Diagnostic Imaging Pathways - Cervical Cancer (Staging)
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This pathway provides guidance on the staging of cervical cancer.
Date reviewed: April 2019
Date of next review: April 2022
Published: July 2019
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SYMBOL | RRL | EFFECTIVE DOSE RANGE |
![]() | None | 0 |
![]() | Minimal | < 1 millisieverts |
![]() | Low | 1-5 mSv |
![]() | Medium | 5-10 mSv |
![]() | High | >10 mSv |
Teaching Points
Teaching Points
- Staging of cervical cancer has traditionally been performed with clinical assessment and biopsy
- Imaging has been found to better evaluate the extent of disease and often changes management. Imaging investigations are recommended when they are available
- MRI is the best imaging modality to assess the primary tumour size, location, and invasion into the parametrium, pelvic sidewall and adjacent organs
- PET/CT is the best modality to assess nodal and extrapelvic metastatic disease, and is recommended in patients at high risk of lymphatic involvement
- Treatment for early stages of cervical cancer is generally surgical whereas chemoradiotherapy is usually indicated in advanced disease
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Cervical Cancer
- Globally, cervical cancer remains the fourth most common cancer in women
- It is now recognised that cervical cancer is a rare long-term outcome of persistent infection of the lower genital tract by one of the high-risk Human Papilloma Virus (HPV) types 1
- Since the introduction of formal screening programs (Pap smear and now liquid-based cytology and HPV testing) and more recently prevention programs with HPV vaccination, cervical cancer incidence and mortality have halved in high-income countries 2
- The majority of cases now occur in low-income and middle-income countries 1,2
- Cervical cancer spreads by direct extension into the parametrium, vagina, uterus and adjacent organs. It also spreads via lymphatics to regional lymph nodes. Distant metastasis to the lungs, liver and bones is a late phenomenon 1
- Accurate staging is crucial to determine the most appropriate treatment
- The International Federation of Gynaecology and Obstetrics (FIGO) system is the most widely used in cervical cancer staging
- FIGO staging is mainly based on clinical examination, in part because it is accessible in low and middle-income countries. However, evidence suggests that parametrial, pelvic sidewall, bladder and rectal invasion, and metastatic disease are often poorly evaluated on clinical assessment alone 1,3-5
- When available, imaging investigations (ultrasound, CT, MRI and PET/CT) can provide further details about tumour size, nodal status and systemic spread, and can improve staging accuracy, help plan treatment (e.g. radiation therapy fields) and estimate prognosis. Chest radiographs are also helpful in some cases 1-4,6
- The 2018 revision of the FIGO staging system now allows imaging and pathological findings, when accessible, to help assign the stage 1
- Treatment for early disease where the cancer is confined to the cervix/upper vagina is usually with surgery (up to stage IIA) whereas advanced disease where the cancer extends beyond the cervix/upper vagina to involve the parametrium or lower vagina is generally treated with radiation therapy (stage IIB and above). Chemotherapy is a valuable adjunct treatment. Stage IB2 and IIA are also treated with chemoradiation at some centres 7-9
Staging of cervical cancer based on the International Federation of Gynaecology and Obstetrics (FIGO) and the American Joint Committee on Cancer TNM staging systems 1,2,10,11
FIGO Stage | TNM | |
---|---|---|
I | Cervical carcinoma confined to the cervix | T1 |
IA | Invasive carcinoma diagnosed only by microscopy with a maximum depth of invasion < 5mm | T1a |
IA1 | Measured stromal invasion < 3mm | T1a1 |
IA2 | Measured stromal invasion ≥ 3mm but < 5mm in depth | T1a2 |
IB | Invasive carcinoma with measured deepest invasion ≥ 5mm, lesion limited to cervix uteri | T1b |
