Hypoxia In Cervical Cancer Research Articles

A Prospective Investigation of Tumor Hypoxia Imaging with 68Ga-Nitroimidazole PET/CT in Patients with Carcinoma of the Cervix Uteri and Comparison with 18F-FDG PET/CT: Correlation with Immunohistochemistry.

Hypoxia in cervical cancer has been associated with a poor prognosis. Over the years 68Ga labelled nitroimidazoles have been studied and have shown improved kinetics. We present our initial experience of hypoxia Positron Emission Tomography (PET) imaging in cervical cancer with 68Ga-Nitroimidazole derivative and the correlation with 18F-FDG PET/CT and immunohistochemistry. Twenty women with cervical cancer underwent both 18F-FDG and 68Ga-Nitroimidazole PET/CT imaging. Dual-point imaging was performed for 68Ga-Nitroimidazole PET. Immunohistochemical analysis was performed with hypoxia inducible factor-1α (HIF-1α). We documented SUVmax, SUVmean of the primary lesions as well as tumor to muscle ratio (TMR), tumor to blood (TBR), metabolic tumor volume (MTV) and hypoxic tumor volume (HTV). There was no significant difference in the uptake of 68Ga-Nitroimidazole between early and delayed imaging. Twelve patients had uptake on 68Ga-Nitroimidazole PET. Ten patients demonstrated varying intensities of HIF-1α expression and six of these also had uptake on 68Ga-Nitroimidazole PET. We found a strong negative correlation between HTV and immunohistochemical staining (r = −0.660; p = 0.019). There was no correlation between uptake on PET imaging and immunohistochemical analysis with HIF-1α. Two-thirds of the patients demonstrated hypoxia on 68Ga-Nitroimidazole PET imaging.

Genomic Profiling of Chinese Cervical Cancer Patients Reveals Prevalence of DNA Damage Repair Gene Alterations and Related Hypoxia Feature.

BackgroundCervical cancer is responsible for 10–15% of cancer-related deaths in women worldwide. In China, it is the most common cancer in the female genital tract. However, the genomic profiles of Chinese cervical cancer patients remain unclear.Materials and MethodsA total of 129 cervical cancer patients were enrolled in this study (113 squamous, 12 adenocarcinoma, 2 adenosquamous, and 2 neuroendocrine carcinoma). To classify the clinical features and molecular characteristics of cervical cancer, the genomic alterations of 618 selected genes were analyzed in the samples of these patients, utilizing target next-generation sequencing (NGS) technology. Furthermore, the findings from the Chinese cohort were then compared with the data of Western patients downloaded from The Cancer Genome Atlas (TCGA) database, in terms of gene expression files, mutation data, and clinical information.ResultsAll studied patients had valid somatic gene alterations, and the most frequently altered genes were PIK3C, TP53, FBXW7, ARID1A, ERBB2, and PTEN. Comparison of genomic profiling showed significantly different prevalence of genes, including TP53, KMT2C, and RET, between the Chinese and the TCGA cohorts. Moreover, 57 patients (44.19%) with 83 actionable alterations were identified in our cohort, especially in PI3K and DNA damage repair (DDR) pathways. After an in-depth analysis of cervical cancer data from the TCGA cohort, DDR alteration was found to be associated with extremely higher tumor mutation burden (TMB) (median mutation count: 149.5 vs 66, p <0.0001), and advanced stages (p <0.05). Additionally, DDR alteration, regardless of its function, was positively correlated with hypoxia feature and score. Moreover, patients with a high hypoxia score were positively correlated with a high abundance of mast cell resting, but lower abundance of CD8+ T cells and activated mast cell. Finally, CDHR5 was identified as the hub gene to be involved in the DDR–hypoxia network, which was negatively correlated with both the DDR alteration and hypoxia score.ConclusionsOverall, a unique genomic profiling of Chinese patients with cervical cancer was uncovered. Besides, the prevalent actionable variants, especially in PI3K and DDR pathways, would help promote the clinical management. Moreover, DDR alteration exerted the significant influence on the tumor microenvironment in cervical cancer, which could guide the clinical decisions for the treatment. CDHR5 was the first identified hub gene to be negatively correlated with DDR or hypoxia in cervical cancer, which had potential effects on the treatment of immune checkpoint inhibitors (ICIs).

