Professional Documents
Culture Documents
Cervical Cancer in The Pregnant Population
Cervical Cancer in The Pregnant Population
https://doi.org/10.1007/s00261-023-03836-x
Received: 24 October 2022 / Revised: 24 January 2023 / Accepted: 26 January 2023 / Published online: 18 April 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Abstract
Cervical cancer is the second most encountered cancer in pregnant patients. The 2018 International Federation of Gynecology
and Obstetrics (FIGO) staging system for cervical cancer updated the staging of primary cervical carcinoma and disease pro-
cess, with formal incorporation of imaging as a vital source of information in the management process to improve accuracy.
Diagnosis and treatment of the pregnant population is a complex interplay of achieving adequate diagnostic information
and optimal treatment while minimizing toxicity and risks to the mother and fetus. While novel imaging techniques and
anticancer therapies are rapidly developed, much information on the safety and feasibility of different therapies is not yet
available in the pregnant population. Therefore, managing pregnant patients with cervical cancer is complex and requires a
multidisciplinary approach.
Keywords Cervical cancer · Pregnant · FIGO 2018 · Magnetic resonance imaging · Ultrasound · Computed tomography
13
Vol.:(0123456789)
1680 Abdominal Radiology (2023) 48:1679–1693
with peak incidence occurring between 35–39 years and Patients with abnormal cytology on Pap smear are
60–65 years old in the normal population, the average age referred for further evaluation with colposcopy. In general,
of pregnant women with cervical cancer ranges from 30 to colposcopy examination of pregnant women requires exper-
35 years old [4]. Approximately 1.6 to 10.6 cases of mater- tise and experience as pregnancy-related cervical changes
nal cervical cancer are identified per 10,000 births [2]. such as stromal edema, cervical ripening, and ectropion limit
The risk factors of cervical cancer include human papil- the ability to detect neoplasia on colposcopy exams. In addi-
lomavirus (HPV) infection, multiple sexual partners, early tion, the normal decidual reaction of the cervix stimulated
intercourse experience, multiparity, smoking, low socio- by pregnancy hormones can mimic the appearance of cervi-
economic status, and lack of cervical cancer preventative cal cancer. Conversely, neoplastic lesions may be mistaken
screening [5]. The overall incidence of invasive cervical for regular early pregnancy-related changes.
cancer has decreased in recent years from increased screen- There are critical differences in the diagnostic workup
ing with Papanicolaou (Pap) smear and HPV vaccination. of pregnant women and nonpregnant cohorts. One is the
The routine Pap smear with regular obstetric examination preferential deferral of diagnostic conization until postpar-
facilitates early detection in the pregnant population. Preg- tum to avoid pregnancy disruption. Conization should only
nant women are three times more likely to be diagnosed with be performed during pregnancy if confirmation of invasive
stage 1 disease than the nonpregnant cohort [6]. Addition- cancer will alter the pregnancy management, including tim-
ally, with an increasing number of women delaying preg- ing and route of delivery. Some complications of conization
nancy to later years, it is expected that cervical cancer in the include hemorrhage, miscarriage, premature rupture of the
pregnant population will be more frequently encountered. membrane, infection, and preterm labor [11].
13
Abdominal Radiology (2023) 48:1679–1693 1681
Table 1 TNM (8th edition) and revised FIGO (2018) classification of cervical cancer
TNM FIGO Description
13
1682 Abdominal Radiology (2023) 48:1679–1693
Fig. 2 A pregnant patient underwent a staging MRI for a newly diag- tion (d, e). The tumor margin extends to the posterior left cervical
nosed cervical cancer (arrows). Stage IB, the mass demonstrates T1 stroma without stromal breaching or evidence of parametrial invasion
hypointense (a), T2 hypointense (b, c) signal, with diffusion restric-
hypointense cervical stromal ring excludes parametrial axis is considered the threshold. However, the size criterion
involvement, with a negative predictive value of 94–100% alone is inaccurate, with sensitivity ranging from 29 to 86%
[15]. for MRI [15]. Additional features, including round shape
In FIGO stage III disease, the carcinoma invades the regardless of nodal size, central necrosis, soft tissue or tumor
lower third of the vagina, and/or extends to the pelvic side signal intensity, or extracapsular tumor extension beyond the
wall, and/or causes hydronephrosis, and/or involves the pel- nodal capsule, are used to identify nodal involvement. The
vic or para-aortic lymph node. presence of necrosis within the lymph node has a positive
The integration of abdominopelvic retroperitoneal lymph predictive value of 100% for nodal disease detection [20].
node status in the staging of cervical cancer is an additional In FIGO stage IV, the carcinoma involves adjacent organs,
change in the 2018 FIGO staging system, previously not including the bladder or rectum, or extends beyond the true
included in the 2014 version. The presence of nodal metas- pelvis with metastasis to distant organs.
