Uterine cervical carcinoma: preoperative staging with 3.0-T MR imaging--comparison with 1.5-T MR imaging

VEGFR2 targeted microbubble-based ultrasound molecular imaging improving the diagnostic sensitivity of microinvasive cervical cancer

BACKGROUND

The current diagnostic methods of microinvasive cervical cancer lesions are imaging diagnosis and pathological evaluation. Pathological evaluation is invasive and imaging approaches are of extremely low diagnostic performance. There is a paucity of effective and noninvasive imaging approaches for these extremely early cervical cancer during clinical practice. In recent years, ultrasound molecular imaging (USMI) with vascular endothelial growth factor receptor type 2 (VEGFR2) targeted microbubble (MB_VEGFR2) has been reported to improve the early diagnosis rates of breast cancer (including ductal carcinoma in situ), pancreatic cancer and hepatic micrometastases. Herein, we aimed to assess the feasibility of MB_VEGFR2-based USMI in extremely early cervical cancer detection to provide an accurate imaging modality for microinvasive cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) Stage IA1 and IA2).

RESULTS

We found MB_VEGFR2-based USMI could successfully distinguish extremely early lesions in diameter < 3 mm from surrounding normal tissues (all P < 0.05), and the sensitivity gradually decreased along with increasing tumor diameter. Moreover, normalized intensity difference (NID) values showed a good linear correlation with microvessel density (MVD) (R² = 0.75). In addition, all tumors could not be identified from surrounding muscles in subtracted ultrasound images when mice were administered MB_Con.

CONCLUSIONS

Overall, MB_VEGFR2-based USMI has huge potential for clinical application for the early detection of microinvasive cervical cancer (FIGO Stage IA1 and IA2), providing the foothold for future studies on the imaging screening of this patient population.

Revised FIGO Staging for Cervical Cancer - A New Role for MRI

Cervical cancer is still the fourth most common malignancy in women worldwide and has a high mortality rate. The prognosis as well as the therapy depends largely on the extent of the tumor at the time of initial diagnosis. This shows the importance of correct staging of cervical cancer. In order to promote a globally uniform approach, staging of cervical cancer in the past was based on widespread examinations such as exam under anesthesia, histology from cervical conization or biopsy, systematic lymphadenectomy, cystoscopy, proctoscopy, i. v.-pyelogram and chest X-ray. However, as the primary tumor stage was often underestimated, the 2018 revised FIGO classification now permits cross-sectional imaging techniques and pathological findings to be incorporated into disease staging or an already existing stage to be adapted based on radiological findings. Thanks to its excellent soft tissue contrast, magnetic resonance imaging (MRI) is the method of choice for local-regional staging of cervical cancer, evaluating the response to treatment, detecting tumor recurrence and for follow-up examinations. It is important that radiologists interpreting pelvic MRI in case of suspected cervical cancer are familiar with the current FIGO staging system. This is the only way to determine the tumor stage as precisely as possible and thus lay the foundation for the success of therapy for patients. The aim of this review is to present the changes of the revised FIGO classification as well as to show the importance of MRI as the method of choice for local-regional tumor staging as a complement to clinical examination. KEY POINTS::   · Cervical cancer is still the world's fourth most common female cancer and has a high mortality rate.. · The FIGO classification for staging cervical cancer in the past was based on clinical and widespread examinations.. · The primary tumor stage has often been underestimated with the FIGO staging system since 2018.. · Since 2018, cross-sectional imaging techniques have been incorporated into disease staging.. · MRI is the method of choice for local-regional tumor staging, evaluation of the response to treatment, detection of tumor recurrence and possible complications.. CITATION FORMAT: · Merz J, Bossart M, Bamberg F et al. Revised FIGO Staging for Cervical Cancer - A New Role for MRI. Fortschr Röntgenstr 2020; 192: 937 - 944.

