Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies

Endometrial carcinoma with cervical stromal invasion: Three case reports

BACKGROUND

Endometrial cancer is a kind of well-known tumors of female genitourinary system. Cervical stromal invasion is an adverse factor for poor prognosis of endometrial cancer. There is still controversy regarding the use of magnetic resonance imaging (MRI) in the diagnosis of cervical stromal invasion of endometrial cancer. The diagnosis of cervical stromal invasion varies significantly between different observers and institutions. We present a limited case series of the particular pattern of endometrial cancer, which infiltrates the cervical stroma and is often overlooked.

CASE SUMMARY

We present three cases of endometrial carcinoma with cervical stromal invasion with cancer-free uterine cavity. One patient, a reproductive-aged woman, exhibited irregular menstruation and was diagnosed with endometrial polyps by hysteroscopy and segmental curettage. A MRI scan revealed polypoid nodules within the internal cervical orifice. The other two cases were postmenopausal women who presented with abnormal vaginal bleeding. Hysteroscopy and segmental curettage suggested atypical hyperplasia of the endometrium. MRI scans did not detect any malignant signs in the endometrium. In one case, a non-thickened endometrium was observed, while in another, hyperplasia of the endometrium was seen. Notably, none of these patients had malignant tumors identified in the uterine cavity via MRI scans. However, postoperative pathological results following hysterectomy consistently indicated cervical stromal invasion.

CONCLUSION

Cervical stromal invasion is easily missed if no cancer is found in the uterine body on MRI. Immunohistochemistry of endoscopic curettage specimens should be conducted to avoid underestimation of the disease.

An Update on the Role of MRI in Treatment Stratification of Patients with Cervical Cancer

Cervical cancer is the fourth most common cancer in women worldwide and the most common gynaecological malignancy. The FIGO staging system is the most commonly utilised classification system for cervical cancer worldwide. Prior to the most recent update in the FIGO staging in 2018, the staging was dependent upon clinical assessment alone. Concordance between the surgical and clinical FIGO staging decreases rapidly as the tumour becomes more advanced. MRI now plays a central role in patients diagnosed with cervical cancer and enables accurate staging, which is essential to determining the most appropriate treatment. MRI is the best imaging option for the assessment of tumour size, location, and parametrial and sidewall invasion. Notably, the presence of parametrial invasion precludes surgical options, and the patient will be triaged to chemoradiotherapy. As imaging is intrinsic to the new 2018 FIGO staging system, nodal metastases have been included within the classification as stage IIIC disease. The presence of lymph node metastases within the pelvis or abdomen is associated with a poorer prognosis, which previously could not be included in the staging classification as these could not be reliably detected on clinical examination. MRI findings corresponding to the 2018 revised FIGO staging of cervical cancers and their impact on treatment selection will be described.

Gynecologic oncology tumor board: the central role of the radiologist

This manuscript is a collaborative, multi-institutional effort by members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focus Panel and the European Society of Urogenital Radiology Women Pelvic Imaging working group. The manuscript reviews the key role radiologists play at tumor board and highlights key imaging findings that guide management decisions in patients with the most common gynecologic malignancies including ovarian cancer, cervical cancer, and endometrial cancer.

