Role of ADC values in assessing clinical response and identifying residual disease post-chemo radiation in uterine cervix cancer

Abstract

Objectives: To evaluate the role of apparent diffusion coefficient (ADC) values in assessing response after chemo-radiotherapy in cervix cancer and investigate the utility of ADC as a tool to identify residual disease, after the treatment completion. Methods: A prospective study was done in 100 patients with histopathologically proven cancer of uterine cervix who were classified as either complete response (CR) or residual disease posttreatment. MRI was done pretreatment and after 6 weeks post-treatment with chemo-radiation. 53 patients among the cohort also underwent a fluoro-deoxy glucose positron-emission computed tomography (FDG-PET CT). ADC values, change in ADC values, and metabolic activity obtained from FDG-PET CT were correlated with clinical outcome, and statistical analysis was done to determine the better tool for assessing response evaluation between ADC and PET-CT. Results: Residual lesions have notably lower ADC value than that of posttreatment changes. The mean ADC values of residual tumors: 1.26 ± 0.238 × 10⁻³ mm²/s and mean ADC values of lesions due to posttreatment changes: 1.540 ± 0.218 × 10⁻³ mm²/s (statistically significant difference between malignant and posttreatment lesions, P < 0.05). ADC has 67% sensitivity, 83% specificity, 35% positive predictive values (PPV), 95% negative predictive values (NPV), and 81% accuracy in differentiating residual disease from post treatment changes. PPV, NPV, sensitivity, and specificity with PET-CT were 93%, 89%, 98%, and 73%, respectively. PPV, NPV, sensitivity, and specificity of contrast MRI were 16%, 91%, 58%, and 59%, respectively. Conclusion: Diffusion imaging differentiates residual cervix malignancies from post treatment changes based on ADC values and can be a promising and evocative biomarker. Complimentary use of ADC and PET/CT may increase diagnostic confidence.

Keywords

Apparent diffusion coefficient values - biomarker - fluoro-deoxy glucose positron-emission computed tomography - response assessment - uterine cervix

Publication History

Received: 10 August 2019

Accepted: 26 November 2019

Article published online:
21 July 2021

• References

• 1 Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C. et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11. Lyon, France: 2013
• 2 Dhoot NM, Kumar V, Shinagare A, Kataki AC, Barmon D, Bhuyan U. Evaluation of carcinoma cervix using magnetic resonance imaging: Correlation with clinical FIGO staging and impact on management. J Med Imaging Radiat Oncol 2012; 56: 58-65
• 3 Kraljević Z, Visković K, Ledinsky M, Zadravec D, Grbavac I, Bilandzija M. et al. Primary uterine cervical cancer: Correlation of preoperative magnetic resonance imaging and clinical staging (FIGO) with histopathology findings. Coll Antropol 2013; 37: 561-8
• 4 Chen J, Zhang Y, Liang B, Yang Z. The utility of diffusion-weighted MR imaging in cervical cancer. Eur J Radiol 2010; 74: e101-6
• 5 Harry VN, Semple SI, Gilbert FJ, Parkin DE. Diffusion weighted magnetic resonance imaging in the early detection of response to chemoradiation in cervical cancer. Gynecol Oncol 2008; 111: 213-20
• 6 Schwarz JK, Siegel BA, Dehdashti F, Grigsby PW. Association of posttherapy positron emission tomography with tumor response and survival in cervical carcinoma. JAMA 2007; 298: 2289-95
• 7 Nakamura K, Joja I, Nagasaka T, Fukushima C, Kusumoto T, Seki N. et al. The mean apparent diffusion coefficient value (ADC mean) on primary cervical cancer is a predictive marker for disease recurrence. Gynecol Oncol 2012; 127: 478-83
• 8 Antunes D, Cunha TM. Recurrent cervical cancer: How can radiology be helpful. OMICS J Radiology 2013; 2: 138
• 9 Kinkel K, Ariche M, Tardivon AA, Spatz A, Castaigne D, Lhomme C. et al. Differentiation between recurrent tumor and benign conditions after treatment of gynecologic pelvic carcinoma: Value of dynamic contrast-enhanced subtraction MR imaging. Radiology 1997; 204: 55-63
• 10 Gu KW, Kim CK, Choi CH, Yoon YC, Park W. Prognostic value of ADC quantification for clinical outcome in uterine cervical cancer treated with concurrent chemoradiotherapy. Eur Radiol 2019; 29: 6236-44
• 11 Padhani AR, Liu G, Koh DM, Chenevert TL, Thoeny HC, Takahara T. et al. Diffusion-weighted magnetic resonance imaging as a cancer biomarker: Consensus and recommendations. Neoplasia 2009; 11: 102-25
• 12 Cui Y, Zhang XP, Sun YS, Tang L, Shen L. Apparent diffusion coefficient: Potential imaging biomarker for prediction and early detection of response to chemotherapy in hepatic metastases 1. Radiology 2008; 248: 894-900
• 13 Liu Y, Bai R, Sun H, Liu H, Wang D. Diffusion-weighted magnetic resonance imaging of uterine cervical cancer. J Comput Assist Tomogr 2009; 33: 858-62
• 14 Harry VN, Semple SI, Gilbert FJ, Parkin DE. Diffusion-weighted magnetic resonance imaging in the early detection of response to chemoradiation in cervical cancer. Gynecol Oncol 2008; 111: 213-20
• 15 Vincens E, Balleyguier C, Rey A, Uzan C, Zareski E, Gouy S. et al. 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 2008; 113: 2158-65
• 16 McVeigh PZ, Syed AM, Milosevic M, Fyles A, Haider MA. Diffusion-weighted MRI in cervical cancer. Eur Radiol 2008; 18: 1058-64
• 17 Sarabhai T, Tschischka A, Stebner V, Nensa F, Wetter A, Kimmig R. et al. Simultaneous multiparametric PET/MRI for the assessment of therapeutic response to chemo radiotherapy or concurrent chemoradiotherapy of cervical cancer patients: Preliminary results. Clin Imaging 2018; 49: 163-8