Utility of PET-CT to evaluate retroperitoneal lymph node metastasis in advanced cervical cancer: Results of ACRIN6671/GOG0233 trial

Predictive value of number of metastatic lymph nodes and lymph node ratio for prognosis of patients with FIGO 2018 stage IIICp cervical cancer: a multi-center retrospective study

BACKGROUND

To identify the cut-off values for the number of metastatic lymph nodes (nMLN) and lymph node ratio (LNR) that can predict outcomes in patients with FIGO 2018 IIICp cervical cancer (CC).

METHODS

Patients with CC who underwent radical hysterectomy with pelvic lymphadenectomy were identified for a propensity score-matched (PSM) cohort study. A receiver operating characteristic (ROC) curve analysis was performed to determine the critical nMLN and LNR values. Five-year overall survival (OS) and disease-free survival (DFS) rates were compared using Kaplan-Meier and Cox proportional hazard regression analyses.

RESULTS

This study included 3,135 CC patients with stage FIGO 2018 IIICp from 47 Chinese hospitals between 2004 and 2018. Based on ROC curve analysis, the cut-off values for nMLN and LNR were 3.5 and 0.11, respectively. The final cohort consisted of nMLN ≤ 3 (n = 2,378) and nMLN > 3 (n = 757) groups and LNR ≤ 0.11 (n = 1,748) and LNR > 0.11 (n = 1,387) groups. Significant differences were found in survival between the nMLN ≤ 3 vs the nMLN > 3 (post-PSM, OS: 76.8% vs 67.9%, P = 0.003; hazard ratio [HR]: 1.411, 95% confidence interval [CI]: 1.108-1.798, P = 0.005; DFS: 65.5% vs 55.3%, P < 0.001; HR: 1.428, 95% CI: 1.175-1.735, P < 0.001), and the LNR ≤ 0.11 and LNR > 0.11 (post-PSM, OS: 82.5% vs 76.9%, P = 0.010; HR: 1.407, 95% CI: 1.103-1.794, P = 0.006; DFS: 72.8% vs 65.1%, P = 0.002; HR: 1.347, 95% CI: 1.110-1.633, P = 0.002) groups.

CONCLUSIONS

This study found that nMLN > 3 and LNR > 0.11 were associated with poor prognosis in CC patients.

TMVP1448, a novel peptide improves detection of primary tumors and metastases by specifically targeting VEGFR-3

Lymphangiogenesis at primary tumor and draining lymph nodes plays a pivotal role in tumor metastasis, which has been demonstrated to be regulated by the vascular endothelial growth factor receptor 3 (VEGFR-3) pathway. However, the effect of molecular imaging peptides, which specifically bind VEGFR-3, in tracing tumors remains unclear. We prepared a novel peptide, TMVP1448, with high-affinity to VEGFR-3. The dissociation constant (KD) of TMVP1448 with VEGFR-3 was 7.07 ×10-7 M. In vitro cellular assay showed that TMVP1448 could bind specifically with VEGFR-3. Near infrared imaging results showed that Cy7-TMVP1448 was able to accurately trace primary and metastatic cancers, and PET/CT results showed that [68Ga]Ga-DOTA-TMVP1448 was superior to commonly used radiotracers 18F-FDG. Additionally, no significant negative effect of TMVP1448 was found in mice. Our results suggested that TMVP1448 had great potential for future clinical applications in fluorescence imaging and nuclear imaging of tumors.

Diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer

OBJECTIVES

To assess the diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer, to compare the outcomes for pelvic and para-aortic regions, and to detect macrometastases and micrometastases separately.

METHODS

Patients were retrospectively included if they met the following inclusion criteria: pathologically verified cervical cancer; ultrasonography performed by one of four experienced sonographers; surgical lymph node staging, at least in the pelvic region-sentinel lymph node biopsy or systematic pelvic lymphadenectomy or debulking. The final pathological examination was the reference standard.

RESULTS

390 patients met the inclusion criteria between 2009 and 2019. Pelvic node macrometastases (≥2 mm) were confirmed in 54 patients (13.8%), and micrometastases (≥0.2 mm and <2 mm) in another 21 patients (5.4%). Ultrasonography had sensitivity 72.2%, specificity 94.0%, and area under the curve (AUC) 0.831 to detect pelvic macrometastases, while sensitivity 53.3%, specificity 94.0%, and AUC 0.737 to detect both pelvic macrometastases and micrometastases (pN1). Ultrasonography failed to detect pelvic micrometastases, with sensitivity 19.2%, specificity 85.2%, and AUC 0.522. There was no significant impact of body mass index on diagnostic accuracy. Metastases in para-aortic nodes (macrometastases only) were confirmed in 16 of 71 patients who underwent para-aortic lymphadenectomy. Ultrasonography yielded sensitivity 56.3%, specificity 98.2%, and AUC 0.772 to identify para-aortic node macrometastases.

CONCLUSION

Ultrasonography performed by an experienced sonographer can be considered a sufficient diagnostic tool for pre-operative assessment of lymph nodes in patients with cervical cancer, showing similar diagnostic accuracy in detection of pelvic macrometastases as reported for other imaging methods (18F-fluorodeoxyglucose positron emission tomography/CT or diffusion-weighted imaging/MRI). It had low sensitivity for detection of small-volume macrometastases (largest diameter <5 mm) and micrometastases. The accuracy of para-aortic assessment was comparable to that for pelvic lymph nodes, and assessment of the para-aortic region should be an inseparable part of the examination protocol.

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.

68Ga-labeled TMTP1 radiotracer for PET imaging of cervical cancer

Molecular imaging enables visualization and characterization of biological processes that influence tumor behavior and response to therapy. The TMTP1 (NVVRQ) peptide has shown remarkable affinity to highly metastatic tumors and and its potential receptor is aminopeptidase P2. In this study, we have designed and synthesized a 68Ga-labeled cyclic TMTP1 radiotracer (68Ga-DOTA-TMTP1), for PET imaging of cervical cancer. The goal of this study was to investigate the properties of this radiotracer and its tumor diagnostic potential. The radiochemical yield of 68Ga-DOTA-TMTP1 was high and the radiochemical purity was greater than 95%. The octanol-water partition coefficient for 68Ga-DOTA-TMTP1 was -2.76 ± 0.08 and 68Ga-DOTA-TMTP1 has showed excellent stability in in vitro studies. The cellular uptake and efflux of 68Ga-DOTA-TMTP1 in paired highly metastatic and lowly metastatic cervical cancer cell line HeLa and C-33A as well as normal cervical epithelial cell line End1 were measured in a γ counter. 68Ga-DOTA-TMTP1 exhibited higher uptake in HeLa cells than in C-33A cells. The binding to HeLa and C-33A cells could be blocked by excess TMTP1. On microPET images, HeLa tumors were clearly visualized within 60 min and the uptake of the radiotracer in HeLa tumors was higher than that of C-33A tumors. After blocking with TMTP1, HeLa tumors uptake was significantly reduced and the specificity 68Ga-DOTA-TMTP1 was thus validated. Overall, we have successfully synthesized 68Ga-DOTA-TMTP1 with high yield and high specific activity and have demonstrated its potential role for highly metastatic tumor-targeted diagnosis.

Nuclear Medicine and Molecular Imaging Applications in Gynecologic Malignancies: A Comprehensive Review

Gynecologic malignancies, consisting of endometrial, cervical, ovarian, vulvar, and vaginal cancers, pose significant diagnostic and management challenges due to their complex anatomic location and potential for rapid progression. These tumors cause substantial morbidity and mortality, often because of their delayed diagnosis and treatment. An estimated 19% of newly diagnosed cancers among women are gynecologic in origin. In recent years, there has been growing evidence supporting the integration of nuclear medicine imaging modalities in the diagnostic work-up and management of gynecologic cancers. The sensitivity of fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) combined with the anatomical specificity of computed tomography (CT) and magnetic resonance imaging (MRI) allows for the hybrid evaluation of metabolic activity and structural abnormalities that has become an indispensable tool in oncologic imaging. Lymphoscintigraphy, using technetium 99m (99mTc) based radiotracers along with single photon emission computed tomography/ computed tomography (SPECT/CT), holds a vital role in the identification of sentinel lymph nodes to minimize the surgical morbidity from extensive lymph node dissections. While not yet standard for gynecologic malignancies, promising therapeutic nuclear medicine agents serve as specialized treatment options for patients with advanced or recurrent disease. This article aims to provide a comprehensive review on the nuclear medicine applications in gynecologic malignancies through the following objectives: 1) To describe the role of nuclear medicine in the initial staging, lymph node mapping, response assessment, and recurrence/surveillance imaging of common gynecologic cancers, 2) To review the limitations of 18F-FDG PET/CT and promising applications of 18F-FDG PET/MRI in gynecologic malignancy, 3) To underscore the promising theragnostic applications of nuclear medicine, 4) To highlight the current role of nuclear medicine imaging in gynecologic cancers as per the National Comprehensive Cancer Network (NCCN), European Society of Surgical Oncology (ESGO), and European Society of Medical Oncology (ESMO) guidelines.

