MRI and PET scans for primary staging and detection of cervical cancer recurrence

Application value of artificial intelligence algorithm-based magnetic resonance multi-sequence imaging in staging diagnosis of cervical cancer

The aim of this research is to explore the application value of Deep residual network model (DRN) for deep learning-based multi-sequence magnetic resonance imaging (MRI) in the staging diagnosis of cervical cancer (CC). This research included 90 patients diagnosed with CC between August 2019 and May 2021 at the hospital. After undergoing MRI examination, the clinical staging and surgical pathological staging of patients were conducted. The research then evaluated the results of clinical staging and MRI staging to assess their diagnostic accuracy and correlation. In the staging diagnosis of CC, the feature enhancement layer was added to the DRN model, and the MRI imaging features of CC were used to enhance the image information. The precision, specificity, and sensitivity of the constructed model were analyzed, and then the accuracy of clinical diagnosis staging and MRI staging were compared. As the model constructed DRN in this research was compared with convolutional neural network (CNN) and the classic deep neural network visual geometry group (VGG), the precision was 67.7, 84.9, and 93.6%, respectively. The sensitivity was 70.4, 82.5, and 91.2%, while the specificity was 68.5, 83.8, and 92.2%, respectively. The precision, sensitivity, and specificity of the model were remarkably higher than those of CNN and VGG models (P < 0.05). As the clinical staging and MRI staging of CC were compared, the diagnostic accuracy of MRI was 100%, while that of clinical diagnosis was 83.7%, showing a significant difference between them (P < 0.05). Multi-sequence MRI under intelligent algorithm had a high diagnostic rate for CC staging, deserving a good clinical application value.

Patterns of Recurrent Disease in Cervical Cancer

Uterine cervical cancer is one of the most common causes of cancer-related deaths among women worldwide. Patients with cervical cancer are at a high risk of pelvic recurrence or distant metastases within the first few years after primary treatment. However, no definitive agreement exists on the best post-treatment surveillance in these patients. Imaging may represent an accurate method of detecting relapse early, right when salvage treatment could be effective. In patients with recurrent cervical cancer, the correct interpretation of imaging may support the surgeon in the proper selection of patients prior to surgery to assess the feasibility of radical surgical procedure, or may help the clinician plan the most adaptive curative therapy. MRI can accurately define the extension of local recurrence and adjacent organ invasion; CT and 18F-FDG PET/CT may depict extra-pelvic distant metastases. This review illustrates different patterns of recurrent cervical cancer and how imaging, especially MRI, accurately contributes towards the diagnosis of local recurrence and the assessment of the extent of disease in patients with previous cervical cancer. Normal post-therapy pelvic appearance and possible pitfalls related to tissue changes for prior treatments will be also illustrated.

Quantitative kinetic parameters of primary tumor can be used to predict pelvic lymph node metastasis in early-stage cervical cancer

PURPOSE

To investigate the role of kinetic parameters of primary tumor derived from dynamic contrast-enhanced MRI (DCE-MRI) in predicting pelvic lymph node metastasis (PLNM) in patients with cervical cancer.

METHODS

66 women with newly diagnosed cervical cancer were included between July 2017 and August 2019. All patients had a FIGO stage IB-IIA cancer and treated with hysterectomy and bilateral lymphadenectomy. Kinetic parameters of the primary tumor were derived from DCE-MRI data. The tumor diameter, ADC value, kinetic parameters, and nodal short-axis diameter were compared between patients with or without PLNM. Logistic regression analysis was used to determine the independent predictors for PLNM and receiver operator characteristic curve was used to evaluate the predictive performance.

RESULTS

There were 20 patients with PLNM and 46 patients without PLNM. Tumor diameter, the efflux rate constant (K_ep), and nodal short-axis diameter were significantly higher in patients with PLNM (P < 0.01). Multivariate logistic regression analysis showed that K_ep and short-axis diameter were independent predictors for PLNM. Combining K_ep and nodal short-axis diameter yielded the highest area under the curve (AUC) of 0.839. Combined with K_ep, the sensitivity, specificity, negative predictive value, and positive predictive value of nodal short-axis diameter increased from 0.500, 0.957, 0.815, and 0.833 to 0.600, 0.978, 0.923, and 0.849, respectively. With 1.113 min^-1 as threshold, the sensitivity and specificity values of K_ep in predicting PLNM in patients with normal-sized lymph nodes were 0.909 and 0.667, respectively.