Pretreatment Lymph Node Metastasis as a Prognostic Significance in Cervical Cancer: Comparison between Disease Status

PURPOSE

Lymph node metastasis (LNM) is the most significant prognostic factor in cervical cancer that was recently incorporated into the International Federation of Gynecology and Obstetrics (FIGO) staging system. This study was performed to evaluate whether the prognostic significance of LNM differs according to disease status.

MATERIALS AND METHODS

Patients with FIGO stage IB or higher cervical cancer who had pretreatment computed tomography and/or magnetic resonance imaging studies as well as long-term follow-up were enrolled in this retrospective study. The hazard ratio (HR) of Cox regression was used to determine the prognostic significance of LNM. The HRs were compared between the different tumor groups (based on stage, histology, tumor size, primary treatment, age, parametrium involvement, and lymphovascular space invasion).

RESULTS

A total of 970 patients treated between January 1999 and December 2007 were included. The pretreatment LNM had prognostic significance in patients with stage IB1/IIA (HR for progression-free survival 2.10, p=0.001; HR for overall survival 1.99, p=0.005). However, the significance gradually decreased or disappeared with advancing stages. Similarly, the prognostic significance of the pretreatment LNM decreased with advancing disease status, including old age, parametrial involvement or lymphovascular space involvement. In contrast, the tumor size was associated with the prognostic significance of LNM with advancing status. The significance of the clinical LNM did not reflect the significance of the clinical stage. In contrast, the tumor size, parametrial involvement, and significance of the pathologic LNM reflected the clinical stage.

CONCLUSION

In patients with cervical cancer, pretreatment LNM on imaging has different clinical significance depending on the tumor status.

Diagnostic Performance of MRI for Assessing Parametrial Invasion in Cervical Cancer: A Head-to-Head Comparison between Oblique and True Axial T2-Weighted Images

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.

Diagnostic performance of MR imaging in evaluating prognostic factors in patients with cervical cancer: a meta-analysis

OBJECTIVES

This study aims to determine the diagnostic performance of conventional magnetic resonance imaging (MRI) in assessing the distance between the tumor and the internal os, stromal infiltration, lymph node metastasis, and parametrial invasion in patients with cervical cancer.

METHODS

A systematic English-language literature search of conventional MRI in the evaluation of human cervical cancer was performed in the PubMed, Cochrane Library, Embase, and Web of Science databases from 1995 to 2018. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and positive and negative likelihood ratios (PLR and NLR) of all studies were calculated. The results were then plotted in a hierarchical summary receiver operating characteristic (HSROC) plot, and meta-regression and subgroup analyses of the parametrial invasion were also performed.

RESULTS

The pooled sensitivity, specificity, DOR, PLR, and NLR were 86%, 97%, 167.91, 24.74, and 0.15, respectively, in evaluating the internal os involvement (6 studies, 454 patients); 87%, 91%, 73.41, 10.22, and 0.14, respectively, in evaluating the stromal infiltration (11 studies, 672 patients); 51%, 89%, 8.63, 4.72, and 0.55, respectively, in evaluating the lymph node metastasis (15 studies, 997 patients); and 75%, 92%, 34.01, 9.38, and 0.28, respectively, in evaluating the parametrial invasion (19 studies, 1748 patients). The meta-regression of the parametrial invasion showed that the application of contrast enhancement was a significant factor affected the heterogeneity (p = 0.039).

CONCLUSIONS

Conventional MRI can accurately evaluate the distance between the tumor and the internal os, as well as stromal infiltration, and performs well in diagnosing the parametrial invasion. However, this method exhibited a limited ability in diagnosing the lymph node metastasis.

KEY POINTS

• MRI can help clinicians to accurately assess the distance between the tumor and the internal os, stromal infiltration, and parametrial invasion in patients with uterine cervical neoplasms. • MRI exhibits a limited ability in diagnosing the lymph node metastasis. • Management of patients with uterine cervical neoplasms becomes more appropriate.

Parametrial Involvement on Magnetic Resonance Imaging Has No Effect on the Survival of Early-Stage Cervical Cancer Patients

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.

