Susan J. Freeman

The Added Role of MR Imaging in Treatment Stratification of Patients with Gynecologic Malignancies: What the Radiologist Needs to Know

Many treatment options are available to patients with endometrial, cervical, or ovarian cancer. Magnetic resonance (MR) imaging plays an important role in the patient journey from the initial evaluation of the extent of the disease to appropriate treatment selection and follow-up. The purpose of this review is to highlight the added role of MR imaging in the treatment stratification and overall care of patients with endometrial, cervical, or ovarian cancer. Several MR imaging techniques used in evaluation of patients with gynecologic malignancies are described, including both anatomic MR imaging sequences (T1- and T2-weighted sequences) and pulse sequences that characterize tissue on the basis of physiologic features (diffusion-weighted MR imaging), dynamic contrast agent-enhanced MR imaging, and MR spectroscopy. MR imaging findings corresponding to the 2009 revised International Federation of Gynecology and Obstetrics staging of gynecologic malignancies are also described in detail, highlighting possible pearls and pitfalls of staging. With the growing role of the radiologist as a core member of the multidisciplinary treatment planning team, it is crucial for imagers to recognize that MR imaging has become central in tailoring treatment options and therapy in patients with gynecologic malignancies.

The Revised FIGO Staging System for Uterine Malignancies: Implications for MR Imaging

Cancers of the uterine corpus and cervix are the most common gynecologic malignancies worldwide. The International Federation of Gynecology and Obstetrics (FIGO) staging system was first established in 1958, when it was recognized that the recurrence rate and patient outcomes were directly related to the degree of tumor spread at the patients initial presentation. Changes in understanding of tumor biology led to a recent update in the FIGO staging system that reflects the variation in treatment strategies between endometrial and cervical cancer. Patients with endometrial cancer are primarily treated with hysterectomy; thus, staging is done at surgery and histologic analysis. Magnetic resonance (MR) imaging may accurately depict the extent of endometrial cancer at diagnosis and, in conjunction with the tumor grade and histologic subtype, help stratify risk, which determines the therapeutic course. Cervical carcinoma is staged at clinical examination because many tumors are inoperable at the time of patient presentation. Preoperative MR imaging criteria are not formally included in the revised FIGO staging system because cervical carcinoma is most prevalent in developing countries, where imaging resources are limited. However, MR imaging is highly sensitive and specific for depicting important prognostic factors and, when available, is recommended as an adjunct to clinical examination. The MR imaging findings of uterine carcinoma should be discussed in a multidisciplinary setting in conjunction with clinical and histologic findings, an approach that provides accurate staging and risk stratification and allows for individualized treatment.

Quality of CT pulmonary angiography for suspected pulmonary embolus in pregnancy

The main objective of this study was to assess the quality of CT pulmonary angiography (CTPA) for suspected pulmonary embolus (PE) in the pregnant population. We retrospectively identified 40 consecutive pregnant patients who underwent CTPA from January 2005 to December 2006. Forty consecutive age-matched non-pregnant women were used as a control group. Studies were subjectively graded according to overall image quality by two readers in consensus, in randomised and blinded manner. Moreover, contrast enhancement of pulmonary arteries was subjectively and objectively evaluated. The proportion of sub-optimal studies was more than three times higher in the pregnant group (27.5%, n = 11) compared with the non-pregnant group (7.5%, n = 3; p = 0.015). Mean contrast enhancement was consistently higher in the non-pregnant group compared with pregnant group, both subjectively and objectively. The percentage of inadequately opacified vascular segments was more than two times higher in the pregnant group (28.7%, n = 264) than in the non-pregnant group (13.3%, n = 122; p = 0.0001). The incidence of sub-optimal CTPA studies is higher in pregnancy when compared with an age-matched non-pregnant control group. In addition to radiation issues, this should also be considered when implementing diagnostic strategies for suspected PE in pregnancy.

A framework for optimization of diffusion-weighted MRI protocols for large field-of-view abdominal-pelvic imaging in multicenter studies

PURPOSE To develop methods for optimization of diffusion-weighted MRI (DW-MRI) in the abdomen and pelvis on 1.5 T MR scanners from three manufacturers and assess repeatability of apparent diffusion coefficient (ADC) estimates in a temperature-controlled phantom and abdominal and pelvic organs in healthy volunteers. METHODS Geometric distortion, ghosting, fat suppression, and repeatability and homogeneity of ADC estimates were assessed using phantoms and volunteers. Healthy volunteers (ten per scanner) were each scanned twice on the same scanner. One volunteer traveled to all three institutions in order to provide images for qualitative comparison. The common volunteer was excluded from quantitative analysis of the data from scanners 2 and 3 in order to ensure statistical independence, giving n = 10 on scanner 1 and n = 9 on scanners 2 and 3 for quantitative analysis. Repeatability and interscanner variation of ADC estimates in kidneys, liver, spleen, and uterus were assessed using within-patient coefficient of variation (wCV) and Kruskal-Wallis tests, respectively. RESULTS The coefficient of variation of ADC estimates in the temperature-controlled phantom was 1%-4% for all scanners. Images of healthy volunteers from all scanners showed homogeneous fat suppression and no marked ghosting or geometric distortion. The wCV of ADC estimates was 2%-4% for kidneys, 3%-7% for liver, 6%-9% for spleen, and 7%-10% for uterus. ADC estimates in kidneys, spleen, and uterus showed no significant difference between scanners but a significant difference was observed in liver (p < 0.05). CONCLUSIONS DW-MRI protocols can be optimized using simple phantom measurements to produce good quality images in the abdomen and pelvis at 1.5 T with repeatable quantitative measurements in a multicenter study.

