Abstract
Currently, ultrasound (US) is a valuable imaging tool for the initial assessment and evaluation of the female genital organs, uterus, and adnexa. However, it is easy to overlook the uterine cervix while conducting a pelvic US. Uterine cervical lesions may range from benign to malignant in nature. Therefore, meticulous examination with US may play a key role in assessing uterine cervical lesions. Although there is substantial overlap in the US findings across various uterine cervical lesions, some US features, in tandem with clinical characteristics, may suggest a specific diagnosis. Familiarity with the clinical settings and US characteristics of different uterine cervical lesions can support prompt and accurate diagnosis of suspicious lesions. This review article aims to describe the features of US and possible values for distinction of these lesions in the uterine cervix.
Introduction
Ultrasound (US) of the female pelvic region is widely used as the first-line imaging modality to diagnose various uterine and adnexal disorders.1–3 Occasionally, examiners erroneously ignore a lesion in the uterine cervix by focusing only on other parts of the pelvis, such as the endometrium, body of the uterus, and adnexa.2 Magnetic resonance (MR) imaging is an excellent problem-solving imaging modality for visualising normal cervical anatomy and evaluating cervical lesions, such as characterising indeterminate US abnormalities and staging cervical carcinoma.1,2
In this article, we review the normal uterine cervical anatomy and various clinical and US manifestations of uterine cervical lesions. Additionally, we elaborate on the continuum of lesions from benign to malignant in the uterine cervix, and on multilocular cystic lesions as special considerations. Furthermore, we describe the US features that render it possible to distinguish between different lesions in the uterine cervix.
Normal anatomy of the uterine cervix
The uterus is divided into three anatomical sections based on the level of the insertion of the fallopian tubes and internal os: the fundus, body, and cervix (Figure 1). The size and shape of the uterus and cervix depend on the female’s age and hormonal status (Figure 2).1,2 With sexual maturation, the adult uterus acquires a pear-shape, meaning the length of the body is double that of the cervix, with the average length being 5–8 cm. The normal cervix is 2.5–3 cm in length and 2.5 cm in width.2 However, a prepubertal uterus has an inverse pear-shape with a relatively larger cervix (Figure 2). The neonatal uterus is relatively larger in size than the prepubertal uterus because of exposure to maternal hormones during foetal life.1
Figure 1.
Schematic diagram of uterine anatomy and its vascular supply.
Figure 2.
Prepubertal and pubertal uterus (a) Sagittal transabdominal ultrasound obtained in a 7-year-old girl shows a tubular uterus; endometrial lining appears as a thin echogenic line (arrow). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. B: bladder (b) Sagittal transabdominal ultrasound obtained in a 13-year-old girl shows that the fundus is larger than the cervix; the endometrium is well seen (arrow). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. B: bladder
The cervix generally appears cylindrical in shape in the sagittal view, and round-to-ovoid in shape in the axial view of US (Figure 3).2 The uterine cavity extends to the vagina through the endocervical canal (Figure 1). The endocervical canal consists of the inner part of the cervix between the internal and external os, and is lined by columnar epithelium. It is best seen in the sagittal view and typically appears as an echogenic line representing the interface between the anterior and posterior layers of the mucosa (Figure 3).2 Using imaging, this can be used as a reference point to standardize the approach toward recognizing cervical lesions.
Figure 3.
Normal ultrasound appearance of the uterine cervix (a), (b) Sagittal transabdominal ultrasound (a) and transvaginal ultrasound (b) obtained in a 35-year-old female show that the cervix appears cylindrical. The echogenic central line represents the interface between the two mucosal layers. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. B: bladder (c), (d) Sagittal (c) and coronal (d) T2-weighted magnetic resonance images obtained in a 32-year-old female show normal zonal anatomy of the uterus. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. E: endometrium; B: bladder
Normal vascular anatomy of the uterine cervix
The uterine arteries originate from the anterior branch of the internal iliac artery. They ascend on the lateral surfaces of the uterus up to the hilum of the ovary, and then join the ovarian arteries.
On colour Doppler US, little or no vascularization is typically observed in the cervix.2 The uterine arteries are detected with a colour Doppler at the level of the corpocervical junction, i.e., the internal os (Figure 1).4 Usually, they have a high-velocity and high-resistance pattern with an obvious dicrotic notch.4 High-resistance patterns with resistive index values of approximately 0.7 in premenopausal, nonpregnant females and 0.93 ± 0.09 in postmenopausal females are usually observed (Figure 4). In contrast, a low-resistance pattern with a decreasing resistive index occurs with increasing gestational weeks.
