This document discusses imaging of malignant lesions of the uterus. It begins by reviewing carcinoma of the cervix, noting that MRI is excellent for defining local tumor extent and metastatic spread. It then discusses endometrial carcinoma, the most common gynecological malignancy in developed countries. Imaging findings on ultrasound, CT, and MRI are presented for staging endometrial carcinoma, from Stage I confined to the uterus to Stage IV with distant metastasis. Other rare malignant lesions of the uterus mentioned include endometrial stromal sarcoma and leiomyosarcoma.

1. Imaging in Malignant
lesions of uterus
Dr. Gobardhan Thapa
Resident, MD Radiodiagnosis
NAMS Bir hospital, Kathmandu

2. Presentation outline
• Relevant anatomy of uterus.
• Carcinoma of cervix.
• Malignant lesions of the
uterine body.
– Endometrial Carcinoma
– Other rare entities.
• conclusions

3. Fig. Female pelvis: sagittal section showing
pelvic floor
Fig. Uterus and fallopian tubes: coronal
section to show blood supply and
ureter relative to uterine artery, cervix
and vaginal fornices.

4. Fig. Support ligaments of female pelvis Fig. Transverse ultrasound of uterus and broad
ligament. The broad ligament is outlined by
fluid, and therefore can be seen The right
ovary lies in its anterior surface.

5. ultrasound
Fig. Ultrasound of uterus and vagina (A) Longitudinal image;
(B) Transverse image; (C) Endovaginal sagittal image The
ultrasound probe is in the posterior fornix of the vagina,
directed anteriorly so that the transducer is parallel to the
long axis of the uterus and cervix .

6. Fig. CECT of female pelvis showing uterus and ovaries.

7. Fig. MRI of female pelvis: (A) transverse T 2 -weighted
image showing lower body of uterus and both ovaries
Note the high signal of endometrium and ovarian
follicles; (B) Sagittal section midline.

8. Gynecological Cancers: epidemiology
in Nepal
Histological patterns of gynecological cancers, Dhakal et al

9. CARCINOMA OF THE UTERINE CERVIX
• Typically in younger women, average age at
onset: 45 years.
Clinical presentation:
• vaginal bleeding
• vaginal discharge
• subclinical: abnormal cervical cancer
screening test

10. Risk factors:
• human papillomavirus (HPV) 16 and 18 infections: for
most types of Ca cervix.
• Multiple sexual partners or a male partner with
multiple previous or current sexual partners.
• Young age at first intercourse.
• High parity.
• Immunosuppression.
• Certain HLA subtypes
• oral contraceptives
• nicotine/smoking

11. Pathogenesis:
• Cervix: endocervix and the ectocervix.
• The ectocervix is covered with stratified
squamous epithelium whereas the endocervix
is covered by columnar mucin secreting
endocervical epithelium.
• The junction of these two epithelia is called
the squamocolumnar junction (SCJ).

12. • During puberty and reproductive
years of a woman, the
squamocolumnar junction moves
up and the epithelium between the
old and the new SCJ is referred to
as the ‘transitional zone’ (TZ).
• most cervical carcinomas originate
in the Transitional Zone.
• Precancerous state of Ca cervix -
cervical intraepithelial neoplasia or
CIN.
• Papanicolaou smear - Screening for
cervical cancer.

13. • Human papilloma virus infection (genotypes
16 and 18 ) - cervical cancer and precancer.

14. Microscopically,
squamous cell carcinoma is most common
followed by adenocarcinoma.
• The squamous cell carcinomas may be
keratinizing or nonkeratinizing and may be
well, moderately or poorly differentiated.
• Adenocarcinoma - Endocervical,
endometrioid and other subtypes.

15. Role of imaging
• Ultrasound – first
line assessment.
• Trans vaginal
ultrasound.

16. • CT: limited use in local staging
• Able to depict extra uterine spread of disease
– enlarged lymph nodes, fistulation into the
bladder or rectum, and distant metastases.
• Contrast CT: variable enhancement.
• Identification of primary cervical tumor often
difficult of CT - 50% of tumors isodense to
cervical stroma.

17. MRI:
• Excellent soft tissue contrast resolution and
• Defines local extent of primary tumor and
metastatic spread.
• Angled trans-axial and sagittal T2 W images
are useful for tumor extension and detection
of cervical cancer.

