Is MRI helpful in assessing the distance of the tumour from the internal os in patients with cervical cancer below FIGO Stage IB2?

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Invasive Cancer of the Cervix: 2023 Update

Cervical cancer is a common gynecological malignancy worldwide. Cervical cancer is staged based on the International Federation of Gynecology and Obstetrics (FIGO) classification system, which was revised in 2018 to incorporate radiologic and pathologic data. Imaging plays an important role in pretreatment assessment including initial staging and treatment response assessment of cervical cancer. Accurate determination of tumor size, local extension, and nodal and distant metastases is important for treatment selection and for prognostication. Although local recurrence can be diagnosed by physical examination, imaging plays a critical role in detection and follow-up of local and distant recurrence and subsequent treatment selection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Radiomics Based on Nomogram Predict Pelvic Lymphnode Metastasis in Early-Stage Cervical Cancer

The accurate prediction of the status of PLNM preoperatively plays a key role in treatment strategy decisions in early-stage cervical cancer. The aim of this study was to develop and validate a radiomics-based nomogram for the preoperative prediction of pelvic lymph node metastatic status in early-stage cervical cancer. One hundred fifty patients were enrolled in this study. Radiomics features were extracted from T2-weighted MRI imaging (T2WI). Based on the selected features, a support vector machine (SVM) algorithm was used to build the radiomics signature. The radiomics-based nomogram was developed incorporating radiomics signature and clinical risk factors. In the training cohort (AUC = 0.925, accuracy = 81.6%, sensitivity = 70.3%, and specificity = 92.0%) and the testing cohort (AUC = 0.839, accuracy = 74.2%, sensitivity = 65.7%, and specificity = 82.8%), clinical models that combine stromal invasion depth, FIGO stage, and MTD perform poorly. The combined model had the highest AUC in the training cohort (AUC = 0.988, accuracy = 95.9%, sensitivity = 92.0%, and specificity = 100.0%) and the testing cohort (AUC = 0.922, accuracy = 87.1%, sensitivity = 85.7%, and specificity = 88.6%) when compared to the radiomics and clinical models. The study may provide valuable guidance for clinical physicians regarding the treatment strategies for early-stage cervical cancer patients.

Diagnostic Accuracy of Magnetic Resonance Imaging for International Federation of Gynecology and Obstetrics 2018 IB to IIB Cervical Cancer Staging: Comparison Among Magnetic Resonance Sequences and Pathologies

OBJECTIVE

This study aimed to investigate the most accurate magnetic resonance (MR) sequence for tumor detection, maximal tumor diameter, and parametrial invasion compared with histopathologic diagnoses.

METHODS

Fifty-one patients with International Federation of Gynecology and Obstetrics 2018 IB1 to IIB cervical cancer underwent preoperative MR imaging and surgical resection. Two radiologists independently evaluated the tumor detection, parametrial invasion, and tumor size in each of T2-weighted image, diffusion-weighted image, and contrast-enhanced T1-weighted image. Results obtained for squamous cell carcinoma (SCC) and adenocarcinoma were also compared.

RESULTS

Neither the tumor detection rate nor parametrial invasion was found to be significantly different among sequences. Tumor size assessment using MR imaging with pathology showed good correlation: r = 0.63-0.72. The adenocarcinoma size tended to be more underestimated than SCC in comparison with the pathologic specimen.

CONCLUSIONS

Cervical cancer staging by MR images showed no significant difference among T2-weighted image, diffusion-weighted image, and contrast-enhanced T1-weighted image. Adenocarcinoma was prone to be measured as smaller than the pathologic specimen compared with SCC.

Cervical Cancer Diagnosis: Insights into Biochemical Biomarkers and Imaging Techniques

Cervical malignancy is known as one of the important cancers which is originated from cervix. This malignancy has been observed in women infected with papillomavirus who had regular oral contraceptives, multiple pregnancies, and sexual relations. Early and fast cervical cancer diagnosis is known as two important aspects of cervical cancer therapy. Several investigations indicated that early and fast detection of cervical cancer could be associated with better treatment process and increasing survival rate of patients with this malignancy. Imaging techniques are very important diagnosis tools that could be employed for diagnosis and following responses to therapy in various cervical cancer stages. Multiple lines of evidence indicated that utilization of imaging techniques is related to some limitations (i.e. high cost, and invasive effects). Hence, it seems that along with using imaging techniques, finding and developing new biomarkers could be useful in the diagnosis and treatment of subjects with cervical cancer. Taken together, many studies showed that a variety of biomarkers including, several proteins, mRNAs, microRNAs, exosomes and polymorphisms might be introduced as prognostic, diagnostic and therapeutic biomarkers in cervical cancer therapy. In this review article, we highlighted imaging techniques as well as novel biomarkers for the diagnosis of cervical cancer.