Figure 4.
Normal spectral Doppler waveform of uterine cervix (a) Spectral Doppler analysis of the uterine artery at the corpocervical junction (internal os) reveals a high-resistance waveform; the resistive index value is approximately 0.77, with a typical dicrotic notch (arrows) in a 40-year-old premenopausal female. (b) High-resistance waveform uterine artery with resistive index value 0.96 in a 68-year-old postmenopausal female.
Technical consideration of us
Both transabdominal US (TAS) and transvaginal US (TVS) are optimally used for performing female pelvic US examination.1–5 TAS serves to provide a general descriptive view of the pelvic anatomy. TVS offers better anatomical information, tissue characterisation, and evaluation of vascular flow at the cost of a limited field of view.2 In several patients, TAS of the cervix may not provide sufficient spatial resolution to depict cervical disorders; thus, TVS is regarded as the optimal technique (Figure 3).2 To ensure that the entire cervix has been examined completely, the examiner sweeps the US beam through the entire length of the cervix, from the internal os above, to the external os and upper vagina, and sweeps laterally through the cervix to include the parametrial and other adjacent pelvic tissues on TAS and TVS. This allows confident identification of the cervical borders, delineation of the extent of any masses or lesions, and characterisation of pathological processes from areas that may secondarily involve the cervix.2
Three-dimensional US may be especially helpful for evaluation of the cervix to delineate complex anatomic relationships, particularly abnormalities of the Müllerian ducts.2
For identification of solid and vascular masses, routine use of colour Doppler US is important, which can enable the detection of subtle lesions.1,2 When the tumour is hypervascular, tumour growth and progression are based on the process of angiogenesis.6 Tumour vessels appear more dilated, saccular, and tortuous compared to normal vessels. To confirm and further characterise the vascularity identified with colour Doppler US, spectral Doppler US can be added.4
Microvascular imaging and contrast-enhanced US are used to assess the microvasculature. Microvascular imaging provides an outstanding depiction of low-velocity flow without motion artifacts.7 Contrast-enhanced US may help differentiate a potentially benign or malignant lesion with hemodynamic evaluation. Moreover, it can be used as an alternative to contrast-enhanced CT and MRI because of its outstanding safety profile, patient compliance, and absence of issues related to organ dysfunction or radiation exposure.7
Elastography offers information on the tissue stiffness and enables real-time colour-coded visualisation of images. It is classified into strain elastography and shear-wave elastography based on whether an external pressure transducer or internal artificial impulse is used to detect the shear velocity.7 Hard tissues are more resistant to extrinsic compression, whereas soft lesions show greater strain and displacement. It can detect the change in stiffness of the tissues in cervical cancer (Figure 5), estimate the areas of tumour infiltration8 and differentiate benign from malignant disease.8,9 Uterine cervical elastography is also used to predict success of labour induction success.8,10
Figure 5.
Uterine cervical carcinoma (adenocarcinoma) in a 62-year-old female. (a) Colour Doppler ultrasound image shows a heterogeneous echotexture mass (M) with intralesional hypervascularity (asterisk) arising from the cervix. B: bladder (b) Sagittal transvaginal ultrasound and comparable strain elastography show an increased intralesional stiffness (blue coloured), which indicates a hard mass, i.e. malignant tumour. B: bladder
Benign lesions
Congenital cervical anomalies
Clinical features
Congenital cervical anomalies originate from the Müllerian ducts that form the uterus and proximal two-thirds of the vagina.11 Congenital cervical anomalies can be divided into four subtypes: uterine agenesis; uterine duplication anomalies such as septate uterus, bicornuate uterus and uterus didelphys; unicornuate uterus; and arcuate uterus.
US features
The US can easily diagnose congenital cervical anomalies. Imaging should not only focus on conventional imaging of the pelvis, but also include orthogonal images along the long axis of the uterus to characterise the external uterine contours.11 US has a reported pooled accuracy of approximately 90–92%.11
Septate uterus is the most common uterine developmental anomaly and can be detected on US by identification of the septum. Uterus didelphys results from the failed fusion of the Müllerian ducts, resulting in two separate cervices without communication. Cervical duplication is not unique to uterus didelphys and can rarely occur in septate and bicornate uterine configurations as well.2
Cervicitis
Clinical features
Cervicitis is a general term used to describe inflammation in the cervix; it can be acute or chronic and infectious or non-infectious. However, most cases of acute cervicitis occur secondary to an infection.2 Patients usually have purulent or mucopurulent cervical and vaginal discharge and may report pelvic pressure or discomfort.
