Benedetta Gui

Endometrial cancer: magnetic resonance imaging

Carcinoma of the endometrium is the most common invasive gynecologic malignancy of the female genital tract. Clinically, patients with endometrial carcinoma present with abnormal uterine bleeding. The role of magnetic resonance imaging (MRI) in endometrial carcinoma is disease staging and treatment planning. MRI has been shown to be the most valuable imaging mod-ality in this task, compared with endovaginal ultrasound and computed tomography, because of its intrinsic contrast resolution and multiplanar capability. MRI protocol includes axial T1-weighted images; axial, sagittal, and coronal T2-weighted images; and dynamic gadolinium-enhanced T1-weighted imaging. MR examination is usually performed in the supine position with a phased array multicoil using a four-coil configuration. Endometrial carcinoma is isointense with the normal endometrium and myometrium on noncontrast T1-weighted images and has a variable appearance on T2-weighted images demonstrating heterogeneous signal intensity. The appearance of noninvasive endometrial carcinoma on MRI is characterized by a normal or thickened endometrium, with an intact junctional zone and a sharp tumor-myometrium interface. Invasive endometrial carcinoma is characterized disruption or irregularity of the junctional zone by intermediate signal intensity mass on T2-weighted images. Invasion of the cervical stroma is diagnosed when the low signal intensity cervical stroma is disrupted by the higher signal intensity endometrial carcinoma. MRI in endometrial carcinoma performs better than other imaging modalities in disease staging and treatment planning. Further, the accuracy and the cost of MRI are equivalent to those of surgical staging.

Early-stage cervical cancer: Tumor delineation by magnetic resonance imaging and ultrasound - A European multicenter trial

OBJECTIVE To compare the diagnostic accuracy of ultrasound (US) and magnetic resonance imaging (MRI) in the preoperative assessment of early-stage cervical cancer using pathologic findings as the reference standard. PATIENTS AND METHODS Prospective multi-center trial enrolling 209 consecutive women with early-stage cervical cancer (FIGO IA2-IIA) scheduled for surgery. The following parameters were assessed on US and MRI and compared to pathology: remaining tumor, size, tumor stromal invasion<2/3 (superficial) or ≥2/3 (deep), and parametrial invasion. RESULTS Complete data were available for 182 patients. The agreement between US and pathology was excellent for detecting tumors, correctly classifying bulky tumors (>4cm), and detecting deep stromal invasion (kappa values 0.84, 0.82, and 0.81 respectively); and good for classifying small tumors (<2cm) and detecting parametrial invasion (kappa values 0.78 and 0.75, respectively). The agreement between MRI and histology was good for classifying tumors as <2cm, or >4cm, and detecting deep stromal invasion (kappa values 0.71, 0.76, and 0.77, respectively). It was moderately accurate in tumor detection, and in assessing parametrial invasion (kappa values 0.52 and 0.45, respectively). The agreement between histology and US was significantly better in assessing residual tumor (p<0.001) and parametrial invasion (p<0.001) than the results obtained by MRI. Imaging methods were not significantly influenced by previous cone biopsy. CONCLUSION US and MRI are highly accurate for the preoperative assessment of women with early-stage cervical cancer, although US may be more accurate in detecting residual tumors and assessing parametrial invasion.

Imaging in prostate cancer staging: present role and future perspectives.

Despite recent improvements in detection and treatment, prostate cancer continues to be the most common malignancy and the second leading cause of cancer-related mortality. Thus, although survival rate continues to improve, prostate cancer remains a compelling medical health problem. The major goal of prostate cancer imaging in the next decade will be more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information in order to plan the most appropriate therapeutic strategy. No consensus exists regarding the use of imaging for evaluating primary prostate cancer. However, conventional and functional imaging are expanding their role in detection and local staging and, moreover, functional imaging is becoming of great importance in oncologic management and monitoring of therapy response. This review presents a multidisciplinary perspective on the role of conventional and functional imaging methods in prostate cancer staging.

