Imaging diagnostics of abdomen and pelvis complications in female reproductive system malignancies

Female reproductive system malignancies are frequently associated with a high risk of abdominopelvic complications, arising both from the tumor process itself and due to therapeutic interventions, including surgery, radiotherapy, chemotherapy, and immunotherapy. Such complications may profoundly worsen prognosis, impair quality of life, and hinder further treatment. Imaging diagnostics plays a crucial role in their timely detection, providing an opportunity not only to evaluate an extent and distribution of pathology but also to differentiate expected post-therapeutic changes from true complications. This article reviews the most common complications encountered after surgical procedures, such as lymphatic complications, fistulas, and infectious processes, as well as those following pelvic exenteration. Radiation-induced toxic effects are described, including both early and late changes affecting the gastrointestinal tract, urinary system, and musculoskeletal structures. Particular attention is paid to complications associated with chemotherapy and contemporary systemic therapies, including targeted agents and immunotherapy, which may result in hepatobiliary, pancreatic, gastrointestinal, vascular, and skeletal toxicities. Typical radiological manifestations related to such complications are discussed primarily outlining those following computed tomography (CT) and magnetic resonance imaging (MRI) exerting an essential role for early diagnosis, treatment planning, and follow-up. A comprehensive understanding of imaging features for abdominopelvic complications in patients with gynecologic malignancies is required for accurate diagnosis, prevented misinterpretation, and patient care optimization.

1. Bray F., Laversanne M., Sung H. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. https://doi.org/10.3322/caac.21834.

2. Ignatyeva V.I., Kontsevaya A.V., Kalinina A.M. et al. Socio-economic efficiency of the early cancer detection during the medical checkup. [Social'no-ekonomicheskaya effektivnost' meropriyatij po rannemu vyyavleniyu onkologicheskih zabolevanij pri dispanserizacii]. Profilakticheskaya medicina. 2024;27(1):36–44. (In Russ.). https://doi.org/10.17116/profmed20242701136.

3. Abdallah Hasaneen M., Ali I.K., Gamal A.M., Khalil A.K. Assessment of health problems caused by gynecological malignancies treatments. Menoufia Nurs J. 2021;6(2):51–64.

4. Hutchcraft M.L., Miller R.W. Bleeding from gynecologic malignancies. Obstet Gynecol Clin North Am. 2022;49(3):607–22. https://doi.org/10.1016/j.ogc.2022.02.022.

5. Loran O.B., Sinyakova L.A., Tekeev M.A. Urological complications in oncogynecological patients. [Urologicheskie oslozhneniya u onkoginekologicheskih bol'nyh]. Urologiya. 2013;(5):108–11. (In Russ.).

6. Khan S.R., Arshad M., Wallitt K. et al. What's new in imaging for gynecologic cancer? Curr Oncol Rep. 2017;19(12):85. https://doi.org/10.1007/s11912-017-0640-3.

7. Zhou X.H., Yang D.N., Zou Y.X. et al. Long-term survival trend of gynecological cancer: a systematic review of population-based cancer registration data. Biomed Environ Sci. 2024;37(8):897–921. https://doi.org/10.3967/bes2024.133.

8. Moradi B., Hejazian S.S., Tahamtan M. et al. Imaging the post-treatment pelvis with gynecologic cancers. Abdom Radiol (NY). 2024;49(4):1248–63. https://doi.org/10.1007/s00261-023-04163-x.

9. Rubtsova N.A., Berezovskaia T.P., Bychenko V.G. et al. Imaging of cervical cancer. Consensus of experts. [Luchevaya diagnostika raka shejki matki. Konsensus ekspertov]. Medicinskaya vizualizaciya. 2024;28(1):141–56. (In Russ.). https://doi.org/10.24835/1607-0763-1341.

10. Adamo S.H., Gereke B.J., Shomstein S., Schmidt J. From "satisfaction of search" to "subsequent search misses": a review of multiple-target search errors across radiology and cognitive science. Cogn Res Princ Implic. 2021;6(1):59. https://doi.org/10.1186/s41235-021-00318-w.