US features
The cervix shows a diffusely heterogeneous echotexture in patients with acute cervicitis, although the main finding is significantly increased vascularity.2 Although it is not a specific finding, chronic cervicitis has been associated with the presence of small groups of bright dots in the endocervical canal (Figure 6).
Figure 6.
Chronic endocervicitis in a 50-year-old female. Sagittal transvaginal ultrasound shows a multilocular cystic lesion and echogenic foci (arrows) within the uterine cervix. Doppler ultrasound showed no intralesional vascularity (not shown). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown.
Cervical stenosis
Clinical features
Cervical stenosis results from inflammation and fibrosis of the cervical mucosa secondary to infections, iatrogenic causes, or endometriosis. It may also result from secondary stenosis due to the mass effect exerted by cervical polyps or cervical carcinoma.2
US features
The US finding is either normal or a thickening of the endocervical canal with fluid retention in the endometrial cavity.2
Endocervical hyperplasia
Clinical features
Diffuse hyperplasia of the epithelium of the endocervix is usually a non-specific incidental finding, although it can be associated with a watery vaginal discharge. It is frequently seen in females who use oral progestational agents for contraception and females who are pregnant or postpartum.2,12
US features
The US finding is preservation of the overall form and structure of the endocervical canal. The endocervical mucosa may appear diffusely thickened, accentuating the interdigitating branching folds of the plicae palmatae.2
Nabothian cyst
Clinical features
Nabothian cysts are retention cysts that are the most common benign mass-like lesions seen in the cervix.2 They are hypothesised to occur secondary to chronic mild cervical inflammation and are most frequently seen in females in their reproductive years.
Tunnel clusters are a special subtype of nabothian cysts that appear as complex multicystic dilatations of the endocervical glands.12 They are pseudoneoplastic glandular lesions of the cervix that occur in up to 8% of females, most frequently in multigravid females older than 30 years.2
US features
Nabothian cysts are typically seen as echogenic small cysts (usually a few millimetres in size) without vascularity and well-defined margins on US (Figure 7).
Figure 7.
Tunnel cluster in a 41-year-old female. Colour Doppler ultrasound shows multilocular cystic lesions (arrows) without intralesional vascularity in the uterine cervix.
Leiomyoma
Clinical features
Most cases of uterine leiomyoma involve the myometrium, but they can also occur in the uterine cervix. Cervical leiomyomas account for up to 10% of all uterine leiomyomas.13,14 Cervical leiomyomas are usually polypoid tumours and pedunculate into the endocervical canal; therefore, they occasionally cause ulceration and haemorrhage.13
US features
A leiomyoma generally appears as a round, well-defined hypoechoic mass (Figure 8).13,14 It appears relatively hypovascular on Doppler US compared to the surrounding normal myometrium with the uterine vessels splayed around the mass (Figure 8). Degenerative leiomyomas appear to be more heterogeneous on US images. A more hyperechoic mass is usually associated with haemorrhage caused by red or cavernous degeneration.
Figure 8.
Uterine cervical leiomyoma in a 69-year-old female. (a) Colour Doppler ultrasound image shows a mass (arrow) with hypoechogenicity arising from the cervix without intralesional hypervascularity. (b) Sagittal T2-weighted magnetic resonance image shows a homogeneous, low-signal intensity mass (arrow) in the enlarged uterine cervix.
Endocervical polyp
Clinical features
Cervical polyps are the most common benign growths of the cervix, accounting for more than 60% of cervical polypoid lesions, with a prevalence of 1.5–10%.5,14 They are focal hyperplastic endocervical folds consisting of vascular connective tissue stroma covered with epithelium. They are rarely known to have malignant potential. Most cervical polyps are asymptomatic; however, few perimenopausal patients can experience vaginal discharge and bleeding.
US features
Compared to the normal cervical mucosa, endocervical polyps usually appear well-circumscribed and slightly hyperechoic, and can be mobile during dynamic imaging with the use of a pressure transducer.2 The key to diagnosis of a cervical polyp is the identification of feeder vessels (vascular stalk) arising from the cervical wall on Doppler US.
