The Role of Magnetic Resonance Imaging in Pretreatment Evaluation of Early-Stage Cervical Cancer

Current development of theragnostic nanoparticles for women's cancer treatment

In the biomedical industry, nanoparticles (NPs-exclusively small particles with size ranging from 1-100 nanometres) are recently employed as powerful tools due to their huge potential in sophisticated and enhanced cancer theragnostic (i.e. therapeutics and diagnostics). Cancer is a life-threatening disease caused by carcinogenic agents and mutation in cells, leading to uncontrolled cell growth and harming the body's normal functioning while affecting several factors like low levels of reactive oxygen species, hyperactive antiapoptotic mRNA expression, reduced proapoptotic mRNA expression, damaged DNA repair, and so on. NPs are extensively used in early cancer diagnosis and are functionalized to target receptors overexpressing cancer cells for effective cancer treatment. This review focuses explicitly on how NPs alone and combined with imaging techniques and advanced treatment techniques have been researched against 'women's cancer' such as breast, ovarian, and cervical cancer which are substantially occurring in women. NPs, in combination with numerous imaging techniques (like PET, SPECT, MRI, etc) have been widely explored for cancer imaging and understanding tumor characteristics. Moreover, NPs in combination with various advanced cancer therapeutics (like magnetic hyperthermia, pH responsiveness, photothermal therapy, etc), have been stated to be more targeted and effective therapeutic strategies with negligible side effects. Furthermore, this review will further help to improve treatment outcomes and patient quality of life based on the theragnostic application-based studies of NPs in women's cancer treatment.

Intratumoral and peritumoral MRI radiomics nomogram for predicting parametrial invasion in patients with early-stage cervical adenocarcinoma and adenosquamous carcinoma

OBJECTIVE

To develop a comprehensive nomogram based on MRI intra- and peritumoral radiomics signatures and independent risk factors for predicting parametrial invasion (PMI) in patients with early-stage cervical adenocarcinoma (AC) and adenosquamous carcinoma (ASC).

METHODS

A total of 460 patients with IB to IIB cervical AC and ASC who underwent preoperative MRI examination and radical trachelectomy/hysterectomy were retrospectively enrolled and divided into primary, internal validation, and external validation cohorts. The original (Ori) and wavelet (Wav)-transform features were extracted from the volumetric region of interest of the tumour (ROI-T) and 3mm- and 5mm-peritumoral rings (ROI-3 and ROI-5), respectively. Then the Ori and Ori-Wav feature-based radiomics signatures from the tumour (RST) and 3 mm- and 5 mm-peritumoral regions (RS3 and RS5) were independently built and their diagnostic performances were compared to select the optimal ones. Finally, the nomogram was developed by integrating optimal intra- and peritumoral signatures and clinical independent risk factors based on multivariable logistic regression analysis.

RESULTS

FIGO stage, disruption of the cervical stromal ring on MRI (DCSRMR), parametrial invasion on MRI (PMIMR), and serum CA-125 were identified as independent risk factors. The nomogram constructed by integrating independent risk factors, Ori-Wav feature-based RST, and RS5 yielded AUCs of 0.874 (0.810-0.922), 0.885 (0.834-0.924), and 0.966 (0.887-0.995) for predicting PMI in the primary, internal and external validation cohorts, respectively. Furthermore, the nomogram was superior to radiomics signatures and clinical model for predicting PMI in three cohorts.

CONCLUSION

The nomogram can preoperatively, accurately, and noninvasively predict PMI in patients with early-stage cervical AC and ASC.

CLINICAL RELEVANCE STATEMENT

The nomogram can preoperatively, accurately, and noninvasively predict PMI and facilitate precise treatment decisions regarding chemoradiotherapy or radical hysterectomy in patients with early-stage cervical AC and ASC.

KEY POINTS

The accurate preoperative prediction of PMI in early-stage cervical AC and ASC can facilitate precise treatment decisions regarding chemoradiotherapy or radical hysterectomy. The nomogram integrating independent risk factors, Ori-Wav feature-based RST, and RS5 can preoperatively, accurately, and noninvasively predict PMI in early-stage cervical AC and ASC. The nomogram was superior to radiomics signatures and clinical model for predicting PMI in early-stage cervical AC and ASC.

Diagnostic Value of Diffusion-Weighted Imaging with Background Body Signal Suppression (DWIBS) for the Pre-Therapeutic Loco-Regional Staging of Cervical Cancer: A Feasibility and Interobserver Reliability Study

(1) Background: cervical cancer is one of the leading causes of cancer-related deaths and the fourth most common cancer among women worldwide. Magnetic resonance imaging (MRI) is the modality of choice for loco-regional staging of cervical cancer in the primary diagnostic workup beginning with at least stage IB. (2) Methods: we retrospectively analyzed 16 patients with histopathological proven cervical cancer (FIGO IB1−IVA) for the diagnostic accuracy of standard MRI and standard MRI with diffusion-weighted imaging with background body signal suppression (DWIBS) for the correct pre-therapeutic assessment of the definite FIGO category. (3) Results: In 7 out of 32 readings (22%), DWIBS improved diagnostic accuracy. With DWIBS, four (13%) additional readings were assigned the correct major (I−IV) FIGO stages pre-therapeutically. Interobserver reliability of DWIBS was weakest for parametrial infiltration (k = 0.43; CI-95% 0.00−1.00) and perfect for tumor size <2 cm, infiltration of the vaginal lower third, infiltration of adjacent organs and loco-regional nodal metastases (k = 1.000; CI-95% 1.00−1.00). (4) Conclusions: the pre-therapeutic staging of cervical cancer has a high diagnostic accuracy and interobserver reliability when using standard MRI but can be further optimized with the addition of DWIBS sequences when reporting is performed by an experienced radiologist.

Can MRI Be Used as a Sole Diagnostic Modality in Determining Clinical Stage in Cervical Cancer?

OBJECTIVE

The objective of this study was to compare staging by MRI to clinical staging in patients with cervical cancer and to determine the histological accuracy of staging by MRI and examination under anesthesia (EUA) in early stage disease.

