Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

The Roles of Ovarian-Adnexal Reporting and Data System US and Ovarian-Adnexal Reporting and Data System MRI in the Evaluation of Adnexal Lesions

The Ovarian-Adnexal Reporting and Data System (O-RADS) is an evidence-based clinical support system for ovarian and adnexal lesion assessment in women of average risk. The system has both US and MRI components with separate but complementary lexicons and assessment categories to assign the risk of malignancy. US is an appropriate initial imaging modality, and O-RADS US can accurately help to characterize most adnexal lesions. MRI is a valuable adjunct imaging tool to US, and O-RADS MRI can help to both confirm a benign diagnosis and accurately stratify lesions that are at risk for malignancy. This article will review the O-RADS US and MRI systems, highlight their similarities and differences, and provide an overview of the interplay between the systems. When used together, the O-RADS US and MRI systems can help to accurately diagnose benign lesions, assess the risk of malignancy in lesions suspicious for malignancy, and triage patients for optimal management.

Staging of Cervical Cancer: A Practical Approach Using MRI and FDG PET

This review provides a practical approach to the imaging evaluation of patients with cervical cancer (CC), from initial diagnosis to restaging of recurrence, focusing on MRI and FDG PET. The primary updates to the International Federation of Gynecology and Obstetrics (FIGO) CC staging system, as well as these updates' relevance to clinical management, are discussed. The recent literature investigating the role of MRI and FDG PET in CC staging and image-guided brachytherapy is summarized. The utility of MRI and FDG PET in response assessment and posttreatment surveillance is described. Important findings on MRI and FDG PET that interpreting radiologists should recognize and report are illustrated. The essential elements of structured reports during various phases of CC management are outlined. Special considerations, including the role of imaging in patients desiring fertility-sparing management, differentiation of CC and endometrial cancer, and unusual CC histologies, are also described. Finally, future research directions including PET/MRI, novel PET tracers, and artificial intelligence applications are highlighted.

An Update on the Role of MRI in Treatment Stratification of Patients with Cervical Cancer

Cervical cancer is the fourth most common cancer in women worldwide and the most common gynaecological malignancy. The FIGO staging system is the most commonly utilised classification system for cervical cancer worldwide. Prior to the most recent update in the FIGO staging in 2018, the staging was dependent upon clinical assessment alone. Concordance between the surgical and clinical FIGO staging decreases rapidly as the tumour becomes more advanced. MRI now plays a central role in patients diagnosed with cervical cancer and enables accurate staging, which is essential to determining the most appropriate treatment. MRI is the best imaging option for the assessment of tumour size, location, and parametrial and sidewall invasion. Notably, the presence of parametrial invasion precludes surgical options, and the patient will be triaged to chemoradiotherapy. As imaging is intrinsic to the new 2018 FIGO staging system, nodal metastases have been included within the classification as stage IIIC disease. The presence of lymph node metastases within the pelvis or abdomen is associated with a poorer prognosis, which previously could not be included in the staging classification as these could not be reliably detected on clinical examination. MRI findings corresponding to the 2018 revised FIGO staging of cervical cancers and their impact on treatment selection will be described.

MR Imaging of Gynecologic Tumors: Pearls, Pitfalls, and Tumor Mimics

MR imaging is the modality of choice for the pre-treatment evaluation of patients with gynecologic malignancies, given its excellent soft tissue contrast and multi-planar capability. However, it is not without pitfalls. Challenges can be encountered in the assessment of the infiltration of myometrium, vagina, cervical stroma, and parametria, which are crucial prognostic factors for endometrial and cervical cancers. Other challenges can be encountered in the distinction between solid and non-solid tissue and in the identification of peritoneal carcinomatosis for the sonographically indeterminate adnexal mass.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

Diagnostic Accuracy of Magnetic Resonance Imaging in the Pre-Operative Staging of Cervical Cancer Patients Who Underwent Neoadjuvant Treatment: A Clinical–Surgical–Pathologic Comparison

