DOI: 10.1148/rg.232025065
(Radiographics. 2003;23:425-445.)
© RSNA, 2003
MR Imaging of the Uterine Cervix: Imaging-Pathologic Correlation1
Yoshikazu Okamoto, MD,
Yumiko O. Tanaka, MD,
Masato Nishida, MD,
Hajime Tsunoda, MD,
Hiroyuki Yoshikawa, MD and
Yuji Itai, MD
1 From the Department of Radiology, Tsukuba University Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan (Y.O.); the Departments of Radiology (Y.O.T., Y.I.) and Obstetrics and Gynecology (H.T., H.Y.), Institute of Clinical Medicine, University of Tsukuba; and the Department of Obstetrics and Gynecology, National Kasumigaura Hospital, Tsuchiura, Japan (M.N.). Recipient of a Cum Laude award for an education exhibit at the 2001 RSNA scientific assembly. Received March 25, 2002; revision requested April 30 and received June 13; accepted June 14. Address correspondence to Y.O. (e-mail: okamotchi@muf.biglobe.ne.jp).
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Abstract
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Magnetic resonance (MR) imaging is useful not only for preoperative staging of gynecologic malignancies but also for prediction of the histopathologic features of a variety of intrapelvic tumors. Familiarity with the specific imaging findings that have been reported for the uterine cervix is a goal of radiologists. The typical MR imaging findings of uterine cervical lesions correspond to the histopathologic features. These lesions can be categorized as epithelial neoplasms, nonepithelial neoplasms, and nonneoplastic diseases. Cervical carcinoma accounts for most cases of malignant lesions and is staged by using the classification system established by the International Federation of Gynecology and Obstetrics. MR imaging allows differentiation between endophytic and exophytic growth and between normal and abnormal findings after hysterectomy and irradiation. Other epithelial neoplasms of the uterine cervix include adenoma malignum, which is a special type of cervical adenocarcinoma, as well as carcinoid tumor and malignant melanoma. Nonepithelial neoplasms of the uterine cervix include malignant lymphoma and leiomyoma. Nonneoplastic diseases of the uterine cervix include cervical pregnancy, cervicitis, nabothian cysts, polyps, and endometriosis.
© RSNA, 2003
Index Terms: Endometriosis, 854.3192 • Pregnancy, ectopic, 854.8234 • Uterine neoplasms, diagnosis, 854.30 • Uterus, cysts, 854.311 • Uterus, diseases, 854.2179
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LEARNING OBJECTIVES FOR TEST 4
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After reading this article and taking the test, the reader will be able to:
- List the various types of diseases that affect the uterine cervix.
- Recognize the MR imaging characteristics of common diseases of the uterine cervix.
- Describe the correlations between these MR imaging findings and the histopathologic findings.
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Introduction
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Uterine cervical cancer is one of the most common malignancies seen by gynecologic radiologists. However, many other kinds of diseases can affect the uterine cervix, including tumors, inflammation, and even ectopic pregnancy. This article presents the various kinds of uterine cervical lesions with typical magnetic resonance (MR) imaging findings for each. These lesions are divided into three categories: epithelial neoplasms, nonepithelial neoplasms, and nonneoplastic diseases.
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Anatomy
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The uterine cervix is composed of the portio, which protrudes into the vagina, and the supravaginal part of the cervix.
Squamous cells cover the epithelial surface of the portio continuing from the vagina. With age, they grow back to cover the columnar cells of the endocervical gland. This transitional area is called the squamocolumnar junction (SCJ) (Fig 1). Carcinoma of the cervix develops almost exclusively within the transformation zone that extends between the original SCJ and the physiologic SCJ (Fig 1).
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Figure 1. Drawing of the uterus and vagina. The cervix consists of two different types of epithelium: squamous epithelium and glandular epithelium. Squamous cells cover the epithelial surface of the portio continuing from the vagina, and columnar cells cover the glandular epithelium of the endocervical gland, which produces mucin. With age, squamous cells grow back to cover the columnar cells. This transitional area is the SCJ (arrow).