Transvaginal ultrasonography and magnetic resonance imaging for assessment of presence, size and extent of invasive cervical cancer

To prospectively assess the diagnostic performance of transvaginal ultrasound and magnetic resonance imaging (MRI), using histology as the gold standard, with regard to the presence, size, and extent of invasive cervical cancers and the detection of metastatic lymph nodes.

Adenomyosis: from the sign to the diagnosis. Imaging, diagnostic pitfalls and differential diagnosis: a pictorial review

Adenomyosis is a pathological gynaecological condition characterised by benign invasion of the endometrium into the myometrium. It is often misdiagnosed, or is not easily recognised, although it is responsible for disabling symptoms such as menorrhagia, abnormal uterine bleeding, dysmenorrhoea and infertility in premenopausal women. The aim of this pictorial review is to analyse the features of adenomyosis by illustrating the most usual and typical imaging patterns, along with the unusual appearances, seen in a vast array of gynaecological imaging modalities. The different findings of focal and diffuse adenomyosis along with the diagnostic limitations of ultrasound, hysterosalpingography and magnetic resonance imaging are described, as are the pitfalls and differential diagnosis with other pathological conditions that are often misdiagnosed as adenomyosis. The role of the different imaging modalities in planning appropriate treatment and their usefulness in monitoring therapy are also discussed.RiassuntoL’adenomiosi è caratterizzata dall’invasione benigna del miometrio da parte dell’endometrio ed è spesso sottostimata o diagnosticata con ritardo, nonostante sia invalidante in quanto possibile causa di menorragia, metrorragia, dismenorrea ed infertilità. Lo scopo del lavoro è quello di analizzare gli aspetti diagnostici dell’adenomiosi mostrando i quadri più semplici e quelli più rari e difficili da caratterizzare, raccolti in una ampia galleria che prende in esame tutte le più note tecniche di imaging ginecologico. La forma diffusa di adenomiosi e quelle focali saranno analizzate sulla base dei segni di semeiotica elementare. I limiti e possibilità delle varie tecniche di imaging, ecografia, isterosalpingografia e risonanza magnetica, saranno illustrate ponendo anche particolare attenzione alla diagnostica differenziale con le altre forme morbose più facilmente equivocabili. Sarà infine discusso il ruolo delle metodiche di imaging nella pianificazione del tipo di trattamento e nel monitoraggio dell’efficacia terapeutica.

Localized cervical cancer (stage <IIB): accuracy of MR imaging in planning less extensive surgery

