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Al Khuri M, Al Salmi I, Al Ajmi H, Al Hadidi A, Alabousi A, Haider E, Vasudev P, Al Salmi A, Jose S, Alrahbi N. Validating the diagnostic accuracy of an MRI-based scoring system for differentiating benign uterine leiomyomas from leiomyosarcomas. Int J Gynecol Cancer 2024; 34:1027-1033. [PMID: 38658016 DOI: 10.1136/ijgc-2023-005220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Uterine leiomyomas are the most common benign uterine tumors. They are difficult to distinguish from their malignant counterparts-smooth muscle tumors of unknown malignant potential (STUMP) and leiomyosarcoma. The purpose of this study is to propose and validate the diagnostic accuracy of the MRI-based Oman-Canada Scoring System of Myometrial Masses (OCSSMM) to differentiate uterine leiomyomas from STUMP/leiomyosarcomas. METHODS This is a retrospective study performed at two tertiary care centers. All patients with a pathology-proven uterine mass who underwent pre-operative pelvic MRI between January 2010 and January 2020 were included. Using a 1.5T MRI machine, sequences included were axial/coronal/sagittal T2 and T1 weighted imaging, axial diffusion weighted and apparent diffusion coefficient map, and axial or sagittal dynamic contrast-enhanced sequences. A scoring system was designed based on previously published worrisome MRI features for uterine leiomyosarcoma. Each feature was allocated a score from 0 to 2 according to the strength of association with malignancy. Subsequently, the MR images were blindly and independently reviewed by a fellowship-trained radiologist and a clinical fellow/senior resident. Each uterine mass was scored according to their imaging features. The scores were divided into five categories according to the sum of scores. Category III and above was considered positive for leiomyosarcoma/STUMP. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 244 women were included (age range 20-74 years, mean 40). Of these, 218 patients had benign leiomyoma, 13 had STUMP, and 13 had leiomyosarcoma. The sensitivity and specificity of the scoring system were 92.3% and 64.7%, respectively. The negative predictive value was 98.6%. No leiomyosarcoma was missed using this scoring system. The presence of non-cystic T2 hyperintensity or diffusion restriction in a uterine mass were the most sensitive signs of a leiomyosarcoma/STUMP. CONCLUSION The proposed multi-parametric MRI scoring system may be useful in differentiating benign uterine leiomyomas from leiomyosarcomas/STUMP.
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Affiliation(s)
- Maryam Al Khuri
- Radiology Department, Sohar Hospital, Sohar, Al Batinah North, Oman
- Department of Medical Imaging, McMaster University, Hamilton, Canada
| | - Ishaq Al Salmi
- Radiology Department, The Royal Hospital, Seeb, Muscat, Oman
| | - Hawra Al Ajmi
- Radiology Department, Sohar Hospital, Sohar, Al Batinah North, Oman
| | - Aymen Al Hadidi
- Radiology Department, Khoula Hospital, Mina Al Fahal, Muscat, Oman
| | - Abdullah Alabousi
- Department of Medical Imaging, McMaster University, Hamilton, Canada
- Diagnostic Imaging, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Ehsan Haider
- Department of Medical Imaging, McMaster University, Hamilton, Canada
- Diagnostic Imaging, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Pooja Vasudev
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
- St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Ahmed Al Salmi
- Radiology Department, Rustaq Hospital, Rustaq, Al Batinah South, Oman
| | - Sachin Jose
- Research and Studies Department, Oman Medical Speciality Board, Al-Athaiba, Muscat, Oman
| | - Nasser Alrahbi
- Histopathology Department, The Royal Hospital, Seeb, Muscat, Oman
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Woo S, Beier SR, Tong A, Hindman NM, Vargas HA, Kang SK. Utility of ADC Values for Differentiating Uterine Sarcomas From Leiomyomas: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2024. [PMID: 38899844 DOI: 10.2214/ajr.24.31280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Background: Uterine sarcomas are rare; however, they display imaging features that overlap those of leiomyomas. The potential for undetected uterine sarcomas is clinically relevant because minimally invasive treatment of leiomyomas may lead to cancer dissemination. ADC values have shown potential for differentiating benign and malignant uterine masses. Objective: The purpose of this study was to perform a systematic review of the diagnostic performance of ADC values in differentiating uterine sarcomas from leiomyomas. Evidence acquisition: We searched three electronic databases (MEDLINE, EMBASE, and Cochrane databases) for studies distinguishing uterine sarcomas from leiomyomas using MRI, including ADC, with pathologic tissue confirmation or imaging follow-up as the reference standard. Data extraction and QUADAS-2 quality assessment were performed. Sensitivity and specificity were pooled using hierarchic models, including bivariate and hierarchic summary ROC models. Metaregression was used to assess the impact of various factors on heterogeneity. Evidence synthesis: Twenty-one studies met study inclusion criteria. Pooled sensitivity and specificity were 89% (95% CI, 82-94%) and 86% (95% CI, 78-92%), respectively. Area under the summary ROC curve was 94% (95% CI, 92-96%). Context of ADC interpretation (i.e., standalone vs part of multiparametric MRI [mpMRI]) was the only factor found to account significantly for heterogeneity (p = .01). Higher specificity (95% [95% CI, 92-99%] vs 82% [95% CI, 75-89%]) and similar sensitivity (94% [95% CI, 89-99%] vs 88% [95% CI, 82-93%]) were observed when ADC was evaluated among mpMRI features as compared with standalone ADC assessment. ADC cutoff values ranged (0.87-1.29 × 10-3 mm2/s) but were not associated with statistically different performance (p = .37). Pooled mean ADC values in sarcomas and leiomyomas were 0.904 × 10-3 mm2/s and 1.287 × 10-3 mm2/s, respectively. Conclusion: As part of mpMRI evaluation of uterine masses, mass ADC value less than 0.904 × 10-3 mm2/s may be a useful test-positive threshold for uterine sarcoma, consistent with a prior expert consensus statement. Institutional protocols may influence locally selected ADC values. Clinical Impact: Using ADC as part of mpMRI assessment improves detection of uterine sarcoma, which could influence candidate selection for minimally invasive treatments.
