Combined pre-treatment MRI and 18F-FDG PET/CT parameters as prognostic biomarkers in patients with cervical cancer

Quantitative accuracy of positron emission tomography/magnetic resonance and positron emission tomography/computed tomography for cervical cancer

With the spread of positron emission tomography/magnetic resonance (PET/MR), the question of comparability of studies becomes important. We aim to determine whether PET/MR and PET/computed tomography (PET/CT) are comparable for the case of cervical cancer. Fifteen cervical cancer patients identified by either a radiation oncologist or an oncologic surgeon had both PET/MR and PET/CT performed for initial staging within 3 weeks. We then compared the results both quantitatively (measuring standardized uptake values [SUVs] on visible lesions) as well as qualitatively (having radiologists and nuclear medicine physicians interprets the results). While interpretations between PET/MR and PET/CT varied in many cases, SUVs of primary lesions were similar to within 25% in all but one case, and correlation coefficient was 0.92. Maximum SUV ranged between 4.9 and 25.2 for PET-MR and between 5.8 and 30.4 for PET-CT for primary tumors and between 1.5 and 18.8 for PET-MR and between 1.8 and 20.8 for PET-CT for nodes. However, clinical reads often varied significantly between PET/MR and PET/CT. This suggests that SUV is similar on PET/MR and PET/CT although the differing anatomic modalities available for correlation may make the difference in terms of qualitative interpretation.

DWI of Pancreatic Ductal Adenocarcinoma: A Pilot Study to Estimate the Correlation With Metastatic Disease Potential and Overall Survival

OBJECTIVE

The purpose of this study is to analyze the relationship between the apparent diffusion coefficient (ADC) of pancreatic ductal adenocarcinoma (PDAC) and the presence or development of metastasis and overall survival (OS).

MATERIALS AND METHODS

Of 290 consecutive patients with histopathologically proven PDAC from January 2013 to December 2014, staging DWI was performed for 124 patients. Image quality was adequate in 112 studies. Sixty-five patients were treatment naïve, but 17 of the 65 were excluded because of the presence of other associated pancreatic pathologic abnormalities. Data for the remaining 48 patients (24 men and 24 women; median age, 65.5 years; interquartile range, 56-77 years) were obtained during a 4-year follow-up period (mean [± SD], 397 ± 415.1 days). The correlation between ADC and the presence or development of metastasis was assessed using descriptive statistics. OS was determined and mortality analysis was performed using Pearson correlation and Kaplan-Meier curves.

RESULTS

Of 48 patients, 10 had metastases at staging MRI, and 12 later developed metastatic disease. Among the latter, the mean time from staging MRI to metastasis was 258 ± 274.1 days. Most (86%) metastases were hepatic (n = 19). During the follow-up period, the remaining 26 patients (54%) never developed metastases. Patients with metastatic disease (n = 22) had significantly lower mean ADCs than did those without metastases (1.27 × 10^-3 vs 1.43 × 10^-3 mm²/s; p = 0.047). The ADC of PDAC had a positive correlation with survival: patients with PDAC with lower ADCs (< 1.36 × 10^-3 mm²/s) had significantly worse 4-year OS rates than did patients with higher ADC values (p = 0.036).

CONCLUSION

Pretreatment ADC values of PDAC may be significantly lower in patients who have or will develop metastatic disease and may correlate with worse OS.

Feasibility and diagnostic performance of hybrid PET/MRI compared with PET/CT for gynecological malignancies: a prospective pilot study

PURPOSE

The purpose of the study was to assess the feasibility and diagnostic performance of FDG-PET/MR imaging compared to PET/CT for staging of patients with a gynecological malignancy.

METHODS

25 patients with a gynecological malignancy were prospectively enrolled into this pilot study. Patients underwent sequential full-body PET/CT and PET/MR of the abdomen and pelvis after administration of a single dose of F-18 FDG. PET/MRI and PET/CT images were independently reviewed by two expert radiologists. Readers were blinded to the results of the other imaging procedures. Clinical and pathologic information was abstracted from medical charts.

RESULTS

18 patients were included in the final analysis with a median age of 62 years (range 31-88). 61% of patients (11/18) had cervical cancer, while the remaining patients had endometrial cancer. PET/MRI as compared to PET/CT detected all primary tumors, 7/7 patients with regional lymph nodes, and 1/1 patient with an abdominal metastasis. Two patients had additional lymph nodes outside of the abdominopelvic cavity detected on PET/CT that were not seen on PET/MRI, whereas 6 patients had parametrial invasion and one patient had invasion of the bladder seen on PET/MRI not detected on PET/CT. Five cervical cancer patients had discordant clinical vs. radiographic staging based on PET/MRI detection of soft tissue involvement. Management changed for two patients who had clinical stage IB1 and radiographic stage IIB cervical cancer.

CONCLUSIONS

PET/MRI is feasible and has at least comparable diagnostic ability to PET/CT for identification of primary cervical and endometrial tumors and regional metastases. PET/MRI may be superior to PET/CT for initial radiographic assessment of cervical cancers.

Amide proton transfer imaging to evaluate the grading of squamous cell carcinoma of the cervix: A comparative study using 18 F FDG PET

BACKGROUND

Amide proton transfer (APT) imaging has shown great potential value in the diagnosis of cancer, but has yet not been applied in cervical carcinoma patients.

PURPOSE

To investigate the utility of APT imaging in estimating histologic grades of squamous cell carcinoma of the cervix (SCCC), compared with the standardized uptake value (SUV).

STUDY TYPE

Prospective.

POPULATION

Thirty-one patients with SCCC (median age 51 years) were included.

FIELD STRENGTH/SEQUENCE

Ingenia 3.0 T CX, Axial T₁ -weighted imaging (T₁ WI), Axial T₂ WI, 3D turbo spin echo sequence for APT imaging.

ASSESSMENT

Patient pathology was confirmed by surgery and the patients were divided into three groups based on histologic grades: Grade 1 (n = 9), Grade 2 (n = 12), and Grade 3 (n = 10). The APT signal intensity (APT SI), maximum SUV (SUV_max ) and mean SUV (SUV_mean ) for each grade were assessed by experienced radiologists in a blinded manner.

STATISTICAL TESTS

The obtained parameters were compared by one-way analysis of variance with Tukey honest significant difference post-hoc test. The correlations between the parameters and histologic grades were analyzed by Spearman's correlation coefficient. The Pearson correlation coefficients of the APT SI with the SUV_max and SUV_mean were also calculated.

RESULTS

The APT SIs for the three grades were significantly different (P = 0.0002). The APT SIs of Grade 2 and Grade 3 had significant differences (P = 0.009). The Spearman correlation coefficients for the correlations between the parameters and histological grade were as follows: APT SI: 0.684 (P = 0.00002), SUV_max : 0.318 (P = 0.082), and SUV_mean : 0.261 (P = 0.157). The Pearson correlation coefficients of the APT SI with the SUV_max and SUV_mean were 0.108 (P = 0.564) and 0.178 (P = 0.337), respectively.

DATA CONCLUSION

The APT SI was positively correlated with the SCCC grades. APT imaging maybe a promising method for predicting SCCC histologic grades.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:261-268.

Predictive Value of FDG PET/CT to Detect Lymph Node Metastases in Cervical Cancer

PURPOSE

The aim of this study was to determine the prognostic significance of PET/CT findings in women with cervical cancer and describe the normalization of lymph node SUVmax (nSUVmax).

MATERIALS AND METHODS

A retrospective review was performed of 113 patients with cervical cancer who underwent a PET/CT before receiving definitive therapy. SUVmax measurements were normalized to the SUV of the pelvic blood pool. Patient, tumor, and PET/CT data were correlated to extracervical recurrence-free survival (ecRFS) and lymph node pathology.

RESULTS

Of 113 patients, there were 23 (20%) extracervical recurrences. On univariate analysis, stage, histology, nSUVmax, and radiographic size of the primary tumor, and nSUVmax of the most hypermetabolic lymph node were significantly associated with ecRFS. On multivariable analysis, nSUVmax and radiographic size of the primary tumor remained associated with ecRFS (both P < 0.001). Sixty-six patients underwent pelvic, common iliac, and/or para-aortic nodal sampling. The sensitivity, specificity, false-negative, and false-positive rates of PET/CT for lymph node metastases were 53%, 75%, 6%, and 82%, respectively. On univariate analysis, nSUVmax, and radiographic size of the primary tumor, and nSUVmax of the most hypermetabolic lymph node, and radiographic size of the largest lymph node, were associated with the presence of at least one pathologically positive lymph node. On multivariable analysis, only the radiographic size of the largest lymph node remained significantly associated with lymph node metastases (P < 0.001).

CONCLUSIONS

The size and nSUVmax of the primary tumor were associated with ecRFS. PET/CT has a low false-negative rate but high false-positive rate for lymph node metastases.