11. Moyett J.M., Howell E.P., Broadwater G. et al. Understanding the spectrum of malignant bowel obstructions in gynecologic cancers and the application of the Henry score. Gynecol Oncol. 2023;174:114–20. https://doi.org/10.1016/j.ygyno.2023.04.023.

12. Lee Y.C., Jivraj N., O'Brien C. et al. Malignant bowel obstruction in advanced gynecologic cancers: an updated review from a multidisciplinary perspective. Obstet Gynecol Int. 2018;2018:1867238. https://doi.org/10.1155/2018/1867238.

13. Siddiqui E. Differentiating large from small bowel. In: Essential Radiology Review. Eds. A. Eltorai, C. Hyman, T. Healey. Springer, Cham, 2019. https://doi.org/10.1007/978-3-030-26044-6_78.

14. Nelms D.W., Kann B.R. Imaging modalities for evaluation of intestinal obstruction. Clin Colon Rectal Surg. 2021;34(4):205–18. https://doi.org/10.1055/s-0041-1729737.

15. Solopova A.E., Ternovoi S.K., Alipov V.I., Makatsariya A.D. Ovarian cancer staging: comparison between diffusion-weighted mri and multispiral computed tomography. [Sravnitel'naya harakteristika diffuzionno-vzveshennyh posledovatel'nostej MRT i mul'tispiral'noj komp'yuternoj tomografii v stadirovanii raka yaichnikov]. Obstetrics, Gynecology and Reproduction. 2017;11(1):19–25. (In Russ.) https://doi.org/10.17749/2313-7347.2017.11.1.019-025.

16. Pavlovic K., Lange D., Chew B.H. Stents for malignant ureteral obstruction. Asian J Urol. 2016;3(3):142–9. https://doi.org/10.1016/j.ajur.2016.04.002.

17. Perri T., Meller E., Ben-Baruch G. et al. Palliative urinary diversion in patients with malignant ureteric obstruction due to gynaecological cancer. BMJ Support Palliat Care. 2022;12(e6):e855–e861. https://doi.org/10.1136/bmjspcare-2019-001771.

18. Medina A.A., García I.L., Tello F.G. et al. The challenging management of malignant ureteral obstruction: analysis of a series of 188 cases. Curr Urol. 2024;18(1):34–42. https://doi.org/10.1097/CU9.0000000000000183.

19. Chao K.S., Leung W.M., Grigsby P.W. et al. The clinical implications of hydronephrosis and the level of ureteral obstruction in stage IIIB cervical cancer. Int J Radiat Oncol Biol Phys. 1998;40(5):1095–100. https://doi.org/10.1016/s0360-3016(97)00899-7.

20. Dyer R.B., Chen M.Y., Zagoria R.J. Intravenous urography: technique and interpretation. Radiographics. 2001;21(4):799–821. https://doi.org/10.1148/radiographics.21.4.g01jl26799.

21. Zhu G.G., Rais-Bahrami S. Diagnosis and management of obstructive uropathy in the setting of advanced pelvic malignancies. J Nephrol Res. 2015;1(3):90–6. https://doi.org/10.17554/j.issn.2410-0579.2015.01.21.

22. Taylor A.T., Blaufox M.D., De Palma D. et al. Guidance document for structured reporting of diuresis renography. Semin Nucl Med. 2012;42(1):41–8. https://doi.org/10.1053/j.semnuclmed.2010.12.006.

23. Blaufox M.D., De Palma D., Taylor A. et al. The SNMMI and EANM practice guideline for renal scintigraphy in adults. Eur J Nucl Med Mol Imaging. 2018;45(12):2218–28. https://doi.org/10.1007/s00259-018-4129-6.

