Objective: To evaluate the role of magnetic resonance imaging in the assessment of disease extent and staging of cervical cancer, and to analyze its correlation with histopathologic findings in surgically treated patients.

Methods: A retrospective observational single-center study was conducted including patients with cervical cancer who underwent surgical treatment between March 2017 and February 2022. MRI findings performed before or after diagnostic conization were reviewed and compared with definitive histopathologic results. Tumor size, parametrial involvement, and lymph node status were analyzed. Diagnostic performance parameters were calculated.

Results: Thirty-eight patients were included, with a mean age of 42.4 years. Histology was squamous cell carcinoma in 79% and adenocarcinoma in 21%. MRI demonstrated a sensitivity of 100% and a specificity of 81% for parametrial involvement, with a high negative predictive value (100%). For lymph node assessment, MRI showed low sensitivity (14%) but high specificity (96%). Regarding tumor size, MRI demonstrated a sensitivity of 57% and a specificity of 96% for tumors larger than 4 cm. For tumors smaller than 2 cm, MRI achieved a sensitivity of 60% and a specificity of 78%.

Conclusion: Magnetic resonance imaging is a valuable tool for the local staging of cervical cancer, showing high accuracy for assessing tumor size and excluding parametrial involvement. While its sensitivity for detecting lymph node metastases remains limited, MRI provides important complementary information for surgical planning and patient selection, particularly in centers with expertise in gynecologic imaging.

Keywords: magnetic resonance imaging, cervical cancer, lymph node, tumor

Cervical cancer is the fourth most frequent malignancy worldwide and the fourth leading cause of cancer-related death, preceded only by breast, lung, and colorectal cancers. In 2020, a total of 604,127 new cases were diagnosed globally, with 375,304 deaths reported. Both incidence and prevalence are higher in countries in Africa, Central and South Asia, and South America, highlighting that cervical cancer predominantly affects low- and middle-income countries.^1,2

In Argentina, in 2020 there were 4,583 new cases of cervical cancer and 2,553 deaths, making it the second most frequent gynecologic malignancy after breast cancer. According to national estimates, approximately 4,500–4,900 new cases and around 2,000–2,300 deaths occur annually, and several Argentine studies have documented marked geographic and socioeconomic inequalities in cervical cancer mortality and in access to screening and treatment.^3–5

Since the implementation of cervical cancer screening programs, the proportion of women diagnosed at early stages has increased substantially over recent decades. Persistent infection with oncogenic human papillomavirus (HPV) types is recognized as the central etiologic agent of cervical carcinogenesis and is considered a necessary, although not sufficient, cause for the development of the disease.⁶ Additional risk factors that enhance the likelihood of HPV acquisition and persistence include early onset of sexual activity, long-term use of oral contraceptives, and a high number of sexual partners. These factors collectively contribute to increased exposure to HPV and promote progression in the presence of permissive host and environmental conditions.

The use of imaging in the diagnosis of cervical cancer has gained increasing importance in recent years. In 2018, the revised FIGO staging system formally incorporated the role of imaging in the staging of cervical cancer.⁷ Imaging plays a fundamental role in improving staging accuracy and in planning appropriate treatment strategies. High-resolution abdominopelvic magnetic resonance imaging is considered the imaging modality of choice for the staging of cervical cancer.

The importance of pelvic magnetic resonance imaging (MRI) lies in its ability to accurately assess tumor size, parametrial involvement, extension to the pelvic wall, and invasion of adjacent organs. In early-stage disease, in which lesions are small, contrast-enhanced magnetic resonance imaging plays a key role in surgical planning for patients seeking fertility-sparing treatments, as it provides high accuracy in determining the distance between the tumor and free surgical margins. MRI demonstrates a high negative predictive value (94–100%) for parametrial invasion, although reported sensitivity ranges widely from 40% to 100%.^8,9

Objective

To evaluate the role of magnetic resonance imaging in assessing disease extent and staging of cervical cancer, and to determine its correlation with histopathologic findings in surgically treated patients.

This was a retrospective observational study conducted at a single institution. Patients with a diagnosis of cervical cancer who underwent surgical treatment between March 2017 and February 2022 were included. Clinical data were obtained from the institutional database and electronic medical records.