Evaluation of 18F-FDG PET/CT parameters for reflection of aggressiveness and prediction of prognosis in early-stage cervical cancer

PURPOSE

The aim of this study was to investigate the value of five typical fluorine-18-fluorodeoxyglucose PET/computed tomography (CT) parameters (including SUVmax, SUVmean, SUVpeak, MTV and TLG) in the reflecting aggressiveness and predicting prognosis in patients with early-stage cervical cancer.

PATIENTS AND METHODS

Our study enrolled 85 primary cervical cancer patients who underwent preoperative fluorine-18-fluorodeoxyglucose PET/CT scans. We investigated the association of five parameters derived from PET/CT with clinicopathological characteristics. Immunohistochemistry was utilized to evaluate the expression of glucose transporter protein-1 (GLUT-1), TP53-induced glycolysis and apoptosis regulator (TIGAR), and vascular endothelial growth factor (VEGF), and the correlation between PET/CT parameters and the expression of GLUT-1, TIGAR, and VEGF was analyzed. In addition, we also investigated the correlation between disease-free survival of cervical cancer patients and PET/CT parameters.

RESULTS

The mean peak standardized uptake value (SUV)peak showed significant differences between all three International Federation of Gynecology and Obstetrics stages (P<0.001-0.032). The patients with lymph node metastasis had significantly higher SUVpeak, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) compared with those with the absence of lymph node metastasis (P=0.038, 0.024, and 0.010, respectively). All the five parameters showed an association with tumor size and cervical stromal invasion depth. Immunohistochemistry results indicated that the SUVpeak showed the highest association with the expression of GLUT-1, TIGAR, and VEGF (rs=0.705, P<0.001, rs=-0.466, P<0.001, rs=0.580, P<0.001, respectively) in these five parameters. The survival analysis showed that SUVpeak, MTV, and TLG were correlated with disease-free survival (P=0.042, P<0.001, and P=0.004, respectively).

CONCLUSION

Early-stage cervical cancer with high SUVpeak may reflect more aggressive behavior, and SUVpeak, MTV, and TLG can be used to predict the prognosis of early-stage cervical cancer patients. It may help with the choice of individualized treatment options.

The Utility of Pretreatment and Posttreatment Lymphopenia in Cervical Squamous Cell Carcinoma Patients Treated With Definitive Chemoradiotherapy

OBJECTIVE

The aim of this study was to investigate the prognostic significance of pretreatment and posttreatment lymphopenia in locally advanced squamous cell carcinoma (SCC) cervical cancer patients treated with definitive chemoradiotherapy (ChRT).

METHODS

Data from 95 patients with SCC were retrospectively analyzed. Relationships between pretreatment or posttreatment lymphopenia and patient or tumor characteristics, and overall survival (OS) and disease-free survival (DFS) were evaluated.

RESULTS

Median follow-ups for the entire cohort and survivors were 68 months (range, 3-133 months) and 88 months (range, 22-133 months), respectively. Ten patients (11%) exhibited pretreatment lymphopenia, whereas 58 patients (61%) exhibited posttreatment lymphopenia. Median pretreatment total lymphocyte counts decreased from 2029 cells/μL to 506 cells/μL 2 months after ChRT (P < 0.001). The 5-year OS and DFS rates were significantly higher in patients without pretreatment lymphopenia compared with patients with pre-retreatment lymphopenia (61% vs 20% [P < 0.001], 55% vs 20% [P < 0.001]). Patients without posttreatment lymphopenia had significantly higher 5-year OS and DFS rates than their counterparts (70% vs 46% [P = 0.02], 70% vs 39% [P = 0.004]). Complete response (CR) was observed in significantly fewer patients with pretreatment lymphopenia than in those without, after ChRT. Patients with posttreatment lymphopenia had higher rates of lymph node metastasis (P = 0.001) and lower posttreatment CR rates (P = 0.01) versus patients without posttreatment lymphopenia. In univariate analysis, International Federation of Gynecology and Obstetrics stage, tumor size, lymph node metastasis, and treatment response were prognostic for OS and DFS. In multivariate analysis, pretreatment lymphopenia, lymph node metastasis, and treatment response were independent predictors of OS and DFS. Age was predictive of OS. Tumor size was prognostic for DFS.

CONCLUSIONS

Pretreatment lymphopenia and posttreatment lymphopenia are associated with worse treatment response in patients given ChRT for cervical SCC. Pretreatment lymphopenia is predictive for OS and DFS. Therapeutic strategies including pretreatment or posttreatment immune preservation or modulation may improve response rates and survival in women with cervical SCC.

Combined pretreatment with 18F-FDG PET/CT and Comet assay guides the concurrent chemoradiotherapy of locally advanced cervical cancer: study protocol for a randomized controlled trial

Background

Cisplatin-based chemoradiation is the standard of care for patients with locally advanced cervical cancer. Nevertheless, an increasing number of radio-resistant tumors still recur.

Methods and design

Three hundred cervical cancer patients with FIGO stages IB2–IVA and no para-aortic lymphadenopathy (> 10 mm) will be enrolled. All patients will be randomly divided into four arms to receive either (1) intensity modulated radiation therapy (IMRT), (2) RapidArc, (3) positron emission tomography/computed tomography (PET/CT) with F-18 fluorodeoxyglucose (FDG), or (4) Comet assay-guided IMRT, PET/CT, and Comet assay-guided RapidArc. All patients will receive definitive radiotherapy consisting of external beam whole pelvic radiation therapy and high-dose rate intracavitary brachytherapy. Cisplatin 30 mg/m² weekly will be administered concurrently for five courses. Two to four cycles of TP (Taxol 135 mg/m², D1, and DDP 75 mg/m², D1–3) sequential chemotherapy will be performed according to MRI or PET/CT after cisplatin-based chemoradiation. The primary outcome measure is progression-free survival, and the second outcome measures are overall survival and time to progression.

Discussion

RapidArc has an obvious advantage in improving the degree of target coverage, improving organs at risk, sparing healthy tissue, and significantly reducing the treatment time. FDG-PET/CT can increase the agreement between biopsies and delineated tumor volume and has the potential to positively impact the course of treatment. The Comet assay is attractive as a potential clinical test of tumor radiosensitivity. During radiotherapy, accurately defining disease areas is critical to avoid the unnecessary irradiation of normal tissue. Based on FDG-PET/CT and Comet assay, higher doses can be safely delivered to accurate tumor volumes, while the doses to the bladder and rectum are relatively low.

Trial registration

ClinicalTrials.gov Protocol Registration and Results System Receipt Release Date: May 21, 2017 – Retrospectively registered. NCT03163979.

Prognostic model based on magnetic resonance imaging, whole-tumour apparent diffusion coefficient values and HPV genotyping for stage IB-IV cervical cancer patients following chemoradiotherapy

OBJECTIVES

To develop and validate a prognostic model of integrating whole-tumour apparent diffusion coefficient (ADC) from pretreatment diffusion-weighted (DW) magnetic resonance (MR) imaging with human papillomavirus (HPV) genotyping in predicting the overall survival (OS) and disease-free survival (DFS) for women with stage IB-IV cervical cancer following concurrent chemoradiotherapy (CCRT).

METHODS

We retrospectively analysed three prospectively collected cohorts comprising 300 patients with stage IB-IV cervical cancer treated with CCRT in 2007-2014 and filtered 134 female patients who underwent MR imaging at 3.0 T for final analysis (age, 24-92 years; median, 54 years). Univariate and multivariate Cox regression analyses were used to evaluate the whole-tumour ADC histogram parameters, HPV genotyping and relevant clinical variables in predicting OS and DFS. The dataset was randomly split into training (n = 88) and testing (n = 46) datasets for construction and independent bootstrap validation of the models.

RESULTS

The median follow-up time for surviving patients was 69 months (range, 9-126 months). Non-squamous cell type, ADC₁₀ <0.77 × 10^-3 mm²/s, T3-4, M1 stage and high-risk HPV status were selected to generate a model, in which the OS and DFS for the low, intermediate and high-risk groups were significantly stratified (p < 0.0001). The prognostic model improved the prediction significantly compared with the International Federation of Gynaecology and Obstetrics (FIGO) stage for both the training and independent testing datasets (p < 0.0001).

CONCLUSIONS

The prognostic model based on integrated clinical and imaging data could be a useful clinical biomarker to predict OS and DFS in patients with stage IB-IV cervical cancer treated with CCRT.

KEY POINTS

• ADC ₁₀ is the best prognostic factor among ADC parameters in cervical cancer treated with CCRT • A novel prognostic model was built based on histology, ADC ₁₀ , T and M stage and HPV status • The prognostic model outperforms FIGO stage in the survival prediction.