Predicting Parametrial Invasion in Cervical Carcinoma (Stages IB1, IB2, and IIA): Diagnostic Accuracy of T2-Weighted Imaging Combined With DWI at 3 T

OBJECTIVE

The objective of our study was to retrospectively evaluate the efficacy of combined analysis of T2-weighted imaging and DWI in the diagnosis of parametrial invasion (PMI) in cervical carcinoma.

MATERIALS AND METHODS

The clinical records of 192 patients with cervical carcinoma who met the study requirements were reviewed for this retrospective study. The signal intensities of suspicious PMI tissue were assessed on T2-weighted images, DW images, and apparent diffusion coefficient maps independently by two experienced radiologists. The radiologist observers predicted the presence of PMI by scoring T2-weighted imaging alone and then by scoring T2-weighted imaging and DWI combined. The results were compared with histopathologic findings.

RESULTS

Histopathologic findings revealed PMI in 24 of 192 study subjects. In positively predicting the presence of PMI, T2-weighted imaging and DWI combined scored significantly better than T2-weighted imaging alone, as proven by high sensitivity (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 75.0% vs 83.3% [p = 0.477]; observer 2, 66.7% vs 91.7% [p < 0.05]), high specificity (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 84.5% vs 98.8% [p < 0.001]; observer 2, 85.7% vs 98.8% [p < 0.001]), and high accuracy (T2-weighted imaging alone vs T2-weighted imaging and DWI combined: observer 1, 83.3% vs 96.9% [p < 0.001]; observer 2, 83.3% vs 97.9% [p < 0.001]). The area under the ROC curve was also significantly higher for T2-weighted imaging and DWI combined (observer 1, 0.911; observer 2, 0.952) than for T2-weighted imaging alone (observer 1, 0.798; observer 2, 0.762). Although the interobserver agreement was good for T2-weighted imaging (κ = 0.695) and excellent for T2-weighted imaging and DWI combined (κ = 0.753), the improvement failed to achieve statistical significance (p = 0.28).

CONCLUSION

Combined analysis of T2-weighted imaging and DWI enhances the accuracy of diagnosing PMI in patients with cervical cancer compared with T2-weighted imaging alone.

Magnetic resonance imaging for detection of parametrial invasion in cervical cancer: An updated systematic review and meta-analysis of the literature between 2012 and 2016

OBJECTIVE

To review the diagnostic performance of MRI for detection of parametrial invasion (PMI) in cervical cancer patients.

METHODS

MEDLINE and EMBASE databases were searched for studies providing diagnostic performance of MRI for detecting PMI in patients with cervical cancer. Studies published between 2012 and 2016 using surgico-pathological results as reference standard were included. Study quality was evaluated using QUADAS-2. Sensitivity and specificity of all studies were calculated. Results were pooled and plotted in a hierarchical summary receiver operating characteristic plot. Meta-regression and subgroup analyses were performed.

RESULTS

Fourteen studies (1,028 patients) were included. Study quality was generally moderate. Pooled sensitivity was 0.76 (95% CI 0.67-0.84) and specificity was 0.94 (95% CI 0.91-0.95). The possibility of heterogeneity was considered low: Cochran's Q-test (p = 0.471), Tau² (0.240), Higgins I² (0%). With meta-regression analysis, magnet strength, use of DWI, and antispasmodic drugs were significant factors affecting heterogeneity (p < 0.01). Subgroup analysis for studies solely using radical hysterectomy as reference standard yielded pooled sensitivity and specificity of 0.73 (95% CI 0.60-0.83) and 0.93 (95% CI 0.90-0.95), respectively.

CONCLUSIONS

MRI shows good performance for detection of PMI in cervical cancer. Using 3-T scanners and DWI may improve diagnostic performance.

KEY POINTS

• MRI shows good performance for detection of parametrial invasion in cervical cancer. • Subgroup of studies using only radical hysterectomy showed consistent results. • Using 3-Tesla scanners and diffusion-weighted imaging may improve diagnostic performance.