Imaging of Tumor Hypoxia With 18F-EF5 PET/MRI in Cervical Cancer.

The aim of this study was to evaluate the distribution of hypoxia using 18F-EF5 as a hypoxia tracer in cervical cancer patients with PET/MRI. We investigated the association between this 18F-EF5-PET tracer and the immunohistochemical expression of endogenous hypoxia markers: HIF1α, CAIX, and GLUT1. Nine patients with biopsy-proven primary squamous cell cervix carcinoma (FIGO 2018 radiological stages IB1-IIIC2r) were imaged with dual tracers 18F-EF5 and 18F-FDG using PET/MRI (Int J Gynaecol Obstet. 2019;145:129-135). 18F-EF5 images were analyzed by calculating the tumor-to-muscle ratio to determine the hypoxic tissue (T/M ratio >1.5) and further hypoxic subvolume (HSV) and percentage hypoxic area. These 18F-EF5 hypoxic parameters were correlated with the size and localization of tumors in 18F-FDG PET/MRI and the results of hypoxia immunohistochemistry. All primary tumors were clearly 18F-FDG and 18F-EF5 PET positive and heterogeneously hypoxic with multiple 18F-EF5-avid areas in locally advanced cancer and single areas in clinically stage I tumors. The location of hypoxia was detected mainly in the periphery of tumor. Hypoxia parameters 18F-EF5 max T/M ratio and HSV in primary tumors correlated independently with the advanced stage (P = 0.036 and P = 0.040, respectively), and HSV correlated with the tumor size (P = 0.027). The location of hypoxia in 18F-EF5 imaging was confirmed with a higher hypoxic marker expression HIF1α and CAIX in tumor fresh biopsies. The 18F-EF5 imaging has promising potential in detecting areas of tumor hypoxia in cervical cancer.

ALDH-1-positive cells exhibited a radioresistant phenotype that was enhanced with hypoxia in cervical cancer

BackgroundWe have previously found there was a small subpopulation of cells with cancer stem cell-like phenotype ALDH-1 in cervical cancer. Radiotherapy has been applied in most of the cervical cancer. However,the mechanisms underlying radioresistance still remained elusive. Our study is to explore whether ALDH+ cell promotes radioresistance by hypoxia.MethodsCells were respectively cultured in hypoxia and normoxia environment and analyzed for marker stability, and cell cycle distribution. Results: Cell growth, apoptosis, cell cycle, sphere formation were affected by hypoxia. ALDH-1 and CHK2 were upregulated after hypoxia.ConclusionsHere we show that ALDH-1 positive cells contribute to cervical carcinoma radioresistance through preferential activation of the DNA damage checkpoint response and an increase in DNA repair capacity. The fraction of these cells is enriched after radiation in cervical carcinoma.

Abstract B38: Hypoxia mediates downregulation of mTOR via miR-100 in cervical cancer cells

Abstract Objectives: Hypoxia occurs during development of cervical cancer and is considered to correlate with its malignancy. We found that hypoxia induced miR-100 whose expression was low in cervical cancer. We sought to determine the target molecules during hypoxia in cervical cancer. Methods and Results: We found that the expression of miR-100 was significantly higher under hypoxic condition (1% O2) by realtime RT-PCR. According to the results of in silico analysis, miR-100 targeted mechanistic target of rapamycin (mTOR). Hypoxia and overexpression of miR-100 respectively decreased the activity of luciferase-reporter containing the 3’-untranslated region (UTR) of mTOR with the predicted miR-100-binding site in cervical cancer cell lines, CA and HeLa. By Western blot analysis, hypoxia downregulated the endogenous mTOR protein expression. mTOR mRNA level was also downregulated by hypoxia using realtime RT-PCR. Conclusions: Our results suggest that miR-100 and mTOR could be a therapeutic target for cervical cancer. Citation Format: Shigeatsu Takamizawa, Zenta Yamanaka, Hirotaka Nishi. Hypoxia mediates downregulation of mTOR via miR-100 in cervical cancer cells [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2018 Nov 27-30; Miami Beach, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(4 Suppl):Abstract nr B38.

Intratumoral heterogeneity and hypoxia gene expression signatures: Is a single biopsy adequate?

