Value of magnetic resonance and ¹⁸FDG PET-CT in predicting tumor response and resectability of primary locally advanced cervical cancer after treatment with intensity-modulated arc therapy: a prospective pathology-matched study

18F-FDG PET/CT- and MRI-Based Locally Advanced Cervical Cancer Early-Response Assessment after Concurrent Chemo- and Radiotherapy-Impact on Patient Outcomes and Survival Prediction

With one third of patients with locally advanced cervical cancer (LACC) expected to develop cancer recurrence in the first two years after therapy, accurate assessment of the response and timely detection of cancer recurrence after concurrent chemo- and radiotherapy (CCRT) treatment is of great importance. Although there is neither definite consensus about the preferred imaging modality, nor the time interval until the first diagnostic examination after CCRT, the National Comprehensive Cancer Network (NCCN) recommends the use of MRI and 18F-FDG PET/CT as a post-treatment LACC response-assessment imaging tools. In this study, we tried to appraise the early therapy response in LACC patients by both 18F-FDG PET/CT and MRI in regard to the follow-up imaging results and their mutual interrelationship, and to ascertain if the post-treatment 18F-FDG PET/CT and MRI results were related to the progression-free and overall survival rate in women with LACC after CCRT. We also aimed to estimate the early and follow-up diagnostic imaging impact on further therapy management. Based on our results, we concluded that 18F-FDG PET/CT did surpass MRI in the early assessment of therapeutic response in LACC patients after CCRT. Both modalities provided information that may serve as predictive biomarkers of outcome and LACC patients' survival.

Prediction of Patient Outcomes in Locally Advanced Cervical Carcinoma Following Chemoradiotherapy-Comparative Effectiveness of Magnetic Resonance Imaging and 2-Deoxy-2-[18F]fluoro-D-glucose Imaging

PURPOSE

To evaluate the utility and comparative effectiveness of three five-point qualitative scoring systems for assessing response on PET-CT and MRI imaging individually and in combination, following curative-intent chemoradiotherapy (CRT) in locally advanced cervical cancer (LACC). Their performance in the prediction of subsequent patient outcomes was also assessed; Methods: Ninety-seven patients with histologically confirmed LACC treated with CRT using standard institutional protocols at a single centre who underwent PET-CT and MRI at staging and post treatment were identified retrospectively from an institutional database. The post-CRT imaging studies were independently reviewed, and response assessed using five-point scoring tools for T2WI, DWI, and FDG PET-CT. Patient characteristics, staging, treatment, and follow-up details including progression-free survival (PFS) and overall survival (OS) outcomes were collected. To compare diagnostic performance metrics, a two-proportion z-test was employed. A Kaplan-Meier analysis (Mantel-Cox log-rank) was performed.

RESULTS

The T2WI (p < 0.00001, p < 0.00001) and DWI response scores (p < 0.00001, p = 0.0002) had higher specificity and accuracy than the PET-CT. The T2WI score had the highest positive predictive value (PPV), while the negative predictive value (NPV) was consistent across modalities. The combined MR scores maintained high NPV, PPV, specificity, and sensitivity, and the PET/MR consensus scores showed superior diagnostic accuracy and specificity compared to the PET-CT score alone (p = 0.02926, p = 0.0083). The Kaplan-Meier analysis revealed significant differences in the PFS based on the T2WI (p < 0.001), DWI (p < 0.001), combined MR (p = 0.003), and PET-CT/MR consensus scores (p < 0.001) and in the OS for the T2WI (p < 0.001), DWI (p < 0.001), and combined MR scores (p = 0.031) between responders and non-responders.

CONCLUSION

Post-CRT response assessment using qualitative MR scoring and/or consensus PET-CT and MRI scoring was a better predictor of outcome compared to PET-CT assessment alone. This requires validation in a larger prospective study but offers the potential to help stratify patient follow-up in the future.