Cervical endometriosis
Clinical features
The cervix is a rare implantation site of endometriosis. Cervical endometriosis occurs in 0.11–2.4% of patients with endometriosis.2,15 Most cases are asymptomatic, although rarely, they can also cause abnormal vaginal bleeding or pelvic pain.
US features
Cervical endometriosis can present as a cystic (Figure 9) or polypoid (Figure 10) mass involving the endocervical canal.14 It is diffusely hypoechoic internally with echogenic nodularity of the cystic wall.
Figure 9.
Uterine cervical endometriosis in a 45-year-old female. (a) Sagittal transvaginal ultrasound shows a cystic cervical mass (arrow) with posterior acoustic enhancement and suspicious echogenic foci (asterisks) in the cystic wall. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. (b) Sagittal T2-weighted magnetic resonance image shows a low to intermediate signal intensity mass (arrow) in the enlarged uterine cervix. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown.
Figure 10.
Uterine cervical endometriosis in a 42-year-old female. (a) Axial transvaginal ultrasound shows a complex cystic cervical mass (calibers) with posterior acoustic enhancement. (b) Axial susceptibility-weighted magnetic resonance image shows low signal intensity voids (arrows) of the lesion (calibers) in the enlarged uterine cervix.
Cervical pregnancy
Clinical features
Cervical pregnancy is a rare type of ectopic pregnancy in which the developing embryo is implanted within the endocervical canal rather than the uterine cavity, and the incidence is reported to be less than 1% of all reported pregnancies.16
US features
The shape of the uterine fundus is typically seen as an hourglass or figure-of-eight appearance because of the enlarged cervix. A live embryo with a foetal heartbeat, present within the cervix, accompanied by a closed internal os, without definite intrauterine pregnancy, suggests cervical pregnancy (Figure 11).17
Figure 11.
Two cases of cervical pregnancy. (a) Sagittal transvaginal ultrasound obtained in a 35-year-old female shows a live cervical pregnancy (arrows). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. (b) Sagittal transvaginal ultrasound obtained in a 28-year-old female shows a round gestational sac (arrow) and internal yolk sac (asterisk). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. C: cyst
Cervical abortion
Clinical features
Cervical abortion is the spontaneous abortion of a normal intrauterine pregnancy in which the aborted sac is within the cervix with an open internal os and closed external os. With clinical manifestations of cervical pregnancy and abortion being painless vaginal bleeding and elevation of β-hCG level, they can be difficult to diagnose.
US features
The most important US finding to identify cervical abortion is a dilated internal os.17,18 In cases of cervical abortion, the uterine fundus is enlarged and relatively globular in shape with inhomogeneous and mixed echogenicity (Figure 12).17,18 In addition, there is no foetal cardiac activity, suggesting foetal demise. A distorted gestational sac associated with cervical abortion is shown in Figure 12.
Figure 12.
Two cases of cervical abortion. (a) Sagittal transvaginal ultrasound obtained in a 41-year-old female shows complex echoic mass-like lesions (arrows) within the dilated cervix. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. (b) Sagittal transvaginal ultrasound obtained in a 44-year-old female shows a distorted gestational sac (arrow) within the endocervical canal. This case is suggestive of an “abortion in progress”. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown.
Short uterine cervix and cervical incompetence
Clinical features
When the cervical length is less than 25 mm and shows funnelling, it is defined as a short cervix, that is, the mean cervical length is approximately 35 mm at 24 gestational weeks. Due to the length of the cervix being shortened, it is a common cause of rise in the rates of preterm birth and pregnancy failure in the second trimester.19
US features
TVS is the most accurate technique for measuring the cervical length. It is measured from the internal to external os along the endocervical canal and is revealed as a bright echogenic line.19 The shortest length of the closed cervix is the best diagnostic measurement (Figure 13). Cervical incompetence is the widening of the internal os and expansion of the foetal membranes into the endocervical canal (Figure 14).
Figure 13.
Short uterine cervix in a 38-year-old female. Sagittal transvaginal ultrasound shows a short cervix measuring 1.92 cm in diameter (line and calibers). The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown.
Figure 14.