Magnetic resonance imaging examinations performed either before or after diagnostic conization were reviewed and compared with the corresponding histopathologic findings. Variables analyzed from abdominopelvic magnetic resonance imaging reports and pathology specimens included tumor size, parametrial involvement, suspected lymph node involvement, and depth of stromal invasion.

At the time of admission, all patients provided written informed consent.

A total of 38 patients who underwent surgical treatment for cervical cancer were included. The mean age was 42.4 years. Fifty percent of the patients had a history of intraepithelial lesions. Regarding histologic subtype, 30 patients (79%) had squamous cell carcinoma and 8 (21%) had adenocarcinoma.

Overall, 36% of patients (14/38) underwent prior cervical conization; among these, magnetic resonance imaging was performed after conization in 78% of cases. Therefore, imaging data were analyzed in correlation with findings from subsequent definitive surgery.

Radical hysterectomy with bilateral salpingo-oophorectomy was performed in 86.8% of patients (33/38), extrafascial hysterectomy in 5.2%, radical trachelectomy in 1 patient (2.6%), and cervical conization alone in 1 patient (2.6%). According to surgical criteria, lymph node assessment was omitted in only two patients.

Among the total cohort, 8 patients (21%) showed suspected parametrial involvement on MRI; however, only one patient had parametrial involvement confirmed at surgery, concordant with MRI findings. This resulted in a sensitivity of 100% and a specificity of 81% for MRI in the assessment of parametrial invasion. Accordingly, the positive predictive value was low (12.5%) (Table 1).

Of the 38 patients included, 7 (19.4%) had lymph node metastases confirmed on histopathologic examination; among these, only one case (14.2%) had been identified by MRI. This corresponds to a low sensitivity of 14% and a high specificity of 96% for MRI in lymph node assessment in cervical cancer (Table 2).

Regarding tumor size, 5 patients (13.1%) had tumors larger than 4 cm on MRI, while 7 patients (18%) were found to have tumors larger than 4 cm on postoperative histopathologic evaluation. Concordance between MRI and pathology was observed in 4 patients, yielding a sensitivity of 57% and a specificity of 96% for the assessment of tumors greater than 4 cm.

As part of the evaluation for fertility-sparing management, 14 of the 38 patients (36.8%) had preoperative MRI reports describing tumors smaller than 2 cm. Concordance between MRI and histopathologic findings was observed in 9 cases (64%). MRI demonstrated a sensitivity of 60% and a specificity of 78% for the identification of tumors smaller than 2 cm.

MRI has been preferred for pretreatment staging of early-stage cervical cancer since the FIGO 2018 update ⁽⁷⁾. Although clinical staging is quite reliable in early-stage disease—achieving approximately 85% accuracy in stages IA to IB1—its accuracy drops markedly in more advanced cases, falling below 35% in stage IIA and down to 21% in stage IIB when compared with surgical findings.¹⁰ MRI can reliably rule out bladder or rectal invasion, eliminating the need for invasive cystoscopic or endoscopic staging in most cervical carcinoma patients. It has been extensively evaluated and compared with standard clinical pelvic examination, with variable results reported across studies. One possible explanation for the differences in sensitivity and specificity observed in the literature may be related to the type of MRI scanner used, the imaging protocols applied, and the level of radiologist expertise in gynecologic imaging. Nevertheless, in centers with specific training and experience in magnetic resonance imaging, this diagnostic modality has demonstrated consistently high sensitivity and specificity.^11,12

Accurately evaluating prognostic factors before treatment helps determine the best therapy and improve outcomes. Surgery is recommended for early-stage disease, while chemoradiotherapy is used for bulky or locally advanced cancer. If surgery reveals spread to the parametrium or lymph nodes, adjuvant chemoradiotherapy is needed, which may increase morbidity. In this context, results from the SHAPE trial have emphasized the importance of precise preoperative tumor characterization, demonstrating that carefully selected patients with low-risk early-stage cervical cancer can safely undergo less radical surgical procedures without compromising oncologic outcomes.¹³ These findings underscore the central role of high-quality MRI, particularly when interpreted in conjunction with prior diagnostic conization, in identifying appropriate candidates for tailored surgical strategies and in minimizing the risk of overtreatment.

