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Xiao ML, Fu L, Wei Y, Liu AE, Cheng JJ, Ma FH, Li HM, Li YA, Lin ZJ, Zhang GF, Qiang JW. Intratumoral and peritumoral MRI radiomics nomogram for predicting parametrial invasion in patients with early-stage cervical adenocarcinoma and adenosquamous carcinoma. Eur Radiol 2024; 34:852-862. [PMID: 37610442 DOI: 10.1007/s00330-023-10042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 08/24/2023]
Abstract
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.
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Affiliation(s)
- Mei Ling Xiao
- Department of Radiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai, 201508, China
| | - Le Fu
- Department of Radiology, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 536 ChangleRoad, Shanghai, 200092, China
| | - Yan Wei
- Department of Automation, Zhejiang University of Technology, 288 Liuhe Road, Hangzhou, 310023, China
| | - Ai E Liu
- Department of Research Center, Shanghai United Imaging Intelligence Co., Ltd, 701 Yunjin Road, Shanghai, 200032, China
| | - Jie Jun Cheng
- Department of Radiology, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 536 ChangleRoad, Shanghai, 200092, China
| | - Feng Hua Ma
- Departments of Radiology, Obstetrics & Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Hai Ming Li
- Department of Radiology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai, 200032, China
| | - Yong Ai Li
- Department of Radiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai, 201508, China
| | - Zi Jing Lin
- Department of Radiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai, 201508, China
| | - Guo Fu Zhang
- Departments of Radiology, Obstetrics & Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, 200090, China
| | - Jin Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Shanghai, 201508, China.
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Jeon J, Park BK, Lee JW, Choi CH, Lee YY, Kim TJ, Kim BG. Invisible cervical cancers on MRI: Can the type of histology (SCC versus non-SCC) influence surgical planning? Front Oncol 2022; 12:996516. [PMID: 36568188 PMCID: PMC9773832 DOI: 10.3389/fonc.2022.996516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Background Invisible cervical cancers on MRI can indicate less invasive surgery. Cervical cancers consist of squamous cell carcinoma (SCC) and non-SCC, each with different long-term outcomes. It is still unclear if surgical planning should be changed according to the histologic type of cervical cancer when it is not visible on MRI. Purpose The purpose of the study was to determine if surgical planning for cervical cancer that is not visible on MRI is influenced by the histologic type. Materials and methods Between January 2007 and December 2016, 155 women had Federation of Gynecology and Obstetrics (FIGO) stage 1B1 cervical cancer that was not visible on preoperative MRI. They underwent radical hysterectomies and pelvic lymph node dissections. Among them, 88 and 67 were histologically diagnosed with SCC and non-SCC, respectively. The size of the residual tumor, depth of stromal invasion, parametrial invasion, vaginal invasion, lymphovascular invasion, and lymph node metastasis were compared between these patients using the t-test, Mann-Whitney U test, Chi-squared test, or Fisher's exact test. The recurrence-free and overall 10-year survival rates were compared between the groups by Kaplan-Meier analysis. Results The mean sizes of residual tumors were 8.4 ± 10.4 mm in the SCC group and 12.5 ± 11.9 mm in the non-SCC group (p = 0.024). The mean depth of stromal invasion in the SCC group was 12.4 ± 21.2% (0%-100%), whereas that in the non-SCC group was 22.4 ± 24.4 (0%-93%) (p = 0.016). However, there was no difference in parametrial or vaginal invasion, lymphovascular invasion, or lymph node metastasis (p = 0.504-1.000). The recurrence-free and overall 10-year survival rates were 98.9% (87/88) and 95.5% (64/67) (p = 0.246), and 96.6% (85/88) and 95.5% (64/67) (p = 0.872), respectively. Conclusions The non-SCC group tends to have larger residual tumors and a greater depth of stromal invasion than the SCC group, even though neither is visible on MRI. Therefore, meticulous care is necessary for performing parametrectomy in patients with non-SCC cervical cancer.
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Affiliation(s)
- Jungeun Jeon
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,*Correspondence: Byung Kwan Park, ; Jeong-Won Lee,
| | - Jeong-Won Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,*Correspondence: Byung Kwan Park, ; Jeong-Won Lee,
| | - Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoo-Young Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae-Joong Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byoungi-Gie Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Erdem B, Çelebi İ, Aşıcıoğlu O, Akgöl S, Yüksel İT, Özaydin İY, Topbaş F, Akbayir Ö. Preoperative prediction of retroperitoneal lymph node involvement in clinical stage IB and IIA cervical cancer. J Cancer Res Ther 2022; 18:1548-1552. [PMID: 36412408 DOI: 10.4103/jcrt.jcrt_106_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective Lymph node metastasis (LNM) is the most important factor affecting survival in early-stage cervical cancer (CC). International Federation of Gynecology and Obstetrics revised the staging of CC in 2018 and reported LNM as a staging criterion. We investigated the preoperatively assessable risk factors associated with LNM in surgically treated stage IB1-IIA2 CC patients. Materials and Methods This was a retrospective cohort study of women who underwent radical hysterectomy and pelvic lymphadenectomy with or without para-aortic lymphadenectomy for CC stage IB1-IIA2 from 2004 to 2019. All patients included in this study were examined with speculum inspection, parametrial assessment by rectovaginal palpation under general anesthesia, transvaginal ultrasonography, magnetic resonance imaging (MRI), and chest radiography. Clinical staging was done according to the preoperative findings. MRI was used to measure tumor and lymph node dimensions. Results Out of the 149 women included in the study, 29 (19.4%) had LNM. Univariate analysis revealed that larger tumor size (≥30 mm), lymphovascular space invasion (LVSI) detected with diagnostic biopsy, parametrial involvement, and deep stromal invasion status were significantly different between the group with LNM and the group without LNM. In multivariate analysis, specific preoperative risk factors such as MRI based tumor diameter ≥30 mm and LVSI (+) on the diagnostic biopsy were found to be independent risk factors for LNM in the multivariate analysis. Conclusion The rate of LNM is high in patients with CC with a tumor size ≥30 mm and preoperative biopsy LVSI status even if they are clinically in early stages. Surgeons can take this into account while deciding between primary surgery and chemoradiotherapy in the treatment of CC.
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Affiliation(s)
- Baki Erdem
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - İbrahim Çelebi
- Department of Obstetrics and Gynecology, İstinye University, Gaziosmanpaşa Medical Park Hospital, Istanbul, Turkey
| | - Osman Aşıcıoğlu
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Sedat Akgöl
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - İlkbal Temel Yüksel
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - İpek Yıldız Özaydin
- Department of Pathology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Fitnat Topbaş
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Özgür Akbayir
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
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Utility of 3T MRI in Women with IB1 Cervical Cancer in Determining the Necessity of Less Invasive Surgery. Cancers (Basel) 2022; 14:cancers14010224. [PMID: 35008388 PMCID: PMC8750208 DOI: 10.3390/cancers14010224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Cervical cancer that is invisible on magnetic resonance imaging (MRI) may suggest lower tumor burden than physical examination. Recently, 3 tesla (3T) MRI has been widely used prior to surgery because of its higher resolution than 1.5T MRI. The aim was to retrospectively evaluate the utility of 3T MRI in women with early cervical cancer in determining the necessity of less invasive surgery. MATERIALS AND METHODS Between January 2010 and December 2015, a total of 342 women with FIGO stage IB1 cervical cancer underwent 3T MRI prior to radical hysterectomy, vaginectomy, and lymph node dissection. These patients were classified into cancer-invisible (n = 105) and cancer-visible (n = 237) groups based on the 3T MRI findings. These groups were compared regarding pathologic parameters and long-term survival rates. RESULTS The cancer sizes of the cancer-invisible versus cancer-visible groups were 11.5 ± 12.2 mm versus 30.1 ± 16.2 mm, respectively (p < 0.001). The depths of stromal invasion in these groups were 20.5 ± 23.6% versus 63.5 ± 31.2%, respectively (p < 0.001). Parametrial invasion was 0% (0/105) in the cancer-invisible group and 21.5% (51/237) in the cancer-visible group (odds ratio = 58.3, p < 0.001). Lymph node metastasis and lymphovascular space invasion were 5.9% (6/105) versus 26.6% (63/237) (5.8, p < 0.001) and 11.7% (12/105) versus 40.1% (95/237) (5.1, p < 0.001), respectively. Recurrence-free and overall 5-year survival rates were 99.0% (104/105) versus 76.8% (182/237) (p < 0.001) and 98.1% (103/105) versus 87.8% (208/237) (p = 0.003), respectively. CONCLUSIONS 3T MRI can play a great role in determining the necessity of parametrectomy in women with IB1 cervical cancer. Therefore, invisible cervical cancer on 3T MRI will be a good indicator for less invasive surgery.
