Open Journal of Radiology, 2012, 2, 81-91
http://dx.doi.org/10.4236/ojrad.2012.23015 Published Online September 2012 (http://www.SciRP.org/journal/ojrad)
MRI-Brachytheraphy of Cervical Carcinoma
—A Pictorial Review for the Radiologist
M. Jiménez de la Peña1, E. del Cerro Peñalver2, E. Alvárez Moreno1,
R. Cano Alonso1, V. Martínez de Vega1
1Department of Diagnostic Imaging, Hospital Universitario Quirón Madrid, Madrid, Spain
2Department of Radiation Oncology, Hospital Universitario Quirón Madrid, Madrid, Spain
Received May 30, 2012; revised June 29, 2012; accepted July 11, 2012
ABSTRACT
Exact staging of cervical malignant neoplasms is essential in the selection of the most favorable therapy. MR imaging
plays a comprehensive role in primary tumor staging. It monitors response to treatment, detects recurrence and helps in
the planning of radiotherapy. Patients with advanced disease usually receive external-beam radiation therapy followed
by intracavitary brachytherapy with concurrent chemotherapy. Brachytherapy based on cross-sectional imaging, espe-
cially MR imaging, improves local control and overall survival. MRI-based brachytherapy allows accurate positioning
of the probe and the depiction of the tumor volume contour, which also permits individualized treatment planning. In
order to obtain successful radiation treatment, the radiologist must provide the radiation oncologist with adequate
knowledge regarding this technique and its possible complications.
Keywords: MRI-Brachytherapy; Cervical Carcinoma; High Resolution MRI
1. Introduction
Imaging, especially MR imaging studies, has become an
important feature in the clinical assessment of uterine
cervical cancer. Because MR imaging is optimal for the
evaluation of the main progno stic factors and p lanning of
therapeutic strategy, it is now widely accepted as a com-
prehensive part in primary tumor staging, in the moni-
toring of response to treatment, and for detection of re-
currence as well as planning of radiotherapy.
Patients with cervical cancer and stages IB2 (tumors
larger than 4 cm) and following stages commonly receive
chemoradiation therapy and brachytherapy. Brachyther-
apy plays a critical role in the treatment of malignant
cervical tumors, especially in patients with advanced
disease where brachytherapy increases both local control
and overall survival.
In cervical cancer, imaging-guided intracavitary bra-
chytherapy is used for the delivery of high dose radia-
tion to a focal tumoral area through an intrauterine ap-
plicator. Cross-sectional imaging with MR imaging or
CT scan is necessary after brachytherapy probe insertion
to assess the correct location of the app licator. CT studies
are usually enough to delineate the organs at risk. How-
ever, these studies are clearly suboptimal to define the
residual tumor because of its lack of tissue resolution
contrast in the pelvis.
The benefits of MR imaging for brachytherapy plan-
ning are that it provides accurate verification of the ap-
plicator position, identification of the residual tumor and
detection of procedure-related complications. On the
other hand, MRI-based brachytherapy provides an op-
portunity for conformal dose distributions to tumor vol-
ume and organs at risk as well as the possibility for dose
escalation leading to improved local control and reduced
toxicity.
This procedure is feasible and efficient in rou tine clin-
ical practice for patients with locally advanced cervical
cancer. Therefore, the radiologist and radiation oncolo-
gist must be familiarized with this increasingly used
therapy.
The purpose of this article is to highlight the knowl-
edge that the radiologist must have regarding the MRI-
guided brachytherapy technique and its possible compli-
cations.
2. Indications
(Chemorradiotherapy followed by brachytherapy is usu-
ally the standard treatment for patients with locally ad-
vanced uterine cervical cancer (>IB FIGO stage) [1],
(Figure 1), but other therapeutics options are possible.
General inclusion criteria are:
 Inoperable Stage IA1 and IA2 cervical cancer patients
C
opyright © 2012 SciRes. OJRad

M. J. DE LA PEÑA ET AL.
82
(a) (b)
(c) (d)
Figure 1. Cervical carcinoma FIGO stages IB, IIA and IIB.