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

OBJECTIVE

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

CONCLUSIONS

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

Pre-treatment prediction of early response to chemoradiotherapy by quantitative analysis of baseline staging FDG-PET/CT and MRI in locally advanced cervical cancer

BACKGROUND

Early prediction of response to concurrent chemoradiotherapy (cCRT) could aid to further optimize treatment regimens for locally advanced cervical cancer (LACC) in the future.

PURPOSE

To explore whether quantitative parameters from baseline (pre-therapy) magnetic resonance imaging (MRI) and FDG-PET/computed tomography (CT) have potential as predictors of early response to cCRT.

MATERIAL AND METHODS

Forty-six patients with LACC undergoing cCRT after staging with FDG-PET/CT and MRI were retrospectively analyzed. Primary tumor volumes were delineated on FDG-PET/CT, T2-weighted (T2W)-MRI and diffusion-weighted MRI (DWI) to extract the following quantitative parameters: T2W volume; T2W signal_mean; DWI volume; ADC_mean; ADC_SD; MTV_42%; and SUV_max. Outcome was the early treatment response, defined as the residual tumor volume on MRI 3-4 weeks after start of external beam radiotherapy with chemotherapy (before the start of brachytherapy): patients with a residual tumor volume <10 cm³ were classified as early responders. Imaging parameters were analyzed together with FIGO stage to assess their performance to predict early response, using multivariable logistic regression analysis with bi-directional variable selection. Leave-one-out cross-validation with bootstrapping was used to simulate performance in a new, independent dataset.

RESULTS

T2W volume (OR 0.94, P = 0.003) and SUV_max (OR 1.15, P = 0.18) were identified as independent predictors in multivariable analysis, rendering a model with an AUC of 0.82 in the original dataset, and AUC of 0.68 (95% CI 0.41-0.81) from cross-validation.

CONCLUSION

Although the predictive performance achieved in this small exploratory dataset was limited, these preliminary data suggest that parameters from baseline MRI and FDG-PET/CT (in particular pre-therapy tumor volume) may contribute to prediction of early response to cCRT in cervical cancer.

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

Objective

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

Method

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

Results

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

Conclusion

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

Prognostic value of posttreatment FEDG-PET imaging following combined chemoradiation therapy in locally advanced cervical cancer

OBJECTIVES

To evaluate the performances of posttreatment FEDG-PET to predict the prognosis of patients treated with concurrent chemoradiotherapy (CT/RT) for locally advanced cervical cancer.

MATERIALS AND METHODS

The medical records of 131 patients treated in 9 French academic institutions for IB2-IIB cervical cancer and for which a posttherapy FEDG-PET was performed were reviewed. All patients received CT/RT, possibly completed with vaginal brachytherapy (VBT) and completion surgery. Posttreatment FEDG-PET was performed within 3 months after completion of CT/RT or VBT. Incomplete metabolic response (IMR) was defined as the persistence of FEDG uptake.

RESULTS

An IMR was identified in 44 (33.6 %) cases. IMR was associated with higher risk of recurrence (aHR = 2.8; 95 %CI: 1.3-5.7; p = 0.006) and death (aHR = 4.5 ;95 %CI: 1.4-13.8; p = 0.009). Completion surgery was performed in 61 (46.9 %) patients with histologic cervical residual disease identified in 31 (50.8 %). FEDG-PET sensitivity and specificity in predicting cervical residual disease following CT/RT was 48.4 % (95 %CI: 30.8-66) and 80 % (95 %CI: 65.7-94.3), respectively.

CONCLUSIONS

In patients treated with CT/RT for locally advanced cervical cancer, despite limited performances to predict cervical residual disease, posttreatment FEDG-PET is predictive of patients' prognosis and long-term outcome.

Tumor radiomic heterogeneity: Multiparametric functional imaging to characterize variability and predict response following cervical cancer radiation therapy

BACKGROUND

Robust approaches to quantify tumor heterogeneity are needed to provide early decision support for precise individualized therapy.