18. Fig. Correct imaging plane for evaluation of cervical cancer with MR imaging a) Sagittal T2-
weighted image, obtained to localize the cervix, shows an imaging plane (dashed lines) that is
axial to the cervix. (b) MR image obtained in the plane indicated by the dashed lines in a shows
the cervix (TRILAMINAR)as a “doughnut” with the endocervical canal in the center. Normal
cervical stroma is dark on T2-weighted images with a rim of intermediate SI smooth muscle.

19. Cervical cancer:
• appears as T2 hyperintense lesion in T2 hypointense
cervical stroma.
• Mostly isointense in T1 WI
• May demonstrate areas of necrosis or blood products.
• Enlarged barrel shaped cervix with an abnormal
intermediate to high T2 signal intensity mass that
replaces the low signal intensity cervical stroma.
• Tumors enhance earlier than adjacent cervical stroma.
• May be restricted on DWI/ADC maps.

20. Fig. Cervical cancer in a 47-year-old patient. A, T2-weighted image shows a mass
larger than 4 cm in diameter (arrow) in the posterior aspect of the cervix, protruding
into the vagina. The vagina shows high signal intensity (asterisk) due to opacification
with ultrasound gel. The normal low signal intensity of the posterior cervix is replaced
by the intermediate-signal-intensity mass. B, Axial T2-weighted image shows a small
peripheral rim of normal cervical stroma of low signal intensity (arrows), ruling out
parametrial invasion.

22. Stage I.
• A rim of surrounding T2
low-intensity cervical
stroma should remain
intact at this stage to
indicate tumor
confinement within the
cervix.
Fig. Cervical Carcinoma-Stage IA-MR. This T2 WI MR
image was obtained in an oblique coronal plane to the
patient in order to image the cervix in transverse
orientation. The tumor (T) appearing dark gray has nearly
completely replaced the normal cervix seen only as a
black rim (arrowheads). No parametrial invasion is
evident. Free intraperitoneal fluid (ff) is seen in the culde-
sac. B, bladder.

23. Stage II
• extend beyond the uterus and involve the upper two
thirds of the vagina but do not extend to the pelvic
side wall or the lower one third of the vagina.
• Involvement of the upper two thirds of the vagina is
characterized by a T2-hyperintense lesion disrupting
the T2-hypointense vaginal wall.

24. Parametrial invasion
• disruption of the low-signal-intensity cervical stromal
ring, with nodular or irregular tumor extending into the
parametrium.
• Additional features suggesting parametrial invasion
include segmental disruption with a spiculated tumor-
parametrium interface, soft tissue extension into the
parametrium, and encasement of the periuterine
vessels.
• Conversely, parametrial invasion can be confidently
excluded if the T2-hypointense cervical stromal rim is
thicker than 3 mm, with a specificity of 99%.

25. Fig. Cervical Carcinoma---Stage IIB-CT.
Heterogeneous tumor (T) has completely
replaced the cervix on this CT scan. Stranding
densities (arrowheads) into the paracervical
fat indicate parametrial invasion by tumor.
Fig. Parametrial extension of cervical
cancer. T2-weighted MR image shows
that an intermediate-signal-intensity
tumor has replaced all of the normal
low-signal-intensity cervical stroma.
Fingerlike projections of the tumor
(arrows) extend into the parametrial
fat.

26. Stage III
• IIIA, tumors extend to the lower one third of
the vagina but not the pelvic sidewall.
• IIIB - extension to the pelvic sidewall or
involvement of the ureters, which causes
hydronephrosis.

27. Stage IVA:
• local pelvic organ invasion, which is characterized
by infiltration of the rectal mucosa or urinary
bladder.
• T2-weighted images: rectal invasion indicated by
segmental disruption of the hypointense
muscularis layer by the hyperintense tumor.
Stage IVB:
• tumors spread beyond the pelvis to distant
organs.

28. Stage IVA cervical cancer. A, Bulky enlargement of the cervix by a large mass of
intermediate signal intensity is seen on the sagittal T2-weighted image. It extends to the
middle third of the anterior vagina. Disruption of the low signal intensity of the posterior
deep bladder wall and the irregular surface of the bladder (B) wall over a distance of 2.5
cm is shown (arrow). B, Angulated transaxial T2-weighted image shows an enlarged left
iliac lymph node suggestive of metastasis (arrow). Cystoscopy confirmed mucosal bladder
wall invasion.