IB1 | Invasive carcinoma ≥ 5mm depth of stromal invasion, and < 2cm in greatest dimension | T1b1 |
IB2 | Invasive carcinoma ≥ 2cm and < 4cm in greatest dimension | T1b2 |
IB3 | Invasive carcinoma ≥ 4cm in greatest dimension | |
II | Cervical carcinoma invades beyond the uterus but not the pelvic wall or lower third of vagina | T2 |
IIA | Tumour without parametrial invasion | T2a |
IIA1 | Invasive carcinoma < 4cm in greatest dimension | T2a1 |
IIA2 | Invasive carcinoma ≥ 4cm in greatest dimension | T2a2 |
IIB | With parametrial invasion but not up to the pelvic wall | T2b |
III | Carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes | T3 |
IIIA | Tumour involves lower third of vagina without extending to the pelvic wall | T3a |
IIIB | Tumour extends to pelvic wall, causes hydronephrosis or non-functioning kidney, or both | T3b |
IIIC | Involvement of pelvic and/or para-aortic lymph nodes, irrespective of tumour size and extent | |
IIIC1 | Pelvic lymph node metastasis only | |
IIIC2 | Para-aortic lymph node metastasis | |
IV | Tumour invades mucosa of bladder or rectum, extends beyond the true pelvis, or both | T4 |
IVA | Spread to adjacent pelvic organs | T4a |
IVB | Spread to distant organs | T4b |
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Clinical presentation, examination and biopsy
- In its early stages cervical cancer is usually asymptomatic and may be diagnosed on screening or pelvic examination 2
- Symptoms can include post-coital bleeding, abnormal vaginal bleeding, pelvic pain, and profuse malodorous vaginal discharge. Lower limb oedema, flank pain and sciatica in advanced disease suggest pelvic sidewall invasion. Invasive disease can result in passage of urine or faeces through the vagina from vesicovaginal or rectovaginal fistulae respectively 2
- Clinical assessment is the first step in allocation of stage and should include pelvic examination, visualisation of the cervix and vaginal mucosa and cervical cytology 1,2
- Biopsy should be performed when there is obvious macroscopic disease
- In women with positive cytology without visible lesions, a colposcopy and loop electrosurgical excision procedure or cone biopsy is necessary 1
- For microscopic lesions, stage is assigned following conisation when tumour dimensions can be determined histologically. For larger lesions, stage can be determined clinically based on tumour size and the degree of pelvic extension 2
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Magnetic Resonance Imaging (MRI)
- A number of international guidelines (e.g. the European Society for Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology, the European Society for Urogenital Radiology, and the American College of Radiology) recommend pelvic MRI for assessment of pelvic tumour extent. It is recommended for staging of all tumours IB and above, or smaller if fertility sparing surgery is being considered 4,12,13
- MRI is the best imaging modality to assess the primary tumour and is accurate in determining tumour size, location, depth of stromal invasion, parametrial and local extension. This can have significant implications in deciding between surgery or primary chemoradiotherapy and, when surgery is indicated, whether fertility-sparing surgery can be considered 1,4-6,14-17
- For women with advanced disease, MRI provides clear visualisation of the cervical tumour in multiple planes allowing for a reliable volumetric definition of the target tissue for external beam radiation and brachytherapy treatment planning 8
- Overall staging accuracy ranges from 75-96% and tumour measurements are within 5mm of surgical size in 70-94% of cases 4
- Sensitivity for evaluating parametrial invasion ranges from 40-84% and specificity 77-91%. Accuracy is reported to lie between 74-96%. 4,8,18
- A systematic review by Thomeer et al. comparing clinical examination with MRI found a pooled sensitivity of 40% for the evaluation of parametrial invasion with clinical examination compared with 84% with MRI. For the evaluation of advanced disease, sensitivity of clinical examination was 53% compared with 79% for MRI 19