METHODS

This was a retrospective cohort study of patients diagnosed with cervical cancer between 2010 and 2020 at the Radboud University Medical Centre, the Netherlands. Pretreatment stage (FIGO 2009) by MRI was compared with staging by EUA. Diagnostic accuracy in terms of sensitivity, specificity, positive, and negative predictive value was calculated for MRI and EUA in patients undergoing surgery (early stage disease) with histological results as a reference standard.

RESULTS

A total of 358 patients were included in the study and MRI-based stage differed from EUA stage in 30.7%. In 12.3% this meant a discrepancy in treatment assignment between MRI and EUA. Diagnostic accuracy of MRI in terms of sensitivity and specificity for detecting early stage disease was comparable to EUA in surgical patients. Further analyses showed that premenopausal status, early stage disease and a tumor diameter of <2 cm were associated with improved comparability of MRI and EUA (98%).

CONCLUSION

There is still a large discrepancy between MRI and EUA. In patients with suspected early stage disease, diagnostic accuracy of MRI is similar to EUA, especially for premenopausal women with early stage disease and a tumor diameter of <2 cm.

Radiomics Based on Nomogram Predict Pelvic Lymphnode Metastasis in Early-Stage Cervical Cancer

The accurate prediction of the status of PLNM preoperatively plays a key role in treatment strategy decisions in early-stage cervical cancer. The aim of this study was to develop and validate a radiomics-based nomogram for the preoperative prediction of pelvic lymph node metastatic status in early-stage cervical cancer. One hundred fifty patients were enrolled in this study. Radiomics features were extracted from T2-weighted MRI imaging (T2WI). Based on the selected features, a support vector machine (SVM) algorithm was used to build the radiomics signature. The radiomics-based nomogram was developed incorporating radiomics signature and clinical risk factors. In the training cohort (AUC = 0.925, accuracy = 81.6%, sensitivity = 70.3%, and specificity = 92.0%) and the testing cohort (AUC = 0.839, accuracy = 74.2%, sensitivity = 65.7%, and specificity = 82.8%), clinical models that combine stromal invasion depth, FIGO stage, and MTD perform poorly. The combined model had the highest AUC in the training cohort (AUC = 0.988, accuracy = 95.9%, sensitivity = 92.0%, and specificity = 100.0%) and the testing cohort (AUC = 0.922, accuracy = 87.1%, sensitivity = 85.7%, and specificity = 88.6%) when compared to the radiomics and clinical models. The study may provide valuable guidance for clinical physicians regarding the treatment strategies for early-stage cervical cancer patients.

Interobserver agreement and prognostic impact for MRI-based 2018 FIGO staging parameters in uterine cervical cancer

OBJECTIVES

To evaluate the interobserver agreement for MRI-based 2018 International Federation of Gynecology and Obstetrics (FIGO) staging parameters in patients with cervical cancer and assess the prognostic value of these MRI parameters in relation to other clinicopathological markers.

METHODS

This retrospective study included 416 women with histologically confirmed cervical cancer who underwent pretreatment pelvic MRI from May 2002 to December 2017. Three radiologists independently recorded MRI-derived staging parameters incorporated in the 2018 FIGO staging system. Kappa coefficients (κ) for interobserver agreement were calculated. The predictive and prognostic values of the MRI parameters were explored using ROC analyses and Kaplan-Meier with log-rank tests, and analyzed in relation to clinicopathological patient characteristics.

RESULTS

Overall agreement was substantial for the staging parameters: tumor size > 2 cm (κ = 0.80), tumor size > 4 cm (κ = 0.76), tumor size categories (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) (κ = 0.78), parametrial invasion (κ = 0.63), vaginal invasion (κ = 0.61), and enlarged lymph nodes (κ = 0.63). Higher MRI-derived tumor size category (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) was associated with a stepwise reduction in survival (p ≤ 0.001 for all). Tumor size > 4 cm and parametrial invasion at MRI were associated with aggressive clinicopathological features, and the incorporation of these MRI-based staging parameters improved risk stratification when compared to corresponding clinical assessments alone.

CONCLUSION

The interobserver agreement for central MRI-derived 2018 FIGO staging parameters was substantial. MRI improved the identification of patients with aggressive clinicopathological features and poor survival, demonstrating the potential impact of MRI enabling better prognostication and treatment tailoring in cervical cancer.

KEY POINTS

• The overall interobserver agreement was substantial (κ values 0.61-0.80) for central MRI staging parameters in the 2018 FIGO system. • Higher MRI-derived tumor size category was linked to a stepwise reduction in survival (p ≤ 0.001 for all). • MRI-derived tumor size > 4 cm and parametrial invasion were associated with aggressive clinicopathological features, and the incorporation of these MRI-derived staging parameters improved risk stratification when compared to clinical assessments alone.

Combination of Estrogen Receptor Alpha and Histological Type Helps to Predict Lymph Node Metastasis in Patients with Stage IA2 to IIA2 Cervical Cancer

Objective

This study aimed to identify a subset of patients with stage IA2 to IIA2 cervical cancer who are at low risk of lymph node metastasis (LNM) using pathological parameters including estrogen receptor alpha (ERα) and progesterone receptor (PR).

Methods

The clinical data of patients with stage IA2 to IIA2 cervical cancer who underwent radical surgery between 2014 and 2015 were retrospectively reviewed. Immunohistochemical staining was used to determine the expression of ERα and PR. A low-risk criterion for LNM was identified using logistic regression analysis, and its performance was estimated through receiver-operating characteristic curve analysis.

Results

Of 263 patients, 57 (21.7%) had pathological LNM. ERα (adjusted odds ratio [aOR], 7.582; 95% confidence interval [CI], 2.991–19.222; P < 0.001) and squamous cell carcinoma (aOR, 3.520; 95% CI, 1.887–6.568; P < 0.001) were identified as independent predictors for no LNM by multivariate logistic regression analysis, while PR had no effect on LNM. The rate of LNM was 1.4% for low-risk patients (n = 73) identified as ERα positive with squamous cell carcinoma. The 5-year disease-free survival in low-risk patients was significantly greater than in those negative for ERα and/or those with non-squamous cell carcinoma (96.9% vs 80.1%, P = 0.002).