PET/CT and MRI in the imaging assessment of cervical cancer

Imaging plays a central role in the evaluation of patients with cervical cancer and helps guide treatment decisions. The purpose of this pictorial review is to describe magnetic resonance (MR) imaging and positron emission tomography (PET)/computed tomography (CT) assessment of cervical cancer, including indications for imaging, important findings that may result in management change, as well as limitations of both modalities. The International Federation of Gynecology and Obstetrics cervical cancer staging system does not officially include imaging; however, the organization endorses the use of MR imaging and PET/CT in the management of patients with cervical cancer where these modalities are available. MR imaging provides the best visualization of the primary tumor and extent of soft tissue disease. PET/CT is recommended for assessment of nodal involvement, as well as distant metastases. Both MR imaging and PET/CT are used to follow patients post-treatment to assess for recurrence. This review focuses on the current MR imaging and PET/CT protocols, the utility of these modalities in assessing primary tumors and recurrences, with emphasis on imaging findings which change management and on imaging pitfalls to avoid. It is important to be familiar with the MR imaging and PET/CT appearance of the primary tumor and metastasis, as well as the imaging pitfalls, so that an accurate assessment of disease burden is made prior to treatment.

Current imaging strategies for the evaluation of uterine cervical cancer

Uterine cervical cancer still remains an important socioeconomic issue because it largely affects women of reproductive age. Prognosis is highly depended on extent of the disease at diagnosis and, therefore, accurate staging is crucial for optimal management. Cervical cancer is clinically staged, according to International Federation of Gynecology and Obstetrics guidelines, but, currently, there is increased use of cross sectional imaging modalities [computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT)] for the study of important prognostic factors like tumor size, parametrial invasion, endocervical extension, pelvic side wall or adjacent/distal organs involvement and lymph node status. Imaging indications also include cervical cancer follow-up, evaluation of tumor response to treatment and selection of suitable candidates for less radical surgeries like radical trachelectomy for fertility preservation. The preferred imaging method for local cervical cancer evaluation is MRI; CT is equally effective for evaluation of extrauterine spread of the disease. PET-CT shows high diagnostic performance for the detection of tumor relapse and metastatic lymph nodes. The aim of this review is to familiarize radiologists with the MRI appearance of cervical carcinoma and to discuss the indications of cross sectional imaging during the course of the disease in patients with cervical carcinoma.

Comparison of optimised endovaginal vs external array coil T2-weighted and diffusion-weighted imaging techniques for detecting suspected early stage (IA/IB1) uterine cervical cancer

OBJECTIVE

To compare sensitivity and specificity of endovaginal versus external-array coil T2-W and T2-W + DWI for detecting and staging small cervical tumours.

METHODS

Optimised endovaginal and external array coil MRI at 3.0-T was done prospectively in 48 consecutive patients with stage Ia/Ib1 cervical cancer. Sensitivity/specificity for detecting tumour and parametrial extension against histopathology for a reading radiologist were determined on coronal T2-W and T2W + DW images. An independent radiologist also scored T2-W images without and with addition of DWI for the external-array and endovaginal coils on separate occasions >2 weeks apart. Cohen's kappa assessed inter- and intra-observer agreement.

RESULTS

Median tumour volume in 19/38 cases positive on subsequent histology was 1.75 cm(3). Sensitivity, specificity, PPV, NPV were: reading radiologist 91.3 %, 89.5 %, 91.3 %, 89.5 %, respectively; independent radiologist T2-W 82.6 %, 73.7 %, 79.1 %, 77.8 % for endovaginal, 73.9 %, 89.5 %, 89.5 %, 73.9 % for external-array coil. Adding DWI improved sensitivity and specificity of endovaginal imaging (78.2 %, 89.5 %); adding DWI to external-array imaging improved specificity (94.7 %) but reduced sensitivity (66.7 %). Inter- and intra-observer agreement on T2-W + DWI was good (kappa = 0.67 and 0.62, respectively).

