Effects of external radiotherapy on uterine blood flow in patients with advanced cervical carcinoma assessed by color Doppler ultrasonography

Assessment of cervical vascularization density in patients with locally advanced squamous cell cervical carcinoma evaluated in colour Doppler and power Doppler functions

Purpose

The aim of the prospective study was to assess changes during treatment and prognostic significance of cervical vascularization density in patients with cervical squamous cell carcinoma (SCC) staged II B and III B and to find relationship of cervical vascularization density with tumour diameter, grading, staging and age of patients.

Methods

The study group included 50 patients who underwent transvaginal Doppler ultrasonography prior to chemoradiotherapy, after external beam radiation therapy (EBRT) and 6 weeks after HDR brachytherapy. The colour Doppler (CD) vascularity index (CDVI) and the power Doppler (PD) vascularity index (PDVI) in cervical tumour were examined.

Results

CDVI and PDVI values decreased significantly during radiotherapy (0.13 (95% CI 0.09–0.16); 0.09 (95% CI 0.07–0.11) and 0.05 (95% CI 0.03–0.06) for CDVI (p < 0.001) and 0.26 (95% CI 0.22–0.31); 0.18 (95% CI 0.14–0.22) and 0.08 (95% CI 0.06–0.11) for PDVI (p < 0.001)). No statistically significant associations of CDVI and PDVI with tumour diameter, grading, staging and age of patients were found. The higher (above median) CDVI values before EBRT were associated with better OS (p = 0.041). The higher (above median) PDVI values before EBRT were associated with superior DFS (p = 0.011) and OS (p < 0.001). DFS and OS did not differ significantly regarding CDVI and PDVI values after EBRT and after the treatment.

Conclusions

In the study group, cervical vascularization density evaluated in CD and PD functions did not depend on tumour diameter, grading, staging and age of patients and decreased during radiotherapy. The prognosis for our patients with CDVI and PDVI before the treatment above the median value was better than compared to patients with these parameters below the median value.

Assessment of cervical volume and spectral Doppler parameters in tumour dominant vessel of patients with locally advanced squamous cell cervical carcinoma

We evaluated cervical volume and spectral Doppler parameters: peak systolic velocity (PSV), resistance index (RI) and pulsatility index (PI) in the tumour dominant vessel of 50 patients with cervical squamous cell carcinoma (SCC) staged IIB and IIIB and their changes during treatment. The patients underwent transvaginal Doppler ultrasonography prior to treatment, after external beam radiation therapy (EBRT) and 6 weeks after brachytherapy. Radiotherapy decreased cervical volume and PSV values of the tumour dominant vessel. The PSV values before EBRT in G1 + G2 tumours were higher than in G3 tumours. No correlations between cervical volume, PSV, RI and PI values with disease-free survival (DFS) and overall survival (OS) were found. We concluded, that sonographic assessment of changes in cervical volume of patients with locally advanced cervical SCC during treatment did not allow to predict treatment results. Spectral Doppler parameters PSV, RI and PI of tumour dominant vessel did not predict prognosis for these patients.Impact StatementWhat is already known on this subject? Transvaginal Doppler sonography is considered as a useful diagnostic method in patients with cervical carcinoma. However, despite numerous studies, the value of spectral Doppler parameters in tumour dominant vessel and cervical volume of patients with locally advanced cervical SCC is still not well defined.What the results of this study add? In our prospective study, we found that sonographic assessment of changes in cervical volume of patients with locally advanced cervical SCC during treatment did not allow to predict treatment results and spectral Doppler parameters of tumour dominant vessel did not predict prognosis for these patients.What the implications are of these findings for clinical practice and/or further research? Our study underlines the limited value of spectral Doppler technique in patients with cervical carcinoma. Further research should be focussed on identifying and validating novel prognostic and predictive factors.

Advanced Magnetic Resonance Imaging Techniques in Management of Brain Metastases

Brain metastases are the most common intracranial tumors and occur in 20–40% of all cancer patients. Lung cancer, breast cancer, and melanoma are the most frequent primary cancers to develop brain metastases. Treatment options include surgical resection, whole brain radiotherapy, stereotactic radiosurgery, and systemic treatment such as targeted or immune therapy. Anatomical magnetic resonance imaging (MRI) of the tumor (in particular post-Gadolinium T₁-weighted and T₂-weighted FLAIR) provide information about lesion morphology and structure, and are routinely used in clinical practice for both detection and treatment response evaluation for brain metastases. Advanced MRI biomarkers that characterize the cellular, biophysical, micro-structural and metabolic features of tumors have the potential to improve the management of brain metastases from early detection and diagnosis, to evaluating treatment response. Magnetic resonance spectroscopy (MRS), chemical exchange saturation transfer (CEST), quantitative magnetization transfer (qMT), diffusion-based tissue microstructure imaging, trans-membrane water exchange mapping, and magnetic susceptibility weighted imaging (SWI) are advanced MRI techniques that will be reviewed in this article as they pertain to brain metastases.

Temporal evolution of perfusion parameters in brain metastases treated with stereotactic radiosurgery: comparison of intravoxel incoherent motion and dynamic contrast enhanced MRI

Intravoxel incoherent motion (IVIM) is a magnetic resonance imaging (MRI) technique that is seeing increasing use in neuro-oncology and offers an alternative to contrast-enhanced perfusion techniques for evaluation of tumor blood volume after stereotactic radiosurgery (SRS). To date, IVIM has not been validated against contrast enhanced techniques for brain metastases after SRS. In the present study, we measure blood volume for 20 brain metastases (15 patients) at baseline, 1 week and 1 month after SRS using IVIM and dynamic contrast enhanced (DCE)-MRI. Correlation between blood volume measurements made with IVIM and DCE-MRI show poor correlation at baseline, 1 week, and 1 month post SRS (r = 0.33, 0.14 and 0.30 respectively). At 1 week after treatment, no significant change in tumor blood volume was found using IVIM or DCE-MRI (p = 0.81 and 0.41 respectively). At 1 month, DCE-MRI showed a significant decrease in blood volume (p = 0.0002). IVIM, on the other hand, demonstrated the opposite effect and showed a significant increase in blood volume at 1 month (p = 0.03). The results of this study indicate that blood volume measured with IVIM and DCE-MRI are not equivalent. While this may relate to differences in the type of perfusion information each technique is providing, it could also reflect a limitation of tumor blood volume measurements made with IVIM after SRS. IVIM measurements of tumor blood volume in the month after SRS should therefore be interpreted with caution.

Hypoxia-Related Marker GLUT-1, CAIX, Proliferative Index and Microvessel Density in Canine Oral Malignant Neoplasia

For various types of tumor therapy, it is suggested that co-targeting of tumor microenvironment, mainly tumor vasculature, mediates tumor response mechanisms. Immunohistochemistry for glucose transporter-1 (GLUT-1), carbonic anhydrase-IX (CAIX), Ki-67, and von Willebrand factor VIII for microvessel density (MVD) were performed on formalin-fixed paraffin-embedded samples of canine oral malignant neoplasms. Polarographic oxygen measurements (median pO2) and perfusion data via contrast-enhanced power Doppler ultrasound (median vascularity, median blood volume) provided additional information. Ninety-two samples were analyzed: sarcomas (n = 32), carcinomas (n = 30), and malignant melanomas (n = 30). Polarographic oxygen and perfusion data was available in 22.8% (sarcomas n = 9, carcinomas n = 7, melanomas n = 5), and 27.1% (sarcomas n = 10, carcinomas n = 8, melanomas n = 7) of cases, respectively. GLUT-1 expression was detected in 46.7% of all samples, and was generally weak. CAIX expression was found in 34.8% of all samples. Median Ki-67 score and MVD count was 19% and 17, respectively. The evaluation of the GLUT-1 score and continuous data showed significantly lower GLUT-1 levels in sarcomas (mean 5.1%, SD 6.2) versus carcinomas and melanomas (mean 16.5%/ 19.0%, SD 17.3/ 20.9, p = 0.001). The expression of CAIX correlated mildly positively with GLUT-1 (p = 0.018, rho = 0.250) as well as with Ki-67 (p = 0.014, rho = 0.295). MVD showed a significantly lower level in melanomas (mean 12.6, SD 7.7) versus sarcomas and carcinomas (mean 21.8/ 26.9, SD 13.0/20.4, p = 0.001). Median vascularity and blood volume were significantly lower in sarcomas (mean 10.4%, SD 11.0, and mean 6.3%, SD 6.5, respectively) versus carcinomas (mean 39.2%, SD 16.4 and mean 33.0%, SD 25.6, respectively) and melanomas (mean 36.0%, SD 18.3, and 31.5%, SD 24.5). Between the 3 histological groups, there was neither a significant difference in the GLUT-1 and CAIX score and continuous data, nor the Ki67 score, or polarographic oxygen measurements. GLUT-1 continuous data and Ki-67 (p<0.001, rho = 0.403), as well as Ki-67 and MVD (p = 0.029, rho = 0.228) correlated positively and a mild correlation was found between vascularity and GLUT-1 (p = 0.043, rho = 0.408). GLUT-1, CAIX, proliferative index and MVD levels were established as microenvironmental descriptors with the purpose of creating a baseline in order to follow changes seen in the tumor microenvironment after hypofractionated radiation with high doses.

The role of ultrasound in the assessment of uterine cervical cancer

Uterine cervical cancer is the second most frequent gynecological malignancy worldwide. The assessment of the extent of disease is essential for planning optimal treatment. Imaging techniques are increasingly used in the pre-treatment work-up of cervical cancer. Currently, MRI for local extent of disease evaluation and PET-scan for distant disease assessment are considered as first-line techniques. Notwithstanding, in the last few years, ultrasound has gained attention as an imaging technique for evaluating women with cervical cancer. In this paper, current knowledge about the use of ultrasound for assessing uterine cervical cancer will be reviewed and discussed.

Radiation-induced vascular damage in tumors: implications of vascular damage in ablative hypofractionated radiotherapy (SBRT and SRS)

We have reviewed the studies on radiation-induced vascular changes in human and experimental tumors reported in the last several decades. Although the reported results are inconsistent, they can be generalized as follows. In the human tumors treated with conventional fractionated radiotherapy, the morphological and functional status of the vasculature is preserved, if not improved, during the early part of a treatment course and then decreases toward the end of treatment. Irradiation of human tumor xenografts or rodent tumors with 5-10 Gy in a single dose causes relatively mild vascular damages, but increasing the radiation dose to higher than 10 Gy/fraction induces severe vascular damage resulting in reduced blood perfusion. Little is known about the vascular changes in human tumors treated with high-dose hypofractionated radiation such as stereotactic body radiotherapy (SBRT) or stereotactic radiosurgery (SRS). However, the results for experimental tumors strongly indicate that SBRT or SRS of human tumors with doses higher than about 10 Gy/fraction is likely to induce considerable vascular damages and thereby damages the intratumor microenvironment, leading to indirect tumor cell death. Vascular damage may play an important role in the response of human tumors to high-dose hypofractionated SBRT or SRS.

Assessment of changes in vascularity and blood volume in canine sarcomas and squamous cell carcinomas during fractionated radiation therapy using quantified contrast-enhanced power Doppler ultrasonography: a preliminary study

Radiation therapy does not only target tumour cells but also affects tumour vascularity. In the present study, changes in tumour vascularity and blood volume were investigated in five grade 1 oral fibrosarcomas, eight other sarcomas (non-oral soft tissue and bone sarcomas) and 12 squamous cell carcinomas in dogs during fractionated radiation therapy (total dose, 45-56 Gy). Contrast-enhanced power Doppler ultrasound was performed before fraction 1, 3, 6, 8, 10, 12, 14 and 15 or 16 (sarcomas) or 17 (squamous cell carcinomas). Prior to treatment, median vascularity and blood volume were significantly higher in squamous cell carcinomas (P=0.0005 and 0.001), whereas measurements did not differ between oral fibrosarcomas and other sarcomas (P=0.88 and 0.999). During the course of radiation therapy, only small, non-significant changes in vascularity and blood volume were observed in all three tumour histology groups (P=0.08 and P=0.213), whereas median tumour volume significantly decreased until the end of treatment (P=0.04 for fibrosarcomas and other sarcomas, P=0.008 for squamous cell carcinomas). It appeared that there was a proportional decrease in tumour volume, vascularity and blood volume. Doppler measurements did not predict progression free interval or survival in any of the three tumour groups (P=0.06-0.86). However, the number of tumours investigated was small and therefore, the results can only be considered preliminary.