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Park BK, Kim TJ. Useful MRI Findings for Minimally Invasive Surgery for Early Cervical Cancer. Cancers (Basel) 2021; 13:cancers13164078. [PMID: 34439231 PMCID: PMC8391577 DOI: 10.3390/cancers13164078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 01/02/2023] Open
Abstract
Simple Summary Radical hysterectomy and lymph node dissection are extensive procedures with severe post-operative morbidities and should be avoided on patients with low risk of recurrence. Still, due to lack of good prognostic tools, radical surgery is performed on most patients with early stage cervical cancer, leading to overtreatment and unnecessary morbidities. The recent International Federation of Gynecology and Obstetrics (FIGO) staging system accepts the use of magnetic resonance imaging (MRI) in addition to physical examination. Currently, 3 Tesla (3T) MRI is available widely and, due to its high soft tissue contrast, can provide more useful information on precise estimation of tumor size and metastasis than can physical examination in patients with cervical cancer. Therefore, this imaging modality can help gynecologic oncologists to determine whether minimally invasive surgery is necessary and can be used for early detection of small recurrent cancers. Abstract According to the recent International Federation of Gynecology and Obstetrics (FIGO) staging system, Stage III cervical cancer indicates pelvic or paraaortic lymph node metastasis. Accordingly, the new FIGO stage accepts imaging modalities, such as MRI, as part of the FIGO 2018 updated staging. Magnetic resonance imaging (MRI) is the best imaging modality to estimate the size or volume of uterine cancer because of its excellent soft tissue contrast. As a result, MRI is being used increasingly to determine treatment options and follow-up for cervical cancer patients. Increasing availability of cancer screening and vaccination have improved early detection of cervical cancer. However, the incidence of early cervical cancers has increased compared to that of advanced cervical cancer. A few studies have investigated if MRI findings are useful in management of early cervical cancer. MRI can precisely predict tumor burden, allowing conization, trachelectomy, and simple hysterectomy to be considered as minimally invasive treatment options for early cervical cancer. This imaging modality also can be used to determine whether there is recurrent cancer following minimally invasive treatments. The purpose of this review is to highlight useful MRI features for managing women with early cervical cancer.
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Affiliation(s)
- Byung Kwan Park
- Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Korea
- Correspondence: (B.K.P.); (T.-J.K.); Tel.: +82-2-3410-6457 (B.K.P.); +82-2-3410-0630 (T.-J.K.)
| | - Tae-Joong Kim
- Department of Obstetrics & Gynecology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Korea
- Correspondence: (B.K.P.); (T.-J.K.); Tel.: +82-2-3410-6457 (B.K.P.); +82-2-3410-0630 (T.-J.K.)
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Charoenkwan P, Shoombuatong W, Nantasupha C, Muangmool T, Suprasert P, Charoenkwan K. iPMI: Machine Learning-Aided Identification of Parametrial Invasion in Women with Early-Stage Cervical Cancer. Diagnostics (Basel) 2021; 11:diagnostics11081454. [PMID: 34441388 PMCID: PMC8391438 DOI: 10.3390/diagnostics11081454] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/18/2023] Open
Abstract
Radical hysterectomy is a recommended treatment for early-stage cervical cancer. However, the procedure is associated with significant morbidities resulting from the removal of the parametrium. Parametrial cancer invasion (PMI) is found in a minority of patients but the efficient system used to predict it is lacking. In this study, we develop a novel machine learning (ML)-based predictive model based on a random forest model (called iPMI) for the practical identification of PMI in women. Data of 1112 stage IA-IIA cervical cancer patients who underwent primary surgery were collected and considered as the training dataset, while data from an independent cohort of 116 consecutive patients were used as the independent test dataset. Based on these datasets, iPMI-Econ was then developed by using basic clinicopathological data available prior to surgery, while iPMI-Power was also introduced by adding pelvic node metastasis and uterine corpus invasion to the iPMI-Econ. Both 10-fold cross-validations and independent test results showed that iPMI-Power outperformed other well-known ML classifiers (e.g., logistic regression, decision tree, k-nearest neighbor, multi-layer perceptron, naive Bayes, support vector machine, and extreme gradient boosting). Upon comparison, it was found that iPMI-Power was effective and had a superior performance to other well-known ML classifiers in predicting PMI. It is anticipated that the proposed iPMI may serve as a cost-effective and rapid approach to guide important clinical decision-making.
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Affiliation(s)
- Phasit Charoenkwan
- College of Arts, Media and Technology, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Watshara Shoombuatong
- Center of Data Mining and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, Bangkok 73170, Thailand;
| | - Chalaithorn Nantasupha
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (C.N.); (T.M.); (P.S.)
| | - Tanarat Muangmool
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (C.N.); (T.M.); (P.S.)
| | - Prapaporn Suprasert
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (C.N.); (T.M.); (P.S.)
| | - Kittipat Charoenkwan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (C.N.); (T.M.); (P.S.)
- Correspondence:
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Yang Q, Zhou Q, He X, Cai J, Sun S, Huang B, Wang Z. Retrospective analysis of the incidence and predictive factors of parametrial involvement in FIGO IB1 cervical cancer. J Gynecol Obstet Hum Reprod 2021; 50:102145. [PMID: 33848645 DOI: 10.1016/j.jogoh.2021.102145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Radical surgery is the standard primary treatment for patients with stage IB1 (FIGO 2009 staging) cervical cancer due to latent parametrial involvement. Recent studies suggested that less radical surgery was applicable for patients with no or low risk of parametrial involvement. In this study, we aimed to determine the incidence and possible predictive factors of parametrial involvement in patients with stage IB1 cervical cancer so as to evaluate whether less radical surgery was suitable for selected patients. METHODS Clinical data of patients who underwent type C radical hysterectomy with pelvic lymphadenectomy and diagnosed as stage IB1 cervical cancer at Union Hospital, Wuhan, China from October 2014 to December 2017 were collected and analysed retrospectively. The incidence of parametrial involvement was calculated and the risk factors for parametrial involvement were evaluated by univariate and multivariate logistic regression. RESULTS Among 282 eligible patients, 33 (11.7%) had parametrial involvement. Postmenopause, lymphovascular space invasion (LVSI), lymph node metastasis (LNM), deep stromal invasion (outer 1/3) and tumor size larger than 2 cm were statistically associated with parametrial involvement. Multivariate analysis showed that LNM (OR = 11.431; 95%CI: 3.455 - 37.821), deep stromal invasion (OR = 6.080; 95%CI: 1.814 - 20.382) and LVSI (OR = 7.147; 95%CI: 1.863-27.411) remained as independent risk factors for parametrial involvement in patients with stage IB1 cervical cancer. CONCLUSIONS The incidence of parametrial involvement in stage IB1 cervical cancer is non-negligible. Only LNM, LVSI and deep stromal invasion were independent predictors, which were not easy to evaluate accurately before surgery. Less radical surgery requires modified pre-treatment evaluation methods and prospective data support.
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Affiliation(s)
- Qiang Yang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China
| | - Qinghui Zhou
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China; Department of Obstetrics and Gynecology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiaoqi He
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China
| | - Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China
| | - Si Sun
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China
| | - Bangxing Huang
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China.
| | - Zehua Wang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, China.
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Balaya V, Bresset A, Guani B, Benoit L, Magaud L, Bonsang-Kitzis H, Ngo C, Mathevet P, Lécuru F. Pre-operative surgical algorithm: sentinel lymph node biopsy as predictor of parametrial involvement in early-stage cervical cancer. Int J Gynecol Cancer 2020; 30:1317-1325. [DOI: 10.1136/ijgc-2020-001586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022] Open
Abstract
IntroductionRadical 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.MethodsWe 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.ResultsOf 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.ConclusionsLess 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.
