Novel imaging techniques as response biomarkers in cervical cancer

The contribution of the 1H-MRS lipid signal to cervical cancer prognosis: a preliminary study

Background

The aim of this study was to investigate the role of the lipid peak derived from ¹H magnetic resonance (MR) spectroscopy in assessing cervical cancer prognosis, particularly in assessing response to neoadjuvant chemotherapy (NACT) of locally advanced cervical cancer (LACC).

Methods

We enrolled 17 patients with histologically proven cervical cancer who underwent 3-T MR imaging at baseline. In addition to conventional imaging sequences for pelvic assessment, the protocol included a single-voxel point-resolved spectroscopy (PRESS) sequence, with repetition time of 1,500 ms and echo times of 28 and 144 ms. Spectra were analysed using the LCModel fitting routine, thus extracting multiple metabolites, including lipids (Lip) and total choline (tCho). Patients with LACC were treated with NACT and reassessed by MRI at term. Based on tumour volume reduction, patients were classified as good responder (GR; tumour volume reduction > 50%) and poor responder or nonresponder (PR-or-NR; tumour volume reduction ≤ 50%).

Results

Of 17 patients, 11 were LACC. Of these 11, only 6 had both completed NACT and had good-quality ¹H-MR spectra; 3 GR and 3 PR-or-NR. A significant difference in lipid values was observed in the two groups of patients, particularly with higher Lip values and higher Lip/tCho ratio in PR-NR patients (p =0.040). A significant difference was also observed in choline distribution (tCho), with higher values in GR patients (p = 0.040).

Conclusions

Assessment of lipid peak at ¹H-MR spectroscopy could be an additional quantitative parameter in predicting the response to NACT in patients with LACC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41747-022-00300-1.

Imaging Biomarkers and Liquid Biopsy in Assessment of Cervical Cancer

ABSTRACT

The role of imaging has been increasing in pretherapy planning and response assessment in cervical cancer, particularly in high-resource settings that provide access to computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). In 2018, imaging was incorporated into the International Federation of Gynecology and Obstetrics staging system for cervical cancer. Magnetic resonance imaging is advantageous over CT for evaluation of the primary cervical cancer size and extent, because of superior contrast resolution. Furthermore, quantitative methods, including diffusion-weighted and dynamic contrast-enhanced MRI, show promise in improving treatment response and prognosis evaluation. Molecular imaging with fluorodeoxyglucose-PET/CT and PET/MRI can be particularly helpful in the detection of nodal disease and distant metastases. Semiautomated delineation of 3-dimensional tumor regions of interest has facilitated the development of novel PET-derived biomarkers that include metabolic volume and radiomics textural analysis features for prediction of outcomes. However, posttreatment inflammatory changes can be a confounder and lymph node evaluation is challenging, even with the use of PET/CT. Liquid biopsy has emerged as a promising tool that may be able to overcome some of the drawbacks inherent with imaging, such as limited ability to detect microscopic metastases or to distinguish between postchemoradiotherapy changes and residual tumor. Preliminary evidence suggests that liquid biopsy may be able to identify cervical cancer treatment response and resistance earlier than traditional methods. Future work should prioritize how to best synergize imaging and liquid biopsy as an integrated approach for optimal cervical cancer management.

Added-Value of Diffusion-Weighted Imaging (DWI) and Dynamic Contrast-Enhanced (DCE-MRI) Magnetic Resonance Imaging in the Preoperative Assessment of Cervical Cancer

Purpose

To evaluate the added-value of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in the preoperative assessment of carcinoma cervix.

Methods

This prospective study was carried out on histopathologically proven 45 patients of carcinoma cervix presented to a tertiary care hospital with bleeding per vagina between August 2017 and July 2018. Relevant local per vaginal examination and MRI examination of the pelvis were performed.

Results

A total of 45 patients with carcinoma of the cervix, having 11 patients (24.4%) in Stage-I, 22 patients (48.9%) in Stage-II, 3 patients (6.7%) in Stage-III and 9 patients (20%) in stage-IV, were included in this study sample. The mean ADC value of the carcinoma of cervix was 0.802 ± 0.123 [SD] × 10^-3 mm²/s. The stage-I carcinoma cervix had a mean ADC value of 0.915 ± 0.109 [SD] × 10^-3 mm²/s, Stage-II 0.778 ± 0.099 [SD] × 10^-3 mm²/s, Stage-III 0.762 ± 0.123 [SD] × 10^-3 mm²/s and Stage-IV 0.737 ± 0.116 [SD] × 10^-3 mm²/s. ROC curve analysis showed the percentage of signal intensity changes within cervical tumor on arterial phase of DCE-MRI had a threshold value of 42.25 in differentiating Stage-I carcinoma of cervix from other stages with a sensitivity of 81.8% and specificity of 44.1%.

Conclusion

The DWI and DCE-MRI added valuable inputs over conventional MR sequences in the early diagnosis and preoperative staging of carcinoma cervix. DCE-MRI had a high accuracy for assessing the cervical stromal and parametrial invasions, which helps in selecting the optimal therapeutic protocol and prognostication in gynecological malignancies.

Diffusion-Weighted MRI in the Genitourinary System

Diffusion weighted imaging (DWI) constitutes a major functional parameter performed in Magnetic Resonance Imaging (MRI). The DW sequence is performed by acquiring a set of native images described by their b-values, each b-value representing the strength of the diffusion MR gradients specific to that sequence. By fitting the data with models describing the motion of water in tissue, an apparent diffusion coefficient (ADC) map is built and allows the assessment of water mobility inside the tissue. The high cellularity of tumors restricts the water diffusion and decreases the value of ADC within tumors, which makes them appear hypointense on ADC maps. The role of this sequence now largely exceeds its first clinical apparitions in neuroimaging, whereby the method helped diagnose the early phases of cerebral ischemic stroke. The applications extend to whole-body imaging for both neoplastic and non-neoplastic diseases. This review emphasizes the integration of DWI in the genitourinary system imaging by outlining the sequence's usage in female pelvis, prostate, bladder, penis, testis and kidney MRI. In gynecologic imaging, DWI is an essential sequence for the characterization of cervix tumors and endometrial carcinomas, as well as to differentiate between leiomyosarcoma and benign leiomyoma of the uterus. In ovarian epithelial neoplasms, DWI provides key information for the characterization of solid components in heterogeneous complex ovarian masses. In prostate imaging, DWI became an essential part of multi-parametric Magnetic Resonance Imaging (mpMRI) to detect prostate cancer. The Prostate Imaging-Reporting and Data System (PI-RADS) scoring the probability of significant prostate tumors has significantly contributed to this success. Its contribution has established mpMRI as a mandatory examination for the planning of prostate biopsies and radical prostatectomy. Following a similar approach, DWI was included in multiparametric protocols for the bladder and the testis. In renal imaging, DWI is not able to robustly differentiate between malignant and benign renal tumors but may be helpful to characterize tumor subtypes, including clear-cell and non-clear-cell renal carcinomas or low-fat angiomyolipomas. One of the most promising developments of renal DWI is the estimation of renal fibrosis in chronic kidney disease (CKD) patients. In conclusion, DWI constitutes a major advancement in genitourinary imaging with a central role in decision algorithms in the female pelvis and prostate cancer, now allowing promising applications in renal imaging or in the bladder and testicular mpMRI.