Diagnostic accuracy of MRI, CT, and [18F]FDG-PET-CT in detecting lymph node metastases in clinically early-stage cervical cancer - a nationwide Dutch cohort study

OBJECTIVES

Imaging is increasingly used to assess lymph node involvement in clinically early-stage cervical cancer. This retrospective study aimed to evaluate the diagnostic accuracy of MRI, CT, and [18F]FDG-PET-CT.

METHODS

Women with International Federation of Gynaecology and Obstetrics (FIGO) 2009 stage IA2-IIA cervical cancer and pretreatment imaging between 2009 and 2017 were selected from the Netherlands Cancer Registry. Patient-based and region-based (i.e. pelvic and common iliac) nodal status was extracted from radiology reports. Pathology results were considered the reference standard for calculating accuracy indices. Multiple imputation was used for missing pathology to limit verification bias risk.

RESULTS

Nodal assessment was performed in 1676 patients with MRI, 926 with CT, and 379 with [18F]FDG-PET-CT, with suspicious nodes detected in 17%, 16%, and 48%, respectively. [18F]FDG-PET-CT was used to confirm MRI/CT results in 95% of patients. Pathology results were imputed for 30% of patients. [18F]FDG-PET-CT outperformed MRI and CT in detecting patient-based nodal metastases with sensitivities of 80%, 48%, and 40%, and AUCs of 0.814, 0.706, and 0.667, respectively, but not in specificity: 79%, 92%, and 92%. Region-based analyses showed similar indices in the pelvic region, but worse performance in the common iliac region with AUCs of 0.575, 0.554, and 0.517, respectively.

CONCLUSIONS

[18F]FDG-PET-CT outperformed MRI and CT in detecting nodal metastases, which may be related to its use as a verification modality. However, MRI and CT had the highest specificity. As MRI is generally performed routinely to assess local and regional spread of cervical cancer, [18F]FDG-PET-CT can be used to confirm suspicious nodes.

CRITICAL RELEVANCE STATEMENT

Accurate assessment of the nodal status in clinically early-stage cervical cancer is essential for tumour staging, treatment decision making and prognosis.

KEY POINTS

• The accuracy of MRI, CT or [18F]FDG-PET-CT for nodal staging in early cervical cancer is a subject of discussion. • Overall, [18F]FDG-PET-CT outperformed MRI, followed by CT, when used as a verification modality. • Staging with MRI and the addition of [18F]FDG-PET-CT to verify high-risk cases seems to be a good approach.

Preoperative Imaging Evaluation of Endometrial Cancer in FIGO 2023

The staging of endometrial cancer is based on the International Federation of Gynecology and Obstetrics (FIGO) staging system according to the examination of surgical specimens, and has revised in 2023, 14 years after its last revision in 2009. Molecular and histological classification has incorporated to new FIGO system reflecting the biological behavior and prognosis of endometrial cancer. Nonetheless, the basic role of imaging modalities including ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography, as a preoperative assessment of the tumor extension and also the evaluation points in CT and MRI imaging are not changed, other than several point of local tumor extension. In the field of radiology, it has also undergone remarkable advancement through the rapid progress of computational technology. The application of deep learning reconstruction techniques contributes the benefits of shorter acquisition time or higher quality. Radiomics, which extract various quantitative features from the images, is also expected to have the potential for the quantitative prediction of risk factors such as histological types and lymphovascular space invasion, which is newly included in the new FIGO system. This article reviews the preoperative imaging diagnosis in new FIGO system and recent advances in imaging analysis and their clinical contributions in endometrial cancer. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 3.

Surgical Treatment for Early Cervical Cancer in the HPV Era: State of the Art

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes' involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cervical cancer worldwide.

18F-FDG PET/MRI and 18F-FDG PET/CT for the Management of Gynecological Malignancies: A Comprehensive Review of the Literature

OBJECTIVE

Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) or magnetic resonance imaging (18F-FDG PET/MRI) has emerged as a promising tool for managing various types of cancer. This review study was conducted to investigate the role of 18F- FDG PET/CT and FDG PET/MRI in the management of gynecological malignancies.

SEARCH STRATEGY

We searched for relevant articles in the three databases PubMed/MEDLINE, Scopus, and Web of Science.

SELECTION CRITERIA

All studies reporting data on the FDG PET/CT and FDG PET MRI in the management of gynecological cancer, performed anywhere in the world and published exclusively in the English language, were included in the present study.

DATA COLLECTION AND ANALYSIS

We used the EndNote software (EndNote X8.1, Thomson Reuters) to list the studies and screen them on the basis of the inclusion criteria. Data, including first author, publication year, sample size, clinical application, imaging type, and main result, were extracted and tabulated in Excel. The sensitivity, specificity, and diagnostic accuracy of the modalities were extracted and summarized.

MAIN RESULTS

After screening 988 records, 166 studies published between 2004 and 2022 were included, covering various methodologies. Studies were divided into the following five categories: the role of FDG PET/CT and FDG-PET/MRI in the management of: (a) endometrial cancer (n = 30); (b) ovarian cancer (n = 60); (c) cervical cancer (n = 50); (d) vulvar and vagina cancers (n = 12); and (e) gynecological cancers (n = 14).

CONCLUSIONS

FDG PET/CT and FDG PET/MRI have demonstrated potential as non-invasive imaging tools for enhancing the management of gynecological malignancies. Nevertheless, certain associated challenges warrant attention.

Diagnostic Performance of Preoperative Imaging in Endometrial Cancer

BACKGROUND

Endometrial cancer is one of the most common gynecological malignancies. Because the findings mentioned in radiogram interpretation reports issued by diagnostic radiologists influence treatment strategies, we aimed to evaluate the diagnostic accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) interpretation results in clinically relevant settings.

METHODS

The clinical records of patients diagnosed with endometrial cancer treated at Tohoku University Hospital from January 2012 to December 2021 were reviewed. The preoperative and pathologically estimated cancer stages were compared based on the results mentioned in the radiogram interpretation report.

RESULTS

The preoperative and postoperative cancer stages were concordant in 70.0% of the patients. By contrast, the cancer stage was underdiagnosed and overdiagnosed in 21.7% and 8.2% of the patients, respectively. The sensitivities of MRI for deep myometrial invasion, cervical stromal invasion, vaginal invasion, and adnexal metastasis were 65.1%, 58.2%, 33.3%, and 18.4%, respectively. The sensitivity and specificity for pelvic lymph node metastasis using a combination of CT and MRI were 40.9% and 98.4%, respectively. Those for para-aortic lymph node metastases using CT were 37.0% and 99.5%, respectively.

CONCLUSIONS

The low sensitivity observed in this study clarified the limitations of preoperative diagnostic performance in current clinical practice.

Recommandations pour la pratique clinique Nice/Saint-Paul-de-Vence 2022–2023 : prise en charge du cancer de l'endomètre localisé

Recommendations for clinical practice, Nice/Saint-Paul-de-Vence 2022-2023: Management of localized endometrial cancer Endometrial cancer is the most frequent gynecological cancers in industrialized countries and its incidence increases. The newmolecularclassification allows determination of the risk of recurrence and helps orienting therapeutic management. Surgery remains the cornerstone of treatment. Minimally invasive approach must be preferred for stages I and II. Surgery includes hysterectomy with bilateral adnexectomy, sentinel lymph node biopsy even in high risk diseases and omentectomy for non-endometrioid tumors (except in case of clear cells tumors). Fertility preservation can be proposed in low grade, stage I tumors without myometrial involvement. In stage III/IV disease, lymph node debulking without totallymphadenectomy is indicated. In case of peritoneal carcinomatosis, first-line cytoreductive surgery is recommended if complete resection can be achieved. Adjuvant therapy is not recommended in low risk tumors. In intermediate risk tumors, curietherapy is indicated. In tumors with high-intermediate risk, curietherapy and external radiotherapy are indicated according to prognostic factors (stage II, lymphovascular invasion); adjuvant chemotherapy can be considered on a case-by-case basis. In high risk tumors, chemotherapy and external radiotherapy are recommended using a concomitant or sequential approach.