tases is a significant indicator of poor prognosis and survival
[16]. The risk of pelvic nodal involvement increases with
larger tumors, specifically 6% for tumors smaller than 2 cm Imaging modalities
and 36% for tumors larger than 4 cm [17]. The 5-year sur-
vival rate for node-positive patients is 39–54%, in contrast Magnetic resonance imaging (MRI)
to 67–92% in patients without nodal disease [18, 19]. The
added identification of lymphadenopathy precludes curative MRI is not used in evaluating stage IA disease as small
surgery and allows upstaging patients at higher risk and bet- tumors (< 5 mm) cannot be reliably detected with imag-
ter targeting of radiation and neoadjuvant chemotherapy in ing. However, in tumors over 10 mm in size, MRI imag-
those eligible. In high-stage tumors, identification of nodal ing is indicated and is considered the optimal modality for
disease is also helpful in radiotherapy planning, though locoregional staging of cervical cancer, complementary
radiation is contraindicated if pregnancy is preserved, Fig. 3. to the clinical examination. Studies have shown that the
In general, cervical cancer metastasizes to parametrial MRI assessment of locoregional disease does not depend
nodes, obturator nodes, then iliac nodes. Size is the main cri- on administering a Gadolinium-based contrast agent [21,
terion to identify nodal metastasis; typically, a 10 mm short 22]. Using T2 weighted and diffusion-weighted (DWI)
13
Abdominal Radiology (2023) 48:1679–1693 1683
Fig. 3 A pregnant patient undergoes pelvic MRI to stage a newly diagnosed cervical cancer stage IIIC. The mass demonstrates T2 hypointense
signal (a, b), diffusion restriction (c, d, e), with parametrial invasion (white arrows) and pelvic nodal metastases (f, black arrow)
sequences, readers can accurately assess the disease extent, therefore, patients are encouraged to empty their bladder 1 h
including evaluation of tumor size, parametrial and pelvic before the exam. A surface array coil rather than a body coil
wall invasion, involvement of adjacent organs, and iden- is used to achieve higher signal-to-noise, spatial resolution,
tification of nodal and organ metastases [21]. The combi- and shorter imaging time [15, 25]. An anterior presaturation
nation of T2/DWI can improve specificity for parametrial band can be applied to reduce breathing motion artifacts.
invasion (96.5–99%) compared to T2 weighted imaging Presaturation pulses above and below the area of interest
alone (85.2–88.7%), with similar sensitivity (67–75%) [23]. may also help reduce intravascular pelvic vessels signal. The
Additionally, in a meta-analysis comparing MRI, PET/CT, use of vaginal gel to distend the canal has been shown to
and CT, DWI-MRI has the highest sensitivity for detecting improve the detection of vaginal involvement and is cur-
nodal metastases with an area under the curve of 0.92, while rently utilized at many institutions [26, 27].
FDG- PET/CT is 0.9 and CT 0.83 [24]. To achieve the highest accuracy for staging, pelvic MRI
DWI relies on the principle of random motion of water should include the following key sequences: large field-of-
molecules within tissues. Information regarding cellularity, view (FOV) axial T2 and T2 weighted imaging of the pel-
microcirculation, and cellular membrane integrity can be vis, sagittal T2 weighted imaging of the pelvis, axial small
inferred based on DWI. In conjunction with the apparent FOV oblique T2 and T1 weighted imaging perpendicular to
diffusion coefficient (ADC), DWI improves the detection the long axis of the cervix, coronal small FOV oblique T2
and characterization of abnormal tissue. Cervical cancer weighted imaging parallel to the long axis of the cervix, and
generally demonstrates higher signal than adjacent normal axial T2 weighted imaging or SSFP in the upper abdomen
cervical tissue, particularly with higher b- values, while the [21]. Multiplanar acquisition perpendicular and parallel to
corresponding mean ADC is significantly lower than normal the plane of the cervix is crucial for tumor delineation and
cervical tissue. assessment of local extension. DWI can accurately detect
tumor extension and identify nodal and peritoneal metasta-
MRI protocol ses. Additional use of axial oblique DWI perpendicular to
the plane of the cervix is also crucial for tumor delineation
Patient preparation and imaging technique are crucial to and increases specificity and accuracy. Large FOV T1 and
achieving high-quality images. The patient should fast for T2 weighted imaging of the pelvis help assess the integrity
4 h prior to the examination in order to limit artifacts asso- of local organs and skeletal structures. T2 imaging of the
ciated with small bowel peristalsis. An antiperistaltic agent upper abdomen can delineate the extent of retroperitoneal
is also needed to further suspend bowel movements. The nodal disease and survey the liver for metastases. The sug-
bladder should also be partially full at the time of the scan; gested sequences are outlined in Table 2.
13
1684 Abdominal Radiology (2023) 48:1679–1693
Large field-of-view (FOV) axial T2 weighted imaging of the pelvis Assess local organs and skeletal structures
Sagittal T2 weighted imaging of the pelvis Tumor delineation
Axial small FOV oblique T2 and T1 weighted imaging perpendicular to major axis of cervix Tumor delineation and local extension
Coronal small FOV oblique T2 weighted imaging parallel to the major axis of the cervix Tumor delineation and local extension
Axial oblique DWI perpendicular to major axis of the cervix and pelvic DWI Tumor extension, nodal and peritoneal metastases
Axial T2 weighted imaging of SSFP of the upper abdomen Extent of retroperitoneal nodal disease and survey
the liver for metastases
3 T MRI demonstrates superior signal-to-noise ratio Being aware of this physiologic change can negate the ten-
and contrast resolution compared to 1.5 T MRI, providing dency to overestimate the degree of tumor involvement.
excellent anatomical details of pelvic viscera, allowing for Patients in late-stage pregnancy may experience physi-
more accurate cervical cancer staging [28, 29]. 3 T MRI, ologic hydronephrosis from compression of the ureter by the
therefore, may be preferred for staging pelvic malignan- enlarged gravid uterus, estimated to be present in up to 80%
cies. However, its use in pregnancy is currently debated of pregnant patients [33]. This phenomenon more commonly
given the fetal exposure to the high static magnetic field, occurs on the right side, thought to be related to dextrorota-
high radiofrequency absorption (SAR), high tissue heating tion of the uterus by the left-sided sigmoid colon [33]. It is
and acoustic noise, and the theoretical risk of intrauterine essential to distinguish this from tumor involving the ureter,
growth retardation and fetal hearing loss, though currently a marker of stage III disease. In physiologic hydronephro-
there is no documented risk on humans in the literature. The sis, it is often difficult to delineate the ureter to the point of
Society of Pediatric Radiology and the American College of obstruction. Conversely, in pathologic hydronephrosis, the
Radiology (ACR) recommend that the radiologist assess the source of obstruction may be more apparent and identifi-
risk–benefit of using 3 T MRI in pregnant women and keep able. Careful evaluation of the tumor and clear identifica-
SAR within the permitted limit [30, 31]. tion of tumor signal intensity extending to the pelvic wall
is required. In ureteral cancer involvement, hydronephrosis
MR imaging findings and pitfalls occurs ipsilateral to the side of the tumor [34].