Magnetic resonance imaging (MRI) has been proven to ensure high diagnostic accuracy in the identification of vaginal, parametrial, and lymph node involvement in patients affected by cervical cancer (CC), thus playing a crucial role in the preoperative staging of the disease. This study aims to compare the accuracy of MRI for the preoperative staging of patients with CC who underwent neoadjuvant treatment (NAT) or direct surgery. Retrospective data analysis of 126 patients with primary CC International Federation of Gynecology and Obstetrics stage IB3-IIB who underwent NAT before radical surgery (NAT group = 94) or received surgical treatment alone (control arm = 32) was prospectively performed. All enrolled patients were clinically assessed with both a pelvic examination and MRI before surgical treatment. Data from the clinical examination were compared with the histopathological findings to assess the accuracy of MRI for staging purposes after NAT or before direct surgery. MRI showed an overall accuracy of 46.1%, proving it to be not superior to pelvic and physical examination. The overall MRI accuracy for the evaluation of parametrial, vaginal, and lymph node status was 65.8%, 79.4%, and 79.4%, respectively. In the NAT group, the accuracy for the detection of parametrial, lymph node, and vaginal involvement was lower than the control group; however, the difference was not significant (p ≥ 0.05). The overall accuracy of MRI for the preoperative staging of CC after NAT is shown to be not unsatisfactory. The limits of MRI staging are especially evident when dealing with pre-treated patients.

Imaging of Endometrial Cancer

Endometrial cancer is the most common gynecologic cancer in the United States and Europe, with an increasing incidence rate in high-income countries. MR imaging is recommended for treatment planning because it provides critical information on the extent of myometrial and cervical invasion, extrauterine spread, and lymph node status, all of which are important in the selection of the most appropriate therapy. This article highlights the added value of imaging, focused on MR imaging, in the assessment of endometrial cancer and summarizes the role of MR imaging for endometrial cancer risk stratification and management.

MR Imaging in Cervical Cancer

Cervical cancer remains a significant contributor to morbidity and mortality for women globally despite medical advances in preventative medicine and treatment. The 2018 Internal Federation of Gynecology and Obstetrics committee modified their original 2009 staging scheme to incorporate advanced imaging modalities, where available, to increase the accuracy of staging and to guide evolving treatments. Having a robust understanding of the newest staging iteration, its consequences on treatment pathways, and common imaging pitfalls will aid the radiologist in generating valuable and practical reports to optimize treatment strategies.

O-RADS MRI After Initial Ultrasound for Adnexal Lesions: AJR Expert Panel Narrative Review

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) and MRI risk stratification systems were developed by an international group of experts in adnexal imaging to aid radiologists in assessing adnexal lesions. The goal of imaging is to appropriately triage patients with adnexal lesions. US is the first-line imaging modality for assessment, whereas MRI can be used as a problem-solving tool. Both US and MRI can accurately characterize benign lesions such as simple cysts, endometriomas, hemorrhagic cysts, and dermoid cysts, avoiding unnecessary or inappropriate surgery. In patients with a lesion that does not meet criteria for one of these benign diagnoses, MRI can further characterize the lesion with an improved specificity for cancer and the ability to provide a probable histologic subtype in the presence of certain MRI features. This allows personalized treatment, including avoiding overly extensive surgery or allowing fertility-sparing procedures for suspected benign, borderline, or low-grade tumors. When MRI findings indicate a risk of an invasive cancer, patients can be expeditiously referred to a gynecologic oncologic surgeon. This narrative review provides expert opinion on the utility of multiparametric MRI when using the O-RADS US and MRI management systems.

Outcomes of ovarian transposition in cervical cancer; an updated meta-analysis

Background

Cervical cancer is the most common indication for ovarian transposition in reproductive-age women. Ovarian transposition should be performed in premenopausal women undergoing pelvic irradiation to preserve ovarian function, and prevent early menopause. As women become more knowledgeable about their fertility options, it is still unclear who will benefit from the intervention. We updated our previous meta-analysis of ovarian function preservation, symptomatic ovarian cysts, and metastases to the transposed ovaries following ovarian transposition in cervical cancer patients to further guide current clinical practice.

