Magnetic resonance imaging in recurrent carcinoma of the cervix

Positron emission tomography alone, positron emission tomography-computed tomography and computed tomography in diagnosing recurrent cervical carcinoma: a systematic review and meta-analysis

INTRODUCTION

The aim of the study was to assess systematically the accuracies of positron emission tomography (PET), PET/computed tomography (CT), and CT in diagnosing recurrent cervical cancer.

MATERIAL AND METHODS

We searched for articles published from January 1980 to June 2013 using the following inclusion criteria: articles were reported in English; the use of PET, interpreted with or without the use of CT; use of CT to detect recurrent cervical cancer; and histopathologic analysis and/or close clinical and imaging follow-up for at least 6 months. We extracted data to calculate sensitivity, specificity, summary receiver operating characteristic curves, and the area under the receiver operating characteristic curve (AUC) as well as test for heterogeneity.

RESULTS

In 23 included studies, PET had the highest pooled specificity at 92% (95% CI: 90-94), whereas PET/CT had the highest pooled sensitivity at 94% (95% CI: 90-97). The area under the curve (AUC) of PET alone, PET/CT, and CT were 0.9594, 0.9508, and 0.9363, respectively. Results of the pairwise comparison between each modality show that the specificity of PET was higher than that of PET/CT (p < 0.05). The difference in the pooled sensitivities and AUC of PET alone and PET/CT showed no statistical significance. No evidence of publication bias was found. However, evidence of heterogeneity was observed.

CONCLUSIONS

The PET/CT may be a useful supplement to current surveillance techniques, particularly for patients with negative CT imaging. However, in terms of diagnostic accuracy, interpreted CT images may have limited additional value to PET in detecting recurrent cervical cancer.

Evaluating PET-CT in the detection and management of recurrent cervical cancer: systematic reviews of diagnostic accuracy and subjective elicitation

BACKGROUND

Positron emission tomography-computed tomography (PET-CT) is recommended to triage women for exenterative surgery and surveillance after treatment for advanced cervical cancer.

OBJECTIVE

To evaluate diagnostic accuracy of additional whole body PET-CT compared with CT/magnetic resonance imaging (MRI) alone in women with suspected recurrent/persistent cervical cancer and in asymptomatic women as surveillance.

DESIGN

Systematic reviews. Subjective elicitation to supplement diagnostic information.

SEARCH STRATEGY/SELECTION CRITERIA/DATA COLLECTION AND ANALYSIS

Searches of electronic databases were performed to June 2013. Studies in women with suspected recurrent/persistent cervical cancer and in asymptomatic women undergoing follow up with sufficient numeric data were included. We calculated sensitivity, specificity and corresponding 95% confidence intervals. Meta-analyses employed a bivariate model that included a random-effects term for between-study variations (CT studies) and univariate random effects meta-analyses (PET-CT studies) for sensitivity and specificity separately.

SUBJECTIVE ELICITATION

Prevalence of recurrence and the accuracy of imaging elicited using the allocation of points technique. Coherence of elicited subjective probabilities with estimates in the literature examined.

RESULTS

We identified 15 relevant studies; none directly compared additional PET-CT with MRI or CT separately. Most CT and MRI studies used older protocols and the majority did not distinguish between asymptomatic and symptomatic women. Meta-analysis of nine PET-CT studies in mostly symptomatic women showed sensitivity of 94.8 (95% CI 91.2-96.9), and specificity of 86.9% (95% CI 82.2-90.5). The summary estimate of the sensitivity of CT for detection of recurrence was 89.64% (95% CI 81.59-94.41) and specificity was 76% (95% CI 43.68-92.82). Meta-analysis for MRI test accuracy studies was not possible because of clinical heterogeneity. The sensitivity and specificity of MRI in pelvic recurrence varied between 82 and 100% and between 78 and 100%, respectively. Formal statistical comparisons of the accuracy of index tests were not possible. Subjective elicitation provided estimates comparable to the literature. Subjective estimates of the increase in accuracy from the addition of PET-CT were less than elicited increases required to justify the use in PET-CT for surveillance.