Understanding the Connection between Nanoparticle Uptake and Cancer Treatment Efficacy using Mathematical Modeling

Nanoparticles have shown great promise in improving cancer treatment efficacy while reducing toxicity and treatment side effects. Predicting the treatment outcome for nanoparticle systems by measuring nanoparticle biodistribution has been challenging due to the commonly unmatched, heterogeneous distribution of nanoparticles relative to free drug distribution. We here present a proof-of-concept study that uses mathematical modeling together with experimentation to address this challenge. Individual mice with 4T1 breast cancer were treated with either nanoparticle-delivered or free doxorubicin, with results demonstrating improved cancer kill efficacy of doxorubicin loaded nanoparticles in comparison to free doxorubicin. We then developed a mathematical theory to render model predictions from measured nanoparticle biodistribution, as determined using graphite furnace atomic absorption. Model analysis finds that treatment efficacy increased exponentially with increased nanoparticle accumulation within the tumor, emphasizing the significance of developing new ways to optimize the delivery efficiency of nanoparticles to the tumor microenvironment.

(18F)-FDG PET/CT parameters to predict survival and recurrence in patients with locally advanced cervical cancer treated with chemoradiotherapy

PURPOSE

To identify predictive (¹⁸F)-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT)-based parameters for locoregional control, disease-free survival and overall survival, by testing different thresholds of metabolic tumor volume and total lesion glycolysis in patients with locally-advanced cervical cancer.

PATIENTS AND METHODS

Thirty-seven patients treated with standard chemoirradiation underwent a pretreatment (¹⁸F)-FDG-PET/CT. Using different thresholds of maximum standardized uptake value, the following PET parameters were computed: maximum standardized uptake value, mean standardized uptake value, metabolic tumor volume and total lesion glycolysis for primary tumor and lymph nodes and a new parameter combining the metabolic tumor volume and the distance between lymph nodes and the primary tumor, namely metabolic node distance. Correlation between PET and clinical parameters with clinical outcome (overall survival, disease-free survival, and locoregional control) was assessed using univariate and multivariate analyses (Cox model).

RESULTS

In univariate analyses, PET/CT parameters associated with overall survival and disease-free survival were: metabolic tumor volume and total lesion glycolysis of the primary tumor, total lesion glycolysis of lymph nodes and metabolic node distance. The most predictive threshold segmentation for metabolic tumor volume and total lesion glycolysis was 48% of maximum standardized uptake value for the primary tumor and 30% for the lymph nodes. In multivariate Cox analysis, the total lesion glycolysis of primary tumor 48% and metabolic node distance were the two independent risk factors for overall survival (P<0.01), disease-free survival (P<0.01) and locoregional control (P=0.046).

CONCLUSION

Total lesion glycolysis of primary tumor and distance between the invaded positive lymph node and the primary tumor seem to have the highest predictive value when compared to classical clinical prognostic parameters and may be useful to identify high risk groups at time of diagnosis and to tailor the therapeutic approach in locally-advanced cervical cancer.

Pretreatment metabolic tumour volume and total lesion glycolysis are not independent prognosticators for locally advanced cervical cancer patients treated with chemoradiotherapy

OBJECTIVE

To evaluate the prognostic significance of metabolic parameters derived from fludeoxyglucose (FDG) positron emission tomography (PET)/CT, in cervical cancer patients treated with concurrent chemoradiotherapy.

METHODS

We retrospectively reviewed medical records from 129 biopsy-proven non-metastatic cervical cancer patients treated with external radiotherapy and intracavitary brachytherapy at our department. Correlation between metabolic parameters and tumour characteristics was evaluated. Prognostic factors for survival, local control and distant metastasis were analysed.

RESULTS

The median follow up for all patients and surviving patients was 30.0 months (range, 3.7-94.7 months) and 50.5 months (range, 14.5-94.7 months), respectively. The 2- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 68 42, 54 and 38%, respectively. The maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV) and total lesion glycolysis were significantly higher in patients with larger tumours (>4 cm) and partial regression or progressive disease after definitive treatment compared to patients with smaller tumour (≤4 cm) and post-treatment complete response. On univariate analysis, stage, lymph node metastasis, tumour size >4 cm, SUVmax, MTV, SUVmean and total lesion glycolysis were prognostic factors for OS and DFS. On multivariate analysis, only larger tumour and presence of lymph node metastasis were significant prognostic factors for both OS and DFS. Additionally, extensive stage was a significant prognosticator for DFS.

CONCLUSION

Although, metabolic parameters derived from FDG-PET/CT had a prognostic significance in univariate analysis, the significance was lost in multivariate analysis where tumour stage, size and lymph node status were the only independent parameters. Advances in knowledge: The clinical benefit of using FDG-PET/CT metabolic parameters to evaluate the high-risk patients among cervical cancer patients and to eventually change patient management still needs further clarification.

Parameters of simultaneous 18F-FDG-PET/MRI predict tumor stage and several histopathological features in uterine cervical cancer

The purpose of this study was to analyze associations between apparent diffusion coefficient (ADC) and standardized uptake values (SUV) values and different histopathological parameters in uterine cervical cancer. 21 patients with primary uterine cervical cancer were involved into the study. All patients underwent a whole body simultaneous¹⁸F-FDG PET/MRI. Mean and maximum SUV were noted (SUV_mean and SUV_max). In all tumors minimal, mean, and maximal ADC values (ADC_min, ADC_mean, and ADC_max) were estimated. Combined parameters were calculated: SUV_max/SUV_mean, ADC_min/ ADC_mean, SUV_max/ADC_min and SUV_max/ADC_mean. In all cases the diagnosis was confirmed histopathologically by tumor biopsy. Histological slices were stained by hematoxilin and eosin, MIB 1 monoclonal antibody, and p16. All histopathological images were digitalized and analyzed by using a ImageJ software 1.48v. The following parameters were estimated: cell count, proliferation index KI 67, total and average nucleic areas, epithelial and stromal areas. Spearman's correlation coefficient was used to analyze associations between ADC and SUV values and histological parameters. P values ≤ 0.05 were considered as statistically significant. ADC_min and ADC_min/ ADC_mean were statistically significant lower in N positive tumors. KI 67 correlated statistically significant with SUV_max (r = 0.59, p = 0.005), SUV_mean (0.45, p = 0.04), ADC_min (r = −0.48, p = 0.03), SUV_max/ADC_min (r = 0.71, p = 0.001), SUV_max/ADC_mean (0.75, p = 0.001). SUV_max correlated well with epithelial area (r = 0.71, p = 0.001) and stromal areas (r = −0.71, p = 0.001). SUV values, ADC_min, SUV_max/ADC_min and SUV_max/ADC_mean correlated statistically significant with KI 67 and can be used to estimate the proliferation potential of tumors. SUV values correlated strong with epithelial area of tumor reflected metabolic active areas.

Apparent diffusion coefficient for prediction of parametrial invasion in cervical cancer: a critical evaluation based on stratification to a Likert scale using T2-weighted imaging

PURPOSE

To evaluate the value of apparent diffusion coefficient (ADC) for determining parametrial invasion (PMI) in cervical cancer, by stratifying them into subgroups based on a Likert scale using T2-weighted imaging (T2WI).

MATERIALS AND METHODS

This retrospective study included 87 patients with FIGO stage IA2-IIB cervical cancer who underwent preoperative MRI followed by radical hysterectomy. Radiological PMI was assessed on T2WI using a six-point Likert scale and ADC values of the tumors were measured. MRI findings were compared between patients with and without PMI. Differences in ADC according to the Likert scale were also assessed.

RESULTS

19 (21.8%) patients had pathological PMI. The prevalence of PMI was significantly associated with Likert scale (P < 0.001). ADC values significantly differed according to Likert scale (P < 0.001). However, only tumors with a Likert score of 0 (MRI-invisible) had significantly greater ADC than others (P < 0.001) while no significant difference was observed among tumors with Likert scores of 1-5 (P = 0.070-0.889). Patients with PMI had significantly lower ADC values than those without PMI (P = 0.034). However, no significant difference was seen between patients with and without PMI within each Likert score group (P = 0.180-0.857).

CONCLUSION

T2WI-based Likert score for radiological PMI and ADC values of the tumor were significantly associated with pathological PMI. However, the apparent association seen between ADC values and PMI may be due to contribution of high ADC values of MRI-invisible tumors rather than reflecting their relationship.

The value of advanced MRI techniques in the assessment of cervical cancer: a review

OBJECTIVES

To assess the value of new magnetic resonance imaging (MRI) techniques in cervical cancer.

METHODS

We searched PubMed and MEDLINE and reviewed articles published from 1990 to 2016 to identify studies that used MRI techniques, such as diffusion weighted imaging (DWI), intravoxel incoherent motion (IVIM) and dynamic contrast enhancement (DCE) MRI, to assess parametric invasion, to detect lymph node metastases, tumour subtype and grading, and to detect and predict tumour recurrence.