24. Abdurakhmanov R.A. Percutaneous puncture nephrostomy on the back of a patient with an external fixation apparatus on the bones of the pelvis following a road traffic accident. [Chreskozhnaya punkcionnaya nefrostomiya v polozhenii na spine u pacientki s apparatom vneshnej fiksacii na kostyah taza posle dorozhno-transportnogo proisshestviya]. Kazanskij medicinskij zhurnal. 2020;101(2):275–8. (In Russ.). https://doi.org/10.17816/KMJ2020-275.

25. Chow P.M., Chiang I.N., Chen C.Y. et al. Malignant ureteral obstruction: functional duration of metallic versus polymeric ureteral stents. PLoS One. 2015;10(8):e0135566. https://doi.org/10.1371/journal.pone.0135566.

26. Neimark A.I., Razdorskaya M.V. Topical problems in urogynaecology. urinary incontinence in women (lecture). Obstetrics, Gynecology and Reproduction. 2011;5(4):27–34. (In Russ.).

27. Cohen A., Lim C.S., Davies A.H. Venous thromboembolism in gynecological malignancy. Int J Gynecol Cancer. 2017;27(9):1970–8. https://doi.org/10.1097/IGC.0000000000001111.

28. Slukhanchuk E.V., Bitsadze V.O., Solopova A.G. et al. Thromboinflammation in oncogynecological patients. [Trombovospalenie u onkologicheskih bol'nyh]. Obstetrics, Gynecology and Reproduction. 2022;16(5):611–22. (In Russ.). https://doi.org/10.17749/2313-7347/ob.gyn.rep.2022.355.

29. Wharin C., Tagalakis V. Management of venous thromboembolism in cancer patients and the role of the new oral anticoagulants. Blood Rev. 2014;28(1):1–8. https://doi.org/10.1016/j.blre.2013.11.001.

30. Satoh T., Matsumoto K., Tanaka Y.O. et al. Incidence of venous thromboembolism before treatment in cervical cancer and the impact of management on venous thromboembolism after commencement of treatment. Thromb Res. 2013;131(4):e127–32. https://doi.org/10.1016/j.thromres.2013.01.027.

31. Jeong S.Y., Kim T.J., Park B.K. Epithelial ovarian cancer: a review of preoperative imaging features indicating suboptimal surgery. J Gynecol Oncol. 2020;31(4):e57. https://doi.org/10.3802/jgo.2020.31.e57.

32. Abeler V.M., Røyne O., Thoresen S. et al. Uterine sarcomas in Norway. A histopathological and prognostic survey of a total population from 1970 to 2000 including 419 patients. Histopathology. 2009;54(3):355–64. https://doi.org/10.1111/j.1365-2559.2009.03231.x.

33. Roma A.A., Barbuto D.A., Samimi S.A. et al. Vascular invasion in uterine sarcomas and its significance. A multi-institutional study. Hum Pathol. 2015;46(11):1712–21. https://doi.org/10.1016/j.humpath.2015.07.011.

34. Özcan J., Dülger Ö., Küpelioğlu L. et al. Uterine sarcoma in a 14 year-old girl presenting with uterine rupture. Gynecol Oncol Rep. 2014;10:44–6. https://doi.org/10.1016/j.gynor.2014.05.004.

35. Hindman N., Kang S., Fournier L. et al. MRI evaluation of uterine masses for risk of leiomyosarcoma: a consensus statement. Radiology. 2023;306(2):e211658. https://doi.org/10.1148/radiol.211658.

36. Tirumani S.H., Ojili V., Gunabushanam G. et al. MDCT of abdominopelvic oncologic emergencies. Cancer Imaging. 2013;13(2):238–52. https://doi.org/10.1102/1470-7330.2013.0025.

37. Chan L.Y., Lau T.K., Wong S.F., Yuen P.M. Pyometra. What is its clinical significance? J Reprod Med. 2001;46(11):952–6.

38. Vyas S., Kumar A., Prakash M. et al. Spontaneous perforation of pyometra in a cervical cancer patient: a case report and literature review. Cancer Imaging. 2009;9(1):12–4. https://doi.org/10.1102/1470-7330.2009.0002.

