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Title: Diffusion-weighted magnetic resonance imaging of primary cervical cancer in the detection of sub-centimetre metastatic lymph nodes
Authors: Perucho, JAU
Chiu, KWH
Wong, EMF
Tse, KY
Chu, MMY
Chan, LWC 
Pang, H
Khong, PL
Lee, EYP
Issue Date: 2020
Source: Cancer imaging, 6 Apr. 2020, v. 20, 27, p. 1-9
Abstract: Background: Magnetic resonance imaging (MRI) has limited accuracy in detecting pelvic lymph node (PLN) metastasis. This study aimed to examine the use of intravoxel incoherent motion (IVIM) in classifying pelvic lymph node (PLN) involvement in cervical cancer patients.
Methods: Fifty cervical cancer patients with pre-treatment magnetic resonance imaging (MRI) were examined for PLN involvement by one subspecialist and one non-subspecialist radiologist. PLN status was confirmed by positron emission tomography or histology. The tumours were then segmented by both radiologists. Kruskal-Wallis tests were used to test for differences between diffusion tumour volume (DTV), apparent diffusion coefficient (ADC), pure diffusion coefficient (D), and perfusion fraction (f) in patients with no malignant PLN involvement, those with sub-centimetre and size-significant PLN metastases. These parameters were then considered as classifiers for PLN involvement, and were compared with the accuracies of radiologists.
Results: Twenty-one patients had PLN involvement of which 10 had sub-centimetre metastatic PLNs. DTV increased (p = 0.013) while ADC (p = 0.015), and f (p = 0.006) decreased as the nodal status progressed from no malignant involvement to sub-centimetre and then size-significant PLN metastases. In determining PLN involvement, a classification model (DTV + f) had similar accuracies (80%) as the non-subspecialist (76%; p = 0.73) and subspecialist (90%; p = 0.31). However, in identifying patients with sub-centimetre PLN metastasis, the model had higher accuracy (90%) than the non-subspecialist (30%; p = 0.01) but had similar accuracy with the subspecialist (90%, p = 1.00). Interobserver variability in tumour delineation did not significantly affect the performance of the classification model.
Conclusion: IVIM is useful in determining PLN involvement but the added value decreases with reader experience.
Keywords: Cervical Cancer
Magnetic resonance imaging
Diffusion-weighted imaging
Intravoxel incoherent motion
Lymph node metastasis
Publisher: BioMed Central
Journal: Cancer imaging 
ISSN: 1740-5025
EISSN: 1470-7330
DOI: 10.1186/s40644-020-00303-4
Rights: © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.
The following publication Perucho, J.A.U., Chiu, K.W.H., Wong, E.M.F. et al. Diffusion-weighted magnetic resonance imaging of primary cervical cancer in the detection of sub-centimetre metastatic lymph nodes. Cancer Imaging 20, 27 (2020) is available at
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