Cervical carcinoma is the fourth most common cancer in women worldwide. Squamous cell carcinoma (SCC) is the most common subtype (70-80%), followed by adenocarcinoma (20-25%). HPV infection (especially types 16 and 18) plays a primary role in etiology. Early-stage disease (FIGO IB1 and below) is treated with surgery, while locally advanced stage (IB2-IVA) is treated with concurrent chemoradiotherapy. MRI remains the gold standard for local staging of cervical carcinoma — it plays a critical role in assessing tumor size, parametrial invasion, vaginal invasion, and pelvic sidewall involvement. With the FIGO 2018 update, lymph node status has also been included in staging.
Age Range
30-70
Peak Age
50
Gender
Female predominant
Prevalence
Common
Cervical carcinoma develops almost always as a chronic sequela of HPV (Human Papilloma Virus) infection. HPV E6 and E7 oncoproteins inactivate p53 and pRb tumor suppressor proteins respectively — leading to uncontrolled cell proliferation. The sequence CIN (Cervical Intraepithelial Neoplasia) I → CIN II → CIN III → invasive carcinoma develops over years. SCC originates from the cervical transformation zone (squamocolumnar junction); adenocarcinoma develops from endocervical glandular epithelium. The tumor invades the cervical stroma, then parametrial tissues, vagina, and pelvic sidewall. Imaging findings reflect this pathology: the cervical stromal ring appears hypointense on T2 — tumor invasion disrupts this ring. On DWI, the tumor shows diffusion restriction due to high cellularity. On contrast-enhanced MRI, the tumor enhances less than cervical stroma — the 'stromal ring' sign is the key finding for parametrial invasion assessment. Parametrial invasion is defined as tumor extending beyond the cervical stromal ring into parametrial fat — indicating FIGO stage IIB and changing the treatment approach from surgery to chemoradiotherapy.
The cervical stroma appears as a hypointense ring on T2-weighted MRI — disruption or loss of this ring is the most reliable indicator of parametrial invasion. An intact stromal ring indicates absence of parametrial invasion (surgery indicated), while a completely disrupted ring indicates parametrial invasion (FIGO IIB, chemoradiotherapy indicated).
On T2-weighted MRI, cervical carcinoma appears as a mass with intermediate-to-high signal intensity in the cervix — normal cervical stroma appears homogeneously hypointense on T2 while the tumor provides important contrast as a bright area within this hypointense background. Tumor size (largest diameter) is measured — ≤2 cm (IB1), >2 cm ≤4 cm (IB2), >4 cm (IB3). Stromal ring assessment is critical: if the ring is intact there is no parametrial invasion, if completely disrupted parametrial invasion is present. Extension to vaginal fornices (stage IIA) and to corpus uteri (stage II) are evaluated. Axial and sagittal planes should be used together.
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An intermediate-to-high signal mass measuring [X] cm is identified in the cervix on T2-weighted MRI. The cervical stromal ring is [intact / focally disrupted / completely disrupted], consistent with FIGO stage [IB / IIB].
Cervical carcinoma shows marked diffusion restriction on DWI — bright signal at high b-values (b=800-1000) and low signal on ADC map. ADC values are generally <0.9 x 10-3 mm2/s. DWI is particularly valuable for detecting small tumors, evaluating parametrial invasion undetectable on T2, and detecting residual/recurrent disease after treatment. Adenocarcinoma may show slightly higher ADC values than SCC. DWI also provides added value in detecting pelvic and para-aortic lymph node metastases.
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Marked diffusion restriction is identified in the cervical mass on DWI with low ADC values, consistent with cervical carcinoma.
On dynamic contrast-enhanced MRI, cervical carcinoma enhances less than normal cervical stroma in the delayed phase. In the early phase, the tumor may show intense enhancement but in the delayed phase the stroma enhances more intensely — this difference creates the 'stromal ring enhancement' pattern that clarifies the parametrial invasion boundary. In the presence of parametrial invasion, enhancing tumor tissue extends beyond the stromal ring into parametrial fat. Contrast-enhanced sequences combined with T2 improve accuracy of parametrial invasion assessment.
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The cervical mass appears more hypointense than stroma on delayed-phase contrast-enhanced MRI; the stromal ring is [intact / disrupted] and parametrial invasion [is not / is] detected.
Contrast-enhanced CT shows cervical carcinoma as a heterogeneously enhancing mass in the cervix. CT is limited compared to MRI for parametrial invasion and small tumor assessment, but is valuable for evaluating pelvic and para-aortic lymph node metastases, hydronephrosis/ureteral obstruction, and distant metastases (lung, liver, bone). Lymph node short axis >10 mm is suspicious. Bladder and rectal invasion may be detected as wall thickening or intraluminal mass on CT.