Recommandations pour la pratique clinique Nice/Saint-Paul-de-Vence 2022–2023 : Prise en charge du cancer du col de l'utérus avancé

French recommendations for clinical practice, Nice/Saint-Paul-de-Vence 2022-2023: Management of advanced cervical cancer The prognosis of cervical cancer remained pejorative until recently, first-line treatment consisting of platinum-based chemotherapy, associated with bevacizumab whenever possible, without any other therapeutic innovation for several years. However in 2022, immunotherapy appeared in the therapeutic landscape. Pembrolizumab can now be prescribed, thanks to the early access status granted by the HAS in September 2022, in patients with PD-L1 positive tumors. In parallel, bevacizumab generic is now reimbursed, allowing its association with chemotherapy on top of pembrolizumab, if indicated. For patient relapsing after platinium salts, and who never received immunotherapy, cemiplimab could be delivered and reimboursed since spring 2023, whatever could be PD-L1 status. Pretherapeutic work-up includes imaging combining MRI and PET/CT or CT of the chest, abdomen and pelvis, as well as evaluation of PD-L1 status on tumor and immune cells to define the CPS score that will determine eligibility to pembrolizumab treatment (CPS > 1). Possibilities of locoregional treatment depend on individual situations and are discussed on a case-by-case basis in multidisciplinary meetings. Early supportive care is always recommended and inclusion in clinical trials must be systematically considered.

Association of Sialyl Tn antigen with cervical cancer lymph node status: An NRG oncology/GOG study

OBJECTIVE

Detection of lymph node metastases in cervical cancer patients is important for guiding treatment decisions, however accuracies of current detection methods are limited. We evaluated associations of abnormal glycosylation, represented by Tn and STn antigens on mucin (MUC) proteins, in primary tumor specimens with lymph node metastasis or recurrence of cervical cancer patients.

METHODS

Surgical specimens were prospectively collected from 139 patients with locally-advanced cervical cancer undergoing lymphadenectomy enrolled in a nation-wide clinical trial (NCT00460356). Of these patients, 133 had primary cervix tumor, 67 had pelvic lymph node (PLN) and 28 had para-aortic lymph node (PALN) specimens. Fixed tissue serial sections were immunohistochemically stained for Tn, STn, MUC1 or MUC4. Neuraminidase was used to validate Tn versus STn antibody specificity. Stain scores were compared with clinical characteristics.

RESULTS

Primary tumor STn expression above the median was associated with negative PLN status (p-value: 0.0387; odds ratio 0.439, 95% CI: 0.206 to 0.935). PLN had higher STn compared to primary tumor, while primary tumor had higher MUC1 compared to PALN, and MUC4 compared to PALN or PLN (p = 0.017, p = 0.011, p = 0.016 and p < 0.001, respectively). Tn and STn expression correlated in primary tumor, PALN, and PLN, Tn and MUC1 expression correlated in primary tumors only (Spearman correlation coefficient [r] = 0.301, r = 0.686, r = 0.603 and r = 0.249, respectively).

CONCLUSIONS

STn antigen expression in primary cervical tumors is a candidate biomarker for guiding treatment decisions and for mechanistic involvement in PLN metastases.

Survival effect of pre-RT PET-CT on cervical cancer: Image-guided intensity-modulated radiation therapy era

Condensed abstract

No large-scale, well-designed randomized study with a long-term follow-up has evaluated the survival effect of pretreatment 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on patients with stage IB-IVA cervical cancer receiving image-guided intensity-modulated radiation therapy (IG-IMRT). This is the first head-to-head propensity score-matched, nationwide population-based cohort study evaluating this survival effect. The results revealed that pretreatment ¹⁸FDG-PET-CT might be associated with longer survival in patients with stage IB-IVA cervical cancer receiving radiotherapy or concurrent chemoradiotherapy, especially in the IG-IMRT era.

Purpose

No large-scale, well-designed randomized study with a long-term follow-up has evaluated the survival effect of pretreatment 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on patients with stage IB-IVA cervical cancer receiving image-guided intensity-modulated radiation therapy (IG-IMRT). Therefore, in this propensity score-matched, population-based cohort study, we investigated these survival effects.

Patients and methods

We included 4167 patients with stage IB-IVA cervical cancer receiving radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) through the IG-IMRT technique. The patients were categorized into two 1:2 propensity score-matched groups depending on whether they underwent pretreatment ¹⁸FDG-PET-CT, and their outcomes were compared.

Results

We included 2778 and 1389 patients with cervical cancer in the nonpretreatment and pretreatment PET-CT groups, respectively. Univariable and multivariable analyses revealed an association between pretreatment PET-CT and improved survival in the patients (in the adjusted model, the adjusted hazard ratio [aHR] was 0.88; 95% confidence interval [CI], 0.80-0.97: P = 0.010). Regardless of the cancer stage (early or advanced), pretreatment PET-CT was significantly superior to nonpretreatment PET-CT in terms of all-cause death (aHR, 0.78; 95% CI, 0.60-0.92; P = 0.013 and aHR, 0.90; 95% CI, 0.81-0.99; P = 0.039 for the early [IB-IIA] and advanced stages [IIB-IVA], respectively).

Conclusions

Pretreatment ¹⁸FDG-PET-CT might be associated with longer survival in patients with stage IB-IVA cervical cancer receiving RT or CCRT, especially in the era of IG-IMRT.

The role of pre-treatment paraaortic surgical staging for cervical cancer in the EMBRACE criteria

Background

The State-of-the-Art Treatment for Locally Advanced Cervical Cancer (LACC) is Definite Radio-Chemotherapy based on the Image-guided intensity modulated External beam radiochemotherapy and MRI-based adaptive BRAchytherapy (EMBRACE) trial, according to the FIGO staging. This staging is based on clinical examination and imaging studies; however, there are limitations of imaging techniques which may result in adverse events or death due to insufficient or overtreatment. The aim of the study was to evaluate the feasibility and outcomes of surgical staging in LACC prior to radiotherapy (RT) to personalise target volumes for radiotherapy.

Methods

From 2008 to 2018, 138 patients with FIGO 2018 stages IB3-IIIC2 cervical cancer underwent a pretherapeutic laparoscopic staging procedure. The pathological diagnosis was compared with the results of preoperative CT scan. Patients were treated with chemoradiotherapy tailored according to the staging results.

Results

The mean patient age was 43 years, the mean body mass index was 27 kg/m²; most lesions were squamous cervical cancer (92%). Staging CT scan had a 77% concordance with the histological findings. Sensitivity was 29%, specificity 85%, positive predictive value 21% and negative predictive value 89%. Surgical staging led to change of stage in 24% of cases. Para -aortic dissection led to change the initially planned radiotherapy fields in 47% of the cases. Major complications included involuntary section of the inferior mesenteric artery (IMA) without clinical repercussion, an infected retroperitoneal haematoma and a symptomatic lymphocele requiring laparoscopic drainage.

Conclusion

Laparoscopic staging before primary chemoradiation in patients with LACC was feasible, safe and reproducible, allowing reduction of the radiotherapy treatment volumes of patients.

Quantitative imaging of uterine cancers with diffusion-weighted MRI and 18-fluorodeoxyglucose PET/CT

Imaging plays an important role in the diagnosis and treatment of women with uterine cervical and endometrial cancers. Quantitative imaging, through MRI, PET/CT, and hybrid PET/MRI, allows for characterization of primary tumors beyond anatomic and qualitative descriptors. MRI diffusion-weighted imaging (DWI) yields an apparent diffusion coefficient (ADC), which can be applied in both the pre-and post-treatment assessment of uterine tumors. PET/CT assesses metabolic activity, and measurement of tumor standardized uptake value (SUV) is a useful metric in the staging of uterine malignancies. Hybrid PET/MRI is an emerging modality that combines the soft tissue contrast of MRI with the molecular imaging capability of PET. This review provides an overview of these quantitative imaging modalities, and their current and potential roles in the assessment of uterine cervical and cancer.

