Index terms:

Computed
indications
tomography Computed tomographic evaluation
Uterine neoplasms
computed
metastases
tomographic diagnosis of parametrial extension from
cervical cancer

C. Whitley Vick, M.D.*

&LJ
z James W. Walsh, M.D.*
F-

John B. Wheelock, M.D.t

William H. Brewer, M.D.*

The authors present objective CT criteria for potential use in

evaluating parametrial extension from cervical cancer.

THIS EXHIBIT, A SELECFION OF THE COM-

PUTED TOMOGRAPHY PANEL, WAS DIS-
PLAYED AT THE 69TH SCIENTIFIC ASSEM-
BLY AND ANNUAL MEETING OF THE RADI- Introduction
OLOGICAL SOCIETY OF NORTH AMERICA,
NOVEMBER 13-18, 1983, CHICAGO, ILL!-
NOIS. Therapeutic decisions in cervical cancer are based in pant on the evaluation
of the panametnia for evidence of tumor extension. Radical hysterectomy is generally
reserved for patients with tumor confined to the cervix (Stage I), whereas, radiation
therapy is the treatment of choice for tumors extending to the panametnia or beyond
(Stage JIB or higher). The standard method of assessing the parametnia is the manual
pelvic examination. Although the reliability of manual pelvic examination in
evaluating the panametnia is not precisely known, an accuracy of 92%, compared
to surgical staging has been reported in one study (1). Since it provides detailed cross
sectional images of pelvic anatomy, computed tomography (CT) represents an oh-
jective alternative method for evaluating the panametria in patients with an equivocal
pelvic examination. Unfortunately, previous studies of the reliability of CT for the
evaluation of parametniat extension from cervical cancer report the technique to
be only 30-58% accurate (1-4). With CT, it was not possible to differeniate Stage
From the Department of Radioto-
lB from Stage JIB lesions; and Stage JIB tumors were frequently ovenstaged be-
gy (*) and the Department of Obstetrics
cause of a false positive diagnosis of parametniat tumor extension (1-4). Lack of
and Gynecology (t) Virginia Com-
monwealth University/Medical College detailed knowledge of the CT appearances of normal and pathologic parametnia
of Virginia, Richmond. may have contributed to the inaccuracy of previous CT results. In this study,
Address reprint requests to C. therefore, patients with cervical cancer were examined using 4th generation CT,
Whittey Vick, M.D., Box 615 MCV in an attempt to define CT criteria that would permit one reliably to differentiate
Station, Richmond, VA 23298. a tumor confined to the cervix from a lesion that invades the parametnia.

Volume 4, Number S September 1984 RadioGraphics 787

CT in parametrial extension from cervical cancer Vick et al.

Subjects and Methods

Illustrations were chosen from a total of 35 patients with OH) with a scan duration of 3.3 seconds. Alt patients re-
newly diagnosed, untreated cervical cancer. The status of ceived an intravenous bolus injection of 50 cc of 60%
the parametnia was confirmed by radical hysterectomy (5 Renognafin#{174} (E. R. Squibb & Sons, Princeton, NJ) followed
patients), by parametnial fine-needle aspiration biopsy (6 by a drip infusion of 300 cc of Reno-M-Dip#{174} (Squibb). Ten
patients), by excretory unography (6 patients), or by physical mm thick consecutive sections were made through the pel-
examination (18 patients). The lesions of the patients in- vis, beginning at the symphysis pubis and extending ceph-
eluded in the study were staged as shown in Table I. alad. The procedure was designed to maximize myometrial
CT scans were performed on either a 600 SDTM or a enhancement after the administration of contrast medium
1200 SX scanner (Picker International, Highland Heights, and to opacify the pelvic ureters and blood vessels.