CONCLUSIONS

K_ep of primary tumor can be used as a surrogate marker to predict PLNM in cervical cancer.

Dynamic analysis of circulating tumor DNA to predict prognosis and monitor therapeutic response in metastatic relapsed cervical cancer

Limited and inefficient treatment options exist for metastatic relapsed cervical cancer (MRCC), and there are currently no reliable indicators to guide therapeutic selection. We performed deep sequencing analyses targeting 322 cancer-related genes in plasma cell-free DNA and matched white blood cells in 173 serial blood samples from 82 locally advanced CC (LACC) or MRCC patients and when possible during treatment. We identified five notable nonsynonymous mutant genes (PIK3CA, BRAF, GNA11, FBXW7 and CDH1) in the MRCC samples as the metastatic relapse significantly mutated (MSG) genes and found that MRCC patients with any detectable MSG mutations had significantly shorter progression-free survival (PFS) (P = .005) and overall survival (OS) (P = .007) times than those without detectable MSG mutations. Additionally, analyses of matched prechemotherapy and postchemotherapy plasma revealed that a reduction in the number of MSG mutations after chemotherapy was significantly associated with partial remission (PR) and stable disease (SD) (P = .007). Among the patients included in the longitudinal tracking ctDNA analysis, an increase in MSG mutations was observed earlier in response to disease progression than radiological imaging. Our results outline the mutation profiles of MRCC. We show how longitudinal monitoring with ctDNA in liquid biopsy samples provides both predictive and prognostic information during treatment.

Tumor Size at Magnetic Resonance Imaging Association With Lymph Node Metastasis and Lymphovascular Space Invasion in Resectable Cervical Cancer: A Multicenter Evaluation of Surgical Specimens

Objective

To determine whether gross tumor volume (GTV) and the maximum diameter of resectable cervical cancer at magnetic resonance imaging (MRI) could predict lymph node metastasis (LNM) and lymphovascular space invasion (LVSI).

Materials and Methods

A total of 315 consecutive patients with cervical cancer were retrospectively identified. Gross tumor volume and the maximum diameter of tumor were evaluated on MRI. Univariate and multivariate logistic regression analyses were performed to determine whether tumor size could predict LNM and LVSI. Cutoffs of GTV, maximum diameter, and the International Federation of Gynecology and Obstetrics (FIGO) classification of tumor were first investigated in 255 patients (group A) and then validated in an independent cohort of 60 patients (group B) using area under the receiver operating characteristic curve (AUC) analysis for predicting the presence of LNM and LVSI.

Results

Univariate analysis showed that GTV and the maximum diameter of tumor could predict LNM and LVSI (all P < 0.0001). Multivariate analyses indicated GTV as an independent risk factor of LNM and LVSI (all P < 0.0001). In group A, GTV, the maximum diameter, and the FIGO stage could identify LNM (AUC, 0.813, 0.741, and 0.69, respectively) and LVSI (AUC, 0.806, 0.751, and 0.684, respectively). In group B, GTV, the maximum diameter, and the FIGO stage could help identify LNM (AUC, 0.902, 0.825, and 0.759, respectively) and LVSI (AUC, 0.771, 0.748, and 0.700, respectively).

Conclusions

Gross tumor volume and the maximum diameter of resectable cervical cancer at MRI demonstrated capability in predicting LNM and LVSI, which were more accurate than FIGO stage.