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Affiliation(s)
- Sungmin Woo
- Department of Radiology, NYU Langone Health, New York, NY, USA
| | - Sarah R Beier
- Department of Radiology, NYU Langone Health, New York, NY, USA
| | - Angela Tong
- Department of Radiology, NYU Langone Health, New York, NY, USA
| | | | - Hebert A Vargas
- Department of Radiology, NYU Langone Health, New York, NY, USA
| | - Stella K Kang
- Department of Radiology, NYU Langone Health, New York, NY, USA
- Department of Population Health, NYU Langone Health, New York, NY, USA
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Raffone A, Raimondo D, Neola D, Travaglino A, Giorgi M, Lazzeri L, De Laurentiis F, Carravetta C, Zupi E, Seracchioli R, Casadio P, Guida M. Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 165:22-33. [PMID: 37732472 DOI: 10.1002/ijgo.15136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Magnetic resonance imaging (MRI) represents the second-line diagnostic method after ultrasound for the assessment of uterine masses. OBJECTIVES To assess the accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas. SEARCH STRATEGY A systematic review and meta-analysis was performed searching five electronic databases from their inception to June 2023. SELECTION CRITERIA All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma, which also comprehended a preoperative MRI evaluation of the uterine mass. DATA COLLECTION AND ANALYSIS Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic of MRI in differentiating uterine leiomyomas and sarcomas were calculated as individual and pooled estimates, with 95% confidence intervals (CI). RESULTS Eight studies with 2495 women (2253 with uterine leiomyomas and 179 with uterine sarcomas), were included. MRI showed pooled sensitivity of 0.90 (95% CI 0.84-0.94), specificity of 0.96 (95% CI 0.96-0.97), positive likelihood ratio of 13.55 (95% CI 6.20-29.61), negative likelihood ratio of 0.08 (95% CI 0.02-0.32), diagnostic odds ratio of 175.13 (95% CI 46.53-659.09), and area under the curve of 0.9759. CONCLUSIONS MRI has a high diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas.
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Affiliation(s)
- Antonio Raffone
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Neola
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
- Gynecopathology and Breast Pathology Unit, Department of Woman's Health Science, Agostino Gemelli University Polyclinic, Rome, Italy
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | | | - Carlo Carravetta
- Obstetrics and Gynecology Unit, Salerno ASL, "Villa Malta" Hospital, Sarno, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Renato Seracchioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Huayanay Espinoza JL, Espinoza Figueroa JVJ, Velezmoro Díaz VE, Huanca Amesquita LS, Cruz Baca RC, Rioja Vega MA, Guelfguat M. Soft-Tissue Sarcomas of the Genitourinary Tract with Radiologic-Pathologic Correlation. Radiographics 2024; 44:e230138. [PMID: 38236750 DOI: 10.1148/rg.230138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Genitourinary tract soft-tissue sarcomas are rare neoplasms with varied pathologic and clinical features. While some of these tumors may be aggressive high-grade malignancies, others are low grade with a relatively better prognosis. Given that the grade and extent of the disease are important prognostic factors in these tumors, timely diagnosis is crucial. Unfortunately, most imaging features of these malignancies are not pathognomonic, and various histologic subtypes do not manifest with typical classic imaging features. Therefore, reliable differentiation of the various histologic tumor types is not always possible based solely on the radiologic manifestations. Imaging findings need to be considered in the context of clinical history in corroboration with radiologic-pathologic correlation. The authors discuss the specific imaging and pathologic characteristics of various genitourinary tract soft-tissue sarcomas, emphasizing diagnostic difficulties and differential diagnoses. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Jorge L Huayanay Espinoza
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Jossue V J Espinoza Figueroa
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Vanessa E Velezmoro Díaz
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Lourdes S Huanca Amesquita
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Renier C Cruz Baca
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Marco A Rioja Vega
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
| | - Mark Guelfguat
- From the Departments of Radiology (J.L.H.E., J.V.J.E.F., V.E.V.D.) and Pathology (L.S.H.A., R.C.C.B., M.A.R.V.), Instituto Nacional de Enfermedades Neoplásicas, Av Angamos 2520 Surquillo, 15038 Lima, Peru; and Department of Radiology, Jacobi Medical Center, Bronx, NY (M.G.)