29. Invasive Cervical Carcinoma
Grossly:
• Polypoid, predominantly exophytic tumors with a
cauliflower-like appearance or may be endophytic,
deeply infiltrative resulting in a hard cervix, which is
only slightly enlarged.
• Evaluation of a surgical specimen - extent of
circumferential involvement, upper and lower limits of
the tumor and depth of stromal involvement.
• As cervical cancer spreads locally into the
parametrium, this also needs careful evaluation.

30. Role of Radiologists
• Imaging more important for staging rather
than detection. {detection: Pap smear}
Checklist for a Ca cervix report:
• Tumor size, depth of stromal invasion,
presence of parametrial invasion,
hydronephrosis, lymphadenopathy, distant
mets.
• MR best for assessment of local tumor extent.
• PET/CT: rapidly upcoming tool

31. Fig. PET image shows uptake in the supraclavicular region
(arrow), a known site of skip metastases from cervical
cancer. PET depicts distant nodal disease that would not be
evident at clinical examination.

32. Imaging of complications of treatment:
• Can be evaluated with CECT.
• MRI to distinguish local recurrence from post
operative scarring and fibrosis.

33. Fig. Radiation enteritis in a patient who was
treated for cervical cancer. Contrast-
enhanced CT scan shows thick-walled small
bowel loops of increased permeability, hence
the ascites.
Fig. Local recurrence after hysterectomy for
cervical cancer. T2-weighted MR image
shows a mass in the anterior vaginal wall
(arrow), a finding that represents a local
recurrence of cervical cancer. The vagina is
distended with surgical lubricant, which
allows better delineation of the walls.

34. Malignant lesions of uterus
• include tumors of the endometrium and of
the myometrium.
• Endometrial cancers include endometrial
carcinoma, endometrial stromal sarcoma and
malignant mixed Müllerian tumors (MMMT).
• Leiomyosarcoma
arises from the smooth muscle of the
myometrium.

35. Endometrial carcinoma
• most common gynecological
malignancy in developed
countries.
• It typically occurs in elderly
postmenopausal women.
• 6 and 7 decades of life, with the
mean age of patients being 65
years.

36. Clinically:
• Abnormal uterine bleeding in a post
menopausal patient.
• Endometrial thickness: if > 4 mm – tissue
biopsy

37. Based on the pathogenesis,
two distinct types are
noted:
• Type I, which occurs in a
background of excess
estrogenic stimulation and
develops against a
background of
endometrial hyperplasia;
and
Type II, which occurs de
novo.
Obesity, hypertension,
diabetes and nulliparity are
risk factors for type I
carcinomas.
Other predisposing
conditions include polycystic
ovarian disease (PCOD),
dysfunctional uterine
bleeding (DUB), long
standing estrogen users,
tamoxifen usage and those
with functioning granulosa
cell tumors.

38. Type I: Endometrioid Adenocarcinoma
Gross appearance:
• polypoidal, predominantly exophytic growth arising
from the uterine cavity or as diffusely infiltrating
tumors.
Microscopically:
• like the usual adenocarcinomas and are divided into
grade I-III tumors based on their degree of
differentiation.
• Aspects to be evaluated:
– depth of myoinvasion.
– vertical extent of involvement and
– involvement of the cervix.

39. Type II Carcinoma
• includes serous carcinoma and clear cell
carcinoma.
• highly aggressive and occur in older women.
Serous carcinoma
• characterized by a complex papillary growth
pattern. The lining cells show moderate to severe
pleomorphism and atypia with mitotic figures
and sometimes psammoma bodies.
• Usually deep myoinvasion is present.

40. Clear cell carcinoma
• composed of large clear cells with distinct
cellular margins and abundant cytoplasm
containing abundant glycogen.

41. Staging and role of imaging

42. Imaging
Ultrasound:
• Vary from moderate
endometrial thickening to
an irregularly hypoechoic
intracavitary mass.
• Enlarged diffusely
infiltrated uterus.
• Endovaginal ultrasound:
good at differentiating early
stage disease.
Fig. TVS: poorly defined intrauterine
mass due to endometrial carcinoma.

43. MRI
• T1 isointense and T2 hypointense relative to
normal endometrium, with relatively less
enhancement compared to normal
myometrium.
• Restricted diffusion on DWI and ADC
mappings.