Radiomics-based fertility-sparing treatment in endometrial carcinoma: a review

In recent years, with the increasing incidence of endometrial carcinoma in women of child-bearing age, to decision of whether to preserve patients' fertility during treatment has become increasingly complex, presenting a formidable challenge for both physicians and patients. Non-fertility-sparing treatment can remove lesions more thoroughly than fertility-sparing treatment. However, patients will permanently lose their fertility. In contrast, fertility-sparing treatment can treat tumors without impairing fertility, but the risk of disease progression is high as compared with non-fertility-sparing treatment. Therefore, it is extremely important to accurately identify patients who are suitable for fertility-sparing treatments. The evaluation of prognostic factors, including myometrial invasion, the presence of lymph node metastases, and histopathological type, is vital for determining whether a patient can receive fertility-sparing treatment. As a non-invasive and quantitative approach, radiomics has the potential to assist radiologists and other clinicians in determining more precise judgments with regard to the above factors by extracting imaging features and establishing predictive models. In this review, we summarized currently available fertility-sparing strategies and reviewed the performance of radiomics in predicting risk factors associated with fertility-sparing treatment. This review aims to assist clinicians in identifying patients suitable for fertility-sparing treatment more accurately and comprehensively and informs more appropriate and rigorous treatment decisions for endometrial cancer patients of child-bearing age.Critical relevance statement: Radiomics is a promising tool that may assist clinicians identify risk factors about fertility-sparing more accurately and comprehensively.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

Diagnostic accuracy of MRI for evaluating myometrial invasion in endometrial cancer: a comparison of MUSE-DWI, rFOV-DWI, and DCE-MRI

OBJECTIVES

To compare the image quality of high-resolution diffusion-weighted imaging (DWI) using multiplexed sensitivity encoding (MUSE) versus reduced field-of-view (rFOV) techniques in endometrial cancer (EC) and to compare the diagnostic performance of these techniques with that of dynamic contrast-enhanced (DCE) MRI for assessing myometrial invasion of EC.

METHODS

MUSE-DWI and rFOV-DWI were obtained preoperatively in 58 women with EC. Three radiologists assessed the image quality of MUSE-DWI and rFOV-DWI. For 55 women who underwent DCE-MRI, the same radiologists assessed the superficial and deep myometrial invasion using MUSE-DWI, rFOV-DWI, and DCE-MRI. Qualitative scores were compared using the Wilcoxon signed-rank test. Receiver operating characteristic analysis was performed to compare the diagnostic performance.

RESULTS

Artifacts, sharpness, lesion conspicuity, and overall quality were significantly better with MUSE-DWI than with rFOV-DWI (p < 0.05). The area under the curve (AUC) of MUSE-DWI, rFOV-DWI, and DCE-MRI for the assessment of myometrial invasion were not significantly different except for significantly higher AUC of MUSE-DWI than that of DCE-MRI for superficial myometrial invasion (0.76 for MUSE-DWI and 0.64 for DCE-MRI, p = 0.049) and for deep myometrial invasion (0.92 for MUSE-DWI and 0.80 for DCE-MRI, p = 0.022) in one observer, and that of rFOV-DWI for deep myometrial invasion in another observer (0.96 for MUSE-DWI and 0.89 for rFOV-MRI, p = 0.048).

CONCLUSION

MUSE-DWI exhibits better image quality than rFOV-DWI. MUSE-DWI and rFOV-DWI shows almost equivalent diagnostic performance compared to DCE-MRI for assessing superficial and deep myometrial invasion in EC although MUSE-DWI may be helpful for some radiologists.

Neoadjuvant chemotherapy induces an elevation of tumour apparent diffusion coefficient values in patients with ovarian cancer

OBJECTIVES

Multiparametric magnetic resonance imaging (mMRI) is the modality of choice in the imaging of ovarian cancer (OC). We aimed to investigate the feasibility of different types of regions of interest (ROIs) in the measurement of apparent diffusion coefficient (ADC) values of diffusion-weighted imaging in OC patients treated with neoadjuvant chemotherapy (NACT).

METHODS

We retrospectively enrolled 23 consecutive patients with advanced OC who had undergone NACT and mMRI. Seventeen of them had been imaged before and after NACT. Two observers independently measured the ADC values in both ovaries and in the metastatic mass by drawing on a single slice of (1) freehand large ROIs (L-ROIs) covering the solid parts of the whole tumour and (2) three small round ROIs (S-ROIs). The side of the primary ovarian tumour was defined. We evaluated the interobserver reproducibility and statistical significance of the change in tumoural pre- and post-NACT ADC values. Each patient's disease was defined as platinum-sensitive, semi-sensitive, or resistant. The patients were deemed either responders or non-responders.