Noninvasive diffuse optical measurement of blood flow and blood oxygenation for monitoring radiation therapy in patients with head and neck tumors: a pilot study

This pilot study explores the potential of noninvasive diffuse correlation spectroscopy (DCS) and diffuse reflectance spectroscopy (DRS) for monitoring early relative blood flow (rBF), tissue oxygen saturation (StO(2)), and total hemoglobin concentration (THC) responses to chemo-radiation therapy in patients with head and neck tumors. rBF, StO(2), and THC in superficial neck tumor nodes of eight patients are measured before and during the chemo-radiation therapy period. The weekly rBF, StO(2), and THC kinetics exhibit different patterns for different individuals, including significant early blood flow changes during the first two weeks. Averaged blood flow increases (52.7+/-9.7)% in the first week and decreases (42.4+/-7.0)% in the second week. Averaged StO(2) increases from (62.9+/-3.4)% baseline value to (70.4+/-3.2)% at the end of the second week, and averaged THC exhibits a continuous decrease from pretreatment value of (80.7+/-7.0) [microM] to (73.3+/-8.3) [microM] at the end of the second week and to (63.0+/-8.1) [microM] at the end of the fourth week of therapy. These preliminary results suggest daily diffuse-optics-based therapy monitoring is feasible during the first two weeks and may have clinical promise.

Transvaginal color Doppler sonography for predicting response to concurrent chemoradiotherapy for locally advanced cervical carcinoma

PURPOSE

This study was conducted to evaluate the potential role of transvaginal color Doppler sonography (TVCD) in predicting response to concurrent chemoradiotherapy for locally advanced cervical cancer.

METHODS AND MATERIALS

Tumor vascularity was assessed using TVCD before the start of concurrent chemoradiotherapy in 21 patients (median age, 47 years; range, 31-75 years) with histologically proven locally advanced cervical cancer. The lowest resistance index (RI), lowest pulsatility index (PI), and highest peak systolic velocity (PSV) from central vessels within the tumor were recorded and used for analysis. All patients were clinically evaluated by physical examination and CT scanning after completing the chemoradiotherapy protocol. Complete clinical response (CR) was determined when no residual tumor was found. Partial clinical response (PR) was determined when the tumor volume had decreased more than 50%.

RESULTS

CR was achieved in 11 patients (52%), whereas 10 (48%) had PR. The initial median tumor volume was not statistically different between those with CR (26 cm3) and those with PR (28 cm3) (p = 0.71). RI was higher in those tumors with CR (median, 0.47) than in those with PR (median, 0.29) (p < 0.01). Likewise, PI was higher in tumors with CR (median, 0.81) than in those with PR (median, 0.41) (p < 0.01). No differences were found in PSV. The likelihood ratio for CR for tumors with a lowest RI of 0.35 or more was 2.7 (95% confidence interval, 1.8-3.6) and the likelihood ratio for CR for tumors with a lowest PI of 0.45 or more was 3.3 (95% confidence interval, 2.1-4.5).

CONCLUSIONS

The results suggest that TVCD may be useful in predicting clinical response to concurrent chemoradiation in patients with locally advanced cervical cancer.

Angiographic power 3-dimensional quantitative analysis in gynecologic solid tumors: feasibility and reproducibility

OBJECTIVE

To determine the reproducibility of a simplified method of power Doppler 3-dimensional (3D) sonographic examination.

METHODS

Twenty-nine patients with solid pelvic masses underwent transvaginal 3D power Doppler evaluation. The volume of interest was obtained by drawing the margins of the largest section of the mass in the 3 orthogonal planes. The 3D vascular parameters ("relative color," "average color," and "flow measure") obtained by our method were compared with those calculated by a manufacturer-suggested model based on several parallel section planes drawn on the longitudinal frames. The intraobserver variability was quantified on 5 different 3D images acquired by the same operator at 5-minute intervals for each patient. The intraobserver variability was also assayed in 10 patients at 24-hour intervals. Ten patients were scanned by a second sonographer for interobserver variability.