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A heterogeneously enhancing mass is identified in the cervix on contrast-enhanced CT with [pelvic/para-aortic lymph node metastasis / hydronephrosis / distant metastasis] [detected / not detected].
Transvaginal US may show cervical carcinoma as a heterogeneous, hypoechoic, or mixed echogenicity mass in the cervix. Cervical contour irregularity and obliteration of nabothian cysts may be detected. Doppler shows increased vascular flow and low resistance index. US is used as a first-line screening method especially in developing countries but is insufficient for staging — MRI is required. US-guided transrectal or transvaginal biopsy can be performed.
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A heterogeneous mass is identified in the cervix on transvaginal US with increased vascular flow on Doppler examination; pelvic MRI is recommended for staging.
FDG PET-CT shows increased FDG uptake in cervical carcinoma (SUVmax generally 8-20). PET-CT is superior to CT and MRI especially for detecting lymph node metastases — metabolically active metastatic lymph nodes can be detected even if short axis is normal size. With the FIGO 2018 update, lymph node status has been included in staging (IIIC1 pelvic, IIIC2 para-aortic). Also used for distant metastasis screening and treatment response evaluation. SCC generally shows higher FDG uptake than adenocarcinoma.
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Increased metabolic activity (SUVmax: [X]) is identified in the cervical mass on FDG PET-CT with [pelvic/para-aortic FDG-avid lymph nodes / distant metastasis] [detected / not detected].
Criteria
Most common subtype (70-80%). Originates from the transformation zone (squamocolumnar junction). Strong association with HPV type 16. Keratinizing and non-keratinizing variants exist.
Distinct Features
Higher FDG uptake, radiotherapy response generally better than adenocarcinoma, HPV16-related, SCC antigen can be used as tumor marker.
Criteria
Second most common subtype (20-25%). Originates from endocervical glandular epithelium. Associated with HPV type 18. Incidence has been increasing in recent decades. May present with barrel-shaped cervix.
Distinct Features
Barrel-shaped cervix, endocervical location, mucus-producing glandular differentiation, HPV18-related, stage-matched prognosis similar to SCC but radiotherapy response slightly worse.
Criteria
Shows both squamous and glandular differentiation (3-5%). SCC and adenocarcinoma components coexist. Shows aggressive course.
Distinct Features
Biphasic histology, aggressive course, worse prognosis than pure SCC or adenocarcinoma, indistinguishable on imaging.
Distinguishing Feature
Cervical polyp appears as a well-defined, pedunculated mass — no restriction on DWI, stromal ring intact, variable signal on T2 (fibrous component hypointense).
Distinguishing Feature
Nabothian cysts are well-defined, T2-hyperintense cystic lesions — no restriction on DWI, no enhancement, stromal ring intact, may be multiple.
Distinguishing Feature
Endometrial carcinoma primarily arises from the endometrial cavity and extends downward to the cervix — not a primary cervical mass, JZ disruption is seen at the endometrial-myometrial border (not in cervical stroma).
Distinguishing Feature
Leiomyosarcoma is an intramural mass arising from myometrium — not a cervical mass (except rare cervical leiomyosarcoma), heterogeneous signal on T2, coagulative necrosis T1 hyperintense.
Urgency
urgentManagement
surgicalBiopsy
NeededFollow-up
specialist-referralCervical biopsy (colposcopy-guided punch biopsy or LEEP/conization) is mandatory for diagnosis. Staging is performed with pelvic MRI + abdominopelvic CT (or PET-CT). FIGO stage ≤IB1: radical hysterectomy + pelvic lymph node dissection. FIGO stage ≥IB2: concurrent chemoradiotherapy (cisplatin-based) is the standard treatment. Parametrial invasion (FIGO IIB) changes the treatment approach from surgery to chemoradiotherapy — stromal ring assessment on MRI is of critical importance. Fertility-sparing surgery (radical trachelectomy) can be performed in early-stage small tumors (≤2 cm, stromal invasion <10 mm).
Cervical carcinoma is the 4th most common cancer in women worldwide. It is preventable with HPV vaccination. MRI is the gold standard for local staging. Chemoradiotherapy is the primary treatment for FIGO ≥IB2 cases. Presence of parametrial invasion (Stage IIB+) changes treatment strategy from surgery to chemoradiotherapy.