TABLE I

Number Number
Clinical of Clinical of
Stage Definition Patients Stage Definition Patients

lB (Occult cancer): Frank invasion recognized histologically but 9 lIlA Involvement of the lower third of the vagina but not out 1
not clinically. All other cancers limited to the uterus. to the pelvic sidewall if the parametria are involved

IA Involvement of the vagina but no evidence of parametrial 3 lllB Involvement of one or both parametria out to the sidewall 8
involvement

lB lnfiftration of the parametria but not out to the sidewall 10 VA Involvement of the mucosa of the bladder or rectum 2

IVB Distant metastasis or disease outside the true pelvis 2

eds. Gynecology and obstetrics; health care of women. 1978,

F1GOstaging of cervical cancer. (Abridged from DiSala PJ. The cervix. In: Romney SI, ay
ed. 2, New York, Mcaw-HiII
.tJ, Little AB, et al,
Book Co.)

Normal Anatomy

The uterus is divided structurally and functionally into the lateral margins of the cervix and upper one-third of the
the body (conpus) and the cervix. The parametrium consists vagina. Like the broad ligament, it extends laterally to the
of connective tissue that is contiguous with the lateral aspects pelvic sidewall.
of the uterine body and cervix, and lies between the leaves The pelvic ureter ties within the extnapenitoneal con-
of the broad ligament. nective tissue in the lower and medial parts of the broad
The broad ligament is a sheet-like double fold of ligament. The distal ureter passes through the cardinal
penitoneum that is draped oven the uterus and extends tat- ligament approximately 1-2 cm from the lateral margin of
enally to the pelvic sidewall. Between the leaves of the broad the cervix and then courses anteriorly to the vaginal fonnix
ligament are found in addition to the parametnium, the before entering the bladder.
uterine and ovarian vessels, the fallopian tube, and the round The uterosacral ligament attaches to the postenolatenal
ligament. aspect of the cervix and to the lateral vaginal fonnix and
The cardinal ligament is composed of fibrous and fatty extends in an are-like curve posteriorly to the sacnum.
connective tissue situated at the base of the broad ligament. Connective tissue of the utenosacnat ligament blends ante-
It is considered to be pant of the panametnium attached to nionly with that of the cardinal ligament.

788 RadioGraphics September 1984 Volume 4, Number 5

 CARDI\AL
hG AMEN T

J-CERVIX
- a LEFROSACR\h
. LICAME\T

ANTERIOR TRANSVERSE POSTERIOR

VIEW VIEW VIEW

; - j-_
CT in parametrial extension from cervical cancer Vick et at.

Normal Anatomy

Figure 3
Normal transaxial pelvic anatomy
This CT scan through the uterine
corpus (U) shows the normal tnian-
gular broad ligament (arrows) ta-
pening towards the pelvic sidewalls.

Figure 4
Normal transaxial pelvic anatomy
This CT scan through the cervix (C)
and bladder (B) shows the normal
cardinal ligaments (arrows) extending
laterally from the cervix.

790 RadioGraphics September 1984 Volume 4, Number 5

 - :#{149}

- CT inirametrial extension from cervical cancer

. .

-p Normat Anatomy

Figure 5
Normal transaxial anatomy of the
parametria This CT scan through a
tumor (T) confined to the cervix
shows the normal utenosacral liga-
ments (small straight arrows). The
normal distal ureters (large curved
arrows) are surrounded by fat (the
peniureteral fat planes). Small, opac-
ified paracervical vessels are seen
between the ureters and uterosacral
ligaments.

Figure 6
Stage lB cervical cancer This CT
scan through a small cervical cancer
(cursor) shows smooth peripheral
cervical margins and a normal pen-
uretenal fat plane on the patients left
(straight arrow). The panametnia were
normal at radical hysterectomy.

791
CT in parametrial extension from cervical cancer Vick et at.

Tumor Confined to the Cervix

Figure 7
Stage lB cervical cancer This CT
scan through a cervical cancer (T)
shows smooth cervical margins and
normal panametnial fat containing
small soft tissue structures nepre-
senting normal blood vessels. A tam-
pon within the vaginal fornix (arrow)
is displaced to the right by the pars
vagina/is of the cervix; i.e. that part
,

of the cervix that protrudes into the

upper vagina. The parametnia were
normal at radical hysterectomy.

Figure 8
Stage lB cervical cancer This CT
scan through an enlarged cervix
containing relatively lucent tumor (T)
demonstrates a smooth left lateral
margin and minimal irregularity of the
right lateral margin (black arrow). The
distal uretens (u) and peniuneteral fat
planes are normal bilaterally. Small
paracenvical vessels are seen within
the parametnial fat posterior to the
unetens. The normal inferior gluteal
vessels (ig), branches of the internal
iliac artery and vein, are seen adja-
cent to the pinifonmis muscles bilat-
erally. Radical hysterectomy con-
firmed the presence of tumor con-
fined to the cervix.

792 RadioGraphics September 1984 Volume 4, Number 5

Vick et at. CT in parametrial extension from cervical cancer

Figure 9
Stage lB cervical cancer This CT
scan through an enlarged cervix with
a low attenuation tumor (T) shows
minimal irregularity of the right lateral
cervical margin (black arrow) and a
smooth left lateral margin. Small soft
tissue structures representing normal
vessels are seen adjacent to both
distal ureters (u). The tumor was
confined to the cervix at radical hys-
terectomy. B = bladder

Figure 10
Stage lB (surgical) Stage IIB (CT)
cervical cancer CT scan through a
cervical tumor (T) of varied attenua-
tion shows obliteration of both lateral
cervical margins by soft tissue opa-
cities in both parametnia (arrows). At
radical hysterectomy, the parametnia
were free from tumor. The false pos-
itive CT findings were due to previous
uterine instrumentation resulting in
perforation and subsequent inflam-
matory response.

Volume 4, Number S September 1984 RadioGraphics 793

CT in parametrial extension from cervical cancer Vick et at.

Parametrial Tumor Invasion

Figure 11
Stage IIB cervical cancer This CT
scan through the cervix (C) and upper
vagina (V) demonstrates subtle CT
findings of early parametnial tumor
invasion. The night lateral border of
the cervix is irregular and linear soft
tissue strands extend into parame-
trial fat (arrow). Pelvic examination
corroborated the CT findings of night
parametnial tumor extension.

Figure 12
Stage IIB cervical cancer This CT
scan at the level of the uterine corpus
(U) shows irregularity of both lateral
uterine margins and prominent linear
soft tissue opacities within parauter-
me fat causing partial obliteration of
both peniureteral fat planes (arrows).
Fine needle aspiration biopsy of the
parametnia yielded squamous canci-
noma on the left and was non-diag-
nostic on the right. Pelvic examina-
tion indicated bilateral parametnial
tumor extension. An incidental finding
is a calcified uterine Ieiomyoma (L) on
the left. B = top of bladder

794 RadioGraphics September 1984 Volume 4, Number 5

CT ii narametrial extension from cervical cancer

Figure 13
Stage IIB cervical cancer This CT
scan through the uterine corpus (U)
shows an irregular night lateral uter-
me bonder and prominent linear soft
tissue shadows extending into
parautenine fat. A small parametnial
soft tissue mass (arrow) appears to
be formed by confluence of the linear
strands. Fine needle aspiration of the
night parametnium showed squamous
carcinoma.

Figure 14
Stage 118 cervical cancer Four se-
quential CT scans through a large, low
attenuation cancer show eccentric
tumor growth into the night paname-
tnium (t) and loss of the night pen-
ureteral fat plane (arrows). The distal
left ureter is normal. Pelvic examina-
tion demonstrated right parametnial
tumor extension.

795
CT in parametrial extension from cervical cancer Vick et at.

Parametriat Tumor Invasion

Figure 15
Stage IIIB cervical cancer This CT
scan through the cervix (C) shows an
irregular right lateral cervical margin
and prominent, confluent parametnial
soft tissue shadows obliterating the
right peniuretenal fat plane (arrow).
An excretory urognam demonstrated
right hydronephrosis with partial ob-
struction of the distal ureter at this
level.

Figure 16A & B

Stage IIIB cervical cancer Se-
quential CT scans through the uterine
corpus (Figure 16A) and cervix (Fig-
ure 16B) show a tumor of varied at-
tenuation involving the cervix (C) and
uterine body (U). The lateral margins
are irregular, and prominent param-
etnial soft tissue shadows partially
obliterate both peniuneteral fat planes
(small arrows, Figure 16A) and the
margins of the inferior gluteal vessels
at the posterolateral pelvic sidewalls
(ig, Figure 16A). Confluent parame-
trial soft tissue shadows form a mass
extending to the night pelvic sidewall
(large arrow, Figure 16B). Excretory
urography demonstrated bilateral
hydnonephrosis.