- When evaluating lymph node involvement with MRI, a wide range of sensitivities and specificities have been reported between different studies. 4,20 A systematic review of 15 studies involving 1021 patients found a pooled sensitivity and specificity for diffusion weighted imaging (DWI)-MRI in detecting pelvic lymph node metastases of 86% and 84% respectively. 21 MRI performs less well in detecting small-volume metastatic involvement of normal sized lymph nodes 22
- Hricak et al. found a similar sensitivity and specificity between MRI and CT for detecting lymph node involvement. 23 A meta-analysis by Scheidler et al. also found CT and MRI to perform similarly in detecting lymph node metastasis 24
- Reported sensitivity of MRI in the evaluation of bladder and rectal invasion is 71-100% with a specificity of 88-91%. This has resulted in the reduced use of cystoscopic and endoscopic staging 7
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Positron Emission Tomography/Computed Tomography (PET/CT)
- Whole body PET/CT is recommended in the pre-treatment evaluation of cervical cancer patients with high risk of lymphatic involvement 22,25,26
- Lymph node metastases are associated with a poor prognosis and undetected lymph node involvement can lead to under-treatment 17,27
- 5-year survival of early stage cervical cancer is 90% if no lymph-node metastases are present compared to 65% when lymph-node metastases are present
- Most primary cervical cancers show intense FDG uptake, and although PET/CT is of limited value in evaluation of local disease (e.g. does not provide accurate information on parametrial invasion), it is superior to MRI and CT for detecting lymph node involvement, extra-pelvic disease, and tumour recurrence 17,28-36
- Fleming et al. found that a staging PET/CT changed the management of approximately one-third of patients with locally advanced cervical cancer by altering treatment intent and/or radiotherapy planning. 25 A study by Morkel et al. who investigated the role of PET/CT in patients with stage IIIB cancers also found that PET/CT affected the management in 40% of patients. 19% required a change in the radiation field due to identification of involved para-aortic lymph nodes and 21% were upstaged to stage IVB 37
- The role of preoperative PET/CT in patients with early cervical cancer (IA), however, is less clear and is thought to not change management in most patients 38,39
- Sensitivity and specificity for detecting metastatic lymph nodes by PET alone are reported to be 75-91% and 94-100% respectively. 4 A meta-analysis of 72 studies that included 5042 patients found the pooled sensitivity and specificity of PET for detecting positive lymph nodes was 75% and 98% respectively, higher than MRI (sensitivity 56%, specificity 93%) and CT (sensitivity 58%, specificity 92%) 40
- Sensitivity and specificity for detecting metastatic lymph nodes by combined PET/CT are reported to be 58-82% and 93-99% respectively 4,41
- False-negative results are seen in 4-15% of cases and false positives can occur due to infection or inflammation
- A number of studies have also found a correlation between PET/CT parameters (such as SUVmax), prognosis and recurrence after treatment. PET/CT is also helpful in follow up 34,42-46
- Combined PET/MRI is gaining popularity in view of its excellent soft-tissue contrast and lack of ionizing radiation exposure. There is promising evidence that PET/MRI may have better diagnostic accuracy than PET/CT in detecting lymph node metastasis and may be superior to MRI alone for treatment planning 33,47-50
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Ultrasound (US)
- Although early studies reported a limited role for US in cervical cancer staging, more recent studies investigating the utility of transvaginal and transrectal US have found similar local staging accuracy to MRI when performed by experienced operators 1,17,51
- Transvaginal and transrectal US have a high sensitivity and specificity for the assessment of tumour size and depth of stromal invasion. They have high specificity and moderate sensitivity in evaluating parametrial involvement. There is currently insufficient data evaluating the ability of ultrasound to detect tumour growth into the vagina, infiltration of the vesico-vaginal septum, infiltration into the recto-vaginal septum, and lymph-node metastases 17,52