Cervical incompetence in a 40-year-old female. Sagittal transabdominal ultrasound shows a non-measurable cervix and full funnelling (arrows). Only the regions of the external cervical os (arrowhead) are shown. B: bladder; F: Foetus
Malignant lesions
Uterine cervical carcinoma
Clinical features
Primary uterine cervical carcinoma is one of the most common gynaecological malignancies worldwide is primary uterine cervical carcinoma.2,14 It is mainly a squamous cell carcinoma that arises from the transformation zone in which the squamous epithelium and columnar epithelium cross (squamocolumnar junction), as seen in 80–90% of cervical carcinomas. Of all uterine cervical carcinomas, 5–20% are adenocarcinomas.2 Cervical carcinomas appear to be exophytic in younger patients and endophytic in older patients because of the variable location of the transformation zone with advancing age.14
Adenoma malignum, also known as minimal-deviation adenocarcinoma, is a special subtype of mucinous adenocarcinoma of the cervix.12,20,21 It accounts for approximately 3% of all cervical adenocarcinomas.20 The most common initial symptom is a watery discharge that is often associated with Peutz-Jeghers syndrome and mucinous tumours of the ovary.12,20,21 Although controversial, an unfavourable prognosis has been reported for adenoma malignum. In a recent comprehensive study, however, the prognosis of patients with adenoma malignum was relatively favourable.20
US features
Cervical carcinomas typically have a heterogeneous echotexture, distortion of normal cervical morphology, and increased vascularity (Figures 5, 1 and 16).5,22 Since up to 95% of cervical carcinomas are hypervascular, colour Doppler US can facilitate tumour visualisation and delineation.2,22 Tumour vascularization is higher in squamous cell carcinomas, moderately or poorly differentiated lesions, and advanced-stage tumours.6,22
Figure 15.
Uterine cervical carcinoma (squamous cell carcinoma) in a 47-year-old female. (a) Colour Doppler ultrasound image shows a mass (arrows) with heterogeneous echotexture and intralesional hypervascularity arising from the cervix. (b) Sagittal T2-weighted magnetic resonance image shows a complex solid and cystic intermediate signal intensity mass (arrows) in the enlarged uterine cervix. B: bladder.
Figure 16.
Uterine cervical carcinoma (squamous cell carcinoma) in a 39-year-old female. Colour Doppler ultrasound image shows a heterogeneous echotexture mass (M) with intralesional hypervascularity arising from the cervix.
A detailed assessment allows measurement of the size of the tumour; determination of the depth of stromal infiltration, the location of the tumour, the involvement of the parametrium, bladder, and rectum; and the assessment of pelvic lymph nodes. Most reports suggest that it could be useful for monitoring and predicting response to therapy.6
Adenoma malignum is a representative of malignant multicystic lesions in the uterine cervix (Figure 17).12,20,21 There have been a few reports on solid-appearing adenoma malignum.20
Figure 17.
Adenoma malignum in a 30-year-old female. (a) Axial transvaginal ultrasound shows a multilocular cystic lesion with solid component (arrows) within an enlarged uterine cervix. (b) Colour Doppler ultrasound image shows intralesional hypervascularity (asterisk).
Other malignant lesions
Clinical features
Besides primary cervical carcinoma, cervical malignancy may occur secondary to direct extension from adjacent endometrial or myometrial tumours and, less commonly, from other pelvic organs.2 Uterine metastasis is rare, especially metastasis from extrapelvic tumours.23 Other malignancies, including melanoma, lymphoma, sarcoma, and neuroendocrine tumours (Figure 18), can arise rarely from the uterine cervix and require histopathological examination to differentiate them from cervical carcinoma.14
Figure 18.
