Open Journal of Radiology, 2012, 2, 81-91 Published Online September 2012 (
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
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
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
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-
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
opyright © 2012 SciRes. OJRad
(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
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 .
(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.
[1] C. Balleyguier, E. Sala, T. Da Cunha, et al., “Staging of
Uterine Cervical Cáncer with MRI: Guidelines of the Eu-
ropean Society of Urogenital Radiology,” European Ra-
diology, Vol. 21, No. 5, 2011, pp. 1102-1110.
[2] C. Haie-Meder, B. Fevers, E. Fondrinier, M. Haugh, C.
Lhomme and J. P. Guastalla, “SOR Guidelines for Con-
comitant Chemoradiotherapy for Patients with Uterine
Cervical Cancers: Evidence Update Bulletin 2004,” An-
nals of Oncology, Vol. 16, No. 7, 2005, pp. 1110-1108.
[3] A. Sedlis, B. N. Bundy, M. Z. Rotman, S. S. Lentz, L. I.
Muderspach and R. J. Zaino, “A Randomized Trial of
Pelvic Radiation Therapy versus no Further Therapy in
Selected Patients with Stage IB Carcinoma of the Cervix
after Radical Hysterectomy and Pelvic Lymphadenec-
tomy: A Gynecologic Oncology Group Study,” Gynecol-
ogy Oncology, Vol. 73, No. 2, 1999, pp. 177-183.
[4] P. G. Rose, “Concurrent Chemoradiation for Locally
Advanced Carcinoma of the Cervix: Where Are We in
2006?” Annals of Oncology, Vol. 17, Suppl. 10, 2006, pp.
x224-x229. doi:10.1093/annonc/mdl264
[5] S. Nag, H. Cardenes, S. Chang, et al., “Proposed Guide-
lines for Image-Based Intracavitary Brachytherapy for
Cervical Carcinoma: Report from Image-Guided Brachy-
therapy Working Group,” International Journal of Radia-
tion Oncology Biology Physics, Vol. 60, No. 4, 2004, pp.
1160-1172. doi:10.1016/j.ijrobp.2004.04.032
[6] H. Janaki, C. Zsolt, B. Péter, et al., “Application of MRI
for Improved Local Control in Complex Radiotherapy of
Cervical Cancer,” Archives of Oncology, Vol. 14, No. 3-4,
2006, pp. 95-100. doi:10.2298/AOO0604095H
[7] C. Le Pechoux, Y. Akine, M. Sumi, et al., “High Dose
Rate Brachytherapy for Carcinoma of the Uterine Cérvix:
Comparison of Two Different Fractionation Regimens,”
International Journal of Radiation Oncology Biology
Physics, Vol. 31, No. 4, 1995, pp. 735-741.
[8] J. C. Lindergaard, J. Overgaard, S. M. Bentzen, et al., “Is
There a Radiologic Basis for Improving the Treatment of
Advanced Cervical Cancer?” Monographics National
Cancer Institute, Vol. 21, 1996, pp. 105-112.
[9] P. J. Eifel, “High Dose-Rate Brachytherapy for Carci-
noma of the Cervix: High Tech or High Risk?” Interna-
tional Journal Radiation Oncology Biology Physics, Vol.
24, No. 2, 1992, pp. 383-386.
[10] F. D. Patel, S. C. Sharma, P. S. Negi, et al., “Low Dose
Rate versus High Dose Rate Brachytherapy in the Treat-
ment of Carcinoma of the Uterine Cervix: A Clinical Tri-
al,” International Journal Radiation Oncology Biology
Physics, Vol. 28, No. 2, 1994, pp. 335-341.
[11] C. Orton, “HDR: Forget Not ‘Time’ and ‘Distance’,”
International Journal of Radiation Oncology Biology
Physics, Vol. 20, No. 5, 1991, pp. 1131-1132.
[12] R. Potter, T. H. Knocke, C. Fellner, et al., “Definitive
Radiotherapy Based on HDR Brachytherapy with Iridium
192 in Uterine Cervix Carcinoma: Report on the Vienna
University Hospital Findings (1993-1997) Compared to
the Preceding Period in the Context of ICRU 38 Recom-
Copyright © 2012 SciRes. OJRad
Copyright © 2012 SciRes. OJRad
mendations,” Cancer Radiotherapie, Vol. 4, 2000, pp.
[13] V. Viswanathan, J. Dimopoulus, C. Kirisits, et al., “Com-
puted Tomography versus Magnetic Resonance Imag-
ing-Based Contouring in Cervical Cancer Brachytherapy:
Results of a Prospective Trial and Preliminary Guidelines
for Standardized Contours,” International Journal Radia-
tion Oncology Biology Physics, Vol. 68, No. 2, 2007, pp.
491-498. doi:10.1016/j.ijrobp.2006.12.021
[14] E. A. Barnes, G. Thomas, I. Ackerman, et al., “Prospec-
tive Comparison of Clinical and Computed Tomography
Assessment in Detecting Uterine Perforation with Intra-
cavitary Brachytherapy for Carcinoma of the Cervix,” In-
ternational of Journal Gynecological Cancer, Vol. 17,
No. 4, 2007, pp. 821-826.