RESULTS

Seventy-nine studies were included. The additional use of DWI improved the accuracy and sensitivity of the evaluation of parametrial extension. Most studies reported improved detection of nodal metastases. Functional MRI techniques have the potential to assess tumour subtypes and tumour grade differentiation, and they showed additional value in detecting and predicting treatment response. Limitations included a lack of technical standardisation, which limits reproducibility.

CONCLUSIONS

New advanced MRI techniques allow improved analysis of tumour biology and the tumour microenvironment. They can improve TNM staging and show promise for tumour classification and for assessing the risk of tumour recurrence. They may be helpful for developing optimised and personalised therapy for patients with cervical cancer.

TEACHING POINTS

• Conventional MRI plays a key role in the evaluation of cervical cancer. • DWI improves tumour delineation and detection of nodal metastases in cervical cancer. • Advanced MRI techniques show promise regarding histological grading and subtype differentiation. • Tumour ADC is a potential biomarker for response to treatment.

Molecular Imaging and Precision Medicine in Uterine and Ovarian Cancers

Gynecologic cancer is a heterogeneous group of diseases both functionally and morphologically. Today, PET coupled with computed tomography (PET/CT) or PET/MR imaging play a central role in the precision medicine algorithm of patients with gynecologic malignancy. In particular, PET/CT and PET/MR imaging are molecular imaging techniques that not only are useful tools for initial staging and restaging but provide anatomofunctional insight and can serve as predictive and prognostic biomarkers of response in patients with gynecologic malignancy.

Comparison of FDG PET metabolic tumour volume versus ADC histogram: prognostic value of tumour treatment response and survival in patients with locally advanced uterine cervical cancer

OBJECTIVE

To evaluate the prognostic utility of volume-based parameters of fluorine-18 fludeoxyglucose positron emission tomography (¹⁸F-FDG PET) and apparent diffusion coefficient (ADC) histogram analysis for tumour response to therapy and event-free survival (EFS) in patients with uterine cervical cancer receiving chemoradiotherapy.

METHODS

The study included 21 patients diagnosed with locally advanced uterine cervical cancer who underwent pre-treatment MRI and ¹⁸F-FDG PET and were treated with concurrent chemoradiotherapy. ¹⁸F-FDG parameters: maximum and mean standardized uptake value; metabolic tumour volume (MTV); total lesion glycolysis (TLG); ADC parameters: maximum, mean and minimum values; percentile ADC values (10-90%); skewness and kurtosis of ADC were measured and compared between the responder and non-responder groups using a Wilcoxon rank-sum test. The Cox regression analysis and Kaplan-Meier survival curves were performed for EFS analysis.

RESULTS

MTV and TLG of the primary tumour were significantly higher in the non-responder group than in the responder group (p = 0.04 and p = 0.01). Applying Cox regression multivariate analysis, MTV [hazard ratio (HR), 4.725; p = 0.036], TLG (HR, 4.725; p = 0.036) and 10-percentile ADC (HR, 5.207; p = 0.048) showed a statistically significant association with EFS. With the optimal cut-off value, the EFS rates above the cut-off value for MTV and TLG were significantly lower than that below the cut-off value (p = 0.002 and p = 0.002).

CONCLUSION

Pre-treatment volume-based quantitative parameters of ¹⁸F-FDG PET may have better potential than ADC histogram for predicting treatment response and EFS in patients with locally advanced cervical cancer. Advances in knowledge: In this study, pre-treatment volume-based quantitative parameters of ¹⁸F-FDG PET had better potential than ADC histogram for predicting treatment response and survival in patients with locally advanced cervical cancer.

Role of Imaging in the Era of Precision Medicine

Precision medicine is an emerging approach for treating medical disorders, which takes into account individual variability in genetic and environmental factors. Preventive or therapeutic interventions can then be directed to those who will benefit most from targeted interventions, thereby maximizing benefits and minimizing costs and complications. Precision medicine is gaining increasing recognition by clinicians, healthcare systems, pharmaceutical companies, patients, and the government. Imaging plays a critical role in precision medicine including screening, early diagnosis, guiding treatment, evaluating response to therapy, and assessing likelihood of disease recurrence. The Association of University Radiologists Radiology Research Alliance Precision Imaging Task Force convened to explore the current and future role of imaging in the era of precision medicine and summarized its finding in this article. We review the increasingly important role of imaging in various oncological and non-oncological disorders. We also highlight the challenges for radiology in the era of precision medicine.

Primary and metastatic ovarian cancer: Characterization by 3.0T diffusion-weighted MRI

Objectives

We aimed to investigate whether apparent diffusion coefficients (ADCs) measured by 3.0T diffusion-weighted magnetic resonance imaging (DWI) associate with histological aggressiveness of ovarian cancer (OC) or predict the clinical outcome. This prospective study enrolled 40 patients with primary OC, treated 2011-2014.

Methods

DWI was performed prior to surgery. Two observers used whole lesion single plane region of interest (WLsp-ROI) and five small ROIs (S-ROI) to analyze ADCs. Samples from tumours and metastases were collected during surgery. Immunohistochemistry and quantitative reverse transcription polymerase chain reaction (qRT-PCR) were used to measure the expression of vascular endothelial growth factor (VEGF) and its receptors.

Results

The interobserver reliability of ADC measurements was excellent for primary tumours ICC 0.912 (WLsp-ROI). Low ADCs significantly associated with poorly differentiated OC (WLsp-ROI P = 0.035). In primary tumours, lower ADCs significantly associated with high Ki-67 (P = 0.001) and low VEGF (P = 0.001) expression. In metastases, lower ADCs (WLsp-ROI) significantly correlated with low VEGF receptors mRNA levels. ADCs had predictive value; 3-year overall survival was poorer in patients with lower ADCs (WLsp-ROI P = 0.023, S-ROI P = 0.038).

Conclusion

Reduced ADCs are associated with histological severity and worse outcome in OC. ADCs measured with WLsp-ROI may serve as a prognostic biomarker of OC.

Key Points

• Reduced ADCs correlate with prognostic markers: poor differentiation and high Ki-67 expression

• ADCs also significantly correlated with VEGF protein expression in primary tumours

• Lower ADC values are associated with poorer survival in ovarian cancer

• Whole lesion single plane-ROI ADCs may be used as a prognostic biomarker in OC

Application of magnetic resonance imaging in diagnosis of Uterus Cervical Carcinoma

BACKGROUND AND OBJECTIVE

Effective treatment of Uterus Cervical Carcinoma (UCC) rely heavily on the precise pre-surgical staging. The conventional International Federation of Gynecology and Obstetrics (FIGO) system based on clinical examination is being applied worldwide for UCC staging. Yet its performance just appears passable. Thus, this study aims to investigate the value of applying Magnetic Resonance Imaging (MRI) with clinical examination in staging of UCC.

MATERIALS AND METHODS

A retrospective dataset involving 164 patients diagnosed with UCC was enrolled in this study. The mean age of this study population was 46.1 years (range, 28-#x2013;75 years). All patients underwent operations and UCC types were confirmed by pathological examinations. The tumor stages were determined by two experienced Gynecologist independently based on FIGO examinations and MRI. The diagnostic results were also compared with the post-operative pathologic reports. Statistical data analysis on diagnostic performance was then done and reported.

RESULTS

The study results showed that the overall accuracy of applying MRI in UCC staging was 82.32%, while using FIGO staging method, the staging accuracy was 59.15%.

CONCLUSIONS

MRI is suitable to evaluate tumor extent with high accuracy, and it can offer more objective information for the diagnosis and staging of UCC. Compared with clinical examinations based on FIGO, MRI illustrated relatively high accuracy in evaluating UCC staging, and is worthwhile to be recommended in future clinical practice.

Can Diffusion-weighted Magnetic Resonance Imaging Predict Survival in Patients with Cervical Cancer? A Meta-Analysis

OBJECTIVE

Although diffusion-weighted magnetic resonance imaging (DWI) has been widely used in the diagnosis of cervical cancer, whether it can predict disease recurrence or survival remains inconclusive. This study aimed to systematically evaluate whether DWI can serve as a reliable prognostic predictor in patients with cervical cancer.

METHODS

PubMed, the MEDLINE database and the Cochrane Library were searched for DWI studies with >12 months of prognostic data in patients with cervical cancer. Endpoints included tumor recurrence and death. Methodological quality was assessed using the Quality in Prognostic Studies (QUIPS) tool. Combined estimates of hazard ratios (HRs) were derived.

