The Prognostic Value of Tumor Size, Volume and Tumor Volume Reduction Rate During Concurrent Chemoradiotherapy in Patients With Cervical Cancer

Evaluation of a deep-learning segmentation model for patients with colorectal cancer liver metastases (COALA) in the radiological workflow

OBJECTIVES

For patients with colorectal liver metastases (CRLM), total tumor volume (TTV) is prognostic. A deep-learning segmentation model for CRLM to assess TTV called COlorectal cAncer Liver metastases Assessment (COALA) has been developed. This study evaluated COALA's performance and practical utility in the radiological picture archiving and communication system (PACS). A secondary aim was to provide lessons for future researchers on the implementation of artificial intelligence (AI) models.

METHODS

Patients discussed between January and December 2023 in a multidisciplinary meeting for CRLM were included. In those patients, CRLM was automatically segmented in portal-venous phase CT scans by COALA and integrated with PACS. Eight expert abdominal radiologists completed a questionnaire addressing segmentation accuracy and PACS integration. They were also asked to write down general remarks.

RESULTS

In total, 57 patients were evaluated. Of those patients, 112 contrast-enhanced portal-venous phase CT scans were analyzed. Of eight radiologists, six (75%) evaluated the model as user-friendly in their radiological workflow. Areas of improvement of the COALA model were the segmentation of small lesions, heterogeneous lesions, and lesions at the border of the liver with involvement of the diaphragm or heart. Key lessons for implementation were a multidisciplinary approach, a robust method prior to model development and organizing evaluation sessions with end-users early in the development phase.

CONCLUSION

This study demonstrates that the deep-learning segmentation model for patients with CRLM (COALA) is user-friendly in the radiologist's PACS. Future researchers striving for implementation should have a multidisciplinary approach, propose a robust methodology and involve end-users prior to model development.

CRITICAL RELEVANCE STATEMENT

Many segmentation models are being developed, but none of those models are evaluated in the (radiological) workflow or clinically implemented. Our model is implemented in the radiological work system, providing valuable lessons for researchers to achieve clinical implementation.

KEY POINTS

Developed segmentation models should be implemented in the radiological workflow. Our implemented segmentation model provides valuable lessons for future researchers. If implemented in clinical practice, our model could allow for objective radiological evaluation.

Prognostic implications of tumor volume reduction during radiotherapy in locally advanced cervical cancer: a risk-stratified analysis

BACKGROUND

This study aimed to identify key risk factors in locally advanced cervical cancer (LACC) patients receiving radical radiotherapy and to evaluate the prognostic significance of MRI-determined tumor volume regression (TVR) among varying risk groups.

METHODS

We retrospectively analyzed a cohort of 176 cervical cancer patients (stages IIA-IVA) treated with intensity-modulated radiotherapy from January 2012 to December 2020. Three-dimensional MRI scans were utilized to measure TVR and lymph node volume regression (NVR). Kaplan-Meier analysis was employed to assess overall survival (OS), progression-free survival (PFS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS). Prognostic factors were further analyzed using Cox proportional hazards models.

RESULTS

A tumor TVR of ≥ 94% was significantly associated with improved 5-year overall survival (OS; 82.7% vs. 49.8%, p < 0.001) and progression-free survival (PFS; 82.5% vs. 51.1%, p < 0.001). Patients with TVR ≥ 94% also demonstrated superior LRFS and DMFS compared to those with TVR < 94% (p < 0.001 and p = 0.012, respectively). In the concurrent chemoradiotherapy (CCRT) subgroup, higher TVR correlated with better prognosis, whereas in patients receiving radiotherapy alone, an increased TVR did not significantly impact OS. Notably, the prognostic value of TVR was most evident in patients with CYFRA21-1 levels below 7.7 ng/ml. In the NVR ≥ 94% subgroup, OS, PFS, and LRFS were significantly better than in patients with NVR < 94% (p < 0.01), with a trend towards improved DMFS observed (p = 0.138).

CONCLUSION

TVR serves as a pivotal prognostic marker in LACC patients with CYFRA21-1 levels below 7.7 ng/ml undergoing CCRT. Additionally, within the lymph node metastasis subgroup, patients achieving a NVR of ≥ 94% demonstrated a notably improved prognosis.

