Cervical Cancer MRI Staging (FIGO 2018)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] MRI local staging
   MRI local staging: parametrial invasion / size / extension / nodes? (FIGO 2018 incorporates imaging and pathology; MRI is preferred for local staging (tumor size, depth of stromal invasion, parametrium/vagina/pelvic wall, hydronephrosis, bladder/rectum). Key sign: an intact T2-dark cervical stromal ring = no parametrial invasion; ring disruption/strands = parametrial invasion (→ IIB) (oblique axial best). Nodes assessed by MRI/PET-CT, positive = IIIC. Beware post-biopsy edema/large tumor causing overstaging.)
   • Confined to cervix/upper 2/3 vagina, intact stromal ring, no parametrium → Early (I–IIA1) · mainly surgery
   • Parametrial invasion (ring disruption) / lower 1/3 vagina / pelvic wall / hydronephrosis → Locally advanced (IIB/IIIA/IIIB) · chemoradiation
   • Pelvic or para-aortic nodes positive → Node-positive (IIIC) · chemoradiation ± extended field
   • Bladder/rectal mucosa or beyond the true pelvis/distant → Advanced (IVA/IVB)
2. [End] Early (I–IIA1) · mainly surgery
   Early (confined to cervix or upper 2/3 vagina, intact stromal ring, no parametrium, ≤4 cm): by size IB1 ≤2 cm / IB2 >2–4 cm / IB3 >4 cm; mainly radical hysterectomy + pelvic lymph node dissection; selected early small tumors (adequate distance from the internal os, fertility wish) may have trachelectomy. MRI measurement of size and stromal invasion guides decisions.
3. [End] Locally advanced (IIB/IIIA/IIIB) · chemoradiation
   Parametrial invasion (IIB)/lower 1/3 vagina (IIIA)/pelvic wall or hydronephrosis/non-functioning kidney (IIIB): parametrial invasion or >4 cm not suitable for surgery → concurrent chemoradiation (avoid the double morbidity of postoperative adjuvant radiation); MRI assesses the pelvic wall and ureteric obstruction, delineates the target.
4. [End] Node-positive (IIIC) · chemoradiation ± extended field
   Pelvic (IIIC1)/para-aortic (IIIC2) node-positive (new in 2018, poorer prognosis): imaging (MRI/PET-CT) assesses extranodal extent; concurrent chemoradiation ± extended-field irradiation, adjusting the target by involved sites.
5. [End] Advanced (IVA/IVB)
   Bladder/rectal mucosa (IVA) or beyond the true pelvis/distant metastasis (IVB): IVA selective pelvic exenteration or concurrent chemoradiation; IVB systemic therapy (chemotherapy ± targeted/immunotherapy) ± palliative radiation; multidisciplinary decision.

Source guidelines & references

• Cervical cancer 2018 FIGO revised staging and imaging (AJR 2020; RadioGraphics 2020)
• 2018 FIGO cervical cancer staging and the role of MRI · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways