The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know

99mTc-Nanocolloid SPECT/MRI Fusion for the Selective Assessment of Nonenlarged Sentinel Lymph Nodes in Patients with Early-Stage Cervical Cancer

We aimed to explore the accuracy of (99m)Tc SPECT/MRI fusion for the selective assessment of nonenlarged sentinel lymph nodes (SLNs) for diagnosing metastases in early-stage cervical cancer patients.

METHODS

We consecutively included stage IA1-IIB1 cervical cancer patients who presented to our tertiary referral center between March 2011 and February 2015. Patients with enlarged lymph nodes (short axis ≥ 10 mm) on MRI were excluded. Patients underwent an SLN procedure with preoperative (99m)Tc-nanocolloid SPECT/CT-based SLN mapping. When fused datasets of the SPECT and MR images were created, SLNs could be identified on the MR image with accurate correlation to the histologic result of each individual SLN. An experienced radiologist, masked to histology, retrospectively reviewed all fused SPECT/MR images and scored morphologic SLN parameters on a standardized case report form. Logistic regression and receiver-operating curves were used to model the parameters against the SLN status.

RESULTS

In 75 cases, 136 SLNs were eligible for analysis, of which 13 (9.6%) contained metastases (8 cases). Three parameters-short-axis diameter, long-axis diameter, and absence of sharp demarcation-significantly predicted metastatic invasion of nonenlarged SLNs, with quality-adjusted odds ratios of 1.42 (95% confidence interval [CI], 1.01-1.99), 1.28 (95% CI, 1.03-1.57), and 7.55 (95% CI, 1.09-52.28), respectively. The area under the curve of the receiver-operating curves combining these parameters was 0.749 (95% CI, 0.569-0.930). Heterogeneous gadolinium enhancement, cortical thickness, round shape, or SLN size, compared with the nearest non-SLN, showed no association with metastases (P= 0.055-0.795).

CONCLUSION

In cervical cancer patients without enlarged lymph nodes, selective evaluation of only the SLNs-for size and absence of sharp demarcation-can be used to noninvasively assess the presence of metastases.

Preoperative tumor size at MRI predicts deep myometrial invasion, lymph node metastases, and patient outcome in endometrial carcinomas

Supplemental digital content is available in the text.

Objective

The aim of this study was to explore the relation between preoperative tumor size based on magnetic resonance imaging (MRI) and the surgical pathologic staging parameters (deep myometrial invasion, cervical stroma invasion, and metastatic lymph nodes) and to assess the prognostic impact of tumor size in endometrial carcinomas. Interobserver variability for the different tumor size measurements was also assessed.

Methods/Materials

Preoperative pelvic MRI of 212 patients with histologically confirmed endometrial carcinomas was read independently by 3 radiologists. Maximum tumor diameters were measured in 3 orthogonal planes (anteroposterior, transverse, and craniocaudal planes [CC]), and tumor volumes were estimated. Tumor size was analyzed in relation to surgical staging results and patient survival. The multivariate analyses were adjusted for preoperative risk status based on endometrial biopsy. Intraclass correlation coefficients and receiver operating characteristics curves for the different tumor measurements were also calculated.

Results

Anteroposterior tumor diameter independently predicted deep myometrial invasion (P < 0.001), whereas CC tumor diameter tended to independently predict lymph node metastases (P = 0.06). Based on receiver operating characteristic curves, the following tumor size cutoff values were identified: anteroposterior diameter greater than 2 cm predicted deep myometrial invasion (unadjusted odds ratio [OR], 12.4; P < 0.001; adjusted OR, 6.7; P < 0.001) and CC diameter greater than 4 cm predicted lymph node metastases (unadjusted OR, 6.2; P < 0.001; adjusted OR, 4.9; P = 0.009). Large tumor size was associated with reduced progression/recurrence-free survival (P ≤ 0.005 for all size parameters), and CC diameter had an independent impact on survival (adjusted hazards ratio, 1.04; P = 0.009). The interobserver variability for the different size measurements was very low (intraclass correlation coefficient, 0.78–0.85).