44. Fig. Endometrial cancer. A, T2-weighted image demonstrates a T2-hypointense mass filling the
majority of the endometrial cavity, which demonstrates T1-isointense signal (B). C, Mild postcontrast
enhancement of the endometrial lesion. D and E, Sagittal DWI and corresponding ADC map
demonstrate restricted diffusion.

45. • Stage I:
• Confined to uterus and further subdivided by
the amount of invasion into the
myometrium( ≤50 % invasion).

46. Fig. Stage IB endometrial cancer in a 68-year-
old female with. (A) Sagittal T2W MR image, (B)
T1W post-contrast image, and (C) DW
image show endometrial tumor with more than
50% of myometrial invasion in the anterior wall
(arrows) indicating stage
IB disease
Fig. Stage IA - Sagittal contrast-enhanced
image 6 minutes after contrast injection
shows a hypointense endometrial tumor
(asterisk) invading the posterior and
anterior myometrium in less than 50% of
the entire myometrial thickness.

47. Stage II:
• Stromal invasion of
cervix
Fig. A 65-year-old female with endometrial
cancer. (A) Sagittal T2W MR image, (B)
T1W post-contrast image, (C) DW
image, and (D) ADC map image show a
large and irregular endometrial mass
(white arrows) which disrupts the cervical
stroma (black arrowheads), but does not
extend beyond the uterus indicating stage
II disease. Note normal posterior
cervical lip (white arrowheads)

48. • Stage III:
• Defined by local or regional tumor spread
beyond the uterus but not outside the true
pelvis
• Further subdivided by the extent of
locoregional invasion and presence of
lymphadenopathy.

49. • IIIA: tumors invade
through the serosa,
disrupts the contour
of the outer
myometrium or
involves the adnexa.
• IIIB: extension into
the parametrium or
vaginal involvement.

50. •IIIC: lymph node
involvement.
•Nodal characters: short
axis > than 10 mm,
multiplicity, irregular
contours, internal
necrosis, or abnormal
signal within the lymph
node that is similar to
the primary tumor.

51. • Stage IV:
• IVA: extension into
normally T2 hyperintense
bladder or rectal mucosa.
• IVB: distant metastasis
includes peritoneal
spread (omental caking,
malignant ascites),
paraaortic
lymphadenopathy, and
inguinal lymph node
metastases.

52. Fig. stage IVB endometrial cancer in 75-year-old
female. (A) Axial contrast-enhanced computed
tomography image of the pelvis
shows the thick hypodense endometrium (black
arrow). (B) Axial contrast-enhanced CT image
shows peritoneal implants
(white arrows) in this patient with clear cell
endometrial carcinoma
Fig. Endometrial cancer in a 71-
year-old female. Sagittal T2W MR
image shows focal loss of low signal
intensity wall of
the bladder (arrow) suggestive of
bladder involvement.

53. Role of radiologists
• Ultrasound (esp. TVS) – acceptable modality
for first line assessment of postmenopausal
bleeding. {endometrial thickness threshold: 5
mm}.
• Sonohysterography: in evaluation of
postmenopausal bleeding with abnormal USG
results with negative blind biopsy.
• CT/MRI – to assess extent of endometrial
cancer esp in locally advanced cases.

54. Follow up imaging:
• CECT: routine surveillance, can demonstrate
ascites, adenopathy and distant mets.
• MR imaging: differentiation of soft tissue
masses from bowel, incisional hernia and
hypertrophic scar.

55. Fig. Tumor recurrence in a patient who underwent hysterectomy for
endometrial cancer. The patient experienced pelvic pain for several
months after surgery; because palpation was compromised by body
habitus, MR imaging was performed to evaluate for recurrence. Sagittal
MR image shows implantation of endometrial cancer (arrowhead) in
the hysterectomy scar.

56. Rare uterine malignancies
• Rare heterogeneous groups of tumors of
mesenchymal origin and represents ~8% of
uterine malignancies.
• Can be classified into
– Epithelial or mixed epithelial-nonepithelial
tumors.
• Leiomyosarcoma: most common pure
histologic subtype

57. Leiomyosarcoma
• occurs in older women
• Grossly is seen as a large fleshy intramural
mass with submucous and subserosal
extension.
• Areas of hemorrhage and necrosis.