Conclusion

ERα positivity and squamous cell carcinoma are associated with a low risk of LNM in patients with stage IA2 to IIA2 cervical cancer. Hence, those patients without a low risk of LNM could be considered for definitive chemoradiotherapy to avoid unnecessary surgery.

Extraperitoneal laparoscopy for para-aortic lymphadenectomy in endometrial carcinoma staging: an approach with higher efficiency

Background

Removing more inframesenteric nodes is not only significantly increases the likelihood of finding metastasis for endometrial cancer, but also can add survival advantage. As most patients diagnosed with endometrial cancer are overweight or obesity, a high efficiency approach is important. Aim of this study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and laparotomic para-aortic lymphadenectomy in endometrial carcinoma staging.

Methods

We retrospectively reviewed data of all patients diagnosed with primary endometrial carcinoma who were treated at the Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center from 1 January 2017 to 31 December 2019. The numbers of para-aortic lymph nodes, surgical time, complications, blood loss and hospital stay were compared. The patients’ medical records and pathological reports were carefully reviewed. Statistical significance was defined as p < 0.05.

Results

We retrospectively compared patients who underwent extraperitoneal laparoscopy (Group E, n = 20), transperitoneal laparoscopy (group T, n = 21), and laparotomy (group L, n = 135). The median number of para-aortic lymph nodes was significantly higher in group E than in groups T and L (9.5, 5, and 6, respectively; p = 0.004 and 0.0004, respectively). All patients in group E underwent successfully dissection to the renal vessel level. The median operation time was significantly shorter in group L than in groups T and E (94, 174, and 233 min, respectively; p < 0.0001). The median estimated blood loss volume was higher in group L than in groups T and E (200, 100, and 142.5 ml, respectively; all comparisons p < 0.001), and the length of hospital stay was significantly longer in group L than in Groups T and E (6, 5, and 6 days, respectively; all comparisons p < 0.001).

Conclusion

The extraperitoneal laparoscopic approach for staging endometrial carcinoma harvested higher numbers of para-aortic lymph nodes which could be considered for endometrial carcinoma staging, especially for para-aortic lymph node harvest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02416-x.

Can Conization Specimens Predict Sentinel Lymph Node Status in Early-Stage Cervical Cancer? A SENTICOL Group Study

Simple Summary

Lymph node involvement is one of the major prognosis factors for early-stage cervical cancer. Improvement in preoperative identification of node-positive patients may lead to a more accurate triage to primary chemoradiation for these patients instead of radical surgery followed by adjuvant radiotherapy, given the increased morbidity of combined treatment. Several studies have well established risk factors for node involvement, but they are based on final pathologic examination of radical hysterectomy specimens and are usually extrapolated for preoperative risk assessment. Among these risk factors, tumor size, lymphovascular space invasion (LVSI) and depth of stromal invasion might be assessed in conization specimens. Our findings suggest that patients with depth of stromal invasion lower than 10 mm and no LVSI in conization specimens had lower risk of micro- and macrometastatic SLN. In this subpopulation, full node dissection may be questionable in case of SLN unilateral detection.

Abstract

Background: The prognosis of patients with cervical cancer is significantly worsened in case of lymph node involvement. The goal of this study was to determine whether pathologic features in conization specimens can predict the sentinel lymph node (SLN) status in early-stage cervical cancer. Methods: An ancillary analysis of two prospective multicentric database on SLN biopsy for cervical cancer (SENTICOL I and II) was carried out. Patients with IA to IB2 2018 FIGO stage, who underwent preoperative conization before SLN biopsy were included. Results: Between January 2005 and July 2012, 161 patients from 25 French centers fulfilled the inclusion criteria. Macrometastases, micrometastases and Isolated tumor cells (ITCs) were found in 4 (2.5%), 6 (3.7%) and 5 (3.1%) patients respectively. Compared to negative SLN patients, patients with micrometastatic and macrometastatic SLN were more likely to have lymphovascular space invasion (LVSI) (60% vs. 29.5%, p = 0.04) and deep stromal invasion (DSI) ≥ 10 mm (50% vs. 17.8%, p = 0.04). Among the 93 patients with DSI < 10 mm and absence of LVSI on conization specimens, three patients (3.2%) had ITCs and only one (1.1%) had micrometastases. Conclusions: Patients with DSI < 10 mm and no LVSI in conization specimens had lower risk of micro- and macrometastatic SLN. In this subpopulation, full node dissection may be questionable in case of SLN unilateral detection.

Imaging to assist fertility-sparing surgery

Cytological screening and human papilloma virus testing has led to diagnosis of cervical cancer in young women at an earlier stage. Defining the full extent of the disease within the cervix with imaging aids the decision on feasibility of fertility-sparing surgical options, such as extended cone biopsy or trachelectomy. High spatial resolution images with maximal contrast between tumour and surrounding background are achieved with T2-weighted and diffusion-weighted (DW) magnetic resonance imaging (MRI) obtained using an endovaginal receiver coil. Tumour size and volume demonstrated in this way correlates between observers and with histology and differences between MRI and histology estimates of normal endocervical canal length are not significant. For planning fertility-sparing surgery, this imaging technique facilitates the best oncological outcome while minimising subsequent obstetric risks. Parametrial invasion may be assessed on large field of view T2-weighted MRI. The fat content of the parametrium limits the utility of DW imaging in this context, because fat typically shows diffusion restriction. The use of contrast-enhanced MRI for assessing the parametrium does not provide additional benefits to the T2-weighted images and the need for an extrinsic contrast agent merely adds additional complexity and cost. For nodal assessment, 18fluorodeoxyglucose positron emission tomography-computerised tomography (18FDG PET-CT) remains the gold standard.

Preoperative magnetic resonance imaging criteria for predicting lymph node metastasis in patients with stage IB1-IIA2 cervical cancer

Objective

This study aimed to identify patients with stage IB1‐IIA2 cervical cancer at low risk for lymph node metastasis (LNM) using preoperative magnetic resonance imaging (MRI) parameters.

Methods

Clinical and MRI data of patients with stage IB1‐IIA2 cervical cancer who underwent radical surgery between 2010 and 2015 were retrospectively reviewed. Clinical stage IB1‐IIA2 cervical cancer was diagnosed according to the 2009 International Federation of Gynecology and Obstetrics staging system. The low‐risk criteria for LNM were identified using logistic regression analysis. The performance of the logistic regression analysis was estimated through receiver operating characteristic curve analysis.