MRI Radiomic Features: A Potential Biomarker for Progression-Free Survival Prediction of Patients With Locally Advanced Cervical Cancer Undergoing Surgery

Objectives

To investigate the prognostic role of radiomic features based on pretreatment MRI in predicting progression-free survival (PFS) of locally advanced cervical cancer (LACC).

Methods

All 181 women with histologically confirmed LACC were randomly divided into the training cohort (n = 126) and the validation cohort (n = 55). For each patient, we extracted radiomic features from whole tumors on sagittal T2WI and axial DWI. The least absolute shrinkage and selection operator (LASSO) algorithm combined with the Cox survival analysis was applied to select features and construct a radiomic score (Rad-score) model. The cutoff value of the Rad-score was used to divide the patients into high- and low-risk groups by the X-tile. Kaplan–Meier analysis and log-rank test were used to assess the prognostic value of the Rad-score. In addition, we totally developed three models, the clinical model, the Rad-score, and the combined nomogram.

Results

The Rad-score demonstrated good performance in stratifying patients into high- and low-risk groups of progression in the training (HR = 3.279, 95% CI: 2.865–3.693, p < 0.0001) and validation cohorts (HR = 2.247, 95% CI: 1.735–2.759, p < 0.0001). Otherwise, the combined nomogram, integrating the Rad-score and patient’s age, hemoglobin, white blood cell, and lymph vascular space invasion, demonstrated prominent discrimination, yielding an AUC of 0.879 (95% CI, 0.811–0.947) in the training cohort and 0.820 (95% CI, 0.668–0.971) in the validation cohort. The Delong test verified that the combined nomogram showed better performance in estimating PFS than the clinical model and Rad-score in the training cohort (p = 0.038, p = 0.043).

Conclusion

The radiomics nomogram performed well in individualized PFS estimation for the patients with LACC, which might guide individual treatment decisions.

Influence of menstrual status and pathological type on the apparent diffusion coefficient in cervical cancer: a primary study

BACKGROUND

Apparent diffusion coefficient (ADC) value is an important quantitative parameter in the research of cervical cancer, affected by some factors.

PURPOSE

To investigate the effect of pathological type and menstrual status on the ADC value of cervical cancer.

MATERIAL AND METHODS

A total of 352 individuals with pathologically confirmed cervical cancer between January 2015 to December 2017 were retrospectively enrolled in this study, including 317 cases with squamous cell carcinomas (SCC) and 35 cases with adenocarcinomas (AC); 177 patients were non-menopausal and 175 were menopausal. All patients underwent a routine 3.0-T magnetic resonance imaging (MRI) scan and diffusion-weighted imaging (DWI) examination using b-values of 0, 800, and 1000 s/mm². Three parameters including mean ADC (ADC_mean), maximum ADC (ADC_max), and minimum ADC (ADC_min) of cervical cancer lesions were measured and retrospectively analyzed. Independent samples t-test was used to compare the difference of ADC values in different menstrual status and pathological types.

RESULTS

In all menopausal and non-menopausal patients, the ADC_mean and ADC_min values of SCC were lower than those of AC (P<0.05), the ADC_max of two pathological types showed no statistical difference (P > 0.05). In menopausal patients, the ADC_mean, ADC_max, and ADC_min values of SCC were not statistically different compared with those of AC (P > 0.05). The ADC_mean, ADC_max, and ADC_min values of different pathological types cervical cancers in non-menopausal patients were all higher than those in menopausal patients (P<0.05).

CONCLUSION

The ADC values of the cervical cancers were different in different pathological types and were also affected by menstrual status.

Volume computed tomography perfusion as a predictive marker for treatment response to concurrent chemoradiotherapy in cervical cancer: a prospective study

BACKGROUND

Computed tomography perfusion (CTP) can provide information on blood perfusion as a reliable marker of tumor response to therapy.

PURPOSE

To assess the role of volume CTP (vCTP) parameters in predicting treatment response to concurrent chemoradiotherapy (CCRT) for cervical cancer.

MATERIAL AND METHODS

Thirty-three patients with cervical cancer underwent vCTP. Three CTP parameters of cervical cancer-including arterial flow (AF), blood volume (BV), and permeability surface (PS)-were measured in two different ways: the region of interest incorporating the "local hot" with the highest enhancement and "cold spot" with the lowest enhancement; and "whole-tumor" measurements. The patients were divided into non-residual and residual tumor groups according to the short-term response to treatment. The clinical and perfusion parameters were compared between the two groups.

RESULTS

There was no significant difference in age, body mass index, FIGO stage, pathological grade, or pretreatment tumor size between the two groups (P > 0.05). The non-residual tumor group had higher pretreatment AF in high-perfusion and low-perfusion subregions than the residual tumor group (P <0.05), but the AF in whole-tumor regions was not different between the two groups (P > 0.05). There were no differences in BV and PS between the two groups (P > 0.05). The diagnostic potency of AF in the low-perfusion subregion was higher than that in the high-perfusion subregion.

CONCLUSION

vCTP parameters are valuable for the prediction of short-term effects. The AF in the low-perfusion subregion was a more effective index for predicting treatment response to CCRT of cervical cancer.

Dynamic contrast-enhanced MRI histogram parameters predict progression-free survival in patients with advanced esophageal squamous carcinoma receiving concurrent chemoradiotherapy

BACKGROUND

There is increased interest in dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for predicting the outcomes of patients with advanced esophageal cancer.

PURPOSE

To explore whether DCE-MRI histogram parameters can predict 12-month progression-free survival (PFS) in patients with advanced esophageal squamous carcinoma receiving concurrent chemoradiation therapy (CRT).

MATERIAL AND METHODS

This retrospective study enrolled 134 patients with advanced esophageal squamous carcinoma who were receiving CRT. The pre-CRT DCE-MRI histogram parameters (median, mean, SD, skewness, kurtosis, and 10th and 90th percentiles) of K^trans, K_ep, and V_e were collected. PFS analyses were performed using the Kaplan-Meier method and log-rank tests to compute the survival curves. The significant prognostic predictors among the data characteristics and DCE-MRI parameters were determined using multivariate Cox proportional hazards regression analyses.

RESULTS

There were 65 good responders (PFS ≥ 12 months) and 69 poor responders (PFS < 12 months). The median and mean values of K^trans were higher, and the kurtosis value of K^trans was lower in good responders. The median, mean, and 10th and 90th percentile values of K^trans were higher, and the kurtosis values of K^trans and V_e were lower in good responders. The PFS of patients aged ≥60 years, a CR effect, or a 10th percentile value of K^trans ≥0.13 was increased (P < 0.001, <0.001, and 0.014, respectively).

CONCLUSION

DCE-MRI histogram parameters can be used to evaluate the response to CRT in patients with advanced esophageal squamous carcinoma. The 10th percentile value of K^trans has significant prognostic value for 12-month PFS.

Optimal timing for prediction of pathologic complete response to neoadjuvant chemoradiotherapy with diffusion-weighted MRI in patients with esophageal cancer

OBJECTIVE

This study was conducted in order to determine the optimal timing of diffusion-weighted magnetic resonance imaging (DW-MRI) for prediction of pathologic complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer.

METHODS

Patients with esophageal adenocarcinoma or squamous cell carcinoma who planned to undergo nCRT followed by surgery were enrolled in this prospective study. Patients underwent six DW-MRI scans: one baseline scan before the start of nCRT and weekly scans during 5 weeks of nCRT. Relative changes in mean apparent diffusion coefficient (ADC) values between the baseline scans and the scans during nCRT (ΔADC(%)) were compared between pathologic complete responders (pCR) and non-pCR (tumor regression grades 2-5). The discriminative ability of ΔADC(%) was determined based on the c-statistic.

