{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T14:09:29Z","timestamp":1784642969536,"version":"3.55.0"},"reference-count":32,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2023,5,11]],"date-time":"2023-05-11T00:00:00Z","timestamp":1683763200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100008490","name":"Radiological Society of Finland","doi-asserted-by":"crossref","award":["2021"],"award-info":[{"award-number":["2021"]}],"id":[{"id":"10.13039\/501100008490","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Abdominal Radiology Society of Finland","award":["2021"],"award-info":[{"award-number":["2021"]}]},{"name":"Kuopio University Research Foundation","award":["2021"],"award-info":[{"award-number":["2021"]}]},{"name":"Grands from Kuopio University Hospital","award":["5063542"],"award-info":[{"award-number":["5063542"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Purpose<\/jats:title>\n<jats:p>To evaluate whether 1) the intratumoral apparent diffusion coefficients (ADCs) change during cervical cancer treatment and 2) the pretreatment ADC values or their change after treatment predict the treatment outcome or overall survival of patients with cervical cancer.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We retrospectively enrolled 52 patients with inoperable cervical cancer treated with chemoradiotherapy, who had undergone diffusion weighted MRI before treatment and post external beam radiotherapy (EBRT) and concurrent chemotherapy. A subgroup of patients (n = 28) underwent altogether six consecutive diffusion weighted MRIs; 1) pretreatment, 2) post-EBRT and concurrent chemotherapy; 3\u20135) during image-guided brachytherapy (IGBT) and 6) after completing the whole treatment course. To assess interobserver and intertechnique reproducibility two observers independently measured the ADCs by drawing freehand a large region of interest (L-ROI) covering the whole tumor and three small ROIs (S-ROIs) in areas with most restricted diffusion.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Reproducibility was equally good for L-ROIs and S-ROIs. The pretreatment ADCs were higher in L-ROIs (883 mm<jats:sup>2<\/jats:sup>\/s) than in S-ROIs (687 mm<jats:sup>2<\/jats:sup>\/s, <jats:italic>P<\/jats:italic> &lt; 0.001). The ADCs increased significantly between the pretreatment and post-EBRT scans (L-ROI: <jats:italic>P<\/jats:italic> &lt; 0.001; S-ROI: <jats:italic>P<\/jats:italic> = 0.001). The ADCs remained significantly higher than pretreatment values during the whole IGBT. Using S-ROIs, greater increases in ADCs between pretreatment and post-EBRT MRI predicted better overall survival (<jats:italic>P<\/jats:italic> = 0.018).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>ADC values significantly increase during cervical cancer treatment. Greater increases in ADC values between pretreatment and post-EBRT predicted better overall survival using S-ROIs. Standardized methods for timing and delineation of ADC measurements are advocated in future studies.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0285786","type":"journal-article","created":{"date-parts":[[2023,5,11]],"date-time":"2023-05-11T17:41:09Z","timestamp":1683826869000},"page":"e0285786","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":4,"title":["Greater increases in intratumoral apparent diffusion coefficients after chemoradiotherapy predict better overall survival of patients with cervical cancer"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4896-949X","authenticated-orcid":true,"given":"Erikka","family":"Holopainen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6946-475X","authenticated-orcid":true,"given":"Olli","family":"Lahtinen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mervi","family":"K\u00f6n\u00f6nen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maarit","family":"Anttila","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ritva","family":"Vanninen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Auni","family":"Lindgren","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,5,11]]},"reference":[{"issue":"5","key":"pone.0285786.ref001","doi-asserted-by":"crossref","first-page":"1182","DOI":"10.2214\/AJR.19.21819","article-title":"Cervical cancer: 2018 revised International Federation of Gynecology and Obstetrics staging system and the role of imaging, A.J.R. Am.","volume":"214","author":"M. Saleh","year":"2020","journal-title":"J. Roentgenol"},{"issue":"10","key":"pone.0285786.ref002","first-page":"7802","article-title":"Staging, recurrence and follow-up of uterine cervical cancer using MRI: updated guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018, Eur","volume":"31","author":"L. Manganaro","year":"2021","journal-title":"Radiol"},{"issue":"1","key":"pone.0285786.ref003","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1007\/s00330-017-4989-3","article-title":"Multi-parametric MRI in cervical cancer: early prediction of response to concurrent chemoradiotherapy in combination with clinical prognostic factors","volume":"28","author":"W. Yang","year":"2018","journal-title":"Eur. 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Malayeri","year":"2011","journal-title":"Radiographics"},{"issue":"6","key":"pone.0285786.ref013","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1016\/j.ctrv.2015.03.010","article-title":"A literature review of the association between diffusion-weighted MRI derived apparent diffusion coefficient and tumour aggressiveness in pelvic cancer,","volume":"41","author":"V.R. Bollineni","year":"2015","journal-title":"Cancer Treat. Rev"},{"issue":"3","key":"pone.0285786.ref014","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1002\/jmri.24784","article-title":"Monitoring treatment response in patients undergoing chemoradiotherapy for locally advanced uterine cervical cancer by additional diffusion-weighted imaging: A systematic review","volume":"42","author":"S.M. Schreuder","year":"2015","journal-title":"J. Magn. Reson. 