role of imaging in cervical cancer

Adenosquamous histology predicts a poor outcome for patients with advanced-stage, but not early-stage, cervical carcinoma. Post-surgical inflammatory lesionssuch as granulation tissue, abscesses, or cicatricial endometriosiscan simulate relapse. Cervical Cancer Lymphatic spread of CC occurs along the obturator, external iliac, internal iliac, common iliac, and paraaortic nodes [26]. Local staging of EC requires evaluating the depth of tumor extension into the myometrium. Tumor extension to the parametrial fat implies disruption of the hypointense cervical stromal rim, with extension of nodular or spiculated soft tissue into the adjacent parametrium (Fig. Park JJ, Kim CK, Park SY, et al. Prospective multicenter study evaluating the survival of patients with locally advanced cervical cancer undergoing laparoscopic para-aortic lymphadenectomy before chemoradiotherapy in the era of positron emission tomography imaging. [48] found that using DWI and T2WI improved the staging accuracy of myometrial invasion, with a sensitivity of up to 96%. The value of advanced MRI techniques in the assessment of cervical cancer: a review. WebInternational Federation of Gynecology and Obstetrics (FIGO) staging, which is the fundamentally important cancer staging system for cervical cancer, has changed in 2018. DWI and DCE sequences reflect changes in the oxygenation, perfusion, and tissue physiology of the tumor microstructure and yield quantitative and semi-quantitative parameters that can potentially serve as biomarkers of tumor characteristics. Urinary bladder cancer has a high recurrence rate, necessitating long-term surveillance after initial therapy. Sala E, Rockall AG, Freeman SJ, Mitchell DG, Reinhold C. The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know. Accessibility When a vaginal approach is planned, first, the pelvic nodes are laparoscopically removed and sent for frozen section analysis to confirm node negativity before proceeding with the radical trachelectomy. See cervical cancer staging. Stage IA1 and IA2 cancers are diagnosed by microscopic examination of specimens from a loop electrosurgical excision procedure or cone biopsy. SLNB may be particularly useful in early-stage cervical cancer (FIGO stage IA, IB1, and IB2). doi: 10.1016/j.ajog.2015.07.022. Other causes of hydronephrosis (i.e., endometriosis or lithiasis) should be excluded to avoid misdiagnosis of stage IIB disease (Table6; Fig. WebAbstract. On DCE images, loss of the normal rim of enhancement of the outer myometrium indicates serosal involvement [4, 8]. Abstract. The cells are then sent to a lab where they are analyzed in order to detect any abnormalities. Woo S, Atun R, Ward ZJ, Scott AM, Hricak H, Vargas HA. The inclusion of nodal involvement places greater emphasis on the role of imaging in staging cervical cancer. Some cases may require performance of a small loop biopsy or cone biopsy [26]. Hricak H, Lacey CG, Sandles LG, et al. Squamous cell carcinoma comprises approximately 69% of all cervical cancers. Upon therapy completion, persistent enhancement at the original cervical tumor site or in the post-surgical bed likely indicates residual disease, which is associated with increased risk of recurrence and poor survival [60]. In cases of CC, 6070% of post-treatment recurrences occur within 2years post-treatment and 8998% within 5years after treatment. Epub 2020 May 15. Role T2-weighted MRI findings predictive of parametrial involvement in patients with cervical cancer and histologically confirmed full thickness stromal invasion. WebIn order to diagnose cervical cancer, your doctor may perform: Pap smear: This examination is performed by scraping cells from the cervix. Mayr NA, Wang JZ, Zhang D, et al. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. To improve MRI performance, patients must fast for 46h and bladder and rectal voiding is advised to reduce motion artifacts (Fig. Molecular MRI-Based Monitoring of Cancer Immunotherapy Treatment Response. WebCervical cancer is a significant cause of morbidity and mortality worldwide despite advances in screening and prevention. FIGO IB2 cervical cancer, with post-biopsy cervical edema. Kuang F, Yan Z, Li H, Feng H. Diagnostic accuracy of diffusion-weighted MRI for differentiation of cervical cancer and benign cervical lesions at 3.0T: comparison with routine MRI and dynamic contrast-enhanced MRI. Administration of intravenous contrast improves detection of recurrence, as recurrence shows early enhancement (4590s) and restriction on DWI sequences, whereas fibrosis exhibits no significant enhancement or enhances in late phases. TVUS may also identify complications of local-regional invasion, such as hydronephrosis or endometrial cavity distension secondary to cervical canal obstruction by the tumor. 