RESULTS

A total of 24 patients with 142 DW-MRI scans were included. pCR was observed in seven patients (29%). ΔADC(%) from baseline to week 2 was significantly higher in patients with pCR versus non-pCR (median [IQR], 36% [30%, 41%] for pCR versus 16% [14%, 29%] for non-pCR, p = 0.004). The ΔADC(%) of the second week in combination with histology resulted in the highest c-statistic for the prediction of pCR versus non-pCR (0.87). The c-statistic of this model increased to 0.97 after additional exclusion of patients with a small tumor volume (< 7 mL, n = 3) and tumor histology of the resection specimen other than adenocarcinoma or squamous cell carcinoma (n = 1).

CONCLUSION

The relative change in tumor ADC (ΔADC(%)) during the first 2 weeks of nCRT is the most predictive for pathologic complete response to nCRT in esophageal cancer patients.

KEY POINTS

• DW-MRI during the second week of neoadjuvant chemoradiotherapy is most predictive for pathologic complete response in esophageal cancer. • A model including ΔADCweek 2was able to discriminate between pathologic complete responders and non-pathologic complete responders in 87%. • Improvements in future MRI studies for esophageal cancer may be obtained by incorporating motion management techniques.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictive value of diffusion-weighted MR imaging in early response to chemoradiotherapy of esophageal cancer: a meta-analysis

The results of diffusion-weighted MR imaging (DW-MRI) in predicting early response to chemoradiotherapy in patients with esophageal cancer varied in different studies. We performed this meta-analysis to evaluate the predictive values of DW-MRI and compare the diagnostic efficacy of different apparent diffusion coefficients (ADCs). A comprehensive literature search was performed to identify relevant articles published before November 2017. The quality of study was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under receiver operating characteristic curve of ADC values were calculated to determine the diagnostic performance. Seven studies with a total of 236 patients were included. The pooled sensitivity, specificity, DOR, and area under curve were 93% (95% CI 77%-98%), 85% (95% CI 72%-93%), 78 (95% CI 15-401), and 0.91 (95% CI 0.89-0.94), respectively, for the ▵ADC; and 75% (95% CI 62%-84%), 90% (95% CI 67%-97%), 26 (95% CI 6-110), and 0.85 (95% CI 0.82-0.88), respectively, for the post-ADC. For pre-ADC, meta-analysis was not performed because of conflicting results. In conclusions, our results demonstrate that DW-MRI has good performance for evaluating the response to chemoradiation therapy in patients with esophageal cancer. ▵ADC and post-ADC are promising reliable and valuable predictors.

Imaging strategies in the management of gastric cancer: current role and future potential of MRI

Accurate preoperative staging of gastric cancer and the assessment of tumor response to neoadjuvant treatment is of importance for treatment and prognosis. Current imaging techniques, mainly endoscopic ultrasonography (EUS), computed tomography (CT) and ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET), have their limitations. Historically, the role of magnetic resonance imaging (MRI) in gastric cancer has been limited, but with the continuous technical improvements, MRI has become a more potent imaging technique for gastrointestinal malignancies. The accuracy of MRI for T- and N-staging of gastric cancer is similar to EUS and CT, making MRI a suitable alternative to other imaging strategies. There is limited evidence on the performance of MRI for M-staging of gastric cancer specifically, but MRI is widely used for diagnosing liver metastases and shows potential for diagnosing peritoneal seeding. Recent pilot studies showed that treatment response assessment as well as detection of lymph node metastases and systemic disease might benefit from functional MRI (e.g. diffusion weighted imaging and dynamic contrast enhancement). Regarding treatment guidance, additional value of MRI might be expected from its role in better defining clinical target volumes and setup verification with MR-guided radiation treatment.

Multicystic mucinous adenocarcinoma of the uterine cervix compared with benign multicystic lesions: Multiparametric MR features

BACKGROUND

Multicystic mucinous adenocarcinoma is rarely recognized and has a high misdiagnosis rate.

PURPOSE

To distinguish malignant multicystic mucinous adenocarcinomas from benign multicystic lesions in the uterine cervix using multiparametric MR.

STUDY TYPE

Retrospective.

POPULATION

Forty patients with seven cystic mucinous adenocarcinomas and 33 benign multicystic lesions.

FIELD STRENGTH/SEQUENCE

3.0T. Diffusion-weighted images (DWI) and dynamic contrast-enhanced (DCE) images.

ASSESSMENT

Lesion size, intracystic hemorrhage, solid component, and heterogeneous enhancement were subjectively assessed, and apparent diffusion coefficient (ADC) values, K_trans , K_ep , and V_e parameters were compared.

STATISTICAL ANALYSIS

Student's t-test was used to compare age, tumor size, ADC values, and DCE parameters. Pearson's chi-square test was used to compare intracystic hemorrhage, solid component, and heterogeneous enhancement. Receiver-operating-characteristic (ROC) analysis of ADC values, tumor size, and K_trans were performed.

RESULTS

The size of mucinous adenocarcinomas was larger than benign multicystic lesions (4.09 ± 2.09 vs. 2.23 ± 0.58 cm, P < 0.001); the area under the curve (AUC) for tumor size was 0.859 with a sensitivity of 71.4% and specificity of 90.9%. Stromal ADC value was lower for mucinous adenocarcinomas (1.19 ± 0.22 vs. 1.68 ± 0.22 × 10^-3 mm² /s, P < 0.001); AUC for stromal ADC value was 0.970, with a sensitivity of 86.4% and specificity of 100.0%. Among quantitative DCE parameters, only k_trans offered a discriminative value (1.72 ± 1.42 vs. 0.69 ± 0.30 min^-1 , P = 0.031); the AUC for k_trans was 0.831 with a sensitivity of 71.4% and specificity of 97.0%. Intracystic hemorrhage (3/7), solid component (5/7), and heterogeneous enhancement (4/7) were only found in mucinous adenocarcinomas. Five patients (71.4%) had lymphovascular space invasion and three (42.9%) had lymph node metastasis. The 1-year tumor recurrence or metastasis rate was 28.5% (2/7).

DATA CONCLUSION

Awareness of multiparametric MR features can assist in the differentiation of mucinous adenocarcinomas from benign multicystic lesions.

LEVEL OF EVIDENCE

4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1336-1343.

Diffusion-weighted imaging in gynaecological malignancy

Diffusion weighted imaging (DWI) has become an essential part of the gynaecological magnetic resonance imaging (MRI) protocol. DWI is used as an adjunct to conventional MRI sequences and has been shown to improve reporting accuracy in the imaging of gynaecological malignancy. In this review, we discuss the role of DWI in the diagnosis, staging, and assessment of treatment response of endometrial, cervical, and ovarian cancer. We also review the role of DWI in the assessment of the sonographically indeterminate ovarian lesion. Further, we highlight potential pitfalls that can beset the accurate interpretation of DWI in patients with gynaecological malignancy.

Autodelineation of cervical cancers using multiparametric magnetic resonance imaging and machine learning

BACKGROUND

Tumour delineation is a challenging, time-consuming and complex part of radiotherapy planning. In this study, an automatic method for delineating locally advanced cervical cancers was developed using a machine learning approach.