Correlating Quantitative Para-Aortic Lymph Node Computed Tomography Parameters With Fluorodeoxyglucose Positron Emission Tomography for Cervical Cancer Staging: Possible Solution for Resource Constrained Countries

OBJECTIVE

The aim of the study was to determine the most accurate quantitative morphological parameters on computed tomography (CT) that correlate with fluorodeoxyglucose (FDG)-avid para-aortic nodes (PANs) in patients with cervical cancer.

METHODS

A single-institution retrospective evaluation was performed of women with cervical cancer who underwent pretreatment positron emission tomography (PET)/CT and radiotherapy therapy planning CT between 2009 and 2020. A node-by-node correlation between pretreatment CT and PET/CT was performed for the reference standard of FDG avidity for short- and long-axis diameters, volume, and long-/short-axis ratio (L/S). The FDG-avid PANs were defined as PET-positive and non-FDG-avid PANs from patients without PET-determined PAN metastasis were defined as PET negative. Area under the receiver operator curve was calculated to access diagnostic accuracy of the different quantitative parameters.

RESULTS

A total of 94 women (mean age ± standard deviation, 52 ± 13 years) with cervical cancer were included. Forty-seven patients had PET-positive PANs (181 PET-positive PANs) and 47 patients had no PET-positive PANs (141 PET-negative PANs). The area under the receiver operator curve for volume (0.945) was greater (P < 0.001) than that of short axis (0.895), long axis (0.885), and L/S (0.583). At a specificity set point of 0.90 (127/141 PANs), the cutoff for volume was 0.443 cm3 or greater (0.85 sensitivity [154/181 PANs]; 95% confidence interval, 0.83-0.93) and for short-axis diameter was 5.9 mm or greater (0.75 sensitivity [135/181 PANs]; 95% confidence interval, 0.68-0.81).

CONCLUSIONS

Para-aortic lymph node volume demonstrated that improved node-by-node correlation between CT and PET/CT compared with short-axis diameter, long-axis diameter, and L/S and is an alternative to improve detection of PAN suspicious of metastatic diseases in locations without access to PET/CT.

Imaging to optimize gynecological radiation oncology

Gynecological cancers have particularly benefited from the increasing use of imaging to guide radiation treatment planning for both external beam radiation and brachytherapy. While the different gynecological cancers have varying use of imaging, certain trends predominate. CT represents an economical choice for evaluating initial disease extent or potential metastasis at follow-up, particularly for endometrial and ovarian cancers. F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is particularly useful for assessing the initial disease extent and longer term treatment response of squamous predominant cancers, including cervical, vaginal, and vulvar cancers. With its excellent pelvic soft tissue discrimination, MRI provides the greatest assistance in evaluating the local extent of gynecological tumors, including initial evaluation for non-operative endometrial and vulvar cancer, and assessment before, after and during brachytherapy for cervix, locally recurrent endometrial, and primary vaginal cancers. With more limited availability of MRI, ultrasound can also help guide brachytherapy, particularly during procedures. The benefits of using imaging to better spare bone marrow or earlier assessment of treatment response are topics still being explored, in particular for cervical cancer. As imaging along with radiation oncology technologies continue to evolve and develop, such as with MRI-linacs and ultra high dose rate (FLASH) radiation, we may continue to see increasing use of imaging for advancing gynecological radiation oncology.

Management of Early-Stage Cervical Cancer: A Literature Review

Simple Summary

Despite being a preventable disease, cervical cancer still causes morbidity and deaths worldwide. In the early stages (FIGO IA1 with lymph-vascular space invasion-IIA1), the disease is highly curable. The primary treatment for early-stage cervical cancer is radical hysterectomy with pelvic lymphadenectomy. This surgical treatment has changed during the past decades, and we aimed to review and discuss the advances in the literature. We performed a literature review through PubMed focusing on English articles about the topic of surgical management of early-stage cervical cancer. The emergent topics considered here are the FIGO 2018 staging system update, conservative management for selected patients, sentinel lymph node mapping, fertility preservation, surgical approach, and management of tumors up to 2 cm. These topics show an evolvement to a more tailored treatment to prevent morbidity and assure oncologic safety.

Abstract

Cervical cancer (CC) remains a public health issue worldwide despite preventive measures. Surgical treatment in the early-stage CC has evolved during the last decades. Our aim was to review the advances in the literature and summarize the ongoing studies on this topic. To this end, we conducted a literature review through PubMed focusing on English-language articles on the surgical management of early-stage CC. The emergent topics considered here are the FIGO 2018 staging system update, conservative management with less radical procedures for selected patients, lymph node staging, fertility preservation, preferred surgical approach, management of tumors up to 2 cm, and prognosis. In terms of updating FIGO, we highlight the inclusion of lymph node status on staging and the possibility of imaging. Regarding the preferred surgical approach, we emphasize the LACC trial impact worldwide in favor of open surgery; however, we discuss the controversial application of this for tumors < 2 cm. In summary, all topics show a tendency to provide patients with tailored treatment that avoids morbidity while maintaining oncologic safety, which is already possible in high-income countries. We believe that efforts should focus on making this a reality for low-income countries as well.

Imaging in Carcinoma Cervix and Revised 2018 FIGO Staging System: Implications in Radiology Reporting

The International Federation of Gynecology and Obstetrics (FIGO) staging system of carcinoma cervix saw a radical change in 2018 with the inclusion of cross-sectional imaging tools for the assessment of disease extent and staging. One of the major revisions is the inclusion of lymph node status, detected either on imaging or pathological evaluation, in the staging system. The changes were based on long-term patient follow-up and survival rates reported in literature. Thus, it becomes imperative for a radiologist to be well versed with the recent staging system, its limitations, and implications on the patient management.

ACR Appropriateness Criteria® Staging and Follow-up of Primary Vaginal Cancer

Primary vaginal cancer is rare, comprising 1% to 2% of gynecologic malignancies and 20% of all malignancies involving the vagina. More frequently, the vagina is involved secondarily by direct invasion from malignancies originating in adjacent organs or by metastases from other pelvic or extrapelvic primary malignancies. Data on the use of imaging in vaginal cancer are sparse. Insights are derived from the study of imaging in cervical cancer and have reasonable generalizability to vaginal cancer due to similar tumor biology. Given the trend toward definitive chemoradiation for both cancers in all but early stage lesions, principles of postchemoradiation tumor response evaluation are largely analogous. Accordingly, many of the recommendations outlined here are informed by principles translated from the literature on cervical cancer. For pretreatment assessment of local tumor burden and in the case of recurrent vaginal cancer, MRI is the preferred imaging modality. PET/CT has demonstrated utility for the detection of nodal metastatic and unexpected distant metastatic disease. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Magnetic Resonance Imaging of Uterine Cervix: A Pictorial Essay

Uterine cervix is the lower constricted part of uterus which is best evaluated by magnetic resonance imaging (MRI) due to its higher soft tissue and contrast resolution. The cervical cancer is a common gynecological cancer causing much morbidity and mortality especially in developing countries. Cervical carcinomas mainly occurs in reproductive age group with prognosis mainly depending on the extent of disease at the time of diagnosis, hence it is important to identify these cancerous lesions early and stage them accurately for optimal treatment. In this article, we will review the following: (1) the normal MRI anatomy of uterine cervix; (2) MRI protocol and techniques in evaluation of cervical lesions; (3) imaging of spectrum of various congenital abnormalities and pathologies affecting uterine cervix which ranges from congenital abnormalities to various benign lesions of cervix like nabothian cysts, tunnel cysts, cervicitis, cervical fibroid, and, lastly, endometriosis which usually coexists with adenomyosis; the malignant lesions include carcinoma cervix, adenoma malignum or direct extension from carcinoma endometrium or from carcinoma of vagina; (4) Accurately stage carcinoma of cervix using FIGO classification (2018); and (5) posttreatment evaluation of cervical cancers. MRI is the most reliable imaging modality in evaluation of various cervical lesions, identification of cervical tumors, staging of the cervical malignancy, and stratifying patients for surgery and radiation therapy. It also plays an important role in detection of local disease recurrence.

Ultrasound-guided fine needle aspiration cytology of Para-aortic lymph node metastasis in uterine cervical cancer: diagnostic accuracy and impact on clinical decision making

OBJECTIVE

The main aim of this study was to ascertain the effectiveness of ultrasound-guided fine needle aspiration cytology (US-FNAC) in the diagnosis of para-aortic lymph node (PALN) metastasis in uterine cervical cancer and to establish its potential impact on clinical therapeutic decision making.