Conclusions

Anteroposterior tumor diameter greater than 2 cm predicts deep myometrial invasion, and CC tumor diameter greater than 4 cm predicts lymph node metastases. Tumor size is a strong prognostic factor in endometrial carcinomas. Preoperative tumor measurements based on MRI may potentially improve preoperative risk stratification models and thus enable better tailored surgical treatment in endometrial cancer.

Optimization of MR imaging for pretreatment evaluation of patients with endometrial and cervical cancer

Endometrial and cervical cancer are the most common gynecologic malignancies in the world. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. The current International Federation of Gynecology and Obstetrics (FIGO) staging system does not include modern imaging modalities. However, magnetic resonance (MR) imaging has proved to be the most accurate noninvasive modality for staging endometrial and cervical carcinomas and often helps with risk stratification and making treatment decisions. Multiparametric MR imaging is increasingly being used to evaluate the female pelvis, an approach that combines anatomic T2-weighted imaging with functional imaging (ie, dynamic contrast material-enhanced and diffusion-weighted imaging). MR imaging helps guide treatment decisions by depicting the depth of myometrial invasion and cervical stromal involvement in patients with endometrial cancer and tumor size and parametrial invasion in those with cervical cancer. However, its accuracy for local staging depends on technique and image quality, namely thin-section high-resolution multiplanar T2-weighted imaging with simple modifications, such as double oblique T2-weighting supplemented by diffusion weighting and contrast enhancement.

Uterine sarcoma vs adenocarcinoma: can MRI distinguish between them?

OBJECTIVE

To analyze the MRI characteristics of uterine sarcomas (mainly carcinosarcomas) and to compare them with those of adenocarcinomas to define the findings that would be useful for the differential diagnosis.

MATERIALS AND METHODS

We retrospectively reviewed the MRI studies of 13 patients with histologically diagnosed uterine sarcoma. We analyzed tumor size, signal in T2-weighted, unenhanced and gadolinium-enhanced T1-weighted, and diffusion-weighted sequences. We compared the data obtained with those of another series of 30 consecutive cases of adenocarcinomas studied with MRI.

RESULTS

The sarcomas (> 9cm in 77% of cases) were considerably larger than the adenocarcinomas (p<0.001). There were no differences in FIGO staging by MRI or surgery: both tumor types were diagnosed in early stages. The signal intensity in T2-weighted images differed significantly between the two tumor types: all the sarcomas were heterogeneous and predominantly hyperintense with respect to the myometrium in T2-weighted sequences (p<0.001). In postcontrast studies, all the sarcomas showed enhancement greater than or equal to the myometrium; this finding was significantly different from the adenocarcinomas (p<0.001). In diffusion-weighted sequences, we found no significant differences in ADC values in the areas with greatest restriction, but the ADC map was more heterogeneous in the sarcomas.

CONCLUSION

Uterine sarcomas do not have specific characteristics on MRI, but some findings can indicate the diagnosis. In our study, we found significant differences between sarcomas and adenocarcinomas. Sarcomas were larger, had more hyperintense and heterogeneous signal intensity in T2-weighted sequences, and enhanced more than or at least as much as the myometrium.

Second-Opinion Interpretations of Gynecologic Oncologic MRI Examinations by Sub-Specialized Radiologists Influence Patient Care

PURPOSE

To determine if second-opinion review of gynaecologic oncologic (GynOnc) magnetic resonance imaging (MRI) by sub-specialized radiologists impacts patient care.

METHODS

469 second-opinion MRI interpretations rendered by GynOnc radiologists were retrospectively compared to the initial outside reports. Two gynaecologic surgeons, blinded to the reports' origins, reviewed all cases with discrepancies between initial and second-opinion MRI reports and recorded whether these discrepancies would have led to a change in patient management defined as a change in treatment approach, counselling, or referral. Histopathology or minimum 6-month imaging follow-up were used to establish the diagnosis.