MATERIALS AND METHODS

A method for tumour segmentation based on image voxel classification using Fisher?s Linear Discriminant Analysis (LDA) was developed. This was applied to magnetic resonance (MR) images of 78 patients with locally advanced cervical cancer. The segmentation was based on multiparametric MRI consisting of T2- weighted (T2w), T1-weighted (T1w) and dynamic contrast-enhanced (DCE) sequences, and included intensity and spatial information from the images. The model was trained and assessed using delineations made by two radiologists.

RESULTS

Segmentation based on T2w or T1w images resulted in mean sensitivity and specificity of 94% and 52%, respectively. Including DCE-MR images improved the segmentation model?s performance significantly, giving mean sensitivity and specificity of 85?93%. Comparisons with radiologists? tumour delineations gave Dice similarity coefficients of up to 0.44.

CONCLUSION

Voxel classification using a machine learning approach is a flexible and fully automatic method for tumour delineation. Combining all relevant MR image series resulted in high sensitivity and specificity. Moreover, the presented method can be extended to include additional imaging modalities.

The Emerging Role of PET/MR Imaging in Gynecologic Cancers

This article summarizes recent advances in PET/MR imaging in gynecologic cancers and the emerging clinical value of PET/MR imaging in the management of the 3 most common gynecologic malignancies: cervical, endometrial, and ovarian cancers. PET/MR imaging offers superior soft tissue contrast, improved assessment of primary tumor involvement because of high-resolution multiplanar reformats, and functional MR techniques such as diffusion-weighted MR imaging and dynamic contrast-enhanced MR imaging. This article discusses the challenges, future directions, and technical advances of PET/MR imaging, and the emerging new multimodality, multiparametric imaging techniques for integrating morphologic, functional, and molecular imaging data.

Diffusion MRI of uterine and ovarian masses: identifying the benign lesions

PURPOSE

The purpose of the study was to assess the diagnostic performance of qualitative and quantitative diffusion-weighted imaging (DWI) in differentiating benign from malignant ovarian and uterine masses.

MATERIALS AND METHODS

Institutional review board approval was obtained for this HIPAA-compliant retrospective study, with waiver of informed consent. DWI MRIs of 222 women acquired over 1.5 years were evaluated. Reference standard was pathology or follow-up imaging. For qualitative assessment, two radiologists independently reviewed DWI and apparent diffusion coefficient (ADC) images for diffusion restriction. Differences were resolved by consensus. For quantitative assessment, a single reader measured ADC values. Readers were blinded to the reference standard.

RESULTS

222 lesions, 121 ovarian (99 benign and 22 malignant) and 101 uterine (54 benign and 47 malignant), were included. Final diagnosis was established with pathology in 129 (58%) or with imaging follow-up in 93 (42%). Mean (range) follow-up interval was 27 (13-48) months. Qualitative assessment yielded sensitivity (ratio, 95% CI), specificity, PPV and NPV of 100% (22/22, 85-100), 68% (68/99, 58-76), 41% (22/54, 27-54), and 100% (68/68, 94-100) for ovarian and 94% (44/47, 83-98), 91% (49/54, 80-96), 90% (44/49, 78-95) and 94% (49/52, 84-98) for uterine malignancies. ADC (mean ± SD) between benign ovarian [(1.11 ± 0.76) × 10^-3 mm²/s] vs. malignant [(0.71 ± 0.26) × 10^-3 mm²/s] lesions was significantly different (p < 0.001). ADC cutoff value of 1.55 × 10^-3 mm²/s for ovarian lesions resulted in 99.9% confidence for the absence of malignancy. ADC (mean ± SD) of benign uterine [(0.64 ± 0.38) × 10^-3 mm²/s] vs. malignant [(0.68 ± 0.19) × 10^-3 mm²/s] lesions was not significantly different (P < 0.54).

CONCLUSION

Quantitative and qualitative DWI assessment can be used to confidently characterize a subset of ovarian lesions as benign. With uterine lesions, although DWI is useful in differentiating benign from malignant lesions, the technique does not allow for definitive quantitative characterization.

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.

Assessment of Early Therapeutic Changes to Concurrent Chemoradiotherapy in Uterine Cervical Cancer Using Blood Oxygenation Level-Dependent Magnetic Resonance Imaging

OBJECTIVE

This study aimed to investigate blood oxygenation level-dependent magnetic resonance imaging (MRI) in assessing early therapeutic changes in cervical cancers to concurrent chemoradiotherapy (CCRT).

METHODS

Fifteen consecutive patients with cervical cancer treated with CCRT were evaluated with blood oxygenation level-dependent MRI at 3 T. Magnetic resonance imaging examinations were performed before treatment (preTx), 1 week after treatment (postT1) and 4 weeks after treatment (postT2). At each time, the rate of spin dephasing (R2*) values were measured in tumor and in normal uterus.

RESULTS

Tumor R2* increased from preTx to postT2 (P < 0.01). In pairwise comparisons of tumor R2*, postT2 was significantly higher than preTx or postT1 (P < 0.01), whereas postT1 was not significantly different from preTx (P > 0.05). A significant difference in R2* was found between the tumors and normal uterus at preTx (P = 0.001), postT1 (P < 0.001), and postT2 (P < 0.001).

CONCLUSIONS

Blood oxygenation level-dependent MRI may demonstrate early therapeutic changes of cervical cancers to CCRT.

Uterine cervical cancer volumetry using T2- and diffusion-weighted MR images in patients treated by primary surgery and neoadjuvant chemotherapy

BACKGROUND

Tumor volumetry with magnetic resonance imaging (MRI) is very common; however, the accuracy of such measures remains unclear, especially after treatment.

PURPOSE

To determine the accuracy of preoperative volume measurements of uterine cervical carcinomas resected with and without neoadjuvant chemotherapy (NAC) on T2-weighted (T2W) and diffusion-weighted (DWI) MRI.

MATERIAL AND METHODS

Twenty-nine consecutive patients with surgically confirmed uterine cervical carcinoma were included in this study. MRI scans were performed before preoperative treatment in 17 patients and after two courses of NAC in 12 patients. In all patients, T2W images and DWI were obtained to measure the tumor diameters. The maximum diameter of the surgical specimens was macroscopically measured. The correlation coefficients between the measured tumor size using T2W imaging and DWI and the size measured on the surgical specimens were calculated for all specimens.

RESULTS

The correlation coefficient of the three-dimensional (3D) tumor volume measurement using T2W imaging and DWI was 0.97 in the primary surgery group and was 0.96 in the NAC group. The 3D tumor volume measurement using MRI and the measurement of the actual surgical specimen was 0.55 for T2WI and 0.48 for DWI in the primary surgery group and 0.88 for T2WI and 0.95 for DWI in the NAC group.

CONCLUSION

T2WI and DWI can provide accurate 3D tumor volume measurements of uterine cervical carcinomas in patients with and without preoperative chemotherapy, suggesting that tumor volumetry using 3 T MRI after uterus-preserving treatment is feasible.