CONCLUSION

Evidence to support additional PET-CT is scarce, of average quality and does not distinguish between application for surveillance and diagnosis. Guidelines recommending PET-CT in recurrent cervical cancer need to be reconsidered in the light of the existing evidence base.

Magnetic resonance imaging of the cervix

Due to deficiencies of clinical staging, magnetic resonance (MR) imaging is being increasingly used in the pre-treatment work-up of cervical cancer. Lymph node status, as evaluated by advanced imaging modalities, is also being incorporated into management algorithms. Familiarity with MR imaging features will lead to more accurate staging of cervical cancer. Awareness of impact of staging on management will enable the radiologists to tailor the report to clinically and surgically relevant information. This article emphasizes the guidelines on the MR staging criteria, dependence of newer treatments on imaging staging and lymph node involvement, and MR imaging in post-treatment surveillance of cervical cancer.

Uterine cervical carcinoma after therapy: CT and MR imaging findings

Cervical carcinoma is one of the most frequent causes of death in women. Computed tomography (CT) and magnetic resonance (MR) imaging are the primary modalities for follow-up of treated cervical carcinoma. A normal vaginal cuff after hysterectomy appears as a smooth, low-signal-intensity muscular wall on T2-weighted MR images. Early (2-3 months after treatment) and significant decreases in the signal intensity and volume of the tumor at MR imaging indicate a good response to radiation therapy. Sites of recurrence are the pelvis, lymph nodes, and distant sites. Pelvic recurrence appears as a heterogeneously enhancing mass at contrast material-enhanced CT and often appears as a heterogeneous, high-signal-intensity mass at T2-weighted MR imaging. Lymph node recurrence ranges from scattered, minimally enlarged nodes to large, conglomerate nodal masses. Determination of neoplastic infiltration of lymph nodes is based on size; most researchers consider nodes greater than 1 cm in short-axis diameter to be metastatic. Distant metastases are usually due to recurrent disease and occur in the abdomen, thorax, and bone. Knowledge of the normal therapeutic changes and the spectrum of recurrent tumor in patients with cervical carcinoma is important for accurate interpretation of follow-up CT and MR images.

Explorative laparoscopy prior to exenterative surgery

OBJECTIVE

The objective of this study was to identify the advantages and limits of laparoscopy for assessment of eligibility for exenterative procedures in patients with gynecologic malignancies.

METHODS

Between April 1998 and April 2001, 41 consecutive patients with primary or recurrent gynecologic malignancy underwent explorative laparoscopy to detect eligibility for exenteration.

RESULTS

Mean age of patients was 54 years (range, 31-80 years). Twenty out of 41 (48.7%) patients underwent exclusively explorative laparoscopy due to unresectable disease or intraabdominal spread of disease. Median operative time for this cohort of patients was 69.1 min (range, 10-278), median blood loss was 30 cc (range 10-60) and no complications occurred. Based on findings of explorative laparoscopy 21 out of 41 (51.2%) patients were eligible for exenteration. Evaluation of extension of disease was correctly done by laparoscopy and was not corrected at laparotomy. One patient out of 21 (4.76%) had extension of disease missed at both laparoscopy and laparotomy and discovered only at an advanced phase of exenteration. Histology of exenterative specimens confirmed laparoscopic evaluation in 20 out of 21 patients (95.25%).

CONCLUSIONS

Laparoscopy proved effective for evaluation of patients who were candidates for exenteration and helped to avoid unnecessary laparotomy in half of the candidate patients.

In vivo proton (H1) magnetic resonance spectroscopy for cervical carcinoma

Proton magnetic resonance spectroscopy (MRS) may be a useful tool in both the initial diagnosis of cervical carcinoma and the subsequent surveillance after radiation therapy, particularly when other standard diagnostic methods are inconclusive. Single voxel magnetic resonance (MR) spectral data were acquired from 8 normal volunteers, 16 patients with cervical cancer before radiation therapy, and 18 patients with cervical cancer after radiation therapy using an external pelvic coil at a 1.5-T on a Signa system. The presence or absence of various resonances within each spectrum was evaluated for similarities within each patient group and for spectral differences between groups. Resonances corresponding to lipid and creatine dominated the spectrum for the eight normal volunteers without detection of a choline resonance. Spectra from 16 pretreatment patients with biopsy-proven cervical cancer revealed strong resonances at a chemical shift of 3.25 ppm corresponding to choline. Data acquired from the 18 posttreatment setting studies was variable, but often correlated well with the clinical findings. Biopsy confirmation was obtained in seven patients. H1 MRS of the cervix using a noninvasive pelvic coil consistently demonstrates reproducible spectral differences between normal and neoplastic cervical tissue in vivo. However, signal is still poor for minimal disease recurrence. Further study is needed at intervals before, during, and after definitive irradiation with biopsy confirmation to validate the accuracy of MRS in distinguishing persistence or recurrence of disease from necrosis and fibrosis.

Diagnosis of recurrent uterine cervical cancer: computed tomography versus positron emission tomography

OBJECTIVE

To determine the accuracy of CT and positron emission tomography (PET) in the diagnosis of recurrent uterine cervical cancer.

MATERIALS AND METHODS

Imaging findings of CT and PET in 36 patients (mean age, 53 years) in whom recurrent uterine cervical cancer was suspected were analyzed retrospectively. Between October 1997 and May 1998, they had undergone surgery and/or radiation therapy. Tumor recurrence was confirmed by pathologic examination or follow-up studies.

RESULTS

In detecting recurrent uterine cervical cancer, the sensitivity, specificity, and accuracy of CT were 77.8%, 83.3%, and 80.5%, respectively, while for PET, the corresponding figures were 100%, 94.4%, and 97.2%. The Chi-square test revealed no significant difference in specificity (p =.2888), but significant differences in sensitivity (p =.0339) and accuracy (p =.0244).

CONCLUSION

PET proved to be a reliable screening method for detecting recurrent uterine cervical cancer, but to determine the anatomical localization of recurrent tumors, and thus decide an adequate treatment plan, CT was eventually needed.

Radical hysterectomy for recurrent or persistent cervical cancer following radiation therapy

The objective of this paper was to determine the role of radical hysterectomy in persistent or recurrent cervical cancer after primary radiation therapy. Between 1982 and 1995, 34 patients underwent radical hysterectomy for persistent (n = 15) or recurrent (n = 19) cervical cancer after primary radiotherapy. Univariate analysis using log-rank comparison of survival curves was conducted to identify clinical and pathologic factors predictive of survival. The median tumor size at the time of recurrence or persistence was 3.2 cm (range 1-6 cm). 24 patients (70%) had recurrence limited to the uterine cervix; four (12%) had vaginal involvement and six (18%) had early parametrial involvement. No treatment-related deaths were observed. Eighteen major complications (grade III-IV) occurred in 15 cases (44%); 5 patients experienced a fistula. Mean follow-up time was 81 months (range 33-192 months). Recurrent disease was documented in 20 patients (59%), and median time to recurrence was 37 months (range 4-56 months). Fifteen patients (44%) are alive without evidence of disease at a median survival of 81 months (range 33-192), and 18 patients (53%) died of disease with a median survival of 22 months (range 7-106). One patient died of intercurrent disease. Actuarial 5-year survival rate for the whole group is 49%. Patients with FIGO stage IB-IIA at primary diagnosis, no clinical parametrial involvement, and small (</= 4 cm) tumor diameter at the time of recurrence show a good prognosis (11/17 alive NED) compared to patients who do not fit the above mentioned criteria (4/17 NED, P = 0.01). We conclude that radical hysterectomy can be offered as an alternative procedure to exenteration only in highly selected patients.

