Academic Editor: Enrique Hernandez
Objective: This study aims to compare tumor diameters measured by
transvaginal ultrasonography and MRI in cervical cancer. Materials and
methods: The study includes 127 cervical cancer patients diagnosed and treated
at Akdeniz University Faculty of Medicine between January 2002 and December 2019.
Data were collected retrospectively using the electronic archive system of the
hospital. Patients with pathologically unknown tumor diameters were excluded from
the study. Data were tested for normal distribution, and the mean, standard
deviation, median, min-max values, and frequencies were used as descriptive
statistics. Categorical data were expressed as numbers and percentages (%). The
Student’s t-test, one of the parametric tests, was used to compare tumor
diameters. Statistical Package for the Social Sciences (SPSS) 23 software (IBM
Corp., Chicago, IL, USA) was used for data analysis. A p-value less than
0.05 was considered statistically significant in all tests. Results: The
mean age of patients included in the study was 49.55
Treatment in cervical cancer patients varies according to the stage, and staging
is the basis of the appropriate treatment. International Federation of Gynecology
and Obstetrics (FIGO) staging of uterine cervical cancer dates back to 1958, and
tumor size is still one of the main components of staging, maintaining its place
in treatment and staging. Recently, almost 60 years after the introduction of the
original FIGO staging system, greater emphasis has been placed on the importance
of tumor size in uterine cervical cancer. The 2018 FIGO classification further
divided stage IB into substages IB1 (
Multiplanar imaging is more sensitive in showing deep pelvic invasion, tumor volume and spread, and nodal involvement. It also reduces the need for other imaging and evaluation methods. The agreement between multiplanar imaging and surgical staging is also high. The fact that cross-sectional imaging modalities such as Computed tomography (CT) and MRI were not included in staging until the revision of staging in 2018 is due to FIGO being incompatible with the principle of the universally widespread availability of any staging method. The other reasons why these imaging methods were not included in the FIGO staging before 2018 can be considered as the inability to perform homogeneous imaging in all centers, the low application rate especially in undeveloped regions where uterine cervical cancer is more common, and their unfeasibility to be widely used due to high fees. Although there are many published articles refuting these hypotheses, these articles either partially include the mentioned reasons or report the results of limited case groups [6, 7].
Magnetic resonance imaging is the best imaging modality for determining tumor localization, size, depth of stromal invasion, parametrial extension, and lower uterine segment extension. MRI is recommended because of the increased possibility of parametrial invasion and lymph node metastasis in patients with clinical stage 1B or tumor size greater than 2 cm. The use of MRI compatible with endoscopic surgical staging reduces cost and morbidity [8, 9].
In a publication published in 2019, it was seen that there was no difference in the detection of parametrial invasion between USG, MRI and clinical examination under anesthesia in cervical uteri cancer, only MRI and clinical examination under anesthesia had higher accuracy than ultrasonography in terms of diagnosing parametrial invasion. However, in the detection of cervical uteri tumors of 2 cm and above, the diagnostic accuracy of USG was found to be higher than clinical examination and MRI under anesthesia. In addition, in this study, it was revealed that clinical examination under anesthesia is the best method in determining vaginal involvement. It has been stated that the combination of examination and USG under anesthesia may be the most accurate diagnostic tool, but the diagnostic rates will increase with the addition of MRI, especially in large tumors .
It has been suggested in many studies that the tumor size and local spread of early stage cervical uteri cancer in the preoperative period have similar diagnostic accuracy with transvaginal ultrasonography and MRI, and that it should be the first diagnostic tool especially because of its low cost and ease of use [11, 12, 13].
Today, there are significant inconsistencies and disagreements between the methods and strategies used by gynecologist oncologists, radiologists, and pathologists, especially in the clinical measurement of tumors in the post-surgical specimen, and there is no consensus particularly on the preoperative imaging dependent measurement differences and tumor positivity in surgical margins and other areas.