METHODS

We retrospectively reviewed clinical data from 92 patients diagnosed with cervical cancer with PALN enlargement between 2010 and 2018. Cytological results obtained with US-FNAC were classified by the same experienced cellular pathologists. Diagnostic indicators were determined on the basis of biopsy, imaging and clinical follow-up results. Univariate and multivariate analyses were used to assess the differences of influencing factors. The effect of US-FNAC on clinical decision making was evaluated.

RESULTS

Cytological results of US-FNAC were categorized as malignancy (n = 62; 67.4%), suspicious malignancy (n = 11; 12.0%), undetermined (n = 5; 5.4%), benign (n = 10; 10.9%), and inadequate (n = 4; 4.3%). Satisfactory biopsy samples were obtained from 95.7% of PALNs sampled (88/92). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC in distinguishing benign from malignant cases were 90.1% (95% CI: 0.809-0.953), 100% (95% CI: 0.561-1), 100% (95% CI: 0.938-1), 46.7% (95% CI: 0.223-0.726) and 90.9% (95% CI: 0.848-0.970), respectively. Univariate analysis indicated significant differences in experience of puncture physicians (radiologists) between the correct and wrong diagnosis groups (P < 0.05), which was further confirmed as an independent predictor of diagnostic accuracy in multivariate analysis (p = 0.031, OR = 0.077, 95% CI: 0.354-0.919). All patients tolerated the US-FNAC procedure well and only nine presented slight abdominal discomfort. The therapeutic strategies for 74 patients (80.4%) were influenced by US-FNAC findings.

CONCLUSIONS

US-FNAC was a relatively safe and effective technique for examination of enlarged para-aortic lymph nodes and may therefore serve as a routine diagnostic tool to guide clinical decision making for management of cervical cancer.

Cervix Cancer in Sub-Saharan Africa: An Assessment of Cervical Cancer Management

PURPOSE

Underdeveloped nations carry the burden of most cervical cancer, yet access to adequate treatment can be challenging. This report assesses the current management of cervical cancer in sub-Saharan Africa to better understand the needs of underdeveloped nations in managing cervical cancer.

METHODS

A pre- and postsurvey was sent to all centers participating in the Cervical Cancer Research Network's 4th annual symposium. The pre- and postsurvey evaluated human papillomavirus and HIV screening, resources available for workup and/or treatment, treatment logistics, outcomes, and enrollment on clinical trials. Descriptive analyses were performed on survey responses.

RESULTS

Twenty-nine centers from 12 sub-Saharan countries saw approximately 300 new cases of cervical cancer yearly. Of the countries surveyed, 55% of countries had a human papillomavirus vaccination program and 30% (range, 0%-65%) of women in each region were estimated to have participated in a cervical cancer screening program. In the workup of patients, 43% of centers had the ability to obtain a positron emission tomography and computed tomography scan and 79% had magnetic resonance imaging capabilities. When performing surgery, 88% of those centers had a surgeon with an expertise in performing oncological surgeries. Radiation therapy was available at 96% of the centers surveyed, and chemotherapy was available in 86% of centers. Clinical trials were open at 4% of centers.

CONCLUSION

There have been significant advancements being made in screening, workup, and management of patients with cervical cancer in sub-Saharan Africa; yet, improvement is still needed. Enrollment in clinical trials remains a struggle. Participants would like to enroll patients on clinical trials with Cervical Cancer Research Network's continuous support.

Advances in management of locally advanced cervical cancer

Globally, cervical cancer has the fourth highest cancer incidence and mortality in women. Cervical cancer is unique because it has effective prevention, screening, and treatment options. This review discusses the current cervical cancer advances with a focus on locally advanced cervical cancer. Topics discussed include diagnostic imaging principles, surgical management with adjuvant therapy and definitive concurrent chemoradiotherapy. Emphasis is given on current advances and future research directions in radiation therapy (RT) with an emphasis on three-dimensional brachytherapy, intensity-modulated RT, image-guided RT, proton RT and hyperthermia.

The role of lymph nodes in cervical cancer: incidence and identification of lymph node metastases-a literature review

Correct identification of patients with lymph node metastasis from cervical cancer prior to treatment is of great importance, because it allows more tailored therapy. Patients may be spared unnecessary surgery or extended field radiotherapy if the nodal status can be predicted correctly. This review captures the existing knowledge on the identification of lymph node metastases in cervical cancer. The risk of nodal metastases increases per 2009 FIGO stage, with incidences in the pelvic region ranging from 2% (stage IA2) to 14-36% (IB), 38-51% (IIA) and 47% (IIB); and in the para-aortic region ranging from 2 to 5% (stage IB), 10-20% (IIA), 9% (IIB), 13-30% (III) and 50% (IV). In addition, age, tumor size, lymph vascular space invasion, parametrial invasion, depth of stromal invasion, histological type, and histological grade are reported to be independent prognostic factors for the risk of nodal metastases. Furthermore, biomarkers can contribute to predict a patient's nodal status, of which the squamous cell carcinoma antigen (SCC-Ag) is currently the most widely used in squamous cell cervical cancer. Still, pre-treatment lymph node assessment is primarily performed by imaging, of which diffusion-weighted magnetic resonance imaging has the highest sensitivity and 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission computed tomography the highest specificity. Imaging results can be combined with clinical parameters in nomograms to increase the accuracy of predicting positives nodes. Despite all the progress regarding pre-treatment prediction of lymph node metastases in cervical cancer in recent years, prediction rates are not robust enough to safely abandon surgical staging of the pelvic or para-aortic region yet.

Updates in Cervical Cancer Treatment

Although rates of cervical cancer in the United States have been declining due to vaccination and screening efforts, it remains the fourth most common cancer in women worldwide and is still far from being eradicated, even in developed nations. This review discusses recent developments in cervical cancer treatment and reviews the literature supporting recent practice changes encompassing staging, surgical management, radiation, chemotherapy, targeted agents including immunotherapy, and imaging.

Oncologic outcomes in the era of modern radiation therapy using FIGO 2018 staging system for cervical cancer

BACKGROUND

The recently published ASTRO cervical cancer guidelines recommend the use of modern radiotherapy. Imaging is now incorporated in the updated FIGO 2018 staging with a new stage IIIC. This study aims to evaluate the oncologic outcomes and predictors of survival using FIGO 2018 staging in a cohort of patients treated in an era of high-precision image-guided radiotherapy.

METHODS

We performed a retrospective cohort study of 216 adult cervical cancer patients treated with definitive chemoradiotherapy between 2010 and 2018. Eligible patients had non-metastatic cervical cancer treated at a single academic institution. All patients had pre-treatment MRI and CT/PET. Treatment protocol consisted of external beam intensity-modulated radiotherapy and 3D image-guided brachytherapy. Kaplan-Meier curves were used for survival analysis. Multivariate cox proportional-hazards model was performed to identify potential prognostic factors.

RESULTS

Median age at diagnosis was 50 and median BMI was 26.4 kg/m². Median follow-up time was 44.3 months. Five-year overall survival (OS), disease-free survival and loco-regional disease-free survival rates were 76.8%, 68.5% and 82.6%, respectively. FIGO 2018 showed better OS discrimination compared to FIGO 2009 classification. OS was increasingly worse with positive pelvic and para-aortic nodes (p < 0.001). In a multivariate prediction model, performance status (p = 0.044) and FIGO 2018 classification (stage III p = 0.016; stage IVA p = 0.010) were predictors of mortality; FIGO 2018 classification (stage III p = 0.003; stage IVA p = 0.001) was a predictor of any recurrence; MRI tumor diameter (p ≤ 0.001) and nodal metastases (p = 0.024) were predictors of loco-regional recurrence.

CONCLUSIONS

Integration of state-of-the-art imaging in cervical cancer staging and in radiotherapy planning leads to good loco-regional control rates, however distant recurrence remains an important issue. FIGO 2018 staging better reflects patient prognosis, highlighting the need for new treatment strategies for stage IIIC cervical cancer.

Diagnostic Accuracy of 18F-FDG-PET/CT and MRI in Predicting the Tumor Response in Locally Advanced Cervical Carcinoma Treated by Chemoradiotherapy: A Meta-Analysis

Objective

The aim of this meta-analysis was to compare the diagnostic accuracy of 18F-FDG-PET/CT and MRI in predicting the tumor response in locally advanced cervical carcinoma (LACC) treated by chemoradiotherapy (CRT).