RESULTS

Nine studies involving a total of 796 patients (mean/median age from 45.0 years to 62.9 years) met the inclusion criteria. Methodological quality was relatively high. Eight of the nine studies employed apparent diffusion coefficient (ADC) as an indicator of DWI results. Using disease-free survival (DFS) as an outcome measure, nine studies yielded a combined HR of 1.55 (95% confidence interval (CI): 1.23-1.95), and seven studies that employed pretreatment DWI yielded a combined HR of 1.50 (95% CI: 1.03-2.19), which indicated that unfavorable DWI results were associated with an approximately 1.50-1.55-fold higher risk of tumor recurrence. The two studies investigating the impact of DWI results on overall survival (OS) reported HRs of 7.20 and 2.17, respectively.

CONCLUSION

DWI may serve as a predictor of tumor recurrence in patients with cervical cancer as showed by meta-analysis, and the quantified ADC as a suitable candidate indicator.

Diffusion-Weighted Magnetic Resonance Imaging as a Predictor of Outcome in Cervical Cancer After Chemoradiation

PURPOSE

To determine whether apparent diffusion coefficient (ADC) value is predictive of survival after definitive chemoradiation for cervical cancer independent of established imaging and clinical prognostic factors.

METHODS AND MATERIALS

Between 2011 and 2013, the pretreatment MRI scans for 69 patients treated with definitive chemoradiation for newly diagnosed cervical cancer were retrieved. Scans were acquired with a 1.5-T magnetic resonance scanner, including diffusion-weighted imaging sequences. Mean ADC value was measured within a region of interest in the primary cervical cancer on the baseline MRI scan. Baseline tumor maximum standardized uptake value on positron emission tomography/computed tomography was determined by the reading radiologist. Treatment included external beam radiation therapy to the pelvis followed by brachytherapy in 97%, and with concurrent weekly cisplatin in 99% of patients. Univariate and multivariate analyses were done to investigate the association of clinical and imaging variables with disease control and survival endpoints using a Cox proportional hazard test.

RESULTS

Median follow-up was 16.7 months (range, 3.1-44.2 months). The 1-year overall survival, locoregional recurrence-free survival, and disease-free survival rates were 91%, 86%, and 74%, respectively. The median ADC value was 0.941 × 10^-3 mm²/s (range, 0.256-1.508 × 10^-3 mm²/s). The median standardized uptake value in the primary tumor was 15 (range, 6.2-43.4). In multivariate analysis, higher ADC value (hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.15-0.85, P=.02), higher stage (HR 2.4, 95% CI 1.1-5.5, P=.033), and nonsquamous histology (HR 0.23, 95% CI 0.07-0.82, P=.024) were independent predictors of disease-free survival.

CONCLUSIONS

The mean ADC value of the primary tumor on pretreatment MRI was the only imaging feature that was an independent predictor of disease-free survival in cervical cancer patients treated with chemoradiation. Further validation will be needed to determine whether ADC values may prove useful in identifying cervical patients at high risk of recurrence.

Weekly response assessment of involved lymph nodes to radiotherapy using diffusion-weighted MRI in oropharynx squamous cell carcinoma

Purpose:

Patients with cancers of oropharynx have a favorable prognosis and are an ideal candidate for adaptive therapy. A replan to improve coverage or escalate/de-escalate dose based on morphological information alone may not be adequate as the grossly involved lymph nodes (LNs) of a subset of these patients tend to become cystic and often do not regress. Functional adaptation may be a better approach when considering replanning for these patients. The purpose of this study was to evaluate the weekly trends in treatment related morphological and physiological changes for these LNs using diffusion-weighted MRI (DW-MRI) and evaluate its implications for adaptive replanning.

Methods:

Ten patients with histologically proven oropharynx HNSCC undergoing concurrent chemoradiation were analyzed in this study. MR imaging protocol included axial T1w, T2w, and DW-MRI using a 3 T Philips MR scanner. The patients were scanned weekly in radiation treatment planning position using a 16 element phased-array anterior coil and a 44 element posterior coil. A total of 65 DWI and T2w scans were analyzed. DWI was performed using an optimized single-shot echo planar imaging sequence (TR/TE = 5000/65 ms, slice thickness = 5 mm; slices = 28; b values = 0 and 800 s/mm²). Quantification of the DW-MRI images was performed by calculating the apparent diffusion coefficient (ADC). T2w and DWI scans were imported into the Eclipse treatment planning system and gross tumor volumes (GTVs) corresponding to grossly involved LNs were contoured on each axial slice by physician experts. An attempt was made to remove any cystic or necrotic components so that the ADC analysis was of viable tumor only. A pixel-by-pixel fit of signal intensities within the GTVs was performed assuming monoexponential behavior. From each GTV histogram mean, median, standard deviation, skewness, and kurtosis were calculated. Absolute and percent change in weekly ADC histogram parameters and percent change in T2w GTV were also calculated.

Results:

For all nodes, an immediate change in ADC was observed during first 2–3 weeks after which ADC values either continued to increase or plateaued. A few nodal volumes had a slightly decreased ADC value during later weeks. Percent increase in median ADC from weeks 1 to 6 with respect to baseline was 14%, 25%, 41%, 42%, 45%, and 58%. The corresponding change in median T2 volumes was 8%, 10%, 16%, 22%, 40%, and 42%, respectively. The ADC distribution of the viable tumors was initially highly kurtotic; however, the kurtosis decreased as treatment progressed. The ADC distribution also showed a higher degree of skewness in the first 2 weeks, progressively becoming less skewed as treatment progressed so as to slowly approach a more symmetric distribution.

Conclusions:

Physiological changes in LNs represented by changes in ADC evaluated using DW-MRI are evident sooner than the morphological changes calculated from T2w MRI. The decisions for adaptive replanning may need to be individualized and should be based primarily on tumor functional information. The authors’ data also suggest that for many patients, week 3 maybe the optimal time to intervene and replan. Larger studies are needed to confirm their findings.

Treatment response evaluation using the mean apparent diffusion coefficient in cervical cancer patients treated with definitive chemoradiotherapy

PURPOSE

To investigate the pre- and posttreatment mean apparent diffusion coefficient (ADCmean ) of cervical cancer tumors treated with definitive chemoradiotherapy (CRT) and evaluate their correlation with recurrence and survival rates.

MATERIALS AND METHODS

Forty-four patients with cervical squamous cell carcinoma were retrospectively evaluated. All patients underwent multiparametric 1.5T magnetic resonance imaging (MRI) including T2 -weighted, fat-saturated T2 -weighted, dynamic contrast-enhanced (DCE), and diffusion-weighted imaging (DWI) sequences before and after treatment. Posttreatment MR images were acquired within a median of 3.2 months (range, 2.8-4.1 months) after completing CRT. We assessed the impact of primary tumor pre- and posttreatment ADC values on prognostic factors and treatment outcomes.

RESULTS

The pre- and posttreatment ADCmean values were 0.882 ± 0.096 × 10(-3) mm(2) /sec and 1.159 ± 0.168 × 10(-3) mm(2) /sec, respectively, and the difference was statistically significant (P < 0.001). The median percent ADC change was 33.7% (range, 5.0-70.0%). Patients with disease recurrence had lower ADC values, both pretreatment (0.822 ± 0.096 × 10(-3) mm(2) /sec vs. 0.936 ± 0.058 × 10(-3) mm(2) /sec; P < 0.001) and posttreatment (1.060 ± 0.116 × 10(-3) mm(2) /sec vs. 1.248 ± 0.160 × 10(-3) mm(2) /sec; P < 0.001). The ADC change was lower in patients with recurrence (25.7% ± 13.0% vs. 42.8% ± 15.7; P < 0.001) than in patients without recurrence. In multivariate analysis, pelvic lymph node metastasis and pretreatment ADCmean were prognostic factors for overall survival (OS) and disease-free survival (DFS). ADC change between pre- and posttreatment DW-MRI was a prognostic factor for OS.

CONCLUSION

DWI parameters, measured before and after treatment, may be useful prognostic biomarkers for tumor burden, recurrence, and survival in cervical cancer patients treated with CRT. The primary tumor pretreatment ADCmean is an independent prognostic factor for DFS and OS. J. MAGN. RESON. IMAGING 2016;44:1010-1019.

Pre-treatment MRI minimum apparent diffusion coefficient value is a potential prognostic imaging biomarker in cervical cancer patients treated with definitive chemoradiation

Background

Diffusion Weighted (DW) Magnetic Resonance Imaging (MRI) has been studed in several cancers including cervical cancer. This study was designed to investigate the association of DW-MRI parameters with baseline clinical features and clinical outcomes (local regional control (LRC), disease free survival (DFS) and disease specific survival (DSS)) in cervical cancer patients treated with definitive chemoradiation.