Fertility considerations prior to conservative management of gynecologic cancers

Fertility-sparing management of early-stage gynecologic cancers is becoming more prevalent as increasing evidence demonstrates acceptable oncologic and reproductive outcomes in appropriately selected patients. However, in the absence of randomized controlled trials, most of the commonly used treatment algorithms are based only on observational studies. As women are increasingly postponing childbearing, the need for evidence-based guidance on the optimal selection of appropriate candidates for fertility-sparing therapies is paramount. It is imperative to seriously consider the fertility potential of a given individual prior to making major oncologic treatment decisions that may deviate from the accepted standard of care. It is a disservice to patients to undergo a fertility-sparing procedure in hopes of ultimately achieving a live birth, only to determine later they have poor baseline fertility potential or other substantial barriers to conception including excess financial toxicity. Many women with oncologic diagnoses are of advanced maternal age and their obstetric and neonatal risks must be considered. In the era of advanced assisted reproductive technologies, patients should be provided realistic expectations regarding success rates while understanding the potential oncologic perils. A multidisciplinary approach to the conservative treatment of early-stage gynecologic cancers with early referral to reproductive specialists as well as maternal-fetal medicine specialists is warranted. In this review, we discuss the recommended fertility evaluation for patients with newly diagnosed, early-stage gynecologic cancers who are considering fertility-sparing management.

Imaging modalities in fertility preservation in patients with gynecologic cancers

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

Multimodality Imaging of Uterine Cervical Malignancies

OBJECTIVE. In this article, we provide an updated review on the role of imaging in initial staging, treatment monitoring, and follow-up of cervical cancer with a focus on the role of MRI and FDG PET/CT. In addition, the 2018 International Federation of Gynecology and Obstetrics staging system and its implication on management of cervical cancer are explored. CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases.

Multiparametric MRI-Based Radiomics Nomogram for Predicting Lymph Node Metastasis in Early-Stage Cervical Cancer

BACKGROUND

Lymph node metastasis (LNM) is a critical risk factor affecting treatment strategy and prognosis in patients with early-stage cervical cancer.

PURPOSE

To establish a multiparametric MRI (mpMRI)-based radiomics nomogram for preoperatively predicting LNM status.

STUDY TYPE

Retrospective.

POPULATION

Among 233 consecutive patients, 155 patients were randomly allocated to the primary cohort and 78 patients to the validation cohort.

FIELD STRENGTH

Radiomic features were extracted from a 1.5T mpMRI scan (T₁ -weighted imaging [T₁ WI], fat-saturated T₂ -weighted imaging [FS-T₂ WI], contrast-enhanced [CE], diffusion-weighted imaging [DWI], and apparent diffusion coefficient [ADC] maps).

ASSESSMENT

The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. The area under the receiver operating characteristics curve (ROC AUC), accuracy, sensitivity, and specificity were also calculated.

STATISTICAL TESTS

The least absolute shrinkage and selection operator (LASSO) method was used for dimension reduction, feature selection, and radiomics signature building. Multivariable logistic regression analysis was used to develop the radiomics nomogram. An independent sample t-test and chi-squared test were used to compare the differences in continuous and categorical variables, respectively.

RESULTS

The radiomic signature allowed a good discrimination between the LNM and non-LNM groups, with a C-index of 0.856 (95% confidence interval [CI], 0.794-0.918) in the primary cohort and 0.883 (95% CI, 0.809-0.957) in the validation cohort. Additionally, the radiomics nomogram also had a good discriminating performance and yielded good calibration both in the primary and validation cohorts (C-index, 0.882 [95% CI, 0.827-0.937], C-index, 0.893 [95% CI, 0.822-0.964], respectively). Decision curve analysis demonstrated that the radiomics nomogram was clinically useful.

DATA CONCLUSION

A radiomics nomogram was developed by incorporating the radiomics signature with the MRI-reported LN status and FIGO stage. This nomogram might be used to facilitate the individualized prediction of LNM in patients with early-stage cervical cancer.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:885-896.

