumnar junction (SCJ) Carcinoma of the cervix develops almost exclusively within the transformation zone that extends between the original SCJ and the physiologic (SCJ).

Anatomy.

Radiological imaging.Chest X-Rays: X-ray often can show whether cancer has spread to the lungs.

CT Scan: CT is the imaging modality that is most commonly used in clinical practice to evaluate the extent of spread of cervical cancer. The oral, rectal, or intravenous administration of contrast material is necessary for optimal CT evaluation (unless a contraindication exists). The intravenous injection of contrast material is particularly useful in increasing the conspicuity of the cervical tumor and in facilitating the evaluation of the parametria and the pelvic sidewalls

US has been used to evaluate the size and local regional extent of the tumor. In the early stage of cervical carcinoma, the primary lesion is difficult to depict with any imaging modality, including transvaginal US and TRUS.Eventually, with disease progression, the tumor mass may appear as a hypoechoic or isoechoic region with undefined margins, or the disease may be manifested as an enlarged cervix with heterogeneous echogenicity (see the images below). In general, the intracervical cancer is not clearly distinguished from the surrounding normal cervical stroma.

MRI appearance of cervical carcinoma.Cervical carcinoma has a long T1 and a long T2 that render this disease relatively hyperintense on proton-density–weighted and T2-weighted images, in which the signal intensity of the tumor is approximately similar to that of the endometrium. The hyperintense appearance on T2-weighted images accounts for the essentially consistent conspicuity of the primary tumor against the background of the hypointense normal cervical stroma.

Positron emission tomography (PET) with use of fluorodeoxyglucose (FDG) has some value relative to conventional imaging methods for the detection of nodal metastatic disease and recurrent cervical cancer, possibly being effective in the evaluation of cases of locally advanced cervical cancer in which CT findings are negative or equivocal, and possibly being predictive of survival outcome.

Nonneoplastic Diseases.Cervical PregnancyThe prevalence of cervical pregnancy ranges from 1 in 1,000 to 1 in 24,000 of all pregnancies . Recently, the occurrence has been increasing, possibly due to the increased number of induced abortions. The exact cause is still unknown. Reported risk factors include multiparity, prior surgical manipulation of the cervix or endometrial cavity, cervical or uterine leiomyomas, atrophic endometrium, and septate uterus.

The cervix is made up of two different types of epithelium: squamous epithelium and glandular epithelium. The cause of cervical inflammation depends on the affected epithelium. The same microorganisms as those that cause vaginitis can affect the endocervical squamous epithelium. Trichomonas vaginalis, Candida albicans, and herpes simplex virus can cause inflammation of the ectocervix. Conversely, Neisseria gonorrhoeae and Chlamydia trachomatis infect only the glandular epithelium and are major causes of mucopurulent endocervicitis .

Nabothian Cyst.Nabothian cysts are common retention cysts of the uterine cervix. They are formed as a result of the healing process of chronic cervicitis . During chronic inflammation, the squamous epithelium proliferates, covering the columnar epithelium of the endocervical glands. After that, the mucus secreted by the columnar epithelium (now covered by the squamous epithelium) cannot be evacuated and forms a retention cyst .

Cervical PolypsCervical polyps are one of the most common causes of intermenstrual vaginal bleeding. Most patients are perimenopausal, especially in the 5th decade of life. The polyps are usually pedunculated, with a slender pedicle of varying length, but some are sessile .

Endometriosis.Endometriosis is a common disease that affects the uterine body. Endometriosis seldom affects the uterine cervix. Internal endometriosis is called adenomyosis; in this condition, lesions form an ill-defined hypointense area continuing to the junctional zone with some hyperintense dots on T2-weighted images. However, adenomyosis can form a uterus-like polypoid mass growing into the endocervical canal . It has a cavity surrounded by endometrial mucosa and smooth muscle layers resembling myometrium.

Cervical endometriotic cysts.

Cervical Ectopic Pregnancy Ultrasound.

Cervical pregnancy.

Uterine cervicitis with multiple uterine body fibroids.

Nabothian Cysts.

Nabothian cysts.

Cervical polyp.

Carcinoma of the cervix is the third most common malignancy of the female reproductive tract and the second most common malignancy in women 15 to 34 years of age, with a peak incidence at 45 to 55 years. Risk factors include low socioeconomic class, black race, early sexual activity, multiple sexual partners, multiparity, and infection with herpes simplex virus type 2. Because of extensive Papanicolaou smear screening, the incidence of invasive cervical cancer continues to decline. In the United States, there are an estimated 15,700 new cases diagnosed every year. The vast majority are squamous cell carcinomas(80-80%). Other histologies include adenocarcinoma(10-20%), small cell carcinoma, adenoid cystic carcinoma, sarcoma, and lymphoma(5-10%).