Methods

A systematic search of Medline, Embase, Web of Science, and The Cochrane Library databases, dating from January 1980 to July 2021, was conducted. We computed the summary proportions of women who had ovarian function preservation, non-ovarian cyst formation and metastases to the transposed ovaries following ovarian transposition by random-effects meta-analysis and we explored study heterogeneity by type of radiotherapy.

Results

There were 29 publications reporting on 1160 women with cervical cancer who underwent ovarian transposition. In the group that underwent surgery alone, 91% of the women had preserved ovarian function (95% CI 83–100), 89% (95% CI 80–99) of women who did not develop ovarian cysts, and 99% (95% CI 1–5) of women who did not suffer metastases to the transposed ovaries. In the surgery ± brachytherapy (BR) group, the proportion of women with the preserved ovarian function was 93% (95% CI 76–113), 84% (95% CI 69–103) of women who did not develop ovarian cysts, and 99% (95% CI 82–120) of women who did not suffer metastases to the transposed ovaries. In the external beam pelvic radiotherapy (EBRT) ± BR ± surgery group, the proportion of women with the preserved ovarian function was 61% (95% CI 55–69), and 95% (95% CI 85–107) of women who developed ovarian cysts. There were no metastases to the transposed ovaries in that group.

Conclusions

In women with cervical cancer, ovarian transposition offers a significant preservation of the ovarian function. Despite an expected incidence of ovarian cyst formation, it carries almost no risk for metastases to the transposed ovaries.

O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee

MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the number of false-positive diagnoses for malignancy and thereby avoiding unnecessary or over-extensive surgery in patients with benign lesions or borderline tumors, while women with possible malignancies can be expeditiously referred for oncologic surgical evaluation. The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee is an international collaborative effort formed under the direction of the American College of Radiology and includes a diverse group of experts on adnexal imaging and management who developed the O-RADS MRI risk stratification system. This scoring system assigns a probability of malignancy based on the MRI features of an adnexal lesion and provides information to facilitate optimal patient management. The widespread implementation of a codified reporting system will lead to improved interpretation agreement and standardized communication between radiologists and referring physicians. In addition, it will allow for high-quality multi-institutional collaborations-an important unmet need that has hampered the performance of high-quality research in this area in the past. This article provides guidelines on using the O-RADS MRI risk stratification system in clinical practice, as well as in the educational and research settings.

[Adnexal Masses: Clinical Application of Multiparametric MR Imaging & O-RADS MRI]

Incidental adnexal masses considered indeterminate for malignancy are commonly observed on ultrasonography. Multiparametric MRI is the imaging modality of choice for the evaluation of sonographically indeterminate adnexal masses. Conventional MRI enables a confident pathologic diagnosis of various benign lesions due to accurate tissue characterization of fat, blood, fibrous tissue, and solid components. Additionally, functional imaging sequences, including perfusion- and diffusion-weighted imaging, improve the diagnostic efficacy of conventional MRI in differentiating benign from malignant adnexal masses. The ovarian-adnexal reporting and data system (O-RADS) MRI was recently designed to provide consistent interpretations in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. In this review, we describe the clinical application of multiparametric MRI for the evaluation of adnexal masses and introduce the O-RADS MRI risk stratification system.

The role of MRI in cervical cancer > 2 cm (FIGO stage IB2-IIA1) conservatively treated with neoadjuvant chemotherapy followed by conization: a pilot study

Introduction

MRI is very accurate in selecting young women with cervical cancer for fertility-sparing surgery (FSS), in particular radical hysterectomy (RH). In order to improve obstetrical outcomes, neoadjuvant chemotherapy (NACT) followed by cold knife conization (CKC) has been proposed as alternative technique.

Objective

To investigate the role of MRI in evaluation of response to treatment after neoadjuvant chemotherapy (NACT), followed by CKC, in patients with cervical cancer FIGO stage IB2-IIA1 with tumor size 2 – 4 cm, desiring to preserve their fertility.

Methods

13 young women (23–36 years old) with cervical cancer stage IB2-IIA1 desiring to preserve their fertility were included. Tumor diameter at baseline and after treatment was detected on 1.5 T MRI. Treatment response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and then compared to histopathology result.