RESULTS

There was high agreement between the 3D parameters obtained with the 2 methods. The 3D indices were similar in repeated observations at 5-minute intervals (median coefficients of variation for relative color, average color, and flow measure, 10.9, 4.5, and 13.0, respectively) and at 24-hour intervals (intraclass correlation coefficients for relative color, average color, and flow measure, 0.920, 0.978, and 0.978) and by the second sonographer (interclass correlation coefficients for relative color, average color, and flow measure, 0.978, 0.966, and 0.997).

CONCLUSIONS

The acceptable rates of intraobserver and interobserver variability make this approach potentially suitable for research protocols.

Intra- and intertumor heterogeneity in blood perfusion of human cervical cancer before treatment and after radiotherapy

Knowledge of the intratumor heterogeneity in blood perfusion may lead to increased understanding of tumor response to treatment. In the present work, absolute perfusion values, in units of ml/g.min, were determined in 20 tumor subregions of patients with cervical cancer before treatment (n = 12) and after 2 weeks of radiotherapy (n = 8), by using a method based on contrast-enhanced magnetic resonance imaging. The aims were to evaluate the intratumor heterogeneity in perfusion in relation to the intertumor heterogeneity and to search for changes in the heterogeneities during the early phase of therapy. The intra- and intertumor heterogeneity in perfusion were estimated from components of one-way analyses of variance. The mean perfusion differed significantly among the patients before treatment, ranging from 0.044 to 0.12 ml/g x min. Large differences in perfusion were also observed within individual tumors. The heterogeneity was largest in the best perfused tumors, perfusion values ranging, e.g., from 0.055 to 0.29 ml/g x min were observed. The intratumor heterogeneity was similar to the intertumor heterogeneity. The mean perfusion generally increased or tended to increase during radiotherapy, ranging from 0.064 ml/g x min to 0.13 ml/g x min after 2 weeks of treatment. There was a tendency of increased intratumor heterogeneity in perfusion after therapy, consistent with the higher mean value; a difference in perfusion of more than a factor of 10 was seen within some tumors. These results suggest that cervix tumors contain a significant amount of poorly perfused subregions with high treatment resistance. Moreover, the perfusion and perfusion heterogeneity may increase during the early phase of radiotherapy and influence tumor response.

Transvaginal color Doppler ultrasonic characterization of benign and malignant ovarian cystic teratomas and comparison with serum squamous cell carcinoma antigen

BACKGROUND

The preoperative diagnosis of squamous cell carcinoma (SCC) arising in mature cystic teratoma of the ovary remains difficult. The purpose of this study is to examine the usefulness of transvaginal color Doppler ultrasound (TV-CDU) in differentiating malignant (SCC) from benign cystic teratoma of the ovary.

METHODS

Eighty-eight patients with an ovarian tumor showing gray scale sonographic appearances of mature cystic teratoma were preoperatively evaluated for the presence or absence of intratumoral blood flow by TV-CDU. The blood flow characteristics of the tumor vessels were analyzed using the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). The serum levels of SCC antigen were also randomly examined preoperatively in 50 patients.

RESULTS

Intratumoral blood flow was significantly detected in malignant teratomas (SCCs) (80.0%; 4 of 5) compared with benign teratomas (20.5%; 17 of 83) (P < 0.01). All malignant teratomas with intratumoral blood flow showed both RI less than 0.4 and PI less than 0.6, whereas no benign teratomas showed any such value except for 1 case with struma ovarii. In addition, both the mean RI and the mean PI values in the tumor vessels were significantly lower in the malignant teratomas (RI: 0.31 +/- 0.07; PI: 0.40 +/- 0.16) than in the benign teratomas (RI: 0.62 +/- 0.13; PI: 1.06 +/- 0.44) (P < 0.001). However, the mean PSV value of the malignant teratomas (PSV: 20.6 +/- 8.33) was not significantly different from the benign teratomas (PSV: 18.1 +/- 9.9). Elevation of serum SCC was found in 4 of 5 patients (80%) with malignant teratomas, whereas the elevation was found in 11 of 45 patients (24.4%) with benign teratomas (P < 0.05). The diagnostic accuracy using the RI (cutoff value 0.4) as well as the PI (cutoff value 0.6) was thus 95.2%, which was significantly superior to that obtained by using the serum SCC (76%) (cutoff value, 1.5 ng/mL).