Other pitfalls in imaging pregnant patients include dilata-
The tumor typically appears as intermediate signal on T2 tion of pelvic parametrial vessels during pregnancy that may
weighted imaging, lower than fat but higher than myome- mimic nodal disease on the axial plane, Fig. 4. Multiplanar
trium and cervical stroma, and with diffusion restriction and diffusion-weighted imaging helps delineate the primary
on DWI. However, in pregnant patients, the cervix may tumor, identify nodal disease and avoid this pitfall. Addi-
appear more hyperintense on T2 weighted imaging, making tionally, recognizing flow voids on T2 weighted imaging
the tumor more isointense to the adjacent cervical stroma or blood pool signals on steady-state free precession-based
[21, 32]. This presents a challenge in delineating the tumor. sequences can negate this pitfall.
Fig. 4 T2 weighted (a, b), T2 fat-saturated (c), and ADC (d) images of a pregnant patient with cervical cancer demonstrate dilated parametrial
vessels mimicking pathologic pelvic nodal disease (d), a pitfall to be aware of, especially in pregnant patients (white arrows)
13
Abdominal Radiology (2023) 48:1679–1693 1685
Artifacts from fetal movement may compromise imag- no well-controlled studies on the effect of Gadolinium on
ing of the cervix, Fig. 5. Techniques such as T2 weighted fetuses [36–38]. Also, there are no known cases of nephro-
FSE and SSFSE are fast acquisitions allowing for great genic systemic fibrosis (NSF) in fetal exposure to GBCAs
detail anatomic delineation while minimizing fetal artifacts. [36]. However, a macrocyclic agent with lower NSF associa-
Steady-state free precession-based sequences have a high tion should be used if Gadolinium contrast is required in a
signal-to-noise ratio, are motion insensitive, and may help pregnant patient.
outline the vasculature and detect nodal and peritoneal dis- In the primary staging of cervical cancer, GBCA helps
ease [21]. detect small tumors, which may enhance more avidly in the
MRI is a highly reproducible imaging technique and is early dynamic phase compared with the cervical stroma. It is
increasingly used to assess response to neoadjuvant chemo- estimated that post-contrast images can result in an improved
therapy. The treated tumor typically decreases in size with sensitivity of 92% for small tumors with a depth of stro-
decreased hypercellularity or a higher ADC value. However, mal invasion ranging between 3.1 and 5 mm, compared to
there are technical limitations to MRI, including a lack of 23% sensitivity using only T2-weight images [15]. Using
standardization of protocols, varying ADC values across dynamic multiphase contrast MRI, a study has established
different MRI scanners, and a lack of an established ADC that the peak differential enhancement of tumor and cervi-
value that allows for precise differentiation of tumor aggres- cal stroma is between 45 and 90 s, Fig. 6. [39] Additionally,
siveness [35]. It is therefore recommended that the study be in patients treated with chemoradiotherapy, the addition of
performed on the same scanner with the same sequences post-contrast imaging helps distinguish radiation fibrosis
and parameters for more reliable use of ADC values pre-and from disease recurrence, and improves detection of other
post-treatment in assessing treatment response. complications such as necrosis and fistula [15, 40].
With an appropriate clinical indication, there may be a
Gadolinium‑based contrast agents (GBCAs) role of GBCA in pregnant cervical cancer patients. How-
ever, as the fetal risk from GBCA exposure remains largely
The American College of Radiology (ACR) advises that unknown, it is recommended that there be a thorough discus-
GBCAs not be routinely administered to pregnant patients. sion between the radiologist, referring physician, and patient
GBCAs can pass through the placental barrier, enter the with well-documented informed consent before Gadolinium
fetal circulation, subsequently be excreted via the fetal kid- contrast administration.
neys, and excreted into the amniotic fluid. It may remain
in the amniotic fluid for a long time, increasing the risk of Ultrasound
dissociating toxic-free-Gadolinium from the chelate. Stud-
ies of nonhuman primates have found the persistence of Transvaginal or transrectal ultrasound can assess the pri-
Gadolinium concentrations in amniotic fluid up to 50 days mary tumor and locoregional disease process in patients
after contrast administration, although no human data are with early-stage disease, stage IIB or lower [41]. The tumor
available [36]. Although no cases of teratogenicity from typically appears as an intrinsically vascular hypoechoic
intrauterine GBCA exposure have been reported, there are mass relative to the adjacent cervical stroma, Fig. 7 [41].
Fig. 5 Motion artifacts are prevalent in MR imaging of pregnant weighted images (b, c, arrows). Fast acquisitions such as T2-FSE,
patients due to fetal motion, as demonstrated in this sagittal T2 SSFSE, and HASTE are more resistant to motion and may improve
(a) weighted image. The tumor is only conspicuous on diffusion- the visibility of the lesion
13
1686 Abdominal Radiology (2023) 48:1679–1693
Fig. 6 Staging MRI of the cervical mass on prior ultrasound demon- (d, e) image confirms the findings. Of note, GBCM is not absolutely
strates a T1 hypointense (a), T2 hypointense (b), diffusion restrict- contraindicated during pregnancy and can be given in appropriate
ing (c) mass (arrow), stage IB1 limited to the external cervix with- clinical settings as deemed appropriate by the provider with careful
out stromal invasion or pelvic metastases. Post Gadolinium contrast weighing of risks and benefits and patient consent
Ultrasound can also detect hydronephrosis, which can be IB tumors as it is operator-dependent, and cross-sectional
seen in stage IIIB, and evaluate for liver metastases, stage imaging is preferred.
