MD, Iran University of Medical Science, Shahid Akbarabadi Hospital Assistant Professor
Uterine cervical cancer is the third most common malignancy affecting the female genital tract in middle age group between 45 and 55 years. Its incidence is increasing rapidly in developing countries. Histologically, squamous cell carcinoma is the commonest type .The International Federation of Gynecology and Obstetrics (FIGO) staging system updated in 2009 is commonly used for treatment planning but is inadequate in the evaluation of prognostic factors like tumor volume and nodal status. Magnetic Resonance Imaging (MRI) is the preferred imaging modality because of its ability to assess soft tissue in detail, permitting thereby better identification of stromal and parametrial invasion as compared to computed tomography (CT). MRI tells us the exact volume, shape, and direction of the primary lesion, local extent of the disease, and nodal status accurately, which helps the clinician in treatment planning. Tumor behavior to chemoradiation is also better evaluated with MRI. FIGO staging system is used to stage cervical cancer on MRI.
Error rates in clinical examination are significantly high, hence clinical staging may not be accurate in each and every patient. Important parameters that the clinicians want to know are accurate size of the tumor, status of parametrium, pelvic side walls, presence of lymph nodes, and spread to local and distant organs . MRI answers all these questions. Identification of early disease from advanced disease is crucial for treatment planning.
Standard treatment for stage IA1 is cervical conization or total hysterectomy.. Pelvic lymphadenectomy is generally not advisable because the risk of pelvic lymph node metastasis is less than 1%.
In stage IA2, modified radical hysterectomy with bilateral pelvic lymph node dissection is recommended because the risk of pelvic lymph node metastasis increases to 5%.
Stages IB and IIA are treated either with combined external beam radiation and brachytherapy (BT) or radial hysterectomy and bilateral pelvic lymph node dissection. Concurrent chemotherapy with cisplatin has been shown to improve the patient survival.
Radiation therapy with concurrent chemotherapy is the standard treatment for stage IIB, III, and IVA tumors. Patients without nodal disease or with disease limited to the pelvis are treated with pelvic RT, concurrent cisplatin-based chemotherapy, and BT.
Stage IVB patients are incurable and cisplatin-based chemotherapy is the primary treatment offered to these patients
MRI is very useful in local staging of the disease. It is a valuable tool in assessing the spread of the tumor to local and distant lymph nodes. It also assesses the disease response to chemoradiation and differentiates residual or recurrent disease from radiation fibrosis. Thus, MRI is valuable in deciding the treatment strategies.