Background and PurposeGene expression signatures are often used to identify hypoxic tumors. However, intratumoral heterogeneity raises concern that multiple biopsies may be necessary to assess global hypoxia status. The objective of this study was to compare the impact of heterogeneity on the discriminative capacity of several previously described hypoxia gene signatures and determine if a single biopsy is sufficient to obtain a reliable estimate of hypoxia in cervical cancer. Materials and MethodsMultiple biopsies (33) were obtained from 11 locally advanced (FIGO IB to IVB) cervical cancers prior to treatment. Ten hypoxia gene signatures were analyzed. Variance component analysis was used to determine the ratio of within-tumor variability to total-tumor variability when one to five biopsies are available for analysis (W/T1–5). The mean standardized error in the signature scores was estimated by comparing the score using one biopsy randomly selected from each tumor to the ‘global’ score using all available biopsies. ResultsThe ten hypoxia signatures were comprised of 6–99 genes each. The W/T1 ratios for individual genes commonly found in the signatures ranged from 0.17 to 0.73. W/T1 ratios for the signatures were generally lower (0.21–0.45), implying greater capacity to discriminate among tumors. With additional biopsies, the signature W/T ratios (ie W/T2-5) decreased further. The mean error in the signature scores varied from 0.27 to 0.40 of one standard deviation, suggesting high capacity to discriminate among tumors with different global hypoxia scores. ConclusionsCompared with individual probes, hypoxia gene expression signatures are generally more consistent across multiple biopsies from different regions of a tumor and more tolerant of intratumoral heterogeneity.

High brachytherapy doses can counteract hypoxia in cervical cancer—a modelling study

Tumour hypoxia is a well-known adverse factor for the outcome of radiotherapy. For cervical tumours in particular, several studies indicate large variability in tumour oxygenation. However, clinical evidence shows that the management of cervical cancer including brachytherapy leads to high rate of success. It was the purpose of this study to investigate whether the success of brachytherapy for cervical cancer, seemingly regardless of oxygenation status, could be explained by the characteristics of the brachytherapy dose distributions.To this end, a previously used in silico model of tumour oxygenation and radiation response was further developed to simulate the treatment of cervical cancer employing a combination of external beam radiotherapy and intracavitary brachytherapy. Using a clinically-derived brachytherapy dose distribution and assuming a homogeneous dose delivered by external radiotherapy, cell survival was assessed on voxel level by taking into account the variation of sensitivity with oxygenation as well as the effects of repair, repopulation and reoxygenation during treatment. Various scenarios were considered for the conformity of the brachytherapy dose distribution to the hypoxic region in the target.By using the clinically-prescribed brachytherapy dose distribution and varying the total dose delivered with external beam radiotherapy in 25 fractions, the resulting values of the dose for 50% tumour control, D50, were in agreement with clinically-observed values for high cure rates if fast reoxygenation was assumed. The D50 was furthermore similar for the different degrees of conformity of the brachytherapy dose distribution to the tumour, regardless of whether the hypoxic fraction was 10%, 25%, or 40%. To achieve 50% control with external RT only, a total dose of more than 70 Gy in 25 fractions would be required for all cases considered.It can thus be concluded that the high doses delivered in brachytherapy can counteract the increased radioresistance caused by hypoxia if fast reoxygenation is assumed.

Identification and Validation of Reference Genes for RT-qPCR Studies of Hypoxia in Squamous Cervical Cancer Patients.

Hypoxia is an adverse factor in cervical cancer, and hypoxia-related gene expression could be a powerful biomarker for identifying the aggressive hypoxic tumors. Reverse transcription quantitative PCR (RT-qPCR) is a valuable method for gene expression studies, but suitable reference genes for data normalization that are independent of hypoxia status and clinical parameters of cervical tumors are lacking. In the present work, we aimed to identify reference genes for RT-qPCR studies of hypoxia in squamous cervical cancer. From 422 candidate reference genes selected from the literature, we used Illumina array-based expression profiles to identify 182 genes not affected by hypoxia in cervical cancer, i.e. genes regulated by hypoxia in eight cervical cancer cell lines or correlating with the hypoxia-associated dynamic contrast-enhanced magnetic resonance imaging parameter ABrix in 42 patients, were excluded. Among the 182 genes, nine candidates (CHCHD1, GNB2L1, IPO8, LASP1, RPL27A, RPS12, SOD1, SRSF9, TMBIM6) that were not associated with tumor volume, stage, lymph node involvement or disease progression in array data of 150 patients, were selected for further testing by RT-qPCR. geNorm and NormFinder analyses of RT-qPCR data of 74 patients identified CHCHD1, SRSF9 and TMBIM6 as the optimal set of reference genes, with stable expression both overall and across patient subgroups with different hypoxia status (ABrix) and clinical parameters. The suitability of the three reference genes were validated in studies of the hypoxia-induced genes DDIT3, ERO1A, and STC2. After normalization, the RT-qPCR data of these genes showed a significant correlation with Illumina expression (P<0.001, n = 74) and ABrix (P<0.05, n = 32), and the STC2 data were associated with clinical outcome, in accordance with the Illumina data. Thus, CHCHD1, SRSF9 and TMBIM6 seem to be suitable reference genes for studying hypoxia-related gene expression in squamous cervical cancer samples by RT-qPCR. Moreover, STC2 is a promising prognostic hypoxia biomarker in cervical cancer.