Results

Of 453 patients, 105 (23.2%) exhibited pathological LNM (p‐LNM). The maximal tumor diameter (adjusted odds ratio [aOR], 1.586; 95% confidence interval [CI], 1.312–1.916; p < 0.001) and LNM (aOR, 2.384; 95% CI, 1.418–4.007; p = 0.001) on preoperative MRI (m‐LNM) were identified as independent risk factors for p‐LNM using a multivariate logistic analysis. The p‐LNM rate was 4.0% for low‐risk patients (n = 124) identified using the current criteria (maximal tumor diameter <3.0 cm and no sign of m‐LNM). The 5‐year disease‐free survival rate of low‐risk patients was significantly greater than the rate of patients with a maximal tumor diameter ˃3.0 cm and/or signs of m‐LNM (90.4% vs. 82.1%; p = 0.033).

Conclusions

The low‐risk criteria for p‐LNM were a maximal tumor diameter <3.0 cm and no sign of m‐LNM. Patients with stage IB1‐IIA2 cervical cancer at low risk for m‐LNM could be candidates for radical surgery; hence, they have a lesser need for adjuvant chemoradiotherapy, thus avoiding the severe comorbidities it causes.

A preoperative radiomics model for the identification of lymph node metastasis in patients with early-stage cervical squamous cell carcinoma

OBJECTIVES

To develop and validate a radiomics model for preoperative identification of lymph node metastasis (LNM) in patients with early-stage cervical squamous cell carcinoma (CSCC).

METHODS

Total of 190 eligible patients were randomly divided into training (n = 100) and validation (n = 90) cohorts. Handcrafted features and deep-learning features were extracted from T2W fat suppression images. The minimum redundancy maximum relevance algorithm and LASSO regression with 10-fold cross-validation were used for key features selection. A radiomics model that incorporated the handcrafted-signature, deep-signature, and squamous cell carcinoma antigen (SCC-Ag) levels was developed by logistic regression. The model performance was assessed and validated with respect to its calibration, discrimination, and clinical usefulness.

RESULTS

Three handcrafted features and three deep-learning features were selected and used to build handcrafted- and deep-signature. The model, which incorporated the handcrafted-signature, deep-signature, and SCC-Ag, showed satisfactory calibration and discrimination in the training cohort (AUC: 0.852, 95% CI: 0.761-0.943) and the validation cohort (AUC: 0.815, 95% CI: 0.711-0.919). Decision curve analysis indicated the clinical usefulness of the radiomics model. The radiomics model yielded greater AUCs than either the radiomics signature (AUC = 0.806 and 0.779, respectively) or the SCC-Ag (AUC = 0.735 and 0.688, respectively) alone in both the training and validation cohorts.

CONCLUSION

The presented radiomics model can be used for preoperative identification of LNM in patients with early-stage CSCC. Its performance outperforms that of SCC-Ag level analysis alone.

ADVANCES IN KNOWLEDGE

A radiomics model incorporated radiomics signature and SCC-Ag levels demonstrated good performance in identifying LNM in patients with early-stage CSCC.

Pre-operative surgical algorithm: sentinel lymph node biopsy as predictor of parametrial involvement in early-stage cervical cancer

Introduction

Radical hysterectomy is the gold standard in the management of early-stage cervical cancer. Parametrectomy aims to remove occult disease but is associated with significant surgical morbidity. Avoiding unnecessary parametrectomy in a subset of patients at low risk of parametrial involvement may decrease the incidence of such morbidity. The purpose of this study was to identify patients at low risk of parametrial involvement in early-stage cervical cancer potentially eligible for less radical surgery based on pre-operative criteria and sentinel lymph node (SLN) status.

Methods

We performed an ancillary analysis of data from two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I and II). Patients with International Federation of Gynecology and Obstetrics (FIGO) IA–IIA cervical cancer who underwent primary radical surgery and bilateral SLN mapping were identified between 2005 and 2012 from 25 French oncologic centers. Patients who underwent pre-operative brachytherapy or did not undergo radical surgery (simple trachelectomy, simple hysterectomy, or lymph node staging only) were excluded.

Results

Of 174 patients who fullfiled the inclusion criteria, 9 patients (5.2%) had parametrial involvement and 24 patients (13.8%) had positive SLN. Most patients had 2018 FIGO stage IB1 disease (86.1%) and squamous cell carcinomas (68.9%). Parametrial involvement was significantly associated with tumor size ≥20 mm on pelvic magnetic resonance imaging (MRI) (adjusted odds ratio (ORa) 9.30, 95% CI 1.71 to 50.57, p=0.01) and micrometastic or macrometastatic SLN (ORa 8.98, 95% CI 1.59 to 50.84, p=0.01). Of 114 patients with tumors <20 mm on pre-operative MRI and negative SLN after ultrastaging, only one patient had parametrial involvement (0.9%). By triaging patients with both of these criteria in a two-step surgical procedure, unjustified and contra-indicated radical hysterectomy would have been avoided in 65.5% and 8.6% of cases, respectively.

Conclusions

Less radical surgery may be an option for patients with bilateral negative SLN after ultrastaging and tumors <20 mm. SLN status should be integrated into the decision-making process for tailored surgery in early-stage cervical cancer.

Comparison of laparoscopic and open radical hysterectomy in cervical cancer patients with tumor size ≤2 cm

OBJECTIVE

There is recent evidence that demonstrates worse oncologic outcomes associated with minimally invasive radical hysterectomy when compared with open radical hysterectomy, particularly in patients with tumors >2 cm. The aim of our study was to retrospectively evaluate the oncological outcomes between laparoscopic and open radical hysterectomy in International Federation of Gynecology and Obstetrics(FIGO) 2009 stage IB1 (FIGO 2009) cervical cancer patients with tumor size ≤2 cm.

