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. 2022 Sep 1;95(1138):20200203.
doi: 10.1259/bjr.20200203. Epub 2022 Aug 4.

Value of MRI and diffusion-weighted imaging in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer

Qingling Song  1   2 , Yanyan Yu  1   2 , Xiaomiao Zhang  2 , Yanmei Zhu  2   3 , Yahong Luo  2 , Tao Yu  2 , Jiayi Sun  2 , Fan Liu  2 , Yue Dong  2
Affiliations
Free PMC article

Value of MRI and diffusion-weighted imaging in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer

Qingling Song et al. Br J Radiol. .
Free PMC article

Abstract

Objectives: To investigate the value of conventional MRI and diffusion-weighted imaging (DWI) in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer.

Methods: 102 patients with cervical cancer who underwent MRI and DWI scan were included. 137 lymph nodes were analyzed, including 44 metastatic lymph nodes (MLNs) and 93 non-metastatic lymph nodes (non-MLNs). The morphology and apparent diffusion coefficient (ADC) value of lymph nodes were measured including short-axis diameter (DS), long-axis diameter (DL), ratio of short-to-long-axis diameter (DR), fatty hilum, asymmetry, ADCmax, ADCmean and ADCmin. The Mann-Whitney U-test, independent sample t-test and Chi-square test were employed to compare the differences of all criteria between MLNs and non-MLNs. Logistic regression and decision tree were used to develop the combined diagnostic model. ROC analyses were used to evaluate the diagnostic performance.

Results: The DS and DR of MLNs were significantly higher than those of non-MLNs (p < 0.05), the ADCmax, ADCmean and ADCmin of MLNs were significantly lower than those of non-MLNs (p < 0.05). Presence of fatty hilum and asymmetric lymph nodes between MLNs and non-MLNs were significantly different (p＜0.05). Combined measurement of ADCmin, DS and DR had the highest AUC 0.937 with 90.9% sensitivity and 87.1% specificity. The accuracy of decision tree was 88.3%.

Conclusion: MRI with DWI had potential in diagnosing normal-sized pelvic lymph nodes metastases in patients with cervical cancer. The combined evaluation of DS, DR and ADCmin of lymph nodes and decision tree of the combined measure showed better diagnostic performances than sole criteria.

Advances in knowledge: The short-axis diameter, ratio of short-to-long-axis diameter and ADCmin of lymph nodes have moderate value in the diagnosis of the metastases of the normal-sized lymph nodes for the patient with cervical cancer as the sole indices. The combined evaluation of DS, DR and ADCmin is much more valuable in the detection of metastatic lymph nodes.

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Figures

Figure 1.
Figure 1.
(a-c) Images of a 43-year-old cervical cancer patient, a left external iliac lymph node (arrow) is observed on MRI images. (a) Transverse T2-weighted image of the node (arrow). The DS and DL of the node are 8.73mm and 11.20mm. (b) Coronal T1-weighted image of the corresponding node (arrow). The DS and DLof the node are 8.96mm and 11.30mm. (c) Sagittal T2-weighted image of the same node (arrow). The DS and DL of the node are 9.12mm and 12.20mm. The mean DS of the node is 8.94mm, final DL is 12.20mm, the DR is 0.73. DS, short-axis diameter; DL, long-axis diameter；DR, ratio of short to long-axis diameter..
Figure 2.
Figure 2.
(a) Transverse T2-weighted image of right obturator lymph node (arrow) shows absent fatty hilum，the DS is 9.07mm. This node was histologically positive. (b) Transverse T2-weighted image of right external iliac lymph node (arrow) shows the presence of fatty hilum. This node was histologically negative. DS, short-axis diameter.
Figure 3.
Figure 3.
(a,b) Images of a 28-year-old cervical cancer patient, an external iliac lymph node (arrow) was observed on MRI images, the DS and DL are 8.86mm and 9.74mm.(c) A pathologic section with resected lymph nodes from the same region, the DS and DL of the round node(arrow) are 9mm and 10mm,the size of this node is close to the node observed on MRI images. (d) Histopathological examination (hematoxylin and eosin, magnification, ×200) shows the node is metastatic positive. DS, short-axis diameter; DL, long-axis diameter.
Figure 4.
Figure 4.
(a,b) Images of a 51-year-old cervical cancer patient diagnosed with left obturator and internal iliac lymph nodes metastases. (a) The nodes are slight hyperintensity signal at axial fat suppressed T2-weighted TSE sequence; the DS of left obturator node（yellow arrow） is 6.31mm and the DS of internal iliac node（green arrow） is 9.24mm. (b)The lymph nodes show hyperintensity on DWI; the maximum, mean and minimum ADC values of the left obturator lymph node（yellow arrow） are 0.893×10-3mm2/s,0.642×10-3mm2/s, 0.545×10-3mm2/s; and the ADC values of the internal iliac node（green arrow） are 0.947×10-3mm2/s,0.773×10-3mm2/s,0.608×10-3mm2/s, respectively. (c,d) Images of a 28-year-old cervical cancer patient diagnosed with left obturator lymph node metastasis. (c) The node（yellow arrow） is isointensity signal at axial fat suppressed T2-weighted TSE sequence; the DS is 6.23mm. (d) The same lymph node（yellow arrow） shows hyperintensity on DWI; the maximum, mean and minimum ADC values of the lymph node are 1.135×10-3mm2/s,0.957×10-3mm2/s,0.773×10-3mm2/s,respectively. TSE, turbo spin-echo; DS,short-axis diameter; ADC, apparent diffusion coefficient.
Figure 5.
Figure 5.
(a)The box plot compares the short-axis diameter between MLNs and non-MLNs. (b) The box plot compares the ratio of short to long-axis diameter between MLNs and non-MLNs. (c) The box plots compare the values of ADCmax, ADCmean and ADCminbetween MLNs and non-MLNs. MLN, metastatic lymph node; ADC, apparent diffusion coefficient.
Figure 6.
Figure 6.
The receiver operating characteristic (ROC) curve for size-based criteria and ADC values of lymph nodes and combined measure P1 to differentiate MLNs from non-MLNs.The AUC of combined measure P1 is larger thanother indices indicate combined measure P1 is superior to other indexes. MLN,metastatic lymph node; ADC, apparent diffusion coefficient, AUC, area under the curve.
Figure 7.
Figure 7.
The decision tree according to logistic equation in cervical cancer patients. First, no visible node on T2W or DWI was score 0. Second, ADCmin was employed to evaluate if the patients have MLNs, ADCmin value of a node less than 0.910 ×10-3mm2/s was score 2, a node that ADCminvalue was more than 0.910 ×10-3mm2/s was score 1. Then DSand DR were employed, the node that DS ≥6.12mm or DR≥0.69 was score 3, otherwise score 2. Finally, if the node that DS ≥6.12mm and DR ≥0.69 was score 4. No lymph node metastasis when score was 0,1 or 2, and a node was considered as malignant when score was 3 or 4. ADC,apparent diffusion coefficient. DS, short-axis diameter. DR,ratio of short to long-axis diameter.
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