CONCLUSIONS

Evaluating the presence or absence of intratumoral blood flow, together with blood flow resistance, in tumor vessels using TV-CDU thus may be more useful to differentiate malignant (SCC) from benign cystic teratomas of the ovary than by measuring serum SCC levels.

Blood flow and oxygenation status of human tumors. Clinical investigations

PURPOSE

There is a large body of evidence suggesting that blood flow and oxygenation of human tumors are important research topics which may explain, in particular, resistance to radiation and to many antineoplastic drugs, which can limit the curability of solid tumors by radiotherapy and chemotherapy.

MATERIALS AND METHODS

This manuscript reviews the clinical investigations which have been performed regarding blood flow and oxygenation status of human tumors in radiation oncology.

RESULTS

The possible uses and limitations of the prognostic significance and the changes under therapy measuring blood flow and oxygenation in human tumors were discussed. In addition, several approaches were summarized, which can improve the microvascular O2 availability and perfusion-limited O2 delivery.

CONCLUSION

The clinical data concerning the prognostic significance of blood flow, vascular function and oxygenation of human tumors are relevant for patient selection in clinical oncology. Strategies to improve traditional cancer therapy by modulation of the oxygenation status remain quite promising but more critical research and sophisticated clinical studies are necessary before its true potential is known.

The blood flow characteristics in borderline ovarian tumors based on both color Doppler ultrasound and histopathological analyses

To clarify the tumor behavior in borderline ovarian tumors, we examined the characteristics of neovascularization in these tumors by using a transvaginal color Doppler ultrasound (TV-CDU). Twelve patients with borderline ovarian tumors were preoperatively evaluated for the characteristics of intratumoral blood flow by TV-CDU, using both the resistance index (RI) and pulsatility index (PI). As a control group, 100 patients with benign ovarian tumors and 31 patients with malignant ovarian tumors were also examined by TV-CDU. An intratumoral blood flow was significantly detected in both borderline (91.6%; 11/12) and malignant ovarian tumors (90.3%; 28/31), but not in benign ovarian tumors (53%; 53/100) (P < 0.01). In addition, both the mean RI and mean PI values were significantly lower in the borderline (RI; 0.45, PI; 0.67) and malignant ovarian tumors (RI; 0.39, PI; 0.58) than those in the benign ovarian tumors (RI; 0.61, PI; 1.05) (P < 0.01). In mucinous tumors, the borderline tumors showed a significantly high intratumoral vascularity (P < 0. 01) and both borderline and malignant tumors significantly demonstrated a low-resistance blood flow (P < 0.01), in comparison to those of the benign tumors. Mucinous borderline tumors of the intestinal type also tended to have a lower RI as well as a lower PI value than müllerian type. Regarding neovascularization as represented by intratumoral blood flow characteristics, this study thus suggests that a close relationship exists in the tumor behavior between borderline and malignant ovarian tumors, especially in mucinous epithelial tumors.

Use of colour and spectral Doppler ultrasound examination in gynaecology

Objective: To review and sum up the published literature on gynecological Doppler ultrasound examination. Methods: Publications on gynecological Doppler ultrasound examination already known by the author, publications found in the bibliographic database Medline, and publications found in the reference lists of available studies were read, and relevant information was extracted and summarized. Results: Reference data representative of normal findings at transvaginal color and spectral Doppler ultrasound examination of the uterine and ovarian arteries have been established in healthy pre- and post-menopausal women and in normal early pregnancies. Blood flow velocities in the uterine and ovarian arteries change during the normal menstrual cycle and are very different in pre- and post-menopausal women. Lower blood flow velocities and higher pulsatility index (PI) values have been recorded in the ovarian arteries after the menopause. Uterine artery blood flow velocities increase and uterine artery PI values and resistance index (RI) values decrease with gestational age in the first trimester. There is not yet an established role of the gynecological Doppler ultrasound examination in clinical practice. It remains unclear whether the gynecological Doppler ultrasound examination contributes substantially to the clinical management of early pregnancy complications or infertility problems, to the differential diagnosis of pelvic masses or uterine pathology. Conclusions: Large prospective studies-preferably randomized controled trials-are needed to determine the clinical value of the gynecological Doppler ultrasound examination. Copyright 1997 Elsevier Science Ireland Ltd.