METHODS

A retrospective review of medical records was performed to identify patients who underwent either laparoscopic or open radical hysterectomy during January 2010 and December 2018. Inclusion criteria were: (1) histologically confirmed cervical cancer including all histological types; (2) FIGO 2009 stage IB1; (3) tumor size ≤2 cm (determined by pelvic examination, magnetic resonance imaging or transvaginal ultrasound); (4) had undergone radical hysterectomy (type II or III) with pelvic and/or para-aortic lymphadenectomy as primary surgical treatment; (5) had follow-up information. Patients with FIGO 2009 stage IA1 or IA2, tumor size >2 cm, or who received neo-adjuvant chemotherapy before surgery, those with cervical cancer incidentally found after simple hysterectomy, or with insufficient data were excluded. Concurrent comparison between the laparoscopic and open cohorts was made for disease-free survival and overall survival.

RESULTS

A total of 325 cervical cancer patients were included; of these, 129 patients underwent laparoscopic surgery and 196 patients had open surgery. The median follow-up times were 51.8 months (range 2-115) for laparoscopic surgery and 49.5 months (range 3-108) for open surgery. Patients in the laparoscopic group had significantly worse 5 year disease-free survival than those in the open group (90.4% vs 97.7%; p=0.02). There was no significant difference in 5 year overall survival between groups (96.9% vs 99.4%, p=0.33). The Cox proportional hazards regression analysis indicated that laparoscopic surgery was associated with lower disease-free survival compared with open surgery (adjusted hazard ratio 4.64, 95% CI 1.26 to 17.06; p=0.02). In patients with non-squamous cell carcinoma or with grade II-III, laparoscopic surgery had a significantly worse 5 year disease-free survival compared with the open surgery group (74% vs 100%, p=0.01, and 88.8% vs 98.0%, p=0.02, respectively).

CONCLUSION

Laparoscopic radical hysterectomy was associated with worse disease-free survival for stage IB1 (FIGO 2009) cervical cancer patients with tumor size ≤2 cm compared with open radical hysterectomy. Further studies may shed additional light on the impact of minimally invasive surgery in this low-risk patient population.

Comparison Between Size and Stage of Preoperative Tumor Defined by Preoperative Magnetic Resonance Imaging and Postoperative Specimens After Radical Resection of Esophageal Cancer

BACKGROUND

Our objective is to explore the accuracy of magnetic resonance imaging in determining the preoperative T and N staging, pathological stage, and the length of esophageal tumor in patients with esophageal cancer.

METHODS

This retrospective analysis included 57 patients admitted to the Department of Thoracic Surgery of The First Affiliated Hospital of Nanjing Medical University between January 2015 and December 2016. Postoperative pathological results were used as the reference to verify the accuracy of magnetic resonance imaging in evaluating tumor T and N staging, pathological stage, and tumor length. The correlation between tumor lengths-measured using magnetic resonance imaging and the surgical specimen measurements-was evaluated.

RESULTS

The mean age of the patients was 64.6 ± 7.2 years, with a range of 47 to 77 years. The overall accuracy rate of magnetic resonance imaging in T staging of esophageal cancer was 63.2%; magnetic resonance imaging was generally consistent in the N staging of esophageal cancer. Magnetic resonance imaging and surgical evaluation of tumor length were in excellent agreement (κ = .82, P < .001), while that of gastroscopy and postoperative pathology was moderate (κ = .63, P < .001).

CONCLUSION

Magnetic resonance imaging is highly accurate in determining the preoperative T and N staging, pathologic stage, and tumor length in patients with esophageal cancer, which is important in deciding the choice of preoperative treatment and the surgical approach.

Multiparametric MRI-Based Radiomics Nomogram for Predicting Lymph Node Metastasis in Early-Stage Cervical Cancer

BACKGROUND

Lymph node metastasis (LNM) is a critical risk factor affecting treatment strategy and prognosis in patients with early-stage cervical cancer.

PURPOSE

To establish a multiparametric MRI (mpMRI)-based radiomics nomogram for preoperatively predicting LNM status.

STUDY TYPE

Retrospective.

POPULATION

Among 233 consecutive patients, 155 patients were randomly allocated to the primary cohort and 78 patients to the validation cohort.

FIELD STRENGTH

Radiomic features were extracted from a 1.5T mpMRI scan (T₁ -weighted imaging [T₁ WI], fat-saturated T₂ -weighted imaging [FS-T₂ WI], contrast-enhanced [CE], diffusion-weighted imaging [DWI], and apparent diffusion coefficient [ADC] maps).

ASSESSMENT

The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. The area under the receiver operating characteristics curve (ROC AUC), accuracy, sensitivity, and specificity were also calculated.

STATISTICAL TESTS

The least absolute shrinkage and selection operator (LASSO) method was used for dimension reduction, feature selection, and radiomics signature building. Multivariable logistic regression analysis was used to develop the radiomics nomogram. An independent sample t-test and chi-squared test were used to compare the differences in continuous and categorical variables, respectively.

RESULTS

The radiomic signature allowed a good discrimination between the LNM and non-LNM groups, with a C-index of 0.856 (95% confidence interval [CI], 0.794-0.918) in the primary cohort and 0.883 (95% CI, 0.809-0.957) in the validation cohort. Additionally, the radiomics nomogram also had a good discriminating performance and yielded good calibration both in the primary and validation cohorts (C-index, 0.882 [95% CI, 0.827-0.937], C-index, 0.893 [95% CI, 0.822-0.964], respectively). Decision curve analysis demonstrated that the radiomics nomogram was clinically useful.

DATA CONCLUSION

A radiomics nomogram was developed by incorporating the radiomics signature with the MRI-reported LN status and FIGO stage. This nomogram might be used to facilitate the individualized prediction of LNM in patients with early-stage cervical cancer.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:885-896.

Evaluation of a New Prognostic Tumor Score in Locally Advanced Cervical Cancer Integrating Clinical Examination and Magnetic Resonance Imaging

PURPOSE

The integral results of clinical examination and magnetic resonance imaging (MRI) of patients with locally advanced cervical cancer may provide prognostic information that cannot readily be placed in current staging systems, such as proximal versus distal parametrial invasion, unilateral versus bilateral involvement, or organ infiltration on MRI. The aim was to develop and investigate the performance of a simple but comprehensive tumor score for reporting and prognostication.

