Cervical cancer: value of an endovaginal coil magnetic resonance imaging technique in detecting small volume disease and assessing parametrial extension.

BACKGROUND: Estimation of tumor volume by endovaginal magnetic resonance (MR) imaging is a better indicator of prognosis than FIGO stage in women with cervical cancer treated by standard modalities. However, the introduction of fertility conserving surgical techniques makes fresh demands upon imaging of these small tumors. OBJECTIVE: To determine the sensitivity and specificity of endovaginal MRI in detecting small volume disease and assessing parametrial extension in uterine cervical cancer by comparing the findings with those at radical hysterectomy in order to establish its role in guiding the surgical decision-making process preoperatively. METHODS: A retrospective study was performed in 119 patients who underwent endovaginal and external phased array MR imaging at 0.5 T or 1.5 T before radical hysterectomy. Tumor presence within the cervix and parametrial extension was noted on the endovaginal images. Histopathological findings were correlated with MR imaging results for all patients. RESULTS: The sensitivity and specificity for detecting tumor by endovaginal MR imaging in the 119 patients were 96.9 and 59.0%, respectively. Thirty-six percent of tumors were

Borderline tumors of the ovary: CT and MRI features and tumor markers in differentiation from stage I disease.

OBJECTIVE: We sought to describe MDCT and MRI features and tumor marker levels that differentiate borderline ovarian tumors from stage I ovarian tumors. CONCLUSION: Borderline ovarian tumors are complex masses with imaging features similar to stage I tumors. The thickness of septations and the size of solid components are significantly larger in stage I tumors, and these features may be helpful for predicting likelihood of invasive tumors. However, neither feature allows confident differentiation of borderline tumors from stage I disease.

Pretreatment tumour volume measurement on high-resolution magnetic resonance imaging as a predictor of survival in cervical cancer.

OBJECTIVE: To evaluate pretreatment tumour volume as a predictor of survival in patients with cervical cancer using both endovaginal and external coil magnetic resonance imaging in order to achieve high spatial resolution and delineate small volume disease. DESIGN: A retrosfection case series. SETTING: A tertiary referral centre for gynaecological oncology. POPULATION/SAMPLE: One hundred and six consecutive women with invasive carcinoma of the cervix underwent endovaginal and external coil magnetic resonance imaging on a 0.5-T or 1.5-T scanner. METHODS: T2-W FSE images, sagittal and transverse to the cervix, were obtained and tumour volume was calculated on the sagittal images by the standard technique of multiplying the sum of the areas by the slice thickness. Patients were treated in accordance with normal clinical practice and their subsequent outcome was recorded. The relationships between clinical or imaging parameters and survival were assessed with Cox's proportional hazard method. MAIN OUTCOME MEASURES: Disease-free survival. RESULTS: In 89 of these women, the tumour was Stage I and 88 of the 106 were treated principally by surgery. The median tumour volume was 4.75 cm(3) (upper and lower quartiles 22 and 0.6). The median length of follow up of surviving patients was 223 weeks (quartiles 158 and 274 weeks). Stage, treatment type, lymphovascular space involvement, invasion of the parametrium, closeness of the excision margin, lymph node metastases, and magnetic resonance imaging measurements of tumour volume, parametrial invasion and lymph node disease were all significantly associated with survival in univariate analysis. Only magnetic resonance imaging measurement of tumour volume remained consistently and strongly associated with survival after multivariate analysis of parameters available prior to treatment (P= 0.001, Wald statistic 10.74). A receiver operating characteristic curve of tumour volume and disease-free survival confirmed the utility of this investigation and suggested that a cutoff around 13.0 cm(3) would predict survival with a positive predictive value of 0.93 and a negative predictive value of 0.75. CONCLUSION: Magnetic resonance imaging assessment of tumour volume using both an endovaginal and an external coil approach provides an accurate prediction of prognosis in cervical cancer and defines a population of women at high risk of recurrence and death. The predictive value of this investigation is superior to the clinical and histological parameters previously used. Use of this technique permits a more accurate choice of treatment options. These results suggest that it is the size of tumour burden that determines the outcome rather than invasion beyond the anatomical margins of the uterus.

Needle versus loop diathermy excision of the transformation zone for the treatment of cervical intraepithelial neoplasia: a randomised controlled trial.

OBJECTIVE: To determine whether lower rates or incomplete resection of cervical intraepithelial neoplasia (CIN) may be achieved by needle excision of the transformation zone (NETZ) than with loop excision (LLETZ). DESIGN: A prospective randomised controlled trial. SETTING: A gynaecological oncology centre and a teaching hospital in West London. POPULATION: Four hundred and four women due to receive treatment for suspected CIN. METHODS: Women were randomised to receive either LLETZ or NETZ. MAIN OUTCOME MEASURES: The study was designed to demostrate a difference in the proportion of women with clear histological margins of 82% for LLETZ compared to 94% for NETZ with 90% power at a 5% significance level, allowing for absence of CIN in the treatment specimen in 15%. RESULTS: Four randomised women were excluded from the analysis, as they were ineligible for the study. Three hundred and forty-seven (87%) had CIN in the treatment specimen and could be included in the analysis of excision margins. More women in the NETZ arm had clear histological margins (84.8%vs 75%, (P= 0.03). The median volume of specimens in the NETZ arm was 739 mm(3) larger (P= 0.33) and they were less likely to be removed in multiple pieces (2.5%vs 29.5%, RR 0.09, 95% CI 0.04 to 0.20). Needle excision took longer to perform (median treatment time 210 vs 90 seconds, P<0.0001) and surgeons more often reported the procedure as 'difficult' (9.5%vs 3.0%, RR = 3.17%, 95% CI 1.33 to 7.58). No difference in peri-operative or post-operative complication rates could be demonstrated between the two groups. CONCLUSION: NETZ is more likely to produce a specimen in one piece and with clear margins compared to LLETZ.