RESULTS

Second-opinion review of GynOnc MRIs would theoretically have affected management in 94/469 (20 %) and 101/469 (21.5 %) patients for surgeons 1 and 2, respectively. Specifically, second-opinion review would have theoretically altered treatment approach in 71/469 (15.1 %) and 60/469 (12.8 %) patients for surgeons 1 and 2, respectively. According to surgeons 1 and 2, these treatment changes would have prevented unnecessary surgery in 35 (7.5 %) and 31 (6.6 %) patients, respectively, and changed surgical procedure type/extent in 19 (4.1 %) and 12 (2.5 %) patients, respectively. Second-opinion interpretations were correct in 103 (83 %) of 124 cases with clinically relevant discrepancies between initial and second-opinion reports.

CONCLUSIONS

Expert second-opinion review of GynOnc MRI influences patient care.

KEY POINTS

• Outside gynaecologic oncologic MRI examinations are often submitted for a second-opinion review. • One-fifth of MRIs had important discrepancies between initial and second-opinion interpretations. • Second-opinion review of gynaecologic oncologic MRI is a valuable clinical service.

Incremental prognostic value of MRI in the staging of early cervical cancer: a prospective study and review of the literature

This is to evaluate the predictive ability of clinical examination and preoperative magnetic resonance imaging (MRI) for the staging of early cervical cancer. We prospectively evaluated 115 patients with cervical cancer, International Federation of Gynecologic and Obstetrics (FIGO) stage <IIB; receiver operating characteristic (ROC) analysis determined the predictive ability of MRI, clinical assessment, and their combination for tumor staging. Surgery was the standard of reference. MRI was more accurate than clinical examination for tumor estimate, parametrial or internal os involvement. When combined with MRI, the predictive ability of clinical examination for overall staging [area under the curve (AUC)=0.59, P>.05) increased significantly (AUC=0.84, P<.05). Our results support the official incorporation of MRI into FIGO classification system.

Integrated PET/MRI for whole-body staging of patients with primary cervical cancer: preliminary results

PURPOSE

To assess the diagnostic value of integrated PET/MRI for whole-body staging of cervical cancer patients, as well as to investigate a potential association between PET/MRI derived functional parameters and prognostic factors of cervical cancer.

METHODS

The present study was approved by the local institutional review board. Twenty-seven patients with histopathologically confirmed cervical cancer were prospectively enrolled in our study. All patients underwent a whole-body PET/MRI examination after written informed consent was obtained. Two radiologists separately evaluated the PET/MRI data sets regarding the determination of local tumor extent of primary cervical cancer lesions, as well as detection of nodal and distant metastases. Furthermore, SUV and ADC values of primary tumor lesions were analyzed and correlated with dedicated prognostic factors of cervical cancer. Results based on histopathology and cross-sectional imaging follow-up served as the reference standard.

RESULTS

PET/MRI enabled the detection of all 27 primary tumor lesions of the uterine cervix and allowed for the correct determination of the T-stage in 23 (85 %) out of the 27 patients. Furthermore, the calculated sensitivity, specificity and diagnostic accuracy for the detection of nodal positive patients (n = 11) were 91 %, 94 % and 93 %, respectively. PET/MRI correctly identified regional metastatic disease (N1-stage) in 8/10 (80 %) patients and non-regional lymph node metastases in 5/5 (100 %) patients. In addition, quantitative analysis of PET and MRI derived functional parameters (SUV; ADC values) revealed a significant correlation with pathological grade and tumor size (p < 0.05).

CONCLUSIONS

The present study demonstrates the high potential of integrated PET/MRI for the assessment of primary tumor and the detection of lymph node metastases in patients with cervical cancer. Providing additional prognostic information, PET/MRI may serve as a valuable diagnostic tool for cervical cancer patients in a pretreatment setting.

Magnetic resonance appearance of gastric-type adenocarcinoma of the uterine cervix in comparison with that of usual-type endocervical adenocarcinoma: a pitfall of newly described unusual subtype of endocervical adenocarcinoma

OBJECTIVE

The aim of this study was to evaluate the characteristics of gastric-type adenocarcinoma (GAS) of the uterine cervix, compared with usual-type endocervical adenocarcinoma (UEA) and squamous cell carcinoma (SCC), using magnetic resonance (MR) imaging.