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Cianci S, Gulino FA, Palmara V, La Verde M, Ronsini C, Romeo P, Occhipinti S, Incognito GG, Capozzi VA, Restaino S, Vizzielli G, Palumbo M. Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:64. [PMID: 38256325 PMCID: PMC10820219 DOI: 10.3390/medicina60010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.
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Affiliation(s)
- Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Ferdinando Antonio Gulino
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Paola Romeo
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Sara Occhipinti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Vito Andrea Capozzi
- Department of Obstetrics and Gynecology, University of Parma, 43125 Parma, Italy;
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
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Rosa F, Martinetti C, Magnaldi S, Rizzo S, Manganaro L, Migone S, Ardoino S, Schettini D, Marchiolè P, Ragusa T, Gandolfo N. Uterine mesenchymal tumors: development and preliminary results of a magnetic resonance imaging (MRI) diagnostic algorithm. LA RADIOLOGIA MEDICA 2023:10.1007/s11547-023-01654-1. [PMID: 37311925 DOI: 10.1007/s11547-023-01654-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE The aim of our study is to propose a diagnostic algorithm to guide MRI findings interpretation and malignancy risk stratification of uterine mesenchymal masses with a multiparametric step-by-step approach. METHODS A non-interventional retrospective multicenter study was performed: Preoperative MRI of 54 uterine masses was retrospectively evaluated. Firstly, the performance of MRI with monoparametric and multiparametric approach was assessed. Reference standard for final diagnosis was surgical pathologic result (n = 53 patients) or at least 1-year MR imaging follow-up (n = 1 patient). Subsequently, a diagnostic algorithm was developed for MR interpretation, resulting in a Likert score from 1 to 5 predicting risk of malignancy of the uterine lesion. The accuracy and reproducibility of the MRI scoring system were then tested: 26 preoperative pelvic MRI were double-blind evaluated by a senior (SR) and junior radiologist (JR). Diagnostic performances and the agreement between the two readers with and without the application of the proposed algorithm were compared, using histological results as standard reference. RESULTS Multiparametric approach showed the best diagnostic performance in terms of accuracy (94.44%,) and specificity (97.56%). DWI was confirmed as the most sensible parameter with a relative high specificity: low ADC values (mean 0.66) significantly correlated to uterine sarcomas diagnosis (p < 0.01). Proposed algorithm allowed to improve both JR and SR performance (algorithm-aided accuracy 88.46% and 96%, respectively) and determined a significant increase in inter-observer agreement, helping even the less-experienced radiologist in this difficult differential diagnosis. CONCLUSIONS Uterine leiomyomas and sarcomas often show an overlap of clinical and imaging features. The application of a diagnostic algorithm can help radiologists to standardize their approach to a complex myometrial mass and to easily identify suspicious MRI features favoring malignancy.
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Affiliation(s)
- Francesca Rosa
- Diagnostic Imaging Department, San Paolo Hospital-ASL 2, via Genova, 30, Savona, Italy.