Clinical implementation of multisequence MRI-based adaptive intracavitary brachytherapy for cervix cancer

The purpose of this study was to describe the clinical implementation of a magnetic resonance image (MRI)-based approach for adaptive intracavitary brachytherapy (ICBT) of cervix cancer patients. Patients were implanted with titanium tandem and colpostats. MR imaging was performed on a 1.5-T Philips scanner using T2-weighted (T2W), proton-density weighted (PDW), and diffusion-weighted (DW) imaging sequences. Apparent diffusion coefficient (ADC) maps were generated from the DW images. All images were fused. T2W images were used for the definition of organs at risk (OARs) and dose points. ADC maps in conjunction with T2W images were used for target delineation. PDW images were used for applicator definition. Forward treatment planning was performed using standard source distribution rules normalized to Point A. Point doses and dose-volume parameters for the tumor and OARs were exported to an automated dose-tracking application. Brachytherapy doses were adapted for tumor shrinkage and OAR variations during the course of therapy. The MRI-based ICBT approach described here has been clinically implemented and is carried out for each brachytherapy fraction. Total procedure time from patient preparation to delivery of treatment is typically 2 hrs. Implementation of our tech-nique for structure delineation, applicator definition, dose tracking, and adaptation is demonstrated using treated patient examples. Based on published recommendations and our clinical experience in the radiation treatment of cervix cancer patients, we have refined our standard approach to ICBT by 1) incorporating a multisequence MRI technique for improved visualization of the target, OARs, and applicator, and by 2) implementing dose adaptation by use of automated dose tracking tools.

Prognostic Role of Diffusion-weighted MR Imaging for Resectable Gastric Cancer

PURPOSE

To prospectively investigate the role of apparent diffusion coefficient (ADC) calculated from diffusion-weighted magnetic resonance (MR) imaging as a potential prognostic biomarker in the evaluation of the aggressiveness of gastric cancer.

MATERIALS AND METHODS

This prospective study had institutional review board approval. Informed consent was obtained from all patients. Between October 2009 and December 2013, a total of 99 patients (65 men, 34 women; mean age, 62.02 years; age range, 32.33-85.15 years) with biopsy-proved cancer (28 esophagogastric junction and 71 gastric cancers) were examined with a 1.5-T MR imaging system, including T1-, T2-, and diffusion-weighted sequences. ADC measurements were obtained. Seventy-one patients were directly treated with surgery, while 28 underwent neoadjuvant chemotherapy beforehand. Pathologic ADC, pathologic T and N stages, tumor location, surgical approach, and histologic subtype were investigated with univariate and multivariate analyses by using the Cox regression model.

RESULTS

At a total median follow-up period of 21 months, 31 patients had died. The median follow-up was 25 months for the surgery-only group (19 of 31 events [61%]) and 28 months for the chemotherapy group (12 of 31 events [39%]). In the multivariate analysis, ADC values of 1.5 × 10(-3) mm(2)/sec or lower were associated with a negative prognosis, both in the total population (log-relative risk, 1.73; standard error, 0.56; P = .002) and in the surgery-only (log-relative risk, 1.97; standard error, 0.66; P = .003) and chemotherapy (log-relative risk, 2.93; standard error, 1.41; P = .03) groups, along with other significant prognostic factors (in particular, pathologic T and N stages).

CONCLUSION

Pathologic ADC represents a strong independent prognostic factor in the evaluation of the aggressiveness of gastric cancer, in addition to clinical and surgical variables.

Diffusion-weighted imaging and dynamic contrast-enhanced MRI in assessing response and recurrent disease in gynaecological malignancies

Magnetic resonance imaging (MRI) has an established role in imaging pelvic gynaecological malignancies. It is routinely used in staging endometrial and cervical cancer, characterizing adnexal masses, selecting optimal treatment, monitoring treatment and detecting recurrent disease. MRI has also been shown to have an excellent performance and an evolving role in surveillance of patients after chemoradiotherapy in cervical cancer, post-trachelectomy, detecting early recurrence and planning exenterative surgery in isolated central recurrences in both cervical and endometrial cancer and in young patients on surveillance for medically managed endometrial cancer. However, conventional MRI still has limitations when the morphological appearance of early recurrent or residual disease overlaps with normal pelvic anatomy or treatment effects in the pelvis. In particular, after chemoradiotherapy for cervical cancer, distinguishing between radiotherapy changes and residual or early recurrent disease within the cervix or the vaginal vault can be challenging on conventional MRI alone. Therefore, there is an emerging need for functional imaging to overcome these limitations. The purpose of this paper is to discuss the emerging functional MRI techniques and their applications in predicting treatment response, detecting residual disease and early recurrent disease to optimize the treatment options available using diffusion-weighted imaging and dynamic contrast enhancement particularly in cervical and endometrial cancer.

Parametrial invasion in cervical cancer: fused T2-weighted imaging and high-b-value diffusion-weighted imaging with background body signal suppression at 3 T

PURPOSE

To retrospectively investigate the value of fused T2-weighted and high-b-value diffusion-weighted imaging with background body signal suppression (DWIBS) at 3 T to evaluate parametrial invasion in cervical cancer.

MATERIALS AND METHODS

In this institutional review board-approved study, 152 consecutive patients with biopsy-proven cervical cancer who underwent radical hysterectomies also underwent pretreatment magnetic resonance imaging (T2-weighted imaging and DWIBS) at 3 T. Two radiologists independently evaluated the presence of parametrial invasion at T2-weighted imaging, fused T2-weighted imaging and high-b-value DWIBS (ie, fused T2-weighted DWIBS), and combined T2-weighted imaging and fused T2-weighted DWIBS, and the results were compared with histopathologic findings.

RESULTS

Parametrial invasion was identified by pathologic analysis in 37 of 152 patients (24.3%). For association with parametrial invasion, the specificity and accuracy of fused T2-weighted DWIBS (97.4% and 90.1%, respectively, for reader 1; 95.7% and 89.5%, respectively, for reader 2) and combined T2-weighted imaging and fused T2-weighted DWIBS (99.1% and 93.4%, respectively, for reader 1; 96.5% and 92.8%, respectively, for reader 2) were significantly better than those of T2-weighted imaging alone (88.7% and 85.5%, respectively, for reader 1; 85.2% and 83.6%, respectively, for reader 2) (all P < .05). The respective sensitivity of T2-weighted imaging, fused T2-weighted DWIBS, and combined T2-weighted imaging and fused T2-weighted DWIBS was 75.7%, 67.6%, and 75.7% for reader 1 and 78.4%, 70.3%, and 81.1% for reader 2, and did not show significant differences (P value, ≤.375 to >.999). The respective area under the curve for association with parametrial invasion of T2-weighted imaging, fused T2-weighted DWIBS, and combined T2-weighted imaging and fused T2-weighted DWIBS was 0.912, 0.951, and 0.976 for reader 1 and 0.890, 0.932, and 0.968 for reader 2 (P < .05). Interreader agreements were excellent (κ = 0.89, 0.9, and 0.86 for T2-weighted imaging, fused T2-weighted DWIBS, and combined T2-weighted imaging and fused T2-weighted DWIBS, respectively).

CONCLUSION

Fusion of high-b-value DWIBS with T2-weighted imaging can improve the diagnostic performance in association with parametrial invasion in cervical cancer compared with T2-weighted imaging alone.

Diagnostic efficacy of diffusion-weighted MRI for pre-operative assessment of myometrial and cervical invasion and pelvic lymph node metastasis in endometrial carcinoma

INTRODUCTION

To determine the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) for the pre-operative assessment of patients with endometrial carcinoma and to assess myometrial and cervical invasion as well as pelvic lymph node metastasis.

METHODS

Fifty-eight women who underwent surgery for histopathologically confirmed endometrial carcinoma were included in the current study. Prior to surgery, patients were evaluated using pelvic DW-MRI and gadolinium-enhanced T1-weighted imaging (Gd-T1WI). Gd-T1WI was evaluated together with T2-weighted images. DW-MR images were obtained in the axial plane using echo-planar spin-echo pulse sequences with different b factors. Endometrial carcinomas were observed as areas of increased intensity on DW-MRI images, and their intensity was compared with the surrounding hypo-intense myometrium. Pre-operative DW-MRI and Gd-T1WI results were compared with post-operative histopathological findings that served as reference standards.