2023 Feb 16;13:1100087. doi: 10.3389/fonc.2023.1100087. Tumor epicenter determination with MRI reportedly shows high accuracy (up to 88%) for identification of tumor origin [78, 79]. However, there are significant Implications of the new FIGO staging and the role of imaging in On DCE images, small tumors may show early enhancement compared to the normal endometrium, and slower enhancement than the myometrium. b Coronal T2WI. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases. In the follow-up of high-risk patients, CT is routinely used to identify recurrent disease within the lungs or LNs. WebThe role and contribution of treatment and imaging modalities in global cervical cancer management: survival estimates from a simulation-based analysis Authors Surgery is indicated for early disease, but insufficient pretreatment evaluation may result in an unnecessary procedure or the need for adjuvant therapy. Imaging Influence of lymphadenectomy on survival for early-stage endometrial cancer. Purpose: This study aimed to develop predictive models for pathological residual disease after neoadjuvant chemoradiation (CRT) in locally advanced cervical cancer (LACC) by integrating parameters derived from transvaginal ultrasound, MRI and PET/CT imaging at different time points and time intervals. Imaging in cervical cancer - PubMed Park KJ, Braschi-amirfarzan M, Dipiro PJ et al (2016) Multimodality imaging of locally recurrent and metastatic cervical cancer: emphasis on histology, prognosis, and management. doi: 10.1016/j.ijgo.2009.02.012. Int J Gynaecol Obstet 143(Suppl. sharing sensitive information, make sure youre on a federal ce In another patient, an endometrial stromal sarcoma mimicking cervical cancer is visualized by sagittal T2WI (c), axial T2WI+DWI (d), and DCE (e), revealing a cervical-centered mass with parametrial invasion and adenopathies (arrows in d). Unauthorized use of these marks is strictly prohibited. Somoye G, Harry V, Semple S, et al. Cervical Cancer Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Local-regional staging of endometrial carcinoma: role of MR imaging in surgical planning. 20). However, the vaginal vault can be difficult to assess with CT, and MRI provides improved soft-tissue resolution. MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) (2009) and TNM (8th Edition) systems (Table1) [30, 31]. Young women with larger tumors (FIGO IB1, IB2) are usually selected for ART or neoadjuvant chemotherapy plus conservative surgery [10, 35]. role Endometrial tumor is not delineated on axial oblique T2WI images (a) and is well-defined on DWI (b=1000, ADC map) (arrows) (b), FIGO IB tumor exhibiting left cornual extension. MRI is an accurate technique for evaluating bladder or rectum involvement, with a sensitivity of 71100% and specificity of 8891% [2, 10, 11]. Pitfalls and pearls, FOV field of view, MARS metal artifact reduction sequences. The middle and lower parts of the uterus drain into the parametrium and the paracervical and obturator nodes, while the upper part of the uterus drains into the common iliac and paraaortic LNs. ADC map shows diffusion restriction, and DCE imaging reveals enhancement of the right lateral wall indicating early parametrial invasion (arrows). eCollection 2023. [51] recently demonstrated that the presence of deep myometrial infiltration and a tumor/uterus volume ratio of >0.13 correlated with high-grade EC, whereas ADC values were not useful for predicting the histological grade of EC. Stage IB1 cervical cancer: role of preoperative MR imaging in selection of patients for fertility-sparing radical trachelectomy. Cervical Cancer CONCLUSION. Latest world cancer statistics. WebThe purpose of this review is to highlight the role of cross-sectional imaging techniques in treatment stratification and overall management of patients with