**1. Introduction**

Cervical cancer is one of the leading causes of morbidity and mortality in women, representing the second most common cancer in developing countries and the fourth worldwide [1].

Although a pelvic examination continues to be the first approach to detecting cervical cancer, the 2018 FIGO classification has updated the cancer staging, highlighting the central role of imaging. In fact, imaging techniques allow a better definition of the tumor size, parametrial invasion, extension to the pelvic wall or adjacent organs, and lymph node involvement [2].

Many diagnostic methods are used in clinical practice; their use depends on availability, cost, and the expertise of clinicians and radiologists. Although magnetic resonance imaging (MRI) is considered the main technique to assess tumor size and parametrial extension [3–6], transvaginal ultrasound (TVUS) or transrectal ultrasound (TRUS) can provide comparable information (especially if performed by expert examiners) while being more widely available, faster, and cheaper [4,7–10]. Moreover, the sonographic appearance of cervical lesions seems to predict the histopathological subtype: hypoechogenicity is associated with squamous cell carcinoma in 73% of cases, while isoechogenicity suggests an adenocarcinoma in 68% of women [11]. The role of imaging in assessing vaginal invasion

**Citation:** Vidal Urbinati, A.M.; Pino, I.; Iacobone, A.D.; Radice, D.; Azzalini, G.; Guerrieri, M.E.; Preti, E.P.; Martella, S.; Franchi, D. Vaginosonography versus MRI in Pre-Treatment Evaluation of Early-Stage Cervical Cancer: An Old Tool for a New Precision Approach?. *Diagnostics* **2022**, *12*, 2904. https:// doi.org/10.3390/diagnostics12122904

Academic Editor: Ralph P. Mason

Received: 20 October 2022 Accepted: 21 November 2022 Published: 22 November 2022

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is less clear, as several false-negative and false-positive results have been reported for large tumors that spread to the upper vagina [2,8]. Several sonographic and anatomical factors may reduce the performance of ultrasound techniques in the detection of vaginal and distal cervix lesions, such as similar echogenicity and collapsed vaginal walls [9,11,12].

Vaginosonography (VGS) is a technique first described by Dessole et al. in 2003 [13] that combines TVUS with the vaginal instillation of saline solution or ultrasound gel. It is used to evaluate local disorders of the cervix and vagina, such as benign or malignant lesions, malformations, and infiltrating endometriosis. The acoustic window created by the passive distention of the vaginal walls allows a better analysis of the anatomical structures, making the ultrasound evaluation easier, especially in the detection of exophytic early-stage cervical cancers [13–15].

Our study aims to analyze the sensitivity of VGS and MRI in the preoperative local evaluation of early-stage cervical cancers and to assess their accuracy in the detection of tumor presence, size of the lesion, and stromal invasion by comparing them with the final histopathology report.