Preinvasive and invasive cervical cancer: an ex vivo proton magic angle spinning magnetic resonance spectroscopy study.

The aim of this study was to obtain (1)H MR spectra using magic angle spinning (MAS) techniques from punch biopsies (<20 mg) of preinvasive and invasive cervical disease and to correlate the spectral profiles with sample classification on the basis of histopathology. Tissue samples were obtained at colposcopic examination, during local treatment of cervical intraepithelial neoplasia (CIN) or at hysterectomy. (1)H MAS MRS was performed at 25 degrees C while spinning the sample at 4.5 kHz. After measurement, the tissue was immersed in formalin and the pathology determined. Histological examination after (1)H MAS MRS defined 27 samples with squamous cell carcinoma (SCC), 12 with CIN and 39 with only normal tissue. The standardized integrals of the lipid, choline and creatine regions of the spectra were significantly higher in SCC than in normal or CIN tissue. There was no obvious difference in the standardized integral of the region 4.15-3.5 ppm. The acyl fatty acid side-chain length was longer or less unsaturated in SCC than in normal tissue. Normal tissue from patients with SCC showed significantly higher triglycerides than normal tissue from patients with benign uterine disease but significantly lower triglycerides than SCC tissue. (1)H MAS MRS of the uterine cervix ex vivo may be used to differentiate non-invasive from invasive cervical lesions, increase interpretation of in vivo MRS and provide insights into tumor biology.

(1)H magnetic resonance spectroscopy of preinvasive and invasive cervical cancer: in vivo-ex vivo profiles and effect of tumor load.

PURPOSE: To compare in vivo (1)H magnetic resonance (MR) spectra of preinvasive and invasive cervical lesions with ex vivo magic angle spinning (MAS) spectra of intact biopsies from the same subjects and to establish the effects of tumor load in the tissue sampled on the findings. MATERIALS AND METHODS: A total of 51 subjects (nine with normal cervix, 10 with cervical intraepithelial neoplasia [CIN], and 32 with cervical cancer) underwent endovaginal MR at 1.5 T. Single-voxel (3.4 cm(3)) (1)H MR spectra were acquired and voxel tumor load was calculated (tumor volume within voxel as a percentage of voxel volume). Resonances from triglycerides -CH(2) and -CH(3) and choline-containing compounds (Cho) were correlated with voxel tumor load. Biopsies analyzed by (1)H MAS-MR spectroscopy (MRS) had metabolite levels correlated with tumor load in the sample at histology. RESULTS: In vivo studies detected Cho in normal, CIN, and cancer patients with no significant differences in levels (P = 0.93); levels were independent of voxel tumor load. Triglyceride -CH(2) and -CH(3) signals in-phase with Cho were present in 77% and 29%, respectively, of cancer subjects (but not in normal women or those with CIN), but did not correlate with voxel tumor load. Ex vivo cancer biopsies showed levels of triglycerides -CH(2) and -CH(3) and of Cho that were significantly greater than in normal or CIN biopsies (P < 0.05); levels were independent of the tumor load in the sample. The presence of -CH(2) in vivo predicted the presence of cancer with a sensitivity and specificity of 77.4% and 93.8% respectively, positive (PPV) and negative (NPV) predictive values were 96% and 68.2%; for -CH(2) ex vivo, sensitivity was 100%; specificity, 69%; PPV, 82%; and NPV, 100%. CONCLUSION: Elevated lipid levels are detected by MRS in vivo and ex vivo in cervical cancer and are independent of tumor load in the volume of tissue sampled.

1H magnetic resonance spectroscopy of invasive cervical cancer: an in vivo study with ex vivo corroboration.

The objective of this study was to establish in vivo (1)H-magnetic resonance (MR) spectroscopic appearances of cervical cancer using an endovaginal receiver coil and corroborate findings with magic angle spinning (MAS) MR spectroscopy of tissue samples. Fifty-three women (14 controls and 39 with cervical cancer) underwent endovaginal coil MR imaging at 1.5 T with T(1)- and T(2)-weighted scans sagittal and transverse to the cervix. Localized (1)H MR spectra (PRESS technique, TR 1600 ms, TE 135 ms) were accumulated in all controls and 29 cancer patients whose tumour filled > 50% of a single 3.4 cm(3) voxel. Peaks from triglyceride-CH(2) and -CH(3) were defined as present and in-phase (with the choline resonance), present but out-of-phase, or not present. Peak areas of choline-containing compounds were standardized to the area of unsuppressed tissue water resonance. Comparisons in observed resonances between groups were made using Fisher's exact test (qualitative data) and a t-test (quantitative data). Biopsies from these women analysed using MAS-MR spectroscopy and normalized to the intensity of an external standard of silicone rubber were similarly compared. Adequate water suppression permitted spectral analysis in 11 controls and 27 cancer patients. In-phase triglyceride-CH(2) resonances (1.3 ppm) were observed in 74% of tumours but in no control women (p < 0.001). No differences were observed in the presence of a 2 ppm resonance, choline-containing compounds or creatine in cancer compared with control women. However, ex vivo analysis showed significant differences not only in -CH(2), but also in -CH(3), a 2 ppm resonance, choline-containing compounds and creatine between tissues from control women and cancer tissue (p < 0.001, = 0.001, = 0.036, < 0.001 and = 0.004 respectively). On in vivo (1)H-MR spectroscopy, the presence of positive triglyceride-CH(2) resonances can be used to detect and confirm the presence of cervical cancer. However, technical improvements are required before routine clinical use.