Uterine cervical neuroendocrine carcinoma in a 45-year-old female. (a) Axial transvaginal ultrasound shows a large heterogeneous necrotic mass (M) within the enlarged uterine cervix. (b) Sagittal T2-weighted magnetic resonance image shows heterogeneous high signal intensity mass involving the endometrium (E), uterine body (arrows) and cervix (asterisks). Multiple pelvic and paraaortic metastatic lymph node enlargements (not shown) were evident. The regions of the internal cervical os (small arrow) and external cervical os (arrowhead) are shown. B: bladder
US features
US findings of other malignant tumours are non-specific. These tumours usually appear as heterogeneous growths with markedly increased vascularity on Doppler US. The extent of cervical invasion can also be assessed using the US.23 Accuracy of TVS for assessing cervical invasion of endometrial cancer is reported to range from 73 to 98%.24
Multilocular cystic lesion
Multilocular cystic lesions in the uterine cervix differ widely from benign lesions such as cervicitis (Figure 6), hyperplasia, nabothian cysts, tunnel clusters (Figure 7), and adenofibroma, to malignant lesions, such as adenocarcinoma, adenoma malignum (Figure 17), and lymphoma, since any cervical glandular proliferation can show multicystic traits.12,20,21 Early differentiation of malignant lesions from benign lesions is important, but difficult. Malignant lesions invade deep into the cervical stroma and usually contain solid components. On the contrary, benign lesions are smaller and have well-defined margins.12
Summary and conclusion
US is useful for evaluating uterine cervical lesions. Identifying and characterising uterine cervical lesions requires a thorough US technique and knowledge of the normal US appearance of the cervix.2 A summary of US findings for uterine cervical lesions has been provided in Tables 1–3.
Table 1.
Summary of Clinical and US Features of Benign Uterine Cervical Lesions
| Cervical Lesion | Clinical Features | US Features |
|---|---|---|
| Cervicitisa | Most common gynaecological disease Tenacious jellylike, yellow, or turbid discharge Sensation of pelvic pressure or discomfort | Diffusely heterogeneous echotexture Key finding: markedly increased vascularity Chronic stage: small groups of bright dots |
| Hyperplasiaa | Use of oral contraceptive agents, pregnancy or postpartum | Superficial layer of the cervical wall |
| Nabothian cysta | A common incidental finding A retention cyst Caused by chronic inflammation with scarring | Usually located in the endocervical gland Occasionally extends deep into the cervical stroma |
| Tunnel clustera | A specific type of nabothian cyst | Complex multicystic dilatation of endocervical glands |
| Endocervical polyp | Most common mass of cervix Rarely associated with malignant potential Asymptomatic, but some perimenopausal patients present vaginal discharge and bleeding | Well-circumscribed slightly hyperechoic mass Mobile at dynamic imaging with the use of pressure transducer Can identify the feeder vessel from the cervical wall on Doppler US |
| Leiomyoma | Up to 10% of total uterine leiomyoma cases Polypoid tumours that pedunculate into the endocervical canal Cause ulceration and haemorrhage | Round, well-defined hypoechoic mass Hypovascular compared to surrounding normal myometrium. Uterine vessels are splayed around the mass on Doppler US |
| Endometriosis | Rare site of endometrial implantation Asymptomatic, but it can rarely be a cause of abnormal vaginal bleeding or pelvic pain | Cystic or polypoid mass involving the endocervical canal Diffusely hypoechoic internally with echogenic nodularity of cystic wall |
| Congenital cervical anomalies | Originated from Müllerian ducts that form the uterus and proximal two-thirds of the vagina Four subtypes: uterine agenesis, uterine duplication anomalies, unicornuate uterus and arcuate uterus | US if the initial approach, helps diagnosis easily Not only focus on conventional imaging of the pelvis but also include orthogonal images along the long axis of the uterus |
| Cervical stenosis | Results from inflammation and fibrosis of cervical mucosa | Normal or thickening of the endocervical canal with fluid retention in the endometrial cavity |
| Adenofibromaa | Rare benign Müllerian mixed tumour Most commonly occurs in the endometrium Cervical adenofibroma: 10% of all uterine adenofibromas | Echogenic solid portions with multiple variable-sized small cysts Large solid masses embracing the uterus |
US, Ultrasound.
Can appear as a multilocular cystic lesion.
Table 2.
Summary of Clinical and US Features of Pregnancy-related Uterine Cervical Lesions
| Cervical Lesion | Clinical Features | US Features |
|---|---|---|
| Pregnancy | Rare type of ectopic pregnancy Less than 1% of all reported pregnancies |
Hour-glass or a figure-of-eight appearance of the uterine fundus Live embryos with foetal heartbeat within the cervix with closed state of the internal os |
| Abortion | Spontaneous abortion of a normal intrauterine pregnancy Painless vaginal bleeding with elevation of β-hCG: similar to cervical pregnancy |
Dilated internal os Enlarged and relatively globular-shaped uterine fundus No foetal cardiac activity, suggesting foetal demise Distorted gestational sac Open internal os and closed external os |
| Short uterine cervix and cervical incompetence | Short uterine cervix and full funnelling | Measured along the endocervical canal from internal to external os showing a bright echogenic line Widening of the internal os and bulging of the foetal membranes into the endocervical canal |
β-hCG, Beta subunit of human chorionic gonadotropin.