796 RadioGraphics September 1984 Volume 4, Number 5

Vick et at. CT in parametrial extension from cervical cancer

Figure 17A
Stage IVA cervical cancer Four se-
quential CT scans through the uterine
corpus show a large low attenuation
tumor extending directly into the
parametnia bilaterally and causing
hydronephrosis (arrows).

Figure 17B
Excretory urognam (left posterior
oblique projection) shows bilateral
hydronephnosis with partial obstruc-
tion of the distal uneters (arrows) due
to parametnial tumor extension.
Cystoscopic biopsy demonstrated
tumor extension into the bladder.

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CT in parametrial extension from cervical cancer Vick et at.

Parametriat Tumor Invasion

Figure 18
Stage IVB cervical cancer This CT
scan through a tumor of varied at-
tenuation involving the uterine corpus
(U) shows direct lateral growth of
tumor into both panametnia obliter-
ating the peniunetenal fat planes (an-
rows). Tumor in the left panametnial
region is contiguous with enlarged left
obturator nodes (n). CT-guided bi-
opsy of an enlarged pana-aontic lymph
node was positive for squamous car-
cinoma.

Conclusion

The normal parametria are seen on CT as regions whose from previous uterine instrumentation may mimic tumor
attenuation is that of fat and that outline the lateral margins infiltration. In equivocal cases, transvaginal, fine needle
of the uterine corpus and cervix. Small blood vessels can be aspiration biopsy may be used for further evaluation prior
seen coursing through the parametnia, and the normal to treatment. More reliable signs of parametniat tumor ex-
uterine ligaments may or may not be visualized. The distal tension recorded by CT include: 1, the presence of a pan-
ureters adjacent to the cervix are normally surrounded by ametrial soft tissue mass and 2, obliteration of the peniuret-
fat, which we have termed the peniureterat fat planes. erat fat planes. These findings presumably indicate ad-
CT findings indicating that a cervical cancer is confined vanced or late parametriat tumor extension; they were not
to the cervix include: 1, smooth lateral cervical margins seen in any of our cases of cancer confined to the cervix.
outlined by parametrial fat; 2, absence of prominent soft This investigation suggests a potential rote for CT in
tissue strands or masses within the parametnial fat, and 3, differentiating normal from abnormal parametnia in cervical
preservation of the peniureterat fat planes. cancer. Based on objective findings, CT potentially can be
The earliest CT findings of parametrial tumor extension used to evaluate the parametria in patients whose pelvic
are: 1, irregularity of the cervical margins and 2, prominent examinations are equivocal or to confirm extracervical ex-
parametriat soft tissue strands. These findings, although tension in patients with suspected advanced disease. The
suggestive of parametriat invasion, are not always reliable accuracy of the staging of cervical cancer on the basis of CT,
and may occasionally be seen when a tumor is confined to employing the objective criteria illustrated here, remains
the cervix. Inflammatory changes in the parametria resulting to be assessed.

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Vick et at. CT in parametrial extension from cervical cancer

References

1. Grumbine FC, Rosenshein NB, Zerhouni EA, Siegetman SS.

Abdominopetvic computed tomography in the preoperative
evaluation of early cervical cancer. Gynecol Oncol 1981; 12:
286-290.
2. Walsh JW, Gopterud DR. Prospective comparison between
clinical and CT staging in primary cervical carcinoma. AJR
1981; 137:997-1003.
3. Whittey NO, Brenner DE, Francis A, et at. Computed tomo-
graphic evaluation of carcinoma of the cervix. Radiology 1982;
142:439-446.
4. Vittasanta U, Whittey NO, Haney PJ, et al. Computed tomog-
raphy in invasive carcinoma of the cervix: An appraisal. Obstet
Gynecot 1983; 62:218-224.

The authors acknowledge with gratitude the assistance of

Pauline E. Friedman in the preparation of this manuscript.

Volume 4, Number 5 September 1984 RadioGraphics 799