MATERIALS AND METHODS

A total of 15 histopathologically defined GASs, 12 UEAs, and 40 SCCs were retrieved from archive files and were included for evaluation. Microscopic features, as well as topography and tumor growth pattern, and presence or absence of coexistence of cystic cavities were evaluated. Accuracy of evaluation for parametrial tissue and vaginal wall invasion was also evaluated by 2 diagnostic radiologists, independently, without clinical information on cases.

RESULTS

Thirteen (86.70%) of the 15 cases of GAS exhibited tumors in the higher portion of cervical canal or the entire cervix. On the other hand, SCCs and UEAs were mainly located in the lower portion of cervical canal, at a frequency of 21 of 40 (52.5%) and 9 of 12 (75.0%), respectively. Involvement of the corpus was observed more frequently in cases of GAS with an occurrence of 8 of 15 (53.3%), whereas in all cases of UEA and in 5 of the 40 cases of SCC, the corpus was free of tumor. In GAS cases, the predominant pattern of growth was highly infiltrating and endophytic (14/15, 93.3%), whereas an exophytic growth pattern was observed in 31 (77.5%) of the 40 SCC cases and 11 (91.7%) of the 12 UEA cases. Cystic cavities associated with tumors were identified in only 1 case of SCC but occurred in 12 (80.0%) of the 15 GASs and 4 (33.3%) of the 12 UEAs. Diagnostic accuracies of more than 70% and more than 60% were reached in parametrial invasion and vaginal invasion, respectively, in GAS.

CONCLUSION

Distinctive MR imaging features of GAS were infiltrating mass of endophytic growth, location in the upper cervical canal, and association with tiny cysts. This characteristic appearance can be a clue for the evaluation of extent of tumor based on MR imaging.

Metabolic Tumor Volume on 18F-FDG PET/CT Improves Preoperative Identification of High-Risk Endometrial Carcinoma Patients

Our objective was to prospectively explore the diagnostic value of (18)F-FDG PET/CT for preoperative staging in endometrial carcinomas and to investigate whether (18)F-FDG PET-specific quantitative tumor parameters reflect clinical and histologic characteristics.

METHODS

Preoperative (18)F-FDG PET/CT was prospectively performed on 129 consecutive endometrial carcinoma patients. Two physicians who did not know the clinical findings or staging results independently reviewed the images, assessing primary tumor, cervical stroma involvement and metastatic spread, and determining maximum and mean standardized uptake value (SUVmax and SUVmean, respectively) for tumor, metabolic tumor volume (MTV), and total lesion glycolysis (TLG). All parameters were analyzed in relation to histomorphologic and clinical tumor characteristics. Receiver-operating-characteristic curves for identification of deep myometrial invasion and lymph node metastases were generated, and MTV cutoffs for predicting deep myometrial invasion and lymph node metastases were calculated.

RESULTS

The sensitivity, specificity, and accuracy of (18)F-FDG PET/CT for the detection of lymph node metastases were 77%-85%, 91%-96%, and 89%-93%, respectively. SUVmax, SUVmean, MTV, and TLG were significantly related to deep myometrial invasion, presence of lymph node metastases, and high histologic grade (P < 0.015 for all) and independently predicted deep myometrial invasion (P < 0.015) and lymph node metastases (P < 0.025) after adjustment for preoperative histologic risk (based on subtype and grade) in endometrial biopsies. Optimal cutoffs for MTV in predicting deep myometrial invasion (20 mL) and the presence of lymph node metastases (30 mL) yielded odds ratios of 7.8 (P < 0.001) and 16.5 (P = 0.001), respectively.

CONCLUSION

(18)F-FDG PET/CT represents a clinically valuable tool for preoperatively evaluating the presence of lymph node metastases in endometrial carcinoma patients. Applying MTV cutoffs for the prediction of deep myometrial invasion and lymph node metastases may increase diagnostic accuracy and aid preoperative identification of high-risk patients, enabling restriction of lymphadenectomy for patients with a low risk of aggressive disease.