| | - Carola Martinetti
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
| | - Silvia Magnaldi
- Diagnostic Imaging Unit, Esperia Medical Center, Porcia, PN, Italy
| | - Stefania Rizzo
- Service of Radiology, Imaging Institute of Southern Switzerland, Clinica di Radiologia EOC, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), via Buffi 23, 6900, Lugano, Switzerland
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00185, Rome, Italy
| | - Stefania Migone
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
| | - Silvia Ardoino
- Anatomic Pathology Unit, San Paolo Hospital-ASL 2, via Genova, 30, Savona, Italy
| | - Daria Schettini
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
| | - Pierangelo Marchiolè
- Obstetrics and Gynecology Unit, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
- Obstetrics and Gynecology Department, IRCCS ospedale Policlinico San Martino, Genoa, Italy
| | - Tommaso Ragusa
- Anatomic Pathology Unit, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
| | - Nicoletta Gandolfo
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, Corso Scassi 1, Genoa, Italy
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Petrocelli R, Hindman N, Reinhold C. Current Concepts in the Imaging of Uterine Sarcomas. Radiol Clin North Am 2023; 61:627-638. [PMID: 37169428 DOI: 10.1016/j.rcl.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Uterine sarcomas are a group of rare uterine tumors comprised of multiple subtypes with different histologic characteristics, prognoses, and imaging appearances. Identification of uterine sarcomas and their differentiation from benign uterine disease on imaging is of critical importance for treatment planning to guide appropriate management and optimize patient outcomes. Herein, we review the spectrum of uterine sarcomas with a focus on the classification of primary sarcoma subtypes and presenting the typical MR imaging appearances.
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Hindman N, Kang S, Fournier L, Lakhman Y, Nougaret S, Reinhold C, Sadowski E, Huang JQ, Ascher S. MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement. Radiology 2023; 306:e211658. [PMID: 36194109 PMCID: PMC9885356 DOI: 10.1148/radiol.211658] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/01/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.
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Affiliation(s)
- Nicole Hindman
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Stella Kang
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Laure Fournier
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Yulia Lakhman
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Stephanie Nougaret
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Caroline Reinhold
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Elizabeth Sadowski
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Jian Qun Huang
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
| | - Susan Ascher
- From the Departments of Radiology (N.H., S.K.) and Gynecology
(J.Q.H.), NYU Grossman School of Medicine, 660 First Ave, 3rd Floor, New York,
NY 10016; Department of Radiology, Université Paris Cité, AP-HP,
Hôpital Européen Georges Pompidou, PARCC UMRS 970, INSERM, Paris,
France (L.F.); Department of Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY (Y.L.); Department of Radiology, Cancer Institute Montpellier,
Montpellier, France (S.N.); Department of Radiology, McGill University,
Montreal, Quebec, Canada (C.R.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (E.S.); and
Department of Radiology, Georgetown University School of Medicine, Washington,
DC (S.A.)
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9
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Chatziantoniou C, Schoot RA, van Ewijk R, van Rijn RR, ter Horst SAJ, Merks JHM, Leemans A, De Luca A. Methodological considerations on segmenting rhabdomyosarcoma with diffusion-weighted imaging-What can we do better? Insights Imaging 2023; 14:19. [PMID: 36720720 PMCID: PMC9889596 DOI: 10.1186/s13244-022-01351-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/04/2022] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Diffusion-weighted MRI is a promising technique to monitor response to treatment in pediatric rhabdomyosarcoma. However, its validation in clinical practice remains challenging. This study aims to investigate how the tumor segmentation strategy can affect the apparent diffusion coefficient (ADC) measured in pediatric rhabdomyosarcoma. MATERIALS AND METHODS A literature review was performed in PubMed using search terms relating to MRI and sarcomas to identify commonly applied segmentation strategies. Seventy-six articles were included, and their presented segmentation methods were evaluated. Commonly reported segmentation strategies were then evaluated on diffusion-weighted imaging of five pediatric rhabdomyosarcoma patients to assess their impact on ADC. RESULTS We found that studies applied different segmentation strategies to define the shape of the region of interest (ROI)(outline 60%, circular ROI 27%), to define the segmentation volume (2D 44%, multislice 9%, 3D 21%), and to define the segmentation area (excludes edge 7%, excludes other region 19%, specific area 27%, whole tumor 48%). In addition, details of the segmentation strategy are often unreported. When implementing and comparing these strategies on in-house data, we found that excluding necrotic, cystic, and hemorrhagic areas from segmentations resulted in on average 5.6% lower mean ADC. Additionally, the slice location used in 2D segmentation methods could affect ADC by as much as 66%. CONCLUSION Diffusion-weighted MRI studies in pediatric sarcoma currently employ a variety of segmentation methods. Our study shows that different segmentation strategies can result in vastly different ADC measurements, highlighting the importance to further investigate and standardize segmentation.