How can laparoscopic management assist radiation treatment in cervix carcinoma?

PURPOSE

To determine the role of laparoscopic lymphadenectomy (pelvis +/- para-aortic nodes) and laparoscopic hysterectomy in cervical cancer compared to 'classic radical surgery' in patients undergoing surgery in comparison with modern imaging in patients treated with radiotherapy alone.

MATERIALS AND METHODS

The limitations of modern imaging are presented as well as how complication rates can be increased when classic laparotomy is followed by radiation therapy. Laparoscopic procedures are described with particular emphasis on how to provide information on lymph node metastases with the risk of overlooking microscopic involvement. A number of clinical experiences are cited to illustrate this problem and show how treatment approaches can be adapted.

RESULTS

The role of laparoscopy is evaluated according to different clinical situations and treatment protocols emphasizing the possibilities offered by this method to the radiotherapist.

CONCLUSION

When developing laparoscopic techniques for the management of cervical carcinoma, caution must be exercised to ensure that these techniques are not detrimental to the prognosis.

Dynamic MR imaging of recurrent postoperative cervical cancer

The value of dynamic-contrast enhanced MR imaging using FLASH technique was studied in 13 patients with postoperative recurrent cervical cancer verified histopathology and in 9 patients without recurrence. Dynamic FLASH imaging and conventional spin-echo T1- and T2-weighted sequences were compared in a prospective fashion with regard to accuracy of the diagnosis of recurrent tumor using biopsy results as the gold standard. The contrast between the recurrent tumor and the surrounding pelvic tissues was also analyzed. The accuracy of depicting recurrent tumor or dynamic images (82%) was superior to that of pre- and postcontrast T1-weighted images and T2-weighted images (64%, 68%, and 64%, respectively). The contrast between the recurrent tumor and pelvic fat was greater on precontrast T1-weighted and dynamic images than on T2-weighted and postcontrast T1-weighted images. The dynamic images clearly showed involvement of the surrounding pelvic organs, because enhancement was observed exclusively in the tumor in the early dynamic phase. Accuracy regarding involvement of the urinary bladder or rectal wall on pre- and postcontrast T1-weighted images and T2-weighted images was lower than that on the dynamic images. Dynamic MR imaging has potential for use in the detection and evaluation of the extent of recurrent postoperative cervical cancer.

MR evaluation of cervical cancer in hysterectomy specimens: correlation of quantitative T2 measurement and histology

Specimens from modified radical hysterectomies performed for invasive carcinoma of the cervix were analyzed with quantitative T2 magnetic resonance (MR) imaging and histologic study to determine to what degree there was a correlation between the findings of the two modalities. The mean T2 of cervical stroma was 48 msec, while the outer zone of the cervix had a mean T2 of 62 msec and the central canal region typically had T2 values of 115 msec +/- 20 (standard deviation). A total of nine cervical cancers were analyzed, and their mean T2 value was 79 msec. Separation between cervical stroma and tumor was good, with stromal T2 values ranging from 30 to 66 msec, while tumor T2s ranged from 60 to 97 msec. Statistical analysis indicated that these data were associated with a sensitivity of 89% and a specificity of 95%, with 95% confidence intervals of [50%, 99.4%] and [74%, 99.7%], respectively, for separating tumor from stroma on the basis of T2 value. Quantitative T2 imaging was found to provide an effective, nonsubjective means of classifying cervical anatomy and neoplastic disease.

Magnetic resonance evaluation of uterine malignancies

Cervical carcinoma and endometrial carcinoma constitute the principal malignant tumors of the uterus. MRI has assumed an increasingly important role in the clinical staging of these neoplasms, and is particularly valuable for staging cervical carcinoma. The advantages of MRI as compared with computed tomography are superior soft tissue discrimination and multiplanar imaging capability. This review article outlines and illustrates the use of MRI for staging malignant uterine neoplasms and also considers post therapy follow-up of cervical carcinoma.