Hypoxia inducible factor-1 mediates upregulation of urokinase-type plasminogen activator receptor gene transcription during hypoxia in cervical cancer cells.

Hypoxia occurs during development of cervical cancer and is considered to correlate with its invasion. Hypoxia mediates tumor cells to have more invasive property in a variety of cancers. Urokinase plasminogen activator receptor (uPAR) which mediates invasion is considered to be induced by hypoxia. We sought to determine the regulators of uPAR expression during hypoxia in cervical cancer. We showed that cervical cancer cell lines, CaSki and CA, were more invasive under hypoxic condition (1% O2) than under normoxic condition (20% O2) by invasion assays. Using western blot analysis, hypoxia enhanced the endogenous hypoxia-inducible factor (HIF)-1α and uPAR protein expression. uPAR mRNA level was also upregulated by hypoxia using real-time RT-PCR. Overexpression of HIF-1α which is induced by hypoxia activated the transcriptional activity of the uPAR promoter by luciferase assays. HIF-1 protein bound the putative HIF-1 response element on the uPAR promoter using electrophoretic mobility shift analysis, and additional luciferase assays show that this is essential for uPAR transactivation by HIF-1. HIF-1 overexpression enhanced the endogenous uPAR expression and introduction of siRNA for HIF-1α diminishes uPAR expression during hypoxia. These results indicate the upregulation of uPAR by hypoxia in cervical cancer cells is mediated through HIF-1. In cervical cancer tissues, we also demonstrated that uPAR protein expression was detected in cervical cancer but not in normal cervix or cervical intraepithelial neoplasia (CIN) by immunohistopathological staining. Our results provide evidence that regulation of uPAR expression by HIF-1 represents a mechanism for cervical cancer invasion during hypoxia.

Abstract 4378: miR-100 mediates resistance to paclitaxel in cervical cancer cells

Abstract Objectives: Hypoxia occurs during development of cervical cancer and is considered to correlate with its resistance to chemotherapy. We found that hypoxia induced miR-100 whose expression was low in cervical cancer. We sought to determine the regulators of the paclitaxel response during hypoxia in cervical cancer. Methods and Results: We found that the expression of miR-100 was significantly higher under hypoxic condition (1% O2) by realtime RT-PCR. According to the results of in silico analysis, miR-100 targeted human ubiquitin-specific protease (USP) 15. Hypoxia and overexpression of miR-100 respectively decreased the activity of luciferase-reporter containing the 3′-untranslated region (UTR) of USP15 with the predicted miR-100-binding site in cervical cancer cell lines, SiHa and HeLa. By western blot analysis, hypoxia enhanced the endogenous USP15 protein expression. USP15 mRNA level was also up-regulated by hypoxia using realtime RT-PCR. Overexpression of miR-100 induced paclitaxel resistance reducing apoptosis using MTT assays and annexin V staining. Conclusions: Our results provide evidence that regulation of USP15 expression by miR-100 represents a mechanism for paclitaxel resistance in cervical cancer. Our results suggest that miR-100 and USP15 could be a therapeutic target in paclitaxel-resistant cervical cancer. Citation Format: Rina Kato, Hirotaka Nishi, Yuzo Nagamitsu, Toru Sasaki, Keiichi Isaka. miR-100 mediates resistance to paclitaxel in cervical cancer cells. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4378. doi:10.1158/1538-7445.AM2014-4378

Blood oxygenation level-dependent MR imaging as a predictor of therapeutic response to concurrent chemoradiotherapy in cervical cancer: a preliminary experience.