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Epithelial Neoplasms
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Cervical Cancer
In the Japanese population, uterine cervical cancer is the most common malignancy affecting the female genital tract. About 90% of cervical carcinomas in Japan are squamous cell carcinoma, although about 5%–10% are adenocarcinoma and others are rare histologic subtypes (1). In the United States, 15,700 new cases of invasive cervical cancer and approximately 4,900 deaths were anticipated in 1996 (2). Recently, the prevalence of adenocarcinoma has been increasing. We assume that the prevalence of cervical cancer has been decreasing in Japan recently because a cytologic screening program has been widely applied in Japan in the past 20 years. Because it is easy to find abnormal squamous cells by using a Papanicolaou smear, the prevalence of invasive squamous cell carcinoma has decreased. Conversely, the prevalence of cervical adenocarcinoma has not been changed by the Papanicolaou smear. Therefore, the relative percentage of adenocarcinoma is increasing.
Most cervical squamous cell carcinomas grow at the SCJ. In younger women, the SCJ is located outside the external uterine os, and the tumor tends to grow outward (exophytic growth pattern) (Fig 2). In contrast, in elderly patients, the SCJ is located within the cervical canal. In these patients, cervical cancer tends to grow inward along the cervical canal (endophytic growth pattern) (Fig 3). Reserve cells at the SCJ have been watched with interest as an origin site of cervical adenocarcinoma. Therefore, most cervical adenocarcinomas would also arise in the SCJ.
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Figure 2a. Cervical carcinoma with exophytic growth in a 44-year-old woman. The pathologic stage was Ib-1. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, cauliflower-like tumor in the posterior lip of the portio (arrows). The tumor markedly expands the posterior vaginal fornix. (b) Photograph of the cut surface of the resected specimen shows a white mass that expands into the fornix (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of atypical squamous epithelium with cancer "pearls" (arrowheads).
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Figure 2b. Cervical carcinoma with exophytic growth in a 44-year-old woman. The pathologic stage was Ib-1. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, cauliflower-like tumor in the posterior lip of the portio (arrows). The tumor markedly expands the posterior vaginal fornix. (b) Photograph of the cut surface of the resected specimen shows a white mass that expands into the fornix (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of atypical squamous epithelium with cancer "pearls" (arrowheads).
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Figure 2c. Cervical carcinoma with exophytic growth in a 44-year-old woman. The pathologic stage was Ib-1. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, cauliflower-like tumor in the posterior lip of the portio (arrows). The tumor markedly expands the posterior vaginal fornix. (b) Photograph of the cut surface of the resected specimen shows a white mass that expands into the fornix (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of atypical squamous epithelium with cancer "pearls" (arrowheads).
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Figure 3. Cervical carcinoma with endophytic growth in a 59-year-old woman. The preoperative imaging diagnosis was stage IIb carcinoma. Sagittal T2-weighted MR image shows a slightly hyperintense mass that replaces the cervix (white arrows). The lesion is located almost within the cervical canal. The patient also has a mature cystic teratoma of the right ovary, which is seen as a cystic mass (black arrow) behind the uterus.
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MR imaging can provide highly accurate information on the exact extent of tumors because of its fine contrast resolution. Cervical cancers appear as hyperintense masses on T2-weighted images regardless of histopathologic type. The usefulness of dynamic contrast material–enhanced studies in diagnosing parametrial invasion and predicting radiosensitivity has been reported (3–5), although sagittal T1-weighted and T2-weighted images and oblique axial T2-weighted images obtained perpendicular to the uterine axis are sufficient for staging in most cases (6). MR urography and computed tomography (CT) are also indicated in diagnosing hydronephrosis associated with cancer invasion, paraaortic lymph node metastases, or other distant metastases.
In general, staging of cervical carcinoma with MR imaging is based on the classification system of the International Federation of Gynecology and Obstetrics (FIGO) (7) (Table). Thus, stage Ia is defined as a microinvasive tumor that cannot be demonstrated at MR imaging. Stage Ib is defined as a clinically invasive tumor, although it is confined to the cervix and does not invade the vagina or parametrium. In stage Ib, the tumor is completely surrounded by hypointense cervical stroma on axial T2-weighted images (8–10) (Fig 4).
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Figure 4a. Stage Ib cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show a slightly hyperintense mass in the uterine cervix. The mass protrudes into the posterior vaginal fornix; however, the vaginal mucosa attached to the tumor is intact (arrows in a). The tumor is completely surrounded by hypointense cervical stroma on the axial image (arrowheads in b).
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Figure 4b. Stage Ib cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show a slightly hyperintense mass in the uterine cervix. The mass protrudes into the posterior vaginal fornix; however, the vaginal mucosa attached to the tumor is intact (arrows in a). The tumor is completely surrounded by hypointense cervical stroma on the axial image (arrowheads in b).