PET/MRI and PET/CT in advanced gynaecological tumours: initial experience and comparison

PURPOSE

To compare the diagnostic accuracy of PET/MRI and PET/CT for staging and re-staging advanced gynaecological cancer patients as well as identify the potential benefits of each method in such a population.

MATERIAL AND METHODS

Twenty-six patients with suspicious or proven advanced gynaecological cancer (12 ovarian, seven cervical, one vulvar and four endometrial tumours, one uterine metastasis, and one primary peritoneal cancer) underwent whole-body imaging with a sequential trimodality PET/CT/MR system. Images were analysed regarding primary tumour detection and delineation, loco-regional lymph node staging, and abdominal/extra-abdominal distant metastasis detection (last only by PET/CT).

RESULTS

Eighteen (69.2 %) patients underwent PET/MRI for primary staging and eight patients (30.8 %) for re-staging their gynaecological malignancies. For primary tumour delineation, PET/MRI accuracy was statistically superior to PET/CT (p < 0.001). Among the different types of cancer, PET/MRI presented better tumour delineation mainly for cervical (6/7) and endometrial (2/3) cancers. PET/MRI for local evaluation as well as PET/CT for extra-abdominal metastases had therapeutic consequences in three and one patients, respectively. PET/CT detected 12 extra-abdominal distant metastases in 26 patients.

CONCLUSION

PET/MRI is superior to PET/CT for primary tumour delineation. No differences were found in detection of regional lymph node involvement and abdominal metastases detection.

KEY POINTS

• PET/MRI is superior to PET/CT for primary tumour delineation • PET/CT represents a reliable tool to detect extra-abdominal distant metastasis • PET/MRI might be the preferred imaging modality for staging cervical and endometrial tumours • Whole-body staging for detection and evaluation of extra-abdominal metastases is mandatory.

Imaging in endometrial carcinoma

Endometrial carcinoma (EC) is the most common gynecologic malignancy in the United States. Prognosis depends on patient age, histological grade, depth of myometrial invasion and/or cervical invasion, and the presence of lymph node metastases. Although EC is staged surgically according to the International Federation of Gynecology and Obstetrics (FIGO) system, preoperative imaging can assist in optimal treatment planning. Several imaging techniques such as transvaginal ultrasonography (TVUS), computed tomography (CT), and magnetic resonance imaging (MRI) have been used as diagnostic tools for preoperative staging of EC. Recently, positron emission tomography (PET), PET/CT, and PET/MRI have also been used in staging these patients. In this article, we review the value of imaging in diagnosis, staging, treatment planning, and detection of recurrent disease in patients with EC.

Standardized uptake value and apparent diffusion coefficient of endometrial cancer evaluated with integrated whole-body PET/MR: Correlation with pathological prognostic factors

PURPOSE

To evaluate the correlation between maximum standardized uptake value (SUVmax ) and minimum apparent diffusion coefficient (ADCmin ) of endometrial cancer derived from an integrated positron emission tomography / magnetic resonance (PET/MR) system and to determine their correlation with pathological prognostic factors.

MATERIALS AND METHODS

This prospective study was approved by the Institutional Review Board of the hospital, and informed consent was obtained. Between April and December 2014, 47 consecutive patients with endometrial cancer were enrolled and underwent simultaneous PET/MR examinations before surgery. Thirty-six patients with measurable tumors on PET/MR were included for image analysis. Pearson's correlation coefficient was used to evaluate the correlation between SUVmax and ADCmin of the tumors. The Mann-Whitney U-test was utilized to evaluate relationships between these two imaging biomarkers and pathological prognostic factors.

RESULTS

The mean SUVmax and ADCmin were 14.7 ± 7.1 and 0.48 ± 0.13 × 10(-3) mm(2) /s, respectively. A significant inverse correlation was found between SUVmax and ADCmin (r = -0.53; P = 0.001). SUVmax was significantly higher in tumors with advanced stage, deep myometrial invasion, cervical invasion, lymphovascular space involvement, and lymph node metastasis (P < 0.05). ADCmin was lower in tumors with higher grade, advanced stage, and cervical invasion (P < 0.05). The ratio of SUVmax to ADCmin was higher in tumors with higher grade, advanced stage, deep myometrial invasion, cervical invasion, lymphovascular space involvement, and lymph node metastasis (P < 0.05).