Axial T2-weighted images. (a) Normal “doughnut” ap-
pearance of the uterine cervix with hypointensity of the
cervical stroma and the endocervical canal in the center; (b)
Cervical carcinoma stage IB: an intermediate-high signal
intensity mass causes interruption of the low signal intensity
stromal circumference without parametrial invasion (white
arrow); (c) Cervical carcinoma stage IIA: cervical mass
extending to the upper vagina with stromal invasion; (d)
Cervical carcinoma stage IIB: Parametrial extension of
cervical cancer. The tumor has completely replaced the
posterior cervical stroma and extends into the parametrial
fat (black arrow).
may be treated with tandem-based brachytherapy
alone.
 Inoperable Stage IB1 cervical cancer patients should
be treated radically with b rachyth erapy in conju nction
with external beam radiation.
 Patients in stages IA2, IB1 or IIA cervical cancers,
with absent nodal involvement and bad prognostic
factors (tumors larger than 4 cm, invasion of more
than one third of the stroma and lymphovascular in-
vasion), may benefit from adjuvant radiation treat-
ment to reduce the local recurrence rate [1,2].
 Patients in stages IIB-IVA usually receive 5 weeks of
daily external-beam radiation therapy followed by
brachytherapy with concurrent chemotherapy [3].
 Stage IVB cervical cancer may be palliatively treated
with brachytherapy with or without external beam to
decrease the risk of severe hemorrhage or other life
threatening symptoms.
Contraindications to brachytherapy treatment are prior
pelvic radiation with brachytherapy and life expectancy <6
months [4].
3. Technique and Imaging Protocol
3.1. Mri-Brachytherapy Probe Insertion
The brachytherapy applicator is inserted by direct vision
into the vagina while the patient is under general anes-
thesia. The patient is then brought to the MR imaging
room for study.
The most common applicator systems used are called
tandem and colpostats with ovoids, tandem and rings and
tandem and cylinder. We normally used the Fletcher Suit
Dèclos tandem and ovoid applicator (Figure 2). Tan-
dems are available in a variety of curvatures to avoid the
complications from the uterine topog raphy. The colpo stat
has a diameter of 1.5 cm that can be increased by the
addition of plastic caps, covering th e entire upper vagina.
The tandem provides intrauterine radiation and the ovo-
ids deliver radiation directly to the cervix and the upper
vagina (Figure 3). When the lower third of the vagina is
involved, an interstitial implant or a cylinder applicator
with tandem is recommended [5].
Surgical packing is placed in the vagina to avoid va-
ginal lesions during the probe insertion and to hold the
(a) (b)
Figure 2. MRI-compatible brachytherapy probe. (a) Photo-
graph shows a Fletcher-Suit-Dèclos tandem and ovoid ap-
plicator; (b) Frontal and lateral views of 3D MDCT recon-
structions of the applicator.
(a) (b)
Figure 3. Brachytherapy applicator in place. (a) Schematic
diagram showing the applicator position within the uterus
(U) and its relations with the bladder (B), rectus (R) and
vagina (V); (b) Sagittal T2-weighted image shows the tip of
the applicator (white arrow) in the uterine cavity, the ovo-
ids (white dot) in the cervix and a urinary catheter in the
bladder (B).

M. J. DE LA PEÑA ET AL. 83
applicator in place.
The radiation source may be either a high dose-rate as
iridium-192 or low dose-rate as cesium-137 source. Treat-
ment results with low and high dose rates are equivalent in
terms of local control and overall survival [6-9]. High
dose-rate brachytherapy has gained much attention as an
alternative to traditional low dose-rate brachytherapy for
cervical cancer because it causes minimal dislocation of
the applicators and treatment can be performed on an
outpatient basis [10,11]. On the other hand, chemother-
apy may be given with low dose-rate brachytherapy, but
generally, it is not administered on the days of high
dose-rate brachytherapy.