- A study by Han et al. of 80 women who underwent surgical treatment found that transvaginal US had a pre-operative staging accuracy of 92.5% when compared to histology findings. They also found that US was effective in estimating depth of invasion 53
- Transabdominal US is a sensitive, non-invasive means of detecting hydronephrosis but otherwise has a limited role in assessing the local extent of cervical cancer. In cases of grossly invasive disease which has not been imaged with cross-sectional modalities, an ultrasound of the renal tract can be helpful to identify this 4,54
- Advantages of US include: 17,51
- Relatively inexpensive
- Widely available
- Relatively quick to perform
- No ionising radiation
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Chest radiograph
- In patients with frank invasive carcinoma a chest radiograph is recommended 1,54
- Chest radiographs can identify a pleural effusion or pulmonary metastases which can occur in the late stages of cervical cancer. However, chest CT is superior to chest radiographs in both of these circumstances 4
- A number of guidelines include routine chest radiography as the primary diagnostic instrument for detection of thoracic metastatic disease, however, there is limited original research to support this 55
- A study by Hoogendam et al., aimed to assess the utility of routine chest radiographs in cervical cancer patients. They found that chest radiography did not identify pulmonary or skeletal metastases (or incidental pathology requiring treatment) in any of the 244 patients with stage I/II disease. There was no change to the management of these patients. Chest radiographs did lead to upstaging two patients with stage IIIB and IVA cancer. They concluded that there is no value in performing routine chest radiography in the workup of early stage (stage I/II) disease, and it is only in advanced disease (stage III/IV) that continued use of routine chest radiography can be considered if cross-sectional imaging is not routinely employed or available 56
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Computed Tomography (CT) of the Chest/Abdomen
- There is consensus in the literature that CT is valuable in patients with advanced disease, but is of limited value in patients with early disease 4
- CT is an accurate tool for recognising distant metastases to the liver and to the lungs, and is also useful to detect urinary obstruction 17,57
- For patients with high risk of metastatic disease, contrast CT of the chest, abdomen and pelvis may be useful. It may also be helpful when MRI is contraindicated
- Owing to its relatively poor soft-tissue contrast resolution, CT usually does not accurately differentiate between tumour and normal cervical stroma or parametrial structures (cervical cancer appears isodense compared with adjacent normal structures). CT is therefore of limited utility in local staging 17,57
- Sensitivity for parametrial invasion ranges from 17-100%, with an average of 64% 4
- Overall staging accuracy ranges from 32-80% 4
- Pooled sensitivity and specificity for detection of lymph node metastases are 50% and 92% respectively. The low sensitivity is thought to be because the reliance on size criteria alone (> 1cm) to diagnose malignant lymphadenopathy misses micrometastases
- CT can also assist with radiation therapy planning and guide interventional procedures 4
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Cystoscopy and Sigmoidoscopy
- Cystoscopy or sigmoidoscopy may be considered to provide a biopsy if there are suspicious lesions in the urinary bladder or rectum on imaging 12,54
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Treatment
- Treatment for early disease (up to stage IIA) where the cancer is confined to the cervix/upper vagina is usually surgery 7-9