CONCLUSION

SUVmax and ADCmin of endometrial cancer derived from integrated PET/MR are inversely correlated and are associated with pathological prognostic factors.

Staging for cervix cancer: Role of radiology, surgery and clinical assessment

Staging is necessary in determining the extent of disease, its prognosis and in the formulation of optimal treatment protocols for patients with cancer. Clinical examination of patients and subsequent histopathological assessment when available has traditionally been used to determine the application of different primary and adjuvant treatment modalities. Over the years, surgery, radiotherapy and chemotherapy all have been used either singly or in combinations, and the resulting survival and patterns of failure studies have contributed much in the development of less toxic and more effective protocols. All three modalities of treatments work through separate mechanisms, and they are effective in different stages of cervix cancer. Even within the same stage, the extent of the disease, tumour volume, tissue infiltration and lymph-node metastases requires the use of differing protocols for the disease control. More recently, advances in magnetic resonance imaging (MRI) and positron emission tomography/computerised tomography (PET/CT) have made it possible to examine many of the prognostic factors non-invasively. In addition to clinical assessment, surgical and radiological staging has enabled us to triage patients far more accurately for surgery or for primary radiotherapy, such as unnecessary multimodality treatments are avoided. Only patients with poor prognosis are subjected to a combined modality treatment. Those with poorer prognosis still can be selected for clinical studies exploring new treatment.

Imaging techniques for the evaluation of cervical cancer

Improvements in the treatment of cervical carcinoma have made it possible to offer optimal and personalised treatment. Cervical cancer staging is based on clinical examination and histological findings. Many diagnostic methods are used in clinical practice. Magnetic resonance imaging is considered the optimal method for staging cervical carcinoma because of its high accuracy in assessing local extension of disease and distant metastases. Ultrasound has gained increased attention in recent years; it is faster, cheaper, and more widely available than other imaging techniques, and is highly accurate in detecting tumour presence and evaluating local extension of disease. Magnetic resonance imaging and ultrasound are often used together with computed tomography or positron emission tomography combined with computed tomography to assess the whole body, a more accurate detection of pathological lymph nodes and metabolic information of the disease.

Development and external validation of new ultrasound-based mathematical models for preoperative prediction of high-risk endometrial cancer

OBJECTIVES

To develop and validate strategies, using new ultrasound-based mathematical models, for the prediction of high-risk endometrial cancer and compare them with strategies using previously developed models or the use of preoperative grading only.

METHODS

Women with endometrial cancer were prospectively examined using two-dimensional (2D) and three-dimensional (3D) gray-scale and color Doppler ultrasound imaging. More than 25 ultrasound, demographic and histological variables were analyzed. Two logistic regression models were developed: one 'objective' model using mainly objective variables; and one 'subjective' model including subjective variables (i.e. subjective impression of myometrial and cervical invasion, preoperative grade and demographic variables). The following strategies were validated: a one-step strategy using only preoperative grading and two-step strategies using preoperative grading as the first step and one of the new models, subjective assessment or previously developed models as a second step.

RESULTS

One-hundred and twenty-five patients were included in the development set and 211 were included in the validation set. The 'objective' model retained preoperative grade and minimal tumor-free myometrium as variables. The 'subjective' model retained preoperative grade and subjective assessment of myometrial invasion. On external validation, the performance of the new models was similar to that on the development set. Sensitivity for the two-step strategy with the 'objective' model was 78% (95% CI, 69-84%) at a cut-off of 0.50, 82% (95% CI, 74-88%) for the strategy with the 'subjective' model and 83% (95% CI, 75-88%) for that with subjective assessment. Specificity was 68% (95% CI, 58-77%), 72% (95% CI, 62-80%) and 71% (95% CI, 61-79%) respectively. The two-step strategies detected up to twice as many high-risk cases as preoperative grading only. The new models had a significantly higher sensitivity than did previously developed models, at the same specificity.