3.2. Imaging Protocol
Those oncological radiology units that do not have ac-
cess to MR imaging for planning radiotherapy generally
use high resolution CT-based brachytherapy. The CT
images are sufficient to describe possible complications
related to the position of the applicator and to define the
organs at risk. However, they are clearly suboptimal to
delineate the contour of the residual tumor after external
radiation [12,13] (Figure 4).
The MRI-brachytherapy is routinely performed in our
center. The patients are imaged on a 1.5 T (Signa GE,
Milwaukee) with an 8-channel cardiac array coil. Images
are obtained in sagittal, coronal and axial p lanes from the
promontorium to the vulva with the applicator and the
patient in the treatment position .
The MR imaging protocol used in our patients is mainly
high resolution T2 weighted sequences (TE: min, TR:
4800; FOV: 2 8, thickness: 3 mm, matrix 256 × 2 56). We
routinely obtain a pre-implant study that has great rele-
vance because it can identify the residual tumor, which
will appear as a hypointensity mass in T2-weighted se-
quences within the endocervical cavity or as a loss of the
hypointensity cervical stroma. In this pre-implant MR-
study we also performed a diffusion-weighted imaging
sequence (TE: min, TR: 6000; FOV: 128; matrix: 128 ×
128; thickness: 3 mm; B: 600), which identify the resid-
ual tumor as a reduced diffusivity mass (Figure 5). In
addition, this pre-implant study not only makes it possi-
ble to measure the cervicouterine angle and the length of
the uterine cavity, but is also helpful for the correct
placement of the probe.
When the applicator is in place, the patient is brought
to the MR imaging room. The post-implant MR imaging
protocol used only high resolution T2-weighted se-
quences with the same MR imaging parameters. The
brachytherapy probe causes paramagnetic artifacts on the
diffusion images, so that the sequence is not useful in this
MR imaging control study. Respiratory movements arti-
facts are also common due to patient anxiety.
(a) (b)
Figure 4. CT-based brachytherapy. (a) Sagittal maximum
intensity projection (MIP) view of the applicator and (b) 3D
volume rendered (VR) multidetector (MDCT) image. CT
scan can identify both the metallic structure and the dispo-
sitive location. The residual tumor cannot be visualized.
Tandem (white arrow); ovoids (black dots).
(a) (b)
(c)
Figure 5. Cervical carcinoma stage IIB. Pre-treatment MRI
study. (a), (b), (c) Axial T2, axial diffusion and sagittal T2-
weighted images, respectively show a high-signal intensity
cervical mass extending to the left parametrium.
These post-implant images can ensure the correct po-
sition of the applicator and can also detect the residual
volume tumor and detect possible complications of the
treatment. Axial, coronal and sagittal T1-weighted se-
quences can be obtained when the applicator is not
clearly seen.
3.3. MRI-Brachytheraphy Probe Insertion
The MRI-compatible brachytherapy probe causes little
artifact on spin echo sequences. It appears highly hy-
pointense in all sequences.

M. J. DE LA PEÑA ET AL.
84
The best plane to visualize the tip of the probe is the
sagittal T2-weighted sequence, appearing at the bottom
of the uterine cavity. When the applicator is in the correct
position, the position of the tandem must be clearly seen
at midline and midway between the colpostats that
should be positioned in the fornices on the level of the
tumor. Axial and coronal T2 sequences are also very
useful to identify the correct position of the tandem and
ovoids (Figures 6 and 7). When the implant is in an in-
currect position, the result is decreased rates of local
control and survival [14].
On T2 sequences, anterior and posterior vaginal pack-
ing is observed as a hypointensity mass inside the vaginal
cavity, which should not be misinterpreted as a tumor
(Figure 8).
The advantage of a pre-implant MR imaging acquisi-
tion is that it can identify an excessive angulation of the
cervicouterine transition. This excessive angulation may
lead to some difficulties for correct insertion of the ap-
plicator and finally to perforation of the myometrium.
The marked uterine anteversion is sometimes compen-
sated by the bladder filling an d a pull down maneuver of
the anterior uterine cervix.