- Advanced disease (stage IIB and above) where the cancer extends beyond the cervix/upper vagina to involve the parametrium or lower vagina is generally treated with radiation therapy. 7-10 Surgery is unlikely to be curative in these patients and is associated with a high risk of adverse events and morbidity. 2 Stage IB and IIA tumours are also treated with chemoradiation at some centres
- Chemotherapy is a valuable adjunct treatment in some circumstances 7-9
- Definitive chemoradiotherapy and brachytherapy are recommended in patients with unequivocally involved pelvic lymph nodes on imaging. Debulking of suspicious pelvic lymph nodes may be considered 12
- Surgical treatments can include: 1,2
- Cervical conisation
- Trachelectomy
- Hysterectomy – simple extrafascial or radical depending on the stage of disease
- Pelvic and para-aortic lymphadenectomy
- Pelvic exenteration
- Stage of disease, lymphovascular invasion on histology, and fertility wishes of the patient are important factors to consider when deciding on the most appropriate surgical treatment
- A tumour of ≤ 2cm is often used as a cut-off when considering fertility-sparing trachelectomy in women with stage IB1 tumours 2,10
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
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- Cohen PA, Jhingran A, Oaknin A, Denny L. Cervical cancer. Lancet. 2019;393(10167):169-82 (Review article). View the reference
- Narayan K, Lin MY. Staging for cervix cancer: Role of radiology, surgery and clinical assessment. Best Pract Res Clin Obstet Gynaecol. 2015;29(6):833-44 (Review article). View the reference
- Siegel CL, Andreotti RF, Cardenes HR, Brown DL, Gaffney DK, Horowitz NS, et al. ACR Appropriateness Criteria(R) pretreatment planning of invasive cancer of the cervix. J Am Coll Radiol. 2012 (2015 update);9(6):395-402 (Clincial guidelines). View the reference
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- Matsuo K, Machida H, Mandelbaum RS, Konishi I, Mikami M. Validation of the 2018 FIGO cervical cancer staging system. Gynecol Oncol. 2019;152(1):87-93 (Level III evidence). View the reference
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- Cibula D, Potter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018;28(4):641-55 (Clinical guidelines). View the reference
- Balleyguier C, Sala E, Da Cunha T, Bergman A, Brkljacic B, Danza F, et al. Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology. Eur Radiol. 2011;21(5):1102-10 (Clinical guidelines). View the reference
- Rizzo S, Calareso G, Maccagnoni S, Angileri SA, Landoni F, Raimondi S, et al. Pre-operative MR evaluation of features that indicate the need of adjuvant therapies in early stage cervical cancer patients. A single-centre experience. Eur J Radiol. 2014;83(5):858-64 (Level III evidence). View the reference
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- Patel-Lippmann K, Robbins JB, Barroilhet L, Anderson B, Sadowski EA, Boyum J. MR Imaging of Cervical Cancer. Magn Reson Imaging Clin N Am. 2017;25(3):635-49 (Review article). View the reference
- Testa AC, Di Legge A, De Blasis I, Moruzzi MC, Bonatti M, Collarino A, et al. Imaging techniques for the evaluation of cervical cancer. Best Pract Res Clin Obstet Gynaecol. 2014;28(5):741-68 (Review article). View the reference
- Kim M, Suh DH, Kim K, Lee HJ, Kim YB, No JH. Magnetic Resonance Imaging as a Valuable Tool for Predicting Parametrial Invasion in Stage IB1 to IIA2 Cervical Cancer. Int J Gynecol Cancer. 2017;27(2):332-8 (Level III evidence). View the reference
- Thomeer MG, Gerestein C, Spronk S, van Doorn HC, van der Ham E, Hunink MG. Clinical examination versus magnetic resonance imaging in the pretreatment staging of cervical carcinoma: systematic review and meta-analysis. Eur Radiol. 2013;23(7):2005-18 (Level I evidence). View the reference
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- Vural GU, Akkas BE, Demirel BB. Standardized uptake value and metabolic tumor volume measured by (1)(8)F FDG PET/CT are sensitive biomarkers for the presence of lymph node metastasis in patients with cervical carcinoma. Rev Esp Med Nucl Imagen Mol. 2014;33(5):268-73 (Level III evidence). View the reference