RESULTS

The interobserver reproducibility of the L-ROI and S-ROI measurements ranged from good to excellent (ICC range: 0.71-0.99). The mean ADC values were significantly higher after NACT in the primary tumour (L-ROI p  < 0.001, S-ROIs p < 0.01), and the increase after NACT was associated with sensitivity to platinum-based chemotherapy. The changes in the ADC values of the omental mass were associated with a response to NACT.

CONCLUSION

The mean ADC values of the primary tumour increased significantly after NACT in the OC patients, and the amount of increase in omental mass was associated with the response to platinum-based NACT. Our study indicates that quantitative analysis of ADC values with a single slice and a whole tumour ROI placement is a reproducible method that has a potential role in the evaluation of NACT response in patients with OC.

TRIAL REGISTRATION

Retrospectively registered (institutional permission code: 5302501; date of the permission: 31.7.2020).

A practical spatial analysis method for elucidating the biological mechanisms of cancers with abdominal dissemination in vivo

Elucidation of spatial interactions between cancer and host cells is important for the development of new therapies against disseminated cancers. The aim of this study is to establish easy and useful method for elucidating spatial interactions. In this study, we developed a practical spatial analysis method using a gel-based embedding system and applied it to a murine model of cancer dissemination. After euthanization, every abdominal organ enclosed in the peritoneum was extracted en bloc. We injected agarose gel into the peritoneal cavities to preserve the spatial locations of the organs, including their metastatic niches, and then produced specimens when the gel had solidified. Preservation of the original spatial localization was confirmed by correlating magnetic resonance imaging results with the sectioned specimens. We examined the effects of spatial localization on cancer hypoxia using immunohistochemical hypoxia markers. Finally, we identified the mRNA expression of the specimens and demonstrated the applicability of spatial genetic analysis. In conclusion, we established a practical method for the in vivo investigation of spatial location-specific biological mechanisms in disseminated cancers. Our method can elucidate dissemination mechanisms, find therapeutic targets, and evaluate cancer therapeutic effects.

O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee

MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the number of false-positive diagnoses for malignancy and thereby avoiding unnecessary or over-extensive surgery in patients with benign lesions or borderline tumors, while women with possible malignancies can be expeditiously referred for oncologic surgical evaluation. The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee is an international collaborative effort formed under the direction of the American College of Radiology and includes a diverse group of experts on adnexal imaging and management who developed the O-RADS MRI risk stratification system. This scoring system assigns a probability of malignancy based on the MRI features of an adnexal lesion and provides information to facilitate optimal patient management. The widespread implementation of a codified reporting system will lead to improved interpretation agreement and standardized communication between radiologists and referring physicians. In addition, it will allow for high-quality multi-institutional collaborations-an important unmet need that has hampered the performance of high-quality research in this area in the past. This article provides guidelines on using the O-RADS MRI risk stratification system in clinical practice, as well as in the educational and research settings.

[Adnexal Masses: Clinical Application of Multiparametric MR Imaging & O-RADS MRI]

Incidental adnexal masses considered indeterminate for malignancy are commonly observed on ultrasonography. Multiparametric MRI is the imaging modality of choice for the evaluation of sonographically indeterminate adnexal masses. Conventional MRI enables a confident pathologic diagnosis of various benign lesions due to accurate tissue characterization of fat, blood, fibrous tissue, and solid components. Additionally, functional imaging sequences, including perfusion- and diffusion-weighted imaging, improve the diagnostic efficacy of conventional MRI in differentiating benign from malignant adnexal masses. The ovarian-adnexal reporting and data system (O-RADS) MRI was recently designed to provide consistent interpretations in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. In this review, we describe the clinical application of multiparametric MRI for the evaluation of adnexal masses and introduce the O-RADS MRI risk stratification system.