Results

MRI correctly assessed 11 out of 13 cases, according to RECIST 1.1, compared to histopathology. Among these 7 patients with partial response (PR), 2 cases of CR, 1 SD and 1 PD with persistence or enlargement of primary tumor.

Conclusion

Our pilot study supports the usefulness of MRI in assessment of treatment response after NACT, followed by CKC.

Trial registration number

ClinicalTrials.gov: NCT02323841

Implications of the new FIGO staging and the role of imaging in cervical cancer

International Federation of Gynecology and Obstetrics (FIGO) staging, which is the fundamentally important cancer staging system for cervical cancer, has changed in 2018. New FIGO staging includes considerable progress in the incorporation of imaging findings for tumour size measurement and evaluating lymph node (LN) metastasis in addition to tumour extent evaluation. MRI with high spatial resolution is expected for tumour size measurements and the high accuracy of positron emmision tomography/CT for LN evaluation. The purpose of this review is firstly review the diagnostic ability of each imaging modality with the clinical background of those two factors newly added and the current state for LN evaluation. Secondly, we overview the fundamental imaging findings with characteristics of modalities and sequences in MRI for accurate diagnosis depending on the focus to be evaluated and for early detection of recurrent tumour. In addition, the role of images in treatment response and prognosis prediction is given with the development of recent technique of image analysis including radiomics and deep learning.

Ovary: MRI characterisation and O-RADS MRI

Ultrasound has a high specificity for the diagnosis of a benign lesion in cases of classic appearing simple cyst, hemorrhagic cyst, endometrioma and dermoid. However, ultrasound can sometimes be limited for definitive characterisation and risk stratification of other types of lesions, including those with echogenic content that may appear solid, with or without blood flow. Frequently, MRI can be used to further characterise these types of lesions, due to its ability to distinguish solid tissue from non-tissue solid components such as fat, blood, or debris. Incorporating the MR imaging into the evaluation of adnexal lesions can improve diagnostic certainty and guide clinical management potentially avoiding inappropriate surgery for benign lesions and expediting appropriate treatment for malignant lesions, particularly in the females with sonographically indeterminate adnexal lesions.

Staging, recurrence and follow-up of uterine cervical cancer using MRI: Updated Guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018

OBJECTIVES

The recommendations cover indications for MRI examination including acquisition planes, patient preparation, imaging protocol including multi-parametric approaches such as diffusion-weighted imaging (DWI-MR),  dynamic contrast-enhanced imaging (DCE-MR) and standardised reporting. The document also underscores the value of whole-body 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) and highlights potential future methods.

METHODS

In 2019, the ESUR female pelvic imaging working group reviewed the revised 2018 FIGO staging system, the up-to-date clinical management guidelines, and the recent imaging literature. The RAND-UCLA Appropriateness Method (RAM) was followed to develop the current ESUR consensus guidelines following methodological steps: literature research, questionnaire developments, panel selection, survey, data extraction and analysis.

RESULTS

The updated ESUR guidelines are recommendations based on ≥ 80% consensus among experts. If ≥ 80% agreement was not reached, the action was indicated as optional.

CONCLUSIONS

The present ESUR guidelines focus on the main role of MRI in the initial staging, response monitoring and evaluation of disease recurrence. Whole-body FDG-PET plays an important role in the detection of lymph nodes (LNs) and distant metastases.

KEY POINTS

• T2WI and DWI-MR are now recommended for initial staging, monitoring of response and evaluation of recurrence. • DCE-MR is optional; its primary role remains in the research setting. • T2WI, DWI-MRI and whole-body FDG-PET/CT enable comprehensive assessment of treatment response and recurrence.

Radical trachelectomy

Radical trachelectomy is the 'cornerstone' of fertility-sparing surgery in patients with early-stage cervical cancer wishing to preserve fertility. Growing evidence has demonstrated the oncologic safety and subsequent favorable pregnancy outcomes in well-selected cases. In the absence of prospective trials, the decision on the appropriate surgical approach (vaginal, open, or minimally invasive surgery) should be based on local resources and surgeons' preferences. Radical trachelectomy has the potential to preserve fertility in a large proportion of women with early-stage cervical cancer. However, prematurity and premature rupture of membranes are common obstetric complications after radical trachelectomy for cervical cancer. A multidisciplinary approach is crucial to optimize the balance between oncologic and obstetric outcomes. The purpose of this review is to provide an updated overview of the technical, oncologic, and obstetric aspects of radical trachelectomy.