Methods

This was a retrospective study approved by an institutional review board that included 66 women with cervical cancer treated with definitive chemoradiation who underwent pre-treatment MRI at our institution between 2012 and 2013. A region of interest (ROI) was manually drawn by one of three radiologists with experience in pelvic imaging on a single axial CT slice encompassing the widest diameter of the cervical tumor while excluding areas of necrosis. The following apparent diffusion coefficient (ADC) values (×10⁻³ mm²/s) were extracted for each ROI: Minimum - ADC_min, Maximum - ADC_max, Mean - ADC_mean, and Standard Deviation of the ADC - ADC_dev. Receiver operating characteristic (ROC) curves were built to choose the most accurate cut off value for each ADC value. Correlation between imaging metrics and baseline clinical features were evaluated using the Mann Whitney test. Confirmatory multi-variate Cox modeling was used to test associations with LRC (adjusted by gross tumor volume – GTV), DFS and DSS (both adjusted by FIGO stage). Kaplan Meyer curves were built for DFS and DSS. A p-value < 0.05 was considered significant.

Women median age was 52 years (range 23–90). 67 % had FIGO stage I-II disease while 33 % had FIGO stage III-IV disease. Eighty-two percent had squamous cell cancer. Eighty-eight percent received concurrent cisplatin chemotherapy with radiation. Median EQD2 of external beam and brachytherapy was 82.2 Gy (range 74–84).

Results

Women with disease staged III-IV (FIGO) had significantly higher mean ADC_max values compared with those with stage I-II (1.806 (0.4) vs 1.485 (0.4), p = 0.01). Patients with imaging defined positive nodes also had significantly higher mean (±SD) ADC_max values compared with lymph node negative patients (1.995 (0.3) vs 1.551 (0.5), p = 0.03).

With a median follow-up of 32 months (range 5–43) 11 patients (17 %) have developed recurrent disease and 8 (12 %) have died because of cervical cancer. ROC curves based on DSS showed optimal cutoffs for ADC_min (0.488 × 10⁻³), ADC_mean (0.827 × 10⁻³), ADC_max (1.838 × 10⁻³) and ADC_dev (0.148 × 10⁻³). ADC_min higher than the cutoff was significantly associated with worse DFS (HR = 3.632–95 % CI: 1.094–12.054; p = 0.035) and DSS (HR = 4.401–95 % CI: 1.048–18.483; p = 0.043).

Conclusion

Pre-treatment ADC_max measured in the primary tumor may be associated with FIGO stage and lymph node status. Pre-treatment ADC_min may be a prognostic factor associated with disease-free survival and disease-specific survival in cervical cancer patients treated with definitive chemoradiation. Prospective validation of these findings is currently ongoing.

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

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

Primary tumor SUVmax on preoperative FDG-PET/CT is a prognostic indicator in stage IA2-IIB cervical cancer patients treated with radical hysterectomy

The objective of the present study was to investigate the prognostic value of ¹⁸F-fluoro-2-deoxy-D-glucose (FDG) uptake by primary tumors on positron emission tomography/computed tomography (PET/CT) in surgically resectable cervical cancer. A total of 59 patients with stage IA2-IIB cervical cancer who underwent preoperative FDG-PET/CT, followed by radical hysterectomy and lymphadenectomy, were included in the study. The maximum standardized uptake value (SUV_max) of the primary tumor was measured, and the association between the SUV_max and clinicopathological factors or patient outcomes was analyzed. The SUV_max was significantly higher in patients with an advanced stage, lymph node metastasis, lymph-vascular space involvement and large tumors. The overall survival (OS) and progression-free survival (PFS) of patients with a high SUV_max were significantly lower compared with patients with a low SUV_max, using an optimal cut-off value of 7.36 for OS and 5.59 for PFS obtained from receiver operating characteristic curve analysis. Similarly, OS and PFS in patients with a high SUV_max were significantly lower in 39 patients with stage IB using a cut-off value of 7.90 and 6.69 for OS and PFS, respectively. Finally, multivariate analyses showed that the SUV_max of the primary tumor was an independent prognostic factor for impaired PFS in all patients and those with stage IB alone. These findings demonstrated that a high SUV_max on preoperative PET/CT was correlated with unfavorable clinical outcomes in patients receiving radical hysterectomy, suggesting that the SUV_max of the primary tumor may be a prognostic indicator for surgically-treated, early-stage invasive cervical cancer.

Prognostic Use of Pretreatment Hematologic Parameters in Patients Receiving Definitive Chemoradiotherapy for Cervical Cancer

OBJECTIVES

The aim of this work was to evaluate the prognostic role of pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in recipients of definitive chemoradiotherapy (ChRT) for cervical cancer.

METHODS

In 235 patients given definitive ChRT for histologically confirmed cervical cancer, clinical data and pretreatment complete blood cell counts were analyzed. Prognostic and therapeutic ramifications of NLR and PLR were assessed.

RESULTS

Median pretreatment NLR and PLR were 3.03 (range, 1.04-13.03) and 133.02 (range, 36.3-518.16), respectively. Both NLR and PLR correlated significantly with tumor size, lymph node metastasis, and treatment response. In addition to NLR and PLR, tumor stage, size, and nodal metastasis were identified by univariate analysis as significant predictors of overall survival (OS) and progression-free survival (PFS). By multivariate analysis, independent predictors of OS and PFS were NLR (OS: hazard ratio [HR], 3.322; 95% confidence interval [CI], 1.905-5.790; PFS: HR, 3.579; 95% CI, 2.106-6.082; both P < 0.001) and lymph node metastasis (OS: HR, 2.620; 95% CI, 1.706-4.023; PFS: HR, 2.989; 95% CI, 1.918-4.378; both P < 0.001), although patients' age (HR, 1.019; 95% CI, 1.003-1.035; P = 0.02) was also significantly predictive of OS.

CONCLUSIONS

Pretreatment NLR and PLR were associated with larger tumors, lymph node metastasis, and poorer therapeutic responses to definitive ChRT. By multivariate analysis, pretreatment NLR and lymph node metastasis were found independently predictive of OS and PFS, whereas patients' age was significantly predictive of OS only. In patients with advanced cervical cancer, NLR is a potential biomarker, serving to guide systemic therapy and predict treatment outcomes.

Advances in diagnosis and treatment of metastatic cervical cancer

Cervical cancer is one of the most common cancers in women worldwide. The outcome of patients with metastatic cervical cancer is poor. We reviewed the relevant literature concerning the treatment and diagnosis of metastatic cervical cancer. There are two types of metastasis related to different treatments and survival rates: hematogenous metastasis and lymphatic metastasis. Patients with hematogenous metastasis have a higher risk of death than those with lymphatic metastasis. In terms of diagnosis, fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) and PET-computed tomography are effective tools for the evaluation of distant metastasis. Concurrent chemoradiotherapy and subsequent chemotherapy are well-tolerated and efficient for lymphatic metastasis. As for lung metastasis, chemotherapy and/or surgery are valuable treatments for resistant, recurrent metastatic cervical cancer and chemoradiotherapy may be the optimal choice for stage IVB cervical cancer. Chemotherapy and bone irradiation are promising for bone metastasis. A better survival is achieved with multimodal therapy. Craniotomy or stereotactic radiosurgery is an optimal choice combined with radiotherapy for solitary brain metastases. Chemotherapy and palliative brain radiation may be considered for multiple brain metastases and other organ metastases.

Correlation between histological grade and positron emission tomography parameters in cervical carcinoma

The aim of the present study was to evaluate the changes in cervical cancer glucose metabolism for different levels of cellular differentiation. The metabolic activity was measured by standardized uptake value (SUV), SUV normalized to lean body mass, metabolic tumor volume and total lesion glycolysis using fluorine-18 fluorodeoxyglucose positron emission tomography (PET). A correlation study of these values could be used to facilitate therapeutic choice and to improve clinical practice and outcome. This study considered 32 patients with diagnosed cervical cancers, at different International Federation of Gynecology and Obstetrics stages. Glucose metabolism was assessed by PET examination, and histological specimens were examined to determine their initial grade of differentiation. A correlation study of these values was evaluated. Histological examination showed that all cases were of squamous cell carcinoma. Regarding the differentiation of the tumor, 19 well- to moderately-differentiated tumors and 13 poorly-differentiated tumors were determined. Negative findings for correlations between metabolic parameters and initial grade of histological differentiation were found, and considering that histological grade has been shown to have no consistent prognostic value in cervical cancer treatment, PET imaging could play a significant role in cervical cancer prognosis.

Multiparametric [18F]Fluorodeoxyglucose/ [18F]Fluoromisonidazole Positron Emission Tomography/ Magnetic Resonance Imaging of Locally Advanced Cervical Cancer for the Non-Invasive Detection of Tumor Heterogeneity: A Pilot Study

Objectives

To investigate fused multiparametric positron emission tomography/magnetic resonance imaging (MP PET/MRI) at 3T in patients with locally advanced cervical cancer, using high-resolution T2-weighted, contrast-enhanced MRI (CE-MRI), diffusion-weighted imaging (DWI), and the radiotracers [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG) and [¹⁸F]fluoromisonidazol ([¹⁸F]FMISO) for the non-invasive detection of tumor heterogeneity for an improved planning of chemo-radiation therapy (CRT).

