The purpose of this study was to show that in advanced cervical cancer patients treated with curative intent, tumor volume and uterine involvement have independent prognostic value. Eligible patients were those seen at the Peter MacCallum Cancer Centre between December 1995 and June 2001, newly diagnosed with a histologic diagnosis of squamous cell carcinoma or adenocarcinoma of the cervix, FIGO-staged IB-IVA, and having undergone magnetic resonance imaging (MRI) and treated with curative intent. Potential prognostic factors considered were FIGO stage, clinical tumor diameter, histology, age, tumor volume, and corpus invasion status. MRI was used to determine the tumor volume and whether there was invasion of tumor into the corpus uteri. One hundred and seventy-nine patients were eligible for this study. The cut-off date for follow-up was October 2003, one patient was lost to follow-up, and the mean potential follow-up time was 4.5 years (range 0.2-7.7 years). There were 60 (34%), 78 (44%), 34 (19%), and 7 (4%) patients in FIGO stages IB, II, III, and IVA, respectively. The tumors of 107 (60%) patients exhibited corpus invasion. The median tumor volume was 33 mL (range 0.1-200 mL). The four factors, FIGO stage, clinical tumor diameter, corpus invasion, and tumor volume, were all strongly positively correlated (P < 0.001 in each case). The 5-year overall survival (OS) rate for all patients was 55% (standard error = 4%). Of the six factors examined, FIGO stage (P= 0.006), clinical tumor diameter (P= 0.013), corpus invasion (P < 0.001), and tumor volume (P < 0.001) were statistically significantly related to OS duration in unifactor analyses. However, only corpus invasion (P= 0.013) and tumor volume (P= 0.004) were significantly and independently associated with OS in multifactor analyses. In particular, after adjusting for corpus involvement and tumor volume, there was no evidence for any relationship between OS and either FIGO stage (P= 0.49) or clinical tumor diameter (P= 0.58). The results from the analysis of failure-free survival were very similar. We conclude that in patients with advanced cervical cancer, tumor volume and corpus invasion provide important prognostic information over and above that provided by FIGO stage, clinical tumor diameter, histology, and age.

The aims of this study were to determine, firstly, the relationship between FIGO stage and various tumor parameters determined by magnetic resonance imaging (MRI), and, secondly, whether any of these parameters were predictors of lymph node metastases as determined by fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) in cervical cancer patients referred for radiotherapy. In 70 consecutive patients, both PET and MRI visualized all primary tumors except for one previously removed by cone biopsy. While clinical diameter and MRI-derived diameter showed a significant relationship between these two measurements (r = 0.70; P < 0.001) there was a large variability in MRI diameter for each FIGO stage and wide overlap. The average volume of primary cervical tumor on MRI was 60 cc (5-256). In FIGO stages, I, II, III and IV, uterine body involvement was present in 58%, 73%, 88%, and 100% of 19, 30, 16, and 5 patients, respectively (Ptrend= 0.015). Node positivity on FDG PET was present in 11% of patients without uterine body extension, but increased to 75% in those with uterine involvement. Average tumor volume in node-negative patients was 49 cc (5-186). Average tumor volume in node-positive patients was 69 cc (8-256). There was a significant association between nodal involvement and both FIGO stage (P = 0.018) and uterine body involvement (P < 0.001), but tumor volume and longitudinal MRI diameter were not statistically significant in unifactor predictors of nodal involvement. In multivariate analysis only uterine body extension, however, was independently related to the risk of nodal involvement. In conclusion, MRI provides noninvasive tumor size evaluation and can also demonstrate invasion of the uterine body that appears to be associated with an increased risk of nodal metastasis. This may provide clinically important prognostic information not available from current FIGO staging.

Abstract.Narayan K, Hicks RJ, Jobling T, Bernshaw D, McKenzie AF. A comparison of MRI and PET scanning in surgically staged loco-regionally advanced cervical cancer: Potential impact on treatment.The aim of this study was to assess whether positron emission tomography (PET) or magnetic resonance imaging (MRI) could obviate the need for surgical staging in patients with locally advanced cervical carcinoma being planned for radiotherapy (RT). Imaging findings were compared to surgical staging in 27 patients including three with recent resection of the primary tumor. Both PET and MRI visualized all 24 residual cervical tumors. Primary tumor volume, as measured by MRI scan, ranged from 1.25 cc to 140 cc. In 24 patients evaluable for pelvic nodal status, PET had sensitivity, specificity, and positive and negative predictive values of 83%, 92%, 91% and 85%, respectively, with 88% accuracy. MRI detected only six in 12 (50%) patients with confirmed pelvic nodal disease, all of which were also seen by CT and PET, with an overall accuracy of 75%. PET detected only four in seven (57%) cases with confirmed para-aortic (PA) involvement. All histologically confirmed sites not visualized on PET were <1 cm. Without surgical staging, six in 10 (60%) patients with histologically proven pelvic nodal disease would not have received pelvic boost if guided by MRI alone, compared to two in 10 (20%) patients guided by PET alone or in combination with MRI. All four patients with positive PA on PET were confirmed on histology or clinical follow-up, including one case that proved to be a false negative one on surgery . However, in three cases, PET would have yielded an inadequate radiation volume. In conclusion, the positive predictive value of PET in the pelvis and para-aortic region appears sufficient to obviate lymph nodal sampling, but sampling is still required to exclude small-volume disease cranial to sites of abnormality on PET. MRI has insufficient accuracy for nodal staging to impact management.

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