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Woo S, Moon MH, Cho JY, Kim SH, Kim SY. Diagnostic Performance of MRI for Assessing Parametrial Invasion in Cervical Cancer: A Head-to-Head Comparison between Oblique and True Axial T2-Weighted Images. Korean J Radiol 2019; 20:378-384. [PMID: 30799568 PMCID: PMC6389805 DOI: 10.3348/kjr.2018.0248] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/29/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To directly compare the diagnostic performance of true and oblique axial T2-weighted imaging (T2WI) for assessing parametrial invasion (PMI) in cervical cancer. MATERIALS AND METHODS This retrospective study included 71 women with treatment-naive cervical cancer who underwent MRI that included both oblique and true axial T2WI, followed by radical hysterectomy. Two blinded radiologists (Radiologist 1 and Radiologist 2) independently assessed the presence of PMI on both sequences using a 5-point Likert scale. Receiver operating characteristic (ROC) curve analysis was performed, with a subgroup analysis for tumors sized > 2.5 cm and ≤ 2.5 cm in diameter. Inter-reader agreement was assessed with kappa (k) statistics. RESULTS At hysterectomy, 15 patients (21.1%) had PMI. For Radiologist 1, the area under the ROC curve (AUC) was greater for oblique axial than for true axial T2WI {0.941 (95% confidence interval [CI] = 0.858-0.983) vs. 0.917 (95% CI = 0.827-0.969), p = 0.027}. The difference was not significant for Radiologist 2 (0.879 [95% CI = 0.779-0.944] vs. 0.827 [95% CI = 0.719-0.906], p = 0.153). For tumors > 2.5 cm, AUC was greater with oblique than with true axial T2WI (0.906 vs. 0.860, p = 0.046 for Radiologist 1 and 0.839 vs. 0.765, p = 0.086 for Radiologist 2). Agreement between the radiologists was almost perfect for oblique axial T2WI (k = 0.810) and was substantial for true axial T2WI (k = 0.704). CONCLUSION Oblique axial T2WI potentially provides greater diagnostic performance than true axial T2WI for determining PMI, particularly for tumors > 2.5 cm. The inter-reader agreement was greater with oblique axial T2WI.
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Affiliation(s)
- Sungmin Woo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Hoan Moon
- Department of Radiology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Korea
| | - Seung Hyup Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Korea
| | - Sang Youn Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Kong TW, Son JH, Paek J, Chang SJ, Ryu HS. Selection criteria and colpotomic approach for safe minimally invasive radical hysterectomy in early-stage cervical cancer. J Gynecol Oncol 2019; 31:e7. [PMID: 31788997 PMCID: PMC6918891 DOI: 10.3802/jgo.2020.31.e7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/03/2019] [Accepted: 07/08/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To evaluate oncologic outcomes of minimally invasive radical hysterectomy (RH) in early cervical cancer before and after the application of parametrial invasion (PMI) criterion on magnetic resonance imaging (MRI) and vaginal colpotomy (VC). METHODS A total of 216 International Federation of Gynecology and Obstetrics stage IB-IIA cervical cancer patients who underwent minimally invasive RH was identified between April 2006 and October 2018. Patients were classified into the pre-PMI intracorporeal or VC (IVC) (n=117) and post-PMI VC groups (n=99). In the pre-PMI IVC group, PMI criterion (intact stromal ring) on MRI was not applied and the patients received IVC. In the post-PMI VC group, surgical candidates were selected using the PMI criterion on MRI and all patients received VC only. Oncologic outcomes and prognostic factors associated with disease recurrence were analyzed. RESULTS The rate of positive vaginal cuff margins in the pre-PMI IVC group was higher than that in the post-PMI VC group (11.1% vs. 1.0%, p=0.003). Two-year disease-free survival was different between the 2 groups (84.5% in pre-PMI IVC vs. 98.0% in post-PMI VC groups, p=0.005). Disrupted stromal ring on MRI (hazard ratio [HR]=20.321; 95% confidence interval [CI]=4.903-84.218; p<0.001) and intracorporeal colpotomy (HR=3.059; 95% CI=1.176-7.958; p=0.022) were associated with recurrence. CONCLUSION The intact cervical stromal ring on MRI might identify the low-risk group of patients in terms of PMI and lymphovascular/stromal invasion in early cervical cancer. Minimally invasive RH should be performed in optimal candidates with an intact stromal ring on MRI, using VC.
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Affiliation(s)
- Tae Wook Kong
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Joo Hyuk Son
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Jiheum Paek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Suk Joon Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Hee Sug Ryu
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea.
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11
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Assessment of Parametrial Involvement in Early Stages Cervical Cancer With Preoperative Magnetic Resonance Imaging. Int J Gynecol Cancer 2019; 28:1758-1765. [PMID: 30153214 DOI: 10.1097/igc.0000000000001349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective of this study was to develop a predictive model for parametrial involvement (PMI) and to identify low-risk group of PMI in early stages of cervical cancer based on preoperative magnetic resonance imaging (MRI) parameters. METHODS We retrospectively analyzed patients with stages IB1 to IIA2 cervical cancer (N = 1347) who underwent type C radical hysterectomy between 2005 and 2012. Clinical records, preoperative MRI, and its association with pathological data were reviewed. A predictive model for PMI was developed using preoperative MRI parameters for the estimation of its performance. RESULTS Of 1347 patients, 138 (10.2%) had pathological PMI (p-PMI). Multivariate analysis identified the maximal tumor diameter (odds ratio, 2.0; 95% confidence interval, 1.23-3.40; P < 0.001) and PMI (odds ratio, 7.0; 95% confidence interval, 4.49-11.02; P < 0.001) on preoperative MRI (m-PMI) as independent predictive factors for p-PMI. The rate of p-PMI was 1.3% for low-risk patients identified by the current model (maximal tumor diameter ≤2.5 cm and no indication of PMI, n = 448). The 5-year progression-free survival rate was significantly greater (96.7%) in low-risk patients than in those with a maximal tumor diameter greater than 2.5 cm and/or indication of m-PMI (90.8%, P = 0.004). CONCLUSIONS A predictive model for p-PMI was developed in which p-PMI exclusion was set as a maximal tumor diameter less than or equal to 2.5 cm and no indication of m-PMI. Patients with a low risk of m-PMI could be identified so that less radical surgery for stages IB1 to IIA2 cervical cancer could be offered.
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Fokom Domgue J, Schmeler KM. Conservative management of cervical cancer: Current status and obstetrical implications. Best Pract Res Clin Obstet Gynaecol 2019; 55:79-92. [DOI: 10.1016/j.bpobgyn.2018.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 01/27/2023]
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13
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Huang JW, Song JC, Chen T, Yang M, Ma ZL. Making the invisible visible: improving detectability of MRI-invisible residual cervical cancer after conisation by DCE-MRI. Clin Radiol 2018; 74:166.e15-166.e21. [PMID: 30503642 DOI: 10.1016/j.crad.2018.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
AIM To determine whether dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) quantitative parameters increase the detectability of MRI-invisible residual cervical cancer after conisation. MATERIALS AND METHODS This retrospective study included 59 patients with MRI-invisible cervical cancer, but positive conisation pathology. Thirty-five patients were confirmed to have residual cervical cancer, and 24 patients showed non-residual cervical cancer. DCE-MRI quantitative parameters were calculated in the anterior or posterior cervix according to the conisation position. Receiver operating characteristic (ROC) analysis was used to find the threshold of DCE-MRI parameters in differentiate residual cervical cancer patients from non-residual cervical cancer patients after conisation. RESULTS For patients with residual cervical cancer, the Ktrans and Ve values were significantly higher than in their counterparts with non-residual cervical cancer (0.610±0.395 versus 0.366±0.305/min, p=0.013; and 0.703±0.270 versus 0.540±0.280%, p=0.028; respectively). The Ktrans showed the highest area under the ROC curve (AUC) of 0.705 (p=0.004) with a sensitivity of 67.6% and specificity of 68%. CONCLUSION DCE-MRI quantitative parameters increased the detectability of MRI-invisible residual cervical cancer after conisation.
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Affiliation(s)
- J-W Huang
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - J-C Song
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - T Chen
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - M Yang
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Z-L Ma
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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14
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Kubota S, Kobayashi E, Kakuda M, Matsuzaki S, Ueda Y, Yoshino K, Kimura T. Retrospective analysis for predictors of parametrial involvement in IB cervical cancer. J Obstet Gynaecol Res 2018; 45:679-685. [PMID: 30565810 DOI: 10.1111/jog.13855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/14/2018] [Indexed: 11/26/2022]
Abstract
AIM The use of less radical surgery for early stage cervical cancer has often been discussed. To better determine eligible candidates for less radical surgery, we investigated the risk factors for parametrial involvement (PI). METHODS The study included 193 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer who were treated with radical hysterectomy and pelvic lymphadenectomy between 2008 and 2014. The patients were divided into two groups according to whether or not the parametrium was involved pathologically. The two groups were compared with regards to clinical and histopathological variables. RESULTS Univariate analysis showed that International Federation of Gynecology and Obstetrics stage, clinical tumor size, depth of stromal invasion, lymphovascular space invasion and pelvic lymph node metastasis were significantly associated with PI (P < 0.05 each). Multivariate analysis showed pelvic lymph node metastasis was an independent risk factor for PI (odds ratio, 10.70; [95% confidence interval, 3.02-48.08]; P = 0.0006). All patients with clinical tumor size less than or equal to 2 cm and negative for pelvic lymph node metastasis had no PI. CONCLUSION Cervical cancer with the tumor less than or equal to 2 cm and negative for pelvic lymph node metastasis seldom has PI. These patients are good candidates for less radical surgery.