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Stage IIa is defined as a tumor that invades the upper two-thirds of the vagina without parametrial invasion. Segmental disruption of the hypointense vaginal wall is demonstrated on T2-weighted images (8–10) (Fig 5). When the tumor invades beyond the uterus with parametrial invasion without reaching the pelvic wall, it is defined as stage IIb. At MR imaging, triangular protrusion of the tumor through the disrupted hypointense ring of cervical stroma is seen (8–10) (Fig 6).
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Figure 5a. Stage IIa cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show a slightly hyperintense mass that protrudes into the vaginal canal (arrow in a). Most of the vaginal wall surrounding the tumor seems intact (white arrows in b), although the low signal intensity of the vaginal wall is disrupted on the right side (black arrow in b). Parametrial invasion is not seen.
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Figure 5b. Stage IIa cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show a slightly hyperintense mass that protrudes into the vaginal canal (arrow in a). Most of the vaginal wall surrounding the tumor seems intact (white arrows in b), although the low signal intensity of the vaginal wall is disrupted on the right side (black arrow in b). Parametrial invasion is not seen.
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Figure 6a. Stage IIb cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show that the cervix is almost entirely replaced by a slightly hyperintense mass. The tumor protrudes into the parametrium bilaterally (arrowheads in b); however, it does not reach the pelvic wall. Hydrometra, which is caused by the obstructed internal cervical os, is also noted (arrow in a).
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Figure 6b. Stage IIb cervical carcinoma. Sagittal (a) and axial (b) T2-weighted MR images show that the cervix is almost entirely replaced by a slightly hyperintense mass. The tumor protrudes into the parametrium bilaterally (arrowheads in b); however, it does not reach the pelvic wall. Hydrometra, which is caused by the obstructed internal cervical os, is also noted (arrow in a).
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In stage IIIa, vaginal involvement reaches the lower third of the vaginal canal without extending to the pelvic wall. Occasionally, the anterior vaginal wall is partly disrupted and the tumor infiltrates the bladder wall but not the vesical mucosa (Fig 7). When the tumor extends to the pelvic wall or causes hydronephrosis, it is defined as stage IIIb. At MR imaging, the tumor obliterates the entire cardinal ligament and extends to the pelvic muscles. Hydronephrosis caused by tumor invasion of the ureter is also classified as stage IIIb. MR urography can clearly demonstrate hydronephrosis caused by tumor extension (Fig 8).
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Figure 7a. Stage IIIa cervical carcinoma. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid mass that extends along the anterior vaginal wall and reaches the lower one-third of the vagina (arrow). (b) Axial T2-weighted MR image shows that the low signal intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty tissue between the mass and the posterior bladder wall has disappeared. However, the mass does not infiltrate the vesical mucosa.
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Figure 7b. Stage IIIa cervical carcinoma. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid mass that extends along the anterior vaginal wall and reaches the lower one-third of the vagina (arrow). (b) Axial T2-weighted MR image shows that the low signal intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty tissue between the mass and the posterior bladder wall has disappeared. However, the mass does not infiltrate the vesical mucosa.
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Figure 8a. Stage IIIb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, large, solid mass that extends from the uterine cervix to the lower part of the uterine body. It also extends to the lower one-third of the anterior vaginal wall (arrow). (b) Axial T2-weighted MR image shows that the tumor also reaches the left posterior wall of the bladder, although the thinned vesical muscular layer remains (arrowheads). (c) MR urogram clearly shows left hydronephrosis caused by tumor invasion.
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Figure 8b. Stage IIIb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, large, solid mass that extends from the uterine cervix to the lower part of the uterine body. It also extends to the lower one-third of the anterior vaginal wall (arrow). (b) Axial T2-weighted MR image shows that the tumor also reaches the left posterior wall of the bladder, although the thinned vesical muscular layer remains (arrowheads). (c) MR urogram clearly shows left hydronephrosis caused by tumor invasion.
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Figure 8c. Stage IIIb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a slightly hyperintense, large, solid mass that extends from the uterine cervix to the lower part of the uterine body. It also extends to the lower one-third of the anterior vaginal wall (arrow). (b) Axial T2-weighted MR image shows that the tumor also reaches the left posterior wall of the bladder, although the thinned vesical muscular layer remains (arrowheads). (c) MR urogram clearly shows left hydronephrosis caused by tumor invasion.