Predictors of distant metastasis or local recurrent after radiotherapy in patients with cervical cancer

OBJECTIVE

To evaluate risk factors for survival, recurrence and metastasis in patients with FIGO stage IA-IVA cervical cancer who underwent radical radiotherapy (RT) or concurrent chemoradiotherapy (CCRT).

METHODS

We performed a retrospective analysis of 1288 cervical cancer patients. Kaplan-Meier curves, Cox regression models, and log-rank tests were used for statistical analysis.

RESULTS

The 5-year overall survival rate for patients with stage I-II and stage III-IVA are 81.1% and 70.4%. In multivariable analysis, pathological type, 2009 FIGO stage, pre-treatment SCC-Ag level, pre-brachytherapy tumor size, and CCRT are independent influencing factors for patient OS. Patients with non-squamous cell carcinoma are more likely to occur distant metastasis compared to those with squamous cell carcinoma. No significant correlation was observed between histological types among patients with local recurrence. In patients with squamous cell carcinoma, multivariable analysis showed that SCC value > 11.75 at diagnosis was an independent predictor of distant metastasis and local recurrence (P = 0.001 and P = 0.038, respectively). Lymph node metastasis was an independent risk factor for distant metastasis. Age, treatment time of RT, CCRT, and pre-treatment Hb classification showed no significant correlation with cervical cancer distant metastasis and local recurrence.

CONCLUSIONS

Non-squamous cell carcinoma patients may have a worse prognosis than squamous cell carcinoma patients. In patients with squamous cell carcinoma, SCC value at diagnosis, and lymph node metastasis are independent influencing factors for distant metastasis, while SCC value at diagnosis is an independent influencing factor for local recurrence.

Turning the tide: From cervical cancer's grip to complete response: A case report

BACKGROUND

Cervical cancer is a formidable global health issue, particularly affecting women in lower-middle-income countries with little or no access to preventative vaccines, screening programs, and treatment modalities. The case report presents a unique case of a large cervical cancer achieving complete response (CR) with concurrent chemoradiotherapy (CCRT), highlighting the effectiveness of this treatment approach even in advanced stages and underscoring the importance of adaptive radiotherapy (RT) in optimizing patient outcomes.

CASE SUMMARY

We present the case of a 53-year-old woman who presented with four years of abnormal vaginal bleeding and was found to have p16-positive, moderately differentiated cervical squamous cell carcinoma. The tumor measured 14 cm × 12 cm × 8 cm, the largest size reported in the literature to achieve CR with CCRT. Despite this monumental feat, the patient remained disease-free and is currently on follow-up for 2 years; however, she continued to suffer from substantial morbidity caused by a vesicovaginal fistula and hydronephrosis, underscoring the continuing impact of cervical cancer on quality of life.

CONCLUSION

In this case report, we highlight the effectiveness of CCRT in achieving CR, even in cases of bulky cervical cancer, with adaptive RT offering a customized strategy to improve patient outcomes. We also emphasize the necessity for multidisciplinary team discussions and highlight the need for strategies to mitigate treatment-related toxicities and long-term complications.

MRI-Guided Multi-Catheter High-Dose-Rate Interstitial Brachytherapy for Uterine Cervical Cancer

Background/Objectives To evaluate the efficacy and safety of unique magnetic resonance imaging (MRI)-guided interstitial brachytherapy (ISBT) for locally advanced cervical cancer that is unsuitable for intracavitary brachytherapy (ICBT) or intracavitary/interstitial brachytherapy (ICISBT). Methods: We analyzed the clinical outcomes, including toxicity, of 68 previously untreated patients with cervical cancer treated between 2014 and 2024. Results: The median high-risk clinical target volume (HR-CTV) was 53.20 cc (range, 16.34-147.03 cc) with ISBT. With a median follow-up time of 37.5 months (7-115 months), the three-year local control, progression-free survival, and overall survival rates were 89.8%, 52.4%, and 70.9%, respectively. Multivariate analyses showed significant associations of histology with local control, overall treatment times, HR-CTV volume with overall survival rate, over all treatment times, and HR-CTV volume and M category with progression-free survival. Toxicity grade 3 occurred in 12 patients (17.6%) and consisted of four genitourinary (5.8%) and seven gastrointestinal (10.2%) toxicities. Conclusions: MRI-guided ISBT is an effective treatment strategy for obtaining a favorable local control rate for selected advanced diseases with an acceptable complication rate. Future research is warranted to elucidate who would be good candidates for MRI-guided ISBT.

