Utility of preoperative ferumoxtran-10 MRI to evaluate retroperitoneal lymph node metastasis in advanced cervical cancer: Results of ACRIN 6671/GOG 0233

Abstract

Rationale and objectives: To assess if ferumoxtran-10 (f-10) improves accuracy of MRI to detect lymph node (LN) metastasis in advanced cervical cancer.

Materials and methods: F-10 MRI component of an IRB approved HIPAA compliant ACRIN/GOG trial was analyzed. Patients underwent f-10 MRI followed by extra-peritoneal or laparoscopic pelvic and abdominal lymphadenectomy. F-10-sensitive sequences were T2* GRE sequences with TE of 12 and 21. Seven independent blinded readers reviewed f-10-insensitive sequences and all sequences in different sessions. Region correlations were performed between pathology and MRI for eight abdomen and pelvis regions. Sensitivity and specificity were calculated at participant level. Reference standard is based on pathology result of surgically removed LNs.

Results: Among 43 women enrolled in the trial between September 2007 and November 2009, 33 women (mean age 49 ±11 years old) with advanced cervical cancer (12 IB2, 3 IIA, 15 IIB and 3 IIIB, 29 squamous cell carcinomas, 32 grade 2 or 3) were evaluable. Based on histopathology, LN metastasis was 39% in abdomen and 70% in pelvis. Sensitivity of all sequence review in pelvis, abdomen, and combined were 83%, 60%, and 86%, compared with 78%, 54%, and 80% for f-10 insensitive sequences (P: 0.24, 0.44 and 0.14, respectively). Mean diameter of the largest positive focus on histopathology was 13.7 mm in abdomen and 18.8 mm in pelvis (P = 0.018). Specificities of all sequence review in pelvis, abdomen, and combined were 48%, 75%, and 43%, compared with 75%, 83%, and 73% (P: 0.003, 0.14, 0.002 respectively) for f-10 insensitive sequences.

Conclusion: Addition of f-10 increased MRI sensitivity to detect LN metastasis in advanced cervical cancer. Increased sensitivity did not reach statistical significance and was at the expense of lower specificity.

Keywords: Cervical cancer; Ferumoxtran-10; Lymph node metastasis; MRI; USPIO.

Fig. 1

Study schema.

Fig. 2

(A) Axial T1W (TR 175, TE 1.9), and B) axial T2* (TR 2200, TE 21) in a 34 year-old woman with squamous carcinoma of the cervix. A right obturator lymph node is present (arrows) measuring 10 mm × 10 mm that is hypo T1 signal (A), and high T2* signal (B) indicating lack of accumulation of USPIO agent. This was a true positive LN at pathology.

Fig. 3

(A) Axial T2W (TR 5500, TE), and B) axial T2* (84 TR 2200, TE 21) in a 17 year-old-woman with squamous carcinoma of the cervix. A lymph node is present posterior to the right common iliac artery (arrows) measuring 10 mm × 15 mm that is intermediate T2 signal (A), and high T2* signal (B) indicating lack of accumulation of USPIO agent. This was region was called negative at pathology likely because of the location of this lymph node behind the artery and not accessible to lymphadenectomy.