IVB. The utility of ultrasound is even more crucial in preg-
nant patients as computed tomography is generally avoided Computed tomography (CT)
in this population due to the risk of ionizing radiation. How-
ever, ultrasound lacks specificity as hydronephrosis is often Abdominal/pelvic CT is typically performed for the detec-
seen in late gestation. Additionally, ultrasound is not as tion of retroperitoneal lymphadenopathy (stage IIIC) and
accurate for evaluating higher-stage disease or larger stage other intra-abdominal/pelvic metastases (stage IV), typically
13
Abdominal Radiology (2023) 48:1679–1693 1687
as part of the PET/CT examination in the nonpregnant popu- that may limit the imaging quality and analysis. Some
lation, Fig. 8. However, PET/CT is generally not recom- authors have advocated for pregnant patients to fast for 4 h
mended in the pregnant population due to the high radia- before an MRI examination to reduce maternal peristal-
tion dose. Moreover, abdominal/pelvic CT in the pregnant sis and fetal movements [44]. In the nonpregnant cohort,
population is typically avoided as direct pelvic radiation of spasmolytic agents such as hyoscine butylbromide can be
the fetus can have a significant adverse effect depending on used to decrease intestinal peristalsis. However, its use in
the fetal age. A typical CT of the abdomen/pelvis can have pregnant patients is controversial due to the side effect of
a fetal radiation dose of 8–25 mGy [42]. CT is also inferior dilatation of the cervical canal [45].
to MRI for the locoregional staging of cervical cancer due to Additionally, the classic supine position in cross-
its suboptimal tissue contrast. The tumor typically appears sectional imaging may induce discomfort in patients in
homogeneously enhancing, similar to the normal cervical the late stages of pregnancy. The large gravid uterus may
tissue on CT [7]. However, if pelvic magnetic resonance compress the inferior vena cava, compromising venous
imaging (MRI) is unavailable or contraindicated, contrast return and precipitating syncope. Alternative imaging in
CT can be used as an alternative modality for staging, with the left lateral decubitus position may be performed in
careful weighing of risks and benefits to the mother and these patients [44].
fetus. Direct pelvic radiation imaging in the pregnant popu- The duration of the MRI exam should also be kept as
lation should be avoided, especially in the first trimester. short as possible to reduce patient discomfort while main-
A contrast chest CT alone has a low fetal dose of taining a low specific absorption rate (SAR), limited to
0.01–0.66 mGy and can be utilized to assess for thoracic 2W/kg [43]. Short sequences such as T2 weighted fast-
metastases [42]. Studies have shown that indirect fetal expo- spin-echo (FSE) and single-shot-fast-spin-echo (SSFSE)
sure from internal scatter is considered negligible, and chest can be used in pregnant patients to achieve good anatomic
CT should not be withheld when necessary [43]. details while minimizing artifacts related to fetal motion.
In addition, alternating these high SAR sequences with
Other imaging considerations in the pregnant low SAR sequences, such as T1 weighted gradient echo
population (GRE) and steady-state free precession (SSFP) sequences,
can minimize fetal heat deposition.
Imaging the abdomen and pelvis of pregnant patients can
be challenging, partly due to fetal and intestinal artifacts
Fig. 8 A patient with early pregnancy undergoes staging MRI for a ine segment (black arrow). After counseling on risks and benefits,
recently diagnosed cervical cancer. The mass (white arrow) demon- the patient undergoes termination of pregnancy to expedite treat-
strates a T1 isointense signal (a) and T2 mildly hypointense signal (b, ment. Her staging PET/CT (f) demonstrates an FDG avid mass (white
c), with post-contrast avid enhancement (d, e). In addition, there is arrow) and pelvic nodal metastases (grey arrow), Stage IIIC
evidence of parametrial extension and involvement of the lower uter-
13
1688 Abdominal Radiology (2023) 48:1679–1693
Terminate
Is the gestaonal age > 22 to 25 weeks? pregnancy
and
Yes No management
as in
Tumor Tumor nonpregnant
stage stage paent
IA1 to IB1 Stage IB2 (size >/= Stage IA2 to IB1
Stage IA1
(<2cm) 2cm) or higher (size <2cm)
Definive Pelvic
Delay Neoadjuvant treatment lymphadenopathy?
treatment chemotherapy
unl aer with
Stage IB2 (size Yes No
delivery conizaon
>/= 2 cm)
Neoadjuvant
therapy Definive
Pelvic lymphadenopathy if treatment
size >/= 4 cm? (conizaon or
trachelectomy)
No Yes
13
Abdominal Radiology (2023) 48:1679–1693 1689
less than 2 cm) with the presence of nodal metastasis, Fig. 9 the greater risk of significant hemorrhage and obstruction
algorithm. of the birth canal [53].