39. Shchyukina N.A., Buyanova S.N. Purulent-septic complications after gynecologic surgery. [Gnojno-septicheskie oslozhneniya posle ginekologicheskih operacij]. Medicinskij alfavit. 2017;1(3):20–5. (In Russ.).

40. De Blasis I., Vinci V., Sergi M.E. et al. Early and late onset complications of gynaecologic surgery: a multimodality imaging approach. Facts Views Vis Obgyn. 2017;9(1):5–14.

41. Horvath S., George E., Herzog T.J. Unintended consequences: surgical complications in gynecologic cancer. Womens Health (Lond). 2013;9(6):595–604. https://doi.org/10.2217/whe.13.60.

42. Ebott J, Has P, Raker C, Robison K. Bowel Resection Outcomes in Ovarian Cancer Cytoreductive Surgery by Surgeon Specialty. JAMA Surg. 2024;159(10):1188–94. https://doi.org/10.1001/jamasurg.2024.2924.

43. Paspulati R.M., Dalal T.A. Imaging of complications following gynecologic surgery. Radiographics. 2010;30(3):625–42. https://doi.org/10.1148/rg.303095129.

44. Mandava A., Koppula V., Sharma G. et al. Evaluation of genitourinary fistulas in pelvic malignancies with etiopathologic correlation: role of cross sectional imaging in detection and management. Br J Radiol. 2020;93(1111):20200049. https://doi.org/10.1259/bjr.20200049.

45. Lakhman Y., Nougaret S., Miccò M. et al. Role of MR imaging and FDG PET/CT in selection and follow-up of patients treated with pelvic exenteration for gynecologic malignancies. Radiographics. 2015;35(4):1295–313. https://doi.org/10.1148/rg.2015140313.

46. Nougaret S., Lambregts D.M.J., Beets G.L. et al. Imaging in pelvic exenteration-a multidisciplinary practice guide from the ESGAR-SAR-ESUR-PelvEx collaborative group. Eur Radiol. 2025;35(5):2681–91. https://doi.org/10.1007/s00330-024-10940-z.

47. Sbarra M., Miccò M., Corvino M. et al. CT findings after pelvic exenteration: review of normal appearances and most common complications. Radiol Med. 2019;124(7):693–703. https://doi.org/10.1007/s11547-019-01009-9.

48. Hur H.C., Guido R.S., Mansuria S.M. et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J Minim Invasive Gynecol. 2007;14(3):311–7. https://doi.org/10.1016/j.jmig.2006.11.005.

49. Nezhat C., Burns M.K., Wood M. et al. Vaginal cuff dehiscence and evisceration: a review. Obstet Gynecol. 2018;132(4):972–85. https://doi.org/10.1097/AOG.0000000000002852.

50. Ramirez P.T., Klemer D.P. Vaginal evisceration after hysterectomy: a literature review. Obstet Gynecol Surv. 2002;57(7):462–7. https://doi.org/10.1097/00006254-200207000-00023.

51. Hamilton J.D., Kumaravel M., Censullo M.L. et al. Multidetector CT evaluation of active extravasation in blunt abdominal and pelvic trauma patients. Radiographics. 2008;28(6):1603–16. https://doi.org/10.1148/rg.286085522.

52. Wortman J.R., Landman W., Fulwadhva U.P. et al. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol. 2017;90(1075):20170076. https://doi.org/10.1259/bjr.20170076.

53. Crosby-Nwaobi R.R., Faithfull S. High risk of urinary tract infections in post-operative gynaecology patients: a retrospective case analysis. Eur J Cancer Care (Engl). 2011;20(6):825–31. https://doi.org/10.1111/j.1365-2354.2011.01283.x.

54. Glaser G., Dinoi G., Multinu F. et al. Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer. Int J Gynecol Cancer. 2021;31(1):85–91. https://doi.org/10.1136/ijgc-2020-001924.

55. Pleth Nielsen C.K., Sørensen M.M., Christensen H.K., Funder J.A. Complications and survival after total pelvic exenteration. Eur J Surg Oncol. 2022;48(6):1362–7. https://doi.org/10.1016/j.ejso.2021.12.472.

