Korean J Radiol.  2013 Aug;14(4):616-625. 10.3348/kjr.2013.14.4.616.

Pre-Treatment Diffusion-Weighted MR Imaging for Predicting Tumor Recurrence in Uterine Cervical Cancer Treated with Concurrent Chemoradiation: Value of Histogram Analysis of Apparent Diffusion Coefficients

• Heo SH
• Shin SS
• Kim JW
• Lim HS
• Jeong YY
• Kang WD
• Kim SM
• Kang HK

• KMID: 1715766
• DOI: http://doi.org/10.3348/kjr.2013.14.4.616

Abstract

OBJECTIVE
To evaluate the value of apparent diffusion coefficient (ADC) histogram analysis for predicting tumor recurrence in patients with uterine cervical cancer treated with chemoradiation therapy (CRT).
MATERIALS AND METHODS
Our institutional review board approved this retrospective study and waived informed consent from each patient. Forty-two patients (mean age, 56 +/- 14 years) with biopsy-proven uterine cervical squamous cell carcinoma who underwent both pre-treatment pelvic magnetic resonance imaging with a 3.0 T magnetic resonance scanner and concurrent CRT were included. All patients were followed-up for more than 6 months (mean, 36.4 +/- 11.9 months; range 9.0-52.8 months) after completion of CRT. Baseline ADC parameters (mean ADC, 25th percentile, 50th percentile, and 75th percentile ADC values) of tumors were calculated and compared between the recurrence and no recurrence groups.
RESULTS
In the recurrence group, the mean ADC and 75th percentile ADC values of tumors were significantly higher than those of the no recurrence group (p = 0.043 and p = 0.008, respectively). In multivariate analysis, the 75th percentile ADC value of tumors was a significant predictor for tumor recurrence (p = 0.009; hazard ratio, 1.319). When the cut-off value of the 75th percentile ADC (0.936 x 10-3 mm2/sec) was used, the overall recurrence free survival rate above the cut-off value was significantly lower than that below the cut-off value (51.9% vs. 91.7%, p = 0.003, log-rank test).
CONCLUSION
Pre-CRT ADC histogram analysis may serve as a biomarker for predicting tumor recurrence in patients with uterine cervical cancer treated with CRT.

Keyword

Apparent diffusion coefficient; Diffusion-weighted magnetic resonance imaging; Tumor recurrence; Cervical cancer; Uterus

MeSH Terms

Adult
Aged
Aged, 80 and over
Antineoplastic Agents/*therapeutic use
Biopsy
Carcinoma, Squamous Cell/*diagnosis/drug therapy/radiotherapy
Chemoradiotherapy
Diagnosis, Differential
Diffusion Magnetic Resonance Imaging/*methods
Female
Humans
Middle Aged
Neoplasm Recurrence, Local/*diagnosis
Prognosis
Retrospective Studies
Time Factors
Uterine Cervical Neoplasms/*diagnosis/drug therapy/radiotherapy
Antineoplastic Agents

Figure

• 

  Fig. 1 Method of measurement of ADC values in uterine cervical cancer.Tumor border is identified by visual evaluation on axial T2-weighted image (A). ROI is manually drawn to include tumor as much as possible on ADC map (B) at level corresponding to A. ADC = apparent diffusion coefficient, ROI = region of interest

• 

  Fig. 2 Thirty-six-year-old woman with tumor recurrence after CRT for advanced uterine cervical cancer.A. Pre-CRT axial T2-weighted image shows uterine cervical cancer (arrows) with left parametrial invasion (FIGO stage IIB). B. Pre-CRT ADC map depicts manually drawn ROI to include tumor as much as possible. ADC75 value of tumor was 1.078 × 10-3 mm2/sec. C. Gd-enhanced axial T1-weighted image obtained at 10 months after CRT completion demonstrates about 2 cm metastatic lymphadenopathy (arrows) in right external iliac chain (arrows). ADC = apparent diffusion coefficient, CRT = chemoradiation therapy, FIGO = International Federation of Gynecology and Obstetrics, ROI = region of interest

• 

  Fig. 3 Boxplots of ADC values of recurrence (shaded box) and no recurrence (open bar) group.Despite substantial overlap between two groups, mADC and ADC75 in recurrence group are significantly higher than those of no recurrence group (p = 0.043 and p = 0.008, respectively). However, ADC25 and ADC50 are not significantly different between two groups (p = 0.087 and p = 0.319, respectively). ADC = apparent diffusion coefficient

• 

  Fig. 4 ROC curve of ADC75 value for predicting tumor recurrence.When cut-off value of ADC75 was 0.936 × 10-3 mm2/sec, sensitivity, specificity, and accuracy were 77.8%, 75.8% and 71.1%, respectively. Area under ROC curve (Az) is 0.796 (p = 0.007, 95% CI, 0.636-0.958). ADC = apparent diffusion coefficient, CI = confidence interval, ROC = receiver operating characteristic

• 

  Fig. 5 Recurrence-free survival rate according to ADC75 value.There is statistically significant difference in recurrence-free survival rate between patients with ADC75 ≥ 0.936 × 10-3 mm2/sec and ADC75 < 0.936 × 10-3 mm2/sec (51.9% vs. 91.7%, p = 0.003, log-rank test). ADC = apparent diffusion coefficient, RFS = recurrence-free survival

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