BackgroundDiffusion Weighted (DW) Magnetic Resonance Imaging (MRI) has been studed in several cancers including cervical cancer. This study was designed to investigate the association of DW-MRI parameters with baseline clinical features and clinical outcomes (local regional control (LRC), disease free survival (DFS) and disease specific survival (DSS)) in cervical cancer patients treated with definitive chemoradiation.Methods This was a retrospective study approved by an institutional review board that included 66 women with cervical cancer treated with definitive chemoradiation who underwent pre-treatment MRI at our institution between 2012 and 2013. A region of interest (ROI) was manually drawn by one of three radiologists with experience in pelvic imaging on a single axial CT slice encompassing the widest diameter of the cervical tumor while excluding areas of necrosis. The following apparent diffusion coefficient (ADC) values (×10−3 mm2/s) were extracted for each ROI: Minimum - ADCmin, Maximum - ADCmax, Mean - ADCmean, and Standard Deviation of the ADC - ADCdev. Receiver operating characteristic (ROC) curves were built to choose the most accurate cut off value for each ADC value. Correlation between imaging metrics and baseline clinical features were evaluated using the Mann Whitney test. Confirmatory multi-variate Cox modeling was used to test associations with LRC (adjusted by gross tumor volume – GTV), DFS and DSS (both adjusted by FIGO stage). Kaplan Meyer curves were built for DFS and DSS. A p-value < 0.05 was considered significant.Women median age was 52 years (range 23–90). 67 % had FIGO stage I-II disease while 33 % had FIGO stage III-IV disease. Eighty-two percent had squamous cell cancer. Eighty-eight percent received concurrent cisplatin chemotherapy with radiation. Median EQD2 of external beam and brachytherapy was 82.2 Gy (range 74–84).ResultsWomen with disease staged III-IV (FIGO) had significantly higher mean ADCmax values compared with those with stage I-II (1.806 (0.4) vs 1.485 (0.4), p = 0.01). Patients with imaging defined positive nodes also had significantly higher mean (±SD) ADCmax values compared with lymph node negative patients (1.995 (0.3) vs 1.551 (0.5), p = 0.03).With a median follow-up of 32 months (range 5–43) 11 patients (17 %) have developed recurrent disease and 8 (12 %) have died because of cervical cancer. ROC curves based on DSS showed optimal cutoffs for ADCmin (0.488 × 10−3), ADCmean (0.827 × 10−3), ADCmax (1.838 × 10−3) and ADCdev (0.148 × 10−3). ADCmin higher than the cutoff was significantly associated with worse DFS (HR = 3.632–95 % CI: 1.094–12.054; p = 0.035) and DSS (HR = 4.401–95 % CI: 1.048–18.483; p = 0.043).ConclusionPre-treatment ADCmax measured in the primary tumor may be associated with FIGO stage and lymph node status. Pre-treatment ADCmin may be a prognostic factor associated with disease-free survival and disease-specific survival in cervical cancer patients treated with definitive chemoradiation. Prospective validation of these findings is currently ong...

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1 J. Magn. Reson. Imaging 2017;45:118-124.

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The median follow up was 40 months. At the time of analysis, 2547 were alive, 560 dead and 253 deaths were disease related. Histology and treatment information is presented in the table below. The 5-yr DSS for all patients was 89%. Women with grade 1,2,3, and undifferentiated tumors who were treated with RT had a 5-yr DSS of 87%, 86%, 64% and 70% compared to 80%, 76%, 50%, 43% in those without RT (P < 0.001) respectively. When comparing external be external beam radiation therapy (EBRT) vs. brachytherapy (brachy), there was no difference in DSS in patients across all grades. Among the 2313 patients who had a lymph node (LN) assessment, our results show improved DSS in patients with some form of LN assessment particularly in patients with higher-grade tumors treated with RT. The 5-yr DSS in patients with grade 2 and 3 tumors with no LNs assessed, treated with radiation was 90% and 73% compared to the non-RT group 84% and 45% (P Z 0.0015 and P< 0.001) respectively. Women older than 70 had worse DSS, than younger women, but those with higher-grade tumors who received RT showed improvement in DSS. The 5-yr DSS for those over 70 with grade 2 and 3 tumors treated with RT was 89% and 79% compared to 79% and 63% in the non-RT group (P < 0.001 and P Z 0.07), respectively. Moreover, the DSS rates were similar with either brachy or EBRT. Conclusion: RT improves DSS in FIGO stage II patients with grade 2 or higher tumors and survival outcomes appear equivalent regardless of the modality of radiation therapy. RT improves DSS in patients with limited LN or no LN assessment. Patients older than 70 have a worse outcome, than younger patients, but have a DSS benefit when treated with radiation.