56. Causa Andrieu P.I., Woo S., Rios-Doria E. et al. The role of imaging in pelvic exenteration for gynecological cancers. Br J Radiol. 2021;94(1125):20201460. https://doi.org/10.1259/bjr.20201460.

57. Roeske J.C., Lujan A., Rotmensch J. et al. Intensity-modulated whole pelvic radiation therapy in patients with gynecologic malignancies. Int J Radiat Oncol Biol Phys. 2000;48(5):1613–21. https://doi.org/10.1016/s0360-3016(00)00771-9.

58. Caruso G., Wagar M.K., Hsu H.C. et al. Cervical cancer: a new era. Int J Gynecol Cancer. 2024;34(12):1946–70. https://doi.org/10.1136/ijgc-2024-005579.

59. Klopp A.H., Enserro D., Powell M. et al. Radiation therapy with or without cisplatin for local recurrences of endometrial cancer: results from an NRG Oncology/GOG prospective randomized multicenter clinical trial. J Clin Oncol. 2024;42(20):2425–35. https://doi.org/10.1200/JCO.23.01279.

60. Portelance L., Chao K.S., Grigsby P.W. et al. Intensity-modulated radiation therapy (IMRT) reduces small bowel, rectum, and bladder doses in patients with cervical cancer receiving pelvic and para-aortic irradiation. Int J Radiat Oncol Biol Phys. 2001;51(1):261–6. https://doi.org/10.1016/s0360-3016(01)01664-9.

61. Jacobsen M.C., Maheshwari E., Klopp A.H., Venkatesan A.M. Image-guided radiotherapy for gynecologic malignancies: what the radiologist needs to know. Radiol Clin North Am. 2023;61(4):725–47. https://doi.org/10.1016/j.rcl.2023.02.012.

62. Ladbury C., Sueyoshi M.H., Brovold N.M. et al. Stereotactic body radiation therapy for gynecologic malignancies: a case-based Radiosurgery Society Practice Review. Pract Radiat Oncol. 2024;14(3):252–66. https://doi.org/10.1016/j.prro.2023.09.008.

63. Venkat P.S., Parikh N., Beron P. Recent advances in gynecologic radiation oncology. Curr Opin Obstet Gynecol. 2019;31(1):38–42. https://doi.org/10.1097/GCO.0000000000000519.

64. Viswanathan A.N., Lee L.J., Eswara J.R. et al. Complications of pelvic radiation in patients treated for gynecologic malignancies. Cancer. 2014;120(24):3870–83. https://doi.org/10.1002/cncr.28849.

65. Charra-Brunaud C., Harter V., Delannes M. et al. Impact of 3D image-based PDR brachytherapy on outcome of patients treated for cervix carcinoma in France: results of the French STIC prospective study. Radiother Oncol. 2012;103(3):305–13. https://doi.org/10.1016/j.radonc.2012.04.007.

66. Lindegaard J.C., Fokdal L.U., Nielsen S.K. et al. MRI-guided adaptive radiotherapy in locally advanced cervical cancer from a Nordic perspective. Acta Oncol. 2013;52(7):1510–9. https://doi.org/10.3109/0284186X.2013.818253.

67. Pötter R., Dimopoulos J., Georg P. et al. Clinical impact of MRI assisted dose volume adaptation and dose escalation in brachytherapy of locally advanced cervix cancer. Radiother Oncol. 2007;83(2):148–55. https://doi.org/10.1016/j.radonc.2007.04.012.

68. Vittrup A.S., Kirchheiner K., Pötter R. et al. Overall severe morbidity after chemo-radiation therapy and magnetic resonance imaging-guided adaptive brachytherapy in locally advanced cervical cancer: results from the EMBRACE-I study. Int J Radiat Oncol Biol Phys. 2023;116(4):807–24. https://doi.org/10.1016/j.ijrobp.2023.01.002.