If systemic therapy is given during pregnancy, a combi-
nation of cisplatin and paclitaxel is recommended. There
Definitive treatment
is some evidence that cisplatin is filtered by the placenta,
although the concentration in amniotic fluid at delivery is
Definitive treatment, i.e., hysterectomy or trachelectomy, is
relatively low, approximately 11–42% of the concentration
typically deferred until postpartum if pregnancy is preserved
in maternal blood [48, 50]. There may be a risk of fetal oto-
and largely depends on the disease stage and the mother’s
toxicity and transient neutropenia in newborns from intrau-
desire to preserve future fertility. For fertility preservation
terine cisplatin exposure [48]. Therefore, therapy should be
in stage IA1 disease, therapeutic conization may be all that
discontinued about three weeks before planned delivery to
is needed. However, in Stage IA2 disease or large tumors up
minimize neonatal marrow suppression and allow time for
to 4 cm, a radical vaginal trachelectomy can be performed.
cytotoxic drugs to be eliminated and metabolized by the
If a mother does not wish to preserve fertility, a laparoscopic
placenta. Additionally, chemotherapy should be avoided dur-
hysterectomy can be performed for Stage IA1 disease, while
ing the late third trimester due to increased association with
a radical hysterectomy is recommended for tumors of stage
spontaneous labor. Bevacizumab, an anti-VEGF inhibitor
IA1 with lymphovascular space invasion up to stage IB1.
with an anti-angiogenesis effect, is FDA-approved for cer-
Patients with locally advanced diseases requiring neoad-
vical cancer treatment in the nonpregnant population but is
juvant chemotherapy should undergo a radical hysterectomy.
contraindicated during pregnancy due to the risk of severe
fetal harm in animal studies [48]. Safety data of chemo-
therapy during pregnancy is limited; however, a systematic Fertility sparing in cervical cancer
review of 48 human pregnancy exposures to platinum deriv-
atives in 2013 found that 67.3% of neonates were healthy at Several trachelectomy surgical techniques have been
birth, and the most significant problem in remaining births described in the literature with varying outcomes. Vaginal
was associated with prematurity, most frequently respiratory radical trachelectomy (VRT) has a reported 99% 5-year sur-
distress [51]. vival rate. VRT combines laparoscopic pelvic lymphadenec-
In patients with locally advanced cervical cancer (stages tomy with resection of the parametria at the level of radical
IB3 or higher) who elect to terminate the pregnancy, there is hysterectomy. Subsequently, the cervix is transected 1 cm
increased benefit from concurrent chemoradiation therapy, above the tumor margin while preserving at least 1 cm of
which includes external radiation and intracavitary brachy- the cervical stroma. VRT has an overall pregnancy rate of
therapy. However, in patients electing to preserve pregnancy, 30% [54].
radiation is contraindicated. Abdominal radical trachelectomy (ART) is an alterna-
tive procedure performed abdominally. ART is a modifica-
Surveillance during pregnancy tion of the radical abdominal hysterectomy approach, which
includes lymphadenectomy and resection of the uterine
Patients with preinvasive disease should undergo colposcopy artery, parametrium, entire cervix, and vagina. The vagina
examination each trimester of pregnancy. Patients who wish is then sutured directly to the remaining stroma. ART has
to delay definitive therapy until after delivery and those on a reported 88.7- 93.5% 5-year survival rate [55, 56]. The
neoadjuvant therapy should undergo pelvic examinations overall pregnancy rate for ART is 15% [54].
every 3–4 weeks during pregnancy. Additionally, pelvic Simple trachelectomy (ST) is a 2-step procedure involv-
MRI without Gadolinium contrast should be performed to ing laparoscopic pelvic lymphadenectomy with sentinel
monitor for disease progression [48]. lymph node mapping (SLNM). A resection of the parame-
trium is unnecessary in cases with negative pelvic lymph
Delivery nodes with a tumor size less than 2 cm in diameter. There-
fore only a simple trachelectomy is done, usually one week
A term delivery at 37 weeks or later is ideal. However, if after SLNM. The remaining cervix is sutured with the vagi-
earlier delivery is required to expedite treatment, antenatal nal edges, and cervical cerclage is not performed. If positive
steroids may be administered to reduce respiratory morbid- lymph nodes are detected, a fertility-preserving procedure is
ity and mortality. not performed. The pregnancy rate for ST is about 50% [57].
Vaginal delivery is possible in patients with stage IA1 Tumor size and location are critical factors in assess-
and IA2 disease, although an episiotomy should be avoided ing trachelectomy candidacy, with cervix-confined
to prevent tumor seeding [52]. For patients with stage IB1 tumors < 2 cm in size and located > 1 cm from the inter-
or higher, a caesarian section should be performed due to nal cervical os considered ideal features. Some centers will
13
1690 Abdominal Radiology (2023) 48:1679–1693
consider trachelectomy for women with tumors < 4 cm or as examination and detailed history, which are the only con-
close to 0.5 cm from the internal os, Figs. 10 and 11 [58, 59]. sistent methods for detecting recurrence [60, 61]. The
Post-operative complications include dyspareunia, dys- patient should be followed at 3–4 month intervals in the
menorrhea, menstrual irregularities, inflammation/infection, first 2 years and every 6–12 months after. After 5 years of
cervical stenosis, and premature labor. The shortened cervix recurrence-free survival, the patient may return to annual
is a significant risk factor for premature delivery. Therefore population-based general physical examinations. If recur-
patients should be counseled before and monitored during rence is suspected, additional imaging may be performed.
pregnancy [57]. Routine radiologic imaging in asymptomatic patients is not
recommended as it has not been definitively evaluated [61].
Surveillance after pregnancy
Outcome
The Society of Gynecologic Oncology's 2017 updated
statement on post-treatment surveillance of gynecologic The estimated risk of metastatic or recurrent cervical can-
malignancies emphasized the role of follow-up physical cer is 15–61% of patients, usually within the first 2 years
Fig. 10 Trachelectomy for
fertility-sparing. Intraoperative
images demonstrate at least
1 cm of uninvolved cervix from
the tumor
Fig. 11 Before (a, b) and after (c, d, e) simple trachelectomy images demonstrate the expected post-operative appearance of a shortened cervix
secured by a cerclage postoperatively (arrows)
13
Abdominal Radiology (2023) 48:1679–1693 1691
of completing therapy [62]. A study reported that vaginal 7. Lee RB, Neglia W, Park RC. Cervical carcinoma in pregnancy.
delivery was a significant predictor of recurrence in pregnant Obstet Gynecol 1981;58(5):584-9. (In eng).
