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Differentiating metastatic from nonmetastatic lymph nodes in cervical cancer patients by IVIM-DWI and DKI1Department of Radiology, Yunnan Cancer Hospital, Third Affiliated Hospital of Kunming Medical University, Kunming, China, 2Clinical Science, Philips Healthcare, Chengdu, China
Synopsis
This study aimed to investigate the diagnostic value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging and diffusion kurtosis imaging (DKI) in distinguishing metastatic from nonmetastatic lymph nodes (LNs) in cervical cancer patients. The clinical and imaging data of 102 patients with cervical cancer were collected prospectively, including 38 patients with LN metastasis and 64 patients without LN metastasis. The morphological parameters, diffusion parameters and tumor markers of primary tumors and LNs were measured and compared between the two groups. The results showed that the diagnostic efficiency of diffusion parameters were not as good as morphological parameters.
Introduction
Worldwide, cervical cancer is the fourth most common malignancy in women, with an extremely high morbidity and mortality rate, and it represents a serious threat to women’s health and life. Despite widespread screening programs and well-established treatment options, the long-term survival of cervical cancer patients has not been significantly improved due to pelvic lymphatic metastasis and other risk factors.Currently, CT and MRI are the main imaging modalities to evaluate LN metastasis of cervical cancers, but these methods are mainly based on an LN short axis＞10 mm, which cannot provide accurate histopathological information and has low reliability. PET-CT can improve the diagnostic sensitivity, but it is expensive. Therefore, ways to improve the accuracy of the imaging diagnosis of metastatic LNs and imaging biomarkers of LN metastasis are urgently needed.
Diffusion-weighted imaging (DWI) can be used to probe the structure of biological tissue by measuring the diffusion of water molecules. The apparent diffusion coefficient (ADC) value of metastatic LNs is lower than that of normal LNs due to the limited diffusion of water molecules in proliferating tumor cells. However, the DWI identification threshold often overlaps and lacks absolute standards, representing significant limitations. With the development of magnetic resonance equipment and mathematical models, intravoxel incoherent motion (IVIM) imaging and diffusion kurtosis imaging (DKI) have emerged based on traditional DWI. IVIM can distinguish pure molecular diffusion from perfusion diffusion to evaluate the perfusion of living tissue without using contrast agents. DKI can describe the degree of deviation from the Gaussian distribution in water molecules, which can more accurately reflect the tumor microenvironment. Preliminary studies have shown that IVIM has a certain significance in the diagnosis of lymphatic metastasis in cervical cancers, but wide variations exist in the results of different studies. Moreover, only one report used DKI for the diagnosis of lymph node metastasis in cervical cancers. Therefore, this study aimed to explore the value of IVIM and DKI in the diagnosis of lymphatic metastasis in cervical cancers.
Material and Methods
Patients In total, 102 patients were ultimately included in this study (mean age, 48.69 years; range, 20-72 years), including 38 patients with LN metastasis and 64 patients without LN metastasis (see Figure 1 for details).Imaging and data acquisition MR imaging was performed using a Philips 3.0 T scanner (Ingenia, 3.0 T; Philips Medical Systems, The Netherlands). All patients were scanned routinely with an 8-channel, phased-array body coil in the supine position. The parameters of IVIM and DKI were as follows. IVIM was performed with a free-breathing single-shot spin-echo echo-planar sequence in the coronal plane (repetition time/echo time: 9407 ms/60 ms; slice thickness/gap: 4 mm/1 mm; matrix: 128×128; field of view: 380 mm×380 mm; number of excitations: 1; 11 b-values: 0, 20, 50, 100, 150, 200, 500, 800, 1000, 1500 and 2000 s/mm2; and scan time: 12 min 14 s). DKI was performed with a free-breathing single-shot spin-echo echo-planar sequence using 15-directional motion-probing gradients in the coronal plane (repetition time/echo time: 2626 ms/100 ms; slice thickness/gap: 4 mm/1 mm; matrix: 128×128; field of view: 380 mm×380 mm; number of excitations: 2; 3 b-values: 0, 800 and 1500 s/mm2; and scan time: 6 min 33 s).Imaging data analysis and processingRoutine MRI images were analyzed by two pelvic radiologists with more than 5 years of experience with PACS workstations, and the following MR features were analyzed: tumor diameter, location, morphology, lesion margin, T1 and T2 signal intensity, DWI intensity and enhancement pattern. The DWI images were analyzed by using the Philips IntelliSpace Portal (Philips, Best, The Netherlands). The IVIM and DKI images were analyzed by using IMAgenGINE MRToolbox software (Vusion Tech Ltd). Combined with axial T2WI and enhanced scan sequence, the region of interest (ROI) was delineated on the largest slice of the primary tumor and LN, and all ROIs were delineated to avoid cysts and necrotic areas.
Correspondence between imaging and histopathology We separated the largest lymph node from each side of the pelvic lymph node specimen and sent it to the Department of Pathology for evaluation. Furthermore, we observed the largest lymph node on the same side on MRI to ensure that the lymph node observed on MRI corresponds one-to-one to the lymph node detected by histopathology.
Results
In total, 102 patients, including 38 patients pathologically shown to have lymphatic metastasis (containing 63 metastatic LNs) and 64 patients pathologically shown to have no lymphatic metastasis (containing 126 nonmetastatic LNs ) were included in this study. The metastatic LNs exhibited a lower apparent diffusion coefficient, mean diffusivity, and flowing blood volume fraction, a higher short and long diameter, and a lower long-short diameter ratio than those of nonmetastatic LNs. The largest tumor diameter, CEA and CA15-3 levels of the patients were higher in the metastatic groups compared with the nonmetastatic groups (P<0.05). The short diameter of LNs exhibited the highest diagnostic value, with an area under the curve of 0.848.Conclusion
IVIM-DWI and DKI can potentially noninvasively obtain information to evaluate the presence of LN metastasis in cervical cancer. However, traditional morphological parameters of LNs still has a better diagnostic efficiency.Acknowledgements
No acknowledgement found.References
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