(a) (b)
Figure 6. Correct position of the brachytherapy probe. (a),
(b) Sagittal T2-weighted image shows the tip of the tandem
(white arrow) at the bottom of the uterine cavity. Ovoids
(white dots) are placed in the vaginal fornices along the
cervix. U: uterus; B: bladder; R: rectum; V: vagina.
(a) (b)
Figure 7. Correct position of the brachytherapy probe. (a)
Coronal and (b) axial T2-weighted images show the tandem
(white arrow) located in midline and midway between the
colpostats. U: uterus; B: bladder; R: rectum; V: vagina.
(a) (b)
Figure 8. Vaginal packing. (a), (b) Coronal T2-weighted
images identify the low signal intensity of the vaginal pack-
ing (double open white arrow) in the vaginal cavity. Dashed
white arrow: tandem; white dots: ovoids.
When a large part of the tumor component in the cer-
vical cancer is located in the vagina, ovoids are an opti-
mal solution because the ovoid surface covers the whole
vaginal fornix. On the other hand, interstitial needles are
the best therapeutic option for distal vaginal lesions [15].
3.4. Detection of the Residual Tumor
After external radiation treatment, the reduction of the
cervical mass is usually significant on MR images and
the cervical stroma returns to its normal hypointensity.
Small residual lesions are seen as hyperintense lesions on
T2-weighted images and hyperintense on spin echo dif-
fusion weighted images (Figure 9).
Although T2-weighted MR images in axial and sagittal
planes usually depict the residual tumor with the intra-
cavitary device in place (Figure 10), it is convenient to
perform the pre-implant acquisition proposed in our im-
aging protocol, to better detect very small residual tu-
mors after external beam radiation treatment. In our cen-
ter, this procedure is the rule to achieve optimal delinea-
tion of the tumor contour and its relation with the bra-
chytherapy applicator.
4. The Radiation Oncologist’s View
Close collaboration between the radiologist and the ra-
diation oncologist is essential to th e planning of radiation
treatment. Planning must be performed on the three spa-
tial planes because the radiation target is a volume, par-
tially defined by the dates from the diagnostic imaging
modalities (CT scan, MR imaging or PET studies). The
change from 2D to 3D images has been published by
GYN GEC-ESTRO group and the American Image-
Guide Brachytherapy Working Group, who established
the guidelines to define the clinical target volume and to
plan brachytherapy treatment [16,17].
3D-image based MRI-brachytherapy provides proper
information on target, organs at risk and dose volume
histograms [18]. The volumes obtained from MRI-guided
brachytherapy are gross target volume (GTV), clinical

M. J. DE LA PEÑA ET AL. 85
(a) (b)
(c)
Figure 9. Residual tumoral volume. (a) Pre-insertion MR-
study. Radiological findings of abnormal signal intensity of
the right cervical stroma on axial T2-weighted image and (b)
high-signal intensity of the right cervical stroma on diffu-
sion-weighted image are consistent with persistent tumor
(dashed white arrow) after external radiation treatment. (c)
Post-insertion MR-study. Axial T2-weighted image with the
applicator in place (white arrow), allows visualization of the
residual mass.
(a) (b)
(c) (d)
Figure 10. Residual tumoral volume. (a), (b) Pre-insertion
MR-study clearly reveals the residual stromal tumor
(dashed white arrows) as intermediate-signal intensity (c)
MR-imaging based brachytherapy. Sagittal T2-weighted
image with the applicator (white arrow) in a central posi-
tion related to the tumor, which is in direct contact with the
colpostats (white dot); (d) Axial T2-weighted image helps in
the correct identification of the tumor volume.
target volume (CTV) and organs at risk (OAR) (Figure
11). GTV corresponds to the gross palpable or visible/
demonstrable extent and location of the malignant growth
(a) (b)
(c) (d)
Figure 11. Target volume radiation (a), (b) Sagittal and
axial T2-weighted images of the diagnosis MR study of a
bulky endocervical tumor in stage IB2; (c), (d) Sagittal and
axial T2 weighted images with brachytherapy applicator in
place. Great reduction of the tumoral volume after external
beam radiation treatment. GTV (dashed white circle): de-
termines the residual visible tumoral volume; CTV (dashed
orange circle): denotes the GTV plus suspected subclinical
tumor volumes, usually coinciding with the volume of the
tumor at the initial diagnosis; PTV (dashed red circle):
CTV and a margin to account for variations in size, shape,
and position relative to the treatment beam.