Automatic PET cervical tumor segmentation by combining deep learning and anatomic prior

Cervical tumor segmentation on 3D ¹⁸FDG PET images is a challenging task because of the proximity between cervix and bladder, both of which can uptake ¹⁸FDG tracers. This problem makes traditional segmentation based on intensity variation methods ineffective and reduces overall accuracy. Based on anatomy knowledge, including 'roundness' of the cervical tumor and relative positioning between the bladder and cervix, we propose a supervised machine learning method that integrates convolutional neural network (CNN) with this prior information to segment cervical tumors. First, we constructed a spatial information embedded CNN model (S-CNN) that maps the PET image to its corresponding label map, in which bladder, other normal tissue, and cervical tumor pixels are labeled as  -1, 0, and 1, respectively. Then, we obtained the final segmentation from the output of the network by a prior information constrained (PIC) thresholding method. We evaluated the performance of the PIC-S-CNN method on PET images from 50 cervical cancer patients. The PIC-S-CNN method achieved a mean Dice similarity coefficient (DSC) of 0.84 while region-growing, Chan-Vese, graph-cut, fully convolutional neural networks (FCN) based FCN-8 stride, and FCN-2 stride, and U-net achieved 0.55, 0.64, 0.67, 0.71, 0.77, and 0.80 mean DSC, respectively. The proposed PIC-S-CNN provides a more accurate way for segmenting cervical tumors on 3D PET images. Our results suggest that combining deep learning and anatomic prior information may improve segmentation accuracy for cervical tumors.

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.

Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies

Treatments for gynecologic cancer usually result in loss of fertility due to surgery or radical radiation therapy in the pelvis. In countries with an established screening program for cervical cancer, the majority of gynecologic malignancies occur in postmenopausal women. However, a substantial number of affected women are of childbearing age and have not completed their families. In these younger women, consideration of fertility preservation may be important. This article describes the fertility-sparing treatment options that are currently available and outlines the role of imaging in the selection of eligible patients on the basis of a review of the literature. In the setting of cervical cancer, magnetic resonance (MR) imaging is used to delineate the size, position, and stage of the tumor for selection of patients who are suitable for radical trachelectomy. In patients with solitary complex adnexal masses, diffusion- and perfusion-weighted MR imaging sequences are used to categorize the likelihood of invasive or borderline malignancy for consideration of unilateral ovarian resection, with fertility preservation when possible. In patients with endometrial cancer, MR imaging is used to rule out signs of invasive disease before hormone therapy is considered. Imaging is also used at patient follow-up to detect recurrent disease; however, evidence to support this application is limited. In conclusion, imaging is an essential tool in the care of patients with gynecologic malignancies who are considering fertility-preserving treatment options. ^©RSNA, 2016.

Added value of diffusion-weighted MRI in detection of cervical cancer recurrence: comparison with morphologic and dynamic contrast-enhanced MRI sequences

PURPOSE

We aimed to evaluate the added value of diffusion-weighted imaging (DWI) to standard magnetic resonance imaging (MRI) for detecting post-treatment cervical cancer recurrence. The detection accuracy of T2-weighted (T2W) images was compared with that of T2W MRI combined with either dynamic contrast-enhanced (DCE) MRI or DWI.

METHODS

Thirty-eight women with clinically suspected uterine cervical cancer recurrence more than six months after treatment completion were examined with 1.5 Tesla MRI including T2W, DCE, and DWI sequences. Disease was confirmed histologically and correlated with MRI findings. The diagnostic performance of T2W imaging and its combination with either DCE or DWI were analyzed. Sensitivity, positive predictive value, and accuracy were calculated.

RESULTS

Thirty-six women had histologically proven recurrence. The accuracy for recurrence detection was 80% with T2W/DCE MRI and 92.1% with T2W/DWI. The addition of DCE sequences did not significantly improve the diagnostic ability of T2W imaging, and this sequence combination misclassified two patients as falsely positive and seven as falsely negative. The T2W/DWI combination revealed a positive predictive value of 100% and only three false negatives.

CONCLUSION

The addition of DWI to T2W sequences considerably improved the diagnostic ability of MRI. Our results support the inclusion of DWI in the initial MRI protocol for the detection of cervical cancer recurrence, leaving DCE sequences as an option for uncertain cases.

