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Serial Therapy-Induced Changes in Tumor Shape in Cervical Cancer and Their Impact on Assessing Tumor Volume and Treatment Response

¹ Department of Radiation Medicine, Division of Radiation Oncology, Arthur G. James Hospital and Solove Research Institute, The Ohio State University, College of Medicine, 300 W 10th Ave., Rm. 080, Columbus, OH 43210.
² Department of Radiology, The Ohio State University, Columbus, OH.
³ Magnetic Resonance Imaging Center, Department of Radiology, The University of Iowa, Iowa City, IA.
⁴ Department of Radiological Sciences, Oklahoma University Health Sciences Center, Oklahoma City, OK.
⁵ Department of Radiation Oncology, M. D. Anderson Cancer Center, Orlando, FL.
⁶ Department of Radiation Oncology, Baylor College of Medicine, Houston, TX.
⁷ Department of Radiation Oncology, The University of Iowa College of Medicine, Iowa City, IA.
⁸ Department of Obstetrics and Gynecology, University of Connecticut, Hartford, CT.

View larger version (143K): [in a new window]   Fig. 1A —Classification of tumor configuration. Tumors (arrows) were classified into oval configuration characterized by smooth round or oval shape with broad well-defined border without lobulations (A); lobulated configuration with smooth margin and single or multiple lobulated projections, but without infiltrating strands (B); and complex configuration characterized by irregular shape with infiltrating borders or strands extending into surrounding healthy tissue (C). MR images are fast spin-echo T2-weighted sagittal images.

View larger version (130K): [in a new window]   Fig. 1B —Classification of tumor configuration. Tumors (arrows) were classified into oval configuration characterized by smooth round or oval shape with broad well-defined border without lobulations (A); lobulated configuration with smooth margin and single or multiple lobulated projections, but without infiltrating strands (B); and complex configuration characterized by irregular shape with infiltrating borders or strands extending into surrounding healthy tissue (C). MR images are fast spin-echo T2-weighted sagittal images.

View larger version (107K): [in a new window]   Fig. 1C —Classification of tumor configuration. Tumors (arrows) were classified into oval configuration characterized by smooth round or oval shape with broad well-defined border without lobulations (A); lobulated configuration with smooth margin and single or multiple lobulated projections, but without infiltrating strands (B); and complex configuration characterized by irregular shape with infiltrating borders or strands extending into surrounding healthy tissue (C). MR images are fast spin-echo T2-weighted sagittal images.

View larger version (11K): [in a new window]   Fig. 2 —Distribution of tumor configurations at different time points. At radiation therapy (RT) start, all tumors are equally distributed into three configuration categories. Number of tumors with oval shape declines continuously during and after RT. Number of tumors with complex configuration shows sharp and persistent increase during and after RT. Number of tumors with lobulated configuration increases early during RT and then declines in favor of complex configuration.

View larger version (134K): [in a new window]   Fig. 3A —Temporal changes of tumor configuration are shown on serial MR studies (fast spin-echo T2-weighted sagittal images) obtained in 49-year-old woman with stage IIB squamous cell carcinoma of cervix. Imaging before radiation therapy (RT) shows relatively well-circumscribed tumor contour (arrows) that was classified as lobulated.

View larger version (155K): [in a new window]   Fig. 3B —Temporal changes of tumor configuration are shown on serial MR studies (fast spin-echo T2-weighted sagittal images) obtained in 49-year-old woman with stage IIB squamous cell carcinoma of cervix. During course of RT, at 21.6 Gy/2.2 weeks (B) and at 45 Gy/5 weeks (C), tumor (arrows) becomes increasingly irregular and is classified as complex in configuration.

View larger version (155K): [in a new window]   Fig. 3C —Temporal changes of tumor configuration are shown on serial MR studies (fast spin-echo T2-weighted sagittal images) obtained in 49-year-old woman with stage IIB squamous cell carcinoma of cervix. During course of RT, at 21.6 Gy/2.2 weeks (B) and at 45 Gy/5 weeks (C), tumor (arrows) becomes increasingly irregular and is classified as complex in configuration.