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- Scheidler J, Hricak H, Yu KK, Subak L, Segal MR. Radiological evaluation of lymph node metastases in patients with cervical cancer. A meta-analysis. JAMA. 1997;278(13):1096-101 (Level I evidence). View the reference
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- Rose PG, Adler LP, Rodriguez M, Faulhaber PF, Abdul-Karim FW, Miraldi F. Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study. J Clin Oncol. 1999;17(1):41-5 (Level III evidence). View the reference
- Chen MY, Chou HH, Liu FY, Chen CY, Lin G, Yang LY, et al. (18)F-FDG PET in small-cell cervical cancer: a prospective study with long-term follow-up. Eur J Nucl Med Mol Imaging. 2016;43(4):663-74 (Level III evidence). View the reference
- Choi HJ, Roh JW, Seo SS, Lee S, Kim JY, Kim SK, et al. Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymph node metastases in patients with uterine cervical carcinoma: a prospective study. Cancer. 2006;106(4):914-22 (Level II evidence). View the reference
- Dong Y, Wang X, Wang Y, Liu Y, Zhang J, Qian W, et al. Validity of 18F-fluorodeoxyglucose positron emission tomography/computed tomography for pretreatment evaluation of patients with cervical carcinoma: a retrospective pathology-matched study. Int J Gynecol Cancer. 2014;24(9):1642-7 (Level III evidence). View the reference
- Lv K, Guo HM, Lu YJ, Wu ZX, Zhang K, Han JK. Role of 18F-FDG PET/CT in detecting pelvic lymph-node metastases in patients with early-stage uterine cervical cancer: comparison with MRI findings. Nucl Med Commun. 2014;35(12):1204-11 (Level III evidence). View the reference
- Naga Ch P, Gurram L, Chopra S, Mahantshetty U. The management of locally advanced cervical cancer. Curr Opin Oncol. 2018;30(5):323-9 (Review article). View the reference
- Palaniswamy SS, Borde CR, Subramanyam P. 18F-FDG PET/CT in the evaluation of cancer cervix: Where do we stand today? Nucl Med Commun. 2018;39(7):583-92 (Review article). View the reference
- Vandeperre A, Van Limbergen E, Leunen K, Moerman P, Amant F, Vergote I. Para-aortic lymph node metastases in locally advanced cervical cancer: Comparison between surgical staging and imaging. Gynecol Oncol. 2015;138(2):299-303 (Level III evidence). View the reference
- Yen TC, Ng KK, Ma SY, Chou HH, Tsai CS, Hsueh S, et al. Value of dual-phase 2-fluoro-2-deoxy-d-glucose positron emission tomography in cervical cancer. J Clin Oncol. 2003;21(19):3651-8 (Level II evidence). View the reference
- Morkel M, Ellmann A, Warwick J, Simonds H. Evaluating the Role of F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scanning in the Staging of Patients With Stage IIIB Cervical Carcinoma and the Impact on Treatment Decisions. Int J Gynecol Cancer. 2018;28(2):379-84 (Level III evidence). View the reference
- Gemer O, Eitan R, Gdalevich M, Mamanov A, Piura B, Rabinovich A, et al. Integration of PET/CT into the preoperative evaluation of patients with early cervical cancer does not decrease the proportion of patients with positive lymph nodes found after surgery. Int J Gynecol Cancer. 2014;24(8):1461-5 (Level III evidence). View the reference
- Driscoll DO, Halpenny D, Johnston C, Sheehy N, Keogan M. 18F-FDG-PET/CT is of limited value in primary staging of early stage cervical cancer. Abdom Imaging. 2015;40(1):127-33 (Level III evidence). View the reference
- Selman TJ, Mann C, Zamora J, Appleyard TL, Khan K. Diagnostic accuracy of tests for lymph node status in primary cervical cancer: a systematic review and meta-analysis. Cmaj. 2008;178(7):855-62 (Level I evidence). View the reference
- Gee MS, Atri M, Bandos AI, Mannel RS, Gold MA, Lee SI. Identification of Distant Metastatic Disease in Uterine Cervical and Endometrial Cancers with FDG PET/CT: Analysis from the ACRIN 6671/GOG 0233 Multicenter Trial. Radiology. 2018;287(1):176-84 (Level II evidence). View the reference
- Yilmaz B, Dag S, Ergul N, Cermik TF. The efficacy of pretreatment and after treatment 18F-FDG PET/CT metabolic parameters in patients with locally advanced squamous cell cervical cancer. Nucl Med Commun. 2019;40(3):219-27 (Level III evidence). View the reference
