Abstract

Hedvig Hricak
Department of Radiology, Memorial Sloan-Kettering Cancer Center, USA

The objectives of imaging in gynecologic cancer include tumor detection, diagnosis, staging, follow-up, and monitoring treatment response.

For cervical cancer, imaging modalities must be directed to distinguish early disease (stages I and IIA) that can be treated with surgery from advanced disease that must be treated with radiation with or without chemotherapy. Conventional radiological studies have become obsolete, and cross-sectional imaging is now used. CT is mainly used in advanced disease and in the assessment of lymph nodes. For loco-regional staging, MRI is the method of choice because it is accurate in the determination of the tumor size, location, depth of stromal invasion, and local extent. Though still under investigation, PET/CT can be used to assess nodal disease and tumor recurrence.

Endometrial cancer usually presents at stage I; the standard treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy. The role of imaging is to depict the depth of myometrial invasion and the presence of lymphadenopathy, and to stage the tumor extent.

Transvaginal ultrasound (US), considered the primary imaging approach, is limited to the evaluation of stage I disease with emphasis on the depth of myometrial invasion. The role of MRI includes assessing the depth of myometrial invasion and the stage in patients with an equivocal pelvic examination or a medical contraindication to surgical staging. Dynamic contrast-enhanced MRI offers a ‘one-stop’ examination with the highest efficacy for pretreatment evaluation. MRI is significantly better than US and CT for evaluating tumor extension into the cervix and myometrial invasion. CT is very useful in screening for lymphatic or peritoneal metastases in patients with a poorly differentiated carcinoma or sarcoma, and for confirming stage III or IV disease. PET/CT imaging is promising for post-treatment surveillance.

Early ovarian cancer is treated with comprehensive staging laparotomy. Advanced but operable disease is treated with primary cytoreductive surgery followed by chemotherapy.

US is the primary modality for detection and characterization of adnexal masses. MRI is a problem-solving modality in cases of indeterminate adnexal masses on US or staging problems on CT. Abdominal/pelvic CT is the imaging modality of choice for preoperative staging and follow-up and for prediction of tumor resectability. PET/CT is very valuable in the setting of recurrent disease and particularly for detecting tumor deposits in mesentery and bowel serosa.