Method

This meta-analysis has been performed according to PRISMA guidelines. Systematic searches were conducted using PubMed and Embase databases for articles published from January 1, 2010, to January 1, 2020. By using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool, the reviewers assessed the methodological quality scores of the selected studies. We analyzed the sensitivity, specificity, and accuracy of two diagnostic methods using Meta-DiSc 1.4 and Stata 15.

Results

An overall of 15 studies including 1132 patients were included. Sensitivities of PET/CT and MRI were 83.5% and 82.7%, while the corresponding rates for specificities were 77.8% and 68.4%, respectively. The DOR, PLR, and NLR for MRI were 15.140, 2.92, and 22.6. PET/CT had a DOR of 25.21. The PLR and NLR for PET/CT were 4.13 and 0.215, respectively. The diagnostic sensitivity and specificity of PET/CT for the detection of residual tumor were 86% and 95%, respectively. The corresponding rates for MRI were 73% and 96%, respectively. The diagnostic sensitivity and specificity of PET/CT for the detection of tumor metastases were 97% and 99%, while the corresponding rates for MRI were 31% and 98%, respectively.

Conclusion

18F-FDG PET/CT seemed to have a better overall diagnostic accuracy in the evaluation of treatment response to chemoradiotherapy in LACC patients. MRI showed a really poor sensitivity in the detection of metastases, and PET/CT performed significantly better. However, the difference between these two methods in the detection of residual disease was not significant. More studies are needed to be conducted in order to approve that 18F-FDG PET/CT can be a standard option to assess the treatment response.

Optimal treatment in locally advanced cervical cancer

Introduction: Locally advanced cervical cancer (LACC) (International Federation of Gynecology and Obstetrics (FIGO) 2009/2018 - stages IB2-IVA/IB3-IVA, respectively) is treated using a multimodal approach that includes chemoradiotherapy followed by brachytherapy.Areas covered: This review provides an overview of the progress made over the past decade in the treatment of LACC. Prognostic factors, FIGO classification and the role of imaging staging will be discussed. Efficacy of external-beam radiotherapy, brachytherapy and chemotherapy will be detailed. Indications for para-aortic staging lymphadenectomy and adjuvant hysterectomy, as well as follow-up and special population, will be covered.Expert opinion: The initial workup is one of the most crucial steps in the optimal care of patients, which should be realized by a multidisciplinary expert team. With the implementation of modern conformal radiotherapy techniques, the local control rate has been optimized. Nevertheless, 40% of patients experience recurrence with distant metastasis and a dismal prognosis. Currently, a clear benefit of neo- and adjuvant chemotherapy has not been established. The future likely involves (1) improved selection of patients for whom treatment intensification is justified, (2) a combination of new drugs with chemoradiation that are currently being tested in trials, and (3) the development of tailored treatment based on molecular characteristics.

False negative rate at 18F-FDG PET/CT in para-aortic lymphnode involvement in patients with locally advanced cervical cancer: impact of PET technology

Background

The identification of factors responsible for false negative (FN) rate at ¹⁸F- Fluorodeoxyglucose (FDG) Positron Emission Tomography /Computed Tomography (PET/CT) in para-aortic (PA) lymph nodes in the presurgical staging of patients with locally advanced cervical cancer (LACC) is challenging. The aim of this study was to evaluate the impact of PET/CT technology.

Methods

A total of 240 consecutive patients with LACC (International Federation of Gynecology and Obstetrics, FIGO, stage IB2-IVA) and negative Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) and negative ¹⁸F-FDG PET/CT in the PA region, undergoing laparoscopic PA lymphadenectomy before chemoradiotherapy were included. The FN rate in patients studied with Time of flight (TOF) PET/CT (TOF PET) or non-Time of flight PET/CT (no-TOF PET) technology was retrospectively compared.

Results

Patients presented with FIGO stage IB (n = 78), stage IIA-B (n = 134), stage III (n = 18) and stage IVa (n = 10), squamous cell carcinoma (n = 191) and adenocarcinoma (n = 49). 141/240 patients were evaluated with no-TOF PET/CT and 99/240 with TOF PET/CT. Twenty-two patients (9%) had PA nodal involvement at histological analysis and considered PET/CT FN findings. The FN rate was 8.5% for no-TOF PET and 10% for TOF PET subgroup respectively (p = 0.98). Ninety patients (38%) presented with pelvic node uptakes at PET/CT. The FN rate in the PA region was 18% (16/90) and 4% (6/150) in patients with and without pelvic node involvement at PET/CT respectively (19 vs 3% for no-TOF PET and 17 vs 5% for TOF PET subgroup).

Conclusions

In LACC, FN rate in PA lymph nodes detection is a clinical issue even for modern PET/CT, especially in patients with pelvic uptake. Surgical lymphadenectomy should be performed in case of negative PET/CT at PA level in these patients, while it could be discussed in the absence of pelvic uptake.

PET-detected asymptomatic recurrence is associated with improved survival in recurrent cervical cancer

PURPOSE

We aimed to examine utilization patterns of positron emission tomography scans (PET or PET/CT) beyond 6 months after cervical cancer treatment. We investigated survival outcomes of asymptomatic patients with PET-detected recurrence.

METHODS

We performed a retrospective review of 283 patients with stage IA-IVA cervical cancer treated with primary chemoradiation. The 107 patients (37.8%) with recurrence were categorized as "asymptomatic PET-detected recurrence" (n = 23) or "standard detection" (n = 84) and we compared clinical characteristics and outcomes using multivariate logistic regression analysis.

RESULTS

Late post-treatment PET (≥ 6 months after treatment) was performed in 35.3% (n = 100). Indications for late post-treatment PET included restaging in setting of known recurrence (23.6%), follow up of prior ambiguous imaging findings (9.7%), and new symptoms or exam findings (6.7%). However, late post-treatment PET was most commonly performed outside of current imaging guidelines, in asymptomatic patients without suspicion for recurrence (60.0%), presumably for surveillance. The median time to recurrence was 12.1 months (IQR 7.3-26.6). 23 patients (21.5%) had recurrence detected late post-treatment PET while asymptomatic (n = 23/107). Patients with asymptomatic PET-detected recurrence had improved survival by 26.3 months compared to the standard detection cohort (50.3 vs 24.0 months, p = 0.0015). On multivariate analysis, predictors of survival after recurrence were presence of distant metastases at diagnosis (p = 0.010) and asymptomatic PET-detected recurrence (p = 0.039).

CONCLUSIONS

PET imaging in asymptomatic patients beyond 6 months after treatment may have clinical benefit and warrants further study. Detection of recurrence by PET in asymptomatic patients ≥ 6 months after chemoradiation was associated with prolonged survival by more than   2 years.

Significance of para-aortic lymph node evaluation in patients with FIGO IIIC1 cervical cancer

OBJECTIVE

This study investigated the effect of para-aortic lymph node sampling or dissection in recently revised International Federation of Gynecology and Obstetrics IIIC1p cervical cancer treated with primary surgery and adjuvant radiation therapy with concurrent chemotherapy.

METHODS

We retrospectively reviewed the records of 343 patients with early-stage cervical cancer and pathologically proven pelvic lymph node metastasis following curative surgery from 2001 to 2014. No patient had imaging evidence of para-aortic lymph node involvement, and all patients received adjuvant concurrent chemotherapy with or without concurrent chemotherapy. We investigated the significance of para-aortic lymph node sampling or dissection on disease-free survival and overall survival.

RESULTS

After median follow-up of 58.3 months, 5-year disease-free survival and overall survival in all patients were 69.9 and 80.2%, respectively. Disease-free survival and overall survival did not differ between the para-aortic lymph node dissection group and the No para-aortic lymph node dissection group (P = 0.700 and P = 0.605). However, patients with para-aortic lymph node-positive disease had poorer disease-free survival and overall survival compared with those with para-aortic lymph node-negative disease (P < 0.001 and P < 0.001).

CONCLUSIONS

This study found no survival benefit of para-aortic lymph node evaluation among patients with International Federation of Gynecology and Obstetrics IIIC1p cervical cancer who were clinically para-aortic lymph node-negative. Although para-aortic lymph node metastasis is a poor prognosticator, the benefit of para-aortic lymph node dissection in terms of survival needs further investigation.