Thanks to today’s technological progress, high-resolution US devices can measure the tumor diameter quite accurately in cervical cancer. It can be helpful in the patient’s choice of surgical or radiotherapy treatment, especially since it detects cervical tumors smaller than 2 cm or larger than 4 cm with US as well as MRI. Therefore, US can replace MRI in this regard.
This study aims to compare ultrasonography, which is the most ideal imaging method in our developing country, to magnetic resonance in terms of tumor size assessment measured by pelvic examination, preoperative imaging, and pathology in patients with uterine cervical cancer, and to discuss the importance of ultrasonography, which is an inexpensive and easy-to-apply method, especially in underdeveloped regions, in the light of the literature and to reveal its importance.
The study includes 127 cervical cancer patients diagnosed and treated at Akdeniz
University Faculty of Medicine, Antalya, between January 2002 and December 2019.
After the approval of the ethics committee of Akdeniz University, the data were
collected retrospectively using the electronic archive system of the hospital.
Transvaginal ultrasonographic uterine cervical tumor diameter measurements
performed by experienced gynecologists and cervical tumor diameters measured on
magnetic resonance imaging by experienced gyneco-radiologists were
retrospectively analyzed for all patients. Patients with pathologically unknown
tumor diameters were excluded from the study. Moreover, patients with stage IA1
microinvasive cervical cancer and stage IVB metastatic tumors and patients who
had previously received neoadjuvant chemotherapy were excluded. All patients were
restaged according to the lately revised FIGO 2018 classification of cervix
uteri. Histopathological diagnosis of all patients was made by experienced
gynecological pathologists of our hospital. After a detailed systemic and
gynecological examination, each patient was scanned radiologically for
metastasis. Then, the diagnosis and treatment of these patients were arranged by
gynecological oncology specialists. Patients with stage IA1 were treated with
conization or simple hysterectomy. Patients with early-stage (FIGO stage IA2,
IB1, IB2, 2A) underwent radical hysterectomy
In pathological specimens, tumor size was measured macroscopically as the largest diameter and the other largest diameter. And the longest two-dimensional tumor sizes in all ultrasonographic, MRI and pathological examinations were retrospectively included in our study and these were compared with each other in our study.
After the treatment, cervical cytology and pelvic examination were performed every 3 months for the first 2 years, every 6 months for the next 3 years, and annual follow-ups were continued after 5 years. During follow-ups, pelvic examination and transvaginal or transabdominal ultrasonography were performed in all patients, while serum tumor marker evaluations and radiological evaluations (CT and/or Positron emission tomography (PET/CT)) were performed in cases with suspected recurrence. Recurrence diagnosis was established pathologically by biopsies from suspicious sites or clinically or radiologically.
Data were tested for normal distribution, and the mean, standard deviation, median, min-max values, and frequencies were used as descriptive statistics. Categorical data were expressed as numbers and percentages (%). The Student’s t-test, one of the parametric tests, was used to compare tumor diameters. Statistical Package for the Social Sciences (SPSS) 23 software (IBM Corp., Chicago, IL, USA) was used for data analysis. A p-value less than 0.05 was considered statistically significant in all tests.
The mean age of patients included in the study was 49.55
|n = 127|
|High school University||32||25.1|
|Post-coital v. bleeding||54||42.5|
|Postmenopausal v. bleeding||14||11.1|
|Type primary treatment|
|Surgical adj RT||32||25.1|
|Surgery adj CRT||51||40.1|
|SCC, Squamous cell cancer; BMI, Body mass index; Adj RT, Adjuvant radiotherapy; Adj KRT, Adjuvant chemo-radiotherapy; KT, Chemotherapy; NSVB, Normal spontaneous vaginal birth; CS, Cesarean section; OCP, Oral contraceptive pill; IUD, Intrauterine Device.|
The mean tumor diameter measured by transvaginal ultrasonography (TVS) performed
by an experienced gynecologist oncologist was 3.30
|MRI, Magnetic resonance imaging; Tv USG, Transvaginal ultrasonography.|
It has been reported that as the tumor size increases, the involvement of adjacent and distant organs increases, appearing as a poor prognostic factor in terms of recurrence and overall survival . In patients with FIGO 2018 classified uterine cervical cancer, ultrasonography can play a crucial role in assessing and staging tumor size and adjacent organ involvement, as accessing imaging modalities such as MRI or PET/CT is difficult in socio-economically poor countries.
Based on the available literature, the 5-year survival is 91.6% in patients
with tumors of 2 cm or less, 83.3% in tumors
It is crucial to distinguish early-stage (Stage1–2A) cervical cancer with imaging. While early-stage cervical cancer can be treated with surgical methods, Stage 2B and above requires chemotherapy, radiotherapy, and/or combinations.
MRI has long been considered the primary method of choice in the evaluation of
patients with uterine cervical cancer . One of the first studies to evaluate
the role of MRI in determining uterine cervical cancer staging determined
accuracy rates for early-stage tumors to be 79% for clinical staging versus a
higher rate of 81% for MRI. Besides, exclusion of the early-stage cases
(IB1–IIA1) decreased the accuracy of clinical staging to 53%. The same study
found the accuracy rate of MRI in determining tumor location in the cervix as
91% and the accuracy in determining tumor size as 93% . MRI has a high
accuracy in determining tumor size with a
Carcinoma in situ is the name given to preinvasive cancer, not included in FIGO
staging. In stage 1, the tumor is limited to the cervix. Stage 1A1 tumor is too
small to be measured on a T2-weighted image, but contrast enhancement can be seen
in the early arterial phase on MRI with dynamic contrast . In stage 1A2
(stromal invasion depth
In contrast to computed tomography (CT) and ultrasonography, which are limited by poor tissue contrast and the experience of the practitioner, MRI is significantly more accurate in measuring tumor size, delineating cervical tumor borders, and localizing tumor spread due to its distinctive tissue contrast and multiplanar feature . For patients who are candidates for surgery based on clinical staging, some data suggest that tumor size can be more accurately determined by MRI than clinical examination. For example, a prospective study of 208 women, most of whom had stage IB disease and underwent preoperative MRI and CT, showed more consistent results with post-surgical histopathological findings than MRI, CT or clinical examination. All three imaging modalities overestimated tumor size compared to the pathological evaluation of the specimen after surgery. The results of this study are significant because overestimating tumor size in surgical candidates will probably not alter treatment or prognosis while underestimating tumor size will potentially lead to surgical excision, where chemoradiation is the best option .
During the evaluation of tumor size with MRI imaging, false positivity rates increase due to peritumoral edema, necessitating a careful evaluation in order to distinguish from a true tumor. Especially in recent years, the inclusion of diffusion-weighted imaging in pelvic MRI has helped to overcome this obstacle. Furthermore, this method has facilitated the detection of tumors smaller than 1 cm, and many studies have demonstrated the role of MRI in the staging of uterine cervical cancer [22, 23, 24, 25].
In the past years, gynecological ultrasonography has gained great importance especially in the preoperative and postoperative evaluation of uterine cervical cancer patients, as it provides information about tumor presence, size, and local tumor spread with low cost, rapid examination time, and convenient use everywhere when performed by clinicians specialized in the field of gynecological oncology [11, 26].
It has been stated that preinvasive lesions of the uterine cervical stiffness are greater than normal uterine cervical structure with 2-D shear wave elastographic application, which is an application based on tissue softness as an ultrasonographic use, and it has been stated that it can be used in the differential diagnosis of high-grade preinvasive lesion .