To investigate the value of blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) as a predictor of therapeutic response in cervical cancer patients undergoing concurrent chemoradiotherapy (CCRT). Thirty consecutive patients with biopsy-proven cervical cancer were examined by BOLD MRI before (preTx) and after CCRT (postTx). The R2* value (s(-1)) was calculated in the tumour and normal myometrium for preTx and postTx studies. Final tumour responses, as determined by changes of tumour size or volume on MRI, were correlated with tumour R2* values at preTx. The mean R2* values of tumours at preTx (21.1) were significantly lower than those at postTx (39.4 s(-1)) (p < 0.001), while those of normal myometrium were similar between preTx and postTx (p = 0.363). At preTx, tumour R2* values showed significantly negative correlation with final tumour size response (p = 0.022, Spearman's coefficient = -0.415). However, tumour R2* values at preTx were not associated with final tumour volume response (p = 0.069). BOLD MRI at 3 T, as an imaging biomarker, may have the potential to evaluate therapeutic response in cervical cancers. The association between BOLD MRI findings and CCRT responses warrants further validation. • Hypoxia in cervical cancer is an independent risk factor • BOLD MRI reflect oxygenation status of tissue adjacent to perfused microvessels • Pretreatment tumour R2* reveal negative correlation with final tumour size response • Accurate oxygenation assessment in cervical cancer may help clinical decision making.

Intratumoral Heterogeneity of 64Cu-ATSM Uptake is a Prognostic Indicator in Patients with Cervical Cancer

Introduction: Intratumoral heterogeneity determined by FDG-PET is a poor prognostic factor in cervical cancer. Cu- ATSM has been used to evaluate hypoxia in cervical cancer. In this study, FDG and 64Cu-ATSM uptake patterns were compared and the prognostic significance of 64Cu-ATSM heterogeneity was determined. Methods: 15 patients with cervical cancer who underwent pretreatment 64Cu-ATSM- and FDG-PET/CT were included. The 64Cu-ATSM- and FDG-PET/CT images were co-registered and tumor volumes were autocontoured for each image set in 10% increments of the SUVmax ranging from 40% to 80%. The hypoxic fraction defined by 64Cu-ATSM uptake was determined. Concordance between 64Cu-ATSM and FDG uptake was determined by Dice’s coefficient. Heterogeneity of 64Cu-ATSM and FDG uptake was calculated as the variance of the 40-80% isothreshold volumes. The association between heterogeneity of 64Cu-ATSM uptake with tumor-specific factors and outcomes was determined. Results: The hypoxic fraction ranged from 0.773 ± 0.013 to 0.087 ± 0.010 as defined by the 40% to 80% Cu-ATSM isothreshold volumes, respectively. Dice’s similarity coefficients for the FDG and 64Cu-ATSM 40 to 80% isothreshold volumes ranged from 0.476 ± 0.012 to 0.112 ± 0.017. Greater 64Cu-ATSM heterogeneity was associated with increased risk of lymph node metastasis at diagnosis (p<0.01), persistent disease after therapy, (p<0.01), and decreased median progression-free survival (11 months vs. not reached, p=0.03). Conclusion: Significant fractions of cervical tumors are hypoxic. Regions of highest 64Cu-ATSM and FDG uptake were discordant. Elevated 64Cu-ATSM heterogeneity may predict for increased risk of lymph node metastases, decreased responsiveness to treatment, and decreased progression-free survival.

Assessing Tumor Hypoxia in Cervical Cancer by PET with 60Cu-Labeled Diacetyl-Bis(N4-Methylthiosemicarbazone)