58. Microscopically,
• Highly cellular with
large areas of
coagulative tumor
necrosis.
• Cellular atypia is
obvious and mitoses.
Fig. uterine leiomyosarcoma, CT: large
lobulated heterogenous mass lesion seen
replacing uterus, with hypodense necrotic
areas and some calcifications within.

59. • <0.2% - from sarcomatous transformation of a
benign leiomyoma.
MRI:
• Infiltrating heterogeneously enhancing uterine
mass with T1 heterogenously hypointense and
irregular and ill-defined margins.
• T2: intermediate to high signal intensity
• May have areas of central necrosis, hemorrhage
or foci of calcifications.

60. Leiomyosarcoma. T2WI shows a huge heterogeneous tumor mass (arrowheads)
arising from the anterior wall of the retroflexed uterus (arrow). Note that the
uterine cavity is intact. The exophytic myometrial origin and heterogeneity of
the mass is indicative of either a degenerated leiomyoma or a leiomyosarcoma.
The latter diagnosis was confirmed at surgery.

61. Endometrial Stromal Sarcoma
• In the 5th decade of life and present clinically
with vaginal bleeding.
Gross appearance:
• Sharply circumscribed nodule with no
permeation of the surrounding tissue, when
they are designated Endometrial stromal
nodule.

62. Microscopy:
• These tumors are composed of small ovoid
cells resembling the endometrial stromal cells.
• They are individually enveloped by reticulin
fibers.

63. Fig. 42 year old female with endometrial stromal sarcoma
Coronal T2WI showing a large heterogeneous hyperintense mass
in the endometrial cavity extending from the fundal region up to
the vagina, causing distension of the cervical canal (white
arrows). Uterus appears superiorly displaced by the mass.

64. MMMT (malignant mixed mullerian
tumors) Carcinosarcoma
• always seen in
postmenopausal women.
• They present with uterine
bleeding and enlargement.
Grossly,
• soft, polypoidal masses
filling the cavity with areas
of hemorrhage and
necrosis.

65. Microscopically
• admixture of carcinoma and sarcoma-like elements.
• The carcinoma resembles endometrioid, clear cell or
papillary serous types.
• The sarcomatous component may be homologous or
heterologous in nature.
• Homologous refers to a sarcoma resembling
endometrial stromal sarcoma or a spindle cell sarcoma
resembling leiomyosarcoma or fibrosarcoma.
• Heterologous elements may be chondrosarcoma,
osteosarcoma or rhabdomyosarcoma in nature.

66. • MMMTs are highly aggressive neoplasms.
• Extension into the pelvis, lymphatic and
vascular permeation and blood-borne
metastases are common.
• Extension of the tumor to the serosa and
beyond is a sign of even worse prognosis.

67. Müllerian Adenosarcoma
• usually presents in the elderly as a bulky
polypoidal growth filling the endometrial cavity.
Microscopically,
• Epithelial and stromal elements.
• The epithelial component has a benign
appearance whereas the stromal component is
malignant and resembles a sarcoma.
• Müllerian adenosarcoma with a sarcomatous
overgrowth (MASO) is an aggressive variant of
this neoplasm with a poor prognosis.

68. Fig. Müllerian adenosarcoma in a 20-year-old-woman. A, Color Doppler image
showing diffuse enhancement of the uterus. There is a polypoid lesion within the
endometrial canal (arrow). B, T2-weighted MRI showing a polypoid lesion within
the endocervical canal (arrow). There are high T2 signal regions shown within the
thickened junctional zone. C, Contrast-enhanced CT of the uterus showing a
heterogeneous appearance to the uterus with a region of low density and slight
bulging of the surface of the uterus, shown on the right side (arrow).

69. Conclusions
• Diagnostic imaging is critical in the staging of
all gynecologic neoplasms and can help
ensure that the proper therapy is
administered.
• Surgical staging is necessary unless the patient
is not a surgical candidate; that is, if the
performance status is so poor that the patient
could not withstand a laparotomy.

70. References
• Anatomy for diagnostic imaging, 3/e; Ryan
• Diagnostic Imaging Genitourinary imaging, 3/e Berry
series.
• CT and MRI of the whole body, 6/e; John Haaga.
• Ovarian, Cervical, and Endometrial Cancer,
Viswanathan et al, RadioGraphics 2008; 28:289–307.
• Imaging in endometrial carcinoma, Faria et al; Indian
J Radiol Imaging. 2015 Apr-Jun; 25(2): 137–147.