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Affiliation(s)
- Cyrano Chatziantoniou
- grid.7692.a0000000090126352Image Sciences Institute, UMC Utrecht, Utrecht, The Netherlands ,grid.487647.ePrincess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Reineke A. Schoot
- grid.487647.ePrincess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Roelof van Ewijk
- grid.487647.ePrincess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Rick R. van Rijn
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Simone A. J. ter Horst
- grid.487647.ePrincess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands ,grid.417100.30000 0004 0620 3132Department of Radiology and Nuclear Medicine, Wilhelmina Children’s Hospital UMC Utrecht, Utrecht, The Netherlands
| | - Johannes H. M. Merks
- grid.487647.ePrincess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Alexander Leemans
- grid.7692.a0000000090126352Image Sciences Institute, UMC Utrecht, Utrecht, The Netherlands
| | - Alberto De Luca
- grid.7692.a0000000090126352Image Sciences Institute, UMC Utrecht, Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Neurology, UMC Utrecht Brain Center, UMCUtrecht, Utrecht, The Netherlands
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10
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The role of multiparametric MRI in differentiating uterine leiomyosarcoma from benign degenerative leiomyoma and leiomyoma variants: a retrospective analysis. Clin Radiol 2023; 78:47-54. [PMID: 36220736 DOI: 10.1016/j.crad.2022.08.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/14/2022] [Accepted: 08/26/2022] [Indexed: 01/07/2023]
Abstract
AIM To assess qualitative and quantitative magnetic resonance imaging (MRI) factors that can help distinguish leiomyosarcoma (LMS) from benign degenerative leiomyoma (BDL) and leiomyoma variants (LV) and assess the interobserver agreement for the proposed quantitative factors. MATERIALS AND METHODS Retrospective analysis of all histopathology proven cases of LV, BDL, and LMS with a preoperative MRI was performed. Twenty-seven cases were included (five LMS, three LV, and 19 BDL) with each case independently read by a pair of radiologists. Lesion size, margins, presence or absence of degeneration, necrosis, and haemorrhage were assessed on MRI along with quantitative factors such as mean T2-weighted (W) and T1W signal intensity, T1W signal heterogeneity, diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) ratios as well as dynamic contrast enhancement (DCE) characteristics along with the presence or absence of lymphadenopathy and extra-uterine and peritoneal spread. Mean and standard deviation for quantitative variables and frequency with percentages for qualitative variables were assessed. RESULTS Infiltrative margins were seen exclusively in the LMS group (n=1), with the remaining LMS cases showing lobulate or rounded smooth margins similar to BDL or LV. A high T2W signal <25% was seen exclusively in the BDL group (n=8). The presence of concomitant necrosis and haemorrhage was seen exclusively in the LMS group (n=2). Quantitative MRI had good inter-reader correlation but was not significantly different between the LMS, BDL, and LV groups. CONCLUSION LMS, BDL, and LV may have overlapping features on multiparametric MRI making differentiation difficult.
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11
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Ascher SM, Wasnik AP, Robbins JB, Adelman M, Brook OR, Feldman MK, Jones LP, Knavel Koepsel EM, Patel-Lippmann KK, Patlas MN, VanBuren W, Maturen KE. ACR Appropriateness Criteria® Fibroids. J Am Coll Radiol 2022; 19:S319-S328. [PMID: 36436959 DOI: 10.1016/j.jacr.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia.
| | - Ashish P Wasnik
- Panel Vice-Chair, University of Michigan, Ann Arbor, Michigan; Director, Division of Abdominal Radiology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan
| | - Jessica B Robbins
- Panel Chair; Vice Chair, Faculty Development and Enrichment, University of Wisconsin, Madison, Wisconsin
| | - Marisa Adelman
- Technology Assessment Committee, University of Utah, Salt Lake City, Utah; American College of Obstetricians and Gynecologists
| | - Olga R Brook
- Section Chief, Abdominal Imaging; Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Krupa K Patel-Lippmann
- Abdominal Imaging Fellowship Director, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael N Patlas
- McMaster University, Hamilton, Ontario, Canada; Editor-in-Chief, Canadian Association of Radiologists
| | - Wendaline VanBuren
- Section Chair, Gynecological Imaging, Department of Radiology Mayo Clinic, Rochester, Minnesota; Chair, Endometriosis Disease-Focused Panel, Society of Abdominal Radiology
| | - Katherine E Maturen
- Specialty Chair; Associate Chair, Ambulatory Care and Strategy, University of Michigan, Ann Arbor, Michigan
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12
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Clements W, Brown N, Buckley B, Rogan C, Kok HK, Liang E. Quality care guidelines for uterine artery embolisation in women with symptomatic uterine fibroids in Australia and New Zealand: According to the AGREE-II checklist and endorsed by the Interventional Radiology Society of Australasia. J Med Imaging Radiat Oncol 2022; 66:819-825. [PMID: 35785440 PMCID: PMC9545349 DOI: 10.1111/1754-9485.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/21/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Nicholas Brown