CONCLUSION

Endovaginal coil T2-W MRI is more sensitive than external-array coil for detecting tumours <2 cm(3); adding DWI improves specificity of endovaginal imaging but reduces sensitivity of external-array imaging.

KEY POINTS

• Endovaginal more accurate than external-array T2-W MRI for detecting small cervical cancers. • Addition of DWI improves sensitivity and specificity of endovaginal T2-W imaging. • Addition of DWI substantially reduces sensitivity of external-array T2-W imaging.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Advanced MRI in malignant neoplasms of the uterus

Conventional magnetic resonance imaging (MRI) such as T1-weighted and T2-weighted images of the female pelvis provide morphological information with excellent tissue contrast, which reflects the pathology of malignant diseases of the uterus. Owing to the recent improvement in hardware and software, in combination with extensive research in imaging techniques, not only MRI at higher magnetic field was facilitated, but also insight into tumor pathophysiology was provided. These methods include diffusion-weighted imaging (DWI), dynamic contrast-enhanced MRI (DCE-MRI) with pharmacokinetic analysis, and MR spectroscopy (MRS). The application of these techniques is expanding from the brain to the body because information on the tissue microenvironment and cytoarchitecture is helpful for lesion characterization, evaluation of treatment response after chemotherapy or radiation, differentiating posttherapeutic changes from residual active tumor, and for detecting recurrent cancer. These techniques may provide clues to optimize the treatment of patients with malignant diseases of the uterus. In the first half of this article we provide an overview of the technical aspects of MRI of the female pelvis, especially focusing on the state-of-the-art techniques such as 3 T MRI, DCE-MRI, DWI, etc. For the latter half we review the clinical aspects of these newly developed techniques, focusing on how these techniques are applicable, what has been revealed with respect to clinical impact, and the remaining problems.

Clinical examination versus magnetic resonance imaging in the pretreatment staging of cervical carcinoma: systematic review and meta-analysis

OBJECTIVES

To review the literature on the diagnostic performance of clinical examination and magnetic resonance imaging (MRI) in detecting parametrial invasion and advanced stage disease (FIGO stage ≥ IIB) in patients with cervical carcinoma.

METHODS

Reports of studies were searched using the MEDLINE, EMBASE and Cochrane databases. Two observers reported on data relevant for analysis and methodological quality using the QUADAS scoring system. Publication bias was analysed using Deeks funnel plots. Covariates were added to the model to study the influence on the summary results of the technical and methodological aspects of the clinical examination and MRI.

RESULTS

In total, 3,254 patients were included. Partial verification bias was often encountered. Pooled sensitivity was 40 % (95 % CI 25-58) for the evaluation of parametrial invasion with clinical examination and 84 % (95 % CI 76-90) with MRI, 53 % (95 % CI 41-66) for the evaluation of advanced disease with clinical examination, and 79 % (95 % CI 64-89) with MRI. Pooled specificities were comparable between clinical examination and MRI. Different technical aspects of MRI influenced the summary results.

CONCLUSIONS

MRI is significantly better than clinical examination in ruling out parametrial invasion and advanced disease in patients with cervical carcinoma.

KEY POINTS

• MRI has a higher sensitivity than clinical examination for staging cervical carcinoma. • Clinical examination and MRI have comparably high specificity for staging cervical carcinoma. • Quality of clinical examination studies was lower than that of MRI studies. • The use of newer MRI techniques positively influences the summary results. • Anaesthesia during clinical examination positively influences the summary results.

The value of diffusion-weighted magnetic resonance imaging in assessing the response of locally advanced cervical cancer to neoadjuvant chemotherapy

OBJECTIVE

The objective of this study was to investigate whether magnetic resonance diffusion-weighted imaging (DWI) of locally advanced cervical cancer (LACC) both in the sagittal and axial planes could be used to assess the response of LACC to neoadjuvant chemotherapy (NACT).