endometrial, cervical and ovarian cancers. Stage IIIC disease is characterized by the presence of positive adenopathies (FIGO 2018). Cervical Cancer For women not wishing to preserve fertility, pelvic lymphadenectomy is performed along with modified radical hysterectomy or more radical surgery. sharing sensitive information, make sure youre on a federal The lateral extent of the lesion is no longer considered, cThe notations of r (imaging) and p (pathology) are added to indicate the findings used to assign a case as Stage IIIC. Balleyguier C, Sala E, Da Cunha T, et al. Cervical cancer screening programs have improved detection of early invasive cervical carcinomas in women of childbearing age (1,2).Traditionally, treatment for International Federation of Gynecology and Obstetrics (FIGO) stage IB disease has been radical hysterectomy and pelvic lymphadenectomy with en bloc removal of the uterus and Tumor presence in the lumen of the bladder or rectum is an unequivocal sign of infiltration and should be confirmed by biopsy and histologic analysis (Fig. The mean apparent diffusion coefficient value (ADCmean) on primary cervical cancer is a predictive marker for disease recurrence. They are hyperintense on T2WI and may have variable T1 signals. Materials and Methods: Patients with locally advanced cervical cancer (LACC) treated with concurrent chemoradiotherapy (CCRT) were enrolled. Preservation of a stromal rim thickness of >3mm excludes parametrial involvement (specificity, 9699%; NPV, 94100%) [2, 10, 70, 71]. Method: Twelve pregnant women Methods: Patients with histologically proven LACC, b Sagittal T2WI shows loss of the hypointense rim of the posterior bladder wall suggesting invasion (arrows). The management of CC mainly follows the guidelines for the non-pregnant disease state, expert opi Cervical Cancer: 2018 Revised International Federation of The 2-year, disease-free survival was better predicted by PET evidence of lymph node involvement than by CT findings. Haider MA, Patlas M, Jhaveri K, Chapman W, Fyles A, Rosen B. Adenocarcinoma involving the uterine cervix: magnetic resonance imaging findings in tumours of endometrial, compared with cervical, origin. Cervical Cancer Diffusion-weighted magnetic resonance imaging BIR Publications FOIA Kubik-Huch RA, Weston M, Nougaret S, et al. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. Abstract. Horta H, Cunha TM. McEvoy SH, Nougaret S, Abu-Rustum NR et al (2017) Fertility-sparing for Young patients with gynecologic cancer: how MRI can guide patient selection prior to conservative management. Novel imaging techniques may also provide functional biomarkers with potential relevance for developing more targeted treatment strategies in cervical cancer. Transitional bladder cancer invading the cervix (star), visualized by sagittal T2WI (a), axial oblique T2WI (b), and T2WI+DWI (c). Inada et al. Conclusion: This review offers scientific evidence that led to the recent changes in the cervical cancer staging. High perfusion before and during radiotherapy suggests increased vascularity and high tumor oxygenation, which are both associated with better treatment response and prognosis [5558]. Computed tomography (CT) can detect pathological LNs and metastatic disease beyond the pelvis. Radiology 258:785792. Methods: Using a previously On MRI, adenoma malignum appears as a multicystic lesion with a solid component located in the endocervical glands, which extends to the deep stroma, showing a very high T2 signal and slight hyperintensity on T1WI. Preservation of the fat plane between the tumor and bladder or rectum excludes stage IVA disease. Biopsy was performed 2days before MRI. Vargas HA, Akin O, Zheng J, Moskowitz C et al (2011) The value of MR imaging when the site of uterine cancer origin is uncertain. WebObjective: The aim of this study was to compare magnetic resonance imaging (MRI) with positron emission tomography/computed tomography (PET/CT) in the preoperative detection of lymph node metastases in patients with uterine cervical cancer. However, it is well known that additional clinical For young women desiring fertility preservation and in FIGO stages IA2IB1 (tumors 2cm), radical trachelectomy (VRT, ART, or minimally invasive) may be performed. Recurrence of cervical cancer. The size, location, and extent of cervical tumors can