View larger version (9K): [in a new window]   Fig. 4A —Correlation between diameter-based and region-of-interest (ROI)-based methods. Scattergrams of volume measurement derived with diameter-based (x-axis) and ROI-based (y-axis) methods are shown at four measurement time points, at radiation therapy (RT) start (A), at 20-25 Gy/2-2.5 weeks (B), at 45-50 Gy/4-5 weeks (C), and post-RT (follow-up at 1-2 months) (D). Measurements derived by the two methods correlate well before (A) and after (D) RT (r = 0.89 and r = 0.88, respectively) but poorly during RT at 2-2.5 weeks (B) and at 4-5 weeks (C) (r = 0.68 and r = 0.67, respectively). Poor correlation during therapy is likely related to increasing irregularity of tumor volumes that are still sufficiently large during therapy to have impacted correlation. Later, post-RT, as tumor volume decreased further, impact of tumor irregularity is small in magnitude and correlation of diameter-based with 3D ROI-based measurement improves.

View larger version (8K): [in a new window]   Fig. 4B —Correlation between diameter-based and region-of-interest (ROI)-based methods. Scattergrams of volume measurement derived with diameter-based (x-axis) and ROI-based (y-axis) methods are shown at four measurement time points, at radiation therapy (RT) start (A), at 20-25 Gy/2-2.5 weeks (B), at 45-50 Gy/4-5 weeks (C), and post-RT (follow-up at 1-2 months) (D). Measurements derived by the two methods correlate well before (A) and after (D) RT (r = 0.89 and r = 0.88, respectively) but poorly during RT at 2-2.5 weeks (B) and at 4-5 weeks (C) (r = 0.68 and r = 0.67, respectively). Poor correlation during therapy is likely related to increasing irregularity of tumor volumes that are still sufficiently large during therapy to have impacted correlation. Later, post-RT, as tumor volume decreased further, impact of tumor irregularity is small in magnitude and correlation of diameter-based with 3D ROI-based measurement improves.

View larger version (7K): [in a new window]   Fig. 4C —Correlation between diameter-based and region-of-interest (ROI)-based methods. Scattergrams of volume measurement derived with diameter-based (x-axis) and ROI-based (y-axis) methods are shown at four measurement time points, at radiation therapy (RT) start (A), at 20-25 Gy/2-2.5 weeks (B), at 45-50 Gy/4-5 weeks (C), and post-RT (follow-up at 1-2 months) (D). Measurements derived by the two methods correlate well before (A) and after (D) RT (r = 0.89 and r = 0.88, respectively) but poorly during RT at 2-2.5 weeks (B) and at 4-5 weeks (C) (r = 0.68 and r = 0.67, respectively). Poor correlation during therapy is likely related to increasing irregularity of tumor volumes that are still sufficiently large during therapy to have impacted correlation. Later, post-RT, as tumor volume decreased further, impact of tumor irregularity is small in magnitude and correlation of diameter-based with 3D ROI-based measurement improves.

View larger version (7K): [in a new window]   Fig. 4D —Correlation between diameter-based and region-of-interest (ROI)-based methods. Scattergrams of volume measurement derived with diameter-based (x-axis) and ROI-based (y-axis) methods are shown at four measurement time points, at radiation therapy (RT) start (A), at 20-25 Gy/2-2.5 weeks (B), at 45-50 Gy/4-5 weeks (C), and post-RT (follow-up at 1-2 months) (D). Measurements derived by the two methods correlate well before (A) and after (D) RT (r = 0.89 and r = 0.88, respectively) but poorly during RT at 2-2.5 weeks (B) and at 4-5 weeks (C) (r = 0.68 and r = 0.67, respectively). Poor correlation during therapy is likely related to increasing irregularity of tumor volumes that are still sufficiently large during therapy to have impacted correlation. Later, post-RT, as tumor volume decreased further, impact of tumor irregularity is small in magnitude and correlation of diameter-based with 3D ROI-based measurement improves.

View larger version (10K): [in a new window]   Fig. 5 —Temporal change of median tumor volume between ROI-based and diameter-based methods. Sequential median tumor volume before, during, and after radiation therapy (RT) shows that tumors appear larger when measured with diameter-based method (solid line) compared with 3D ROI method (dashed line). This is likely related to overestimation of tumor volume with diameter-based method because maximal orthogonal diameters used for ellipsoid computation cannot adequately account for deviation of tumor shape from presumed oval or ellipsoid tumor shape.

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