PurposeThis study was undertaken to determine the accuracy of magnetic resonance (MR) imaging in the preoperative staging of patients with clinically localised cervical cancer eligible for less extensive surgery.Materials and methodsFifty-three patients with biopsy-proven carcinoma of the uterine cervix and eligible for conservative surgery prospectively underwent MR imaging. Images were assessed for tumour site and size, infiltration of the cervical stroma, infiltration of vaginal fornices and relationship between the tumour and the internal os of the endocervical canal and the presence and dimensions of pelvic and lumboaortic lymph nodes (cutoff values 1 cm and 0.5 cm minimum axial diameter). MR imaging data were compared with the histopathological findings.ResultsThe endocervix was the site of origin of 25% (13/53) of the cervical tumours and the exocervix the site of origin of 75% (40/53). In the assessment of cervical stroma infiltration, there was agreement between MR imaging and histopathology in 75% of cases. MR imaging had 67% sensitivity, 92% specificity and 91% diagnostic accuracy in assessing infiltration of the vaginal fornices. In the evaluation of the infiltration of the internal os, MR imaging had 86% sensitivity, 93% specificity and 92% accuracy. In the assessment of the lymph nodes, when using a cutoff value of 1 cm, MR imaging had a sensitivity, specificity and diagnostic accuracy of 28%, 100% and 89%, respectively. With a cutoff value of 0.5 cm, MR imaging had a sensitivity, specificity and diagnostic accuracy of 33%, 92% and 83%, respectively.ConclusionsMR imaging had a high level of accuracy in the preoperative assessment of the extent of cervical tumour in patients eligible for conservative surgery. Accuracy is lower in the evaluation of the pelvic and lumboaortic lymph nodes.RiassuntoObiettivoValutare l’accuratezza della RM nella stadiazione pre-operatoria delle neoplasie localizzate della cervice uterina, candidate ad una chirurgia meno aggressiva.Materiali e metodiSono state sottoposte ad esame RM 53 pazienti con carcinoma della cervice uterina confermato istologicamente, candidate a chirurgia conservativa. L’analisi delle immagini ha compreso: localizzazione e dimensioni del tumore, infiltrazione dell’anello stromale, infiltrazione dei fornici vaginali ed estensione oltre l’orifizio uterino interno, presenza e dimensioni di linfonodi pelvici o lombo-aortici (valore soglia 1 cm e 0,5 cm di diametro assiale minimo). I risultati sono stati confrontati con quelli istopatologici.RisultatiNella valutazione dell’infiltrazione dello stroma cervicale vi è stata una concordanza RM/istopatologia in 40/53 (75%) casi. Nella valutazione dell’infiltrazione dei fornici vaginali la RM ha riportato una sensibilità del 67%,una specificità del 92% ed un’accuratezza diagnostica del 91%; nella valutazione dell’estensione oltre l’orifizio uterino interno dell’ 86%, 93% e 92%, rispettivamente. Nella valutazione dei linfonodi la RM ha riportato una sensibilità, specificità ed accuratezza diagnostica del 28%, 100% e 89%, usando come valore soglia 1 cm; e del 33%, 92% e 83%, con un valore soglia di 0,5 cm.ConclusioniLa RM ha dimostrato un’elevata accuratezza nella valutazione pre-operatoria dell’estensione (T) tumorale in pazienti candidate ad intervento chirurgico conservativo. L’accuratezza è minore nella valutazione dei linfonodi pelvici e lombo-aortici.

Imaging of gynecologic malignancies with FDG PET-CT: case examples, physiolocic activity, and pitfalls

The utilization of 2-[fluorine 18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in combination with computed tomography (CT) in the assessment of gynecologic malignancies has been rapidly growing in recent years; however, its role in clinical practice has yet to be established. A number of pitfalls are commonly encountered, including normal physiologic activity in bowel loops and blood vessels, or focal retained activity in ureters and urinary bladder. Increased uptake has also been reported in many benign pelvic processes and in premenopausal patients; endometrial activity changes cyclically, whereas increased ovarian uptake may be functional. FDG PET–CT has an emerging role in staging nodal disease and in the evaluation of local recurrence or peritoneal spread of gynecologic malignancies and is also useful in monitoring response to therapy and in long-term follow-up. FDG PET–CT is most suitable in patients with high tumor markers and negative or uncertain conventional imaging data. Patient preparation, proper scanning protocol, combined assessment of PET and CT data, and the evaluation of conventional imaging findings are essential to define disease and to avoid diagnostic pitfalls.

Benign and Suspicious Ovarian Masses—MR Imaging Criteria for Characterization: Pictorial Review

Ovarian masses present a special diagnostic challenge when imaging findings cannot be categorized into benign or malignant pathology. Ultrasonography (US), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) are currently used to evaluate ovarian tumors. US is the first-line imaging investigation for suspected adnexal masses. Color Doppler US helps the diagnosis identifying vascularized components within the mass. CT is commonly performed in preoperative evaluation of a suspected ovarian malignancy, but it exposes patients to radiation. When US findings are nondiagnostic or equivocal, MRI can be a valuable problem solving tool, useful to give also surgical planning information. MRI is well known to provide accurate information about hemorrhage, fat, and collagen. It is able to identify different types of tissue contained in pelvic masses, distinguishing benign from malignant ovarian tumors. The knowledge of clinical syndromes and MRI features of these conditions is crucial in establishing an accurate diagnosis and determining appropriate treatment. The purpose of this paper is to illustrate MRI findings in neoplastic and non-neoplastic ovarian masses, which were assessed into three groups: cystic, solid, and solid/cystic lesions. MRI criteria for the correct diagnosis and characteristics for differentiating benign from malignant conditions are shown in this paper.