CONCLUSION

Two-step strategies with 'new' ultrasound-based models predict high-risk endometrial cancers with good accuracy and do this better than do previously developed models.

MR diffusion imaging for preoperative staging of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis

OBJECTIVES

To compare the diagnostic accuracy of dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MR imaging in detecting deep myometrial invasion in endometrial cancer, using surgical-pathological staging as reference standard.

METHODS

After searching a wide range of electronic databases and screening titles/abstracts, we obtained full papers for potentially eligible studies and evaluated according to predefined inclusion criteria. Quality assessment was conducted by adapting the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. From each study, we extracted information on diagnostic performance of DW and DCE sequences. After exploring heterogeneity, we adopted a bivariate generalized linear mixed model to compare the effect of the two MR sequences jointly on sensitivity and specificity.

RESULTS

Nine studies (442 patients) were considered. Significant evidence of heterogeneity was found only for specificity, both in DW and DCE imaging (I (2)  = 70.8 % and 70.6 %). Pooled sensitivity of DW and DCE was 0.86 and specificity did not significantly differ (p = 0.16) between the two sequences (DW = 0.86 and DCE = 0.82). No difference was found between 3-T and 1.5-T MR. There was no evidence of publication bias.

CONCLUSIONS

MR diagnostic accuracy in presurgical detection of deep myometrial infiltration in endometrial cancer is high. DCE and DW imaging do not differ in sensitivity and specificity.

KEY POINTS

Myometrial invasion is the most important morphological prognostic feature of endometrial cancer. MR diagnostic accuracy in presurgical detection of deep myometrial infiltration is high. MR examination including T2 and DCE imaging is considered the reference standard. DW imaging has been increasingly employed with heterogeneous results. This meta-analysis shows that DCE and DW do not differ in diagnostic accuracy.

Anatomical and functional volume concordance between FDG PET, and T2 and diffusion-weighted MRI for cervical cancer: a hybrid PET/MR study

PURPOSE

To evaluate the concordance among (18)F-FDG PET imaging, MR T2-weighted (T2-W) imaging and apparent diffusion coefficient (ADC) maps with diffusion-weighted (DW) imaging in cervical cancer using hybrid whole-body PET/MR.

METHODS

This study prospectively included 35 patients with cervical cancer who underwent pretreatment (18)F-FDG PET/MR imaging. (18)F-FDG PET and MR images were fused using standard software. The percent of the maximum standardized uptake values (SUV max) was used to contour tumours on PET images, and volumes were calculated automatically. Tumour volumes measured on T2-W and DW images were calculated with standard techniques of tumour area multiplied by the slice profile. Parametric statistics were used for data analysis.

RESULTS

FDG PET tumour volumes calculated using SUV max (14.30 ± 4.70) and T2-W imaging volume (33.81 ± 27.32 cm(3)) were similar (P > 0.05) at 35 % and 40 % of SUV max (32.91 ± 18.90 cm(3) and 27.56 ± 17.19 cm(3) respectively) and significantly correlated (P < 0.001; r = 0.735 and 0.766). The mean DW volume was 30.48 ± 22.41 cm(3). DW volumes were not significantly different from FDG PET volumes at either 35 % SUV max or 40 % SUV max or from T2-W imaging volumes (P > 0.05). PET subvolumes with increasing SUV max cut-off percentage showed an inverse change in mean ADC values on DW imaging (P < 0.001, ANOVA).

CONCLUSION

Hybrid PET/MR showed strong volume concordance between FDG PET, and T2-W and DW imaging in cervical cancer. Cut-off at 35 % or 40 % of SUV max is recommended for (18)F-FDG PET/MR SUV-based tumour volume estimation. The linear tumour subvolume concordance between FDG PET and DW imaging demonstrates individual regional concordance of metabolic activity and cell density.