PURPOSE

To conduct a technical exploration of longitudinal changes in tumor heterogeneity patterns on dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI) and FDG positron emission tomography / computed tomography (PET/CT), and their association to radiation therapy (RT) response in cervical cancer.

STUDY TYPE

Prospective observational study with longitudinal MRI and PET/CT pre-RT, early-RT (2 weeks), and mid-RT (5 weeks).

POPULATION

Twenty-one FIGO IB₂ -IVA cervical cancer patients receiving definitive external beam RT and brachytherapy.

FIELD STRENGTH/SEQUENCE

1.5T, precontrast axial T₁ -weighted, axial and sagittal T₂ -weighted, sagittal DWI (multi-b values), sagittal DCE MRI (<10 sec temporal resolution), postcontrast axial T₁ -weighted.

ASSESSMENT

Response assessment 1 month after completion of treatment by a board-certified radiation oncologist from manually delineated tumor volume changes.

STATISTICAL TESTS

Intensity histogram (IH) quantiles (DCE SI_10% and DWI ADC_10% , FDG-PET SUV_max ) and distribution moments (mean, variance, skewness, kurtosis) were extracted. Differences in IH features between timepoints and modalities were evaluated by Skillings-Mack tests with Holm's correction. Area under receiver-operating characteristic curve (AUC) and Mann-Whitney testing was performed to discriminate treatment response using IH features.

RESULTS

Tumor IH means and quantiles varied significantly during RT (SUV_mean : ↓28-47%, SUV_max : ↓30-59%, SI_mean : ↑8-30%, SI_10% : ↑8-19%, ADC_mean : ↑16%, P < 0.02 for each). Among IH heterogeneity features, FDG-PET SUV_CoV (↓16-30%, P = 0.011) and DW-MRI ADC_skewness decreased (P = 0.001). FDG-PET SUV_CoV was higher than DCE-MRI SI_CoV and DW-MRI ADC_CoV at baseline (P < 0.001) and 2 weeks (P = 0.010). FDG-PET SUV_kurtosis was lower than DCE-MRI SI_kurtosis and DW-MRI ADC_kurtosis at baseline (P = 0.001). Some IH features appeared to associate with favorable tumor response, including large early RT changes in DW-MRI ADC_skewness (AUC = 0.86).

DATA CONCLUSION

Preliminary findings show tumor heterogeneity was variable between patients, modalities, and timepoints. Radiomic assessment of changing tumor heterogeneity has the potential to personalize treatment and power outcome prediction.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1388-1396.

Effects of Treatment of Uterine Cervical Carcinoma Monitored by Magnetic Resonance Imaging - Sarajevo Experience

GOAL

The goal of this study was the determination of the effects in treatment of early stage (

MATERIAL AND METHODS

The study was a prospective, comparative, analytical, and observational and included 74 patients with cervical cancer (PH confirmed). All 74 patients have initially gone through the pre-therapeutic MRI to determine the tumour FIGO stage. At a renewal of the initial MRI findings, patients were divided into two study groups: group A and group B. Group A consisted from 39 patients with early-stage cervical carcinoma (

RESULTS

An analysis of treatment outcomes in group A showed that most patients had no local recurrence or residuum disease in 89.7%, while local recurrence was observed in only 10.3% cases. An analysis of treatment outcomes in group B showed that most patients had complete regression after local chemoradiotherapy in 68.8%, while 25.7% of patients had local progression of the disease, while the 5.7% cases recorded partial local tumour regression(p<0.05). It has been shown that a complete local regression was more frequent in the case of squamous cell carcinoma in 74.2% vs 25% in adenocarcinoma cases. Also local and partial regression was observed more frequently in the case of squamous cell carcinoma in 6.5% compared to 0% in adenocarcinoma, while progression was more common in adenocarcinoma at 75% compared to 19.4% for squamous cell (p<0.05). MRI results showed positive outcome of treatment group A and B in our study, showed a statistically significant difference in favour of group A (89.7%) compared to group B 68.8% (p<0.05).