Deep pelvic endometriosis: don’t forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features

Deep infiltrating endometriosis is an important gynecologic disease that may develop during the reproductive years and is responsible for severe pelvic pain. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligament, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic sites. Surgery remains the best therapeutic treatment for affected patients and an accurate preoperative evaluation of the extension of endometriotic lesions is essential for a successful outcome. However, many atypical locations for deep pelvic endometriosis exist although still lesser known to both gynecologists and radiologists such as endometriosis of the round ligaments of the uterus (RLUs). In this article, we review embryology and anatomy of the RLUs as well clinical characteristics associated with these endometriotic locations. In addition, we describe magnetic resonance (MR) imaging protocol, normal MR imaging appearances of the RLUs and the most common abnormal findings of endometriotic involvement of these ligaments at MR imaging. Radiologists should always keep in mind the RLUs as a possible site of deep pelvic endometriosis localization and should not forget to carefully look for them on MR images.

T2-weighted hypointense lesions within prostate gland: Differential diagnosis using wash-in rate parameter on the basis of dynamic contrast-enhanced magnetic resonance imaging–Hystopatology correlations

BACKGROUND AND AIMS Dynamic contrast enhanced magnetic resonance improves prostate cancer detection. The aims of this paper are to verify whether wash-in-rate parameter (speed of contrast uptake in dynamic contrast enhanced magnetic resonance) can help to differentiate prostate cancer from non-neoplastic T2-weighted hypointense lesions within prostate gland and to assess a cut-off for prostate cancer diagnosis. METHODS Prospective, monocentric, multi-departmental study. Thirty consecutive patients underwent T2-weighted and dynamic contrast enhanced magnetic resonance, and re-biopsy. T2-weighted hypointense lesions, >5mm in size, were noted. Lesions were assessed as cancerous (showing mass effect, or no defined margin within transitional zone) and non cancerous (no mass effect) and were compared with histopathology by 2×2 tables. Wash-in-rate of each lesion was calculated and was correlated with histopathology. Students t-test was adopted to assess significant differences. Receiver operating characteristic (ROC) analysis was employed to identify the best cut-off for wash-in-rate in detecting prostate cancer. RESULTS At re-biopsy, cancer was proven in 43% of patients. On T2-weighted MRI, 111 hypointense lesions ≥5 mm in size were found. Sensitivity, specificity and accuracy of T2-weighted MRI were 80% (±12.4 CI 95%), 74.6% (±10.1 CI 95%), and 76.5% (±7.9 CI 95%), respectively. Mean WR was 5.8±1.9/s for PCa zones and 2.96±1.44/s for non-PCa zones (p<0.00000001). At ROC analysis, the best area under curve (AUC) for wash-in-rate parameter was associated to 4.2/s threshold with 82.5% sensitivity (CI±7.07), 97.2% specificity (CI±4.99) and 91.2% accuracy (CI±5.27). Eighteen false positive lesions on T2-weighted MRI showed low wash-in-rate values suggesting non-cancer lesions, while in 5/8 false negative cases high wash-in-rate values correctly suggested prostate cancer. Nine lesions with surgically proven cancer were not included in the saturation biopsy scheme, in 2/9 cases the only site of cancer. CONCLUSIONS Wash-in-rate parameter allows to differentiate prostate cancer from non-neoplastic lesions, helping cancer detection in areas not included in the biopsy scheme.