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If the tumor invades the vesical or rectal mucosa, it is classified as stage IVa. Segmental disruption of the hypointense vesical or rectal wall or a segmental thickened rectal wall is seen at MR imaging (8–10) (Fig 9). Once any distant metastases occur, the stage is defined as IVb. Although pelvic lymph node metastases do not change the International Federation of Gynecology and Obstetrics stage, paraaortic or inguinal lymph node metastases are classified as stage IVb. Cervical cancer occasionally causes carcinomatous lymphangitis of the lung or hematogenous hepatic metastases. CT plays a major role in diagnosing such advanced disease (Fig 10).
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Figure 9. Stage IVa cervical carcinoma. Sagittal T2-weighted MR image shows a hypointense mass that occupies the uterine cervix and invades the vaginal wall anteriorly. At the level of the vaginal extension, the tumor reaches the mucosa of the posterior vesical wall (arrows).
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Figure 10a. Stage IVb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and hematogenous hepatic metastases (c). These findings are classified as stage IVb disease (Table).
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Figure 10b. Stage IVb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and hematogenous hepatic metastases (c). These findings are classified as stage IVb disease (Table).
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Figure 10c. Stage IVb cervical carcinoma. (a) Sagittal T2-weighted MR image shows a large mass in the uterine cervix. (b, c) CT scans show metastases of paraaortic lymph nodes (arrows in b) and hematogenous hepatic metastases (c). These findings are classified as stage IVb disease (Table).
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MR imaging is also useful for evaluation of the postoperative state (11). Conization is usually performed as a radical surgery for carcinoma in situ or microinvasive carcinomas or as a diagnostic procedure in cases suspected to be invasive cervical carcinoma. After conization, the portio seems smaller than usual (Fig 11). Otherwise, abdominal radical hysterectomy is a standard surgery for stage Ib and IIa disease (Fig 12). Diagnosis of local recurrence after surgery or radiation therapy can also be achieved with MR imaging (Figs 13, 14).
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Figure 12a. Appearance of the pelvis after radical hysterectomy. (a) Sagittal T2-weighted MR image shows that the uterus has disappeared (arrows). (b) Axial T2-weighted MR image shows a small amount of hypointense, bandlike soft tissue at the vaginal stump (arrows).
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Figure 12b. Appearance of the pelvis after radical hysterectomy. (a) Sagittal T2-weighted MR image shows that the uterus has disappeared (arrows). (b) Axial T2-weighted MR image shows a small amount of hypointense, bandlike soft tissue at the vaginal stump (arrows).
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Figure 13a. Local recurrence after radiation therapy. (a) Sagittal T2-weighted MR image shows a large, hypointense mass that occupies the uterine cervix and the lower part of the uterine body (arrowheads). (b) Sagittal T2-weighted MR image obtained 2 months after radiation therapy shows marked regression of the tumor (arrowheads). (c) Sagittal T2-weighted MR image obtained 14 months after radiation therapy shows a slightly hyperintense area in the uterine body (arrowheads). Histologic analysis proved that this area represented a recurrence.
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Figure 13b. Local recurrence after radiation therapy. (a) Sagittal T2-weighted MR image shows a large, hypointense mass that occupies the uterine cervix and the lower part of the uterine body (arrowheads). (b) Sagittal T2-weighted MR image obtained 2 months after radiation therapy shows marked regression of the tumor (arrowheads). (c) Sagittal T2-weighted MR image obtained 14 months after radiation therapy shows a slightly hyperintense area in the uterine body (arrowheads). Histologic analysis proved that this area represented a recurrence.
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Figure 13c. Local recurrence after radiation therapy. (a) Sagittal T2-weighted MR image shows a large, hypointense mass that occupies the uterine cervix and the lower part of the uterine body (arrowheads). (b) Sagittal T2-weighted MR image obtained 2 months after radiation therapy shows marked regression of the tumor (arrowheads). (c) Sagittal T2-weighted MR image obtained 14 months after radiation therapy shows a slightly hyperintense area in the uterine body (arrowheads). Histologic analysis proved that this area represented a recurrence.
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Figure 14a. Local recurrence after hysterectomy. (a) Sagittal T2-weighted MR image shows a cervical carcinoma (arrow). (b, c) Sagittal (b) and axial (c) T2-weighted MR images obtained 6 months after radical hysterectomy show a hyperintense mass along the anterior vaginal wall (arrows). Biopsy demonstrated that the mass was a local recurrence.