and CTV denotes the GTV (when present) as well as
volumes with suspected (subclinical) tumors considered
to need treatment. OARs are normal tissues whose radia-
tion sensitivity may significantly influence treatment
planning. In the case of cervical cancer, these are basi-
cally the bladder and the rectum.
In addition, the planning target volume (PTV) consists
of the CTV and a margin to account for variations in size,
shape, and position relative to the treatment beam.
Therefore, the PTV is a geometrical concept used to en-
sure that the CTV receives the prescribed dose and it is
defined in relation to a fixed coordinate system [19].
Accurate delineation of the tumor contour or GTV is
possible with MRI-brachytherapy, identifying an intra-
luminal cervical mass and/or a loss of the hypointensity
on T2-weighted sequence in cervical stroma. The CTV is
individually tailored taking into consideration the gross
target volume (GTV) in the initial pretreatment MRI-
defined tumor volume. The isodose lines and CTV con-
tours are superimposed for each MR axial image and also

M. J. DE LA PEÑA ET AL.
86
reconstructed in sagittal and coronal planes (Figure 12).
The dose volume h istograms are calculated for the target
volumeand dose volume for the OAR are usually calcu-
lated for the rectum, bladder and sigma [20,21].
MRI-based brachytherapy gives the opportunity for
dose escalation over the tumor area, thus improving local
control without increasing local toxicity to the bladder or
rectum [18].
5. Teaching Points
1) The MRI based brachytherapy images can ensure
not only the correct position of the applicator, but the
detection of the small residual volume tumor and the
possible c omplications of the inse rtion process;
2) An incorrect position of the brachytherapy probe
reduces local control of the tumor and increase the toxic-
ity to the adjacen t tissues;
3) MRI-based brachytherapy is the imaging modality
of choice to delineate the residual volume tumor, which
must be included in the rad iation map. Th e acquisition of
MR images previous of the insertion of the applicator is
crucial to identify small residual tumor;
4) Specialists in diagnostic imaging are important col-
laborators in the contouring process. However, it must be
stressed that in the end, contouring of the volume that is
going to receive the prescribed tumor dose is the respon-
sibility of the radiation oncolo gist.
6. Complications
The goal for the radiation oncologist is to obtain “the
highest probability of cure with the lowest risk of com-
Figure 12. Radiation map. The isodose lines and CTV con-
tours are superimposed for each MR axial image and also
reconstructed in sagittal and coronal planes. The dose vol-
ume histograms are calculated for the target volume and
doses for organs at risk (OAR), usually rectum, bladder and
sigma.
plications.” Early and late sequelae of radiotherapy are
progressively decreasing with modern therapy techniques
and the introduction of pre-implant MR image acquisi-
tion into treatment planning. These have made reduction
in PTV possible and consequ ently a reduction in the lik e-
lihood of complications.
The earlier complication that may appear derived from
the insertion of the brachytherapy probe is uterine perfo-
ration. Medium-long term complications of MRI-based
brachytherapy are vaginal or cervical stenosis, uterine
atrophy, radiation enteritis and colitis, fistulae, proximal
and distal recurrence and minor complications as intrap-
eritoneal free fluid, hydrosalpinx and stress fractures.
6.1. Uterine Perforation
The pelvic tissues are more susceptible to damage after
external beam radiation therapy. Manual insertion of the
applicator can result in a small perforation of the uterine
myometrium, which is usually resolved with conserva-
tive treatment [22]. In our patients, the most common
location of the perforation is the posterior uterine wall,
close to the cervicouterine junction. This complication is
usually derived from an excessive anterior angulation of
the uterus and in the anterior uterine wall (retroflexed or
retroverted uterus) (Figure 13). Bowel perforations are
extremely rare.