Tumor hypoxia indicates a poor prognosis. This study was undertaken to confirm our prior pilot results showing that pretreatment tumor hypoxia demonstrated by PET with (60)Cu-labeled diacetyl-bis(N(4)-methylthiosemicarbazone) ((60)Cu-ATSM) is a biomarker of poor prognosis in patients with cervical cancer. Thirty-eight women with biopsy-proved cervical cancer underwent (60)Cu-ATSM PET before the initiation of radiotherapy and chemotherapy. (60)Cu-ATSM uptake was evaluated semiquantitatively as the tumor-to-muscle activity ratio (T/M). A log-rank test was used to determine the cutoff uptake value that was strongly predictive of prognosis. All patients also underwent clinical PET with (18)F-FDG before the institution of therapy. The PET results were correlated with clinical follow-up. Tumor (60)Cu-ATSM uptake was inversely related to progression-free survival and cause-specific survival (P = 0.006 and P = 0.04, respectively, as determined by the log-rank test). We found that a T/M threshold of 3.5 best discriminated patients likely to develop a recurrence from those unlikely to develop a recurrence; the 3-y progression-free survival of patients with normoxic tumors (as defined by T/M of < or = 3.5) was 71%, and that of patients with hypoxic tumors (T/M of > 3.5) was 28% (P = 0.01). Tumor (18)F-FDG uptake did not correlate with (60)Cu-ATSM uptake, and there was no significant difference in tumor (18)F-FDG uptake between patients with hypoxic tumors and those with normoxic tumors (P = 0.9). Pretherapy (60)Cu-ATSM PET provides clinically relevant information about tumor oxygenation that is predictive of outcome in patients with cervical cancer.

Comparison of Molecular Markers of Hypoxia and Imaging with 60Cu-ATSM in Cancer of the Uterine Cervix

To determine if hypoxia-related molecular markers are associated with (60)Cu labeled diacetyl-bis (N4 -methylthiosemicarbazone); ((60)Cu-ATSM) imaging of tumor hypoxia in cervical cancer. Fifteen patients were enrolled in a prospective study and underwent evaluation of tumor hypoxia with positron emission tomography (PET) using (60)Cu-ATSM. (60)Cu-ATSM-PET imaging was compared with the expression of tissue molecular markers, which included vascular endothelial growth factor (VEGF), cyclo-oxygenase-2 (COX-2), epidermal growth factor receptor (EGFR), carbonic anyhdrase IX (CA-9), and apoptotic index. Six patients had hypoxic tumors determined by (60)Cu-ATSM, and nine had non-hypoxic tumors. The 4-year overall survival estimates were 75% for patients with non-hypoxic tumors and 33% for those with hypoxic tumors (p = 0.04). Overexpression of VEGF (p = 0.13), EGFR (p = 0.05), CA-9 (p = 0.02), COX-2 (p = 0.08), and the presence of apoptosis (p = 0.005) occurred in patients with hypoxic tumors. Cox proportional hazards modeling demonstrated hypoxia as determined by (60)Cu-ATSM to be a significant independent predictor of tumor recurrence (p = 0.0287). (60)Cu-ATSM hypoxia was correlated with overexpression of VEGF, EGFR, COX-2, CA-9, an increase in apoptosis, and a poor outcome.