The role of MRI in cervical cancer > 2 cm (FIGO stage IB2-IIA1) conservatively treated with neoadjuvant chemotherapy followed by conization: a pilot study

Introduction

MRI is very accurate in selecting young women with cervical cancer for fertility-sparing surgery (FSS), in particular radical hysterectomy (RH). In order to improve obstetrical outcomes, neoadjuvant chemotherapy (NACT) followed by cold knife conization (CKC) has been proposed as alternative technique.

Objective

To investigate the role of MRI in evaluation of response to treatment after neoadjuvant chemotherapy (NACT), followed by CKC, in patients with cervical cancer FIGO stage IB2-IIA1 with tumor size 2 – 4 cm, desiring to preserve their fertility.

Methods

13 young women (23–36 years old) with cervical cancer stage IB2-IIA1 desiring to preserve their fertility were included. Tumor diameter at baseline and after treatment was detected on 1.5 T MRI. Treatment response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and then compared to histopathology result.

Results

MRI correctly assessed 11 out of 13 cases, according to RECIST 1.1, compared to histopathology. Among these 7 patients with partial response (PR), 2 cases of CR, 1 SD and 1 PD with persistence or enlargement of primary tumor.

Conclusion

Our pilot study supports the usefulness of MRI in assessment of treatment response after NACT, followed by CKC.

Trial registration number

ClinicalTrials.gov: NCT02323841

Implications of the new FIGO staging and the role of imaging in cervical cancer

International Federation of Gynecology and Obstetrics (FIGO) staging, which is the fundamentally important cancer staging system for cervical cancer, has changed in 2018. New FIGO staging includes considerable progress in the incorporation of imaging findings for tumour size measurement and evaluating lymph node (LN) metastasis in addition to tumour extent evaluation. MRI with high spatial resolution is expected for tumour size measurements and the high accuracy of positron emmision tomography/CT for LN evaluation. The purpose of this review is firstly review the diagnostic ability of each imaging modality with the clinical background of those two factors newly added and the current state for LN evaluation. Secondly, we overview the fundamental imaging findings with characteristics of modalities and sequences in MRI for accurate diagnosis depending on the focus to be evaluated and for early detection of recurrent tumour. In addition, the role of images in treatment response and prognosis prediction is given with the development of recent technique of image analysis including radiomics and deep learning.

Ovary: MRI characterisation and O-RADS MRI

Ultrasound has a high specificity for the diagnosis of a benign lesion in cases of classic appearing simple cyst, hemorrhagic cyst, endometrioma and dermoid. However, ultrasound can sometimes be limited for definitive characterisation and risk stratification of other types of lesions, including those with echogenic content that may appear solid, with or without blood flow. Frequently, MRI can be used to further characterise these types of lesions, due to its ability to distinguish solid tissue from non-tissue solid components such as fat, blood, or debris. Incorporating the MR imaging into the evaluation of adnexal lesions can improve diagnostic certainty and guide clinical management potentially avoiding inappropriate surgery for benign lesions and expediting appropriate treatment for malignant lesions, particularly in the females with sonographically indeterminate adnexal lesions.

Staging, recurrence and follow-up of uterine cervical cancer using MRI: Updated Guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018

OBJECTIVES

The recommendations cover indications for MRI examination including acquisition planes, patient preparation, imaging protocol including multi-parametric approaches such as diffusion-weighted imaging (DWI-MR),  dynamic contrast-enhanced imaging (DCE-MR) and standardised reporting. The document also underscores the value of whole-body 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) and highlights potential future methods.

METHODS

In 2019, the ESUR female pelvic imaging working group reviewed the revised 2018 FIGO staging system, the up-to-date clinical management guidelines, and the recent imaging literature. The RAND-UCLA Appropriateness Method (RAM) was followed to develop the current ESUR consensus guidelines following methodological steps: literature research, questionnaire developments, panel selection, survey, data extraction and analysis.