69. Papadopoulou I., Stewart V., Barwick T.D. et al. Post-radiation therapy imaging appearances in cervical carcinoma. Radiographics. 2016;36(2):538–53. https://doi.org/10.1148/rg.2016150117.

70. Fawaz Z.S., Barkati M., Beauchemin M.C. et al. Cervical necrosis after chemoradiation for cervical cancer: case series and literature review. Radiat Oncol. 2013;8:220. https://doi.org/10.1186/1748-717X-8-220.

71. Zulfiqar M., Shetty A., Yano M. et al. Imaging of the vagina: spectrum of disease with emphasis on MRI appearance. Radiographics. 2021;41(5):1549–68. https://doi.org/10.1148/rg.2021210018.

72. Maturen K.E., Feng M.U., Wasnik A.P. et al. Imaging effects of radiation therapy in the abdomen and pelvis: evaluating "innocent bystander" tissues. Radiographics. 2013d;33(2):599–619. https://doi.org/10.1148/rg.332125119.

73. Addley H.C., Vargas H.A., Moyle P.L. et al. Pelvic imaging following chemotherapy and radiation therapy for gynecologic malignancies. Radiographics. 2010;30(7):1843–56. https://doi.org/10.1148/rg.307105063.

74. Gullì C., Russo L., Gavrila D. et al. Pelvic insufficiency fractures in locally advanced cervical cancer: the diagnostic yield of post-treatment MRI in a tertiary centre. Eur J Radiol. 2025;183:111918. https://doi.org/10.1016/j.ejrad.2025.111918.

75. Meixel A.J., Hauswald H., Delorme S., Jobke B. From radiation osteitis to osteoradionecrosis: incidence and MR morphology of radiation-induced sacral pathologies following pelvic radiotherapy. Eur Radiol. 2018;28(8):3550–9. https://doi.org/10.1007/s00330-018-5325-2.

76. Chopra S., Gupta S., Kannan S. et al. Late toxicity after adjuvant conventional radiation versus image-guided intensity-modulated radiotherapy for cervical cancer (PARCER): a randomized controlled trial. J Clin Oncol. 2021;39(33):3682–92. https://doi.org/10.1200/JCO.20.02530.

77. Fedenko A.A., Konev A.A., Gorbunova V.A. Treatment of uterine leiomyosarcomas. [Lechenie lejomiosarkom matki]. Carkomy kostej, myagkih tkanej i opuholi kozhi. 2014;(1):56–63. (In Russ.).

78. Abu-Hejleh T., Mezhir J.J., Goodheart M.J., Halfdanarson T.R. Incidence and management of gastrointestinal perforation from bevacizumab in advanced cancers. Curr Oncol Rep. 2012;14(4):277–84. https://doi.org/10.1007/s11912-012-0238-8.

79. Albano D., Benenati M., Bruno A. et al. Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe. Insights Imaging. 2021;12(1):76. https://doi.org/10.1186/s13244-021-01017-2.

80. Patil N.S., Larocque N., van der Pol C.B. et al. Chemotherapy-induced toxicities: an imaging primer. Can Assoc Radiol J. 2023;74(2):432–45. https://doi.org/10.1177/08465371221120263.

81. Torrisi J.M., Schwartz L.H., Gollub M.J. et al. CT findings of chemotherapy-induced toxicity: what radiologists need to know about the clinical and radiologic manifestations of chemotherapy toxicity. Radiology. 2011;258(1):41–56. https://doi.org/10.1148/radiol.10092129.

82. Furtado V.F., Melamud K., Hassan K. et al. Imaging manifestations of immune-related adverse effects in checkpoint inhibitor therapies: a primer for the radiologist. Clin Imaging. 2020;63:35–49. https://doi.org/10.1016/j.clinimag.2020.02.006.

83. Russo L., Avesani G., Gui B. et al. Immunotherapy-related imaging findings in patients with gynecological malignancies: what radiologists need to know. Korean J Radiol. 2021;22(8):1310–22. https://doi.org/10.3348/kjr.2020.1299.