According to the results of transrectal ultrasonography performed prospectively
and preoperatively in 95 patients with uterine cervical cancer, the accuracy rate
of ultrasonography in tumor diagnosis was 94%, while the accuracy rate of MRI
was 83%. The accuracy of detecting 1 cm or less tumor was 91% for
ultrasonography and 81% for MRI. Ultrasonographic imaging was considered
statistically more valuable (p
Another prospective study evaluated the results of patients who underwent primary surgery and 68 patients who underwent surgery after neoadjuvant chemotherapy. Comparison of the histopathologically measured tumor diameters with the measurements made by ultrasonography and MRI determined accuracy rates of 93% for ultrasonography and 88% for MRI. Additionally, the mean difference between histopathological and ultrasonographic measurements of the craniocaudal diameter of the tumor was 0.62 mm, while the difference between histopathological and MRI examinations was higher, with 1.49 mm. Therefore, ultrasonographic examination was considered more compatible with histopathological evaluation .
A prospective multicenter study involving 182 women investigated the accuracy
rates of preoperative evaluation and MRI and pelvic ultrasonography in terms of
tumor size, taking histopathological findings as a reference, and determined
concordance rates between ultrasonography and pathology in tumor diagnosis and
detection of tumors larger than 4 cm to be as high as 0.84 and 0.82,
respectively. However, this rate decreased in tumors smaller than 2 cm, and was
around 0.78. Comparison of MRI and pathological examination determined the kappa
coefficients of the concordance ratios between tumors below 2 cm and above 4 cm
as 0.71 and 0.76, respectively, while the rate of tumor detection was as low as
0.52, and indeed while MRI primary tumor diagnosis rates were around 90%,
ultrasonographic diagnosis rates are was as high as 97%. Furthermore, there was
a higher and statistically significant agreement between histopathological
examination and ultrasonographic evaluation in terms of tumor detection rates in
the follow-ups after cervical conization compared to MRI (p
It has been stated that MRI evaluation is important in preoperative evaluation, especially in order to evaluate the involvement of pelvic region lymph nodes before fertility-sparing surgery in early stage cervical uteri cancer .
In a recent publication in 2021, it was recommended to use MRI in the preoperative stage, in the evaluation of the response of the tumor to chemotherapy and in the follow-up of the patients after conization, in the cases who were planned for neoadjuvant chemotherapy and then cold conization in patients who wanted fertility-sparing surgery in early stage cervical uteri cancer .
In another new prospective study of 2021, transvaginal and transabdominal ultrasonographic examination performed by experienced gynecologists and MRI imaging methods performed by radiologists experienced in the field of gynecological oncology were compared both among themselves and with pathological examination results in the preoperative and postoperative periods. It has been stated that ultrasonography has the highest accuracy rates in local staging of cervical uteri cancer. It has also been stated that ultrasonography has the same accuracy as MRI imaging in terms of tumor diagnosis, parametrial involvement, uterine corpus involvement and vaginal fornix involvement. With all these results, it has been stated that ultrasonography is superior to MRI imaging in terms of local staging in cervical uteri cancer and because of its ease of use and cheapness .
The limitations of our study are its retrospective design and small sample size. Its advantage is being a single-center and long-term study managed by a team experienced in the field of gynecological oncology.
Considering the significance of tumor size measurement in diagnosis, staging, treatment, and prognosis in uterine cervical cancer, physical examination, imaging methods, and histopathological evaluation are of great importance. MRI is the best imaging modality for determining tumor size as well as vaginal and parametrial involvement. However, when such imaging modalities are not available in developing or underdeveloped areas, pelvic ultrasonography can provide an equally valuable and effective assessment when performed by specialists with experience in gynecologic oncology.
ÖB, MSB and SS conceived and designed the study; MSB, ÖB, HAT and SD performed the study; SS, HAT and SD analyzed the data; TS contributed materials and evaluation; SS, MSB and ÖB wrote the paper. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Akdeniz University (approval number: KAEK-925 and dated 09.12.2020).
We would like to express our gratitude to all those who helped us during the writing of this manuscript. Thanks to all the peer reviewers for their opinions and suggestions.
This research received no external funding.
The authors declare no conflict of interest.