be best evaluated using high-resolution, non-FS T2WI and DWI [10]. The remaining cases comprise rare histological types, including small cell neuroendocrine carcinoma and other epithelial tumors [17, 18]. The role of ultrasound in primary workup of cervical cancer staging (ESGO, ESTRO, ESP cervical cancer guidelines). Dappa E, Elger T, Hasenburg A, Dber C, Battista MJ, Htker AM. Imaging Materials and Methods In this institutional review boardapproved study, 152 consecutive patients with biopsy-proven cervical An official website of the United States government. Before Tumor recurrence typically occurs within 3years after surgery (87%), with the most common recurrence sites being the vaginal vault (42%) and regional lymph nodes (LNs) (46%) [20]. Endometrial-based tumor visualized with sagittal T2WI (a) and sagittal T2WI+DWI (b) was found to be a carcinosarcoma mimicking endometrial carcinoma. Learning objectives Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) 2018 clinical staging of cervical cancer. As a library, NLM provides access to scientific literature. Role Renal abscesses in a 32-year-old woman with cervical cancer who underwent hysterectomy and radiation treatment which were complicated by bowel and renal injury resulting in transverse colon conduit and loop ileostomy. Clin Hemorheol Microcirc. On DWI, they appear as masses with diffusion restriction, usually in the vaginal recess or anastomotic area (secondary to the presence of high cellular and blood content). cervical cancer Thyroid computed tomography imaging: pictorial review The tumor microenvironment (TME) plays a critical role in disease progression and is a key determinant of therapeutic response in cancer patients. Bonatti et al. role Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. FIGO IA endometrial tumor (arrows) with myometrial invasion of <50% is isointense in T2WI images (a) and well-delineated in fused T2WI-DWI images (b). Clipboard, Search History, and several other advanced features are temporarily unavailable. a Axial oblique T2WI. Lin G, Huang YT, Chao A, et al. New FIGO staging includes considerable progress in the incorporation of imaging findings for tumour size measurement and evaluating lymph node (LN) metastasis in addition to tumour Alternatively, the nodes may be assessed using conventional pathologic methods, followed by the radical trachelectomy as a second surgery 1week later [26]. Recurrence risk stratification for locally advanced cervical cancer using multi-modality transformer network. Vaginal infiltration is identified by a hyperintense lesion disrupting the hypointense wall on T2WI and early contrast uptake after contrast administration (Table6) [10, 11, 34]. Kido A, Fujimoto K, Okada T, Togashi K (2013) Advanced MRI in malignant neoplasms of the uterus. Imaging 25) [34]. Appropriate imaging may aid in these decisions. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Endometrial and cervical cancer are the most common gynecologic malignancies in the world. It can be difficult to ascertain by MRI whether the tumor protrudes only into the cervical canal or invades the cervical stroma. in Cervical Cancer cervical cancer These patients may require evaluation by image-guided biopsy or 18FDG PET-CT (Fig. The American College of Radiology recommends MRI as the preferred imaging modality for treatment planning, while the National Comprehensive Cancer Network (NCCN) guidelines advise MRI only in cases of type II endometrial cancer or suspected cervical invasion [28, 29]. Semin Ultrasound CT MRI 10.1053/j.sult.2016.11.005 [. All authors read and approved the final manuscript. Definitive EC diagnosis requires endometrial biopsy or dilation and curettage [3, 8, 27]. MRI in endometrial cancer staging. WebIn order to reduce false positive findings by imaging methods, it is recomended to obtain an ultrasound or CT-guided tru-cut biopsy from any equivocal extrauterine lesion to avoid inappropriate treatment. Here, we propose a On T2WI, uterine serosa invasion appears as an area of intermediate-to-high SI disrupting the normal smooth contour of the outer myometrium. Histologically, type II EC includes grade 3 endometrioid adenocarcinomas and other rare etiologies, such as clear cell carcinoma, undifferentiated serous carcinoma, and carcinosarcoma. DWI and DCE imaging are particularly