RESULTS

The updated ESUR guidelines are recommendations based on ≥ 80% consensus among experts. If ≥ 80% agreement was not reached, the action was indicated as optional.

CONCLUSIONS

The present ESUR guidelines focus on the main role of MRI in the initial staging, response monitoring and evaluation of disease recurrence. Whole-body FDG-PET plays an important role in the detection of lymph nodes (LNs) and distant metastases.

KEY POINTS

• T2WI and DWI-MR are now recommended for initial staging, monitoring of response and evaluation of recurrence. • DCE-MR is optional; its primary role remains in the research setting. • T2WI, DWI-MRI and whole-body FDG-PET/CT enable comprehensive assessment of treatment response and recurrence.

Imaging modalities in fertility preservation in patients with gynecologic cancers

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.

2018 FIGO Staging Classification for Cervical Cancer: Added Benefits of Imaging

Cervical cancer is the fourth most common cancer in women of all ages worldwide. The disease is staged using the International Federation of Gynecology and Obstetrics (FIGO) system, which was updated in 2018. The authors explain the key changes from the 2009 version and the rationale behind them. The changes have been made to reflect common clinical practice, differentiate prognostic outcomes, and guide treatment stratification. Treatment options are dependent on the stage of disease and include fertility-sparing and non-fertility-sparing surgical options as well as chemoradiotherapy for locally advanced disease. The updated FIGO staging gives added importance to MRI as a method of accurately measuring tumor size and depicting the presence of parametrial involvement. With the inclusion of lymph node involvement in the updated 2018 FIGO staging, cross-sectional imaging-and in particular, fluorodeoxyglucose PET/CT-has an increasing role in the depiction of nodal disease. Understanding the radiologic techniques used, the literature supporting them, and common imaging pitfalls ensures accurate staging of disease and optimization of treatment. ^©RSNA, 2020 See discussion on this article by Javitt (pp 1823-1824).

Advances in MR Imaging of the Female Pelvis

This article focuses on advanced MR imaging techniques of the female pelvis and clinical applications for benign and malignant disease. General and abbreviated protocols for female pelvic MR imaging are reviewed. Diffusion-weighted imaging, dynamic contrast-enhanced MR imaging, and susceptibility-weighted imaging are discussed in the context of adnexal mass characterization using the ADNEx-MR scoring system, evaluation of endometriosis, local staging of cervical and endometrial cancers, assessment of nodal and peritoneal metastasis, and potential detection of leiomyosarcoma. MR defecography is also discussed regarding evaluation of multicompartmental pelvic floor disorders.

The Value of IVIM DWI in Combination with Conventional MRI in Identifying the Residual Tumor After Cone Biopsy for Early Cervical Carcinoma

RATIONALE AND OBJECTIVES

To investigate the value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) in combination with conventional MRI in identifying the residual tumor after biopsy for early cervical carcinoma.

MATERIALS AND METHODS

Eighty patients with histologically proven early cervical carcinoma were enrolled into this study. MRI sequences included two sets of MRI sequences including conventional MRI (T1WI, T2WI, and dynamic contrast-enhanced MRI) and IVIM DWI/conventional MRI combinations. The patients were classified into residual tumor and nonresidual tumor group after biopsy. IVIM parameters were quantitatively analyzed and compared between two groups. The diagnostic ability of two sets of MRI sequences were calculated and compared.

RESULTS

The mean D and f values were significantly lower in residual tumor group than in nonresidual tumor group (p < 0.05). The areas under receiver operating characteristic curves of D and f for discriminating between residual tumor and nonresidual tumor group were 0.848 and 0.767, respectively. The sensitivity and accuracy of conventional MRI/IVIM DWI combinations for the detection of residual tumor were 82.7% and 83.8%, respectively, while the sensitivity and accuracy of conventional MRI were 52.4% and 53.8%, respectively.