Table 3.
Summary of Clinical and US Features of Malignant Uterine Cervical Lesions
| Cervical Lesion | Clinical Features | US Features |
|---|---|---|
| Squamous cell carcinoma | 80–90% of primary cervical cancer | Heterogeneous echotexture, distortion of normal cervical morphology Increased vascularity in Doppler US (95%) Increased stiffness in elastography |
| Adenocarcinomaa | 5–20% of primary cervical cancer Preservation of endocervical epithelium due to submucosal location | Can appear as a multilocular cystic lesion |
| Adenoma malignuma | A special subtype of mucinous adenocarcinoma of the cervix Most common initial symptom is a watery discharge Often associated with Peutz-Jeghers syndrome and mucinous tumour of the ovary | Can appear as a multilocular cystic lesion |
| Other malignant tumours | Direct extension from adjacent endometrial or myometrial tumours Rare occurrence, including melanoma, lymphoma*, sarcoma, and neuroendocrine tumour Require histopathologic examination to distinguish them from cervical carcinoma | Nonspecific Heterogeneous mass with marked increased vascularity |
US, Ultrasound.
Can appear as a multilocular cystic lesion.
Although it is not clear whether there is a definite radiologic differentiation between malignant and benign lesions, we propose that familiarity with the clinical settings and US features of uterine cervical lesions will facilitate prompt and accurate diagnosis and treatment.
Contributor Information
Hyunji Oh, Email: 5hyunji@caumc.or.kr.
Sung Bin Park, Email: pksungbin@paran.com.
Hyun Jeong Park, Email: seolly1024@gmail.com.
Eun Sun Lee, Email: seraph377@gmail.com.
Byung Ihn Choi, Email: bichoi@snu.ac.kr.
REFERENCES
- 1.Langer JE, Oliver ER, Lev-Toaff AS, Coleman BG. Imaging of the female pelvis through the life cycle. Radiographics 2012; 32: 1575–97. doi: 10.1148/rg.326125513 [DOI] [PubMed] [Google Scholar]
- 2.Wildenberg JC, Yam BL, Langer JE, Jones LP. Us of the nongravid cervix with multimodality imaging correlation: normal appearance, pathologic conditions, and diagnostic pitfalls. Radiographics 2016; 36: 596–617. doi: 10.1148/rg.2016150155 [DOI] [PubMed] [Google Scholar]
- 3.Sokalska A, Timmerman D, Testa AC, Van Holsbeke C, Lissoni AA, Leone FPG, et al. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet Gynecol 2009; 34: 462–70. doi: 10.1002/uog.6444 [DOI] [PubMed] [Google Scholar]
- 4.Khong SL, Kane SC, Brennecke SP, da Silva Costa F. First-Trimester uterine artery Doppler analysis in the prediction of later pregnancy complications. Dis Markers 2015; 2015: 1–10. doi: 10.1155/2015/679730 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Chu LC, Coquia SF, Hamper UM. Ultrasonography evaluation of pelvic masses. Radiol Clin North Am 2014; 52: 1237–52. doi: 10.1016/j.rcl.2014.07.003 [DOI] [PubMed] [Google Scholar]
- 6.Alcázar JL, Arribas S, Mínguez JA, Jurado M. The role of ultrasound in the assessment of uterine cervical cancer. J Obstet Gynaecol India 2014; 64: 311–6. doi: 10.1007/s13224-014-0622-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Park SB, Kang BS. Value of ultrasonographic evaluation for soft-tissue lesions: focus on incidentally detected lesions on CT/MRI. Jpn J Radiol 2017; 35: 485–94. doi: 10.1007/s11604-017-0657-4 [DOI] [PubMed] [Google Scholar]
- 8.Sun L-tao, Ning C-ping, Liu Y-jie, Wang Z-zhen, Wang L-di, Kong X-chao, et al. Is transvaginal elastography useful in pre-operative diagnosis of cervical cancer? Eur J Radiol 2012; 81: e888–92. doi: 10.1016/j.ejrad.2012.04.025 [DOI] [PubMed] [Google Scholar]