Materials and Methods

Sixteen patients with locally advanced cervix were enrolled in this IRB approved and were examined with fused MP [¹⁸F]FDG/ [¹⁸F]FMISO PET/MRI and in eleven patients complete data sets were acquired. MP PET/MRI was assessed for tumor volume, enhancement (EH)-kinetics, diffusivity, and [¹⁸F]FDG/ [¹⁸F]FMISO-avidity. Descriptive statistics and voxel-by-voxel analysis of MRI and PET parameters were performed. Correlations were assessed using multiple correlation analysis.

Results

All tumors displayed imaging parameters concordant with cervix cancer, i.e. type II/III EH-kinetics, restricted diffusivity (median ADC 0.80x10^-3mm²/sec), [¹⁸F]FDG- (median SUV_max16.2) and [¹⁸F]FMISO-avidity (median SUV_max3.1). In all patients, [¹⁸F]FMISO PET identified the hypoxic tumor subvolume, which was independent of tumor volume. A voxel-by-voxel analysis revealed only weak correlations between the MRI and PET parameters (0.05–0.22), indicating that each individual parameter yields independent information and the presence of tumor heterogeneity.

Conclusion

MP [¹⁸F]FDG/ [¹⁸F]FMISO PET/MRI in patients with cervical cancer facilitates the acquisition of independent predictive and prognostic imaging parameters. MP [¹⁸F]FDG/ [¹⁸F]FMISO PET/MRI enables insights into tumor biology on multiple levels and provides information on tumor heterogeneity, which has the potential to improve the planning of CRT.

Different Prognostic Implications of 18F-FDG PET Between Histological Subtypes in Patients With Cervical Cancer

This study aimed to investigate whether the predictive values of intensity- and volume-based PET parameters are different between histological subtypes in patients with cervical cancer. Ninety patients, 65 with squamous cell carcinoma (SCC) and 25 with non-SCC (NSCC), who underwent pretreatment ¹⁸F-FDG PET/CT and pelvic MRI, were studied retrospectively. In addition to SUVmax and SUVmean, metabolic-tumor-volume (MTV) was determined by thresholding of 40% SUVmax and total-lesion-glycolysis (TLG) was calculated. Clinical factors and PET metabolic indices were compared between SCC and NSCC. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method with cut-offs determined by ROC analyses to stratify SCC and NSCC patients separately. Factors associated with survival were assessed with univariate and multivariate analyses using the Cox regression model. No significant differences were observed in clinical factors other than tumor size or ¹⁸F-FDG PET metabolic indices between SCC and NSCC. The Kaplan-Meier estimates of 2-year PFS and OS rates were 60% and 70% for SCC and 40% and 76% for NSCC, respectively. Multivariate analyses showed that MTV and TLG were the independent prognostic factors for PFS and OS in SCC; in contrast, SUVmax was the independent prognostic factor for PFS and OS in NSCC. Metabolic burden (MTV and TLG) could be beneficial for the prognostic prediction of cervical SCC patients; in contrast, metabolic intensity (SUVmax) could be beneficial for the prognostic prediction of NSCC patients. The different prognostic implications might be based on the differences of tissue integrity and histological heterogeneity between SCC and NSCC.

The Value of Diffusion-Weighted Imaging in Predicting the Prognosis of Stage IB-IIA Cervical Squamous Cell Carcinoma After Radical Hysterectomy

OBJECTIVE

The aim of the study was to investigate the value of mean apparent diffusion coefficient (ADC(mean)) value in predicting the prognosis of stage IB-IIA cervical squamous cell carcinoma (SCC) patients after radical hysterectomy.

MATERIALS AND METHODS

A total of 126 patients who were with stage IB-IIA cervical SCC and underwent magnetic resonance imaging examination and radical hysterectomy were retrospectively investigated. Receiver operating characteristic curve was used to determine the cutoff values of ADC(mean) for predicting earlier recurrence (2 consecutive increases in the SCC antigen value of more than 1 ng/mL or elevation of greater than 1.5 ng/mL). Disease-free survival and overall survival were analyzed using the Kaplan-Meier method, and differences between the survival curves were examined using the log-rank test.

RESULTS

Earlier recurrence was observed in 46 patients (36.2%) during a median follow-up of 22 months. The ADC(mean) value (P = 0.005), parametrial invasion (P = 0.049), and lymphovascular space invasion (P = 0.037) were significantly associated with earlier recurrence. Receiver operating characteristic curve identified that the cutoff value of ADC(mean) for predicting earlier recurrence was 0.785 × 10(-3)mm(2)/s. The ADC(mean) value, parametrial invasion, and lymphovascular space invasion were significantly associated with earlier recurrence. The hazard ratios were 7.33 (95% confidence interval [95% CI], 1.854-28.99), 4.88 (95% CI, 1.00-23.73), and 2.53 (95% CI, 1.058-6.052), respectively. Disease-free survival and overall survival rates of patients with the ADC(mean) less than 0.785 × 10(-3)mm(2)//s were significantly worse than those of patients with the ADC(mean) greater than or equal to 0.785 × 10(-3)mm(2)/s.

CONCLUSIONS

Mean ADC was a good biomarker in predicting the prognosis of stage IB-IIA cervical SCC after radical hysterectomy.

The impact of FDG-PET/CT in the management of patients with vulvar and vaginal cancer

OBJECTIVES

To evaluate the changes in prognostic impression and patient management following PET/CT in patients with vulvar and vaginal carcinoma; and to compare PET/CT findings with those of conventional imaging modalities.

METHODS

We summarized prospectively and retrospectively collected data for 50 consecutive patients from our institution that enrolled in the National Oncologic PET Registry and underwent FDG-PET/CT for a suspected or known primary or recurrent vulvar/vaginal cancer.

RESULTS

54/83 (65%) studies included had a diagnosis of vulvar cancer, and the remaining 29/83 (35%), a diagnosis of vaginal cancer. Following FDG-PET/CT, the physician's prognostic impression changed in 51% of cases. A change in patient management, defined as a change to/from a non-interventional strategy (observation or additional imaging), to/from an interventional strategy (biopsy or treatment), was documented in 36% of studies. The electronic records demonstrated that 95% of the management strategies recorded in the physician questionnaires were implemented as planned. MRI and/or CT were performed within one month of the FDG-PET/CT in 20/83 (24%) and 28/83 (34%) cases, respectively. FDG-PET/CT detected nodes suspicious for metastases on 29/83 (35%) studies performed. MRI and CT detected positive nodes on 6 and 11 studies respectively. Distant metastases were identified in 10 cases imaged with FDG-PET and 5 cases that had additional conventional CT imaging. All suspicious lesions seen on CT were positively identified on PET/CT. In 4 cases, an abnormality identified on PET/CT, was not seen on diagnostic CT.

CONCLUSIONS

FDG-PET/CT may play an important role in the management of vulvar and vaginal carcinoma.

Complementary Prognostic Value of Pelvic Magnetic Resonance Imaging and Whole-Body Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Pretreatment Assessment of Patients With Cervical Cancer

OBJECTIVE

The aim of this study was to evaluate the incremental prognostic value of pelvic magnetic resonance imaging (MRI) and whole-body F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings compared with clinical-histopathologic factors in patients with newly diagnosed cervical cancer.

METHODS

The institutional review board approved this retrospective study of 114 patients (median age, 40.6 years) with International Federation of Gynecology and Obstetrics (FIGO) stage I-IVB cervical cancer who underwent pretreatment MRI and PET/CT. All scans were reviewed for locoregional tumor extent, pelvic or/and para-aortic lymphadenopathy, and distant metastases. Univariate Cox proportional hazard regression was performed to evaluate associations between clinical-histopathologic factors, imaging findings, and progression-free survival (PFS). Multivariate models were built using independent predictors for PFS. Harrell C was used to measure concordance (C index).

RESULTS

Forty patients progressed within a median time of 10.4 months (range, 0.4-40.3 months). At univariate analysis, age, FIGO stage, tumor histology, tumor grade, and all MRI and PET/CT features were significantly associated with PFS (P < 0.0001 to P = 0.0474). A multivariate model including clinical and imaging parameters (parametrial invasion on MRI and para-aortic lymphadenopathy/distant metastases on PET/CT) had significantly higher concordance for predicting PFS than a model including clinical parameters only (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.68 [95% confidence interval, 0.59-0.78]; P < 0.001). The comparison of C indices for the combined clinical and imaging model approached significance when compared with a FIGO stage model (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.75 [95% confidence interval, 0.69-0.82]; P = 0.058).

CONCLUSIONS

In patients with newly diagnosed cervical cancer, a prognostic model including combined MRI and PET/CT findings provides information that complements clinical and histopathologic factors.