8. Hannigan EV. Cervical Cancer in Pregnancy. Clinical Obstet-
patients [63, 64]. Additional case reports have described rics and Gynecology 1990;33(4) (https://journals.lww.com/clini
tumor implantation at episiotomy sites and poor prognosis calobgyn/Fulltext/1990/12000/Cervical_Cancer_in_Pregnancy.
[65–68]. Most available studies suggest similar outcomes 19.aspx).
and prognoses for treated pregnant and nonpregnant cervi- 9. Carusi D. The gynecologic history and pelvic examination.
Uptodate Available from: https://www.uptodate.com/contents/
cal cancer patients when adjusted for the stage. Available the-gynecologic-history-and-pelvic-examination2022.
studies observed similar mortality rates in pregnant and non- 10. Lockwood C. Prenatal care: Initial assessment. Uptodate. Avail-
pregnant patients with cervical cancer [69, 70]. However, able from: https://www.uptodate.com/contents/prenatal-care-initi
pregnant women with cervical cancer have a higher rate of al-assessment?topicRef=3253&source=see_link2022.
11. Baldauf JJ, Dreyfus M, Ritter J, Philippe E. Colposcopy and
spontaneous abortion and iatrogenic prematurity than those directed biopsy reliability during pregnancy: a cohort study. Eur
without cervical cancer [71]. J Obstet Gynecol Reprod Biol 1995;62(1):31-6 (In eng). https://
doi.org/10.1016/0301-2115(95)02178-a.
12. Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R. Cancer of
the cervix uteri. Int J Gynaecol Obstet 2018;143 Suppl 2:22-36
Conclusion (In eng). https://doi.org/10.1002/ijgo.12611.
13. Union for International Cancer Control (UICC) (2017) TNM
classification of malignant tumours, 8th edn. Wiley, Oxford and
Cervical cancer is increasingly diagnosed during pregnancy Hoboken.
with increased antenatal screening and women delaying 14. Speiser D, Köhler C, Schneider A, Mangler M. Radical vaginal
pregnancy to a later age. The FIGO 2018 version and TNM trachelectomy: a fertility-preserving procedure in early cervical
cancer in young women. Dtsch Arztebl Int 2013;110(17):289-295
staging systems primarily rely on imaging as an integral (In eng). https://doi.org/10.3238/arztebl.2013.0289.
component of disease management. Special imaging con- 15. Liyanage SH, Roberts CA, Rockall AG. MRI and PET scans
siderations and protocols are required for pregnant patients, for primary staging and detection of cervical cancer recurrence.
requiring more active research. Although not much data are Womens Health (Lond) 2010;6(2):251–67; quiz 268–9 (In eng).
https://doi.org/10.2217/whe.10.7.
available on the therapeutic effect of pregnant cervical can- 16. Grigsby PW. PET/CT imaging to guide cervical cancer therapy.
cer patients, the available studies suggest similar outcomes Future Oncol 2009;5(7):953-8 (In eng). https://doi.org/10.2217/
to nonpregnant cohorts when appropriate management is fon.09.70.
applied. 17. Paño B, Sebastià C, Ripoll E, et al. Pathways of lymphatic spread
in gynecologic malignancies. Radiographics 2015;35(3):916-45
(In eng). https://doi.org/10.1148/rg.2015140086.
18. Aoki Y, Sasaki M, Watanabe M, et al. High-risk group in node-
positive patients with stage IB, IIA, and IIB cervical carcinoma
References after radical hysterectomy and postoperative pelvic irradiation.
Gynecol Oncol 2000;77(2):305-9 (In eng). https://doi.org/10.
1. de Haan J, Verheecke M, Van Calsteren K, et al. Oncological 1006/gyno.2000.5788.
management and obstetric and neonatal outcomes for women 19. Odunsi KO, Lele S, Ghamande S, Seago P, Driscoll DL. The
diagnosed with cancer during pregnancy: a 20-year international impact of pre-therapy extraperitoneal surgical staging on the
cohort study of 1170 patients. Lancet Oncol 2018;19(3):337-346 evaluation and treatment of patients with locally advanced cervi-
(In eng). https://doi.org/10.1016/s1470-2045(18)30059-7. cal cancer. Eur J Gynaecol Oncol 2001;22(5):325-30. (In eng).
2. Smith LH, Dalrymple JL, Leiserowitz GS, Danielsen B, Gilbert 20. Yang WT, Lam WW, Yu MY, Cheung TH, Metreweli C. Com-
WM. Obstetrical deliveries associated with maternal malig- parison of dynamic helical CT and dynamic MR imaging in the
nancy in California, 1992 through 1997. Am J Obstet Gynecol evaluation of pelvic lymph nodes in cervical carcinoma. AJR Am
2001;184(7):1504–12; discussion 1512–3 (In eng). https://d oi.o rg/ J Roentgenol 2000;175(3):759-66 (In eng). https://doi.org/10.
10.1067/mob.2001.114867. 2214/ajr.175.3.1750759.
3. Van Calsteren K, Vergote I, Amant F. Cervical neoplasia during 21. Gui B, Cambi F, Micco M, et al. MRI in pregnant patients with
pregnancy: diagnosis, management and prognosis. Best Pract Res suspected abdominal and pelvic cancer: a practical guide for radi-
Clin Obstet Gynaecol 2005;19(4):611-30 (In eng). https://d oi.o rg/ ologists. Diagn Interv Radiol 2020;26(3):183-192 (In eng). https://
10.1016/j.bpobgyn.2005.03.002. doi.org/10.5152/dir.2019.19343.
