Multimodality imaging of locally recurrent and metastatic cervical cancer: emphasis on histology, prognosis, and management

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Invasive Cancer of the Cervix: 2023 Update

Cervical cancer is a common gynecological malignancy worldwide. Cervical cancer is staged based on the International Federation of Gynecology and Obstetrics (FIGO) classification system, which was revised in 2018 to incorporate radiologic and pathologic data. Imaging plays an important role in pretreatment assessment including initial staging and treatment response assessment of cervical cancer. Accurate determination of tumor size, local extension, and nodal and distant metastases is important for treatment selection and for prognostication. Although local recurrence can be diagnosed by physical examination, imaging plays a critical role in detection and follow-up of local and distant recurrence and subsequent treatment selection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Post treatment imaging in patients with local advanced cervical carcinoma

Cervical cancer (CC) is the fourth leading cause of death in women worldwide and despite the introduction of screening programs about 30% of patients presents advanced disease at diagnosis and 30-50% of them relapse in the first 5-years after treatment. According to FIGO staging system 2018, stage IB3-IVA are classified as locally advanced cervical cancer (LACC); its correct therapeutic choice remains still controversial and includes neoadjuvant chemo-radiotherapy, external beam radiotherapy, brachytherapy, hysterectomy or a combination of these modalities. In this review we focus on the most appropriated therapeutic options for LACC and imaging protocols used for its correct follow-up. We explore the imaging findings after radiotherapy and surgery and discuss the role of imaging in evaluating the response rate to treatment, selecting patients for salvage surgery and evaluating recurrence of disease. We also introduce and evaluate the advances of the emerging imaging techniques mainly represented by spectroscopy, PET-MRI, and radiomics which have improved diagnostic accuracy and are approaching to future direction.

Importance of tumor subtypes in cancer imaging

Cancer therapy has evolved from being broadly directed towards tumor types, to highly specific treatment protocols that target individual molecular subtypes of tumors. With the ever-increasing data on imaging characteristics of tumor subtypes and advancements in imaging techniques, it is now often possible for radiologists to differentiate tumor subtypes on imaging. Armed with this knowledge, radiologists may be able to provide specific information that can obviate the need for invasive methods to identify tumor subtypes. Different tumor subtypes also differ in their patterns of metastatic spread. Awareness of these differences can direct radiologists to relevant anatomical sites to screen for early metastases that may otherwise be difficult to detect during cursory inspection. Likewise, this knowledge will help radiologists to interpret indeterminate findings in a more specific manner.

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Tumor subtypes can be identified based on their different imaging characteristics.

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Awareness of tumor subtype can help radiologists chose the appropriate modality for additional imaging workup.

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Awareness of differences in metastatic pattern between tumor subtypes can be helpful to identify early metastases.

Diffusion-Weighted MRI in the Genitourinary System

Diffusion weighted imaging (DWI) constitutes a major functional parameter performed in Magnetic Resonance Imaging (MRI). The DW sequence is performed by acquiring a set of native images described by their b-values, each b-value representing the strength of the diffusion MR gradients specific to that sequence. By fitting the data with models describing the motion of water in tissue, an apparent diffusion coefficient (ADC) map is built and allows the assessment of water mobility inside the tissue. The high cellularity of tumors restricts the water diffusion and decreases the value of ADC within tumors, which makes them appear hypointense on ADC maps. The role of this sequence now largely exceeds its first clinical apparitions in neuroimaging, whereby the method helped diagnose the early phases of cerebral ischemic stroke. The applications extend to whole-body imaging for both neoplastic and non-neoplastic diseases. This review emphasizes the integration of DWI in the genitourinary system imaging by outlining the sequence's usage in female pelvis, prostate, bladder, penis, testis and kidney MRI. In gynecologic imaging, DWI is an essential sequence for the characterization of cervix tumors and endometrial carcinomas, as well as to differentiate between leiomyosarcoma and benign leiomyoma of the uterus. In ovarian epithelial neoplasms, DWI provides key information for the characterization of solid components in heterogeneous complex ovarian masses. In prostate imaging, DWI became an essential part of multi-parametric Magnetic Resonance Imaging (mpMRI) to detect prostate cancer. The Prostate Imaging-Reporting and Data System (PI-RADS) scoring the probability of significant prostate tumors has significantly contributed to this success. Its contribution has established mpMRI as a mandatory examination for the planning of prostate biopsies and radical prostatectomy. Following a similar approach, DWI was included in multiparametric protocols for the bladder and the testis. In renal imaging, DWI is not able to robustly differentiate between malignant and benign renal tumors but may be helpful to characterize tumor subtypes, including clear-cell and non-clear-cell renal carcinomas or low-fat angiomyolipomas. One of the most promising developments of renal DWI is the estimation of renal fibrosis in chronic kidney disease (CKD) patients. In conclusion, DWI constitutes a major advancement in genitourinary imaging with a central role in decision algorithms in the female pelvis and prostate cancer, now allowing promising applications in renal imaging or in the bladder and testicular mpMRI.