Value of diffusion-weighted MRI in diagnosis of uterine cervical cancer: a prospective study evaluating the benefits of DWI compared to conventional MR sequences in a 3T environment

BACKGROUND

Imaging of cervical carcinoma remains challenging as local infiltration of surrounding tissues cannot always be discriminated safely. New imaging techniques, like diffusion-weighted imaging (DWI) have emerged, which could lead to a more sensitive tumor detection.

PURPOSE

To evaluate the benefits of DWI for determination of size, local infiltration, and tumor grading, in patients with primary and recurrent cervical cancer.

MATERIAL AND METHODS

In this prospective, study we enrolled 50 patients with primary (n = 35) and recurrent (n = 15) tumors. All patients underwent 3T magnetic resonance imaging (MRI) including conventional (e.g. T1/T2 ± fs ± contrast) sequences and DWI (b-values of 0, 50, 400, 800 s/mm(2)). All images were analyzed by three readers with different experience levels (1, 3, 6 years), who compared image quality, tumor delineation, dimensions, local infiltration, lymph node involvement, and quantified ADC values compared to the histopathological grading.

RESULTS

Additional use of DWI resulted in significantly better (P < 0.001) tumor delineation for the least experienced reader, but not for experienced readers. Tumor dimensions were assessed almost equally (P > 0.05) in conventional sequences and DWI. Use of DWI led to an increase in sensitivity of infiltrated adjacent tissue (from 86% to 90%) and detection of lymph node metastases (from 47% to 67%). Quantitative assessment of carcinomas showed lower ADC values (P < 0.001) with significant inverse correlations between different grading levels.

CONCLUSION

Our study demonstrates the overall benefits using DWI in 3T MRI resulting in a higher reader confidence, sensitivity of tissue infiltration, and tumor-grading for cervical cancer.

Simultaneous positron emission tomography/magnetic resonance imaging for whole-body staging in patients with recurrent gynecological malignancies of the pelvis: a comparison to whole-body magnetic resonance imaging alone

OBJECTIVES

The objective of this study was to assess the diagnostic value of integrated positron emission tomography/magnetic resonance imaging (PET/MRI) for whole-body staging of patients with recurrent gynecological pelvic malignancies, in comparison to whole-body MRI alone.

MATERIALS AND METHODS

The study was approved by the local institutional ethics committee. Written informed consent was obtained before each examination. Thirty-four consecutive patients with a suspected recurrence of cervical (n = 18) or ovarian (n = 16) cancer were prospectively enrolled for an integrated PET/MRI examination, which comprised a diagnostic, contrast-enhanced whole-body MRI protocol including dedicated sagittal dynamic imaging of the pelvis. Two radiologists separately evaluated the data sets regarding lesion count, lesion detection, lesion characterization, and diagnostic confidence. Mean and median values were calculated for each rating. Statistical analyses were performed both per-patient and per-lesion bases using a Wilcoxon signed-rank test to indicate potential significant differences among PET/MRI and MRI (alone) data sets.

RESULTS

Malignant lesions were present in 25 of the 34 patients. Positron emission tomography/magnetic resonance imaging offered correct and superior identification of all 25 patients with cancer recurrence, compared with MRI alone (23/25). A total of 118 lesions (malignant, 89; benign, 29) were detected. Positron emission tomography/magnetic resonance imaging correctly identified 88 (98.9%) of 89 malignant lesions, whereas MRI alone allowed for correct identification of 79 (88.8%) of the 89 malignant lesions. In addition, PET/MRI provided significantly higher lesion contrast and diagnostic confidence in the detection of malignant lesions (P < 0.001) compared with MRI alone.

CONCLUSIONS

These first results demonstrate the high diagnostic potential of integrated PET/MRI for the assessment of recurrence of female pelvic malignancies compared with MRI alone.