Regarding parametrial assessment, several studies have reported high sensitivity of magnetic resonance imaging for detecting parametrial involvement, highlighting its incremental value over clinical examination alone. Bourgioti et al. demonstrated that MRI provides significant prognostic information in the staging of early cervical cancer, particularly in the assessment of parametrial invasion, reinforcing its role in treatment planning.¹⁴ Similarly, Patel-Lippmann et al. emphasized the accuracy of MRI in evaluating local tumor extension and parametrial involvement when standardized imaging protocols and expert interpretation are applied.¹⁵

However, not all studies have shown uniformly optimal results. Zhang et al., in a cohort of patients with FIGO stages IB1–IIA2, reported suboptimal sensitivity for the detection of parametrial infiltration, underscoring the variability in diagnostic performance across different clinical settings and disease stages.⁸ In our study, MRI achieved a sensitivity of 100% and a specificity of 81% for parametrial involvement, findings that are in line with those reported in high-volume centers and support the reliability of MRI for excluding parametrial disease, as reflected by its high negative predictive value.

The presence of lymph node involvement profoundly affects prognosis and therapeutic decision-making in patients with cervical cancer. Similarly as our results, in the study by Choi et al.,¹⁶ magnetic resonance imaging demonstrated low sensitivity (33%) but high specificity (96%) for the detection of lymph node metastases, highlighting the limitations of MRI in identifying nodal disease, particularly in cases of micrometastatic involvement.¹⁶

Similarly, Yang et al. compared computed tomography and dynamic magnetic resonance imaging for the evaluation of pelvic lymph nodes in cervical carcinoma and reported comparable diagnostic performance between both modalities, with limited sensitivity and high specificity.¹⁷ These findings underscore that size-based imaging criteria alone are insufficient to reliably detect nodal metastases and reinforce the need for complementary strategies, such as surgical lymph node assessment or functional imaging such as PET-CT, in selected cases.

Magnetic resonance imaging provides high soft-tissue resolution, allowing accurate assessment of tumor size in cervical cancer. In our study, for tumors smaller than 2 cm (FIGO stages IA1, IA2, and IB1), MRI demonstrated a sensitivity of 83% and a specificity of 85%. These findings are consistent with those reported by Patel-Lippmann et al., who highlighted the accuracy of MRI in evaluating small cervical tumors and emphasized its role in preoperative assessment, particularly in patients considered for fertility-sparing treatment.¹⁵

For larger tumors (>4 cm, bulky disease), the imaging–histopathologic correlation was lower, with a sensitivity of 53% and a specificity of 96% in our cohort. This reduced sensitivity for bulky tumors has also been described in the literature and may be related to tumor heterogeneity, necrosis, or post-biopsy changes that can impact precise size estimation on imaging, as discussed by Patel-Lippmann et al.¹⁵ Nevertheless, the high specificity observed in our study supports the usefulness of MRI in excluding bulky disease when imaging findings are negative.

The main strength of this study lies in the direct correlation between magnetic resonance imaging findings and definitive histopathologic results in a surgically treated cohort, allowing an accurate assessment of MRI performance in local staging of cervical cancer. By directly comparing imaging and surgical pathology, our findings provide clinically relevant information on the accuracy of MRI in key staging parameters, including tumor size, parametrial involvement, and lymph node status, all of which are critical determinants of FIGO stage and treatment selection. Additionally, the homogeneity of imaging protocols and interpretation within a single institution may have contributed to the consistency of the results and reflects real-world practice in specialized centers. However, several limitations should be acknowledged. The retrospective design and the relatively small sample size may limit the generalizability of the findings. Finally, the limited sensitivity of MRI for lymph node involvement, particularly in detecting micrometastatic disease, underscores the intrinsic limitations of morphology-based imaging techniques and highlights the need for complementary diagnostic approaches.

Magnetic resonance imaging is a valuable tool for the local staging of cervical cancer, demonstrating high accuracy in the assessment of tumor size and parametrial involvement. In our study, MRI showed excellent performance in excluding parametrial disease and good accuracy in evaluating small tumors, supporting its role in surgical planning and selection of candidates for fertility-sparing treatment. Although its sensitivity for lymph node involvement remains limited, MRI provides important complementary information when interpreted alongside clinical and histopathologic findings. Overall, these results reinforce the central role of magnetic resonance imaging in the multidisciplinary management of cervical cancer, particularly in centers with expertise in gynecologic imaging.

None.

None.

The authors declare that they have no competing interests.

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