Additional Prognostic Value of SUVmax Measured by F-18 FDG PET/CT over Biological Marker Expressions in Surgically Resected Cervical Cancer Patients

PURPOSE

We compared the prognostic ability of the maximum standardized uptake value (SUVmax) and various biological marker expressions to predict recurrence in patients with surgically resected cervical cancer.

METHODS

A retrospective review identified 60 patients with cervical cancer who received [18F]fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) at the time of the diagnosis of cancer. The SUVmax, expressions of carbonic anhydrase-IX (CA-IX), glucose transporter 1 (GLUT-1), and vascular endothelial growth factor (VEGF), and known prognostic factors were investigated.

RESULTS

The median follow-up time was 22.2 months (range 3.4-43.1 months). Using univariate analyses, the stage (stage II, p = 0.0066), SUVmax (> 6, p = 0.027), parametrial involvement (p < 0.0001), and positivity for CA-IX (p = 0.0191) were associated with recurrences of cervical cancer. With the Cox proportional hazard regression model, the SUVmax was a potent predictor for disease-free survival (DFS).

CONCLUSION

Although CA-IX expression was related to DFS in the current study, the potent predictor for DFS was SUVmax. Therefore, SUVmax is of greater prognostic value than biological marker expression in patients with surgically resected cervical cancer.

Magnetic resonance appearance of gastric-type adenocarcinoma of the uterine cervix in comparison with that of usual-type endocervical adenocarcinoma: a pitfall of newly described unusual subtype of endocervical adenocarcinoma

OBJECTIVE

The aim of this study was to evaluate the characteristics of gastric-type adenocarcinoma (GAS) of the uterine cervix, compared with usual-type endocervical adenocarcinoma (UEA) and squamous cell carcinoma (SCC), using magnetic resonance (MR) imaging.

MATERIALS AND METHODS

A total of 15 histopathologically defined GASs, 12 UEAs, and 40 SCCs were retrieved from archive files and were included for evaluation. Microscopic features, as well as topography and tumor growth pattern, and presence or absence of coexistence of cystic cavities were evaluated. Accuracy of evaluation for parametrial tissue and vaginal wall invasion was also evaluated by 2 diagnostic radiologists, independently, without clinical information on cases.

RESULTS

Thirteen (86.70%) of the 15 cases of GAS exhibited tumors in the higher portion of cervical canal or the entire cervix. On the other hand, SCCs and UEAs were mainly located in the lower portion of cervical canal, at a frequency of 21 of 40 (52.5%) and 9 of 12 (75.0%), respectively. Involvement of the corpus was observed more frequently in cases of GAS with an occurrence of 8 of 15 (53.3%), whereas in all cases of UEA and in 5 of the 40 cases of SCC, the corpus was free of tumor. In GAS cases, the predominant pattern of growth was highly infiltrating and endophytic (14/15, 93.3%), whereas an exophytic growth pattern was observed in 31 (77.5%) of the 40 SCC cases and 11 (91.7%) of the 12 UEA cases. Cystic cavities associated with tumors were identified in only 1 case of SCC but occurred in 12 (80.0%) of the 15 GASs and 4 (33.3%) of the 12 UEAs. Diagnostic accuracies of more than 70% and more than 60% were reached in parametrial invasion and vaginal invasion, respectively, in GAS.

CONCLUSION

Distinctive MR imaging features of GAS were infiltrating mass of endophytic growth, location in the upper cervical canal, and association with tiny cysts. This characteristic appearance can be a clue for the evaluation of extent of tumor based on MR imaging.

A literature review of the association between diffusion-weighted MRI derived apparent diffusion coefficient and tumour aggressiveness in pelvic cancer

Diffusion-weighted magnetic resonance imaging (DW-MRI) is used extensively to improve tumour detection and localization because it offers excellent soft tissue contrast between malignant and non-malignant tissues. It also provides a quantitative biomarker; the apparent diffusion coefficient (ADC) can be derived from DW-MRI sequences using multiple diffusion weightings. ADC reflects the tumour microenvironment, e.g. cell membrane integrity and cellularity and has potential for reporting on tumour aggressiveness. This review focuses on the use of the DW-MRI derived imaging biomarker ADC to reflect tumour aggressiveness and its potential impact in managing pelvic cancer patients. The clinical studies which evaluate the role of ADC in pelvic tumours (prostate, bladder, rectal, ovary, cervix and uterus) are summarized and the evidence linking ADC values with tumour aggressiveness is evaluated.

Fludeoxyglucose F 18 PET-Computed Tomography: Management Changes Effecting Patient Outcomes in Gynecologic Malignancies

Outcome analysis in oncologic imaging is complex because of the multiple variables that can affect survival, including how early disease is diagnosed, the accuracy of staging at diagnosis, and where and how the patient is treated. Risk for tumor recurrence is estimated based on tumor histologic grade, stage at diagnosis, and other factors, including expressed molecular markers. This article reviews the data supporting the use of F 18 fluorodeoxyglucose PET-computed tomography in endometrial, ovarian, and cervical malignancies, with emphasis on the impact of imaging on treatment stratification and prognosis.

Oncological whole-body staging in integrated (18)F-FDG PET/MR: Value of different MR sequences for simultaneous PET and MR reading

OBJECTIVE

To evaluate different magnetic resonance (MR) imaging sequences in integrated positron emission tomography (PET)/MR concerning their ability to detect tumors and allocate increased radionuclide uptake on (18)F-fluorodeoxyglucose ((18)F-FDG) PET in intraindividual comparison with computed tomography (CT) from PET/CT.

MATERIAL AND METHODS

Sixty-one patients (34 female, 27 male, mean age 57.6 y) who were examined with contrast-enhanced PET/CT and subsequent PET/MR (mean delay for PET/MR after injection: 147 ± 43 min) were included. A maximum of ten (18)F-FDG-avid lesions per patient were analyzed on CT from PET/CT and with the following MR sequences from PET/MR: T2, turbo inversion recovery magnitude (TIRM), non-enhanced T1, contrast-enhanced T1, and diffusion-weighted imaging (DWI). All lesions were rated using a four-point ordinal scale (scored from 0 to 3) concerning visual detectability of the lesion against the surrounding background and anatomical allocation of the PET finding. In each category (detectability and allocation), Wilcoxon rank sum tests were performed. Bonferroni-Holm correction was performed to prevent α-error accumulation.

RESULTS

In 225 (18)F-FDG-avid lesions (156 confirmed as malignant by radiological follow up, 69 by histopathology), visual detectability was comparably high on CT (mean: 2.5 ± 0.9), TIRM (mean: 2.5 ± 0.9), T2 (mean: 2.4 ± 0.9), and DWI (mean: 2.5 ± 1.0) and was significantly higher than on non-enhanced T1 (mean: 2.2 ± 1.0). While anatomic allocation of the PET finding was comparable with CT (mean: 2.6 ± 0.7), T2 (mean: 2.6 ± 0.7), and TIRM (mean: 2.8 ± 0.7), it was significantly higher compared to DWI (mean: 2.1 ± 1.0) and non-enhanced T1 (mean: 2.4 ± 0.8).

CONCLUSION

In conclusion, T2, TIRM, and contrast-enhanced T1 provide a high quality of lesion detectability and anatomical allocation of FDG-avid foci. Their performance is at least comparable to contrast-enhanced PET/CT. Non-enhanced T1 may be omitted and the necessity of DWI should be further investigated for specific questions, such as assessment of the liver.

Prediction of clinical outcome after stereotactic body radiotherapy for non-small cell lung cancer using diffusion-weighted MRI and (18)F-FDG PET

PURPOSE/OBJECTIVES

To evaluate the use of diffusion-weighted magnetic resonance imaging (DW-MRI) and (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) for predicting disease progression (DP) among patients with non-small cell lung carcinoma (NSCLC) treated with stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Fifteen patients with histologically confirmed stage I NSCLC who underwent pre-treatment DW-MRI and PET and were treated with SBRT were enrolled. The mean apparent diffusion coefficient (ADC) value and maximum standardised uptake value (SUVmax) were measured at the target lesion and evaluated for correlations with DP.

RESULTS

The median pre-treatment ADC value was 1.04×10(-3) (range 0.83-1.29×10(-3))mm(2)/s, and the median pre-treatment SUVmax was 9.9 (range 1.6-30). There was no correlation between the ADC value and SUVmax. The group with the lower ADC value (≤1.05×10(-3)mm(2)/s) and that with a higher SUVmax (≥7.9) tended to have poor DP, but neither trend was statistically significant (p=0.09 and 0.32, respectively). The combination of the ADC value and SUVmax was a statistically significant predictor of DP (p=0.036).

CONCLUSION

A low ADC value on pre-treatment DW-MRI and a high SUVmax may be associated with poor DP in NSCLC patients treated with SBRT. Using both values in combination was a better predictor.