Korean J Radiol.  2019 Mar;20(3):378-384. 10.3348/kjr.2018.0248.

Diagnostic Performance of MRI for Assessing Parametrial Invasion in Cervical Cancer: A Head-to-Head Comparison between Oblique and True Axial T2-Weighted Images

• Woo S
• Moon MH
• Cho JY
• Kim SH
• Kim SY

• KMID: 2438267
• DOI: http://doi.org/10.3348/kjr.2018.0248

Abstract

OBJECTIVE
To directly compare the diagnostic performance of true and oblique axial T2-weighted imaging (T2WI) for assessing parametrial invasion (PMI) in cervical cancer.
MATERIALS AND METHODS
This retrospective study included 71 women with treatment-naive cervical cancer who underwent MRI that included both oblique and true axial T2WI, followed by radical hysterectomy. Two blinded radiologists (Radiologist 1 and Radiologist 2) independently assessed the presence of PMI on both sequences using a 5-point Likert scale. Receiver operating characteristic (ROC) curve analysis was performed, with a subgroup analysis for tumors sized > 2.5 cm and ≤ 2.5 cm in diameter. Inter-reader agreement was assessed with kappa (k) statistics.
RESULTS
At hysterectomy, 15 patients (21.1%) had PMI. For Radiologist 1, the area under the ROC curve (AUC) was greater for oblique axial than for true axial T2WI {0.941 (95% confidence interval [CI] = 0.858-0.983) vs. 0.917 (95% CI = 0.827-0.969), p = 0.027}. The difference was not significant for Radiologist 2 (0.879 [95% CI = 0.779-0.944] vs. 0.827 [95% CI = 0.719-0.906], p = 0.153). For tumors > 2.5 cm, AUC was greater with oblique than with true axial T2WI (0.906 vs. 0.860, p = 0.046 for Radiologist 1 and 0.839 vs. 0.765, p = 0.086 for Radiologist 2). Agreement between the radiologists was almost perfect for oblique axial T2WI (k = 0.810) and was substantial for true axial T2WI (k = 0.704).
CONCLUSION
Oblique axial T2WI potentially provides greater diagnostic performance than true axial T2WI for determining PMI, particularly for tumors > 2.5 cm. The inter-reader agreement was greater with oblique axial T2WI.

Keyword

Cervical cancer; Magnetic resonance imaging; T2-weighted imaging; Parametrial invasion

MeSH Terms

Area Under Curve
Female
Humans
Hysterectomy
Magnetic Resonance Imaging*
Retrospective Studies
ROC Curve
Uterine Cervical Neoplasms*

Figure

• 

  Fig. 1 Flowchart of patient selection process.FIGO = International Federation of Gynecology and Obstetrics, PMI = parametrial invasion, T2WI = T2-weighted imaging

• 

  Fig. 2 ROC curve analysis for entire study population.In assessments performed by Radiologist 1, AUC was significantly greater for oblique axial T2WI than for true axial T2WI (0.941 [95% CI, 0.858–0.983] vs. 0.917 [95% CI, 0.827–0.969], p = 0.027). In assessments performed by Radiologist 2, difference in AUC was not significant (0.879 [95% CI, 0.779–0.944] vs. 0.827 [95% CI, 0.719–0.906], p = 0.153). AUC = area under curve, CI = confidence interval, ROC = receiver operating characteristic

• 

  Fig. 3 T2WI of 50-year-old woman with biopsy-proven clinical FIGO stage IIA1 cervical cancer, with PMI after surgery.A. True axial plane. B. Oblique axial plane. C. Microscopic image (H&E staining, magnification, × 40). Cervical mass was observed (asterisk). Small nodular soft tissue in right parametrium was better demonstrated on oblique axial T2WI. Using 5-point Likert scale, both radiologists assigned scores of 3 (possible PMI) to true axial T2WI and 4 (PMI probably present) to oblique axial T2WI. Patient underwent radical hysterectomy with bilateral salpingo-oophorectomy, and pelvic and para-aortic lymph node dissection. Histopathological assessment revealed invasive squamous cell carcinoma with right-sided PMI. On histopathological analysis of microscopic slides, PMI was noted (arrows).

• 

  Fig. 4 ROC curve analysis for tumors sized > 2.5 cm.In assessments performed by both radiologists, AUC was greater for oblique axial T2WI than for true axial T2WI. Difference was statistically significant for Radiologist 1 (0.906 [95% CI, 0.767–0.976] vs. 0.860 [95% CI, 0.709–0.951], p = 0.046) and borderline significant for Radiologist 2 (0.839 [95% CI, 0.684–0.938] vs. 0.765 [95% CI, 0.599–0.887], p = 0.086).

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