CONCLUSION

The addition of IVIM DWI to conventional MRI considerably improves the sensitivity and accuracy of the detection of residual tumor after biopsy for early cervical carcinoma.

MRI of cervical cancer with a surgical perspective: staging, prognostic implications and pitfalls

LEARNING OBJECTIVES

Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) 2018 clinical staging of cervical cancer. It is imperative that radiologists are familiar with the imaging appearance of the different stages of cervical cancer as well as the post-treatment changes and imaging pitfalls given the respective clinical manifestations, treatment regimens, and prognosis of an accurate diagnosis. In addition to the different stages of cervical cancer, we address the imaging techniques for diagnosis, staging and treatment implications as well as the changes of the new FIGO staging system.

BACKGROUND

The use of MRI to diagnose and stage cervical cancer is steadily increasing and the new FIGO stagi ng system, previously based on clinical examination, now allows the staging or change of staging based on the imaging findings. MRI can evaluate the extent of disease because of its excellent contrast resolution for pelvic tissues and organs, high accuracy and detailed elaboration of the cervical/uterovaginal anatomy.

CONTENT

Relevant anatomy, including normal MRI appearance of the cervix, parametria and pelvic ligaments; different stages of cervical cancer on MRI with prognostic and therapeutic implications; MRI sequences, other imaging modalities used in the staging and follow-up, treatment of different stages and the appearance of the cervix and cervical cancer post-treatment. Since clinical implications and therapeutic strategies for cervical cancer treatment vary tremendously according to degree of tumor extension, familiarity with relevant MRI techniques and findings is essential for radiologists. It is important that radiologists interpreting pelvic MRI are aware with the different stages of cervical cancer to provide useful information regarding treatment and prognosis. Pitfalls regarding the interpretation of tumor extension can interfere with an accurate diagnosis and have significant therapeutic implications.

MR targeted imaging for the expression of tenascin-C in cervical cancer

OBJECTIVE:

To detect cervical cancer and compare tumor invasiveness using a molecular targeted probe.

METHODS:

Tenascin-C expression was evaluated in 15 specimens. Five of them were cervical cancer with node metastasis (group A), five were cervical cancer without node metastasis (group B), and another five were normal cervix tissues (group C). Superparamagnetic iron oxide (SPIO) nanoparticles and tenascin-C antibody were conjugated as an MR probe. After the fresh tissues incubated with the probe for 24 h, MR was performed to analysis the tissue signal changes.

RESULTS:

Cervical cancer tissues with node metastasis showed highest tenascin-C expression, while normal cervix showed little expression. For the non-metastatic cervical cancer patients, tenascin-C showed moderate expression. Tenascin-C was found diffusely in the stromal surrounding malignant tumor cells. After MR, the image signal changes (contrast-to-noise ratio) kept consistent with tenascin-C expression and showed statistical difference between the three groups (A: 3.87 ± 1.45 vs B: 2.33 ± 1.04 vs C: 0.66 ± 0.31; p = 0.002).

CONCLUSION:

Tenascin-C expression can help to detect cervical cancer. MRI with SPIO-antitenascin-C may be used to evaluate the preoperative cervical cancer patients with node metastasis.

ADVANCES IN KNOWLEDGE:

Tenascin-C expression can help to detect cervical cancer and compare cancer invasiveness. Protein expression difference can be captured and compared on MR with SPIO-antitenascin-C.

The Value of Diffusion-Weighted Imaging in Combination With Conventional Magnetic Resonance Imaging for Improving Tumor Detection for Early Cervical Carcinoma Treated With Fertility-Sparing Surgery

OBJECTIVE

This study aimed to investigate the value of diffusion-weighted imaging (DWI) in combination with conventional magnetic resonance imaging (MRI) for improving tumor detection in young patients treated with fertility-sparing surgery because of early cervical carcinoma.