Selection of Treatment Regimens for Recurrent Cervical Cancer

OBJECTIVE

The selection of individualized treatment for recurrent cervical cancer is challenging. This study aimed to investigate the impact of various therapies on survival outcomes after recurrence.

METHODS

Eligible patients were diagnosed with recurrent cervical cancer between March 2012 and April 2018. Postrecurrence progression-free survival (PFS) and overall survival (OS) were investigated in the whole cohort and in subgroups, categorized by recurrence site and prior radiotherapy history, using a multivariate model that incorporated treatment for primary and recurrent tumors, histological pathology, and FIGO staging.

RESULTS

Two hundred and sixty recurrent cervical cancer patients were included. As of March 1, 2020, the median postrecurrence PFS and OS were 7.0 (range 0-94) and 24.0 (1.8-149.1) months, respectively. In a multivariate model measured by PFS, radiotherapy was superior to other therapies for the whole cohort (p=0.029) and recurrence only within the pelvic cavity (p=0.005), but the advantages of radiotherapy disappeared in patients with a history of radiotherapy (p values >0.05). For recurrence only beyond the pelvic cavity, combination therapy resulted in improved PFS (p=0.028). For recurrence both within and beyond the pelvic cavity, no therapy regimen provided additional PFS benefits (p values >0.05). Radiotherapy and combination therapy were also associated with improved postrecurrence OS for recurrence within the pelvic cavity (p=0.034) and only beyond the pelvic cavity (p=0.017), respectively.

CONCLUSIONS

In cervical cancer patients, postrecurrence radiotherapy can improve PFS and OS for patients with recurrence within the pelvic cavity and without prior radiotherapy. For recurrence beyond the pelvic cavity or cases with a history of radiotherapy, combination or individualized therapy may provide potential survival benefits.

Impact of different therapies on the survival of patients with stage I-IIA cervical cancer with intermediate risk factors

Background

The aim of this study was to determine the effects of different therapies on patients with cervical cancer (CC) with intermediate risk factors.

Methods

Clinicopathological data of 596 patients diagnosed with stage I–IIA CC at the Obstetrics and Gynecology Hospital of Fudan University between January 2013 and November 2015 were retrospectively reviewed. Of the patients, 500 patients received adjuvant therapy including chemotherapy (CT), radiotherapy (RT), and sequential chemotherapy and radiotherapy (CT + RT). Patients who displayed at least one intermediate risk factor number were screened.

Results

The median follow-up was 62 months. The 5-year progression-free survival (PFS) and overall survival (OS) of the entire cohort were 90.4% and 90.9%, respectively. Univariate analysis showed that tumor stage, tumor size, pathological type, lymphovascular space invasion, and numbers of medium risk factors were not risk factors for early-stage CC. Compared with the control group, patients who received CT, RT, or CT + RT showed improved PFS and OS (P<0.05). The RT group had lower PFS and OS than the CT and CT + RT groups (P<0.05). Among the 318 patients with a single intermediate risk factor, 297 patients received CT, RT, and CT + RT benefit from adjuvant therapy (P<0.05). Of the 253 patients with high-risk factors, 220 patients received CT, RT and CT + RT get improved PFS and OS (P<0.05).

Conclusions

Patients who received adjuvant therapy had better postoperative outcomes than those who did not receive adjuvant therapy. Patients had CT alone or CT combined with RT had better efficacy than those had RT alone.

Cervical cancer recurrence - can we predict the type of recurrence?

PURPOSE

We aimed to identify if there is an association between the severity of cervical cancer at diagnosis and the pattern of recurrence.

METHODS

We conducted a retrospective study of recurrent cervical cancers diagnosed between 2016 and 2018. We characterized the cases according to histology, size, FIGO stage (according to 2009 and 2018 FIGO classifications) and nodal involvement at diagnosis, symptoms at the time of recurrence, interval between the end of treatment and recurrence, imaging methods used, and location of the recurrence. Statistical analysis was performed between histology, size, FIGO stage and nodal involvement at diagnosis and time to recurrence and type of recurrence (locoregional versus lymph node, distant or multiple site involvement).

RESULTS

We included 48 patients with recurrent cervical cancer. At diagnosis, mean tumor size was 5 cm and 83% of the patients had squamous cell carcinoma. The FIGO stage changed in 43.8% of patients between the 2009 and the 2018 classifications. A mean of 26 months elapsed between the end of treatment and recurrence. Recurrence was symptomatic in 64.6% of patients. Imaging identified recurrence in 97.9% of patients. The most frequent recurrence sites were locoregional and lymph node metastases. We found a statistically significant association between 2009 FIGO stage and time to recurrence (P = 0.030) and lymph node involvement at diagnosis and type of recurrence (P = 0.022). As expected patients with more advanced disease recurred sooner, though this was only observed for the 2009 FIGO classification. Absence of lymph nodes at initial diagnosis was associated with locoregional recurrence, while presence of lymph node involvement was associated with lymph node, distant or multiple site involvement of recurrence. No other significant associations were found.