METHODS

Thirty women with LACC received conventional magnetic resonance imaging and DWI at 3 different times (before NACT, 2 weeks after the first NACT, and 2 weeks after the second NACT). Treatment response was determined according to the change in tumor size 2 weeks after the second NACT, and they were classified as the effective group and the ineffective group. The apparent diffusion coefficients (ADCs) were compared between 2 imaging planes, and dynamic changes in ADCs were observed in different chemotherapy-sensitive groups and imaging planes. One-way analysis of variance was calculated between those ADC parameters and tumor response.

RESULTS

The effective chemotherapy rate was 76.67%. Apparent diffusion coefficient values of the axial plane at 3 different times were 0.88 (SD, 0.08) × 10⁻³ mm²/s, 0.96 (SD, 0.10) × 10⁻³ mm²/s, and 1.19 (SD, 0.11) × 10⁻³ mm²/s, respectively. Meanwhile, ADC values of the sagittal planes were 0.89 (SD, 0.09) × 10⁻³ mm²/s, 0.97 (SD, 0.12) × 10⁻³ mm²/s, and 1.19 (SD, 0.12) × 10⁻³ mm²/s at 3 different stages. There were no statistical differences between the ADC values of the 2 planes at 3 different times (P = 0.927, P = 0.863, P = 0.946). Apparent diffusion coefficients 2 weeks after the first NACT were significantly increased compared with those before chemotherapy both in the axial and sagittal planes (P = 0.003, P = 0.012). In the ineffective group, ADCs 2 weeks after the first NACT were not statistically higher than those before chemotherapy (axial planes, P = 0.694; sagittal planes, P = 0.900). After 2 weeks of the first NACT, ADCs in both planes were obviously increased in the effective group than those in the ineffective group (P = 0.043, P = 0.022).

CONCLUSIONS

The axial and sagittal DWI may detect the changes in LACC after therapy. Apparent diffusion coefficient values measured both in the 2 planes may be used to evaluate the response of LACC to NACT.

Molecular imaging in the management of cervical cancer

Positron emission tomography (PET), magnetic resonance imaging (MRI), and integrated 18-fluorodeoxyglucose ((18)F-FDG) PET/computed tomography are valuable techniques for assessing prognosis, treatment response after the completion of concurrent chemoradiation, suspicious or documented recurrence, unexplained post therapy elevations in tumor markers, and the response to salvage treatment when managing cervical cancer. However, PET plays a limited role in the primary staging of MRI-defined node-negative patients. Currently, (18)F-FDG is still the only tracer approved for routine use, but several novel targeting PET compounds, high-Tesla MRI machines, diffusion-weighted imaging without contrast, and dynamic nuclear polarized-enhanced (13)C-MR spectroscopic imaging may hold promising applications.

Apparent diffusion coefficients of normal uterus in premenopausal women with 3.0-T magnetic resonance imaging

PURPOSE

To investigate the apparent diffusion coefficients (ADCs) of the normal uterine zonal structures (myometrium, endometrium, and junctional zone) during different phases of the menstrual cycle among premenopausal women with different age groups.

MATERIALS AND METHODS

Magnetic resonance (MR) images of 67 healthy women were obtained during the midproliferative and midsecretory phases. They were further divided into 3 age groups: group A (age range, 20-29 years); group B (age range, 30-39 years), and group C (mean age, 44.62 years; age range, 40-49 years). All the women underwent 3.0-T MR scanning twice. The ADC values were compared among each uterine zonal structure and 3 age groups and were calculated between the midproliferative and midsecretory phase.

RESULTS

The ADC values among each uterine zonal structures were significantly different from one another (P < 0.001). The ADC values for endometrium in women in their 30s were higher than those in their 20s and in their 30s during the midproliferative and midsecretory phases (P < 0.05), and the ADC values for endometrium in each age groups were lower during the midproliferative phase than those during the midsecretory phase (P < 0.05), but there were no statistical differences in the myometrium and the junctional zone between the 2 phases or among age groups (P > 0.05).

CONCLUSION

These preliminary results suggested that the zone, age, and phase of the menstrual cycle in premenopausal women should be considered when interpreting the ADC values of uterine structures (especially for endometrium).