METHODS

Fifty-four patients with stage Ia or Ib1 cervical carcinoma were enrolled into this study. Magnetic resonance examinations were performed for these patients using conventional MRI (including T1-weighted imaging, T2-weighted imaging, and dynamic contrast-enhanced MRI) and DWI. The apparent diffusion coefficient (ADC) values of cervical carcinoma were analyzed quantitatively and compared with that of adjacent epithelium. Sensitivity, positive predictive value, and accuracy of 2 sets of MRI sequences were calculated on the basis of histologic results, and the diagnostic ability of conventional MRI/DWI combinations was compared with that of conventional MRI.

RESULTS

The mean ADC value from cervical carcinoma (mean, 786 × 10 mm/s ± 100) was significantly lower than that from adjacent epithelium (mean, 1352 × 10 mm/s ± 147) (P = 0.01). When the threshold ADC value set as 1010 × 10 mm/s, the sensitivity and specificity for differentiating cervical carcinoma from nontumor epithelium were 78.2% and 67.2%, respectively. The sensitivity and accuracy of conventional MRI for tumor detection were 76.0% and 70.4%, whereas the sensitivity and accuracy of conventional MRI/DWI combinations were 91.7% and 90.7%, respectively. Conventional MRI/DWI combinations revealed a positive predictive value of 97.8% and only 4 false-negative findings.

CONCLUSIONS

The addition of DWI to conventional MRI considerably improves the sensitivity and accuracy of tumor detection in young patients treated with fertility-sparing surgery, which supports the inclusion quantitative analysis of ADC value in routine MRI protocol before fertility-sparing surgery.

Fertility preservation in gynaecologic cancers

Due to substantial improvement in the diagnosis and treatment of gynaecologic cancers, a better understanding of patient care needs to be revised. We reviewed the literature related to fertility preservation strategies in gynaecological cancer and discussed current general management approaches. New technical modalities and patients' own desire for motherhood should be integral and paramount in the clinical evaluation to significantly contribute to preserving fertility in those women diagnosed with gynaecologic cancers during the reproductive years.

Comparison of fertility-sparing treatments in patients with early endometrial cancer and atypical complex hyperplasia: A meta-analysis and systematic review

BACKGROUND

There are some fertility-sparing treatments in patients with early endometrial cancer (EEC) or atypical complex hyperplasia (ACH), and the objective is to compare them by evaluating the oncologic and reproductive outcomes.

METHODS

We searched the published literature using Medline, Cochrane, EMBASE, and Google Scholar databases up to January 3, 2017, with various combinations of keywords fertility-sparing treatments, progesterone, progestin, intrauterine devices, early endometrial cancer, and atypical complex hyperplasia. The primary endpoint is the complete response (CR) rate, and the secondary endpoints are the partial response (PR) rate, relapse rate (RR), pregnancy rate, and live birth rate.

RESULTS

Twenty-eight studies containing 1038 women with EEC or ACH were included for review and meta-analysis. The results demonstrated that women with EEC or ACH managed with progestin had a pooled CR rate of 71% (95% confidence interval [CI]: 63-77%). The pooled pregnancy outcomes showed that 34% of women taking progestin treatment for EEC or ACH became pregnant (95% CI: 30-38%); however, only 20% of them delivered live newborns. The pooled CR rate for women using intrauterine device (IUD) was 76% (95% CI: 67-83%), and pooled RR was 9% (95% CI: 5-17%). The pregnancy rate for women whom underwent IUD was 18% (95% CI: 7-37%), and 14% of them delivered live newborns. In patients using progestin plus IUD, the pooled CR rate was 87% (95% CI: 75-93%); among those patients, 40% became pregnant (95% CI: 20-63%), and 35% delivered live newborns. There is no publication bias for the CR rate.

CONCLUSION

For patients with EEC and ACH, treatments with progestin, with or without IUD, or IUD alone can reach good CR rate; however, the pregnancy outcomes might be worse in patients treated with IUD alone. Further randomized-controlled studies are warranted to find out a better solution.