Significance of hypoxia in cervical cancer

Significance of hypoxia in cervical cancer

Apaf-1 is regulated by hypoxia in cervical cancer

Apaf-1 is regulated by hypoxia in cervical cancer

Apaf-1 is regulated by hypoxia in cervical cancer

Objectives: The aim of this study was to evaluate and compare the use of B-mode transvaginal, utero-ovarian Doppler and intratumoural colour Doppler imaging in the diagnosis of ovarian tumours in order to establish whether they are organic or functional, and malignant or benign in nature prior to surgery. Study Design: A series of 213 women between the ages of 15 and 87 presenting ovarian tumours were examined with pulsed and colour Doppler and the functional state of the ovary at the time of the exploration was also established. Size and morphology were evaluated through a new scoring system called sonographic index. This score is calculated as the sum of the points corresponding to tumoural volume (≤8 ml=1 point; >8 ml and ≤100 ml=2 points; >100 ml=3 points) and the points corresponding to morphological characteristics (negative echogenicity=1 point; mixed echogenicity=2 points; multilocular morphology=3 points; complex morphology=4 points; positive echogenicity=5 points) varying between 2 and 8 points. The flow velocity waveform (FVW) of the utero-ovarian and intratumoural arteries were obtained and analyzed after assessing their resistance indices. Other parameters studied were the presence and location of the colour signal in the intratumoural arteries. Results: Of the total, 84 of the tumours were found to be functional and had disappeared by the time later examinations took place. Surgery was performed in 129 of the patients, and posterior histopathological studies permitted classifying the tumours as benign in 107 cases and malignant in 22. The sonographic index was significantly higher in the organic (4.9±1.5) and malignant (6.9±1.0) tumours than in the functional (3.6±1.5) and the benign (4.1±1.2) tumours. The utero-ovarian and intratumoural blood flow RIs in the malignant tumours (0.48±0.12 and 0.43±0.08, respectively) was significantly lower than in the benign tumours (0.83±0.12 and 0.58±0.15, respectively). There were no significant differences in the utero-ovarian and intratumoural blood flow RIs when organic and functional tumours were compared. In all of the malignant tumours a colour signal was identified; it was centrally located in 90% of the cases. A colour signal was observed in 83% of the functional tumours, and in 52% of the organic benign tumours. In the benign tumours the colour signal was peripherally located in 98% of the cases. The variables for sensitivity, specificity, positive predictive value, negative predictive value and precision when organic tumours were diagnosed were 82.9, 65.5, 78.7, 71.4 and 76.1 for a sonographic index where the score was ≥4; the values for the utero-ovarian RI were 48.4, 90.4, 88.4, 53.6 and 65.1 (cut-off 0.55≥RI≥0.90); the values for the intratumoural RI were 56.5, 68.6, 54.2, 70.6 and 63.8 (cut-off ≤0.55). When malignancy was diagnosed these variables were 95.5, 82.2, 38.2, 99.4 and 83.6 for the sonographic index (score ≥6); 90.9, 98.9, 90.0, 98.9 and 98.1 for the utero-ovarian RI (cut-off ≤0.55) and 80.0, 66.7, 33.3, 94.1 and 69.0 for the intratumoural RI (cut-off ≤0.50). The number of false positives diagnosed on the basis of the intratumoural RI decreased when cases that had been evaluated during the luteal phase were excluded from the study. Notwithstanding, the phase of the cycle does not seem to interfere with the diagnosis when utero-ovarian Doppler imaging is used. Conclusions: B-mode transvaginal ultrasonography and utero-ovarian Doppler velocimetry seem to complement each other to aid in differentiating between organic and functional ovarian tumours. Transvaginal ultrasonography and Doppler imaging provide good results for the diagnosis of malignancy, although the utero-ovarian RI reduces the number of false positives that occur with ultrasonography. Our group, therefore, believes that the combined use of these techniques is beneficial in the clinical diagnosis and management of ovarian tumours.

Assessing tumor hypoxia in cervical cancer by positron emission tomography with 60Cu-ATSM: Relationship to therapeutic response—a preliminary report

Purpose Tumor hypoxia is associated with poor response to therapy. We have investigated whether pretreatment tumor hypoxia assessed by positron emission tomography (PET) with Cu-60 diacetyl-bis(N 4-methylthiosemicarbazone) ( 60Cu-ATSM) predicts responsiveness to subsequent therapy in cervical cancer. Methods and materials Fourteen patients with biopsy-proved cervical cancer were studied by PET with 60Cu-ATSM before initiation of radiotherapy and chemotherapy. 60Cu-ATSM uptake was evaluated semiquantitatively by determining the tumor-to-muscle activity ratio (T/M) and peak slope index of tumor tracer uptake. All patients also underwent clinical PET with F-18 fluorodeoxyglucose (FDG) before institution of therapy. The PET results were correlated with follow-up evaluation (14–24 months). Results Tumor uptake of 60Cu-ATSM was inversely related to progression-free survival and overall survival (log–rank p = 0.0005 and p = 0.015, respectively). An arbitrarily selected T/M threshold of 3.5 discriminated those likely to develop recurrence; 6 of 9 patients with normoxic tumors (T/M < 3.5) are free of disease at last follow-up, whereas all of 5 patients with hypoxic tumors (T/M > 3.5) have already developed recurrence. Similar discrimination was achieved with the peak slope index. The frequency of locoregional nodal metastasis was greater in hypoxic tumors ( p = 0.03). Tumor FDG uptake did not correlate with 60Cu-ATSM uptake ( r = 0.04; p = 0.80), and there was no significant difference in tumor FDG uptake between patients with hypoxic tumors and those with normoxic tumors. Conclusion 60Cu-ATSM-PET in patients with cervical cancer revealed clinically relevant information about tumor oxygenation that was predictive of tumor behavior and response to therapy in this small study.