CONCLUSION

In our cohort of recurrent cervical cancer, we found an association between patients without lymph node metastases at initial diagnosis and locoregional recurrence. Further studies are needed in order to evaluate whether this association has predictive value.

Octamer binding transcription factor-4 expression is associated with cervical cancer malignancy and histological differentiation: a systematic review and meta-analysis

Objective: In this work, the relationship between octamer binding transcription factor 4 (OCT-4) expression and the clinicopathological features of cervical cancer (CC) is evaluated in detail.

Methods: The library databases Pubmed, Embase, Cochrane library, Wan Fang and Chinese National Knowledge Infrastructure (CNKI) were searched for research related to these concepts published from the time the databases were established until May 2018. The obtained studies are screened, extracted, and evaluated according to the inclusion and exclusion criteria, and meta-analysis is carried out via RevMan 5.3.

Results: Ten case–control studies, including 408 cases of CC, 164 cases of cervical intraepithelial neoplasia (CIN), and 148 cases of normal cervix, are included in the analysis. Results show that OCT-4 levels are statistically significantly different between the CC and normal cervical tissue groups (odds ratio (OR) = 15.59, 95% confidence interval (CI): 8.70, 27.94), the CC and CIN groups (OR = 5.64, 95% CI: 3.23, 9.86), the CIN and normal cervical tissues groups (OR = 7.13, 95% CI: 2.41, 21.05), and the CC well/moderately differentiated and poorly differentiated groups (OR = 0.44, 95% CI: 0.24, 0.81). OCT-4 is not statistically significantly different between CIN I + II and CIN III tissues (OR = 0.40, 95% CI: −0.02, 0.81), the CC lymphatic and non-lymphatic metastasis groups (OR = 1.93, 95% CI: 0.83, 4.47), the FIGO I and FIGO II groups (OR = 0.79, 95% CI: 0.29, 2.13), and the adenocarcinoma and squamous cell carcinoma groups (OR = 1.55, 95% CI: 0.70, 3.44).

Conclusions: The available evidence suggests that OCT-4 expression is associated with CC malignancy and histological differentiation. This finding, however, is subject to quantitative studies and quality tests.

Detection of distant metastatic disease by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) at initial staging of cervical carcinoma

OBJECTIVE

The detection of distant metastatic disease in cervical cancer patients at diagnosis is critical in accurate prognostication and directing treatment strategies. This study describes the frequency and sites of distant metastatic disease at diagnosis in patients with cervical cancer as detected by positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET).

METHODS

Patients with newly diagnosed cervical cancer underwent pre-treatment whole-body FDG-PET starting in 1997 at an academic institution. Patients with evidence of distant FDG-avid disease, defined as disease outside of typical sites of lymphatic spread, were included for analyses. Patients were not surgically staged, but biopsy to confirm metastatic disease was attempted at the discretion of the treating physicians. Overall survival was calculated using Kaplan-Meier analysis.

RESULTS

From 1997 to 2017, 72 (6.2%) of 1158 consecutively evaluated cervical cancer patients exhibited FDG-avid distant disease at diagnosis; 27 (38%) of these had biopsy confirmation of distant disease. Only 35 (49%) of FDG-detected metastases were clinically apparent. The sites of distant disease were lung (35%), multiple sites (25%), omentum (16.5%), bone (16.5%), and liver (7%). There were 12 (17%) patients with distant disease who did not display FDG-avid lymph nodes. Median overall survival among patients with distant FDG-avid disease was 7.0 months (95% CI 4.3 to 9.7). Patients with multiple sites of distant disease demonstrated the worst overall survival.

CONCLUSIONS

Distant metastatic disease detected by FDG-PET is found in 6.2% of patients with cervical cancer at the time of initial diagnosis and the most common site of disease is the lung. Further prospective investigation is warranted to delineate best treatment practices for cervical cancer patients presenting with distant metastases.

Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Endometrial cancer (EC) is the most common malignant tumor of the female genital tract in Western countries. EC patients are divided into risk categories based on histopathological tumor type, grade, and myometrial invasion depth. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) system. Since FIGO (2009) stage correlates with prognosis, preoperative staging is essential for tailored treatment. MRI reveals myometrial invasion depth, which correlates with tumor grade and lymph node metastases, and thus correlates with prognosis. Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. The FIGO Gynecologic Oncology Committee recently revised its CC staging guidelines, allowing staging based on imaging and pathological findings when available. The revised FIGO (2018) staging includes node involvement and thus enables both therapy selection and evaluation, prognosis estimation, and calculation of end results. MRI can accurately assess prognostic indicators, e.g., tumor size, parametrial invasion, pelvic sidewall, and lymph node invasion. Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Awareness of mimics that can simulate both cancers is critical. With careful application, functional MRI with DWI and DCE sequences can help establish a correct diagnosis, although it is sometimes necessary to perform biopsy and histopathological analysis.