Magnetic resonance imaging of female pelvic masses and local recurrent tumors at an ultra low (0.02 T) magnetic field: correlation with computed tomography

Pelvic MR (41 patients) and CT (36 patients) examinations were performed on 14 females with a primary pelvic complaint, and on 28 females with a suspicion of local recurrent disease of gynecologic malignant tumor. Benign cystic tumors were found in eight patients, five patients had endometriomas, one had a lymphoma, and one had a small androblastoma. Ten local recurrent tumors were confirmed histopathologically or cytologically. All cysts, one endometrioma, the lymphoma, and six recurrent tumors were detected on images obtained by our ultra low field magnetic unit. The smallest cyst detected was 16 mm in diameter. Small scattered implants of endometriosis were not discerned. The appearance of the tumors did not differ essentially from those described at high magnetic fields. Physical examination detected all 10 recurrent tumors, CT detected 8 of them, and MRI 6 out of 9 cases. The sensitivities of physical examination, CT and MRI to find recurrent diseases were 100%, 80%, and 67%, respectively. Corresponding specificities were 93%, 67%, and 80%. The results indicate that physical examination is most important in recurrent diseases. CT is the basic method for imaging malignant pelvic tumors. MR imaging at 0.02 T magnetic field provides a convenient and inexpensive method for more specific information, if CT findings are equivocal. MRI at 0.02 T is also accurate in detecting benign pelvic masses, but the findings are not very specific.

Advances in gynecologic imaging and intervention

Advances in diagnostic imaging of the female genital tract facilitate characterization of many pelvic masses. Preoperative assessment of gynecologic malignant tumors provides information that may alter the surgical approach or timing of radiation therapy. Image-guided biopsy accurately confirms recurrent malignant lesions. Transcervical techniques have improved diagnostic assessment of infertile couples; thus, effective and inexpensive treatment options can be offered. Postoperative complications of gynecologic procedures can be detected with imaging, and many can be treated with image-guided techniques.

Quantitative magnetic resonance imaging in cervical carcinoma: a report on 30 cases

T1 and T2 relaxation times were calculated, before radiation therapy, in 30 patients with cervical carcinoma. Eight healthy young women were submitted to magnetic resonance imaging (MRI) to determine T1 and T2 times of the normal cervix. Magnetic resonance imaging was repeated, in 22 patients, during radiation therapy and at follow-up. During treatment and follow-up, patients with complete tumour response showed a significant T1 reduction compared with the pre-treatment values. With persistence of palpable or visible tumour, T1 times showed a small decrease during therapy, and a marked increase at subsequent examinations. The results suggest that the modifications of T1 times, during radiation therapy and follow-up, could be considered as a useful discriminant between patients with differing tumour response.

Magnetic resonance imaging, computed tomography and endosonography in the local staging of carcinoma of the cervix

Thirty-seven patients with carcinoma of the cervix were prospectively staged by examination under anaesthesia (EUA), transvaginal and transrectal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). Pathological correlation was available for 20 patients. In the pathologically staged patients, EUA agreed with the staging in 17, understaging three patients. Endosonography agreed with the staging in 19, CT in 16 and MRI in 18 patients. For the remaining 17 patients, endosonography agreed with the EUA findings in 13, CT in 12 and MRI in 12. This study has shown that endosonography and MRI are more accurate than CT in the local staging of carcinoma of the cervix. Computed tomography was least accurate in staging early tumours and differentiating between Stage Ib and IIb disease. Lymph node involvement was detected with equal frequency by both CT and MRI. Magnetic resonance imaging was useful in identifying vaginal and bladder wall involvement and in one patient showed features due to an unsuspected early pregnancy.