Rosemarie Forstner

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

Objective: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. Methods: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. Results: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. Conclusions: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Staging of endometrial cancer with MRI: Guidelines of the European Society of Urogenital Imaging

The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2xa0min ± 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.

ESUR guidelines: ovarian cancer staging and follow-up

ObjectiveTo design clear guidelines for the staging and follow-up of patients with ovarian cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences.MethodsGuidelines for ovarian cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 12 leading institutions and a critical review of the literature.ResultsComputed tomography (CT) with coverage of the base of the lungs to the inguinal region is regarded as the imaging technique of choice for preoperative staging. Critical diagnostic criteria are presented and the basis for a structured report for preoperative staging is outlined. Following primary treatment for ovarian cancer, clinical assessment and CA-125 are routinely used to monitor patients. For suspected recurrence, CT remains the imaging modality of choice, with positron emission tomography (PET)/CT emerging as the optimal imaging technique for suspected recurrence, particularly in patients with negative CT or magnetic resonance imaging (MRI).ConclusionsCT is the imaging modality of choice for preoperative staging and detection of recurrence in patients with ovarian cancer.

Genitourinary Applications of Diffusion-weighted MR Imaging in the Pelvis

Diffusion-weighted (DW) magnetic resonance (MR) imaging has a large number of potential clinical applications in the female and male pelvis and can easily be added to any routine MR protocol. In the female pelvis, DW imaging allows improvement of staging in endometrial and cervical cancer, especially in locally advanced disease and in patients in whom contrast medium administration should be avoided. It can also be helpful in characterizing complex adnexal masses and in depicting recurrent tumor after treatment of various gynecologic malignancies. DW imaging shows promising results in monitoring treatment response in patients undergoing radiation therapy of cervical cancer. An increase in apparent diffusion coefficient (ADC) values of responders precedes changes in size and may therefore allow early assessment of treatment success. In the male pelvis, the detection of prostate cancer in the peripheral zone is relatively easier than in the central gland based on the underlying ADC values, whereas overlapping values reported in the central gland still need further research. DW imaging might also be applied in the noninvasive evaluation of bladder cancer to differentiate between superficial and muscle-invasive tumors. Initial promising results have been reported in differentiating benign from malignant pelvic lymph nodes based on the ADC values; however, larger-scale studies will be needed to allow the detection of lymph node metastases in an individual patient. Prerequisites for successfully performing DW imaging of the female and male pelvis are standardization of the DW imaging technique, including the choice of b values, administration of an antiperistaltic drug, and comparison of DW findings with those of morphologic MR imaging.

Pelvic fistulas : appearances on MR images

Abstract.Background: This multi-institutional study examines appearances of pelvic fistulas on magnetic resonance (MR) images.nnMethods: MR images of 46 patients with documented fistulas from five teaching hospitals were retrospectively reviewed. All patients underwent T1-weighted (T1WI), T2-weighted (T2WI), and intravenous gadolinium chelate-enhanced T1-weighted (Gd-T1WI) images. Imaging sequences were separately and then collectively reviewed. The following determinations were made: fistula detection, fistula morphology and signal intensity, and the presence of associated abnormalities. Fistulas were classified into two categories: (1) fistulas that communicate with the bladder and (2) fistulas that do not communicate with the bladder. Fistulas within these two groups were subclassified further. The presence of fistulas was documented by surgery (five patients), endoscopy (six patients), fistulogram (20 patients), or physical exam (15 patients).nnResults: Among the 46 patients, 53 fistulas were documented by means other than MR. Overall T1WI, T2W1 and Gd-T1WI images demonstrated 23, 31, and 39 of 53 fistulas, respectively. Gd-T1W1 detected significantly more fistulas than T1W1 (p < 0.05). Bladder fistulas were better shown on Gd-T1WI (8/15 fistulas) than on T1WI and T2WI (2/15 and 3/15) (p < 0.05). Nonbladder fistulas were demonstrated by T1WI, T2WI, and Gd-T1WI images in 21, 28, and 31 of 38 fistulas, respectively. Among all fistulas, perianal fistulas (a subcategory of nonbladder fistula) had the highest detection by T1WI, T2WI, and Gd-T1WI in 19, 20 and 22 of 23 fistulas, respectively. On T1WI, 19 of 23 detected fistulas were low in signal intensity. On T2WI, 28 of 39 detected fistulas were high in signal intensity. On Gd-T1WI images, 29 of 40 fistulas were low in signal intensity, with enhanced tract wall.nnConclusion: Bladder fistulas were best shown on Gd-T1WI, which was significantly greater than on T1WI or T2WI. Nonbladder fistulas were comparably shown by all techniques, with all performing modestly well. Perianal fistulas were shown equally well by all MR sequences and were the fistulas demonstrated with the highest sensitivity on MR images.nnn