CERVICAL CANCER.Epithelial Neoplasms:

Signs and symptoms.Vaginal bleeding.Menstrual bleeding is longer and heavier than usual.Bleeding after menopause or increased vaginal discharge.Bleeding following intercourse or pelvic examination.Pain during intercourse.

Other symptoms that may occur include:Unusual vaginal dischargePain in the pelvic areaExcessive tirednessSwollen or painful legsLower back pain.

Adenoma MalignumAdenoma malignum (also known as minimal deviation adenocarcinoma) is a special subtype of mucinous adenocarcinoma of the cervix. Its prevalence is about 3% of all cervical adenocarcinomas. The most common initial symptom is a watery discharge. The prognosis of this tumor has been reported to be unfavorable , as it disseminates into the peritoneal cavity even in the early stage of the disease and its response to radiation or chemotherapy is poor. Therefore, its deceptively benign histologic appearance occasionally leads to an incorrect diagnosis.

Malignant MelanomaMalignant melanoma of the female genital tract accounts for 1%–5% of all melanoma cases . It usually occurs in the vaginal mucosa and occasionally involves the uterine cervix. Malignant melanoma arising in the uterine cervix is extremely rare, with only about 30 cases reported in the literature.

Nonepithelial Neoplasms.Malignant Lymphoma.

Malignant lymphoma frequently infiltrates the uterus in advanced disease. However, it rarely involves the uterine cervix as the initial manifestation . Its frequency in Western countries was reported to be 0.008% of primary cervical tumors and 2% of extranodal lymphomas in women . The common presenting symptoms are vaginal bleeding, perineal discomfort, and vaginal discharge . Cervical lymphomas are treated with chemotherapy alone or in combination with irradiation or surgery.

Cervical Leiomyoma.As about 90% of uterine leiomyomas occur in the uterine body, cervical leiomyoma is relatively rare. Its prevalence is reported to be less than 10% of all leiomyomas of the uterus . Clinical symptoms of cervical leiomyomas, including hypermenorrhea, dysmenorrhea, or abdominal distention, are identical to those of leiomyomas in the uterine body. They occasionally form polypoid tumors and protrude into the cervical canal or even the vagina when they grow in the submucosal region. Because they are located along the birth canal, they occasionally cause maternal dystocia.

Cervical carcinoma with exophytic growth.

Cervical carcinoma with endophytic growth.

Stage Ib cervical carcinoma.

Cervical carcinoma stage IB

Stage IB cervical carcinoma.

Stage IIa cervical carcinoma.

IIB cervical carcinoma.

Stage IIB cervical carcinoma.

Stage IIb cervical carcinoma

Stage IIIa cervical carcinoma.

Stage IIIb cervical carcinoma.

Stage IVa cervical carcinoma.

Advanced cervical carcinoma.

Stage IVb cervical carcinoma with metastasis at the para-aortic lymph nodes.

IVB cervical carcinoma with pelvic LN , ureteric and uterine involvement.

Stage IVb cervical carcinoma.

Local recurrence after radiation therapy.

Adenoma malignum.

Adenoma malignum in a patient with Peutz-Jeghers syndrome.

Adenoma malignum

Atypical carcinoid tumor of the uterine cervix

Malignant melanoma of the vagina with direct invasion of the cervix

Malignant lymphoma of the uterine cervix

Two cases of Lymphoma of the cervix.

Cervical tumor PET.

Metastasis to the uterine cervix is a complication of breast cancer

Conclusions.

MR imaging is an essential modality for diagnosing cervical lesions because the signal intensity or configuration of the lesion demonstrated on MR images reflects the pathologic findings. Although sagittal T1-weighted and T2-weighted images and oblique axial T2-weighted images perpendicular to the uterine axis are sufficient for staging cervical carcinoma in most cases, only a detailed reading based on the pelvic anatomy and the pathologic features of the tumor can allow an accurate staging diagnosis. However, some tumors or tumor-like lesions can show similar MR imaging findings, such as adenocarcinoma, adenoma malignum, and florid endocervical hyperplasia. Therefore, a diagnosis should be made based on clinical manifestations in conjunction with imaging findings.

Thank You.