Gynecologic tumors: how to communicate imaging results to the surgeon

Gynecologic cancers are a leading cause of morbidity and mortality for female patients, with an estimated 88,750 new cancer cases and 29,520 deaths in the United States in 2012. To offer the best treatment options to patients it is important that the radiologist, surgeon, radiation oncologist, and gynecologic oncologist work together with a multidisciplinary approach. Using the available diagnostic imaging modalities, the radiologist must give appropriate information to the surgeon in order to plan the best surgical approach and its timing.

Monitoring response to cytostatic cisplatin in a HER2(+) ovary cancer model by MRI and in vitro and in vivo MR spectroscopy

Background:

Limited knowledge is available on alterations induced by cytostatic drugs on magnetic resonance spectroscopy (MRS) and imaging (MRI) parameters of human cancers, in absence of apoptosis or cytotoxicity. We here investigated the effects of a cytostatic cisplatin (CDDP) treatment on ¹H MRS and MRI of HER2-overexpressing epithelial ovarian cancer (EOC) cells and in vivo xenografts.

Methods:

High-resolution MRS analyses were performed on in vivo passaged SKOV3.ip cells and cell/tissue extracts (16.4 or 9.4 T). In vivo MRI/MRS quantitative analyses (4.7 T) were conducted on xenografts obtained by subcutaneous implantation of SKOV3.ip cells in SCID mice. The apparent diffusion coefficient (ADC) and metabolite levels were measured.

Results:

CDDP-induced cytostatic effects were associated with a metabolic shift of cancer cells towards accumulation of MRS-detected neutral lipids, whereas the total choline profile failed to be perturbed in both cultured cells and xenografts. In vivo MRI examinations showed delayed tumour growth in the CDDP-treated group, associated with early reduction of the ADC mean value.

Conclusion:

This study provides an integrated set of information on cancer metabolism and physiology for monitoring the response of an EOC model to a cytostatic chemotherapy, as a basis for improving the interpretation of non-invasive MR examinations of EOC patients.

The Role of (18) F-FDG PET/CT in Assessing Therapy Response in Cervix Cancer after Concurrent Chemoradiation Therapy

PURPOSE

To determine whether persisting cervical fluorodeoxyglucose (FDG) uptake after concurrent chemoradiotherapy (CCRT) for cervical cancer can reflect residual malignancy.

METHODS

F-FDG PET/CT was performed before and after CCRT in 136 patients with cervical cancer. The maximum and mean standardized uptake values (SUVmax and SUVmean) were recorded from PET/CT scans performed pre- and post-treatment. SUVs were correlated with treatment response after CCRT. Final treatment response was determined by MRI and further follow-up PET/CT. One hundred four of 136 patients underwent pelvic MRI, and 32 of 136 patients underwent further follow-up PET/CT. Patients were classified into two categories: patients with residual tumor or patients without residual tumor (complete responder). Pre- and post-treatment serum squamous cell carcinoma antigen (SCC) levels were also recorded for comparison. The optimal cutoff value of SUVmax for predicting residual cervical tumor was determined using receiver-operating characteristic (ROC) analysis.

RESULTS

Of 136 patients, 124 showed complete response on further follow-up studies and 12 were confirmed to have residual tumor. The post-treatment SUVmax and pre-/post-treatment SUVmean of complete responders were significantly lower than those of patients with residual tumor: 2.5 ± 0.8 and 7.2 ± 4.2/1.9 ± 0.7 for complete responders and 5.7 ± 2.6 and 12.8 ± 6.9/3.7 ± 0.7 for patients with residual tumor (p < 0.05). The pre-treatment SUVmax and pre-/post-treatment serum SCC levels of the complete responders tended to be lower than those of patients with residual tumor, but this did not have statistical significance. Using ROC analysis, an optimal cutoff SUVmax of 4.0 on the post-treatment PET/CT yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92 %, 94 %, 61 %, and 99 %, respectively (p < 0.001).

CONCLUSIONS

Persistent cervical FDG uptake in(18)F-FDG PET/CT after CCRT for cervical cancer may be caused by residual tumor or post-therapy inflammation. A higher cutoff SUVmax than conventional criteria for cervical cancer in post-CCRT PET/CT might help to detect residual tumor.