# Preoperative staging of cervical cancer: time to shift from cystoscopy to MRI

## TL;DR

MRI can replace cystoscopy for cervical cancer staging, as it better predicts tumor recurrence and survival.

## Contribution

MRI-defined bladder wall invasion is shown to be a more reliable prognostic indicator than cystoscopy in cervical cancer.

## Key findings

- MRI-defined bladder wall invasion was an independent risk factor for tumor recurrence and mortality.
- Cystoscopy-detected mucosal infiltration was not associated with recurrence or mortality.
- MRI showed significant differences in survival between patients with and without bladder wall invasion.

## Abstract

To evaluate the impact of MRI-defined bladder wall invasion from uterine cervical cancer (CC) on disease recurrence and overall survival.

IRB-approved multicenter retrospective study including women who underwent staging MRI for histologically confirmed CC (Jan 2015–Dec 2020). Image analysis was independently performed by two radiologists. Bladder wall invasion was diagnosed if ≥ 3 of the following criteria were met: loss of the cervix-bladder fat plane, bladder wall thickening, loss of bladder wall T2-hypointensity, and presence of endoluminal tumor growth. MRI findings were compared with endoscopy/cytology. The impact of MRI-defined bladder wall invasion on tumor recurrence and survival was assessed using logistic regression. Survival curves were compared using the log-rank test.

We included 214 women with a median age of 55 (IQR 47–65) years. MRI-defined bladder wall invasion was observed in 21.5% of patients. Cystoscopy revealed bladder mucosal infiltration in 7.0% of patients, all of whom demonstrated MRI-defined bladder wall invasion. No patients without MRI-defined bladder wall invasion showed mucosal infiltration on cystoscopy/cytology. The median follow-up was 32 months: 46.7% of patients had recurrence, and 23.4% had CC-related death. On logistic regression, MRI-defined bladder wall invasion was an independent risk factor for tumor recurrence (OR 2.24, p = 0.047) and mortality (OR 3.55, p = 0.006), whereas cystoscopy-defined bladder mucosa infiltration was not. The log-rank test demonstrated a significant difference in survival between patients with and without MRI-defined bladder wall invasion (χ² = 15.40, p = 0.0001).

MRI-defined bladder wall invasion represents an independent negative prognostic factor in patients with cervical cancer.

Question
The prognostic significance of MRI-defined bladder wall invasion in patients with cervical cancer remains unclear with respect to disease recurrence and survival.

Findings
Bladder wall invasion identified on MRI is an independent predictor of tumor recurrence and tumor-specific mortality, whereas mucosal infiltration detected via cystoscopy is not.

Clinical relevance
MRI can safely replace cystoscopy in the preoperative staging of patients with uterine cervical cancer. This approach can reduce costs and expedite the staging process.