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Figure 14b. Local recurrence after hysterectomy. (a) Sagittal T2-weighted MR image shows a cervical carcinoma (arrow). (b, c) Sagittal (b) and axial (c) T2-weighted MR images obtained 6 months after radical hysterectomy show a hyperintense mass along the anterior vaginal wall (arrows). Biopsy demonstrated that the mass was a local recurrence.
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Figure 14c. Local recurrence after hysterectomy. (a) Sagittal T2-weighted MR image shows a cervical carcinoma (arrow). (b, c) Sagittal (b) and axial (c) T2-weighted MR images obtained 6 months after radical hysterectomy show a hyperintense mass along the anterior vaginal wall (arrows). Biopsy demonstrated that the mass was a local recurrence.
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Adenoma Malignum
Adenoma malignum (also known as minimal deviation adenocarcinoma) is a special subtype of mucinous adenocarcinoma of the cervix. Its prevalence is about 3% of all cervical adenocarcinomas (12). The most common initial symptom is a watery discharge. The prognosis of this tumor has been reported to be unfavorable (13), as it disseminates into the peritoneal cavity even in the early stage of the disease and its response to radiation or chemotherapy is poor. Therefore, its deceptively benign histologic appearance occasionally leads to an incorrect diagnosis.
At histopathologic analysis, the tumor is composed of well-differentiated endocervical glands that extend from the surface to the deeper portion of the cervical wall. They form an annular or nodular mass, with cystic spaces filled with mucin (12,14) (Fig 15).
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Figure 15a. Adenoma malignum. (a) Sagittal T2-weighted MR image shows a multicystic lesion with a solid component in the deep cervical stroma (arrowhead). (b) Sagittal MR image obtained after administration of a gadolinium-based contrast agent shows obvious enhancement of the solid component of the lesion (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the endocervical glands in the upper row have no atypia. However, those in the lower row have larger nuclei located at the center of the cells, an appearance indicative of cellular atypia.
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Figure 15b. Adenoma malignum. (a) Sagittal T2-weighted MR image shows a multicystic lesion with a solid component in the deep cervical stroma (arrowhead). (b) Sagittal MR image obtained after administration of a gadolinium-based contrast agent shows obvious enhancement of the solid component of the lesion (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the endocervical glands in the upper row have no atypia. However, those in the lower row have larger nuclei located at the center of the cells, an appearance indicative of cellular atypia.
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Figure 15c. Adenoma malignum. (a) Sagittal T2-weighted MR image shows a multicystic lesion with a solid component in the deep cervical stroma (arrowhead). (b) Sagittal MR image obtained after administration of a gadolinium-based contrast agent shows obvious enhancement of the solid component of the lesion (arrows). (c) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the endocervical glands in the upper row have no atypia. However, those in the lower row have larger nuclei located at the center of the cells, an appearance indicative of cellular atypia.
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At MR imaging, adenoma malignum is characterized by multicystic lesions that extend from the endocervical glands to the deep cervical stroma with solid components (15,16) (Fig 15). The differential diagnosis includes deep nabothian cysts, florid endocervical hyperplasia, and even well-differentiated adenocarcinoma, because any cervical glandular proliferation can show multicystic features within the deep cervical stroma (15–17). The possibility of differentiating these lesions from adenoma malignum with MR imaging is controversial. It has been reported that a multicystic lesion with some solid components in the deep cervical stroma is evidence of adenoma malignum at MR imaging, although some benign cystic lesions that affect the cervix also appear multicystic with solid features (16–20) (Fig 16).
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Figure 16a. Endocervical hyperplasia. (a) Sagittal T2-weighted MR image shows a multicystic mass surrounding the cervical canal (arrows). An area that is hyperintense relative to the normal cervical stroma near the cysts is also noted. (b) Sagittal MR image obtained after administration of gadolinium-based contrast material shows intense enhancement of the relatively hyperintense area near the cysts on the T2-weighted image (arrows). (c) Photomicrograph (original magnification, x4; hematoxylin-eosin stain) shows that the tumor is composed of normal endocervical glands without malignant features.
