Predicting treatment response to concurrent chemoradiotherapy in squamous cell carcinoma of the cervix using amide proton transfer imaging and intravoxel incoherent motion imaging

Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women worldwide [1]. Squamous cell carcinoma of the cervix (SCCC) is the most common pathological subtype of cervical cancer. The treatment choice for SCCC depends on its clinical stage. Concurrent chemoradiotherapy (CCRT) is currently the standard treatment option for locally advanced cervical cancer [2]. However, the patients do not always respond in the same way to CCRT due to inter-tumor heterogeneity [3]. Furthermore, radiotherapy may cause radiation-induced injuries to pelvic organs, including lymphedema, proctitis, cystitis, and ovarian dysfunction [4], [5], [6]. Thus, predicting tumor response to CCRT before treatment has important clinical significance for optimizing treatment options or modifying therapeutic strategies to avoid adverse side effects.

Magnetic resonance imaging (MRI) plays an important role in the diagnosis, staging, treatment planning, and response assessment of cervical cancer. However, conventional MRI only shows the changes of tumor size, morphology and signal intensity, while functional MRI provides more detailed information by assessing the biological characteristics of the tumor to predict treatment outcomes. Intravoxel incoherent motion (IVIM) magnetic resonance is based on a bi-exponential model, using multiple b values to obtain water molecule diffusion and perfusion-related properties, which can reflect the movement of water molecules in tumor tissues. Although studies have investigated the importance of IVIM-derived parameters in the prediction and evaluation of treatment efficacy in cervical cancer [7,8], discrepant conclusions have been reported. Amide proton transfer (APT) imaging is a new molecular imaging technology based on chemical exchange saturation transfer [9], which can be used to detect the contents of endogenous free proteins and peptides in tissues, reflecting cell metabolism and pathophysiological information. The imaging principle is to saturate amide protons in free proteins/peptides in the tissue with a specific radio-frequency pulse; because of the chemical exchange between amide protons and free water protons, the signal strength of proteins/peptides is amplified to allow an indirect measurement of their amounts. APT imaging currently attracts increasing attention in the field of molecular imaging and has been applied for the identification, differential diagnosis, treatment response evaluation and prognosis of tumors [10], [11], [12], [13]. The application of APT imaging in the field of cervical cancer is also gradually increasing. However, APT-related studies of cervical cancer mostly focus on differential diagnosis and histological characteristics [14], [15], [16], and reports assessing the feasibility of APT in the prediction of treatment response to CCRT in cervical cancer are scarce.

The purpose of this study was to investigate the value of APT and IVIM imaging for predicting treatment response to CCRT in patients with SCCC.

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