METHODS AND MATERIALS

In the present study, 400 consecutive patients with locally advanced cervical cancer treated 2005 to 2018 with chemoradiation and image guided adaptive brachytherapy (IGABT) were analyzed. The diagnostic workup included clinical examination, positron emission tomography/computed tomography, and MRI. International Federation of Gynecology and Obstetrics 2009 stage distribution was IB to IIA 9%, IIB 61%, and III to IV 30%. Involvement of 8 anatomic locations (cervix, left parametrium, right parametrium, vagina, bladder, ureter, rectum, and uterine corpus) was scored according to a ranked ordinal scale with 0 to 3 points. The total sum of points constituted the tumor score (T-score).

RESULTS

The median T-score was 6 (range, 0-20). Based on the frequency distribution of the T-score, 4 equally sized groups were formed: 0 to 4, 5 to 6, 7 to 9, and >9 points. The T-score grouping was highly significant in both univariate and multivariable analysis and outperformed International Federation of Gynecology and Obstetrics stage for both survival and local control enabling also intrastage prognostication. Used as a linear variable, the T-score was correlated with IGABT target volume (high-risk clinical target volume, CTV_HR), use of interstitial needles, dose (D90 of CTV_HR), and total reference air kerma.

CONCLUSIONS

The T-score is a simple instrument for combining clinical findings and imaging into a powerful prognostic factor for survival and local control with capabilities surpassing traditional staging. In addition, the T-score may already at diagnosis predict essential IGABT parameters and may be used for audit and comparison of results in multicenter settings.

Staging early cervical cancer in China: data from a multicenter collaborative

BACKGROUND

In 2018 the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system of cervical cancer. This study aimed to assess the quality of staging early cervical cancer in China before the revision.

METHODS

This multicenter retrospective study included 34 tertiary hospitals in China. Medical records of patients with cervical cancer who underwent primary surgical treatment between January 2010 and December 2015 were reviewed retrospectively. All patients were clinically staged according to the 2009 FIGO staging system. Eligibility criteria included: histopathologically confirmed cervical cancer; 2009 FIGO stage IA-IIA2 based on 2009 FIGO staging system; primary surgical treatment including extrafascial, type II or type III radical hysterectomy; radical trachelectomy; with or without pelvic lymphadenectomy; regardless of surgical route via laparotomy or laparoscopy; and complete clinical and pathological data. Patients who received non-surgical treatment, neoadjuvant treatment, or those with incomplete data were excluded. The accuracy of clinical staging was assessed by comparison between clinical and pathologic stage using the latter as the reference standard.

RESULTS

A total of 23 933 cases of cervical cancer were identified and 12 681 fulfilled the inclusion criteria. Of these patients, 69.6% were staged accurately, 9.4% were clinically understaged, and 21.0% were clinically overstaged. The accuracy of stage IA, IB1, IB2, IIA1, and IIA2 was 90.0%, 87.5%, 57.4%, 20.3%, and 25.5%, respectively. The causes of stage inaccuracy were as follows: vaginal involvement (62.3%), maximal tumor diameter (24.6%), extent of cervical stromal invasion (7.1%), parametrial invasion (5.8%), bladder or rectal infiltration (0.1%), and distant metastases (0.1%).

CONCLUSION

The accuracy of staging early cervical cancer in China was suboptimal before the revision of the staging system, especially for IIA1 and IIA2. The most common reasons for staging inaccuracy were vaginal involvement and tumor diameter.

The safety of fertility preservation for microinvasive cervical adenocarcinoma: a meta-analysis and trial sequential analysis

PURPOSE

This study sought to evaluate the safety of conservative treatment in the management of patients with microinvasive cervical adenocarcinoma.

METHODS

The PubMed, PMC, EMBASE, Web of Science and Cochrane databases were searched to collect correlational studies published in English between January 1949 and May 2018. Series reports that evaluating the oncological prognoses of patients with microinvasive cervical adenocarcinoma who were treated with fertility-sparing surgery versus hysterectomy were pooled for meta-analysis and trial sequential analysis.

RESULTS

A total of 8 articles with 1256 patients were collected, including 7 retrospective reviews and 1 prospective study. Only one (0.08%) patient had parametrial involvement. Positive margins of surgical specimens were identified in 6 patients (2.2%). Lymph node metastasis was found in 5 patients (0.4%). The progression-free survival and overall survival rates were 99.3 and 98.2%. Fertility-sparing surgery had no adverse impact on recurrence or survival (P = 0.524 and 0.485, respectively). Regarding potential selection bias, significantly more patients with stage IA2 tumors than those with stage IA1 disease were treated with hysterectomy (P < 0.001). The trial sequential analysis indicated that the cumulative number of patients failed to meet the required sample size (number of patients).

CONCLUSIONS

The prognosis for patients with microinvasive cervical adenocarcinoma is excellent. Fertility preservation is at least appropriate for young women with stage IA1 adenocarcinoma. Further studies are still warranted to evaluate the safety of this procedure in managing patients with microinvasive cervical adenocarcinoma.

Predictive Factors of Pelvic Lymph Node Metastasis in Early-Stage Cervical Cancer

BACKGROUND

Pelvic lymphadenectomy, which is the routine surgical treatment for early-stage cervical cancer, causes serious morbidity. The goal of the current retrospective study was to identify predictive factors of lymph node metastasis (LNM) in patients with early-stage cervical cancer.

PATIENTS AND METHODS

The study included 496 patients diagnosed with stages IA2-IB1cervical cancer who underwent a radical hysterectomy with pelvic lymphadenectomy. The predictive factors of LNM were evaluated.

RESULTS

The incidence of LNM in this study was 4.6%. LNM was more common in patients with deep stromal invasion (DSI), tumor size > 2 cm, lymph vascular invasion and parametrial involvement (PI). Multivariate analysis showed DSI (p = 0.010) and PI (p = 0.005) were independently associated with LNM. The median follow-up time was 56.9 months. The patients with LNM had poorer 5-year overall survival (77.8%; 95% confidence interval (CI) 44.2-92.6) than the patients without LNM (98.2%; 95% CI 95.6-99.2; p = 0.002) and also poorer 5-year recurrence-free survival (65.5%; 95% CI 38.6-82.8) than the patients without LNM (90.2%; 95% CI 86.5-92.9; p < 0.001).