RESULTS

The sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and diagnostic accuracy of DW-MRI for differentiation between superficial myometrial invasion and deep myometrial invasion were 85%, 89%, 81%, 92% and 88%, respectively. The sensitivity, specificity and diagnostic accuracy rates were 82%, 91% and 89.6% for cervical invasion and 100%, 96% and 96.5% for pelvic lymph node metastasis, respectively. The sensitivity, specificity, PPV and NPV, and diagnostic accuracy of Gd-T1WI for differentiation between superficial myometrial invasion and deep myometrial invasion were 85%, 81.5%, 71%, 91% and 83%, respectively. The sensitivity, specificity and diagnostic accuracy were 73%, 89% and 86% for cervical invasion, respectively.

CONCLUSIONS

These findings suggest that DW-MRI may be a good diagnostic tool with high sensitivity and specificity for assessing myometrial invasion and detecting tumour extension. We suggest that DW-MRI should be considered as a routine part of the pre-operative pelvic MRI in all patients with endometrial carcinoma.

Magnetic resonance imaging of cervical carcinoma using an endorectal surface coil

INTRODUCTION

The objective of this trial is to investigate the diagnostic value of magnetic resonance imaging (MRI) with an endorectal surface coil for precise local staging of patients with histologically proven cervical cancer by comparing the radiological, clinical, and histological results.

MATERIALS AND METHODS

Women with cervical cancer were recruited for this trial between February 2007, and September 2010. All the patients were clinically staged according to the FIGO classification and underwent radiological staging by MRI that employed an endorectal surface coil. The staging results after surgery were compared to histopathology in all the operable patients.

RESULTS

A total of 74 consecutive patients were included in the trial. Forty-four (59.5%) patients underwent primary surgery, whereas 30 (40.5%) patients were inoperable according to FIGO and underwent primary radiochemotherapy. The mean age of the patients was 50.6 years. In 11 out of the 44 patients concordant staging results were obtained by all three staging modalities. Thirty-two of the 44 patients were concordantly staged by FIGO and histopathological examination, while only 16 were concordantly staged by eMRI and histopathological examination. eMRI overstaged tumors in 14 cases and understaged them in 7 cases.

CONCLUSIONS

eMRI is applicable in patients with cervical cancer, yet of no benefit than staging with FIGO or standard pelvic MRI. The most precise preoperative staging procedure still appears to be the clinical examination.

Connective tissue of cervical carcinoma xenografts: associations with tumor hypoxia and interstitial fluid pressure and its assessment by DCE-MRI and DW-MRI

Abstract Background. A high fraction of stroma in malignant tissues is associated with tumor progression, metastasis, and poor prognosis. Possible correlations between the stromal and physiologic microenvironments of tumors and the potential of dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) in quantification of the stromal microenvironment were investigated in this study. Material and methods. CK-160 cervical carcinoma xenografts were used as preclinical tumor model. A total of 43 tumors were included in the study, and of these tumors, 17 were used to search for correlations between the stromal and physiologic microenvironments, 11 were subjected to DCE-MRI, and 15 were subjected to DW-MRI. DCE-MRI and DW-MRI were carried out at 1.5 T with a clinical MR scanner and a slotted tube resonator transceiver coil constructed for mice. Fraction of connective tissue (CTFCol) and fraction of hypoxic tissue (HFPim) were determined by immunohistochemistry. A Millar SPC 320 catheter was used to measure tumor interstitial fluid pressure (IFP). Results. CTFCol showed a positive correlation to IFP and an inverse correlation to HFPim. The apparent diffusion coefficient assessed by DW-MRI was inversely correlated to CTFCol, whereas no correlation was found between DCE-MRI-derived parameters and CTFCol. Conclusion. DW-MRI is a potentially useful method for characterizing the stromal microenvironment of tumors.

The value of diffusion-weighted MRI to evaluate the response to radiochemotherapy for cervical cancer

PURPOSE

To investigate the value of apparent diffusion coefficient (ADC) to predict and monitor the therapy response for cervical cancer patients receiving concurrent radiochemotherapy, and to analyze the influence of different b-value combinations on ADC-based evaluation of treatment response.

MATERIAL AND METHODS

Seventy-five cervical cancer patients treated with radiochemotherapy received conventional MRI and DWI prior to therapy, after 2 weeks of therapy, after four weeks of therapy and after therapy completion. Treatment response was classified as complete response (CR, n=35), partial response (PR, n=22) and stable disease (SD, n=18), which was determined according to final tumor size after 6 months of therapy completion. Dynamic changes of apparent diffusion coefficients (ADC) and tumor size in the three tumor groups were observed and compared. All the ADCs were calculated from b=0, 600s/mm(2) and b=0, 1000s/mm(2).

RESULTS

The ADC increased percentage was higher in CR group than those in PR and SD groups after two weeks and four weeks of therapy, with significant differences in absolute ADCs between CR and PR, SD groups after therapy completion; the overall discriminatory capability for differentiation of CR and PR, SD groups was higher for high b-value combination (0, 1000s/mm(2)) than for low b-value combination (0, 600s/mm(2)).

CONCLUSION

DWI can be used as a predictive and monitoring biomarker of treatment response to radiochemotherapy in patients with cervical cancer. High b-value combination may be more reliable to evaluate the treatment response for cervical cancer.

Dynamic contrast-enhanced MRI in endometrial carcinoma identifies patients at increased risk of recurrence

OBJECTIVES

To study the feasibility of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for assessment of tumour microvasculature in endometrial carcinoma patients, and to explore correlations with histological subtype, clinical course and microstructural characteristics based on apparent diffusion coefficient (ADC) values.

METHODS

Diffusion-weighted imaging (DWI) and three-dimensional DCE-MRI (1.5 T) with high temporal resolution (2.49 s) were acquired preoperatively in 55 patients. Quantitative modelling allowed the calculation of four independent parameters describing microvasculature: blood flow (Fb), extraction fraction (E), capillary transit time (Tc) and transfer constant from the extravascular extracellular space [EES] to blood (Kep); and four derived parameters: blood volume (Vb), volume of EES (Ve), capillary permeability surface area product (PS) and transfer from blood to EES (Ktrans).

RESULTS

Endometrial carcinoma tissue exhibited reduced Fb, E, Vb, Ve, PS and Ktrans compared with normal myometrium. Non-endometrioid carcinomas (n = 12) had lower Fb, and E than endometrioid carcinomas (n = 43; P < 0.05). Tumour Ve positively correlated with tumour ADC value (r = 0.29, P = 0.03). Reduced survival was observed in patients with low tumour Fb and high tumour Tc (P < 0.05).

CONCLUSIONS

We demonstrate the feasibility of DCE-MRI in reflecting histological subtype and clinical course in primary endometrial carcinomas. DCE-MRI may potentially provide future biomarkers for preoperative risk stratification in endometrial carcinomas.

KEY POINTS

• Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) offers new information about endometrial carcinoma. • Pelvic DCE-MRI with subsequent quantitative modelling seems feasible in endometrial carcinoma patients. • Low tumour perfusion is a feature of a more aggressive tumour subtype. • DCE-MRI provides potential biomarkers for preoperative risk stratification in endometrial carcinoma patients.