Diagnosis of lymph node metastasis in uterine cervical cancer: usefulness of computer-aided diagnosis with comprehensive evaluation of MR images and clinical findings

BACKGROUND

Lymph node (LN) status is an important parameter for determining the treatment strategy and for predicting the prognosis for patients with uterine cervical cancer. Computer-aided diagnosis (CAD) can be feasible for differentiating metastatic from non-metastatic lymph nodes in patients with uterine cervical cancer.

PURPOSE

To determine the usefulness of CAD that comprehensively evaluates MR images and clinical findings for detecting LN metastasis in uterine cervical cancer.

MATERIAL AND METHODS

In 680 LNs from 143 patients who underwent radical hysterectomy for uterine cervical cancer, the CAD system using the Bayesian classifier estimated the probability of metastasis based on MR findings and clinical findings. We compared the diagnostic accuracy for detecting metastatic LNs in the CAD and MR findings.

RESULTS

Metastasis was diagnosed in 70 (12%) LNs from 34 (24%) patients. The area under ROC curves of CAD (0.924) was greater than those of the mean ADC (0.854), minimum ADC (0.849), maximum ADC (0.827), short-axis diameter (0.856) and long-axis diameter (0.753) (P < 0.05). The specificity and accuracy of the CAD (86%, 86%) were greater than those of the mean ADC (77%, 77%), maximum ADC (77%, 77%), minimum ADC (68%, 70%), and short-axis diameter (65%, 67%) (P < 0.05).

CONCLUSION

CAD system can improve the diagnostic performance of MR for detecting metastatic LNs in uterine cervical cancer.

The value of MR imaging when the site of uterine cancer origin is uncertain

PURPOSE

To assess the value of magnetic resonance (MR) imaging in determining the site of origin of newly diagnosed uterine cancer (corpus vs cervix) when clinical and/or histologic evaluation is indeterminate.

MATERIALS AND METHODS

The Institutional Review Board approved and waived informed consent for this HIPAA-compliant study of 59 women (median age, 59 years; range, 28-84 years) who underwent pelvic MR imaging to determine the anatomic origin of uterine cancer. Two radiologists independently retrospectively assessed all MR imaging studies. In 48 patients who underwent hysterectomy, surgical pathologic findings were the reference standard, and overall test yields and diagnostic likelihood ratios were measured. Accuracy in detecting invasion of adjacent structures was also calculated. For the remaining patients, imaging and biopsy findings are presented descriptively.

RESULTS

At hysterectomy, 32 patients had uterine corpus cancer and 16 had cervical cancer. Overall test yields for reader 1 and reader 2 were 0.85 and 0.88, respectively. When a reader attributed a tumor's origin to either the uterine corpus or cervix, the odds of the tumor originating from that site were 4.80-6.35 times greater than they would have been if no other information were available. Accuracy levels in detecting invasion of the myometrium, cervical stroma, parametria and/or adnexae, and vagina, respectively, were 72%, 69%, 74%, and 85% for reader 1 and 78%, 77%, 76%, and 85% for reader 2.

CONCLUSION

MR imaging is useful for determining the anatomic origin of uterine cancer and provides helpful information regarding invasion of adjacent structures.

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

OBJECTIVE

To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences.

METHODS

Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature.

RESULTS

The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy.

CONCLUSIONS

Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Cancer imaging: novel concepts in clinical magnetic resonance imaging

Cancer is a major public health problem in the Western world. Imaging is of crucial importance in oncology, because it may reduce cancer-related morbidity and mortality. To improve tumour evaluation, there is a need for functional imaging modalities that go beyond gross assessment of anatomical abnormalities and allow visualization and quantification of biochemical processes in vivo. Magnetic resonance imaging (MRI) not only provides anatomical information, but also offers a wide range of functional sequences that may aid the evaluation of cancerous lesions. Furthermore, MRI provides the opportunity to guide and monitor anticancer therapies noninvasively. The aim of this review is to highlight some of the most promising developments of MRI in the functional assessment of cancer and the guidance and monitoring of (novel) anticancer therapies.