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Figure 16b. Endocervical hyperplasia. (a) Sagittal T2-weighted MR image shows a multicystic mass surrounding the cervical canal (arrows). An area that is hyperintense relative to the normal cervical stroma near the cysts is also noted. (b) Sagittal MR image obtained after administration of gadolinium-based contrast material shows intense enhancement of the relatively hyperintense area near the cysts on the T2-weighted image (arrows). (c) Photomicrograph (original magnification, x4; hematoxylin-eosin stain) shows that the tumor is composed of normal endocervical glands without malignant features.
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Figure 16c. Endocervical hyperplasia. (a) Sagittal T2-weighted MR image shows a multicystic mass surrounding the cervical canal (arrows). An area that is hyperintense relative to the normal cervical stroma near the cysts is also noted. (b) Sagittal MR image obtained after administration of gadolinium-based contrast material shows intense enhancement of the relatively hyperintense area near the cysts on the T2-weighted image (arrows). (c) Photomicrograph (original magnification, x4; hematoxylin-eosin stain) shows that the tumor is composed of normal endocervical glands without malignant features.
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Adenoma malignum is often associated with Peutz-Jeghers syndrome, which is characterized by mucocutaneous pigmentation and multiple hamartomatous polyps of the intestinal tract (21–23) (Fig 17), as well as mucinous tumors of the ovary (24).
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Figure 17a. Adenoma malignum in a patient with Peutz-Jeghers syndrome. (a, b) Photographs show mucocutaneous pigmentation of the lips (a) and digits (b). (c, d) Images from a double-contrast barium study show multiple polyps (arrowhead) in the colon (c) and stomach (d). (e) Sagittal T2-weighted MR image obtained during pregnancy shows a characteristic multicystic mass in the uterine cervix (arrows). (Case courtesy of Takeshi Nihei, MD, Mito Saiseikai General Hospital, Mito, Japan.)
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Figure 17b. Adenoma malignum in a patient with Peutz-Jeghers syndrome. (a, b) Photographs show mucocutaneous pigmentation of the lips (a) and digits (b). (c, d) Images from a double-contrast barium study show multiple polyps (arrowhead) in the colon (c) and stomach (d). (e) Sagittal T2-weighted MR image obtained during pregnancy shows a characteristic multicystic mass in the uterine cervix (arrows). (Case courtesy of Takeshi Nihei, MD, Mito Saiseikai General Hospital, Mito, Japan.)
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Figure 17c. Adenoma malignum in a patient with Peutz-Jeghers syndrome. (a, b) Photographs show mucocutaneous pigmentation of the lips (a) and digits (b). (c, d) Images from a double-contrast barium study show multiple polyps (arrowhead) in the colon (c) and stomach (d). (e) Sagittal T2-weighted MR image obtained during pregnancy shows a characteristic multicystic mass in the uterine cervix (arrows). (Case courtesy of Takeshi Nihei, MD, Mito Saiseikai General Hospital, Mito, Japan.)
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Figure 17d. Adenoma malignum in a patient with Peutz-Jeghers syndrome. (a, b) Photographs show mucocutaneous pigmentation of the lips (a) and digits (b). (c, d) Images from a double-contrast barium study show multiple polyps (arrowhead) in the colon (c) and stomach (d). (e) Sagittal T2-weighted MR image obtained during pregnancy shows a characteristic multicystic mass in the uterine cervix (arrows). (Case courtesy of Takeshi Nihei, MD, Mito Saiseikai General Hospital, Mito, Japan.)
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Figure 17e. Adenoma malignum in a patient with Peutz-Jeghers syndrome. (a, b) Photographs show mucocutaneous pigmentation of the lips (a) and digits (b). (c, d) Images from a double-contrast barium study show multiple polyps (arrowhead) in the colon (c) and stomach (d). (e) Sagittal T2-weighted MR image obtained during pregnancy shows a characteristic multicystic mass in the uterine cervix (arrows). (Case courtesy of Takeshi Nihei, MD, Mito Saiseikai General Hospital, Mito, Japan.)
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Neuroendocrine Tumors
Another histologic type of epithelial carcinoma of the uterine cervix in addition to squamous cell carcinoma or adenocarcinoma is classified by the World Health Organization as small cell carcinoma. It is similar to pulmonary small cell carcinoma and contains neuroendocrine granules (25). Carcinoid is a rare neuroendocrine tumor arising in the uterine cervix. Albores-Saavedra et al (26) reported that only 12 of 3,507 malignant cervical tumors (0.34%) could be diagnosed as carcinoid with Grimelius staining. Most cases show nonspecific symptoms indistinguishable from those of squamous cell carcinoma, because carcinoid syndrome is rare in patients with uterine carcinoid (27). Because neuroendocrine tumors of the uterine cervix are very aggressive, early diagnosis and subsequent treatment are warranted (28).
