Accuracy of Diffusion-Weighted Echo-Planar MR Imaging and ADC Mapping in the evaluation of residual Cervical Carcinoma after radiation therapy

doi:10.1016/j.ygyno.2011.06.009

Gynecologic Oncology

Volume 123, Issue 1, October 2011, Pages 110-115

https://doi.org/10.1016/j.ygyno.2011.06.009 Get rights and content

Abstract

Objectives

The impact of diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADCs) of MR imaging on the evaluation of residual Uterine Cervical Carcinoma after Radiation Therapy, in addition to conventional MR images.

Methods

Fourty-nine women presenting with a uterine cervical cancer were examined with 1.5 T MRI and DWI, 8 (4–20) weeks after treatment. Treatment response was determined based on the histopathological results after therapy and was classified as a complete response (CR) or residual disease (RD). Post-treatment DWI and ADC results were compared.

Results

Five (11%) and 44 (89%) patients were considered as having histologically-proven RD or a CR respectively. The mean ADC of cervical tissue for all patients was 1.74 ± 0.324 × 10^− 3 mm²/s and the SD was 1.94 ± 1.11 × 10^− 4. The mean ADC was 1.62 ± 0.21 × 10^− 3 mm²/s (SD = 1.45 × 10^− 4) for the 5 patients with RD versus 1.76 ± 0.33 × 10^− 3 mm²/s (SD = 1.99 × 10^− 4) for the 44 patients with a CR (p = 0.09). Using 1.7 × 10^− 3 mm²/s as a radiological cut-off value for the ADC, all patients classified as having histologically-proven RD had a mean ADC of ≤ 1.7 × 10^− 3. In 12 (25%) cases, RD was suspected on T2-weighted MRI images alone. Eight of these cases were considered as false positives compared to the histological results. Their mean ADC was 1.98 × 10^− 3 mm²/s and none of them had an ADC of < 1.7 × 10^− 3 mm²/s.

Conclusion

Although our results were not statistically significant, ADC values could potentially be used to predict and monitor the response of uterine cervical cancer.

Highlights

► Diffusion-Weighted Echo-Planar MR Imaging and ADC Mapping could be used to diagnose residual Cervical Carcinoma after radiation therapy. ► All patients classified as having histologically-proven residual disease had a mean ADC of ≤ 1.7 × 10–3.

Introduction

In 2009, it was estimated that 11,270 new cases of uterine cervical cancer would be diagnosed in the United States, and that 4070 women would die of the disease [1]. Nowadays, conventional MRI with T2-weighted sequences and dynamic contrast-enhanced images provide an adequate estimation of the tumor size and the extent of loco-regional disease [2], [3]. However, the evaluation of residual disease after treatment remains difficult, and the risk of false-positive results is high [4]. Different reports showed that the median ADC value of cervical cancer (0.757–1.09 × 10^− 3 mm²/s) was significantly lower than those of the normal cervix (1.33–2.09 × 10^− 3 mm²/s) (p < 0.001) [5], [6], [7], [8]. This suggested that DWI and ADC mapping could potentially play a role in the diagnosis and as a surrogate biomarker of treatment response in advanced cervical cancers. Naganawa et al. showed that among 75% of the patients treated with chemotherapy and/or radiation therapy, the mean ADC values after 2 weeks of therapy reflected a significant correlation between the eventual MR response and the clinical response [6]. Evaluating response at the end of treatment is a major endpoint for clinicians, because completion surgery is considered for the subgroup of patients with “residual cervical disease”. The purpose of this study was to evaluate the accuracy of DWI and ADC mapping in the evaluation of residual disease in patients treated with radiation therapy for uterine cervical carcinoma.

Section snippets

Patients

This retrospective study was conducted at a single institution between June 2007 and July 2009, and included 49 female patients (median age: 48 years; age range: 29–73 years) with histologically-proven uterine cervical cancer, stage IB1 to IVA according the International Federation of Gynecology and Obstetrics (FIGO) classification. Initial MR imaging with DWI and ADC mapping was performed in order to assess the extent of the disease and for local staging. All patients were treated with radiation

Patient diagnosis, therapy and outcome

Between June 2007 and December 2009, retrospective data of 49 patients with carcinoma of the uterine cervix were analyzed. Before therapy, all cervical tumors were depicted on MRI as homogeneously hyperintense lesions compared to adjacent skeletal muscle on both T2-weighted images and DW images. On pseudo-color ADC maps they all appeared as a blue or green region. After therapy, 44 (90%) patients had no residual tumor on T2-weighted images (Fig. 1). On DWI images they exhibited heterogeneously

Discussion

MRI is the standard imaging technique used for the initial evaluation of local spread and the lymph node status in patients with uterine cervical cancer [2], [10]. For patients with locally advanced cervical carcinoma, it has also been applied to assess treatment response after chemoradiation and brachytherapy [4]. Radiological evaluation of residual disease following local radiation and/or chemoradiation therapy for cervix carcinoma is another important endpoint. To date, there is no clinical

Conclusion

To our knowledge, our report is the first to compare the histological follow-up with morphological MRI and DWI evaluation. The histological results and DWI were not significantly correlated due to the low number of cases of RD in our population. As suggested by other reports, DW-MRI could potentially serve as a surrogate marker of treatment response in advanced cervical cancers. A further follow-up study with a larger number of patients and a longer follow-up period may be required to confirm

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Acknowledgments

The authors would like to thank Lorna St. Ange for editing.

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Accuracy of Diffusion-Weighted Echo-Planar MR Imaging and ADC Mapping in the evaluation of residual Cervical Carcinoma after radiation therapy

Abstract

Objectives

Methods

Results

Conclusion

Highlights

Introduction

Section snippets

Patients

Patient diagnosis, therapy and outcome

Discussion

Conclusion

Conflict of interest statement

Acknowledgments

Eur J Radiol

Int J Radiat Oncol Biol Phys

Radiother Oncol

Gynecol Oncol

Clin Radiol

Cancer statistics, 2009

CA Cancer J Clin

Role of imaging in cancer of the cervix. American College of Radiology. ACR Appropriateness Criteria

Radiology

American College of Radiology Imaging Network 6651; Gynecologic Oncology Group 183. Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network 6651-Gynecologic Oncology Group 183

J Clin Oncol

Accuracy of magnetic resonance imaging in predicting residual disease in patients treated for stage IB2/II cervical carcinoma with chemoradiation therapy: correlation of radiologic findings with surgicopathologic results

Cancer