- Zhang L, Sun H, Du S, Xu W, Xin J, Guo Q. Evaluation of 18F-FDG PET/CT parameters for reflection of aggressiveness and prediction of prognosis in early-stage cervical cancer. Nucl Med Commun. 2018;39(11):1045-52 (Level III evidence). View the reference
- Takagi H, Sakamoto J, Osaka Y, Shibata T, Fujita S, Sasagawa T. Usefulness of the maximum standardized uptake value for the diagnosis and staging of patients with cervical cancer undergoing positron emission tomography/computed tomography. Medicine (Baltimore). 2018;97(7):e9856 (Level III evidence). View the reference
- Lee JW, Jeon S, Mun ST, Lee SM. Prognostic Value of Fluorine-18 Fluorodeoxyglucose Uptake of Bone Marrow on Positron Emission Tomography/Computed Tomography for Prediction of Disease Progression in Cervical Cancer. Int J Gynecol Cancer. 2017;27(4):776-83 (Level III evidence). View the reference
- Gubbi A, Kacheria S, Ahmad S, Stavitzski NM, Kendrick JE. Prognostic Significance of the Standardized Uptake Value of Pretherapeutic 18F-Labeled 2-Fluoro-2-Deoxyglucose Positron Emission Tomography/Computed Tomography in Patients With Locally Advanced Cervical Cancer. Int J Gynecol Cancer. 2017;27(3):530-6 (Level III evidence). View the reference
- Stecco A, Buemi F, Cassara A, Matheoud R, Sacchetti GM, Arnulfo A, et al. Comparison of retrospective PET and MRI-DWI (PET/MRI-DWI) image fusion with PET/CT and MRI-DWI in detection of cervical and endometrial cancer lymph node metastases. Radiol Med. 2016;121(7):537-45 (Level III evidence). View the reference
- Grueneisen J, Schaarschmidt BM, Heubner M, Aktas B, Kinner S, Forsting M, et al. Integrated PET/MRI for whole-body staging of patients with primary cervical cancer: preliminary results. Eur J Nucl Med Mol Imaging. 2015;42(12):1814-24 (Level II evidence). View the reference
- Sarabhai T, Schaarschmidt BM, Wetter A, Kirchner J, Aktas B, Forsting M, et al. Comparison of (18)F-FDG PET/MRI and MRI for pre-therapeutic tumor staging of patients with primary cancer of the uterine cervix. Eur J Nucl Med Mol Imaging. 2018;45(1):67-76 (Level II evidence). View the reference
- Kitajima K, Suenaga Y, Ueno Y, Kanda T, Maeda T, Deguchi M, et al. Fusion of PET and MRI for staging of uterine cervical cancer: comparison with contrast-enhanced (18)F-FDG PET/CT and pelvic MRI. Clin Imaging. 2014;38(4):464-9 (Level III evidence). View the reference
- Moloney F, Ryan D, Twomey M, Hewitt M, Barry J. Comparison of MRI and high-resolution transvaginal sonography for the local staging of cervical cancer. J Clin Ultrasound. 2016;44(2):78-84 (Level II evidence). View the reference
- Arribas S, Alcazar JL, Arraiza M, Benito A, Minguez JA, Jurado M. Three-Dimensional Transvaginal Sonography and Magnetic Resonance Imaging for Local Staging of Cervical Cancer: An Agreement Study. J Ultrasound Med. 2016;35(5):867-73 (Level II evidence). View the reference
- Han XS, Ning CP, Sun LT, Li XY, Peng YQ, Dang MZ. Three-dimensional transvaginal tomographic ultrasound imaging for cervical cancer staging. Ultrasound Med Biol. 2015;41(9):2303-9 (Level III evidence). View the reference
- Bermudez A, Bhatla N, Leung E. Cancer of the cervix uteri. Int J Gynaecol Obstet. 2015;131 Suppl 2:S88-95. View the reference
- ACOG practice bulletin. Diagnosis and treatment of cervical carcinomas. Number 35, May 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;78(1):79-91 (Review article). View the reference
- Hoogendam JP, Zweemer RP, Verkooijen HM, de Jong PA, van den Bosch MA, Verheijen RH, et al. No Value for Routine Chest Radiography in the Work-Up of Early Stage Cervical Cancer Patients PLoS One. 2015;10(7):e0131899 (Level III evidence). View the reference
- Prasad TV, Thulkar S, Hari S, Sharma DN, Kumar S. Role of computed tomography (CT) scan in staging of cervical carcinoma. Indian J Med Res. 2014;139(5):714-9 (Level II evidence). View the reference
Special Thanks:
Professor Yee Leung, Consultant Gynaecologist, King Edward Memorial Hospital, Perth, Western Australia.
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