If the applicator is properly reposition ed before the in-
itiation of the radiation therapy local control and overall
survival are not affected if the applicator is correctly re-
positioned (Figure 14).
Pre-insertion pre-implant MR image acquisition study
clearly benefits the process (measurement of the length
of the uterine cavity, uterine position, election of the di-
ameter of the applicator), decreasing overall complica-
tion rates. In centers where MR is not accessible for ra-
diation therapy, an alternative method is US-guided in-
sertion to assess the position of the tandem in the center
of the uterine canal [23].
6.2. Focal Stenosis and Atrophy
Cervical stenosis is a common delayed sequelae of the
brachytherapy treatment. On sagittal T2-weighted images,
a hypointense narrow cervical channel with enlargement
of the uterine cavity secondary to the retention of fluids
can be visualized. Vaginal stenosis is also seen in serial
MR imaging controls as a small canal with marked walls
thickening (Figure 15).
There is no reliable evidence to show that routine va-
ginal dilation during or after radiotherapy prevents the
late effects of radiotherapy or improves quality of life,
but some women may benefit from dilation therapy once
inflammation has decreased, usually 2 - 4 weeks after
radiation therapy.

M. J. DE LA PEÑA ET AL. 87
(a) (b)
(c) (d)
Figure 13. Complication:uterine perforation. (a) Sagittal
T2-weighted image identifies the penetration of the tandem
(white arrow) in the myometrium; (b) Sagittal T2-weighted
image reveals posterior uterine perforation with the tandem
close to the bowel loops (dashed white arrow); (c), (d) Ante-
rior uterine perforation visible on sagittal and axial T2-
weighted images, without affection of the posterior bladder
wall.
(a) (b) (c)
Figure 14. Relocation of the brachytherapy applicator. Sag-
ittal T2-weighted images. (a) Pre-implant MR study without
evidence of residual tumor; (b) The tandem (open arrow) is
anteriorly located, perforating the ventral myometrium due
to the marked retroflexed uterus; (c) A relocation was per-
formed, displacing inferiorly the tandem. White dots: col-
postats.
The combination of the external radiation and brachy-
therapy can lead to uterine and ovarian atrophy. Control
MR imaging studies show progressive loss of uterine and
ovarian volume and a cervical effacement (Figure 16).
The clinical importance of this complication is related to
ovarian atrophy in premenopausal young women. An
oophoropex y and ovarian transposition can be performed
(a) (b)
Figure 15. Complication: focal stenosis. Sagittal T2-weighted
images. (a) Cervical stenosis. Wall thickening and low-sig-
nal intensity of the cervix (white arrow) secondary to radia-
tion treatment, without visualization of the endocervical
canal. Uterine cavity distension with retention of fluids
(open white arrow); (b) Vaginal stenosis. Small distal va-
gina with closed of the upper two thirds of the vaginal cav-
ity (dashed arrow).
(a) (b)
Figure 16. Complication: atrophy. (a), (b) Uterine atrophy.
Progressive small uterus is seen on serial sagittal T2-
weighted images with effacement of the cervix.
prior to pelvic radiation to preserve gonadal function.
6.3. Radiation Enteritis and Colitis
Conformal dose brachytherapy has reduced the toxicity
to the rectosigma. However, the majority of the patients
with brachytherapy treatment have undergone previous
external radiotherapy and a common finding is damage
in the mucosa of the bowel loops, rectum, sigma or
bladder. This is frequently a transient disorder, but may
sometimes require hospitalization and surgical interven e-
tion [24]. Acute toxicity is more common with concomi-
tant chemotherapy.
On CT scan or MR imaging, radiation enteritis can be
seen as abnormal distribution and distension of the bowel
loops, thickening of the walls and heterogeneity of the
pelvic fat (Figure 17). Rectosigmoiditis can be seen as
marked wall thickening consistent with a symptomatic
patient (abdominal pain, diarrhea and sometimes bleed-
ing).

