• 2019-10
  • 2019-11
  • 2020-03
  • 2020-07
  • 2020-08
  • 349085-38-7 br After confirming normality by using the Shapi


    After confirming normality by using the Shapiro-Wilk test, a two-sided paired t-test was used to compare the volumes of GTVT2 and GTVADC. In order to investigate the ADC value in visible tumour and its concordance with the ADC value of suspected 349085-38-7 nodes during treatment, mean ADC-values and standard deviations (SD) of GTVADC, GTVNx, and reference volumes were calculated and visualised. If no normality was confirmed by neither visual evaluation of histograms nor the Shapiro-Wilk test, the Friedmans test was used for analyses. Thereby comparing the concordance of each lymph node with the primary tumour of that particular patient. The significance of difference in ADC values during treatment (ΔADC) was evaluated using Friedmans test. Concordance between GTVADC and GTVNx was calculated using the Wilcoxon signed rank test.
    3. Results
    Twenty patients were included with a median follow-up of
    Table 1
    Baseline characteristics. FIGO = International Federation of Gynaecology and Obstetrics; SCC = squamous cell carcinoma; AC = adenocarcinoma; ASC = adenosqaumous carcinoma.
    Parameter Value
    Number of patients (n) 20
    Median age at start of radiotherapy treatment (years) 50(29–70)
    FIGO stage 4
    IIA 1
    IIB 9
    IIIB 6
    Histopathological subtype 15
    ASC 1
    Nodal disease 13
    Number of patients
    treatment. ADC values
    Compared to the pre-treatment situation, GTVADC
    showed a significant average increase from MRI 1 to 4 starting from
    Fig. 3. GTVNx ADC values of suspected lymph nodes at baseline (MRI 1) and during treatment (MRI2–4).
    and GTVNx within the same patients. The ADC values in reference sample volumes S1, S2, and S3 did not significantly increase or decrease during treatment.
    After 3 months 12/20 and 12 months 19/20 of the patients showed complete radiological response to treatment. Four patients developed a relapse according to radiology reports (Table 2). Patient 1 had regional and distant relapse 6 months after treatment. When comparing with MRI before treatment, three lymph node recurrences could be identified within the initially boost target volumes and had received ≥57.5 Gy. Seven lymph node recurrences were in the electively treated volume but without visible nodes in the respective region at time of diagnosis. Three of them were near high dose boost volumes and got approxi-mately 55 Gy or more, and 4 got elective dose only. The three nodes which were identified as target volumes at initial treatment planning could be identified on ADC mapping on MRI 1–4 and showed ΔADC during treatment of 0.08 × 10−3 mm2/s, 0.57 × 10−3 mm2/s and 0.42 × 10−3 mm2/s. Patient 2 showed at 9 months diffuse regional and distant relapse with one node that was within a boost target volume. This lymph node showed a ΔADC between MRI 1 and 4 of 0.75 × 10−3 mm2/s. Patient 3 showed a relapse in the primary tumour region on routine MRI at 12 months which was confirmed by histo-pathology. Patient 4 had relapse also at 12 months after treatment in an obturator lymph node close to the right parametrium. As shown in Fig. 4, all four patients with a recurrence showed a maximum GTVADC volume reduction during treatment of 30%, while 13/16 (81%) of the patients without recurrence had GTVADC volume reduction well above this 30%. Similar results were found when GTV was delineated on T2 (not shown). The maximum volume reductions of GTVT2 in patients with a recurrence was 37%, and 13/16 (81%) of the patients without recurrence showed a volume reduction of > 41%. A relation between 
    Fig. 4. Overall relapse in relation to ADC value increase (blue diamonds) and volume reduction (red circles) in GTVADC. Each case is connected by a line to visualise relation between outcomes of individual patients. Red: eighty percent of the patients with no recurrence after 12 months show a GTVADC reduction of > 47%, while patients with a recurrence have a tumour reduction of no more than 30% in this study. Blue: ADC increase of patients with a recurrence is only slightly lower than patients that have no sign of recurrence. The ‘hollow’ data points indicate a local relapse whereas the other three patients recurred re-gionally of whom 2 also distantly. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
    ΔADC values and recurrence was not found.
    There were no significant correlations between GTVADC/T2/Nx vo-lume reductions/ΔADC and/or baseline characteristics. The correlation found between volume reduction and ADC increase of the GTVADC volume was small and not significant (Pearson correlation coefficient 0.43, p = 0.07) as visualised in Fig. 5. No relation between lymph node volume change, lymph node ΔADC and recurrence was found (Fig. A.1). If ADC values per patients were plotted, four patients have overall