Resectability rates of previously irradiated recurrent cervical cancer (PIRCC) treated with pelvic exenteration: is still the clinical involvement of the pelvis wall a real contraindication? a twenty-year experience

OBJECTIVE

(1) To determine the accuracy of a standard clinical and radiological assessment of resectability in patients with previously irradiated recurrent cervical cancer (PIRCC), and (2) to report the outcome and prognostic factors in this high-risk population treated with an exenterative procedure.

METHODS

Forty-eight patients with centrally located (n=20, 41.7%) or lateralized (n=28, 58.3%) PIRCC treated with exenterative procedures were analyzed. All patients underwent standard assessment of resectability with pelvic exam and radiological studies. Patients with centrally located tumors were considered as resectable and lateralized tumors were deemed unresectable.

RESULTS

Complete surgical resection with negative margins (R0) was achieved in 28.6% of the patients with lateral recurrences and in 65.0% of the patients with central recurrences (p<0.019). After a median follow-up of 114.6 months (3.0-244.9 months), the 10-year local control rate for the whole group was 36.3%, 43.1% in the central PIRCC group and 31.5% in the lateral PIRCC group, respectively (p=0.290). Multivariate analysis showed that improved local control was significantly associated with the presence of negative margins (p=0.004). The 10-year distant failure rate was 69%, 56.6% in the central PIRCC group and 83.2% in the lateral PIRCC group (p=0.178), respectively. Multivariate analysis showed that the development of distant metastases was significantly correlated with the absence of local control (p=0.01). The 10-year disease-specific survival (DSS) for central and lateral PIRCC was 27.2% and 14.9%, respectively (p=0.239). Multivariate analysis showed that negative margins (p=0.001), local control (p=0.001) and distant control (p=0.006) were all significantly associated with improved DSS. Location of PIRCC (central vs. lateral) was irrelevant for DSS in completely resected (R0) patients. Overall morbidity rate was 65.0% and 73.3% for central and lateral PIRCC patients, respectively (p=0.528).

CONCLUSION

About one-third of the patients with lateral PIRCC classified as unresectable with non-surgical means may ultimately undergo complete (R0) resections and about one-third of the patients with centrally located PIRCC and judged as resectable will undergo non-curative (R1) resections. A curative (R0) resection significantly impacts local control rates, distant metastases-free rates and DSS.

MR imaging of endometrial carcinoma for preoperative staging at 3.0 T: comparison with imaging at 1.5 T

PURPOSE

To prospectively compare magnetic resonance imaging (MRI) at 3.0 T and 1.5 T in the same patients for preoperative evaluation of endometrial carcinoma.

MATERIALS AND METHODS

Thirty consecutive patients with endometrial carcinoma underwent MRI at both 3.0 T and 1.5 T as well as surgery. Quantitative and qualitative analyses were performed. Two radiologists independently evaluated images. MR findings were compared with surgicopathologic findings.

RESULTS

Image homogeneity of T2-weighted images at 3.0 T was significantly inferior to that at 1.5 T (P = 0.007). The scores of image homogeneity and susceptibility artifacts were not significantly different between 3.0 T gadolinium-enhanced imaging and 1.5 T imaging (P = 0.09 and 0.36). Kappa statistics showed good interobserver agreement between the two radiologists for local-regional staging on T2-weighted images (kappa>0.6). The area under the receiver operating characteristic curve (Az) values for T2-weighted imaging in terms of myometrial invasion, cervical invasion, and lymph node metastases were 0.88 (3.0 T) versus 0.91 (1.5 T), 0.84 versus 0.83, and 0.94 versus 0.95 for reader 1, respectively. There were no significant differences between imaging at 3.0 T and at 1.5 T in Az values for either reader (P > 0.35).

CONCLUSION

3.0 T MRI is an equivalent imaging modality to 1.5 T imaging for presurgical evaluation of endometrial carcinoma, although not significantly superior to 1.5 T imaging.