- The University of Queensland, St Lucia, Queensland, Australia.,Wesley Hospital, Auchenflower, Queensland, Australia
| | - Brendan Buckley
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Chris Rogan
- Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse, Camperdown, Sydney, New South Wales, Australia.,Sydney Adventist Hospital, Wahroonga, Sydney, New South Wales, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Eisen Liang
- Sydney Fibroid Clinic, Sydney, New South Wales, Australia
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13
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Chen X, Huang G, Zhang L, Bai J. Predictive value of image indexes of B-mode and power Doppler sonography on the efficacy of high intensity focused ultrasound ablation for uterine fibroids. Int J Hyperthermia 2022; 39:772-779. [PMID: 35654459 DOI: 10.1080/02656736.2022.2081734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To investigate the value of the image indexes of B-mode and power Doppler sonography in predicting the therapeutic efficacy of high intensity focused ultrasound (HIFU) ablation for uterine fibroids. MATERIALS AND METHODS Two hundred and three patients with a solitary uterine fibroid were enrolled in this study. Every patient underwent transvaginal sonography (TVS) and magnetic resonance imaging (MRI) before HIFU. The patients were divided into hypointense, isointense and hyperintense fibroid groups based on T2 weighted MR imaging characteristics, and ultrasonic image indexes of the fibroids in different groups were compared. Multiple linear regression analysis was used to evaluate the correlation between ultrasonic image indexes and energy efficiency factor (EEF), non-perfused volume (NPV) ratio of uterine fibroids. RESULTS Among them, 72 patients had a hypointense fibroid, 70 had an isointense fibroid and 61 had a hyperintense fibroid. Significant differences were observed in the ultrasound imaging gray scale value difference between the myometrium and uterine fibroids (GSmyo-fib), the ultrasound imaging gray scale value ratio of fibroids over the myometrium (GSfib/myo), and the ratio of power Doppler pixel area to fibroid area (PDPA/FA) among the three groups (p < 0.05). Linear regression analysis showed that the PDPA/FA and the location of fibroids were the factors affecting the NPV ratio, a model for predicting the NPV ratio was established. CONCLUSIONS A model with the PDPA/FA for NPV ratio could be used to predict the therapeutic efficacy of HIFU for fibroids.
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Affiliation(s)
- Xiaohui Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China
| | - Guohua Huang
- Department of Gynecology, Suining Central Hospital, Sichuan, PR China
| | - Lian Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China
| | - Jin Bai
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, PR China
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14
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Condic M, Egger EK, Hohenberger P, Staerk C, Mayr A, Armbrust R, Roser E, Mustea A, Sehouli J. Clinical value of pre-operative scoring systems to predict leiomyosarcoma: results of a validation study in 177 patients from the NOGGO-REGSA Registry. Int J Gynecol Cancer 2022; 32:619-625. [DOI: 10.1136/ijgc-2021-003334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
ObjectivesBenign leiomyomas are the most common uterine tumors. In contrast, uterine leiomyosarcomas are malignancies with a poor prognosis due to difficulties in early diagnosis and inappropriate surgical treatment. Most often they are diagnosed incidentally after surgery performed for treatment of leiomyoma. As the appropriate surgical treatment is crucial for survival of the patient, there is a high demand to predict leiomyosarcoma pre-operatively. Available scoring systems to discriminate leiomyoma from leiomyosarcoma are based on retrospective studies with limited numbers of patients and are not implemented in routine clinical practice.MethodsThe aim of our study was to evaluate a recently published score—the pre-operative leiomyosarcoma (pLMS) score—to determine whether it would have been predictive of leiomyosarcoma in 177 patients from the NOGGO-REGSA study, a German register of histologically proven gynecological sarcoma detected during routine clinical investigation.ResultsThe threshold of the pLMS score for ‘leiomyosarcoma not probable’ (< −3) failed for 7.5% of the patients and the threshold ‘indicator for leiomyosarcoma’ (>+1) was true for 39.1% of the patients. 53.4% of the patients were attributed to the group ‘additional investigations are recommended’ (−3 to +1). The most relevant parameters in our analysis were suspicious sonography and rapid growth, but neither have been quantitatively defined.ConclusionIn our validation cohort, the pLMS score seems not to be a reliable tool to predict leiomyosarcoma and therefore we do not recommend its clinical implementation to identify leiomyosarcoma.