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Affiliation(s)
- Satoshi Kubota
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiji Kobayashi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mamoru Kakuda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Ueda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Obstetrics and Gynecology, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan
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15
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Tseng JH, Aloisi A, Sonoda Y, Gardner GJ, Zivanovic O, Abu-Rustum NR, Leitao MM. Less versus more radical surgery in stage IB1 cervical cancer: A population-based study of long-term survival. Gynecol Oncol 2018; 150:44-49. [PMID: 29776598 DOI: 10.1016/j.ygyno.2018.04.571] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 04/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Standard surgical treatment for women with stage IB1 cervical cancer consists of radical hysterectomy. This study assesses survival outcomes of those treated with less radical surgery (LRS; conization, trachelectomy, simple hysterectomy) compared to more radical surgery (MRS; modified radical, radical hysterectomy). METHODS Using the Surveillance, Epidemiology and End Results database, we identified women <45 years with FIGO stage IB1 cervical cancer diagnosed from 1/1998 to 12/2012. Only those who underwent lymph node (LN) assessment were analyzed. Disease-specific survivals (DSSs) of LRS were compared with those of MRS. RESULTS Of 2571 patients, 807 underwent LRS and 1764 underwent MRS, all with LN assessment. For LRS vs. MRS, 28% vs. 23% were diagnosed with adenocarcinoma (p = 0.024), 31% vs. 39% had G3 disease (p < 0.001), 40% vs. 45% had tumor size >2 cm (p < 0.001), and 27% vs. 29% received adjuvant radiation therapy (p = 0.005). Median follow-up was 79 months (range, 0-179). Ten-year DSS for LRS vs. MRS was 93.5% vs. 92.3% (p = 0.511). There was no difference in 10-year DSS when stratified by tumor size ≤2 cm (LRS 95.1% vs. MRS 95.6%, p = 0.80) or > 2 cm (LRS 90.1% vs. MRS 88.2%, p = 0.48). Factors independently associated with increased risk of death included adenosquamous histology (HR 2.37), G3 disease (HR 2.86), tumors >2 cm (HR 1.82), and LN positivity (HR 2.42). Compared to MRS, LRS was not associated with a higher risk of death. CONCLUSIONS In a select group of young women with stage IB1 cervical cancer, LRS compared to MRS does not appear to compromise DSS.
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Affiliation(s)
- Jill H Tseng
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessia Aloisi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Wang P, Thapa D, Wu G, Sun Q, Cai H, Tuo F. A study on diffusion and kurtosis features of cervical cancer based on non-Gaussian diffusion weighted model. Magn Reson Imaging 2018; 47:60-66. [PMID: 29103978 DOI: 10.1016/j.mri.2017.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/12/2017] [Accepted: 10/31/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To explore the diffusion and kurtosis features of cervical cancer (CC) and study the feasibility of diffusion kurtosis imaging (DKI) based on the non-Gaussian diffusion-weighted model to differentiate the stage and grade of CC. METHODS A total of 50 patients with pathologically confirmed CC were enrolled. MRI examinations including DKI (with 5b values 200, 500, 1000, 1500, and 2000smm-2 were performed before any treatment. The apparent coefficient (Dapp) and the apparent kurtosis value (Kapp) were derived from the non-gaussian diffusion model, and the apparent diffusion coefficient (ADC) was derived from the Gaussian model. The parameters of CC and normal tissue (myometrium) were obtained, analyzed statistically, and evaluated with respect to differentiating stage and grade between the tissue and the CC. RESULTS ADC and Dapp values of CC were significantly lower than that of the normal myometrium (P=0.024 and P<0.001, respectively), while the Kapp value was not found to exhibit a significant difference. Compared to the well/moderately differentiated CC, poorly differentiated CC had a significantly decreased mean ADC and Dapp (P=0.018 and P=0.026, respectively); however, the mean Kapp (P=0.035) increased significantly. In the clinical staging, the DKI sequence was advantageous over conventional MRI sequences (degree of accuracy: 90% vs. 74%), Although in the quantitative analysis, these parameters did not show a significant difference. CONCLUSIONS The pilot study demonstrated that these diffusion and kurtosis indices from DKI based on the non-Gaussian diffusion-weighted model putatively differentiated the grade and stage of CC.
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Affiliation(s)
- Panying Wang
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China
| | - Deepa Thapa
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China
| | - Guangyao Wu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China.
| | - Qunqi Sun
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China; Department of Radiology, Yuebei People's Hospital, Shantou University Medical College, Shaoguan, 512026, PR China
| | - Hongbin Cai
- Department of Female Tumor, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China
| | - Fei Tuo
- Department of Female Tumor, Zhongnan Hospital of Wuhan University, Wuhan 430071, PR China
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Parametrial Involvement on Magnetic Resonance Imaging Has No Effect on the Survival of Early-Stage Cervical Cancer Patients. Int J Gynecol Cancer 2018; 27:507-513. [PMID: 28129242 DOI: 10.1097/igc.0000000000000909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Parametrial involvement (PMI) in patients with cervical cancer is known to be an unfavourable prognostic factor. The purpose of this study was to investigate the prognostic significance of PMI on magnetic resonance imaging (MRI) in patients with early-stage cervical cancer. METHODS Three hundred three patients with stage IB or IIA cervical cancer treated by adjuvant radiotherapy or concurrent chemoradiotherapy following primary surgery from 2001 to 2011 were enrolled in this study. We reviewed preoperative MRI and pathologic findings and compared recurrence and survival of group defined according to PMI status. RESULTS There were 73 patients (24.1%) with PMI based on MRI and 52 patients (17.2%) with PMI based on surgical pathology. The accuracy of MRI for detecting PMI was 77.2% (sensitivity, 53.8%; specificity, 82.1%). In all patients, pathology-based evidence of PMI had a negative effect on both 5-year disease-free survival (73.2% vs 85.3%, P = 0.048) and 5-year overall survival (76.6% vs 91.4%, P = 0.009), but PMI on MRI did not have a significant effect on survival. In subgroups defined according to PMI status on MRI and surgical pathology, subgroups with pathology-based evidence of PMI showed a trend of a lower survival rate, regardless of PMI on MRI, but without statistical significance. CONCLUSIONS Unlike pathologic results, PMI on MRI was not associated with recurrence or survival in patients with early-stage cervical cancer.
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Factors associated with parametrial involvement in patients with stage IB1 cervical cancer: Who is suitable for less radical surgery? Obstet Gynecol Sci 2017; 61:88-94. [PMID: 29372154 PMCID: PMC5780326 DOI: 10.5468/ogs.2018.61.1.88] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/22/2017] [Accepted: 07/06/2017] [Indexed: 11/08/2022] Open
Abstract
Objective To detect the possible clinicopathologic factors associated with parametrial involvement in patients with stage IB1 cervical cancer and to identify a cohort of patients who may benefit from less radical surgery. Methods We retrospectively reviewed 120 patients who underwent radical hysterectomy and pelvic lymphadenectomy as treatment for stage IB1 cervical cancer. Results Overall, 18 (15.0%) patients had parametrial tumor involvement. Tumor size larger than 2 cm, invasion depth greater than 1 cm, presence of lymphovascular space involvement (LVSI), corpus involvement, and positive lymph nodes were statistically associated with parametrial involvement. Multivariate analysis for other factors showed invasion depth >1 cm (P=0.029), and corpus involvement (P=0.022) were significantly associated with parametrial involvement. A subgroup with tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. Conclusion Tumor size smaller than 2 cm showed no parametrial involvement, regardless of invasion depth or presence of LVSI. Invasion depth >1 cm and corpus involvement were significantly associated with parametrial involvement in multivariate analysis. These finding may suggest that tumor size may a strong predictor of parametrial involvement in International Federation of Gynecology and Obstetrics stage IB1 cervical cancer, which can be used to select a subgroup population for less radical surgery.