Dual convolution-transformer UNet (DCT-UNet) for organs at risk and clinical target volume segmentation in MRI for cervical cancer brachytherapy

Objective. MRI is the standard imaging modality for high-dose-rate brachytherapy of cervical cancer. Precise contouring of organs at risk (OARs) and high-risk clinical target volume (HR-CTV) from MRI is a crucial step for radiotherapy planning and treatment. However, conventional manual contouring has limitations in terms of accuracy as well as procedural time. To overcome these, we propose a deep learning approach to automatically segment OARs (bladder, rectum, and sigmoid colon) and HR-CTV from female pelvic MRI.Approach. In the proposed pipeline, a coarse multi-organ segmentation model first segments all structures, from which a region of interest is computed for each structure. Then, each organ is segmented using an organ-specific fine segmentation model separately trained for each organ. To account for variable sizes of HR-CTV, a size-adaptive multi-model approach was employed. For coarse and fine segmentations, we designed a dual convolution-transformer UNet (DCT-UNet) which uses dual-path encoder consisting of convolution and transformer blocks. To evaluate our model, OAR segmentations were compared to the clinical contours drawn by the attending radiation oncologist. For HR-CTV, four sets of contours (clinical + three additional sets) were obtained to produce a consensus ground truth as well as for inter/intra-observer variability analysis.Main results. DCT-UNet achieved dice similarity coefficient (mean ± SD) of 0.932 ± 0.032 (bladder), 0.786 ± 0.090 (rectum), 0.663 ± 0.180 (sigmoid colon), and 0.741 ± 0.076 (HR-CTV), outperforming other state-of-the-art models. Notably, the size-adaptive multi-model significantly improved HR-CTV segmentation compared to a single-model. Furthermore, significant inter/intra-observer variability was observed, and our model showed comparable performance to all observers. Computation time for the entire pipeline per subject was 12.59 ± 0.79 s, which is significantly shorter than the typical manual contouring time of >15 min.Significance. These experimental results demonstrate that our model has great utility in cervical cancer brachytherapy by enabling fast and accurate automatic segmentation, and has potential in improving consistency in contouring. DCT-UNet source code is available athttps://github.com/JHU-MICA/DCT-UNet.

The Role of Lymph Node Downstaging Following Neoadjuvant Treatment in a Group of Patients with Advanced Stage Cervical Cancer

Background and Objectives: Cervical cancer is the fourth most frequent type of neoplasia in women. It is most commonly caused by the persistent infection with high-risk strands of human papillomavirus (hrHPV). Its incidence increases rapidly from age 25 when routine HPV screening starts and then decreases at the age of 45. This reflects both the diagnosis of prevalent cases at first-time screening and the likely peak of HPV exposure in early adulthood. For early stages, the treatment offers the possibility of fertility preservation.. However, in more advanced stages, the treatment is restricted to concomitant chemo-radiotherapy, combined, in very selected cases with surgical intervention. After the neoadjuvant treatment, an imagistic re-evaluation of the patients is carried out to analyze if the stage of the disease remained the same or suffered a downstaging. Lymph node downstaging following neoadjuvant treatment is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with advanced cervical cancer. This study aims to ascertain the important survival role of radiotherapy in the downstaging of the disease and of lymphadenectomy in the control of lymph node invasion for patients with advanced-stage cervical cancer. Material and Methods: We describe the outcome of patients with cervical cancer in stage IIIC1 FIGO treated at Bucharest Oncological Institute. All patients received radiotherapy and two-thirds received concomitant chemotherapy. A surgical intervention consisting of type C radical hysterectomy with radical pelvic lymphadenectomy was performed six to eight weeks after the end of the neoadjuvant treatment. Results: The McNemar test demonstrated the regression of lymphadenopathies after neoadjuvant treatment-p: <0.001. However, the persistence of adenopathies was not related to the dose of irradiation (p: 0.61), the number of sessions of radiotherapy (p: 0.80), or the chemotherapy (p: 0.44). Also, there were no significant differences between the adenopathies reported by imagistic methods and those identified during surgical intervention-p: 0.62. The overall survival evaluated using Kaplan-Meier curves is dependent on the post-radiotherapy FIGO stage-p: 0.002 and on the lymph node status evaluated during surgical intervention-p: 0.04. The risk factors associated with an increased risk of death were represented by a low preoperative hemoglobin level (p: 0.003) and by the advanced FIGO stage determined during surgical intervention (p-value: 0.006 for stage IIIA and 0.01 for stage IIIC1). In the multivariate Cox model, the independent predictor of survival was the preoperative hemoglobin level (p: 0.004, HR 0.535, CI: 0.347 to 0.823). Out of a total of 33 patients with neoadjuvant treatment, 22 survived until the end of the study, all 33 responded to the treatment in varying degrees, but in 3 of them, tumor cells were found in the lymph nodes during the intraoperative histopathological examination. Conclusions: For advanced cervical cancer patients, radical surgery after neoadjuvant treatment may be associated with a better survival rate. Further research is needed to identify all the causes that lead to the persistence of adenopathies in certain patients, to decrease the FIGO stage after surgical intervention, and, therefore, to lower the risk of death. Also, it is mandatory to correctly evaluate and treat the anemia, as it seems to be an independent predictor factor for mortality.