4. Duggan B, Muderspach LI, Roman LD, Curtin JP, d'Ablaing 22. Amant F, Berveiller P, Boere IA, et al. Gynecologic cancers in
G, 3rd, Morrow CP. Cervical cancer in pregnancy: reporting on pregnancy: guidelines based on a third international consensus
planned delay in therapy. Obstet Gynecol 1993;82(4 Pt 1):598- meeting. Ann Oncol 2019;30(10):1601-1612 (In eng). https://doi.
602. (In eng). org/10.1093/annonc/mdz228.
5. Nguyen C, Montz FJ, Bristow RE. Management of stage I cervical 23. Park JJ, Kim CK, Park SY, Park BK. Parametrial invasion in cer-
cancer in pregnancy. Obstet Gynecol Surv 2000;55(10):633-43 (In vical cancer: fused T2-weighted imaging and high-b-value diffu-
eng). https://doi.org/10.1097/00006254-200010000-00022. sion-weighted imaging with background body signal suppression
6. Zemlickis D, Lishner M, Degendorfer P, Panzarella T, Sutcliffe at 3 T. Radiology 2015;274(3):734-41 (In eng). https://d oi.o rg/1 0.
SB, Koren G. Maternal and fetal outcome after invasive cervical 1148/radiol.14140920.
cancer in pregnancy. Journal of clinical oncology : official journal 24. Liu B, Gao S, Li S. A Comprehensive Comparison of CT, MRI,
of the American Society of Clinical Oncology 1991;9(11):1956- Positron Emission Tomography or Positron Emission Tomog-
61 (In eng). https://doi.org/10.1200/jco.1991.9.11.1956. raphy/CT, and Diffusion Weighted Imaging-MRI for Detecting
13
1692 Abdominal Radiology (2023) 48:1679–1693
the Lymph Nodes Metastases in Patients with Cervical Cancer: subtraction MR imaging. Radiology 1997;204(1):55-63 (In eng).
A Meta-Analysis Based on 67 Studies. Gynecol Obstet Invest https://doi.org/10.1148/radiology.204.1.9205223.
2017;82(3):209-222 (In eng). https://d oi.o rg/1 0.1 159/0 00456 006. 40. Hricak H, Swift PS, Campos Z, Quivey JM, Gildengorin V, Göran-
25. Yu KK, Hricak H, Subak LL, Zaloudek CJ, Powell CB. Preopera- son H. Irradiation of the cervix uteri: value of unenhanced and
tive staging of cervical carcinoma: phased array coil fast spin-echo contrast-enhanced MR imaging. Radiology 1993;189(2):381-8 (In
versus body coil spin-echo T2-weighted MR imaging. AJR Am J eng). https://doi.org/10.1148/radiology.189.2.8210364.
Roentgenol 1998;171(3):707-11 (In eng). https://d oi.o rg/1 0.2 214/ 41. Alcázar JL, Arribas S, Mínguez JA, Jurado M. The role of ultra-
ajr.171.3.9725301. sound in the assessment of uterine cervical cancer. J Obstet
26. Engelaere C, Poncelet E, Durot C, Dohan A, Rousset P, Hoeffel Gynaecol India 2014;64(5):311-316 (In eng). https://doi.org/10.
C. Pelvic MRI: Is Endovaginal or Rectal Filling Needed? Korean 1007/s13224-014-0622-4.
J Radiol 2018;19(3):397-409 (In eng). https://d oi.o rg/1 0.3 348/k jr. 42. Woitek R, Prayer D, Hojreh A, Helbich T. Radiological staging in
2018.19.3.397. pregnant patients with cancer. ESMO Open 2016;1(1):e000017
27. Brown MA, Mattrey RF, Stamato S, Sirlin CB. MRI of (In eng). https://doi.org/10.1136/esmoopen-2015-000017.
the female pelvis using vaginal gel. AJR Am J Roentgenol 43. Vandecaveye V, Amant F, Lecouvet F, Van Calsteren K, Dresen
2005;185(5):1221-7 (In eng). https://d oi.o rg/1 0.2 214/a jr.0 4.1 660. RC. Imaging modalities in pregnant cancer patients. Int J Gynecol
28. Kataoka M, Kido A, Koyama T, et al. MRI of the female pelvis at Cancer 2021;31(3):423-431 (In eng). https://doi.org/10.1136/
3T compared to 1.5T: evaluation on high-resolution T2-weighted ijgc-2020-001779.
and HASTE images. J Magn Reson Imaging 2007;25(3):527–34 44. Leyendecker JR, Gorengaut V, Brown JJ. MR imaging of maternal
(In eng). https://doi.org/10.1002/jmri.20842. diseases of the abdomen and pelvis during pregnancy and the
29. Jeong SY, Park BK, Choi CH, et al. Utility of 3T MRI in Women immediate postpartum period. Radiographics 2004;24(5):1301-16
with IB1 Cervical Cancer in Determining the Necessity of Less (In eng). https://doi.org/10.1148/rg.245045036.
Invasive Surgery. Cancers (Basel) 2022;14(1) (In eng). https://d oi. 45. Rohwer AC, Khondowe O, Young T. Antispasmodics for labour.
org/10.3390/cancers14010224. Cochrane Database Syst Rev 2013;2013(6):Cd009243 (In eng).