- 9.Lu R, Xiao Y, Liu M, Shi D. Ultrasound elastography in the differential diagnosis of benign and malignant cervical lesions. J Ultrasound Med 2014; 33: 667–71. doi: 10.7863/ultra.33.4.667 [DOI] [PubMed] [Google Scholar]
- 10.Thomas A, Kümmel S, Gemeinhardt O, Fischer T. Real-Time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix. Acad Radiol 2007; 14: 193–200. doi: 10.1016/j.acra.2006.11.010 [DOI] [PubMed] [Google Scholar]
- 11.Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004; 233: 19–34. doi: 10.1148/radiol.2331020777 [DOI] [PubMed] [Google Scholar]
- 12.Bin Park S, Lee JH, Lee YH, Song MJ, Choi HJ. Multilocular cystic lesions in the uterine cervix: broad spectrum of imaging features and pathologic correlation. AJR Am J Roentgenol 2010; 195: 517–23. doi: 10.2214/AJR.09.3619 [DOI] [PubMed] [Google Scholar]
- 13.Rashid SQ, Chou Y-H, Tiu C-M. Ultrasonography of uterine leiomyomas. J Med Ultrasound 2016; 24: 3–12. doi: 10.1016/j.jmu.2015.12.006 [DOI] [Google Scholar]
- 14.Okamoto Y, Tanaka YO, Nishida M, Tsunoda H, Yoshikawa H, Itai Y. MR imaging of the uterine cervix: imaging-pathologic correlation. Radiographics 2003; 23: 425–45. doi: 10.1148/rg.232025065 [DOI] [PubMed] [Google Scholar]
- 15.Wang S, Li XC, Lang JH. Cervical endometriosis: clinical character and management experience in a 27-year span. Am J Obstet Gynecol 2011; 205: 452.e1–452.e5. doi: 10.1016/j.ajog.2011.06.070 [DOI] [PubMed] [Google Scholar]
- 16.Singh S. Diagnosis and management of cervical ectopic pregnancy. J Hum Reprod Sci 2013; 6: 273. doi: 10.4103/0974-1208.126312 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Gun M, Mavrogiorgis M. Cervical ectopic pregnancy: a case report and literature review. Ultrasound in Obstetrics and Gynecology 2002; 19: 297–301. doi: 10.1046/j.1469-0705.2002.00559.x [DOI] [PubMed] [Google Scholar]
- 18.Vas W, Suresh PL, Tang-Barton P, Salimi Z, Carlin B. Ultrasonographic differentiation of cervical abortion from cervical pregnancy. J Clin Ultrasound 1984; 12: 553–7. doi: 10.1002/jcu.1870120905 [DOI] [PubMed] [Google Scholar]
- 19.Owen J, Iams JD, Hauth JC. Vaginal sonography and cervical incompetence. Am J Obstet Gynecol 2003; 188: 586–96. doi: 10.1067/mob.2003.137 [DOI] [PubMed] [Google Scholar]
- 20.Park SB, Lee JH, Lee YH, Song MJ, Lim KT, Hong SR, et al. Adenoma malignum of the uterine cervix: imaging features with clinicopathologic correlation. Acta Radiol 2013; 54: 113–20. doi: 10.1258/ar.2012.120059 [DOI] [PubMed] [Google Scholar]
- 21.Park SB, Moon MH, Hong SR, Lee MS, Cho HC, Han BH, et al. Adenoma malignum of the uterine cervix: ultrasonographic findings in 11 patients. Ultrasound Obstet Gynecol 2011; 38: 716–21. doi: 10.1002/uog.9078 [DOI] [PubMed] [Google Scholar]
- 22.Epstein E, Di Legge A, Måsbäck A, Lindqvist PG, Kannisto P, Testa AC. Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix. Ultrasound Obstet Gynecol 2010; 36: 512–6. doi: 10.1002/uog.7638 [DOI] [PubMed] [Google Scholar]
- 23.Patel S, Liyanage SH, Sahdev A, Rockall AG, Reznek RH. Imaging of endometrial and cervical cancer. Insights Imaging 2010; 1(5-6): 309–28. doi: 10.1007/s13244-010-0042-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Alcázar JL, Orozco R, Martinez-Astorquiza Corral T, Juez L, Utrilla-Layna J, Mínguez JA, et al. Transvaginal ultrasound for preoperative assessment of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 46: 405–13. doi: 10.1002/uog.14905 [DOI] [PubMed] [Google Scholar]