Shaping surgical decisions: a practical MRI approach to cervical stromal invasion assessment in the post-SHAPE era

Radical hysterectomy has historically been the standard surgical treatment for early-stage cervical cancer, but growing evidence supports less radical approaches in carefully selected low-risk patients. The SHAPE trial demonstrated that simple hysterectomy is noninferior to radical hysterectomy for pelvic recurrence in women with low-risk early-stage disease, while substantially reducing urinary morbidity. Critically, both the SHAPE and ConCerv trials used limited stromal invasion as a key eligibility criterion, embedding depth of stromal invasion (DSI) as a central surgical selection parameter and, for the first time in the case of SHAPE, incorporating MRI-based stromal invasion percentage as a formal trial criterion. This shift has meaningful implications for radiologic practice. Although stromal invasion percentage is not part of FIGO 2018 staging, a reproducible MRI estimate of less than 50% stromal involvement can directly inform eligibility for simple hysterectomy or fertility-sparing surgery. A report limited to tumor size and FIGO stage is no longer sufficient for contemporary multidisciplinary decision-making. In the post-SHAPE era, radiologists are expected to deliver structured, decision-oriented reports that systematically address tumor size, maximal depth of stromal invasion and its estimated percentage, outer stromal rim integrity, parametrial and vaginal status, uterine extension, distance to the internal os, and nodal disease. This review describes how MRI can be optimized and structured to meet this clinical need. We discuss patient preparation, protocol design, and the technical requirements of true oblique axial T2-weighted imaging as the cornerstone of local staging. We detail a stepwise approach to stromal invasion assessment, address common pitfalls that may lead to under- or overestimation of disease extent, and propose a structured reporting checklist to support reproducible, surgically actionable MRI interpretation in patients with early-stage cervical cancer.