M. J. DE LA PEÑA ET AL.
88
(a) (b)
Figure 17. Complication: enteritis. (a) Axial enhanced-CT
image (b) Axial T2-weighted image. Abnormal distribution
and distension of the bowel loops, thickening and post-con-
trast enhancement of the bowel walls (arrows) and hetero-
geneity of the pelvic fat.
6.4. Fistula
Large tumor volumes sometimes require focal increases
in radiation doses, which may lead to these major com-
plications. Furthermore, the tissues around the tumor are
often more friable and therefore are more susceptible to
damage that favors fistulization. Bulky tumor necrosis
secondary to the radiation therapy can also create a direct
communication between any pelvic organ affected by the
tumor.
Vaginal fistula (vesicovaginal, ureterovaginal or rec-
tovaginal fistula) is the most common type of fistula in
cervical malignancies, especially in patient with brachy-
therapy [25]. In the irradiated tissue, the fistulas are
complex, with large or multiple tracts. Less frequent types
of fistulae are enterovesical or enterocutaneous fistulae.
Imaging of the fistulous tracts can be depicted with CT
scan or MR imaging. MR imaging can clearly identify
the fistulous tract on T2-weighted images, where the fis-
tula is typically seen as a high-signal intensity, fluid-
filled communication. Saturation fat and diffusion se-
quences may help identify the small tracts (Figure 18).
Imaging, basically MR imaging, is crucial to differen-
tiate whether the fistula is secondary to treatment effects
or secondary to recurrence. This fact determines what
type of surgery is appropriate: interposition graft, diver-
sion or exenteration techniques. Exenteration is the sur-
gery of choice in local recurrence without affection of the
pelvic side wall [26].
When a communication with the urinary tract is sus-
pected, intravenous contrast uro-CT scan in the excretory
phase may be an excellent imaging modality. Three-di-
mensional CT reconstructions of complex vesicovaginal
fistulas provide the detailed anatomic views that the sur-
geon needs for preoperat ive planning (Figure 19).
6.5. Recurrence
Relapse cervical carcinoma after intracavitary brachy-
therapy can be focal or diffuse. Focal recurrence is seen
(a) (b)
(c) (d)
Figure 18. Complication: vesicovaginal fistula. (a) Sagittal
T2-weighted image evidence a bulky cervical mass invading
the upper vagina (large white arrow) and the bladder wall
(white arrows); (b) Post-brachytherapy treatment. Partial
response with residual cervical tumor extending to the
bladder and the anterior vaginal wall. Sagittal T2-weighted
image depict a small high-signal intensity tract (dashed
white arrow) connecting the vagina and the posterior wall
of the bladder, suggesting a fistula; (c), (d) Post-gadolinium-
enhanced images in sagittal and axial planes show a huge
vesicovaginal fistula secondary to tumoral necrosis.
(b)
(a) (c)
Figure 19. Vesicovaginal fistula. Patient with complete re-
mission after chemoradiation treatment and hysterectomy.
Six months later, persistent vaginal discharge led to the
clinical suspicion of a vesicovaginal fistula. (a) Three di-
mensional-Maximum intensity projection (3D-MIP) recon-
structions (b) Volume Rendering CT images and (c) sagittal
MIP reconstruction in a excretory phase. A large vesico-
vaginal fistulae is shown (white arrows) with a large tract
between the bladder and the upper vagina. The iodated
intravenous contrast filled the vaginal cavity (dashed white
arrow). The distal third of the right ureter is not visualized
secondary to peristalsis.

M. J. DE LA PEÑA ET AL. 89
on T2-weighted images as hyperintense nodular ill-de-
fined endoluminal mass and/or hyperintense lesions blur-
ring the cervical stroma similar to the original tumor.
Other radiological findings suggesting focal recurrence
are marked restricted diffusion on spin echo diffusion
weighted images and early enhanced in dynamic post-
gadolinium sequences (Figure 20). The differential di-
agnosis is nodular post-radiation treatment fibrosis (Fig-
ure 21), appearing as hypointense or hyperintense nodu-
lar lesions, with absent restricted diffusion and progress-
sive gadolinium enhancement, although the definitive
radiological diagnosis is no t always possible.