CONCLUSION

The predictive factors of pelvic lymph node metastasis in stage IA2-IB1 cervical cancer patients were DSI and PI. LNM was associated with poorer oncological outcomes.

Preoperatively Assessable Clinical and Pathological Risk Factors for Parametrial Involvement in Surgically Treated FIGO Stage IB-IIA Cervical Cancer

OBJECTIVE

Determining the risk factors associated with parametrial involvement (PMI) is of paramount importance to decrease the multimodality treatment in early-stage cervical cancer. We investigated the preoperatively assessable clinical and pathological risk factors associated with PMI in surgically treated stage IB1-IIA2 cervical cancer.

METHODS

A retrospective cohort study of women underwent Querleu-Morrow type C hysterectomy for cervical cancer stage IB1-IIA2 from 2001 to 2015. All patients underwent clinical staging examination under anesthesia by the same gynecological oncologists during the study period. Evaluated variables were age, menopausal status, body mass index, smoking status, FIGO (International Federation of Obstetrics and Gynecology) stage, clinically measured maximal tumor diameter, clinical presentation (exophytic or endophytic tumor), histological type, tumor grade, lymphovascular space invasion, clinical and pathological vaginal invasion, and uterine body involvement. Endophytic clinical presentation was defined for ulcerative tumors and barrel-shaped morphology. Two-dimensional transvaginal ultrasonography was used to measure tumor dimensions.

RESULTS

Of 127 eligible women, 37 (29.1%) had PMI. On univariate analysis, endophytic clinical presentation (P = 0.01), larger tumor size (P < 0.001), lymphovascular space invasion (P < 0.001), pathological vaginal invasion (P = 0.001), and uterine body involvement (P < 0.001) were significantly different among the groups with and without PMI. In multivariate analysis endophytic clinical presentation (odds ratio, 11.34; 95% confidence interval, 1.34-95.85; P = 0.02) and larger tumor size (odds ratio, 32.31; 95% confidence interval, 2.46-423.83; P = 0.008) were the independent risk factors for PMI. Threshold of 31 mm in tumor size predicted PMI with 71% sensitivity and 75% specificity. We identified 18 patients with tumor size of more than 30 mm and endophytic presentation; 14 (77.7%) of these had PMI.

CONCLUSIONS

Endophytic clinical presentation and larger clinical tumor size (>3 cm) are independent risk factors for PMI in stage IB-IIA cervical cancer. Approximately 78% of the patients with a tumor size of more than 3 cm and endophytic presentation will require adjuvant chemoradiation for PMI following radical surgery. Considering clinical tumor presentation along with tumor size can enhance the physician's prediction of PMI in early-stage cervical cancer.

Clinicopathologic and molecular markers in cervical carcinoma: a prospective cohort study

BACKGROUND

Cervical cancer is a major health problem worldwide. Identification of effective clinicopathologic and molecular markers is vital to improve treatment stratification.

OBJECTIVES

The purpose of this study was to validate a set of well-defined clinicopathologic features in a large population-based, prospectively collected cervical cancer cohort to support their use in the clinic. Further, we explored p53 and human epidermal growth factor receptor 2 as potential prognostic markers in cervical cancer.

STUDY DESIGN

Tissue was collected from 401 patients with cervical cancer. Clinical data that included follow-up evaluations were collected from patient journals. Histopathologic data were evaluated and revised by an expert pathologist. The prognostic impact of selected clinicopathologic variables was analyzed in the whole cohort. Tissue microarrays were prepared from 292 carcinomas, and p53 and human epidermal growth factor receptor 2 protein levels were evaluated by immunohistochemistry. Fresh frozen samples from overlapping cervical carcinomas previously were subjected to human papilloma virus typing (n=94), whole exome (n=100) and RNA (n=79) sequencing; the results were available for our analyses.

RESULTS

Among the clinicopathologic variables, vascular space invasion, histologic type, and tumor size were verified as strong independent prognostic markers. High p53 protein levels were associated significantly with markers for aggressive phenotype and survival, also in multivariate survival analysis, but did not reflect TP53 mutational status. High human epidermal growth factor receptor 2 protein levels were identified in 21% of all tumors. ERBB2 amplification was associated with poor outcome (P=.003); human epidermal growth factor receptor 2 protein level was not.

CONCLUSIONS

Our findings support that the Féderation Internationale de Gynécologie et d'Obstétrique s guidelines should include vascular space invasion and tumor size 2-4 cm and that careful selection of histologic type is essential for stratification of patient risk groups. High p53 levels independently predict poor survival yet do not reflect mutational status in cervical cancer. Amplified ERBB2 significantly links to poor survival, while HercepTest does not. With optimal stratification, human epidermal growth factor receptor 2-based therapy may improve cervical cancer treatment.

Different imaging techniques for the detection of pelvic lymph nodes metastasis from gynecological malignancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the diagnostic performance of different imaging techniques and the corresponding diagnostic criteria for preoperative detection of pelvic lymph node metastasis from gynecological carcinomas.

METHODS

Six databases were systematically searched for retrieving eligible studies. Study inclusion, data extraction and risk of bias assessment were performed by 2 reviewers independently. STATA 14.0 was used to perform the meta-analysis.

RESULTS

Eighty eligible studies were collected. The pooled sensitivity, specificity, and area under curve (AUC) of CT, MRI and DWI were 47%, 93%, 0.7424; 50%, 95%, 0.8039 and 84%, 95%, 0.9523 respectively. As regards PET, PET-CT and US, the pooled sensitivity, specificity and AUC were 56%, 97%, 0.9592; 68%, 97%, 0.9363 and 71%, 99%, 0.9008 respectively. The summary receiver operating characteristic (SROC) curve indicated that the systematic diagnostic performances of PET, PET-CT, DWI were superior to other imaging modalities.

CONCLUSIONS

The present work demonstrated that DWI, PET, PET-CT were the top-priority consideration of imaging modalities for detecting metastatic pelvic lymph node in gynecological carcinoma. DWI was recommended as the first choice for metastasis exclusion and all the other imaging techniques including CT and MRI were suitable for metastasis conformation. However, for the early stage lymph node malignancy, PET or PET-CT could represent a better choice. More studies exploring the diagnostic efficacy of detailed criteria are required in the future.