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15
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Mondelli B, Walker WJ, Dhanoya T, Morton K. Uterine Fibroid Embolization in a Series of Women Older Than 50 Years: An Observational Study. WOMEN'S HEALTH REPORTS 2022; 3:238-242. [PMID: 35262062 PMCID: PMC8896223 DOI: 10.1089/whr.2021.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/18/2022]
Abstract
Objective: Women older than 50 years, and in particular postmenopausal, are not usually considered candidate for uterine artery embolization (UAE). We reviewed the outcome of UAE in a series of women older than 50 years, who presented with different symptoms of uterus enlargement. Population: Women referred to the radiologist from gynecologists in the United Kingdom with minimal age over 50 years. Methods: This is a retrospective observational study. The clinical criteria are women older than 50 years with symptoms related to large fibroids affecting their quality of life, who underwent UAE over a 4-year period at Royal Surrey Foundation Trust Hospital and London Clinic between 2012 and 2016. We retrieved the information from the patients' hospital notes and respective images, including magnetic resonance and ultrasound of the pelvis, and from questionnaires and telephone reviews. Main Outcome Measures: We measured the reduction of uterine size, complications, and overall satisfaction of patients. Results: The overall reduction of uterine size 8 weeks following UAE was between 50% and 64% in 12 out of 23 patients. Thirty-five percent of patients (8/23) experienced a reduction of over 65% of overall uterine volume. Only on 2 occasions, the reduction was below 50%. We asked the patients if they would recommend this operation. Twenty out of 23 would recommend it. Improvement of symptoms was measured with a scale between 0 and 5. Twelve out of 23 had total resolution of symptoms—no change in 1 case. One patient underwent a hysterectomy as symptoms persisted. Conclusions: In our series of women older than 50 years, UAE was an effective alternative to surgery, with reduction in fibroid size and improvement of symptoms.
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Affiliation(s)
- Benedetto Mondelli
- Department of Obstetrics and Gynaecology, Surrey and Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Woodruff John Walker
- Interventional Radiology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Tanveer Dhanoya
- Department of Obstetrics and Gynaecology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Karen Morton
- Department of Obstetrics and Gynaecology, Royal Surrey County Hospital, Guildford, United Kingdom
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16
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Najibi S, Gilani MM, Zamani F, Akhavan S, Zamani N. Comparison of the diagnostic accuracy of contrast-enhanced/DWI MRI and ultrasonography in the differentiation between benign and malignant myometrial tumors. Ann Med Surg (Lond) 2021; 70:102813. [PMID: 34691413 PMCID: PMC8519770 DOI: 10.1016/j.amsu.2021.102813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/28/2021] [Accepted: 09/03/2021] [Indexed: 01/11/2023] Open
Abstract
Background Various modalities including ultrasonography and magnetic resonance imaging (MRI) have been developed as imaging technique for screening malignant myometrial tumors, but a few studies assessed the diagnostic value of these two techniques in differentiation of benign from malignant myometrial tumors that had been the main purpose of this study. Materials and methods This cross-sectional study was performed on 63 women underwent surgery for intrauterine masses that were initially assessed using MRI and ultrasound before surgery at a tertiary hospital in Tehran from 2016 to 2020. Their MRI was reviewed by a reputable radiologist in the field. The findings of histopathological assessment were considered as the gold diagnostic standard. Results The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI to detect sarcoma were revealed to be 94.6%, 92.3%, 94.6%, 92.3%, and 93.7% respectively. Ultrasonography had not preferable applicability to differentiate sarcoma from benign tumors with sensitivity, specificity, PPV, NPV and accuracy of 35.1%, 88.4%, 81.2%, 48.9%, and 57.1% respectively. The diagnostic performance of both modalities was not affected by baseline clinical conditions including pain, abnormal uterine bleeding and menopausal status. Conclusion MRI but not ultrasonography can effectively differentiate benign from malignant myometrial tumors. Pretreatment Diagnosis of malignant myometrial tumors may be challenging. MRI with DWI can be considered as a diagnostic tool in leiomyosarcoma. Pretreatment distinction between benign and malignant myometrial tumors is necessary.
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Affiliation(s)
- Shaparak Najibi
- Department of Obstetrics and Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mitra Modares Gilani
- Department of Gynecologic Oncology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Zamani
- Department of Radiology, Children Medical Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Setare Akhavan
- Department of Gynecologic Oncology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Zamani
- Department of Gynecologic Oncology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
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17
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Abstract
ABSTRACT Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.
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18
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Aminzadeh P, Alibrahim E, Dobrotwir A, Paul E, Goergen S. Multiparametric MR evaluation of uterine leiomyosarcoma and STUMP versus leiomyoma in symptomatic women planned for high frequency focussed ultrasound: accuracy of imaging parameters and interobserver agreement for identification of malignancy. Br J Radiol 2021; 94:20200483. [PMID: 33507806 PMCID: PMC8011260 DOI: 10.1259/bjr.20200483] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/23/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential. METHODS Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites. RESULTS 32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003-0.0004) or irregular (p = 0.003-0.004) lesion margin, T2 hyperintensity >50% (p = 0.001-0.004), and peripheral CE (p = 0.02-0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63-80% of LM. Agreement was greatest for margin characteristics (κ = 0.73-0.81). CONCLUSION Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability. ADVANCES IN KNOWLEDGE Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.