[15] A. N. Viswanathan, B. M. Buttin and A. M. Kennedy,
“Oncodiagnosis Panel 2006: Ovarian, Cervical and En-
dometrial Cancer,” Radiographics, Vol. 28, No. 1, 2008,
pp. 289-307.
[16] C. Kirisits, S. Lang, J. Dimopoulos, D. Berger, D. Georg
and R. Pötter, “The Vienna Applicator for Combined In-
tracavitary and Interstitial Brachytherapy of Cervical
Cancer: Design, Application, Treatment Planning, and
Dosimetric Results,” International Journal Radiation
Oncology Biology Physics, Vol. 65, No. 2, 2006, pp. 624-
630. doi:10.1016/j.ijrobp.2006.01.036
[17] C. Haie-Meder, R. Pötter, E. Van Limburger, et al., “Gy-
naecological (GYN) GEC-ESTRO Working Group. Re-
commendations from Gynaecological (GYN) GEC-ES-
TRO Working Group (I): Concepts and Terms in 3D Im-
age Based 3D Treatment Planning in Cervix Cancer Bra-
chytherapy with Emphasis on MRI Assessment of GTV
and CTV,” Radiotherapy and Oncology, Vol. 74, No. 3,
2005, pp. 235-245.
[18] R. Pötter, C. Haie-Meder, E. Van Limbergen, et al.,
“Recommendations from Gynaecological (GYN) GEC
ESTRO Working Group (II): Concepts and Terms in 3D
Image-Based Treatment Planning in Cervix Cancer Bra-
chytherapy-3D Dose Volume Parameters and Aspects of
3D Image-Based Anatomy, Radiation Physics, Radiobi-
ology,” Radiotheraphy & Oncology, Vol. 78, No. 1, 2006,
pp. 67-77. doi:10.1016/j.radonc.2005.11.014
[19] The Royal College of Radiologists, “Implementing Image
Guided Brachytherapy for Cervix Cancer in the United
Kingdom,” 2008.
[20] A. K. Berthelsena, J. Dobbsb, E. Kjell, et al., “What’s
New in Target Volume Definition for Radiologists in
ICRU Report 71? How Can the ICRU Volume Defini-
tions Be Integrated in Clinical Practice?” Cancer Imaging,
Vol. 7, No. 1, 2007, pp. 104-116.
[21] J. C. Dimopoulos, G. Shard, D. Berger, et al., “System-
atic Evaluation of MRI Findings in Different Stages of
Treatment of Cervical Cancer: Potential of MRI on De-
lineation of Target, Pathoanatomic Structures, and Organs
at Risk,” International Journal Radiation Oncology Bi-
ology Physics, Vol. 64, No. 5, 2006, pp. 1380-1388.
[22] W. Irvin, L. Rice, P. Taylor, W. Anderson and B.
Schneider, “Uterine Perforation at the Time of Brachy-
therapy for Carcinoma of the Cervix,” Gynecology On-
cology, Vol. 90, No. 1, 2003, pp. 113-122.
[23] C. J. McGinn, J. A. Stitt, D. A. Buchler and T. J. Kinsella,
“Intraoperative Ultrasound Guidance during High Dose
Rate Intracavitary Brachytherapy of the Uterine Cervix
and Corpus,” Endocurie Hyperthermial Oncology, Vol. 8,
1992, pp. 101-104.
[24] I. Ogino, T. Kitamura, N. Okamoto, et al., “Late Rectal
Complications Following High Dose Rate Intracavitary
Brachytherapy in Cancer of the Cervix,” International
Journal Radiation Oncology Biology Physics, Vol. 31,
No. 4, 1995, pp. 725-734.
[25] P. Narayanan, M. Nobbenhuis, K. M. Reynolds, et al.,
“Fistulas in Malignant Gynecologic Disease: Etiology,
Imaging and Management,” Radi ographics, Vol. 29, 2009,
pp. 1073-1083. doi:10.1148/rg.294085223
[26] J. S. Berek, C. Howe, L. D. Lagasse and N. F. Hacker,
“Pelvic Exenteration for Recurrent Gynecologic Malig-
nancy: Survival and Morbidity Analysis of the 45 Year
Experience at UCLA,” Gynecology Oncology, Vol. 99,
No. 1, 2005, pp. 153-159.
[27] P. Beddy, R. Deepa Rangarajan and E. Salas, “Role of
MRI in Intracavitary Brachytherapy for Cervical Carci-
noma: What the Radiologist Needs to Know?” American
Journal of Radiology, Vol. 196, 2011, pp. 341-347.
GEC-ESTRO : Groupe Eur opéen de Curiethérapie;
ABS: American Brachytherapy Society;
GTV: Gross Target Volume;
CTV: Clinical Target Volume;
OAR: Organs at Risk;
TV: Planning Target Volume;
MDCT: Multidetector CT;
MIP: Maximum Intensity Projection;
VR: Volume Rendered;
U: Uterus;
B: Bladder;
R: Rectum;
V: Vagina.