Diagnostic Value of FDG PET/MRI in Females With Pelvic Malignancy-A Systematic Review of the Literature

Hybrid imaging with F-18 fludeoxyglucose positron emission tomography/magnetic resonance imaging (FDG PET/MRI) has increasing clinical applications supplementing conventional ultrasound, CT, and MRI imaging as well as hybrid PET/CT imaging in assessing cervical, endometrial, and ovarian cancer. This article summarizes the existing literature and discusses the emerging role of hybrid PET/MRI in gynecologic malignancies. Thus, far, the published literature on the applications of FDG PET/MRI shows that it can have a significant impact on patient management by improving the staging of the cancers compared with PET/CT, influencing clinical decision and treatment strategy. For disease restaging, current literature indicates that PET/MRI performs equivalently to PET/CT. There appears to be a mild-moderate inverse correlation between standard-uptake-value (SUV) and apparent-diffusion-coefficient (ADC) values, which could be used to predict tumor grading and risk stratification. It remains to be seen as to whether multi-parametric PET/MRI imaging could prove valuable for prognostication and outcome. PET/MRI provides the opportunity for reduced radiation exposure, which is particularly relevant for a young female in need of multiple scans for treatment monitoring and follow-up. Fast acquisition protocols and optimized methods for attenuation correction are still evolving. Major limitations of PET/MRI remains such as suboptimal detection of small pulmonary nodules and lack of utility for radiation treatment planning, which pose an impediment in making PET/MRI a viable one-stop-shop imaging option to compete with PET/CT.

Comparison of different lymph node staging systems in patients with node-positive cervical squamous cell carcinoma following radical surgery

Objective: We compared the prognostic accuracy of four lymph node (LN) staging systems - the 2018 International Federation of Gynecology and Obstetrics (FIGO) stage, number of positive lymph node (PLN), metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) systems - in patients with node-positive cervical squamous cell carcinoma (CSCC) following radical surgery and explored the optimal choice for clinical applications. Materials and methods: Data were retrospectively collected from 928 node-positive CSCC patients who underwent radical surgery between 2006 and 2014 in our center. Tree-based recursive partitioning was applied to split variables (PLN, LNR, and LODDS) into low-risk and high-risk groups. The log-rank test was used to compare survival curves, and Cox regression analysis was performed to identify prognostic factors. The relative discriminative abilities of the different staging systems were assessed using Harrell's concordance index (C index) and the Akaike information criterion (AIC). Results: The mean number of PLNs was 3.8 (range: 1-44 nodes). According to the 2018 FIGO staging system, 831 patients had stage IIIC1, and 97 had stage IIIC2. For the PLN system, 761 patients were included in the low-risk group, and 167 were included in the high-risk group. For the LNR system, 658 patients were included in the low-risk group, and 270 were included in the high-risk group. The low-risk LODDS group included 694 patients, while the high-risk LODDS group included 234 patients. All four staging systems had a significant influence on patients' progression-free survival (PFS, P < 0.001) and overall survival (OS, P < 0.001). Univariate analysis and multivariate Cox analysis adjusted for significant factors indicated that the four staging systems were significant prognostic factors for PFS and OS. Among them, the PLN system was noted to have the best prognostic performance for both PFS (C index: 0.582; AIC: 8213.33) and OS (C index: 0.624; AIC: 8433.80). Conclusion: The PLN system seemed to be the most accurate LN staging method for predicting node-positive CSCC following radical surgery.

Surgical or imaging lymph node assessment in locally advanced cervical cancer: a systematic review and meta-analysis

Objective

To evaluate the survival impact of imaging vs surgical nodal assessment in patients with cervical cancer stage IB2–IVA prior to definitive chemoradiotherapy (CRT).

Methods

PubMed, MEDLINE, Cochrane Library, and ClinicalTrials.gov were used to search for publications in English and Chinese over a 50-year period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols was used to conduct this review. Inclusion criteria were studies that compared survival outcomes in International Federation of Gynecology and Obstetrics 2009 stage IB2–IVA cervical cancer patients with pre-therapy pelvic and/or aortic lymphadenectomy (LND) or imaging. One or more of the following modalities were used for nodal assessment: computed tomography (CT), magnetic resonance imaging, or positron emission tomography-CT. The National Institutes of Health Quality Assessment Tool was utilized to assess study quality.

Results

The initial search identified 65 studies, and five met the inclusion criteria. There were a total of 1,112 patients. Seven hundred and fifty-four underwent pelvic and/or aortic LND and 358 had imaging. When compared to LND, imaging had a sensitivity and specificity of 88.9% and 22.2% for pelvic lymph node (LN), and 33%–62.5% and 92%–95.5% for para-aortic LN. There were no differences in progression-free survival (PFS) (hazard ratio [HR]=1.13; 95% confidence interval [CI]=0.73–1.74; I²=75%; p<0.01) and overall survival (OS) (HR=1.06; 95% CI=0.66–1.69; I²=75%; p<0.01) between surgical and imaging nodal assessment.

Conclusions

Imaging and surgical nodal assessment has comparable PFS and OS in patients with cervical cancer stage IB2–IVA.

Trial Registration

PROSPERO Identifier: CRD42020155486

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

[18F]FDG-PET or PET/CT in the evaluation of pelvic and para-aortic lymph nodes in patients with locally advanced cervical cancer: A systematic review of the literature

PURPOSE

Imaging is essential in detecting lymph node metastases for radiotherapy treatment planning in locally advanced cervical cancer (LACC). There are not many data on the performance of [¹⁸F]FDG-PET(CT) in showing lymph node metastases in LACC. We pooled sensitivity and specificity of [¹⁸F]FDG-PET(CT) for detecting pelvic and/or para-aortic lymph node metastases in patients with LACC. Also, the positive and negative posttest probabilities at high and low levels of prevalence were determined.

METHODS

MEDLINE and EMBASE searches were performed and quality characteristics assessed. Logit-sensitivity and logit-specificity estimates with corresponding standard errors were calculated. Summary estimates of sensitivity and specificity with corresponding 95% confidence intervals (CIs) were calculated by anti-logit transformation. Positive and negative likelihood ratios (LRs) were calculated from the mean logit-sensitivity and mean logit-specificity and the corresponding standard errors. The posttest probabilities were determined by Bayesian approach.

RESULTS

Twelve studies were included with a total of 778 patients aged 10-85 years. For pelvic nodes, summary estimates of sensitivity, specificity, LR+ and LR- were: 0.88 (95%CI: 0.40-0.99), 0.93 (95%CI: 0.85-0.97), 11.90 (95%CI: 5.32-26.62) and 0.13 (95%CI: 0.01-1.08). At the lowest prevalence of 0.15 the positive predictive value (PPV) and negative predictive value (NPV) were 0.68 and 0.98, at the highest prevalence of 0.65, 0.96 and 0.81. For the para-aortic nodes, the summary estimates of sensitivity, specificity LR+ and LR- were: 0.40 (95%CI: 0.18-0.66), 0.93 (95%CI: 0.91-0.95), 6.08 (95%CI: 2.90-12.78) and 0.64 (95%CI: 0.42-0.99), respectively. At the lowest prevalence of 0.17 the PPV and NPV were 0.55 and 0.88, at the highest prevalence of 0.50, 0.86 and 0.61.

CONCLUSION

The PPV and NPV of [¹⁸F]FDG-PET(CT) showing lymph node metastases in patients with LACC improves with higher prevalence. Prevalence and predictive values should be taken into account when determining therapeutic strategies based on [¹⁸F]FDG-PET(CT).

18F-FDG PET/MRI Primary Staging of Cervical Cancer: A Pilot Study with PET/CT Comparison

We report our PET/MRI experience from a pilot study that compared the diagnostic performance of ¹⁸F-FDG PET/MRI versus PET/CT in staging of cervical cancer. Methods: Six adults with newly diagnosed cervical cancer underwent a single ¹⁸F-FDG injection with a dual-imaging protocol: standard-of-care PET/CT followed by research PET/MRI. The diagnostic interpretation and SUV_max for the 2 modalities were compared. Results: Both modalities detected all primary tumors (median size, 3.9 cm) and all 4 metastases present in 2 of the 6 patients (median size, 0.9 cm). PET/MRI provided greater diagnostic confidence than PET/CT and upstaged the disease in 4 patients. On the basis of the imaging findings alone, the additional information from PET/MRI would have led to a change in clinical management in 3 of 6 patients. The primary lesion showed a median SUV of 12.8 on PET/CT and 18.2 on PET/MRI (P = 0.03). SUVs, however, correlated strongly between the 2 modalities (ρ = 0.96, P < 0.001). Conclusion: Our pilot study supports the notion that PET/MRI has the potential to impact clinical decisions and treatment strategies in women with cervical cancer. Further studies are, however, warranted to define the value that PET/MRI adds to PET/CT.