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Affiliation(s)
| | | | | | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, Monash University, Commercial Road, Prahran, Victoria, Australia
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19
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Abdel Wahab C, Jannot AS, Bonaffini PA, Bourillon C, Cornou C, Lefrère-Belda MA, Bats AS, Thomassin-Naggara I, Bellucci A, Reinhold C, Fournier LS. Diagnostic Algorithm to Differentiate Benign Atypical Leiomyomas from Malignant Uterine Sarcomas with Diffusion-weighted MRI. Radiology 2020; 297:361-371. [PMID: 32930650 DOI: 10.1148/radiol.2020191658] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Improving the differentiation of uterine sarcomas from atypical leiomyomas remains a clinical challenge and is needed to avoid inappropriate surgery. Purpose To develop a diagnostic algorithm including diffusion-weighted MRI criteria to differentiate malignant uterine sarcomas from benign atypical leiomyomas. Materials and Methods This case-control retrospective study identified women with an atypical uterine mass at MRI between January 2000 and April 2017, with surgery or MRI follow-up after 1 year or longer. A diagnostic algorithm including T2-weighted MRI and diffusion-weighted imaging (DWI) signal and apparent diffusion coefficient (ADC) values was developed to predict for sarcoma. The training set consisted of 51 sarcomas and 105 leiomyomas. Two external validation sets were used to evaluate interreader reproducibility (16 sarcomas; 26 leiomyomas) and impact of reader experience (29 sarcomas; 30 leiomyomas). Wilson confidence intervals (CIs) were calculated for sensitivity and specificity. Results Evaluated were 156 women (median age, 50 years; interquartile range, 44-63 years). Predictive MRI criteria for malignancy were enlarged lymph nodes or peritoneal implants, high DWI signal greater than that in endometrium, and ADC less than or equal to 0.905 × 10-3 mm2/sec. Conversely, a global or focal area of low T2 signal intensity and a low or an intermediate DWI signal less than that in endometrium or lymph nodes allowed readers to confidently diagnose as benign a uterine mass demonstrating one or more of these signs (P < .001) in 100% cases in all three data sets. The sensitivities and specificities of the algorithm for diagnosis of malignancy were 98% (50 of 51 masses; 95% CI: 90%, 100%) and 94% (99 of 105 masses; 95% CI: 88%, 98%) in the training set; 88% (14 of 16 masses; 95% CI: 64%, 97%) and 100% (26 of 26 masses; 95% CI: 87%, 100%) in the validation set; and 83% (24 of 29 masses; 95% CI: 65%, 92%) and 97% (29 of 30 masses; 95% CI: 83%, 99%) for the less experienced reader, respectively. Conclusion A diagnostic algorithm with predictive features including lymphadenopathy, high diffusion-weighted imaging signal with reference to endometrium, and low apparent diffusion coefficient enabled differentiation of malignant sarcomas from atypical leiomyomas, and it may assist inexperienced readers. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Méndez in this issue.
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Affiliation(s)
- Cendos Abdel Wahab
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Anne-Sophie Jannot
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Pietro A Bonaffini
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Camille Bourillon
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Caroline Cornou
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Marie-Aude Lefrère-Belda
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Anne-Sophie Bats
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Isabelle Thomassin-Naggara
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Alexandre Bellucci
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Caroline Reinhold
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
| | - Laure S Fournier
- From the Departments of Radiology (C.A.W., C.B., A.B., L.S.F.), Medical Informatics and Public Health (A.S.J.), Gynecologic and Breast Oncologic Surgery (C.C., A.S.B.), and Pathology (M.A.L.B.), AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Université de Paris, F-75015 Paris, France; Department of Radiology McGill University Health Centre, Montreal, Canada (P.A.B., C.R.); Department of Radiology, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France (I.T.N.); and Université de Paris, PARCC, INSERM, France (A.B., L.F.)
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20
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Sakala MD, Shampain KL, Wasnik AP. Advances in MR Imaging of the Female Pelvis. Magn Reson Imaging Clin N Am 2020; 28:415-431. [PMID: 32624159 DOI: 10.1016/j.mric.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article focuses on advanced MR imaging techniques of the female pelvis and clinical applications for benign and malignant disease. General and abbreviated protocols for female pelvic MR imaging are reviewed. Diffusion-weighted imaging, dynamic contrast-enhanced MR imaging, and susceptibility-weighted imaging are discussed in the context of adnexal mass characterization using the ADNEx-MR scoring system, evaluation of endometriosis, local staging of cervical and endometrial cancers, assessment of nodal and peritoneal metastasis, and potential detection of leiomyosarcoma. MR defecography is also discussed regarding evaluation of multicompartmental pelvic floor disorders.
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Affiliation(s)
- Michelle D Sakala
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kimberly L Shampain
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ashish P Wasnik
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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