MR imaging findings of uterine carcinoid have not been reported, to our knowledge. We have studied a single case of uterine cervical carcinoid with MR imaging (Fig 18). The tumor showed slightly heterogeneous high signal intensity on T2-weighted images and was well enhanced with gadolinium-based contrast material. As these findings are not particularly different from those of squamous cell carcinoma, it could not be differentiated from other types of cervical carcinoma.
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Figure 18a. Atypical carcinoid tumor of the uterine cervix. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a hyperintense solid mass that dilates the upper end of the vaginal tube. (c) Axial gadolinium-enhanced T1-weighted MR image shows marked homogeneous enhancement of the tumor (arrows). (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows diffuse infiltration of small tumor cells. (e) Photomicrograph (original magnification, x10; chromogranin A immunohistochemical stain) shows that the tumor is of neuroendocrine origin. The final diagnosis was atypical carcinoid tumor of the uterine cervix. (Case courtesy of Yuki Satoh, MD, Tsukuba Memorial Hospital, Tsukuba, Japan.)
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Figure 18b. Atypical carcinoid tumor of the uterine cervix. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a hyperintense solid mass that dilates the upper end of the vaginal tube. (c) Axial gadolinium-enhanced T1-weighted MR image shows marked homogeneous enhancement of the tumor (arrows). (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows diffuse infiltration of small tumor cells. (e) Photomicrograph (original magnification, x10; chromogranin A immunohistochemical stain) shows that the tumor is of neuroendocrine origin. The final diagnosis was atypical carcinoid tumor of the uterine cervix. (Case courtesy of Yuki Satoh, MD, Tsukuba Memorial Hospital, Tsukuba, Japan.)
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Figure 18c. Atypical carcinoid tumor of the uterine cervix. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a hyperintense solid mass that dilates the upper end of the vaginal tube. (c) Axial gadolinium-enhanced T1-weighted MR image shows marked homogeneous enhancement of the tumor (arrows). (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows diffuse infiltration of small tumor cells. (e) Photomicrograph (original magnification, x10; chromogranin A immunohistochemical stain) shows that the tumor is of neuroendocrine origin. The final diagnosis was atypical carcinoid tumor of the uterine cervix. (Case courtesy of Yuki Satoh, MD, Tsukuba Memorial Hospital, Tsukuba, Japan.)
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Figure 18d. Atypical carcinoid tumor of the uterine cervix. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a hyperintense solid mass that dilates the upper end of the vaginal tube. (c) Axial gadolinium-enhanced T1-weighted MR image shows marked homogeneous enhancement of the tumor (arrows). (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows diffuse infiltration of small tumor cells. (e) Photomicrograph (original magnification, x10; chromogranin A immunohistochemical stain) shows that the tumor is of neuroendocrine origin. The final diagnosis was atypical carcinoid tumor of the uterine cervix. (Case courtesy of Yuki Satoh, MD, Tsukuba Memorial Hospital, Tsukuba, Japan.)
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Figure 18e. Atypical carcinoid tumor of the uterine cervix. (a, b) Sagittal (a) and axial (b) T2-weighted MR images show a hyperintense solid mass that dilates the upper end of the vaginal tube. (c) Axial gadolinium-enhanced T1-weighted MR image shows marked homogeneous enhancement of the tumor (arrows). (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows diffuse infiltration of small tumor cells. (e) Photomicrograph (original magnification, x10; chromogranin A immunohistochemical stain) shows that the tumor is of neuroendocrine origin. The final diagnosis was atypical carcinoid tumor of the uterine cervix. (Case courtesy of Yuki Satoh, MD, Tsukuba Memorial Hospital, Tsukuba, Japan.)
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Malignant Melanoma
Malignant melanoma of the female genital tract accounts for 1%–5% of all melanoma cases (29). It usually occurs in the vaginal mucosa and occasionally involves the uterine cervix. Malignant melanoma arising in the uterine cervix is extremely rare, with only about 30 cases reported in the literature (30).