CONCLUSION

The results obtained from our studies show that early stage cervical cancer ( Collapse

Key Words

• FIGO stage
• MRI
• cervical cancer
• oncology treatment
• surgical treatment

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Affiliation(s)

Amela Sofic Clinic of Radiology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Azra Husic-Selimovic Institute of Gastroenterohepatology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Nermina Beslic Clinic of Nuclear medicine, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Azra Rasic Oncology Clinic, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Dzenana Begic Oncology Clinic, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Anja Tomic-Cica Clinic of obstetrics and gynecology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Nejira Imsirevic Institute of Gastroenterohepatology, Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina

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A practical review of magnetic resonance imaging for the evaluation and management of cervical cancer

Cervical cancer is a leading cause of mortality in women worldwide. Staging and management of cervical cancer has for many years been based on clinical exam and basic imaging such as intravenous pyelogram and x-ray. Unfortunately, despite advances in radiotherapy and the inclusion of chemotherapy in the standard plan for locally advanced disease, local control has been unsatisfactory. This situation has changed only recently with the increasing implementation of magnetic resonance image (MRI)-guided brachytherapy. The purpose of this article is therefore to provide an overview of the benefits of MRI in the evaluation and management of cervical cancer for both external beam radiotherapy and brachytherapy and to provide a practical approach if access to MRI is limited.

Variability in clinical target volume delineation for intensity modulated radiation therapy in 3 challenging cervix cancer scenarios

PURPOSE

The purpose of this study was to assess variability in contouring the gross tumor volume (GTV) and clinical target volume (CTV) of 3 clinical cervix cancer cases by a cohort of international experts in the field in preparation for the development of an online teaching atlas.

METHODS AND MATERIALS

Twelve international experts participated. Three clinical scenarios: node positivity (PLN), retroverted uterus (RV), and parametrial invasion (PI) were used. Sagittal and axial magnetic resonance images of the clinical cases were downloaded to participants' treatment planning systems for contouring. The GTV/cervix/uterus/parametria/vagina and nodal CTV were contoured. Contour consensus was assessed for sensitivity/specificity using an expectation maximization algorithm called Simultaneous Truth and Performance Level Estimation and experts' overall agreement was summarized by kappa statistics.

RESULTS

Agreement for GTV in the 3 clinical cases was high (Simultaneous Truth and Performance Level Estimation sensitivity, 0.54-0.92; specificity, 0.97-0.98; and kappa measure for PLN, RV, and PI was 0.86, 0.76, and 0.42; P < .0001). Moderate to substantial agreement was seen for nodal CTV (kappa statistics for PLN, RV, and PI was 0.65, 0.58, and 0.62; P < .0001), uterus (kappa for PLN, RV, and PI was 0.45, 0.74, and 0.77; P < .0001), and parametria (kappa for PLN, RV, and PI was 0.49, 0.62, and 0.50; P < .0001). Contouring heterogeneity was greatest for the cervix (kappa measure for PLN, RV, and PI was 0.15, 0.4, and 0.24; P < .0001) and vagina (kappa for PLN, RV, and PI was 0.47, 0.36 and 0.46; P < .0001), reflecting difficulties in determining the interface between GTV and these tissues.

CONCLUSION

Kappa statistics of the different CTV components generally demonstrated moderate to substantial agreement among international experts in the field of gynecological radiation therapy. Further planning target volume margins accounting for organ motion and setup errors are a necessary addition to the CTV.

Laparoscopic Extrafascial Hysterectomy (Completion Surgery) After Primary Chemoradiation in Patients With Locally Advanced Cervical Cancer: Technical Aspects and Operative Outcomes

Objective

This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis.

Background

Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial.

Methods

Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response.

Results

From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21–77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4–10.2 cm). Estimated blood loss was 80 mL (range, 40–150 mL), and mean operative time was approximately 104 minutes (range, 75–130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1–4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = −0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence.

Conclusions

Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.