Diagnostic performance of MR imaging in evaluating prognostic factors in patients with cervical cancer: a meta-analysis

OBJECTIVES

This study aims to determine the diagnostic performance of conventional magnetic resonance imaging (MRI) in assessing the distance between the tumor and the internal os, stromal infiltration, lymph node metastasis, and parametrial invasion in patients with cervical cancer.

METHODS

A systematic English-language literature search of conventional MRI in the evaluation of human cervical cancer was performed in the PubMed, Cochrane Library, Embase, and Web of Science databases from 1995 to 2018. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and positive and negative likelihood ratios (PLR and NLR) of all studies were calculated. The results were then plotted in a hierarchical summary receiver operating characteristic (HSROC) plot, and meta-regression and subgroup analyses of the parametrial invasion were also performed.

RESULTS

The pooled sensitivity, specificity, DOR, PLR, and NLR were 86%, 97%, 167.91, 24.74, and 0.15, respectively, in evaluating the internal os involvement (6 studies, 454 patients); 87%, 91%, 73.41, 10.22, and 0.14, respectively, in evaluating the stromal infiltration (11 studies, 672 patients); 51%, 89%, 8.63, 4.72, and 0.55, respectively, in evaluating the lymph node metastasis (15 studies, 997 patients); and 75%, 92%, 34.01, 9.38, and 0.28, respectively, in evaluating the parametrial invasion (19 studies, 1748 patients). The meta-regression of the parametrial invasion showed that the application of contrast enhancement was a significant factor affected the heterogeneity (p = 0.039).

CONCLUSIONS

Conventional MRI can accurately evaluate the distance between the tumor and the internal os, as well as stromal infiltration, and performs well in diagnosing the parametrial invasion. However, this method exhibited a limited ability in diagnosing the lymph node metastasis.

KEY POINTS

• MRI can help clinicians to accurately assess the distance between the tumor and the internal os, stromal infiltration, and parametrial invasion in patients with uterine cervical neoplasms. • MRI exhibits a limited ability in diagnosing the lymph node metastasis. • Management of patients with uterine cervical neoplasms becomes more appropriate.

Imaging and Staging of Cervical Cancer

Cervical carcinoma remains a common gynecologic malignancy. Physical examination has historically served as the predominant tool for staging and assessment, in part due to lack of availability of additional diagnostic resources in many parts of the world. Cross-sectional imaging in the evaluation of cervical cancer has become standard of care in developed countries, and has recently been incorporated into the official staging classification of the International Federation of Gynecology and Obstetrics. This article will describe the use of computed tomography, magnetic resonance imaging, and positron emission tomography/computed tomography and positron emission tomography/magnetic resonance imaging in cervical cancer patients, review optimal techniques for MR evaluation of the cervix, and describe key aspects of staging and management of cervical carcinoma.

Radical Trachelectomy for Early Stage Cervical Cancer

OPINION STATEMENT

In patients with early-stage cervical cancer, radical hysterectomy and pelvic lymphadenectomy is the gold standard. However, this disease commonly affects women of childbearing age; thus an option to spare fertility is ideal. This option came to fruition in the early 90s when the Dargent procedure or radical trachelectomy was first reported. The procedure has subsequently been modified as technology has improved and now may be performed via minimally invasive techniques. Additionally, with the advent of the sentinel lymph node procedure, the morbidity in this usually young patient population has continued to improve. There is a multitude of data to show that oncologic outcomes, concerning recurrence and mortality, are comparable to radical hysterectomy, as well as obstetrical outcomes are favorable. Data to support its acceptance within the gynecologic oncology community has led to radical trachelectomy being implemented into governing body guidelines and should be offered to appropriate candidates with early-stage cervical cancer who wish to preserve fertility.

Early Cervical Cancer: Current Dilemmas of Staging and Surgery

PURPOSE OF REVIEW

Advances in cervical cancer screening and treatment have resulted in high cure rates in developed countries for early-stage disease. Current research focuses on minimizing morbidity and maximizing quality of life.

RECENT FINDINGS

Imaging has been disappointing in identifying small volume metastases. Sentinel lymph node biopsy represents a significant advantage with high sensitivity, low false negative rates, reduced morbidity, and equivalent survival in recent studies compared to pelvic lymphadenectomy. Non-radical surgical options are currently being investigated for early cervical cancer in a number of large prospective studies in patients at low risk for metastases. Evidence suggests that sentinel lymph node biopsy and non-radical surgery are safe approaches for the staging and management of early cervical cancer in appropriately selected patients with the potential to significantly reduce treatment-related morbidity.

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.