Apparent diffusion coefficient modifications in assessing gastro-oesophageal cancer response to neoadjuvant treatment: comparison with tumour regression grade at histology

OBJECTIVES

To assess changes in apparent diffusion coefficient (ΔADC) and volume (ΔV) after neoadjuvant treatment (NT), and tumour regression grade (TRG) in gastro-oesophageal cancers (GEC), and to discriminate responders from non-responders.

METHODS

Thirty-two patients with biopsy-proven locally-advanced GEC underwent diffusion weighted magnetic resonance imaging (DWI) pre- and post-NT. Lesion ADC, volume, ΔADC and ΔV were calculated. TRG 1-2-3 patients were classified as R; TRG 4-5 as non-responders. ΔADC-TRG and ΔV-TRG correlations, pre-NT and post-NT ADC, ΔADC and ΔV cut-off values for responders and non-responders were calculated. Two readers measured mean tumour ADCs and interobserver variability was calculated. (Spearman's and intraclass correlation coefficient [ICC]).

RESULTS

The interobserver reproducibility was very good both for pre-NT (Spearman's rho = 0.8160; ICC = 0.8993) and post-NT (Spearman's rho = 0.8357; ICC = 0.8663). Responders showed lower pre-NT ADC (1.32 versus 1.63 × 10(-3) mm(2)/s; P = 0.002) and higher post-NT ADC (2.22 versus 1.51 × 10(-3) mm(2)/s; P = 0.001) than non-responders and ADC increased in responders (ΔADC, 85.45 versus -8.21 %; P = 0.00005). ΔADC inversely correlated with TRG (r = -0.71, P = 0.000004); no difference in ΔV between responders and non-responders (-50.92 % versus -14.12 %; P = 0.068) and no correlation ΔV-TRG (r = 0.02 P = 0.883) were observed.

CONCLUSIONS

The ADC can be used to assess gastro-oesophageal tumour response to neoadjuvant treatment as a reliable expression of tumour regression.

KEY POINTS

• DWI is now being used to assess many cancers. • Change in ADC measurements offer new information about oesophageal tumours. • ADC changes are more reliable than dimensional criteria in assessing neoadjuvant treatment. • Such ADC assessment could optimise management of locally advanced gastro-oesophageal cancers.

Pearls and pitfalls in MRI of gynecologic malignancy with diffusion-weighted technique

OBJECTIVE

Developments in MRI techniques have increased the role of MRI in assessment of the pelvis in women. The aims of this review are a short overview of pelvic MRI with an emphasis on diffusion-weighted MRI (DWI) and presentation of a practical approach that includes the pearls and pitfalls of DWI.

CONCLUSION

DWI provides indispensable information in the evaluation of gynecologic malignancies. Prudent application of this technique requires knowledge of the optimal protocols and pitfalls in interpretation.

Pharmacokinetic parameters derived from dynamic contrast enhanced MRI of cervical cancers predict chemoradiotherapy outcome

PURPOSE

To assess the prognostic value of pharmacokinetic parameters derived from pre-chemoradiotherapy dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) of cervical cancer patients.

MATERIALS AND METHODS

Seventy-eight patients with locally advanced cervical cancer underwent DCE-MRI with Gd-DTPA before chemoradiotherapy. The pharmacokinetic Brix and Tofts models were fitted to contrast enhancement curves in all tumor voxels, providing histograms of several pharmacokinetic parameters (Brix: A(Brix), k(ep), k(el), Tofts: K(trans), ν(e)). A percentile screening approach including log-rank survival tests was undertaken to identify the clinically most relevant part of the intratumoral parameter distribution. Clinical endpoints were progression-free survival (PFS) and locoregional control (LRC). Multivariate analysis including FIGO stage and tumor volume was used to assess the prognostic significance of the imaging parameters.

RESULTS

A(Brix), k(el), and K(trans) were significantly (P<0.05) positively associated with both clinical LRC and PFS, while ν(e) was significantly positively correlated with PFS only. k(ep) showed no association with any endpoint. A(Brix) was positively correlated with K(trans) and ν(e), and showed the strongest association with endpoint in the log-rank testing. k(el) and K(trans) were independent prognostic factors in multivariate analysis with LRC as endpoint.

CONCLUSIONS

Parameters estimated by pharmacokinetic analysis of DCE-MR images obtained prior to chemoradiotherapy may be used for identifying patients at risk of treatment failure.

Evaluation of therapeutic response to concurrent chemoradiotherapy in patients with cervical cancer using diffusion-weighted MR imaging

PURPOSE

To investigate the changes in apparent diffusion coefficients (ADCs) in cervical cancer patients receiving concurrent chemoradiotherapy (CCRT), and to assess the relationship between tumor ADCs or changes in tumor ADCs and final tumor responses to therapy.

MATERIALS AND METHODS

Twenty-four patients with cervical cancer who received CCRT were examined with 3 Tesla (T) MRI including diffusion-weighted imaging (DWI). All patients had three serial MR examinations: before therapy (pre-Tx); at 4 weeks of therapy (mid-Tx); and 1 month after completion of therapy (post-Tx). At each examination, ADC was measured in tumors and normal gluteus muscles. Final tumor response as determined by change in tumor size or volume using MRI was correlated with tumor ADCs at each therapeutic time or changes in tumor ADCs at mid-Tx.

RESULTS

From pre-Tx to post-Tx, mean tumor ADCs were 0.88, 1.30, and 1.47 × 10(-3) mm(2)/s in sequence (P < 0.001), while those of normal gluteus muscles were 1.24, 1.29, and 1.21 × 10(-3) mm(2)/s in sequence (P > 0.05). At mid-Tx, tumor ADCs and changes in tumor ADCs had a significant correlation with final tumor size responses (P = 0.029 and 0.025, respectively). However, the tumor ADC values at pre-Tx were not associated with the final tumor size response (P = 0.47). The final tumor volume response was not associated with tumor ADC at pre-Tx or mid-Tx (P > 0.05) or changes in tumor ADCs at mid-Tx (P > 0.05).

CONCLUSION

DWI may have potentials in evaluating the therapeutic response to CCRT in patients with cervical cancer.

Value of magnetic resonance and ¹⁸FDG PET-CT in predicting tumor response and resectability of primary locally advanced cervical cancer after treatment with intensity-modulated arc therapy: a prospective pathology-matched study

OBJECTIVE

To report on the value of magnetic resonance imaging (MRI) and 2-deoxy-2-[18] fluoro-D-glucose positron emission tomography computed tomography (¹⁸FDG PET-CT) in predicting resectability and pathological response of primary locally advanced cervical cancer after neoadjuvant intensity-modulated arc therapy (IMAT) with or without cisplatin (C).

METHODS AND MATERIALS

Twenty-seven patients with International Federation of Gynecology and Obstetrics stages IB2 to IVA cervical cancer were treated with IMAT-C followed by extrafascial hysterectomy (EH). All patients received MRI and ¹⁸FDG PET-CT after IMAT-C. The end points of this study were to: 1. Assess the ability of MRI to predict negative surgical margins (R0). 2. Assess the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI in predicting the following situation at the EH specimen: "no residual disease or minimal microscopically visible residual tumor." 3. Assess the sensitivity, specificity, PPV, and NPV value of ¹⁸FDG PET-CT in predicting "no residual viable tumor cells" at the EH specimen.

RESULTS

An R0 resection was obtained in all patients. None of the EH specimens contained macroscopically visible tumor. In 13 patients, no viable tumor cells were found and only 14 had residual microscopic disease. Twenty-four of 27 MRIs were able to correctly predict R0 resection. A negative MRI was 100% predictive for the end point "R0 resection." The specificity and NPV of MRI (end point 2) were 74% and 100%, respectively. No sensitivity or PPV could be calculated. The sensitivity, specificity, PPV, and NPV of ¹⁸FDG PET-CT were 29%, 62%, 44%, and 44%, respectively (end point 3).