The prognostic effect of tumor volume, reduction ratio, and cumulative doses on external beam radiotherapy with central-shielding method and image-guided adaptive brachytherapy for cervical cancer

Objective

To evaluate the prognostic effect of tumor volume at diagnosis, tumor reduction ratio during external beam radiotherapy (EBRT) with central-shielding method, and cumulative minimal dose to 90% of the high-risk clinical target volume (CTVHR D90) on combined EBRT and image-guided adaptive brachytherapy (IGABT) for cervical cancer.

Methods

Consecutive patients who underwent definitive radiotherapy or concurrent chemoradiotherapy for cervical cancer at Gunma University Hospital between January 2010 and December 2019 were retrospectively reviewed. Tumor volume at diagnosis and reduction ratio were calculated using magnetic resonance imaging at diagnosis and before the first IGABT session. The cumulative dose of EBRT and IGABT was calculated as an equivalent dose in 2 Gy fractions (EQD2). Optimal cutoff values were determined according to a receiver operating characteristic curve. Treatment outcomes were evaluated using the Kaplan-Meier method and compared using the log-rank test and Cox proportional hazards regression.

Results

A total of 254 patients were included in the analysis. The median follow-up for all patients was 57 (2-134) months. The 5-year overall survival (OS) was 81.9%, progression-free survival (PFS) was 71.3%, and local control (LC) was 94.5%. The patients were divided into four groups according to tumor volume at diagnosis and reduction ratio. The group with tumor volume at diagnosis ≥ 34.1 cm3 and reduction ratio < 68.8% showed significantly worse OS, PFS, and LC than the other three groups (All p < 0.05). In this group, the patients with a cumulative CTVHR D90 < 69.6 GyEQD2 showed significantly worse PFS and LC (p = 0.042 and p = 0.027, respectively). In the multivariate analysis of OS, adenocarcinoma/adenosquamous carcinoma, International Federation of Gynecology and Obstetrics 2009 stage III/IV, and a reduction ratio of < 68.8% were independent significant poor prognostic factors (p = 0.045, p = 0.009 and p = 0.001, respectively). In the univariate analysis of LC, a reduction ratio of < 68.8% was the only poor prognostic factor (p = 0.041).

Conclusion

The patients with large and poorly responding tumors had significantly worse prognoses in terms of OS, PFS, and LC, suggesting that dose escalation should be considered for such tumors.

MRI-based volumetric tumor parameters before and during chemoradiation predict tumor recurrence and patient survival in locally advanced cervical cancer: a subgroup analysis of a phase II prospective trial

BACKGROUND

This subgroup analysis of a prospective phase II trial aimed to identify valuable and accessible prognostic factors for overall survival (OS) and progression-free survival (PFS) of patients with locally advanced cervical cancer (LACC).

METHODS

Patients with FIGO II to IVA cervical cancer were assessed in this study. All patients underwent concurrent chemoradiotherapy (CCRT) followed by brachytherapy. Tumor parameters based on MRI scans before and during CCRT were evaluated for Overall survival (OS) and Progression-free survival (PFS).