Imaging modalities in fertility preservation in patients with gynecologic cancers

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.

MRI of cervical cancer with a surgical perspective: staging, prognostic implications and pitfalls

LEARNING OBJECTIVES

Magnetic resonance imaging (MRI) of the pelvis is the most reliable imaging modality for staging, treatment planning, and follow-up of cervical cancer; and its findings may now be incorporated into the International Federation of Gynecology and Obstetrics Federation (FIGO) 2018 clinical staging of cervical cancer. It is imperative that radiologists are familiar with the imaging appearance of the different stages of cervical cancer as well as the post-treatment changes and imaging pitfalls given the respective clinical manifestations, treatment regimens, and prognosis of an accurate diagnosis. In addition to the different stages of cervical cancer, we address the imaging techniques for diagnosis, staging and treatment implications as well as the changes of the new FIGO staging system.

BACKGROUND

The use of MRI to diagnose and stage cervical cancer is steadily increasing and the new FIGO stagi ng system, previously based on clinical examination, now allows the staging or change of staging based on the imaging findings. MRI can evaluate the extent of disease because of its excellent contrast resolution for pelvic tissues and organs, high accuracy and detailed elaboration of the cervical/uterovaginal anatomy.

CONTENT

Relevant anatomy, including normal MRI appearance of the cervix, parametria and pelvic ligaments; different stages of cervical cancer on MRI with prognostic and therapeutic implications; MRI sequences, other imaging modalities used in the staging and follow-up, treatment of different stages and the appearance of the cervix and cervical cancer post-treatment. Since clinical implications and therapeutic strategies for cervical cancer treatment vary tremendously according to degree of tumor extension, familiarity with relevant MRI techniques and findings is essential for radiologists. It is important that radiologists interpreting pelvic MRI are aware with the different stages of cervical cancer to provide useful information regarding treatment and prognosis. Pitfalls regarding the interpretation of tumor extension can interfere with an accurate diagnosis and have significant therapeutic implications.

Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Endometrial cancer (EC) is the most common malignant tumor of the female genital tract in Western countries. EC patients are divided into risk categories based on histopathological tumor type, grade, and myometrial invasion depth. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) system. Since FIGO (2009) stage correlates with prognosis, preoperative staging is essential for tailored treatment. MRI reveals myometrial invasion depth, which correlates with tumor grade and lymph node metastases, and thus correlates with prognosis. Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. The FIGO Gynecologic Oncology Committee recently revised its CC staging guidelines, allowing staging based on imaging and pathological findings when available. The revised FIGO (2018) staging includes node involvement and thus enables both therapy selection and evaluation, prognosis estimation, and calculation of end results. MRI can accurately assess prognostic indicators, e.g., tumor size, parametrial invasion, pelvic sidewall, and lymph node invasion. Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Awareness of mimics that can simulate both cancers is critical. With careful application, functional MRI with DWI and DCE sequences can help establish a correct diagnosis, although it is sometimes necessary to perform biopsy and histopathological analysis.

Challenges and controversies in the conservative management of uterine and ovarian cancer

Uterine cancer is the fifth most common cancer in women worldwide with an estimated 320,000 annual diagnoses. Its most common form, endometrioid adenocarcinoma of the endometrium (endometrial adenocarcinoma [EAC]), is thought to develop through excessive proliferation of endometrial glands, and then increasing steadily in incidence. The current standard treatment for EAC is hysterectomy, which is often curative. However, it may be unacceptably expensive for women with severe medical comorbidities, those who are at risk of intra- and postoperative adverse events and those who desire fertility. Ovarian cancer is the most malignant of all gynaecological cancers, but patients with disease limited to one ovary and patients with non-epithelial tumours may expect a good prognosis. A selected group of young patients who desire fertility may be well treated with conservative surgery. This chapter reviews patient selection, diagnosis, pre-treatment evaluation, treatment options, surveillance and risk of relapse.