The role of ultrasound in the assessment of uterine cervical cancer

Uterine cervical cancer is the second most frequent gynecological malignancy worldwide. The assessment of the extent of disease is essential for planning optimal treatment. Imaging techniques are increasingly used in the pre-treatment work-up of cervical cancer. Currently, MRI for local extent of disease evaluation and PET-scan for distant disease assessment are considered as first-line techniques. Notwithstanding, in the last few years, ultrasound has gained attention as an imaging technique for evaluating women with cervical cancer. In this paper, current knowledge about the use of ultrasound for assessing uterine cervical cancer will be reviewed and discussed.

Multi-modality organ-based approach to expected imaging findings, complications and recurrent tumour in the genitourinary tract after radiotherapy

PURPOSE

Radiotherapy (RT) is an integral component in the management of many abdominal and pelvic malignancies. Imaging follow-up in patients who have received RT is performed to assess for treatment response, evaluate for tumour recurrence and to diagnose complications related to treatment. The purpose of this pictorial review is to depict the expected imaging findings and potential complications following RT in the genitourinary (GU) tract using an organ-based approach and to review the diagnosis of locally recurrent tumour in the GU tract following RT.

CONCLUSIONS

Some GU malignancies, namely cervical and prostatic carcinoma, can be treated with radical RT with intent to cure. More frequently, the GU tract is indirectly treated as a result of RT to adjacent cancers. Expected imaging findings, RT-related complications and the diagnosis of recurrent tumour following RT in the GU tract often necessitate a multi-modality imaging approach, the incorporation of functional imaging techniques and an organ-based approach for diagnosis.

Clinical impact of ¹⁸F-FDG PET/CT in the pretreatment evaluation of patients with locally advanced cervical carcinoma

AIM

The aim of this study was to evaluate the impact of F-fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) on the pretreatment evaluation of patients with locally advanced cervical carcinoma.

METHOD

Forty-seven patients with stage 2b-4a cervical carcinoma underwent F-FDG PET/CT for initial staging and pretreatment evaluation. Concomitant pelvic/abdominal MRI was performed in 38 patients. The contribution of PET/CT to treatment planning was evaluated, and the prognostic performance of PET/CT was compared with that of MRI. Lymph node (LN) status on PET/CT was correlated with patient follow-up data.

RESULTS

PET/CT detected hypermetabolic LNs in 39/47 patients. In 24/39 patients (62%), PET/CT was found to be superior to MRI. In 13/24 patients (54%), PET/CT detected para-aortic ± pelvic LNs, which were not found on MRI. PET/CT successfully detected distant metastases in 10 patients and peritonitis carcinomatosa in one patient; these patients were upstaged clinically. Overall, PET/CT has led to modifications in the extent of the radiotherapy field in 34% of patients and to major alterations in treatment plans in 23% of patients with widespread disease. The frequency of PET-positive LNs was significantly lower in patients who were alive without disease at the time of last follow-up (60%) compared with patients with persistent disease and nonsurvivors (100%, P=0.012).

CONCLUSION

The presence of PET-positive LNs has prognostic significance in patients with cervical carcinoma. PET/CT has the potential to show both lymphatic and distant metastases, which results in modifications to the chemoradiotherapeutic regimen. The use of PET/CT must be included in the initial workup of patients with locally advanced cervical carcinoma.

Significance of E-cadherin, β-catenin, and vimentin expression as postoperative prognosis indicators in cervical squamous cell carcinoma

Although early-stage cervical cancer can be treated by surgery, distant metastases can be life threatening. It has been a challenge to identify reliable biomarkers as indicators of metastasis or poor prognosis. We investigated the prognostic impact of vimentin, E-cadherin, and β-catenin expression measured by immunohistochemistry staining in samples from 135 patients with clinical stage I or II cervical squamous cell cancer and in normal cervical tissues from 55 patients who underwent hysterectomy for reasons other than neoplasia. Down-regulation of E-cadherin and β-catenin was positively related to histologic differentiation (P < .001), metastasis (P < .001), and recurrence (P < .001), whereas up-regulation of vimentin was inversely related to histologic differentiation, metastasis, and recurrence (P < .0001, .020, and .000, respectively). In univariate Cox regression analysis, high expression of E-cadherin or β-catenin was a positive prognostic indicator for overall survival (P < .001 and P < .001, respectively), whereas high expression of vimentin was a negative indicator (P < .001). In multivariate Cox regression analysis, high expression of E-cadherin was a positive prognostic indicator for overall survival (P = .002), whereas high expression of vimentin was a negative indicator (P = .034). The expression of E-cadherin and vimentin was associated with survival, and the 2 proteins were independent prognostic factors in univariate and multivariate analyses. The combination of a decrease of E-cadherin and an increase in vimentin might be a valuable survival indictor in cervical squamous cell cancer.

