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
Email: cataldo@telefonica.net
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 .
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.