MR imaging characteristics have been reported in other organs and consist of high signal intensity on both T1-weighted and T2-weighted images (31). T1 shortening is attributed to either the paramagnetic effects of stable free radicals within melanin granules or the methemoglobin within the intratumoral hemorrhage. However, malignant melanoma may have different signal intensity characteristics according to the melanin concentration and the presence of hemorrhage (32,33). Only two reports of MR imaging findings of malignant melanoma of the cervix or vagina have been published, to our knowledge (34,35). In one report, both of the two vaginal melanomas analyzed showed high signal intensity on T1-weighted images, as expected. Malignant melanoma with rich melanocytes is expected to be hyperintense on T1-weighted images; this might be a suggestive finding for melanoma. However, such tumors can be diagnosed easily, even by visual inspection, because of their characteristic black color (Fig 19).
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Figure 19a. Malignant melanoma of the vagina with direct invasion of the cervix. (a) Sagittal T2-weighted MR image shows a hypointense tumor that involves the uterine cervix and vagina. (b) Sagittal T1-weighted MR image shows characteristic high signal intensity of the tumor (arrowheads). (c) Photograph shows that the tumor is black and occupies the vagina and cervix. (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of melanocytes with rich melanin granules.
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Figure 19b. Malignant melanoma of the vagina with direct invasion of the cervix. (a) Sagittal T2-weighted MR image shows a hypointense tumor that involves the uterine cervix and vagina. (b) Sagittal T1-weighted MR image shows characteristic high signal intensity of the tumor (arrowheads). (c) Photograph shows that the tumor is black and occupies the vagina and cervix. (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of melanocytes with rich melanin granules.
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Figure 19c. Malignant melanoma of the vagina with direct invasion of the cervix. (a) Sagittal T2-weighted MR image shows a hypointense tumor that involves the uterine cervix and vagina. (b) Sagittal T1-weighted MR image shows characteristic high signal intensity of the tumor (arrowheads). (c) Photograph shows that the tumor is black and occupies the vagina and cervix. (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of melanocytes with rich melanin granules.
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Figure 19d. Malignant melanoma of the vagina with direct invasion of the cervix. (a) Sagittal T2-weighted MR image shows a hypointense tumor that involves the uterine cervix and vagina. (b) Sagittal T1-weighted MR image shows characteristic high signal intensity of the tumor (arrowheads). (c) Photograph shows that the tumor is black and occupies the vagina and cervix. (d) Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows that the tumor is composed of melanocytes with rich melanin granules.
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Nonepithelial Neoplasms
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Malignant Lymphoma
Malignant lymphoma frequently infiltrates the uterus in advanced disease. However, it rarely involves the uterine cervix as the initial manifestation (36). Its frequency in Western countries was reported to be 0.008% of primary cervical tumors and 2% of extranodal lymphomas in women (37). The common presenting symptoms are vaginal bleeding, perineal discomfort, and vaginal discharge (38). Cervical lymphomas are treated with chemotherapy alone or in combination with irradiation or surgery.
Uterine involvement by lymphoma is usually observed in the cervix, although there are some case reports in which the tumor mainly affected the uterine body. Lymphoma of the uterus exhibits various appearances at MR imaging, although the tumor tends to be hypointense on T1-weighted images and relatively hyperintense on T2-weighted images (39–42). MR imaging findings of uterine cervical lymphoma closely resemble those of carcinoma of the cervix (39). However, preserved cervical epithelium in the presence of extensive involvement of the cervical stroma may be a clue to the diagnosis of malignant lymphoma (Fig 20). Diffuse enlargement of the uterus without disruption of the endometrial epithelium is also reported to be a characteristic finding for lymphoma involving the uterine body (39).
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Figure 20a. Malignant lymphoma of the uterine cervix. (a) Sagittal T2-weighted MR image shows a hyperintense lobulated tumor that involves the anterior wall of the uterine cervix (arrows). Although the mass is very large, the cervical epithelium remains as a hyperintense band behind the tumor (arrowheads). (b) Sagittal T1-weighted MR image shows that the tumor has low signal intensity (arrows). (c) Sagittal contrast-enhanced MR image shows that the tumor enhances heterogeneously (arrows). (d) Photograph of the surgical specimen shows a preserved cervical canal (arrowheads). (e) Photomicrograph (original magnification, x4; hematoxylin-eosin stain) shows small tumor cells with large nuclei that proliferate diffusely.
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Abstract
LEARNING OBJECTIVES FOR TEST...