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Magnetic Resonance Imaging as a Valuable Tool for Predicting Parametrial Invasion in Stage IB1 to IIA2 Cervical Cancer. Int J Gynecol Cancer 2017; 27:332-338. [DOI: 10.1097/igc.0000000000000878] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
ObjectivesThe aims of study were to determine the predictive value of preoperative magnetic resonance imaging (MRI) for parametrial invasion (PMI) and to develop a predictive model for PMI in patients with stage IB1 to IIA2 cervical cancer.MethodsWe retrospectively analyzed patients with stage IB1 to IIA2 cervical cancer (n = 215) who underwent radical hysterectomy between 2003 and 2014. The presence of PMI from postoperative pathological reports and its association with preoperative MRI findings were evaluated. We developed a predictive model for PMI using independent predictive factors identified by logistic regression and estimated its predictive performance.ResultsThirty patients (14.0%) had PMI from postoperative pathological reports. Among the preoperative MRI findings, a greater tumor diameter (4.2 vs 2.0 cm;P <0.001), a larger tumor volume (92.6 vs 12.7 cm3;P< 0.001), the presence of PMI (53.3% vs 8.6%;P< 0.001), and upper vaginal involvement (73.3% vs 22.7%;P< 0.001) were significantly associated with PMI. Multivariate analysis identified tumor volume (odds ratio, 7.0; 95% confidence interval, 2.63–18.53;P< 0.001) and PMI (odds ratio, 6.1; 95% confidence interval, 2.31–15.97;P< 0.001) from preoperative MRI findings as independent predictive factors for PMI. Our predictive model demonstrates that the presence of PMI or a tumor volume of greater than 18.0 cm3has a higher sensitivity (86.7% vs 53.3%) and lower specificity (74.6% vs 91.4%) than the presence of PMI alone. Specifically, the model's negative predictive value was superior to that of PMI only (97.2% vs 92.3%). In the low-risk group, defined as preoperative MRI findings suggesting no PMI and a tumor volume of 18.0 cm3or less, the proportion of false negative cases was just 2.8%.ConclusionsWhen tumor volume with findings suggesting that PMI is considered, preoperative MRI is useful in excluding PMI. A predictive model based on preoperative MRI findings seems to be valuable in identifying potential candidates for less radical surgery in stage IB1 to IIA2 cervical cancer.
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Peng J, Wang W, Zeng D. Application of magnetic resonance imaging in diagnosis of Uterus Cervical Carcinoma. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2017; 25:205-211. [PMID: 28234273 DOI: 10.3233/xst-17254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Effective treatment of Uterus Cervical Carcinoma (UCC) rely heavily on the precise pre-surgical staging. The conventional International Federation of Gynecology and Obstetrics (FIGO) system based on clinical examination is being applied worldwide for UCC staging. Yet its performance just appears passable. Thus, this study aims to investigate the value of applying Magnetic Resonance Imaging (MRI) with clinical examination in staging of UCC. MATERIALS AND METHODS A retrospective dataset involving 164 patients diagnosed with UCC was enrolled in this study. The mean age of this study population was 46.1 years (range, 28-#x2013;75 years). All patients underwent operations and UCC types were confirmed by pathological examinations. The tumor stages were determined by two experienced Gynecologist independently based on FIGO examinations and MRI. The diagnostic results were also compared with the post-operative pathologic reports. Statistical data analysis on diagnostic performance was then done and reported. RESULTS The study results showed that the overall accuracy of applying MRI in UCC staging was 82.32%, while using FIGO staging method, the staging accuracy was 59.15%. CONCLUSIONS MRI is suitable to evaluate tumor extent with high accuracy, and it can offer more objective information for the diagnosis and staging of UCC. Compared with clinical examinations based on FIGO, MRI illustrated relatively high accuracy in evaluating UCC staging, and is worthwhile to be recommended in future clinical practice.
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Affiliation(s)
- Jidong Peng
- Department of Radiology, Ganzhou People's Hospital, Jiangxi, China
| | - Weiqiang Wang
- Department of Gynecology, The Northwest Women and Children's Hospital, Xi-an, China
| | - Daohui Zeng
- Department of Radiology, First Affiliated Hospital of Guangzhou University of TCM, Guangzhou, Guangdong, China
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Supoken A, Kietpeerakool C, Laopaiboon M, Lumbiganon P. Simple versus radical hysterectomy with pelvic lymphadenectomy for women with stage IA2-IB1 cervical cancer. Hippokratia 2016. [DOI: 10.1002/14651858.cd012335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Amornrat Supoken
- Department of Obstetrics and Gynaecology, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Chumnan Kietpeerakool
- Department of Obstetrics and Gynaecology, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - Malinee Laopaiboon
- Department of Epidemiology and Biostatistics, Faculty of Public Health; Khon Kaen University; Khon Kaen Thailand
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
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Complementary Prognostic Value of Pelvic Magnetic Resonance Imaging and Whole-Body Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Pretreatment Assessment of Patients With Cervical Cancer. Int J Gynecol Cancer 2016; 25:1461-7. [PMID: 26397068 DOI: 10.1097/igc.0000000000000519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the incremental prognostic value of pelvic magnetic resonance imaging (MRI) and whole-body F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings compared with clinical-histopathologic factors in patients with newly diagnosed cervical cancer. METHODS The institutional review board approved this retrospective study of 114 patients (median age, 40.6 years) with International Federation of Gynecology and Obstetrics (FIGO) stage I-IVB cervical cancer who underwent pretreatment MRI and PET/CT. All scans were reviewed for locoregional tumor extent, pelvic or/and para-aortic lymphadenopathy, and distant metastases. Univariate Cox proportional hazard regression was performed to evaluate associations between clinical-histopathologic factors, imaging findings, and progression-free survival (PFS). Multivariate models were built using independent predictors for PFS. Harrell C was used to measure concordance (C index). RESULTS Forty patients progressed within a median time of 10.4 months (range, 0.4-40.3 months). At univariate analysis, age, FIGO stage, tumor histology, tumor grade, and all MRI and PET/CT features were significantly associated with PFS (P < 0.0001 to P = 0.0474). A multivariate model including clinical and imaging parameters (parametrial invasion on MRI and para-aortic lymphadenopathy/distant metastases on PET/CT) had significantly higher concordance for predicting PFS than a model including clinical parameters only (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.68 [95% confidence interval, 0.59-0.78]; P < 0.001). The comparison of C indices for the combined clinical and imaging model approached significance when compared with a FIGO stage model (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.75 [95% confidence interval, 0.69-0.82]; P = 0.058). CONCLUSIONS In patients with newly diagnosed cervical cancer, a prognostic model including combined MRI and PET/CT findings provides information that complements clinical and histopathologic factors.
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Kong TW, Kim J, Son JH, Kang SW, Paek J, Chun M, Chang SJ, Ryu HS. Preoperative nomogram for prediction of microscopic parametrial infiltration in patients with FIGO stage IB cervical cancer treated with radical hysterectomy. Gynecol Oncol 2016; 142:109-114. [DOI: 10.1016/j.ygyno.2016.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/02/2016] [Accepted: 05/06/2016] [Indexed: 11/28/2022]
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Bai H, Cao D, Yuan F, Wang H, Xiao M, Chen J, Cui Q, Shen K, Zhang Z. Accuracy of conization procedure for predicting pathological parameters of radical hysterectomy in stage Ia2-Ib1 (≤2 cm) cervical cancer. Sci Rep 2016; 6:25992. [PMID: 27181832 PMCID: PMC4867621 DOI: 10.1038/srep25992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 04/26/2016] [Indexed: 11/16/2022] Open
Abstract
The accuracy of conization for the prediction of radical hysterectomy (RH) pathological variables in patients with stage Ia2 to Ib1 (≤2 cm) cervical cancer was retrospectively evaluated in the present study. Endocervical or deep resection margin (RM) involvement in the conization specimens was found to be independently associated with residual disease in the hysterectomy specimens (P < 0.001, = 0.003, respectively). When a tumor width of >20 mm in the final RH pathology analysis was predicted by a tumor width of >2 mm or involvement of endocervical or deep RMs in the conization specimens, the sensitivity and negative predictive value (NPV) of conization were 98.2% and 95.2%, respectively. In addition, when deep stromal invasion in the final RH pathology analysis was predicted by deep stromal invasion or involvement of the endocervical or deep RMs in the conization specimens, the sensitivity and NPV of conization were 98.4% and 95.8%, respectively. The sensitivity and NPV of this prediction model for identifying LVSI in the final RH pathology analysis were both 100%. These findings suggest that conization variables and endocervical and deep resection margin statuses can be analyzed to effectively predict RH pathological parameters.