useful for distinguishing between postradiotherapy soft-tissue thickening and inflammation or recurrent disease [6, 20]. J Comput Assist Tomogr 39(5):661673 [, Fu C, Bian D, Liu F, Feng X, Du W, Wang X (2012) The value of diffusion-weighted magnetic resonance imaging in assessing the response of locally advanced cervical cancer to neoadjuvant chemotherapy. Dynamic contrast-enhanced (DCE) images are obtained using a 3D FS gradient-echo (GRE) T1WI sequence, following intravenous administration of 0.1mmol/kg gadolinium at a rate of 23mL/s. Combining imaging results with clinicopathological parameters and/or biomarkers in nomograms may help to increase the accuracy of predicting LNM in patients with cervical cancer . WebObjective: The aim of this study is to evaluate the accuracy of magnetic resonance imaging (MRI) in the preoperative assessments of primary tumor size, parametrial invasion, and pelvic lymph node metastasis in patients with early-stage cervical cancer. Role of MRI in staging and follow-up of endometrial and cervical Nougaret S, Horta M, Sala E, et al. MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R (2018) Cancer of the cervix uteri. 18FDG PET-CT remains the imaging modality of choice for evaluating LNs and distant disease, having a sensitivity of 96% and specificity of 95% [61]. Furthermore, use of contrast-enhanced CT and FDG PET/CT for detection of distal spread of disease is demonstrated. Cervical Cancer Early Detection, Diagnosis, and Staging The purpose of this pictorial review is to describe magnetic resonance (MR) imaging and positron emission tomography (PET)/computed tomography (CT) assessment of cervical cancer, including indications for imaging, important findings that This review details the instrumentation and clinical testing of devices currently deployed in low-resource locations worldwide. Cervical cancer screening, which usually includes a Pap smear and/or an HPV test, is an important and necessary preventive procedure for women starting at the age of TNM defines only regional lymph nodes, with N0 (i+) indicating isolated tumor cells in regional lymph node(s) no greater than 0.2 mm, and N1 indicating regional lymph node metastasis. Core tip: Although cervical cancer staging is based on clinical assessment, there is a wide use of cross sectional imaging [magnetic resonance imaging, computed tomography (CT), positron emission tomography-CT] in the pre- and post-treatment work up of these patients. CONCLUSION. In T2WI, an EC tumor appears as a diffuse or well-delineated soft tissue mass within the endometrial cavity, which shows heterogeneous intermediate SI relative to the hyperintense normal endometrium and hypointense myometrium. The goal of this study was to evaluate the value of the IR-783 dye, a near-infrared heptamethine carbocyanine, as an imaging agent for rapid detection of human cervical cancer and the underlying mechanism of IR-783 mediated imaging. MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. WebCervical cancer is a significant cause of morbidity and mortality worldwide despite advances in screening and prevention. In low-risk cases, adequate surgical treatment may comprise simple hysterectomy or trachelectomy, with either pelvic lymphadenectomy or SLNB [26]. Andersen EK, Hole KH, Lund KV, et al. During later phases, these tumors may appear hypointense relative to the myometrium. To obtain axial oblique images of a tilted uterus, double oblique images angled in both the sagittal and coronal planes create a true oblique that is exactly orthogonal to the endometrial or endocervical cavities [8]. Endometrial cancer MRI staging: update guidelines of the European Society of Urogenital Radiology. 2). 