Synergistic effects of hemoglobin and tumor perfusion on tumor control and survival in cervical cancer

Int J Radiat Oncol Biol Phys. 2009 Aug 1;74(5):1513-21. doi: 10.1016/j.ijrobp.2008.09.050. Epub 2009 Mar 13.


Purpose: The tumor oxygenation status is likely influenced by two major factors: local tumor blood supply (tumor perfusion) and its systemic oxygen carrier, hemoglobin (Hgb). Each has been independently shown to affect the radiotherapy (RT) outcome in cervical cancer. This study assessed the effect of local tumor perfusion, systemic Hgb levels, and their combination on the treatment outcome in cervical cancer.

Methods and materials: A total of 88 patients with cervical cancer, Stage IB2-IVA, who were treated with RT/chemotherapy, underwent serial dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before RT, at 20-22 Gy, and at 45-50 Gy. The DCE-MRI perfusion parameters, mean and lowest 10th percentile of the signal intensity distribution in the tumor pixels, and the Hgb levels, including pre-RT, nadir, and mean Hgb (average of weekly Hgb during RT), were correlated with local control and disease-specific survival. The median follow-up was 4.6 years.

Results: Local recurrence predominated in the group with both a low mean Hgb (<11.2 g/dL) and low perfusion (lowest 10th percentile of signal intensity <2.0 at 20-22 Gy), with a 5-year local control rate of 60% vs. 90% for all other groups (p = .001) and a disease-specific survival rate of 41% vs. 72% (p = .008), respectively. In the group with both high mean Hgb and high perfusion, the 5-year local control rate and disease-specific survival rate was 100% and 78%, respectively.

Conclusion: These results suggest that the compounded effects of Hgb level and tumor perfusion during RT influence the radioresponsiveness and survival in cervical cancer patients. The outcome was worst when both were impaired. The management of Hgb may be particularly important in patients with low tumor perfusion.

MeSH terms

  • Adenocarcinoma / blood
  • Adenocarcinoma / blood supply
  • Adenocarcinoma / mortality
  • Adenocarcinoma / radiotherapy
  • Adult
  • Aged
  • Aged, 80 and over
  • Carcinoma, Squamous Cell / blood
  • Carcinoma, Squamous Cell / blood supply
  • Carcinoma, Squamous Cell / mortality
  • Carcinoma, Squamous Cell / radiotherapy
  • Cell Hypoxia / physiology
  • Combined Modality Therapy / methods
  • Disease-Free Survival
  • Female
  • Follow-Up Studies
  • Hemoglobin A / analysis
  • Hemoglobin A / physiology*
  • Humans
  • Magnetic Resonance Imaging / methods
  • Middle Aged
  • Neoplasm Recurrence, Local / blood
  • Neoplasm Recurrence, Local / blood supply
  • Neoplasm Recurrence, Local / mortality
  • Prospective Studies
  • Radiotherapy Dosage
  • Survival Rate
  • Treatment Outcome
  • Uterine Cervical Neoplasms* / blood
  • Uterine Cervical Neoplasms* / blood supply
  • Uterine Cervical Neoplasms* / mortality
  • Uterine Cervical Neoplasms* / radiotherapy


  • Hemoglobin A