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Affiliation(s)
- Huimin Bai
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China.,Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Fang Yuan
- Department of Obstetrics and Gynecology, the Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Huilan Wang
- Department of Obstetrics and Gynecology, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meizhu Xiao
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Quancai Cui
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing, China
| | - Zhenyu Zhang
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital affiliated with China Capital Medical University, Beijing, China
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Choi HJ, Lee S, Park BK, Kim TJ, Kim CK, Park JJ, Choi CH, Lee YY, Lee JW, Bae DS, Kim BG. Long-term outcomes of magnetic resonance imaging-invisible endometrial cancer. J Gynecol Oncol 2016; 27:e38. [PMID: 27102247 PMCID: PMC4864514 DOI: 10.3802/jgo.2016.27.e38] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/08/2016] [Accepted: 03/27/2016] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) is useful for staging endometrial cancer. The treatment and prognosis of MRI-invisible endometrial cancer remain unclear. The purpose of this study was to retrospectively evaluate the long-term outcomes of patients with MRI-invisible endometrial cancer. METHODS Between February 1995 and December 2011, we reviewed the medical records of 433 patients with endometrial cancer, which was staged IA on MRI. Of these patients, 89 had MRI-invisible cancer and 344 had MRI-visible cancer. Both cancers were treated with simple hysterectomy with or without lymph node dissection according to the surgeon's decision. Both cancers were compared regarding pathologic findings, recurrence rates, and survival rates. RESULTS The median sizes of MRI-invisible and MRI-visible cancers were 4 mm (0 to 40 mm) and 20 mm (0 to 89 mm), respectively (p<0.001). Myometrial invasion of these groups were detected in 20.2% (18/89) and 56.7% (195/344), respectively (p<0.001). Lymphadenectomy and follow-up imaging revealed no lymph node metastasis in patients with MRI-invisible cancers, while those revealed in 4.7% (16/344) of patients with MRI-visible cancers (p=0.052). The recurrence rates of MRI-invisible and MRI-visible cancers were 1.1% (1/89) and 7.8% (27/344), respectively (p=0.026). The recurrence-free survival rates of these groups were 98.9% (88/89) and 91.6% (315/344), respectively (p=0.022). CONCLUSION MRI-invisible endometrial cancer can be treated with less invasive surgery because of its lower tumor burden and better prognosis. This cancer may not require lymphadenectomy because of no metastasis or recurrence in lymph nodes.
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Affiliation(s)
- Hyun Jin Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sunyoung Lee
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Tae Joong Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Kyo Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Jae Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo Young Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Won Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Soo Bae
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byoung Gie Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Rauch GM, Kaur H, Choi H, Ernst RD, Klopp AH, Boonsirikamchai P, Westin SN, Marcal LP. Optimization of MR imaging for pretreatment evaluation of patients with endometrial and cervical cancer. Radiographics 2015; 34:1082-98. [PMID: 25019443 DOI: 10.1148/rg.344140001] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Endometrial and cervical cancer are the most common gynecologic malignancies in the world. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. The current International Federation of Gynecology and Obstetrics (FIGO) staging system does not include modern imaging modalities. However, magnetic resonance (MR) imaging has proved to be the most accurate noninvasive modality for staging endometrial and cervical carcinomas and often helps with risk stratification and making treatment decisions. Multiparametric MR imaging is increasingly being used to evaluate the female pelvis, an approach that combines anatomic T2-weighted imaging with functional imaging (ie, dynamic contrast material-enhanced and diffusion-weighted imaging). MR imaging helps guide treatment decisions by depicting the depth of myometrial invasion and cervical stromal involvement in patients with endometrial cancer and tumor size and parametrial invasion in those with cervical cancer. However, its accuracy for local staging depends on technique and image quality, namely thin-section high-resolution multiplanar T2-weighted imaging with simple modifications, such as double oblique T2-weighting supplemented by diffusion weighting and contrast enhancement.
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Affiliation(s)
- Gaiane M Rauch
- From the Departments of Diagnostic Radiology (G.M.R., H.K., H.C., R.D.E., P.B., L.P.M.), Radiation Oncology (A.H.K.), and Gynecologic Oncology and Reproductive Medicine (S.N.W.), University of Texas MD Anderson Cancer Center, 1400 Pressler St, Mail Unit 1473, Houston, TX 77030-4009
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Yamazaki H, Todo Y, Okamoto K, Yamashiro K, Kato H. Pretreatment risk factors for parametrial involvement in FIGO stage IB1 cervical cancer. J Gynecol Oncol 2015. [PMID: 26197769 PMCID: PMC4620361 DOI: 10.3802/jgo.2015.26.4.255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective All patients with stage IB1 cervical cancer do not need to undergo parametrectomy. Some low-risk criteria for parametrial involvement (PI) have been proposed based on pathological findings. The aim of this study was to determine pretreatment risk factors for PI in stage IB1 cervical cancer. Methods We retrospectively reviewed 115 patients with stage IB1 cervical cancer who underwent radical hysterectomy or radical trachelectomy. Magnetic resonance imaging (MRI) was performed and serum concentrations of squamous cell carcinoma antigen (SCC-Ag) and cancer antigen 125 (CA-125) were determined in all patients before initial treatment. The following pretreatment factors were investigated: histological variant, maximum tumor diameter, tumor volume (volume index), pelvic lymph node enlargement, and serum tumor markers. Logistic regression analysis was used to select the independent risk factors for PI. Results Eighteen of the 115 patients (15.7%) were pathologically diagnosed with PI. Multivariate analysis confirmed the following independent risk factors for PI: MRI-based tumor diameter ≥25 mm (odds ratio [OR], 9.9; 95% confidence interval [CI], 2.1 to 48.1), MRI-based volume index ≥5,000 mm3 (OR, 13.3; 95% CI, 1.4 to 125.0), and positive serum tumor markers SCC-Ag ≥1.5 ng/mL or CA-125 ≥35 U/mL (OR, 5.7; 95% CI, 1.3 to 25.1). Of 53 patients with no risk factors for PI, none had PI. Conclusion Less radical surgery may become one of the treatment options for stage IB1 cervical cancer patients with MRI-based tumor diameter <25 mm, MRI-based volume index <5,000 mm3, and negativity for SCC-Ag and CA-125.
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Affiliation(s)
- Hiroyuki Yamazaki
- Division of Gynecologic Oncology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - Yukiharu Todo
- Division of Gynecologic Oncology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan.
| | - Kazuhira Okamoto
- Division of Gynecologic Oncology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - Katsushige Yamashiro
- Division of Pathology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - Hidenori Kato
- Division of Gynecologic Oncology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
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Bai H, Yuan F, Wang H, Chen J, Cui Q, Shen K. The potential for less radical surgery in women with stage IA2-IB1 cervical cancer. Int J Gynaecol Obstet 2015; 130:235-40. [PMID: 26070225 DOI: 10.1016/j.ijgo.2015.03.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/18/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify a subset of patients with stage IA2-IB1 cervical cancer and small tumors (≤2cm) who could be suitable for less radical surgery. METHODS In a retrospective study, the medical records of women treated at nine hospitals in China were reviewed. Included women had undergone radical hysterectomy and pelvic lymph node dissection. The clinicopathologic factors associated with uterine isthmus invasion (UII), vaginal invasion (VI), parametrial invasion (PI), lymph node metastasis (LNM), and prognosis were analyzed. RESULTS Overall, 1632 women were included. Tumor size greater than 2cm (measured postoperatively) was an independent predictor of VI (P=0.002), PI (P=0.001), and UII (P=0.021). Squamous cell carcinoma and superficial stromal invasion were associated with a low frequency of UII (P<0.001 for both). Among patients with adenocarcinoma, deep stromal invasion and lymphovascular space involvement (LVSI) were independently associated with UII (P=0.006 and P=0.004, respectively). Grade 2/3 disease (P=0.009), deep stromal invasion (P=0.015), and LVSI (P<0.001) were independently associated with LNM. LNM was the only independent adverse factor for survival (P<0.001). CONCLUSION Women with stage IA2-IB1 cervical cancer with low-risk factors could be candidates for large-scale prospective clinical trials of less radical surgery and lymphadenectomy omission.