Outcome in early cervical cancer following pre-operative low dose rate brachytherapy: a ten-year follow up of 257 patients treated at a single institution

OBJECTIVE

To report the outcome of preoperative low dose rate uterovaginal brachytherapy (LDR-UVBT) followed by radical surgery in the treatment of early cervical carcinoma.

METHODS

257 patients treated at Institut Curie from 1985 to 2008 for cervical carcinoma less than 4cm (FIGO stages Ib1, IIA and IIB) were studied. Patients received preoperative LDR-UVBT followed by hysterectomy Piver II type, with pelvic lymph nodes dissection (PLND). Predictive factors for pathological response to brachytherapy were analyzed with logistic regression, as well as survival rates.

RESULTS

44% of patients had residual tumor, 4.3% of patients had parametrial invasion and 17.9% of patients had lymph node involvement. Predictive factors for an incomplete pathological response were: initial clinical tumor size 20mm (OR 2.1), pN1 (OR 2.77), glandular carcinoma (OR 2.51) and lymphovascular invasion (OR 4.35). 7.4% and 2.7% of patients had respectively grade 2 and grade 3 post-therapeutic late complications. Median follow up was 122 months [1-282]. Five-year actuarial overall survival and disease free survival were respectively 83% CI [78.3-87.5] and 80.9% CI [76.3-85.7]. In multivariate analysis, factors affecting significantly the overall survival and disease free survival rates were: lymph node involvement (RR 4.53 and 8.96 respectively), parametrial involvement (RR 5.69 and 5.62 respectively), smoking (RR 3.07 and 2.63 respectively).

CONCLUSIONS

Preoperative LDR-UVBT results in good disease control with a low complications rate. Its accuracy could be improved by a better selection of patients. Lymph nodes and parametrial evaluation remains a challenging issue that should be achieved with imaging and minimal invasive surgery.

Trends in cervical cancer in the Netherlands until 2007: has the bottom been reached?

We explored trends in incidence and mortality of cervical cancer by age, stage and morphology, and linked the observed trends to screening activities. Data was retrieved from the Netherlands Cancer Registry during 1989-2007 (incidence) and Statistics Netherlands during 1970-2007 (mortality). Trends were evaluated by calculating the estimated annual percentage change (EAPC). Joinpoint regression analysis was used to detect changes in trends. Cervical intraepithelial neoplasia (CIN) detection rates were calculated by data from "the nationwide network and registry of histo- and cytopathology" during 1990-2006. Total age-adjusted incidence rate (European standardized rate (ESR)) was 7.9 per 100,000 woman years in 2007. During 1989-1998, incidence rates decreased with an EAPC of -1.3% (95% confidence interval (CI) -2.2 to -0.3), during 1998-2001 with -6.7% (95% CI: -16.4 to 4.1), and increased during 2001-2007 with 2.3% (95% CI: 0.4 to 4.2). Total mortality ESR was 1.9 per 100,000 woman years in 2007. Mortality rates decreased during 1970-1994 annually with -4.1% (95% CI: -4.6% to -3.7%), and with -2.6% (95% CI: -3.8% to -1.5%) during 1994-2007. The observed trend in total incidence is similar to the trend in squamous cell carcinomas in age group 35-54 years, suggesting that the observed trends are likely to be associated to changes in the screening program. This is supported by the trend in CINIII detection rates. In conclusion, incidence and mortality overall decreased and leveled off. On top of that there was an extra decrease that was compensated by a following recent increase in incidence, probably resulting from reorganization of the Dutch screening program.