Parametrial invasion in carcinoma of cervix: role of MRI measured tumour volume

Value of diffusion-weighted and dynamic contrast-enhanced MR in predicting parametrial invasion in cervical stromal ring focally disrupted stage IB-IIA cervical cancers

OBJECTIVES

To compare the effectiveness of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging in detecting parametrial invasion (PMI) in cervical stromal ring focally disrupted stage IB-IIA cervical cancers.

METHODS

Eighty-one patients with cervical stromal ring focally disrupted stage IB-IIA cervical cancers (PMI positive, n = 35; PMI negative, n = 46) who underwent preoperative MRI and radical hysterectomy were included in this study. Preoperative clinical variables and MRI variables were analyzed and compared.

RESULTS

The K_trans (min, mean, 10%, 25%, 50%, 75%, 90%), K_ep (min, 10%, 25%, 50%, 75%, 90%), and V_e (min, 10%, 25%, 50%, 75%, 90%) values of patients with PMI were significantly higher than patients without PMI. The apparent diffusion coefficient (ADC) value did not show statistical difference between the two groups (1.01 ± 0.21 vs. 0.97 ± 0.20 10^-3 mm²/s, p = 0.360). Tumor craniocaudal planes were higher in PMI-positive group than PMI-negative group (35.84 ± 15.39 vs. 29.70 ± 11.78 mm, p = 0.048). Tumor craniocaudal planes combined with K_epmin value showed the highest area under the curve (AUCs) of 0.775, with a sensitivity of 72.7% and a specificity of 71.1% (p = 0.000).

CONCLUSIONS

DCE parameters combined tumor craniocaudal planes may represent a prognostic indicator for PMI in cervical stromal ring focally disrupted IB-IIA cervical cancers.

Effect of Electroacupuncture on Natural-Killer Cells and Tumor Size in Patients with Cervical Squamous-Cell Carcinoma: A Randomized Controlled Trial

Background: A natural-killer (NK) cell is a cytotoxic lymphocyte that responds to tumor formation. Electroacupuncture (EA) in patients with cancer, who had chemotherapy, enabled them to maintain their T-cell counts (CD3+, CD4+, and CD8+) and NK-cell activity. Objective: To evaluate NK-cell levels and tumor sizes in patients with cervical squamous-cell carcinoma (SCC) after EA on ST 36 (Zusanli). Design: This study was a randomized, experimental clinical study with a pre-post-test, control group design. Setting The study was performed in the obstetrics and gynecology department, Gynecology Oncology Division of the Rumah Sakit Dokter Soetomo General Hospital, in Surabaya, Jawa Timur, Indonesia, conducted from February 2016 until May 2016. Subjects: Patients with cervical SCC, stages IIb-IIIb (locally advanced)-determined clinically and histopathologically-all of whom had 50 mg/m²/week of cisplatin chemotherapy. The patients were divided, consecutively, into 2 groups by simple random sampling. Intervention: The controls received only received the chemotherapy, while treatment-group patients also had EA 1 day on bilateral ST 36 after each chemotherapy cycle. Outcome Measures: Primary outcomes were percent of NK cells and tumor size. Before the first treatment and after the fourth one, all patients underwent peripheral blood examinations (complete blood counts, serum creatinine and blood-urea-nitrogen levels, and flow-cytometry) to determine percentages of NK cells, and pelvic magnetic resonance imaging to measure cervical tumor sizes. Secondary outcomes were pain, nausea, vomiting, and appetite. Results: There was a significant increase in number of NK cells (P = 0.00) and a significant decrease in tumor sizes (P = 0.03) in the treatment group, compared to the control group. There was a significant increase in appetite (P = 0.00) in the treatment group, compared to baseline, but there were no significant differences in pain (P = 0.061), nausea (P = 0.399), and vomiting (P = 0.854). Conclusions: Patients with cervical SCC at stages IIb-IIIb, who received 4 cycles of chemotherapy using 50 mg/m²/week of cisplatin and EA at ST 36, had increased NK-cell percentages in their peripheral blood and had reductions in their cervical tumors.

Early Cervical Cancer: Predictive Relevance of Preoperative 3-Tesla Multiparametric Magnetic Resonance Imaging

Objective

We assess the predictive significance of preoperative 3-Tesla multiparametric MRI findings.

Methods

A total of 260 patients with FIGO IA2-IIA cervical cancer underwent primary surgical treatment between 2007 and 2016. Univariable and multivariable logistic regression analyses were used to assess the incremental prognostic significance.

Results

The clinical predictive factors associated with pT2b disease were MRI parametrial invasion (PMI) (adjusted odds ratio (AOR) 3.77, 95% confidence interval(CI) 1.62-8.79; P=0.02) and MRI uterine corpus invasion (UCI) (AOR 9.99, 95% CI 4.11-24.32; P<0.0001). In multivariable analysis, for underdiagnoses, histologically squamous carcinoma versus adenocarcinoma and adenosquamous carcinoma (AOR 2.07, 95% CI 1.06-4.07; P=0.034) and MRI tumor size (AOR 0.76, 95% CI 0.63-0.92; P=0.005) were significant predictors; for overdiagnoses, these results were MRI tumor size (AOR 1.51, 95% CI 1.06-2.16; P=0.023), MRI PMI (AOR 71.73, 95% CI 8.89-611.38; P<0.0001) and MRI UCI (AOR 0.19, 95% CI 0.01-1.01; P=0.051).