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Int J Gyn Cancer 2018; 28(4): 641\u2013655. doi: 10.1097\/IGC.0000000000001216","DOI":"10.1097\/IGC.0000000000001216"},{"key":"pone.0285786.ref018","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/j.phro.2019.03.001","article-title":"Cervical cancer apparent diffusion coefficient values during external beam radiotherapy, Phys","volume":"9","author":"P. de Boer","year":"2019","journal-title":"Imaging Radiat. Oncol"},{"key":"pone.0285786.ref019","first-page":"3","article-title":"Early alteration in apparent diffusion coefficient and tumor volume in cervical cancer treated with chemoradiotherapy or radiotherapy: Incremental prognostic value over pretreatment assessments, Radiother","volume":"155","author":"Y. Watanabe","year":"2021","journal-title":"Oncol"},{"issue":"19","key":"pone.0285786.ref020","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1007\/s00330-004-2529-4","article-title":"Apparent diffusion coefficient in cervical cancer of the uterus: comparison with the normal uterine cervix","volume":"15","author":"S. Naganawa","year":"2005","journal-title":"Eur. Radiol"},{"issue":"5","key":"pone.0285786.ref021","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1007\/s00330-007-0843-3","article-title":"Diffusion-weighted MRI in cervical cancer","volume":"18","author":"P.Z. McVeigh","year":"2008","journal-title":"Eur. Radiol"},{"issue":"4","key":"pone.0285786.ref022","doi-asserted-by":"crossref","first-page":"1010","DOI":"10.1002\/jmri.25215","article-title":"Treatment response evaluation using the mean apparent diffusion coefficient in cervical cancer patients treated with definitive chemoradiotherapy","volume":"44","author":"C. Onal","year":"2016","journal-title":"J. Magn. Reson. Imaging"},{"issue":"5","key":"pone.0285786.ref023","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1016\/j.mri.2015.02.002","article-title":"Value of apparent diffusion coefficient (ADC) in assessing radiotherapy and chemotherapy success in cervical cancer","volume":"33","author":"Z.Z. Fu","year":"2015","journal-title":"Magn. Reson. Imaging"},{"issue":"3","key":"pone.0285786.ref024","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1016\/j.ygyno.2012.07.123","article-title":"The mean apparent diffusion coefficient value (ADCmean) on primary cervical cancer is a predictive marker for disease recurrence","volume":"127","author":"K. Nakamura","year":"2012","journal-title":"Gynecol. Oncol"},{"issue":"4","key":"pone.0285786.ref025","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1177\/0284185116656492","article-title":"Predicting tumor recurrence in patients with cervical cancer treated with definitive chemoradiotherapy: Value of quantitative histogram analysis on diffusion-weighted MR images","volume":"58","author":"G. Erbay","year":"2017","journal-title":"Acta Radiol"},{"issue":"11","key":"pone.0285786.ref026","doi-asserted-by":"crossref","first-page":"2319","DOI":"10.1007\/s00330-012-2496-0","article-title":"Early diffusion weighted magnetic resonance imaging can predict survival in women with locally advanced cancer of the cervix treated with combined chemo-radiation","volume":"22","author":"G. Somoye","year":"2012","journal-title":"Eur. Radiol"},{"issue":"8","key":"pone.0285786.ref027","first-page":"1604","article-title":"Can diffusion-weighted magnetic resonance imaging predict tumor recurrence of uterine cervical cancer after concurrent chemoradiotherapy? Abdom","volume":"41","author":"J.M. Bae","year":"2016","journal-title":"Radiol. (N.Y.)"},{"issue":"3","key":"pone.0285786.ref028","doi-asserted-by":"crossref","first-page":"1163","DOI":"10.21873\/anticanres.14873","article-title":"Pre-treatment apparent diffusion coefficient does not predict therapy response to radiochemotherapy in cervical cancer: A systematic review and meta-analysis","volume":"41","author":"H.J. Meyer","year":"2021","journal-title":"Anticancer Res"},{"issue":"54","key":"pone.0285786.ref029","doi-asserted-by":"crossref","first-page":"92442","DOI":"10.18632\/oncotarget.21374","article-title":"Whole-lesion ADC histogram and texture analysis in predicting recurrence of cervical cancer treated with CCRT","volume":"8","author":"J. Meng","year":"2017","journal-title":"Oncotarget"},{"issue":"10","key":"pone.0285786.ref030","doi-asserted-by":"crossref","first-page":"e0138702","DOI":"10.1371\/journal.pone.0138702","article-title":"Diffusion-Weighted Imaging in 3.0 Tesla Breast MRI: Diagnostic Performance and Tumor Characterization Using Small Subregions vs. Whole Tumor Regions of Interest","volume":"10","author":"O Arponen","year":"2015","journal-title":"PLoS One"},{"issue":"5","key":"pone.0285786.ref031","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1007\/s00330-016-4564-3","article-title":"Diffusion-weighted imaging of breast lesions: Region-of-interest placement and different ADC parameters influence apparent diffusion coefficient values","volume":"27","author":"H. Bickel","year":"2017","journal-title":"Eur. Radiol"},{"key":"pone.0285786.ref032","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.mri.2018.10.016","article-title":"Associations between whole tumor histogram analysis parameters derived from ADC maps and expression of EGFR, VEGF, Hif 1-alpha, Her-2 and Histone 3 in uterine cervical cancer","volume":"57","author":"H.J. Meyer","year":"2019","journal-title":"Magn. Reson. 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