A distal focal uterine recurrence sometimes occurs in
the limits of the brachytherapy area. A hyperintensity
mass in the uterine cavity can be id entified on sagittal or
axial T2-weighted images with different degrees of
myometrial invasion (Figure 22).
Diffuse recurrence of cervical carcinoma can appear as
multiple pelvic peritoneal implants, enlarged retroperito-
neal enlarged lymph nodes or distant metastases.
6.6. Minor Complications
Coexistent pathological pelvic minor complications [27]
as intraperitoneal free fluid or small hydrosalpinx (Fig-
ure 23) may often develop between the interval of the
external beam radiotherapy and brachytherapy.
Sacral insufficiency fractures are another possible
(a) (b)
(c) (d)
Figure 20. Focal cervical recurrence. Vaginal distension
with sterile gel. (a), (b) Focal ill-defined high-signal inten-
sity mass (white arrow) on sagittal and axial T2-weighted
images; (c) High-signal intensity on diffusion-weighted im-
age and (d) increase nodular uptake of gadolinium contrast
on enhanced sequence, suggesting cervical relapse.
(a) (b)
(c) (d)
Figure 21. Post-brachytherapy treatment fibrosis. Vaginal
distension with sterile gel. (a), (b) Cervical effacement
(dashed white arrow) with diffuse low-signal intensity on
sagittal and axial T2-weighted images; (c) Absence of ab-
normal signal intensity on diffusion-weighted image; (d)
Gadolinium-enhanced image do not show any uptake of
contrast in cervical tissue.
(a) (b)
(c) (d)
Figure 22. Distal uterine recurrence in a patient with a pre-
vious complete regression of a cervical carcinoma after
chemoradiation treatment. (a), (b) Sagittal and axial T2-
weighted images reveal an intermediate-signal intensity
mass in the uterine fundus (white arrows), invading the
myometrium. Retention fluids are seen in the endometrial
cavity (asterisk); (c) The compact mass is highly hyperin-
tense on diffusion-weighted image and (d) enhances par-
tially (white arrow) in post-gadolinium images.

M. J. DE LA PEÑA ET AL.
90
(a) (b)
Figure 23. Hydrosalpinx. (a), (b) Small left hydrosalpinx
(black arrow) is seen on coronal T2-weighted images as a
high-signal intensity fluid filled tubular structure that arise s
from the upper lateral margin of the uterus.
(a) (b)
Figure 24. Sacral insufficiency fractures. (a) Axial T1-
weighted image shows symmetrical low-signal intensity in
both sacral wings; (b) Axial T2-weighted image evidence
bilateral abnormal high-signal intensity secondary to the
medullary edema. Dashed ar rows: fractures lines.
complication derived from the external radiation therapy
that frequently appear at the time of the brachytherapy
treatment. Hyperintensity areas on fat-suppressed T2-
weighted images secondary to edema are clearly visual-
ized in patients with back pain (Figure 24).
7. Conclusions
Brachytherapy increases both local control and overall
survival, especially in patients with advanced disease,
indicating the critical role of brachytherapy in the treat-
ment of malignant cervical tumors.
Dose conformation with MRI-based brachytherapy
improves local control and reduces the rate of complica-
tions. In routine clinical practice, this procedure is feasi-
ble and efficient for patients with locally advanced cer-
vical cancer
The radiologist must be familiarized with this increas-
ingly-used therap y and its possible complications.
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Abbreviations
GEC-ESTRO : Groupe Eur opéen de Curiethérapie;
ABS: American Brachytherapy Society;
GTV: Gross Target Volume;
CTV: Clinical Target Volume;
OAR: Organs at Risk;
P
TV: Planning Target Volume;
MDCT: Multidetector CT;
MIP: Maximum Intensity Projection;
VR: Volume Rendered;
U: Uterus;
B: Bladder;
R: Rectum;
V: Vagina.