Functional MR Imaging in Gynecologic Cancer

Dynamic-contrast enhanced (DCE) and diffusion-weighted (DW) MR imaging are invaluable in the detection, staging, and characterization of uterine and ovarian malignancies, for monitoring treatment response, and for identifying disease recurrence. When used as adjuncts to morphologic T2-weighted (T2-W) MR imaging, these techniques improve accuracy of disease detection and staging. DW-MR imaging is preferred because of its ease of implementation and lack of need for an extrinsic contrast agent. MR spectroscopy is difficult to implement in the clinical workflow and lacks both sensitivity and specificity. If used quantitatively in multicenter clinical trials, standardization of DCE- and DW-MR imaging techniques and rigorous quality assurance is mandatory.

Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

Background:Investigating tumour evolution and acquired chemotherapy resistance requires analysis of sequential tumour material. We describe the feasibility of obtaining research biopsies in women with relapsed ovarian high-grade serous carcinoma (HGSC).Methods:Women with relapsed ovarian HGSC underwent either image-guided biopsy or intra-operative biopsy during secondary debulking, and samples were fixed in methanol-based fixative. Tagged-amplicon sequencing was performed on biopsy DNA.Results:We screened 519 patients in order to enrol 220. Two hundred and two patients underwent successful biopsy, 118 of which were image-guided. There were 22 study-related adverse events (AE) in the image-guided biopsies, all grades 1 and 2; pain was the commonest AE. There were pre-specified significant AE in 3/118 biopsies (2.5%). 87% biopsies were fit-for-purpose for genomic analyses. Median DNA yield was 2.87 μg, and was higher in biopsies utilising 14 G or 16 G needles compared to 18 G. TP53 mutations were identified in 94.4% patients.Conclusions:Obtaining tumour biopsies for research in relapsed HGSC is safe and feasible. Adverse events are rare. The large majority of biopsies yield sufficient DNA for genomic analyses—we recommend use of larger gauge needles and methanol fixation for such biopsies, as DNA yields are higher but with no increase in AEs.

Imaging benign gynaecological conditions

Abstract Radiology continues to play an essential role in the management of benign gynaecological conditions. Multiple imaging modalities are utilised to investigate benign conditions: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging benign gynaecological conditions. The imaging findings of common benign female pelvic pathology are discussed and illustrated.

Structured reporting of pelvic MRI leads to better treatment planning of uterine leiomyomas.

Over the years, the role of the radiologist within the multidisciplinary team has evolved remarkably, with imaging providing crucial information for patient management. Through close collaboration with referring clinicians, most radiology practices now strive for their radiology reports to provide the maximum value for individualized patient care [1]. Therefore, the development of structured radiology reports has gained impetus as an essential tool toward delivering personalized medicine. In fact, structured report templates provide a platform for potentially providing clear, concise, consistent and actionable reports that can assist the referring clinician in triaging the patient to appropriate treatment [1]. The key to adding value to radiology reporting lies in the disease-specific structured reports that are developed by radiologists in collaboration with the clinical management team. However, in the era of increasing workload, the balance between a succinct, generic structured report and a time-consuming disease-specific report is important. In general, structured reporting allows information to be more easily extracted and improves communication with clinicians. In addition, the use of structured reporting reduces ambiguous terms and errors due to use of speech recognition systems, typically seen with narrative reports, which could lead to misinterpretation and in turn impact patient management [2]. Furthermore, standardized template reporting enhances the value of natural language processing and machine learning techniques, which have been shown to successfully extract relevant prognostic information from radiology reports [3]. The clarity of the radiology report is essential to the integration of imaging, pathology, multi-omics and clinical data and provides one of the cornerstones of integrative and personalized medicine. Aiming at enhancing the quality and efficiency of radiology reports, the Radiology Society of North America (RSNA) and the European Society of Radiology (ESR) have jointly formed the Template Library Advisory Panel (TLAP) [4]. TLAP provides reporting templates that are based on established data standards and incorporate structured terminology such as RSNA RadLex radiology lexicon, as well as access to tools to create and modify templates. The overall goal is to improve the value of the radiology service to patients and their treating physicians by providing consistent and datarich reports, which also enable better data analysis for outcomes research when compared to narrative unstructured reports. Several studies have analyzed the value of structured reporting, most of them focusing on various oncological applications [5–7]. Brook and colleagues showed that implementation of structured reports leads to improvement in staging and surgical planning in patients with pancreatic cancer [5]. Yee and colleagues developed a computed tomography (CT) colonography structured reporting template that led to improved clarity of interpretation and thus better communication with the referring physicians [6]. In patients with primary rectal cancer, structured rectal magnetic resonance imaging (MRI) reporting templates facilitated surgical planning and led to higher satisfaction level of referring surgeons compared to narrative reports [7]. Other studies assessed the structured format of the conclusion/impression section of the report as a means to provide better value to the managing team [8, 9]. Introduction of a structured format in the impression section of a coronary CT angiography report led to an improved agreement on the number of significant stenotic vessels [8]. More recently, Wibmer and colleagues [9] found that the implementation of a lexicon of diagnostic certainty in prostate MRI This editorial comment refers to the article available at https://doi.org/10. 1007/s00330-017-5161-9.