9.3.1 Imaging Features Considered in the Detection of Cervix Cancer. Abdom Radiol (NY). c, d MRI was performed 6months after surgery, including axial oblique T2WI (c) and coronal MIP-DCE sequence imaging (d). Union for International Cancer Control (UICC). role of imaging Cervical Cancer role Involvement of imaging in An important goal in CC staging is to discriminate early disease (IA and IB stages) that can be treated with surgical resection from more advanced CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases. The risk of pelvic LN involvement increases with greater tumor size, from 6% for tumors with a maximal diameter of <2cm to 36% for tumors with a maximal diameter of >4cm [37]. WebAbstract. The rarity of the disease and lack of randomised control studies have prevented the establishment of treatment guidelines. Recto-sigmoidoscopy and/or cystoscopy may be necessary to determine the tumor origin or to exclude secondary bladder or rectal invasion by CC (Fig. Non-invasive tumor microenvironment evaluation and treatment Recent evidence suggests that sentinel LN biopsy (SLNB), with or without dissection, also has an important role in CC investigation [24, 39]. Recent findings: 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. On the other hand, type II EC affects older women (postmenopause), is more commonly diagnosed at an advanced stage (60%) and can lead to the development of peritoneal carcinomatosis (as also occurs in ovarian cancer). Early diffusion weighted magnetic resonance imaging can predict survival in women with locally advanced cancer of the cervix treated with combined chemo-radiation. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The following possible pitfalls can result in underestimation or overestimation of myometrial invasion (Table5): no detection of isointense tumors on T2WI; poor endometrialmyometrial interface contrast due to the presence of fibroids or adenomyosis (Fig. MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. AlHilli MM, Dowdy SC, Weaver AL, et al. Stage III is now subdivided into three categories. Abstract. Imaging On DCE images, small tumors may show earlier enhancement than adjacent stroma [10, 6466]. Current imaging strategies for the evaluation of uterine cervical cancer. Locally advanced and node-positive cervical cancers are usually treated with external beam radiation therapy and intracavitary brachytherapy with concomitant chemotherapy. Future work should focus on determining the optimal pretreatment imaging for women with cervical cancer and developing guidelines to 10.1007/978-3-540-85689-4_26 Springer-Verlag Berlin Heidelberg. Because of the prognostic significance of LNM in cervical cancer, accurate identification and appropriate treatment of these metastases is crucial. However, as more is known about the natural history of thyroid cancer, the role of imaging is becoming more established. Pitfalls and pearls, Uterus of postmenopausal woman exhibits myomas and FIGO IA endometrial cancer. WebThe role of brachytherapy for the curative treatment of cervical cancer was solidified by the work of Dr Howard Kelly, the Gynecologist-in-Chief at the Johns Hopkins Hospital. 11). Choi HJ, Roh JW, Seo SS, et al. 2023 Mar 6;10(3):331. doi: 10.3390/bioengineering10030331. Yellow line indicates the coronal plane, red line indicates the axial oblique plane. The ADC values are significantly lower for EC compared to endometrial polyps and normal endometrium. When large adenopathies are found, inflammatory and infectious diseases (i.e., tuberculosis and HIV) should be excluded. The .gov means its official. MRI is the best method for assessing primary tumors over 10mm in size, since it can accurately determine tumor size, parametrial invasion, pelvic sidewall invasion, and LN metastasis, with up to 95% accuracy for stage IB or higher [2, 10, 11, 26, 33]. d, e DWI (b=1000/ADC map) reveals diffusion restriction of the cervical mass, with extension to the left ureter. According to FIGO staging system 2018, stage IB3-IVA are classified as locally advanced Both images show intracavitary endometrial proliferation that is hyperintense relative to the myometrium. Body diffusion-weighted MR imaging of uterine endometrial cancer: is it helpful in the detection of cancer in nonenhanced MR imaging? The addition of DWI and DCE imaging enables the detection of tumors smaller than 1cm (Table6) [2, 32, 68]. eCollection 2023. Visualization by sagittal T2WI (a) and axial oblique T2WI (b) reveals a large multicystic ovarian mass (white arrow) and endometrial cancer (red arrow). Diagnostic imaging by MRI/TVS/TRS and PET-CT/CT is instrumental for pretreatment staging in uterine cervical cancer and guides optimal treatment strategy. In more advanced stages, the sensitivity for detecting paraaortic node involvement increases to 75%, with 95% specificity [24]. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the management of patients with cervical cancer.