One of the key aspects in the assessment of the patient with suspected or known gynecologic cancer is imaging. Upon patient presentation, it is often the next step in its management following a thorough history and detailed physical examination. The role of imaging is equally crucial during the preoperative evaluation as well as during the postoperative surveillance period for the documentation of clinical remission or suspected tumor relapse and/or metastasis.

In this section, we summarize the main features of endometrial, ovarian, and cervical cancer. We will also point out the key clinical implications of the current imaging techniques tailored to each gynecologic cancer type. These clinical pearls can be equally helpful to the gynecologic oncologist, medical oncologist, radiation oncologist, pathologist, and radiologist in the everyday clinical setting.

1 Endometrial Cancer

It is the most common gynecologic malignancy and fourth overall malignancy in women in developed countries (in developing countries, it is the second most common gynecologic malignancy following cervical cancer) [1]. A woman’s lifetime risk for endometrial cancer in Western societies is 2.6% [2].

There are two main types of endometrial cancer that differ: type I and type II.

Type I is the typical endometrioid adenocarcinoma grade 1 or 2, accounting for over 80% of all endometrial cancer cases. In nearly 70% of patients, it is diagnosed at an early stage (stage I or II) and carries a favorable prognosis. Type II is less common and encompasses grade 3 endometrioid tumors, serous or clear cell endometrial cancers, and other rarest high-grade and also histologic subtypes. Unfortunately type II endometrial cancer is usually diagnosed at later stages and carries a poor prognosis [3].

Endometrial cancer is surgically staged (Table 40.1). Prognosis is directly related to surgical stage (Table 40.2). Besides stage other risk factors for relapse and/or metastasis are histologic type and histologic grade, lymph-vascular space involvement (LVSI) , as well as tumor size [4, 5].

Table 40.1 Endometrial cancer surgical staging (FIGO 2009)
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Table 40.2 Endometrial cancer FIGO surgical stage 5-year survival (%)
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Remission or cure is accomplished primarily with surgery and optimal debulking if deemed necessary. Adjuvant radiation therapy in the form of intracavitary or external beam radiation is often applied. Chemotherapy may also be instituted in later stages or high-risk disease.

Metastasis and relapse in endometrial cancer are equally distributed in the pelvis, vagina, abdomen, and lungs.

Imaging holds a strong pivotal role in the preoperative assessment as well as in the confirmation of remission, in cure, and in the documentation of relapse and metastasis.

2 Ovarian Cancer

Ovarian cancer is the second most common gynecologic malignancy. It is the leading cause of death from gynecologic cancers and fifth overall from cancer death in women in developed countries. The lifetime risk of developing ovarian cancer in developed countries is 1.4% [2, 6]. (In developing countries it is the third most common gynecologic cancer after cervical and endometrial cancers.)

Nearly 95% of all cases of ovarian cancer arise from the ovarian surface epithelium . These so-called epithelial ovarian carcinomas (EOCs) include serous, mucinous, endometrioid, and clear cell subtypes, and besides being the most common, they also exhibit an aggressive biologic behavior and tend to be diagnosed at a later stage. Unfortunately, less aggressive ovarian cancers are also less common and include those arising from germ cells, sex cord, or stromal cells as well as mixed types [7].

Overall, nearly three fourths of all cases are diagnosed at advanced stages when permanent cure is less feasible compared to earlier stages (I or II). Its indolent course at earlier stages, nonspecific symptoms, and lack of successful screening strategies up to date all contribute to the lethality of the disease. EOC is staged surgically according to the revised FIGO 2014 staging (Table 40.3).

Table 40.3 Ovarian cancer staging
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Prognosis is directly related to stage (Table 40.4).

Table 40.4 Ovarian cancer FIGO surgical stage and 2-year and 5-year survival (%)
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The gold standard in the management of ovarian cancer is still primary surgery and ideally primary optimal cytoreduction, followed in most instances by chemotherapy. Imaging plays a crucial role in both the preoperative evaluation and in the surveillance of remission and relapse.

The revised staging of ovarian cancer (FIGO 2014 classification) is shown in Table 40.3.

3 Cervical Cancer

Cervical cancer is the third most common gynecologic cancer in developed countries and a relatively infrequent cause of cancer death overall. The lifetime risk of developing cervical cancer in the United States, based upon national data from 2000 to 2004, is 0.76% [10, 11]. In developing countries, however, it is the most common gynecologic cancer as well as the second leading cause of cancer death in women [11].

The above figures reflect unfortunately the lack of cervical cancer screening with Papanicolaou smear in third world and developing nations.

Cervical cancer is caused by persistent infection from high-risk oncogenic HPV types in 99.7% of all cases [12].

Diagnosis is made by histologic confirmation of cervical biopsies.

According to the International Federation of Gynecology and Obstetrics, cervical cancer is still clinically staged (FIGO—Table 40.5). In developed countries, however, various imaging studies are being used to assess nodal status or parametrial spread and tailor further management [13].

Table 40.5 Cervical cancer FIGO clinical stage (2009)
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Cervical cancer can be treated by both surgery and radiotherapy in stages up to IIA. Greater stages are being treated primarily by radiation therapy with concurrent chemosensitization. Sometimes adjuvant surgery may be used.