A Predictive Model for Parametrial Invasion in Patients With FIGO Stage IB Cervical Cancer: Individualized Approach for Primary Treatment

OBJECTIVE

The aim of this study was to preoperatively identify high- and low-risk subgroups of patients with parametrial involvement in those with FIGO (International Federation of Gynecology and Obstetrics) stage IB cervical cancer treated with radical hysterectomy according to menopause.

MATERIALS AND METHODS

We retrospectively reviewed data of 197 patients with FIGO stage IB cervical cancer. None of the patients had definite evidence of parametrial invasion in a preoperative examination and underwent type III radical hysterectomy between February 2006 and March 2015. Preoperative risk criteria predicting parametrial involvement were identified in premenopausal and postmenopausal women, respectively.

RESULTS

Tumor size on magnetic resonance imaging (MRI) more than 4 cm (odds ratio [OR], 10.029; 95% confidence interval [95% CI], 2.300-43.741; P = 0.002) and serum squamous cell carcinoma-antigen level of 3.60 ng/mL or more (OR, 4.132; 95% CI, 1.086-5.723; P = 0.037) were independent factors for parametrial invasion in premenopausal women. Significant factors associated with parametrial involvement in postmenopausal women were tumor size on MRI more than 3 cm (OR, 11.353; 95% CI, 2.614-49.306; P = 0.001) and Cyfra 21-1 level of 2.40 ng/mL or more (OR, 8.048; 95% CI, 1.240-52.221; P = 0.029). Patients were categorized into low- and high-risk groups according to risk criteria. Significant differences in the rates of parametrial invasion were observed between the groups (2.3% vs 38.6% in the premenopausal group, P < 0.001; 11.1% vs 77.3% in the postmenopausal group, P < 0.001).

CONCLUSIONS

A model using preoperative tumor size on MRI, serum squamous cell carcinoma-antigen, and Cyfra 21-1 level was highly predictive of parametrial invasion in patients with FIGO stage IB cervical cancer. In particular, postmenopausal women were likely to have microscopic parametrial invasion, even among tumors 3 cm or less. Therefore, individualized approaches considering several preoperative factors are needed.

Can pelvic lymphadenectomy be omitted in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer?

Purpose

This study aimed to identify the surgical-pathologic risk factors of lymph node metastasis (LNM) in patients with early stage squamous cell cervical cancer and to evaluate the potential efficacy of omitting pelvic lymphadenectomy.

Methods

A total of 276 patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer receiving primary radical hysterectomy with pelvic lymphadenectomy were included in this study.

Results

The incidences of LNM in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer were 0 % (0/8), 17.4 % (36/207), and 29.5 % (18/61), respectively. The most common location of LNM was the obturator lymph node. Human papilloma virus 16 subtype was the most common infection in early stage squamous cell cervical cancer. Univariate analysis revealed that squamous cell carcinoma antigen (SCCAg) greater than 1.5 μg/L (p < 0.001), tumor size greater than 2 cm (p < 0.001), tumor size greater than 3 cm (p < 0.001), depth of stromal invasion (p < 0.001) and lymphovascular invasion (p < 0.001) were associated with LNM. Logistic regression analysis revealed that depth of stromal invasion {model 1 [p = 0.006; odds ratio (OR) 2.161; 95 % confidence interval (CI) 1.251–3.734], model 2 [p = 0.002; OR 2.344; 95 % CI 1.337–3.989]}, lymphovascular invasion [model 1 (p = 0.004; OR 2.967; 95 % CI 1.411–6.237), model 2 (p = 0.004; OR 2.978; 95 % CI 1.421–6.243)], and SCCAg greater than 1.5 μg/L [model 1 (p = 0.023; OR 2.431; 95 % CI 1.129–5.235), model 2 (p = 0.024; OR 2.418; 95 % CI 1.125–5.194)] were independently associated with LNM.

Conclusions

Pelvic lymphadenectomy may be omitted in patients with SCCAg lower than 1.5 μg/L, superficial stromal invasion and without lymphovascular invasion in stage IA2, IB1, IIA1 squamous cell cervical cancer.

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trial-to-trial latency variability of somatosensory evoked potentials as a prognostic indicator for surgical management of cervical spondylotic myelopathy

Background

Early detection of neural conductivity changes at the compressed spinal cord is important for predicting the surgical outcomes of patients with cervical spondylotic myelopathy (CSM). The prognostic value of median nerve somatosensory evoked potential (SEP) has been proposed previously. The present prospective study evaluates the use of trial-to-trial variability in SEP as a valuable predictor of neurological recovery after surgery of CSM.

Methods

A total of 35 CSM patients who underwent surgery with up to 6-month follow-up were recruited in this study. SEP signals were recorded preoperatively. The single trial SEP was extracted by a newly developed second-order blind identification method. The postoperative recovery was assessed using the modified Japanese Orthopaedic Association. The correlation between the latency variability of trial-to-trial SEP and post-operative recovery ratio was analyzed. The prognostic value of trial-to-trial SEP for CSM was evaluated using a receiver operator characteristic curve which can accurately reflect the relationship between sensitivity and specificity of a diagnostic method and represent the accuracy of prognosis.

Results

The correlation coefficient of trial-to-trial latency variability and the 6-month recovery ratio was statistically significant (r = −0.82, P < 0.01). The trial-to-trial SEP had a higher prognostic accuracy (AUC = 0.928, P < 0.001) with an optimal prognostic value of 9.25 % compared with averaged SEP when the threshold of recovery ratio was 40 %, and was more sensitive (93.80 %) than the averaged SEP (43.80 %).

Conclusions

These findings indicate that the latency variability of trial-to-trial SEP reflect the recovery ratio of CSM patients after surgery. It is suggested that the latency variability of trial-to-trial SEP is useful for predicting the surgical outcomes for patients with CSM, which would be a potential indication of surgical treatment for CSM to help decision making of surgical planning for CSM patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-015-0042-4) contains supplementary material, which is available to authorized users.