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Affiliation(s)
- Huimin Bai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, China Capital Medical University, Beijing, China
| | - Fang Yuan
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
| | - Huilan Wang
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Quancai Cui
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Lee JY, Youm J, Kim JW, Cho JY, Kim MA, Kim TH, Suh DH, Lim MC, Park NH, Song YS. Identifying a low-risk group for parametrial involvement in microscopic Stage IB1 cervical cancer using criteria from ongoing studies and a new MRI criterion. BMC Cancer 2015; 15:167. [PMID: 25885786 PMCID: PMC4374417 DOI: 10.1186/s12885-015-1184-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 03/12/2015] [Indexed: 11/10/2022] Open
Abstract
Background There are currently three ongoing studies on less radical surgery in cervical cancer: ConCerv, GOG-278, and SHAPE. The aim of this study was to evaluate the performance of the criteria used in ongoing studies retrospectively and suggest a new, simplified criterion in microscopic Stage IB1 cervical cancer. Methods A retrospective analysis was performed in 125 Stage IB1 cervical cancer patients who had no clinically visible lesions and were allotted based on microscopic findings after conization. All patients had magnetic resonance imaging (MRI) after conization and underwent type C2 radical hysterectomy. We suggested an MRI criterion for less radical surgery candidates as patients who had no demonstrable lesions on MRI. The rates of parametrial involvement (PMI) were estimated for patients that satisfied the inclusion criteria for ongoing studies and the MRI criterion. Results The rate of pathologic PMI was 5.6% (7/125) in the study population. ConCerv and GOG-278 identified 11 (8.8%) and 14 (11.2%) patients, respectively, as less radical surgery candidates, and there were no false negative cases. SHAPE and MRI criteria identified 78 (62.4%) and 74 (59.2%) patients, respectively, as less radical surgery candidates; 67 patients were identified as less radical surgery candidates by both sets of criteria. Of these 67 patients, only one had pathologic PMI with tumor emboli. Conclusions This study suggests that the criteria used in three ongoing studies and a new, simplified criterion using MRI can identify candidates for less radical surgery with acceptable false negativity in microscopic Stage IB1 disease.
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Affiliation(s)
- Jung-Yun Lee
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 120-752, Seoul, Korea.
| | - Jina Youm
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
| | - Min A Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea.
| | - Tae Hun Kim
- Department of Obstetrics and Gynecology, Korea Cancer Center, Seoul, Korea.
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Gyeonggi-di, Korea.
| | - Myong Cheol Lim
- Center for Uterine Cancer and Gynecologic Cancer Branch, National Cancer Center, Goyang, Gyeonggi-do, Korea.
| | - Noh Hyun Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
| | - Yong-Sang Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea.
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Narayan K, Lin MY. Staging for cervix cancer: Role of radiology, surgery and clinical assessment. Best Pract Res Clin Obstet Gynaecol 2015; 29:833-44. [PMID: 25898789 DOI: 10.1016/j.bpobgyn.2015.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 01/27/2015] [Indexed: 12/20/2022]
Abstract
Staging is necessary in determining the extent of disease, its prognosis and in the formulation of optimal treatment protocols for patients with cancer. Clinical examination of patients and subsequent histopathological assessment when available has traditionally been used to determine the application of different primary and adjuvant treatment modalities. Over the years, surgery, radiotherapy and chemotherapy all have been used either singly or in combinations, and the resulting survival and patterns of failure studies have contributed much in the development of less toxic and more effective protocols. All three modalities of treatments work through separate mechanisms, and they are effective in different stages of cervix cancer. Even within the same stage, the extent of the disease, tumour volume, tissue infiltration and lymph-node metastases requires the use of differing protocols for the disease control. More recently, advances in magnetic resonance imaging (MRI) and positron emission tomography/computerised tomography (PET/CT) have made it possible to examine many of the prognostic factors non-invasively. In addition to clinical assessment, surgical and radiological staging has enabled us to triage patients far more accurately for surgery or for primary radiotherapy, such as unnecessary multimodality treatments are avoided. Only patients with poor prognosis are subjected to a combined modality treatment. Those with poorer prognosis still can be selected for clinical studies exploring new treatment.
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Affiliation(s)
- Kailash Narayan
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia.
| | - Ming Yin Lin
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
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Kato T, Takashima A, Kasamatsu T, Nakamura K, Mizusawa J, Nakanishi T, Takeshima N, Kamiura S, Onda T, Sumi T, Takano M, Nakai H, Saito T, Fujiwara K, Yokoyama M, Itamochi H, Takehara K, Yokota H, Mizunoe T, Takeda S, Sonoda K, Shiozawa T, Kawabata T, Honma S, Fukuda H, Yaegashi N, Yoshikawa H, Konishi I, Kamura T. Clinical tumor diameter and prognosis of patients with FIGO stage IB1 cervical cancer (JCOG0806-A). Gynecol Oncol 2015; 137:34-9. [PMID: 25662625 DOI: 10.1016/j.ygyno.2015.01.548] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/29/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In order to determine indications for less radical surgery such as modified radical hysterectomy, the risk of pathological parametrial involvement and prognosis of FIGO stage IB1 cervical cancer patients undergoing standard radical hysterectomy with pre-operatively assessed tumor diameter≤2 cm were investigated. METHODS We conducted a retrospective multi-institutional chart review of patients with FIGO stage IB1 cervical cancer who underwent primary surgical treatment between 1998 and 2002. The eligibility criteria for the analyses were (i) histologically-proven squamous cell carcinoma, adenocarcinoma or, adenosquamous cell carcinoma, (ii) radical hysterectomy performed, (iii) clinical tumor diameter data available by MR imaging or specimens by cone biopsy, and (iv) age between 20 and 70. Based on the clinical tumor diameter, patients were stratified into those with the following tumors: i) 2 cm or less (cT≤2 cm) and ii) greater than 2 cm (cT>2 cm). We expected 5-year OS of ≥95% and parametrial involvement<2-3% for patients with cT≤2 cm who underwent radical hysterectomy. RESULTS Of the 1269 patients enrolled, 604 were eligible for the planned analyses. Among these, 571 underwent radical hysterectomy (323 with cT≤2 cm and 248 with cT>2 cm). Parametrial involvement was present in 1.9% (6/323) with cT≤2 cm and 12.9% (32/248) with cT>2 cm. Five-year overall survivals were 95.8% (95% CI 92.9-97.6%) in cT≤2 cm and 91.9% (95% CI 87.6-94.8%) in cT>2 cm patients. CONCLUSION Patients with cT≤2 cm had lower risk of parametrial involvement and more favorable 5-year overall survival. They could therefore be good candidates for receiving less radical surgery.
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Affiliation(s)
- Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Japan.
| | - Atsuo Takashima
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Takahiro Kasamatsu
- Department of Gynecologic Oncology, National Cancer Center Hospital, Japan
| | - Kenichi Nakamura
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Toru Nakanishi
- Department of Gynecologic Oncology, Aichi Cancer Center, Japan
| | | | - Shoji Kamiura
- Department of Gynecology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Takashi Onda
- Department of Obstetrics and Gynecology, Kitasato University, Japan
| | - Toshiyuki Sumi
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Japan
| | | | - Toshiaki Saito
- Gynecologic Service, National Kyushu Cancer Center, Japan
| | | | | | - Hiroaki Itamochi
- Department of Obstetrics and Gynecology, Tottori University, Japan
| | | | - Harushige Yokota
- Department of Gynecologic Oncology, Saitama Cancer Center, Japan
| | - Tomoya Mizunoe
- Department of Gynecologic Oncology, Kure Medical Center, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Japan
| | - Kenzo Sonoda
- Department of Obstetrics and Gynecology, Kyushu University, Japan
| | - Tanri Shiozawa
- Department of Obstetrics and Gynecology, Shinshu University, Japan
| | - Takayo Kawabata
- Department of Obstetrics and Gynecology, Kagoshima City Hospital, Japan
| | - Shigeru Honma
- Department of Gynecology, Niigata Cancer Center Hospital, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center, Multi-institutional Clinical Trial Support Center, National Cancer Center, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University, Japan
| | | | - Ikuo Konishi
- Department of Gynecology and Obstetrics, Kyoto University, Japan
| | - Toshiharu Kamura
- Department of Obstetrics and Gynecology, Kurume University, Japan
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Postoperative outcomes of MR-invisible stage IB1 cervical cancer. Am J Obstet Gynecol 2014; 211:168.e1-7. [PMID: 24607752 DOI: 10.1016/j.ajog.2014.02.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/24/2014] [Accepted: 02/26/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Tumor volume is a significant prognostic factor of cervical cancer. It is still unknown about outcome of biopsy-proven IB1 cervical cancer, which is invisible on preoperative magnetic resonance imaging (MRI). The aim was to evaluate retrospectively the postoperative outcomes of MR-invisible stage IB1 cervical cancers. STUDY DESIGN Between January 2001 and December 2007, we reviewed the medical records of 86 patients with biopsy-proven IB1 cervical cancer that was invisible on MRI. During the same period, we also reviewed the medical records of 260 patients with biopsy-proven IB1 cervical cancer that was visible on MRI. Both of these cancer groups were treated with radical hysterectomy and lymph node dissection. MR-invisible and MR-visible IB1 cancers were compared in terms of pathologic parameters and long-term survival rate. RESULTS The median sizes and depths of stromal invasion of MR-invisible vs MR-visible IB1 cancers were 4.5 ± 7.1 mm and 33.3% ± 20.1% vs 30 ± 14 mm and 66.7% ± 26.6%, respectively (P = .000). The incidences of lymph node metastasis, parametrial invasion, and lymphovascular invasion were 1.1% (1/86 cases) and 18.8% (49/260 cases; P = .000; odds ratio, 19.7), 0% (0/86 cases) and 6.5% (17/260 cases; P = .009; odds ratio, 12.4), and 4.7% (4/86 cases) and 26.9% (70/260 cases; P = .000; odds ratio, 7.6) in the MR-invisible and MR-visible IB1 cancers, respectively. Recurrence-free and overall 5-year survival rates of MR-invisible vs MR-visible IB1 cancers were 98.8% (85/86 cases) vs 91.2% (237/260 cases) and 100% (86/86 cases) vs 95.8% (249/260 cases), respectively (P = .011 and .045). CONCLUSION MR-invisible IB1 cancer provides better postoperative outcomes than MR-visible IB1 cancer because of the much lower tumor burden.