Multimodality Imaging of Uterine Cervical Malignancies

OBJECTIVE. In this article, we provide an updated review on the role of imaging in initial staging, treatment monitoring, and follow-up of cervical cancer with a focus on the role of MRI and FDG PET/CT. In addition, the 2018 International Federation of Gynecology and Obstetrics staging system and its implication on management of cervical cancer are explored. CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases.

Comparing survival outcomes between surgical and radiographic lymph node assessment in locally advanced cervical cancer: A propensity score-matched analysis

OBJECTIVE

To investigate progression-free survival (PFS) and overall survival (OS) between women who underwent surgical versus radiographic assessment of pelvic lymph nodes (PLN) and para-aortic lymph nodes (PALN) prior to chemoradiation therapy for cervical cancer.

METHODS

In this retrospective cohort analysis, patients with stage IB2 - IIIB squamous cell, adenocarcinoma and adenosquamous carcinoma of the cervix who completed concurrent chemoradiation therapy (CCRT) between 2000 and 2017 from the Mayo Clinic Cancer Registry were identified. A 1:2 propensity score matching between surgical and imaging groups was performed and PFS and OS were compared between groups.

RESULTS

148 patients were identified and after propensity score matching, 35 from the surgical group and 70 from the imaging group were included in the analysis. There were no statistical differences in baseline characteristics between the 2 groups. The median follow-up time was 41 months (range 7-218) for the surgical group and 51.5 months (range 7-198) for the imaging group. Five-year PFS was 62.6% for the surgical group and 72.4% in imaging group (HR 1.11, 95% CI 0.54-2.30, p = 0.77). Five-year OS was 70.2% for the surgical group and 70.5% for the imaging group (HR 1.02, 95% CI 0.46-2.29, p = 0.96). FIGO stage, PALN metastasis, and parametrial involvement were found to be poor prognosticators for PFS and OS in univariate analysis. Only PALN metastasis significantly predicted unfavorable PFS (HR 2.76, 95% CI 1.23-6.18, p = 0.01) and OS (HR 3.46, 95% CI 1.40-8.55, p = 0.01) in multivariate analysis. There were no differences in locoregional recurrence and distant metastasis between the two groups (p = 0.33 and 0.59 respectively).

CONCLUSION

Patients with cervical cancer who underwent radiographic assessment of PLN and PALN had comparable survival outcomes to surgical assessment.

The added benefit of transvaginal sonography in the clinical staging of cervical carcinoma

INTRODUCTION

Patients diagnosed with cervical cancer face several treatment options, depending on the physical examination and the imaging modality results. Transvaginal sonography (TVS) was proposed as an imaging option to determine local spread of cervical tumors, along with magnetic resonance imaging, also by recently released International Federation of Gynecology and Obstetrics recommendations. We examined whether combined data from physical examination, high-detail TVS, and positron emission tomography with ¹⁸ F-labeled fluoro-2-deoxyglucose and computed tomography (¹⁸ F-FDG PET/CT) may contribute to triage efficiency of cervical cancer patients.

MATERIAL AND METHODS

This is a retrospective study of consecutive women diagnosed with cervical cancer at the Carmel Health Center, Haifa, Israel, during 2010-2015. Inclusion criteria were histology of cervical cancer and the availability of three modalities-a thorough physical examination, a high-detail TVS, and positron emission tomography (PET) with ¹⁸ F-FDG and computed tomography (¹⁸ F-FDG PET/CT). End points were the possibility to predict local invasion to the parametrium and distant lymph node metastasis at the time of triage to surgery or chemoradiation.

RESULTS

Seventy-three patients with cervical cancer were evaluated. TVS correctly predicted no involvement of the parametrium for the 25 who had a postoperative pathological report. TVS measurement of tumor dimension was also matched by the pathological report in these cases. Only three patients were referred for adjuvant therapy according to postoperative pathology criteria. Among 43 women treated with a combination of chemotherapy and radiotherapy due to advanced disease, and with complete data, at least two modalities were congruent with chemoradiation for 33 (77%). Three patients (7%) were referred to chemoradiation due to TVS result alone.

CONCLUSIONS

The combination of high-detail TVS, directed to predict tumor dimensions and local spread, performed by a trained operator, combined with ¹⁸ F-FDG PET/CT and physical examination, can assist in selecting optimal treatment for cervical cancer patients, thus avoiding unnecessary operations.

Impact of tumor histology on detection of pelvic and para-aortic nodal metastasis with 18F-fluorodeoxyglucose-positron emission tomography in stage IB cervical cancer

OBJECTIVE

¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) detection of metastatic nodal disease is useful for guiding cervical cancer treatment but the impact of tumor histology is unknown. This study reports the detection of FDG avid pelvic and para-aortic lymph nodes in patients with early stage cervical cancer with squamous carcinoma and adenocarcinoma tumor histology.

METHODS

Patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-2 cervical cancer who underwent pre-surgical FDG-PET between March 1999 and February 2018 were identified in a tertiary academic center database. All patients had radical hysterectomy with pelvic and para-aortic lymph node dissection. Detection of pelvic and para-aortic lymph nodes by FDG-PET versus surgical dissection was compared. FDG-PET sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined and stratified by tumor histology.

RESULTS

We identified 212 patients with early stage cervical cancer (84% FIGO IB1, 16% IB2) who underwent pre-surgical FDG-PET; 137 (65%) patients had squamous carcinoma and 75 (35%) patients had adenocarcinoma. PET/computed tomography was performed in 189 (89%) patients and 23 (11%) had PET only. Surgical dissection revealed positive pelvic and para-aortic lymph nodes in 25% and 3.3% of patients, respectively. For squamous carcinoma, sensitivity, specificity, PPV, and NPV of FDG-PET for pelvic nodal metastasis were 44%, 99%, 95%, and 78%, respectively. For adenocarcinoma, the corresponding results for pelvic nodal metastasis were 25%, 99%, 67%, and 92%, respectively. The overall values for sensitivity, specificity, PPV, and NPV of FDG-PET for para-aortic nodal metastasis were 29%, 99%, 67%, and 98%, respectively.

DISCUSSION

Pelvic nodal metastasis was less likely to be detected by FDG-PET in patients with early stage adenocarcinoma than with squamous carcinoma.

The diagnostic performance of PET/CT scans for the detection of para-aortic metastatic lymph nodes in patients with cervical cancer: A meta-analysis

Objective

We performed a meta-analysis to evaluate the diagnostic value of positron emission tomography/computed tomography (PET/CT) in the detection of para-aortic lymph node metastasis in cervical cancer.

Methods

We searched the PubMed, Embase, Web of Science, Cochrane Library, Chinese Biological Medicine (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang and VIP databases in all languages from their inception to September 2018. Stat15.0 software was used to obtain pooled estimates of sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) as well as a summary receiver operating characteristic (SROC) curves. Deek‘s funnel plot was used to assess publication bias. QUADAS-2 was used to evaluate the quality of the studies. The protocol for this meta-analysis is registered in PROSPERO (CRD42019115330).

Results

We obtained 14 studies, and the pooled estimates for sensitivity and specificity of PET/CT were 0.71 (95% confidence interval (CI) = 0.54–0.83) and 0.97 (95% CI = 0.93–0.98), respectively. Pooled PLR and NLR were 21.53 and 0.30, respectively. The diagnostic odds ratio (DOR) was70.59, and the area under the curve (AUC) was 0.95.

Conclusion

PET/CT is an effective and important imaging method for the diagnosis of para-aortic lymph node metastasis in early cervical cancer.

FDG-PET Imaging in Cervical Cancer

FDG-PET/CT has an established role in the initial staging of locally advanced cervical cancers, particularly in evaluation of nodal disease and distant metastases. It is common practice to perform FDG-PET/CT 3 months postcompletion of chemoradiotherapy as it can predict outcome and be used to tailor management, including adjuvant therapy and follow-up. It is also routinely used prior to pelvic exenterative surgery to ensure there is no disease outside the pelvis. There is growing evidence that FDG-PET-derived parameters are prognostic and could potentially be used to tailor therapy. This review outlines the use of FDG-PET/CT imaging in cervical cancer.