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Pelvis » Female Pelvis (Gynecology)
Cervical carcinoma
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Presentation A 55 year old woman presents with postmenopausal bleeding. She underwent a cervical biopsy followed by ultrasound.
Caption: Sagittal transvaginal scan of the uterus and cervix.
Description: In the region of the cervix, a well-defined, hypoechoic mass is seen. Irregular echogenic areas showing posterior shadowing are visualized, which may represent air. The uterine endometrial echo appears normal.
Caption: Coronal color Doppler view of the cervix.
Description: Coronal scan demonstrating areas of vascularity within the hypoechoic mass. No obvious parametrial invasion was noted.
Caption: Spectral color Doppler study.
Description: A mixed arterial and venous waveform is demonstrated through the region of neovascularity in the mass.
Differential Diagnosis Cervical carcinoma
Cervical fibroid
Final Diagnosis Cervical carcinoma
Discussion The widely used FIGO (Federation Internationale de Gynecologie et d’Obstetrique) staging for cervical carcinoma is mainly based on clinical findings, although now clinical examination is being combined with imaging to obtain a more accurate assessment of lesion extent. A number of factors including tumor volume, stromal and parametrial invasion and lymph node involvement, especially in the para-aortic area, need to be assessed. Not all of these factors can be completely evaluated clinically, hence the need for imaging. Ultrasound, MRI and helical CT are the most commonly used modalities. However studies have shown CT to be less sensitive than the former two modalities. MR imaging, when available, remains the most important of all these.  However abdominal and endoluminal [transrectal and transvaginal] ultrasound are cost effective and readily available examinations.

The ultrasound appearance of cervical carcinoma is commonly that of a hypoechoic or isoechoic mass, which may occlude the endocervical canal and hydro or pyometra may result. In more than half the cases the mass is isoechoic, in which case cervical enlargement may be the only finding. Transrectal ultrasound may show an ill-defined mass in some of these cases, but lack of contrast resolution may still pose a problem. In these cases MRI is superior. Parametrial invasion may be seen as replacement of the normal echogenic fat by hypoechoic tumor which may extend up to the pelvic side walls. Ultrasound demonstrates this finding well, but MRI is the superior modality. Studies have reported the use of a intracervical probe to improve the visibility and assess the degree of invasiveness of the mass. Ureteral obstruction with hydronephrotic changes in the kidneys and nodal involvement can be demonstrated by transabdominal ultrasound; however this is dependent on the body habitus. Endoluminal ultrasound can identify bladder and rectal wall invasion in unsuspected cases.

Color Doppler studies have a controversial role in cervical cancer. A few studies have described the color Doppler appearance of neovascularity in the mass but the Doppler findings are not definitive. It may be possible to monitor the response to chemotherapy via transvaginal color Doppler. Combined clinical and radiological staging can identify the patients needing post surgical radiotherapy and/or chemotherapy and help in the treatment planning versus clinical exam alone.

Local recurrences following treatment are well assessed radiologically by ultrasound. In cases of doubt, MRI may be performed.

Case References 1. Krjak M, et al. Supplemental imaging methods in evaluation of the extent of cervical carcinoma. Ces Gyne. 2002 Jan; 67(1).
2. Whipp EC, et al. The use of B-mode USG in the management of Ca Cervix: a prelim report. Clin Radiol. 1982 Jan; 33(1):87.
3. Vanderpuye V. Renal sonography in the diagn of renal obstruction or hydronephrosis in cervical cancer. J Clin Ultrasound. 2002 Sep; 30(7):424-7.
4. Houvenaeghel G, et al. Locoregional extension of advanced cervical Ca.Bull Cancer. 1991; 78(10):969.
5. Alcazar, et al. Intratumoral blood flow in cervical cancer as assessed by transvaginal CDS: Correlation with tumor characteristics. Intern J of Gynec Cancer. Jul 2003 Vol 13 (4).
6. Yang W, et al. TRUS in the evaluation of cervical carcinoma and comparison with spiral CT and MRI. BJR.69(823):610.
7. Dubinsky TJ, et al. Intracervical sono-path correlation. JUM. 2003 Jan; 22(1):61-7.
8. Suren A, et al. 3D Color Power Angio imaging. Ultrasound Obs Gynecol. 1998 Feb; 11(2):133.
Follow Up The mass was proven by histopathology to be an invasive squamous carcinoma.
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