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Lee JY, Youm J, Kim TH, Cho JY, Kim MA, Suh DH, Lim MC, Kim JW, Park NH, Song YS. Preoperative MRI criteria for trials on less radical surgery in Stage IB1 cervical cancer. Gynecol Oncol 2014; 134:47-51. [DOI: 10.1016/j.ygyno.2014.02.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/25/2014] [Accepted: 02/03/2014] [Indexed: 11/24/2022]
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A cut-off value of 2 cm in tumor size is of prognostic value in surgically treated FIGO stage IB cervical cancer. Gynecol Oncol 2014; 134:42-6. [PMID: 24768850 DOI: 10.1016/j.ygyno.2014.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/07/2014] [Accepted: 04/13/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Limited knowledge exists about the value of tumor size in surgically treated cervical cancer (CX) using a tumor size of 2 cm as cut-off value. METHODS A total of 366 cases of CX FIGO stage IB who received upfront surgery were evaluated regarding tumor size, the prediction of pelvic lymph node involvement, and recurrence-free and overall survival during a median follow-up time of 94 months. Tumors ≤2.0 cm were defined as small, tumors 2.1-4.0 cm as medium sized and those larger than 4 cm as bulky disease. RESULTS Small tumors were seen in 28.7%, medium sized in 52.5% and bulky tumors in 18.9%. There was a significant higher frequency of pelvic lymph node involvement with increasing tumor size (13.3% vs. 23.4% vs. 43.5%, respectively; p<0.001) and an increase of recurrent disease (6.7% vs. 18.8% vs. 29.4%, respectively; p<0.001). The 5-year overall survival rate was significantly reduced with increasing tumor size (94.0% vs. 85.1% vs. 69.9%, respectively; p<0.001). Pelvic lymph node involvement and maximal tumor size were independent prognostic factors for both recurrence-free and overall survival in multivariate analysis. CONCLUSIONS The results support that tumor size is of prognostic impact in FIGO stage IB cervical carcinomas. A further substaging is suggested for tumors up to 4.0 cm maximum dimension using a cut-off value of 2.0 cm as discriminator. Patients with tumors ≤2.0 cm may represent low risk disease.
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Value of diffusion-weighted imaging in predicting parametrial invasion in stage IA2–IIA cervical cancer. Eur Radiol 2014; 24:1081-8. [DOI: 10.1007/s00330-014-3109-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/20/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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Reade CJ, Eiriksson LR, Covens A. Surgery for early stage cervical cancer: How radical should it be? Gynecol Oncol 2013; 131:222-30. [DOI: 10.1016/j.ygyno.2013.07.078] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/03/2013] [Accepted: 07/07/2013] [Indexed: 11/26/2022]
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Sanuki N, Urabe S, Matsumoto H, Ono A, Komatsu E, Kamei N, Maeda T. Evaluation of microscopic tumor extension in early-stage cervical cancer: quantifying subclinical uncertainties by pathological and magnetic resonance imaging findings. JOURNAL OF RADIATION RESEARCH 2013; 54:719-726. [PMID: 23381955 PMCID: PMC3709675 DOI: 10.1093/jrr/rrt004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/05/2013] [Accepted: 01/07/2013] [Indexed: 06/01/2023]
Abstract
We performed a detailed analysis of hysterectomy specimens of uterine cervical cancer to determine the appropriate length of uterine body to include within the clinical target volume. Between 2008 and 2011, 54 patients with uterine cervical carcinoma underwent hysterectomy. Those with quality pre-operative magnetic resonance imaging (MRI) data were included for analysis. Tumor sizes measured by MRI and microscopy were compared with regard to brachytherapy-oriented parameters. Detailed descriptive analysis focusing on the extent of tumor involvement was also performed. A total of 31 specimens were analyzed. The median maximal tumor length measured by MRI was slightly shorter than microscopic length (19 vs. 24 mm, respectively), while the maximal radius was almost identical. No tumors with a maximal size <2 cm by MRI (n = 6) extended to the uterine body ≥ 1/3. The majority of maximal tumor length underestimation on MRI was within 1 cm. Precise tumor delineation can be made by MRI. For patients with tumors <2 cm on MRI, treating the entire uterine body length may not be necessary. A 1-cm margin around an MRI-based gross tumor seems to be adequate to cover the actual tumor involvement.
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Affiliation(s)
- Naoko Sanuki
- Department of Radiology, Oita Prefectural Hospital, 476, Bunyo, Oita-shi, Oita, 870-8511, Japan.
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Current World Literature. Curr Opin Obstet Gynecol 2013; 25:81-9. [DOI: 10.1097/gco.0b013e32835cc6b6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Crivellaro C, Signorelli M, Guerra L, De Ponti E, Buda A, Dolci C, Pirovano C, Todde S, Fruscio R, Messa C. 18F-FDG PET/CT can predict nodal metastases but not recurrence in early stage uterine cervical cancer. Gynecol Oncol 2012; 127:131-5. [PMID: 22772064 DOI: 10.1016/j.ygyno.2012.06.041] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/26/2012] [Accepted: 06/27/2012] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the role of the metabolic characteristics of cervical tumor uptake as predictors of a) lymph node (LN) metastases, b) recurrence, in the preoperative staging of early-stage cervical cancer. METHODS 89 patients with FIGO stage IB1 and IIA<4 cm cervical cancer were imaged with FDG-PET/CT before radical hysterectomy and pelvic lymphadenectomy. PET/CT images were analyzed and correlated to histological findings. Maximum and mean standardized uptake value (SUVmax, SUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG) of cervical lesions were calculated by an iterative adaptive algorithm. These parameters were correlated to the presence of: a) LN metastases, b) relapse after primary treatment. RESULTS Out of the 89 patients who underwent preoperative PET/CT scan for staging purpose, 16 were negative at cervical level: they were all pN0 and without recurrence during follow-up (mean 34.1±14.5 months). In 69 patients MTV and TLG were significantly higher (p=0.0006 and p=0.03) in pN1 patients in comparison to pN0 patients, while SUV values did not show significant differences between the two groups. No significant correlations were found between SUVmax, SUVmean, MTV, TLG and the evidence of relapse (mean follow-up 29.2±15.5 months). CONCLUSIONS In early-stage cervical cancer MTV and TLG correlate with the presence of nodal metastases, but their clinical impact on patients management has to be clarified. The absence of pathological cervical uptake could be a good prognostic factor, while SUVmax, SUVmean, MTV, TLG of the cervical uptake have not been found predictors of recurrence.
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A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer. Gynecol Oncol 2012; 126:82-6. [DOI: 10.1016/j.ygyno.2012.04.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 04/10/2012] [Accepted: 04/11/2012] [Indexed: 11/20/2022]
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Current World Literature. Curr Opin Obstet Gynecol 2012; 24:194-9. [DOI: 10.1097/gco.0b013e328353d51d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Re:"parametrial involvement in FIGO stage IB1 cervical carcinoma". Int J Gynecol Cancer 2011; 21:966. [PMID: 21705911 DOI: 10.1097/igc.0b013e31821c92c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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