MR imaging evaluation of renal cell carcinoma

Abstract.Background: This study examines the minimally required imaging protocol needed for detection and staging of renal cell carcinoma (RCC).n Methods: In 81 patients (21 women, 60 men; mean age = 62 years) with 85 RCCs, T1-weighted (T1WI), contrast-enhanced T1-weighted (Gd-T1WI), T2-weighted (T2WI), and gradient recalled echo–fast low flip angle shot (GRE/FLASH) images were evaluated alone and in combination. Surgical–pathological findings were available in all patients and were considered the standard of reference.n Results: Tumor detection for lesions smaller than 3 cm was better on Gd-T1WI than on any other sequence, but only the comparison with noncontrast T1WI and GRE/FLASH was statistically significant (detection: T1WI = 33%, Gd-TIWI = 80%, T2WI = 60%, GRE = 47%). The respective accuracies of T1WI, Gd-T1WI, T2WI, and GRE/FLASH images were 81%, 78%, 71%, and 62% for evaluating local tumor extension; 90%, 88%, 89%, and 85% for lymphadenopathy; and 89%, 81%, 91%, and 95% for renal vein thrombus. The combination of T1WI and GRE sequences rendered the highest overall staging accuracy.n Conclusion: For tumor detection, contrast-enhanced T1WI is necessary for lesions smaller than 3 cm. For tumor staging, although the addition of GRE results in significant improvement in the evaluation of venous thrombus, any combination of two sequences will result in similar accuracy, and the use of multiple sequences is not necessary.n

ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update

AbstractAn update of the 2010 published ESUR recommendations of MRI of the sonographically indeterminate adnexal mass integrating functional techniques is provided. An algorithmic approach using sagittal T2 and a set of transaxial T1 and T2WI allows categorization of adnexal masses in one of the following three types according to its predominant signal characteristics. T1 bright masses due to fat or blood content can be simply and effectively determined using a combination of T1W, T2W and FST1W imaging. When there is concern for a solid component within such a mass, it requires additional assessment as for a complex cystic or cystic-solid mass. For low T2 solid adnexal masses, DWI is now recommended. Such masses with low DWI signal on high b value image (e.g. > b 1000xa0s/mm2) can be regarded as benign. Any other solid adnexal mass, displaying intermediate or high DWI signal, requires further assessment by contrast-enhanced (CE)T1W imaging, ideally with DCE MR, where a type 3 curve is highly predictive of malignancy. For complex cystic or cystic-solid masses, both DWI and CET1W—preferably DCE MRI—is recommended. Characteristic enhancement curves of solid components can discriminate between lesions that are highly likely malignant and highly likely benign.Key Points• MRI is a useful complementary imaging technique for assessing sonographically indeterminate masses.n • Categorization allows confident diagnosis in the majority of adnexal masses.n • Type 3 contrast enhancement curve is a strong indicator of malignancy.n • In sonographically indeterminate masses, complementary MRI assists in triaging patient management.

Magnetic resonance imaging of vascular lesions of the scrotum and penis

We report 2 rare cases of vascular lesions in the scrotum and penis: an arteriovenous malformation in a young man and a lymphohemangioma in a boy. Both patients had undergone previous treatment and had recurrent lesions. Magnetic resonance imaging was performed preoperatively for detailed information regarding lesion extent and involvement of adjacent structures.

Update on Imaging of Ovarian Cancer

This review will make familiar with new concepts in ovarian cancer and their impact on radiological practice. Disseminated peritoneal spread and ascites are typical of the most common (70–80xa0%) cancer type, high-grade serous ovarian cancer. Other cancer subtypes differ in origin, precursors, and imaging features. Expert sonography allows excellent risk assessment in adnexal masses. Owing to its high specificity, complementary MRI improves characterization of indeterminate lesions. Major changes in the new FIGO staging classification include fusion of fallopian tube and primary ovarian cancer and the subcategory stage IIIA1 for retroperitoneal lymph node metastases only. Inguinal lymph nodes, cardiophrenic lymph nodes, and umbilical metastases are classified as distant metastases (stage IVB). In multidisciplinary conferences (MDC), CT has been used to predict the success of cytoreductive surgery. Resectability criteria have to be specified and agreed on in MDC. Limitations in detection of metastases may be overcome using advanced MRI techniques.

Adnexal Masses: Characterization of Benign Ovarian Lesions

9.5 Benign Adnexal Lesions 212 9.5.1 Non-neoplastic Lesions of the Ovaries and Adnexa 212 9.5.1.1 Physiologic Ovarian Cysts 212 9.5.1.2 Paraovarian Cysts 214 9.5.1.3 Peritoneal Inclusion Cysts 215 9.5.1.4 Theca Lutein Cysts 216 9.5.1.5 Polycystic Ovary Syndrome 216 9.5.2 Benign Neoplastic Lesions of the Ovaries 219 9.5.2.1 Cystadenoma 219 9.5.2.2 Cystadenofi broma 221 9.5.2.3 Benign Teratoma 221 9.5.2.4 Benign Sex Cord Stromal Tumors 225