CONCLUSIONS

A negative MRI after IMAT-C predicts 100% correctly for R0 resection. The role of FDG PET-CT in predicting viable tumor cells at EH specimen is at least debatable.

Dynamic contrast-enhanced 3-T MR imaging in cervical cancer before and after concurrent chemoradiotherapy

OBJECTIVE

To investigate the changes of dynamic contrast-enhanced MR imaging (DCE-MRI) parameters at 3 T in cervical cancer patients before and after concurrent chemoradiotherapy (CCRT), and to correlate the parameters with final tumour response to therapy.

METHODS

Thirty-five patients with cervical cancer underwent DCE-MRI before CCRT, 4 weeks after starting therapy and at 1 month after the end of therapy. DCE-MRI parameters were calculated in the tumour and normal gluteus muscle. Final response to treatment as determined by changes in tumour size and volume was correlated with pre-treatment DCE-MRI parameters.

RESULTS

DCE-MRI parameters (i.e. K (trans), v (e) and k (ep)) in the tumours showed significant changes in response to CCRT (P < 0.05) and in particular K (trans) and v (e) demonstrated early significant increase (P < 0.01), but those in normal muscle did not show a significant difference (P > 0.05). Before therapy, the mean values of K (trans), k (ep), v (e) and v (p) in the tumours were significantly greater than those in muscle (P < 0.05). DCE-MRI parameters of the tumours at pre-treatment were not statistically associated with final tumour size or volume change.

CONCLUSION

DCE-MRI parameters may help evaluate early changes of cervical cancer to CCRT, but larger, more definitive studies are needed.

KEY POINTS

• DCE-MRI offers new insights into tumour behaviour. • Changes in tumour size lag behind biomarkers which improve quickly in responders. • DCE-MRI is a non-invasive imaging technique that can characterize tumour vasculature. • DCE-MRI of cervical cancer may be useful in monitoring changes with therapy.

The SUVmax (maximum standardized uptake value for F-18 fluorodeoxyglucose) and serum squamous cell carcinoma antigen (SCC-ag) function as prognostic biomarkers in patients with primary cervical cancer

OBJECTIVE

The aim of the present study was to investigate the prognostic significance of FDG uptake measured as maximum standardized uptake value (SUVmax) in primary tumor by positron emission tomography with fluorine-18-fluorodeoxyglucose (FDG-PET/CT) and pretreatment serum squamous cell carcinoma antigen (SCC-ag) in patients with cervical cancer.

METHODS

82 consecutive patients with biopsy-proven cervical cancer who had PET/CT before any treatment were enrolled in this study. The SUVmax of the primary cervical tumor mass was obtained and compared with pretreatment SCC-ag and pathological prognostic factors after the initial treatment.

RESULTS

There was significant correlation between the SUVmax of the primary tumor and tumor maximum size (p = 0.0024). The serum SCC-ag had a statistically significant association with lymph node metastasis (p = 0.0373), although there was no correlation between the SUVmax of the primary tumor and the serum SCC-ag (r (2) = -0.57). The higher SUVmax of primary tumor (≥11.2) plus pelvic lymph node (PLN) metastasis and higher SUVmax plus higher serum SCC-ag (≥6.4 ng/nl) were two most significant variables that predicted worse prognosis (p = 0.0099 and p = 0.0020, respectively).

CONCLUSIONS

Higher pretreatment SUVmax of primary tumor indicated worse prognosis, and the prognosis of patients with higher pretreatment SUVmax plus PLN metastasis was even worse both in patients of squamous cell carcinoma (SCC) and non-SCC of cervix. As for patients with SCC of cervix, higher pretreatment serum SCC-ag not only predicted worse prognosis but also predicted disease recurrence in the posttreatment surveillance.

Role of New Functional MRI Techniques in the Diagnosis, Staging, and Followup of Gynecological Cancer: Comparison with PET-CT

Recent developments in diagnostic imaging techniques have magnified the role and potential of both MRI and PET-CT in female pelvic imaging. This article reviews the techniques and clinical applications of new functional MRI (fMRI) including diffusion-weighted MRI (DWI), dynamic contrast-enhanced (DCE)-MRI, comparing with PET-CT. These new emerging provide not only anatomic but also functional imaging, allowing detection of small volumes of active tumor at diagnosis and early disease relapse, which may not result in detectable morphological changes at conventional imaging. This information is useful in distinguishing between recurrent/residual tumor and post-treatment changes and assessing treatment response, with a clear impact on patient management. Both PET-CT and now fMRI have proved to be very valuable tools for evaluation of gynecologic tumors. Most papers try to compare these techniques, but in our experience both are complementary in management of these patients. Meanwhile PET-CT is superior in diagnosis of ganglionar disease; fMRI presents higher accuracy in local preoperative staging. Both techniques can be used as biomarkers of tumor response and present high accuracy in diagnosis of local recurrence and peritoneal dissemination, with complementary roles depending on histological type, anatomic location and tumoral volume.

Comparison of apparent diffusion coefficient maps to T2-weighted images for target delineation in cervix cancer brachytherapy

Purpose

T2-weighted (T2W) magnetic resonance imaging (MRI) has been used for target delineation in cervix cancer brachytherapy. The objective of this study was to examine the feasibility of using diffusion-weighted magnetic resonance imaging (DWI) for target delineation as compared against T2W imaging.

Material and methods

Fifteen cervix cancer patients, implanted with tandem and ovoid applicators, underwent T2W turbo-spin echo imaging and DWI with a maximum diffusion factor of 800 sec/mm² on a 1.5-T MR scanner. Apparent diffusion coefficient (ADC) maps were derived from the DWI. The gross tumor volume was manually delineated on the T2W and ADC datasets for each patient. The agreement between T2W- and ADC-delineated volumes was assessed using the Dice similarity coefficient (DSC). An algorithm was developed to compare the edge contrast of the delineated volumes on T2W images and ADC maps by calculating the percentage difference in the intensity values of selected regions of pixels inside versus outside the target contour.

Results

ADC-delineated volumes were generally smaller than T2W-delineated volumes, yielding a low DSC of 0.54 ± 0.22. ADC maps were found to display superior definition of the target volume edge relative to T2W images, yielding a statistically significant difference between the mean edge contrast on ADC (12.7 ± 7.7%) versus that on T2W images (4.6 ± 3.2%; p = 0.0010).

Conclusions

These results suggest that incorporating the use of DWI for cervix cancer brachytherapy may yield gross tumor volumes that are different from those based on T2W images alone.

Diffusion weighted imaging of female pelvic cancers: concepts and clinical applications

Early applications of diffusion weighted magnetic resonance imaging (DWI) were limited to neuroimaging, concentrating either on stroke or brain tumours. With recent advances in MRI hardware and software DWI is now increasingly being investigated for cancer assessment throughout the body. Clinical applications of DWI relating to female pelvic cancers have largely concentrated on detection, localisation and staging of disease. More recently investigators have started to evaluate the ability of DWI for determining tumour histology and even predicting the outcome of chemoradiation treatment. This article reviews the physical concepts of MR diffusion weighting, illustrates the biophysical basis of diffusion contrast and reports the clinical applications of DWI for cervical, endometrial, ovarian, rectal and bladder tumours.