30. Murbach M, Cabot E, Neufeld E, et al. Local SAR enhancements https://doi.org/10.1002/14651858.CD009243.pub3.
in anatomically correct children and adult models as a function 46. Ackermann S, Gehrsitz C, Mehlhorn G, Beckmann MW. Man-
of position within 1.5 T MR body coil. Prog Biophys Mol Biol agement and course of histologically verified cervical carci-
2011;107(3):428-33 (In eng). https://doi.org/10.1016/j.pbiom noma in situ during pregnancy. Acta Obstet Gynecol Scand
olbio.2011.09.017. 2006;85(9):1134-7 (In eng). https://doi.org/10.1080/0001634060
31. Pediaditis M, Leitgeb N, Cech R. RF-EMF exposure of fetus 0555926.
and mother during magnetic resonance imaging. Phys Med Biol 47. Paraskevaidis E, Koliopoulos G, Kalantaridou S, et al. Manage-
2008;53(24):7187-95 (In eng). https://d oi.o rg/1 0.1 088/0 031-9 155/ ment and evolution of cervical intraepithelial neoplasia during
53/24/012. pregnancy and postpartum. Eur J Obstet Gynecol Reprod Biol
32. Balleyguier C, Fournet C, Ben Hassen W, et al. Management of 2002;104(1):67-9 (In eng). https:// d oi. o rg/ 1 0. 1 016/ s 0301-
cervical cancer detected during pregnancy: role of magnetic reso- 2115(02)00058-1.
nance imaging. Clinical imaging 2013;37(1):70-6 (In eng). https:// 48. Karam A. Cervical cancer in pregnancy. Uptodate Oct 18, 2021
doi.org/10.1016/j.clinimag.2012.04.004. (https://www.uptodate.com/contents/cervical-cancer-in-pregn
33. Rasmussen PE, Nielsen FR. Hydronephrosis during preg- ancy).
nancy: a literature survey. Eur J Obstet Gynecol Reprod Biol 49. Hammond C. Second-trimester pregnancy termination: Induction
1988;27(3):249-59 (In eng). https:// d oi. o rg/ 1 0. 1 016/ 0 028- (medication) termination. Uptodate. Available from: https://w ww.
2243(88)90130-x. uptodate.com/contents/second-trimester-pregnancy-termination-
34. Mansoori B, Khatri G, Rivera-Colón G, Albuquerque K, Lea J, induction-medication-termination?topicRef=4805&source=see_
Pinho DF. Multimodality Imaging of Uterine Cervical Malignan- link2022.
cies. AJR Am J Roentgenol 2020;215(2):292-304 (In eng). https:// 50. Köhler C, Oppelt P, Favero G, et al. How much platinum passes
doi.org/10.2214/ajr.19.21941. the placental barrier? Analysis of platinum applications in 21
35. Dappa E, Elger T, Hasenburg A, Düber C, Battista MJ, Hötker patients with cervical cancer during pregnancy. Am J Obstet
AM. The value of advanced MRI techniques in the assessment of Gynecol 2015;213(2):206.e1-5 (In eng). https://d oi.o rg/1 0.1 016/j.
cervical cancer: a review. Insights into imaging 2017;8(5):471- ajog.2015.02.022.
481 (In eng). https://doi.org/10.1007/s13244-017-0567-0. 51. Zagouri F, Sergentanis TN, Chrysikos D, Bartsch R. Platinum
36. Prola-Netto J, Woods M, Roberts VHJ, et al. Gadolinium Chelate derivatives during pregnancy in cervical cancer: a systematic
Safety in Pregnancy: Barely Detectable Gadolinium Levels in the review and meta-analysis. Obstet Gynecol 2013;121(2 Pt 1):337-
Juvenile Nonhuman Primate after in Utero Exposure. Radiology 343 (In eng). https://doi.org/10.1097/AOG.0b013e31827c5822.
2018;286(1):122-128 (In eng). https://doi.org/10.1148/radiol. 52. Van den Broek NR, Lopes AD, Ansink A, Monaghan JM. "Micro-
2017162534. invasive" adenocarcinoma of the cervix implanting in an episi-
37. Spencer JA, Tomlinson AJ, Weston MJ, Lloyd SN. Early report: otomy scar. Gynecol Oncol 1995;59(2):297-9 (In eng). https://
comparison of breath-hold MR excretory urography, Doppler doi.org/10.1006/gyno.1995.0025.
ultrasound and isotope renography in evaluation of symptomatic 53. Tewari K, Cappuccini F, Gambino A, Kohler MF, Pecorelli S,
hydronephrosis in pregnancy. Clinical radiology 2000;55(6):446- DiSaia PJ. Neoadjuvant chemotherapy in the treatment of locally
53 (In eng). https://doi.org/10.1053/crad.2000.0443. advanced cervical carcinoma in pregnancy: a report of two cases
38. De Santis M, Straface G, Cavaliere AF, Carducci B, Caruso A. and review of issues specific to the management of cervical car-
Gadolinium periconceptional exposure: pregnancy and neonatal cinoma in pregnancy including planned delay of therapy. Cancer
outcome. Acta Obstet Gynecol Scand 2007;86(1):99-101 (In eng). 1998;82(8):1529–34 (In eng). https://doi.org/10.1002/(sici)1097-
https://doi.org/10.1080/00016340600804639. 0142(19980415)82:8<1529::aid-cncr15>3.0.co;2-6.
39. Kinkel K, Ariche M, Tardivon AA, et al. Differentiation between 54. Schneider A, Erdemoglu E, Chiantera V, et al. Clinical recom-
recurrent tumor and benign conditions after treatment of gyneco- mendation radical trachelectomy for fertility preservation in
logic pelvic carcinoma: value of dynamic contrast-enhanced patients with early-stage cervical cancer. Int J Gynecol Cancer
13
Abdominal Radiology (2023) 48:1679–1693 1693
13