Cervical cancer represents the fourth-most common cancer in women and the leading
gynaecologic malignancies, accounting approximately 570,000 cases and 311,000 deaths in
2018 worldwide. In Europe, during last years, both mean age of pregnant women and number
of nulliparous women have increased (2). Age-specific incidence data indicate that 43% of
patients with cervical cancer have less than 45 years. As consequence, numerous young
women diagnosed with cervical cancer are still desiring to become pregnant.
In women with early-stage cervical cancer (ECC), fertility-sparing surgery techniques
include laparoscopic, abdominal or vaginal radical trachelectomy (RT) and cold knife
conization (CKC) with or without pelvic lymph nodes dissection. Currently, RT is proposed
as fertility-sparing surgery (FSS), alternative to radical hysterectomy, in patients with
ECC staged IA1-IB1, as by the 2018 International Federation of Gynecology and Obstetrics
(FIGO) classification. According to a recent metanalysis, RT and CKC present similar
oncologic outcomes in terms of recurrence rates but CKC presents better obstetrical
outcomes in terms of pregnancy rate (36% for CKC vs. 20% for RT) . NCCN suggested RT as
an alternative to radical hysterectomy (RH) in young women desiring to preserve fertility
with: disease limited to cervix, tumor size < 2 cm (or < 2.5 cm if exophytic lesion),
absence of parametrial extension, an estimated distance of ≥ 1 cm from the proximal
aspect of the tumor to the internal os, absence of lymphadenopathies or metastatic
disease. Some authors have proposed neoadjuvant chemotherapy (NACT) followed by CKC as a
safe and effective approach in ECC FIGO stage IB2.
In 2018 FIGO staging was revised allowing the use of any of the imaging modalities (i.e.
ultrasound, CT, MRI, positron emission tomography (PET)), to provide information on tumor
size, nodal status, and local or systemic spread. MRI is reported to be very accurate in
selecting patients eligible for FSS, in tumor size evaluation and deep stromal invasion
assessment. In the evaluation of parametrial invasion, the specificity and negative
predictive value of MRI were 97% and 100%, respectively.
Furthermore, MRI has demonstrated very high sensitivity and specificity in assessment of
internal os involvement, 90% and 98% respectively. Moreover, MRI including
diffusion-weighted imaging (DWI) assumes an important role in the evaluation of tumor
response after chemotherapy. In addition, MRI is highly sensitive and accurate (90.7% and
91.7% respectively) in tumor size evaluation after FSS, especially in patients who have
undergone cone biopsy before MRI examination.
The purpose of this study is to investigate the role of MRI, including DWI, in the
staging and evaluation of response to fertility sparing treatment, including both primary
surgery (RT or CKC) or after NACT, followed by CKC, in patients with ECC (FIGO 2018 stage
IB1- IIA1), desiring to preserve their fertility.