Conclusion

PMI and UCI on T2-weighted images through preoperative 3T MRI are useful coefficients for accurate prediction of the pT2b stage; however, careful surveillance is required. Therefore, preoperative decision-making for early cervical cancer patients based on MRI diagnosis should be considered carefully, particularly in the presence of factors that are known to increase the likelihood of misdiagnosis.

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.

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.

Incremental prognostic value of MRI in the staging of early cervical cancer: a prospective study and review of the literature

This is to evaluate the predictive ability of clinical examination and preoperative magnetic resonance imaging (MRI) for the staging of early cervical cancer. We prospectively evaluated 115 patients with cervical cancer, International Federation of Gynecologic and Obstetrics (FIGO) stage <IIB; receiver operating characteristic (ROC) analysis determined the predictive ability of MRI, clinical assessment, and their combination for tumor staging. Surgery was the standard of reference. MRI was more accurate than clinical examination for tumor estimate, parametrial or internal os involvement. When combined with MRI, the predictive ability of clinical examination for overall staging [area under the curve (AUC)=0.59, P>.05) increased significantly (AUC=0.84, P<.05). Our results support the official incorporation of MRI into FIGO classification system.

Uterine cervical malignancy: diagnostic accuracy of MRI with histopathologic correlation

Objective:

Cervical cancer is the third most common malignancy in women worldwide. Accurate staging of the disease is crucial in planning the optimal treatment strategy. The aim of this study was to evaluate the role of magnetic resonance imaging (MRI) in the assessment of extension and staging of cervical malignancy in correlation with histopathologic examination.

Materials and Methods:

Thirty females with untreated pathologically proven uterine cervical carcinoma were included in this prospective study. The patients were 40 - 65 years of age and their average age was 45 years. All patients were subjected to routine clinical staging workup and underwent MRI for preoperative staging. Preoperative MRI findings were reviewed and compared with the final pathological staging that is the Gold Standard of reference.

Results:

Histopathologic examination established that of the 30 tumors, 22 (73.3%) were squamous cell carcinoma. According to the International Federation of Gynecology and Obstetrics (FIGO) staging criteria, 2/30 patients (6.6%) were stage IB, 12/30 (40.3%) were IIA, 8/30 were IIB (26.6%), and 8/30 (26.6%) were IVA. MRI had a sensitivity of 100% and specificity 85.7% in the detection of parametrial infiltration, and a sensitivity of 100% and specificity of 90% in the detection of vaginal infiltration. It was sensitive (100%) and specific (100%) in detecting tumor extension to the stroma, urinary bladder, and rectum. Pathological examination demonstrated stage IB cervical carcinoma in 2/30 patients (6.6%), stage IIA disease in 10/30 patients (33.3%), stage IIB in 6/30 patients (20%), and stage IV disease in 8/30 patients (26.6%). MRI features demonstrated stage IB in 2/30 patients (6.6%), stage IIA disease in 12/30 patients (40%), stage IIB in 8/30 patients (26.6%), and stage IV disease in 8/30 patients (26.6%). MRI staging of cervical carcinoma was in concordance with histopathologic staging in stages IB and IVA and over-staging in IIA and IIB stages.

Conclusion:

MRI is an optimal non-invasive modality for preoperative staging of uterine cervical malignancy, and crucial in subsequent more accurate treatment planning.

MRI-based pre-planning in patients with cervical cancer treated with three-dimensional brachytherapy

OBJECTIVE

The aim of this study was to analyse the feasibility and determine the benefits of MRI-based pre-planning with CT/MRI data fusion in patients with cervical cancer treated with radical radiotherapy.

METHODS

Patients underwent MRI examination prior to external beam radiotherapy and prior to the first and fourth fraction of brachytherapy with applicators in place. Insertion of applicators at the radiology department was performed under paracervical anaesthesia. The benefit of MRI pre-planning was determined by comparing conventional treatment planning with dose specification to "point A" and dose specification to 90% of the high-risk clinical target volume (HR-CTV D90). Tolerance of MRI evaluation with applicators, coverage of HR-CTV and dose-volume parameters for organs at risk (OAR) has been assessed in 42 brachytherapy procedures.

RESULTS

Insertion of applicators at the radiology department was successful in all patients and there were no complications. The target dose was higher for MRI planning than for conventional planning (5.3 Gy vs 4.5 Gy). Maximum doses in the bladder and rectum were significantly lower (p<0.05) for MRI planning than for the conventional approach (6.49 Gy vs 7.45 Gy for bladder; 4.57 Gy vs 5.06 Gy for rectum). We found no correlation between the International Commission on Radiation Units (ICRU) point dose for OAR and the maximum dose in OAR. Nevertheless, a strong correlation between the maximum dose in OAR and the minimal dose in a volume of 2 cm(3) has been observed.

CONCLUSION

MRI-based pre-planning with consecutive CT/MRI data fusion is feasible and safe, with the advantage of increasing the dose to the tumour and decreasing the dose to the organs at risk.