RESULTS

A total of 86 patients were included in this analysis with a median follow-up period of 31.7 months. Three-year OS and PFS rates for all patients were 87.1% and 76.5%, respectively. Univariate Cox regression analysis showed that restaging tumor size (rTS) over 2.55 cm (p < 0.001), initial tumor volume (iTV) over 55.99 cc (p < 0.001), downstaging (p = 0.042), and restaging tumor volume (rTV) over 6.25 cc (p = 0.006) were significantly associated with OS. rTS (p < 0.001), iTV (p < 0.001), downstaging (p = 0.027), and rTV (p < 0.001) were identified as significant prognostic factors for PFS. In the stepwise multivariable analysis, only rTS > 2.55 cm showed statistically significant with OS (HR: 5.47, 95% CI 1.80-9.58, p = 0.035) and PFS (HR: 3.83, 95% CI 1.50-11.45; p = 0.025).

CONCLUSIONS

Initial tumor size and restaging tumor volume that are easily accessible during radiotherapy provide valuable prognostic information for cervical cancer. MRI-based measurable volumetric scoring system can be readily applied in real-world practice of cervical cancer.

CLINICAL TRIAL INFORMATION

This study is a subgroup analysis of prospective trial registered at ClinicalTrials.gov Identifier: NCT02993653.

The Impact of Patient Characteristics, Risk Factors, and Surgical Intervention on Survival in a Cohort of Patients Undergoing Neoadjuvant Treatment for Cervical Cancer

Introduction: Cervical cancer is among the most frequent types of neoplasia worldwide and remains the fourth leading cause of cancer death in women, a fact that raises the necessity for further development of therapeutic strategies. NCCN guidelines recommend radiation therapy with or without chemotherapy as the gold standard for locally advanced cervical cancer. Also, some studies claim that performing surgery after chemo-radiation therapy does not necessarily improve the therapeutic outcome. This study aims to determine the impact of the risk factors, various characteristics, and surgical treatment for patients in different stages of the disease on survival rate. Material and methods: Our study started as a retrospective, observational, unicentric one, carried out on a cohort of 96 patients diagnosed with cervical cancer from the surgical department of the Bucharest Oncological Institute, followed from 1 January 2019 for a period of 3 years. After the registration of the initial parameters, however, the study became prospective, as the patients were closely monitored through periodical check-ups. The end-point of the study is either the death of the participants or reaching the end of the follow-up period, and, therefore, we divided the cohort into two subgroups: the ones who survived after three years and the ones who did not. All 96 patients, with disease stages ranging from IA2 to IIIB, underwent radio-chemotherapy followed by adjuvant surgery. Results: Among the 96 patients, 45 (46%) presented residual tumor after radio-chemotherapy. Five patients (5%) presented positive resection margins at the post-operative histopathological examination. The presence of residual tumor, the FIGO stage post-radiotherapy, positive resection margins, and lympho-vascular and stromal invasions differed significantly between the subgroups, being more represented in the subgroup that reached the end-point. Variables correlated with the worst survival in Kaplan-Meier were the pelvic lymph node involvement-50% at three years (p-0.015)-and the positive resection margins-only 20% at three years (p < 0.001). The univariate Cox model identified as mortality-associated risk factors the same parameters as above, but also the intraoperative stage III FIGO (p < 0.001; HR 9.412; CI: 2.713 to 32.648) and the presence of post-radiotherapy adenopathy (p-0.031; HR: 3.915; CI: 1.136 to 13.487) identified through imagistic methods. The independent predictors of the overall survival rate identified were the positive resection margins (p-0.002; HR: 6.646; CI 2.0 to 22.084) and the post-radiotherapy stage III FIGO (p-0.003; HR: 13.886; CI: 2.456 to 78.506). Conclusions: The most important predictor factors of survival rate are the positive resection margins and the FIGO stage after radiotherapy. According to the NCCN guidelines in stages considered advanced (beyond stages IB3, IIA2), the standard treatment is neoadjuvant chemoradiotherapy. In our study, with radical surgery after neoadjuvant therapy, 46% of patients presented residual tumor at the intraoperative histopathological examination, a fact that makes the surgical intervention an important step in completing the treatment of these patients. In addition, based on the patient's features/comorbidities and the clinical response to chemotherapy/radiotherapy, surgeons could carefully tailor the extent of radical surgery, thus resulting in a personalized surgical approach for each patient. However, a potential limitation can be represented by the relatively small number of patients (96) and the unicentric nature of our study.