Time-synchronized 2-deoxy-2-[18F]fluoro-D-glucose PET/MRI with MR-active trigger and Bayesian penalized likelihood reconstruction: Diagnostic utility for locoregional extension of endometrial cancer

PURPOSE

Minimal misregistration of fused PET and MRI images can be achieved with simultaneous positron emission tomography/magnetic resonance imaging (PET/MRI). However, the acquisition of multiple MRI sequences during a single PET emission scan may impair fusion precision of each sequence. This study evaluated the diagnostic utility of time-synchronized PET/MRI using an MR active trigger and a Bayesian penalized likelihood reconstruction algorithm (BPL) to assess the locoregional extension of endometrial cancer.

METHODS

Fifty-five patients with endometrial cancer who underwent pelvic 2-deoxy-2-[18F]fluoro-D-glucose PET/MRI were retrospectively evaluated. The PET emission time for the BPL reconstruction was determined by the MR active trigger of each MR sequence. The concordance rates of image interpretation with pathological T-staging, diagnostic performance for deep myometrial invasion (MI), and diagnostic confidence levels were evaluated by two readers and compared between time-synchronized, overlapping (conventional and simultaneous, but not time-synchronized), and sequential (not simultaneous) PET/MRI and MRI with diffusion-weighted imaging. Misregistration of the PET/MRI-fused images was determined by evaluating the differences in bladder dimensions.

RESULTS

The T classification by time-synchronized PET/MRI was the most concordant with the pathological T classification for the two readers. Time-synchronized PET/MRI had a significantly higher diagnostic performance for deep MI and higher confidence level scores than overlapping PET/MRI for the novice reader (p = 0.033 and p = 0.038, respectively). The differences in bladder dimension on sequential PET/MRI were significantly larger than those on overlapping and time-synchronized PET/MRI (p <0.001).

CONCLUSION

Time-synchronized PET/MRI is superior to conventional PET/MRI for assessing the locoregional extension of endometrial cancer.

The tipping point: Key oncologic imaging findings resulting in critical changes in the management of malignant genitourinary and gynecological tumors

OBJECTIVE

The purpose of this article is to review the staging systems for common malignant genitourinary and gynecological tumors, including renal cell carcinoma, urinary bladder carcinoma, as well as cervical, endometrial, and ovarian carcinoma, and to highlight the key imaging findings ("tipping points") that may alter patient management algorithms based on radiological staging.

CONCLUSION

There are identifiable imaging features for the common genitourinary and gynecological malignancies, including the size of the primary tumor, tumor extension, invasion of adjacent structures, lymph node involvement, and distant metastasis, which provide important prognostic information and determine patient management. Radiologists must be aware of these imaging findings ("tipping points") when interpreting staging examinations.

Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment

INTRODUCTION/BACKGROUND

Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC.

METHODOLOGY

From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard).

RESULTS

Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV.

CONCLUSION

HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.

Multiparametric MRI-based radiomics nomogram for identifying cervix-corpus junction cervical adenocarcinoma from endometrioid adenocarcinoma

OBJECTIVE

To developed a magnetic resonance imaging (MRI) radiomics nomogram to identify adenocarcinoma at the cervix-corpus junction originating from the endometrium or cervix in order to better guide clinical treatment.

METHODS

Between February 2011 and September 2021, the clinicopathological data and MRI in 143 patients with histopathologically confirmed cervical adenocarcinoma (CAC, n = 86) and endometrioid adenocarcinoma (EAC, n = 57) were retrospectively analyzed at the cervix-corpus junction. Radiomics features were extracted from fat-suppressed T2-weighted imaging (FS-T2WI), diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) maps, and delayed phase contrast-enhanced T1-weighted imaging (CE-T1WI) sequences. A radiomics nomogram was developed integrating radscore with independent clinical risk factors. The area under the curve (AUC) was used to evaluate the diagnostic efficacy of the radscore, nomogram and two different experienced radiologists in differentiating CAC from EAC at the cervix-corpus junction, and Delong test was applied to compare the differences of their diagnostic performance.

RESULTS

In the training cohort, the AUC was 0.93 for radscore; 0.97 for radiomics nomograms; 0.85 and 0.86 for radiologists 1 and 2, respectively. Delong test showed that the differential efficacy of nomogram was significant better than those of radiologists in the training cohort (both P < 0.05).

CONCLUSIONS

The nomogram based on radscore and clinical risk factors could better differentiate CAC from EAC at the cervix-corpus junction than radiologists, and preoperatively and non-invasively identify the origin of adenocarcinoma at the cervix-corpus junction, which facilitates clinicians to make individualized treatment decision.

Predictive Value of Magnetic Resonance Imaging in Risk Stratification and Molecular Classification of Endometrial Cancer

This study evaluated the magnetic resonance imaging (MRI) findings of endometrial cancer (EC) patients and identified differences based on risk group and molecular classification. The study involved a total of 175 EC patients. The MRI data were retrospectively reviewed and compared based on the risk of recurrence. Additionally, the associations between imaging phenotypes and genomic signatures were assessed. The low-risk and non-low-risk groups (intermediate, high-intermediate, high, metastatic) showed significant differences in tumor diameter (p < 0.001), signal intensity and heterogeneity on diffusion-weighted imaging (DWI) (p = 0.003), deep myometrial invasion (involvement of more than 50% of the myometrium), cervical invasion (p < 0.001), extrauterine extension (p = 0.002), and lymphadenopathy (p = 0.003). Greater diffusion restriction and more heterogeneity on DWI were exhibited in the non-low-risk group than in the low-risk group. Deep myometrial invasion, cervical invasion, extrauterine extension, lymphadenopathy, recurrence, and stage discrepancy were more common in the non-low-risk group (p < 0.001). A significant difference in microsatellite stability status was observed in the heterogeneity of the contrast-enhanced T1-weighted images (p = 0.027). However, no significant differences were found in MRI parameters related to TP53 mutation. MRI features can be valuable predictors for differentiating risk groups in patients with EC. However, further investigations are needed to explore the imaging markers based on molecular classification.

Prediction of Patient Outcomes in Locally Advanced Cervical Carcinoma Following Chemoradiotherapy-Comparative Effectiveness of Magnetic Resonance Imaging and 2-Deoxy-2-[18F]fluoro-D-glucose Imaging

PURPOSE

To evaluate the utility and comparative effectiveness of three five-point qualitative scoring systems for assessing response on PET-CT and MRI imaging individually and in combination, following curative-intent chemoradiotherapy (CRT) in locally advanced cervical cancer (LACC). Their performance in the prediction of subsequent patient outcomes was also assessed; Methods: Ninety-seven patients with histologically confirmed LACC treated with CRT using standard institutional protocols at a single centre who underwent PET-CT and MRI at staging and post treatment were identified retrospectively from an institutional database. The post-CRT imaging studies were independently reviewed, and response assessed using five-point scoring tools for T2WI, DWI, and FDG PET-CT. Patient characteristics, staging, treatment, and follow-up details including progression-free survival (PFS) and overall survival (OS) outcomes were collected. To compare diagnostic performance metrics, a two-proportion z-test was employed. A Kaplan-Meier analysis (Mantel-Cox log-rank) was performed.

RESULTS

The T2WI (p < 0.00001, p < 0.00001) and DWI response scores (p < 0.00001, p = 0.0002) had higher specificity and accuracy than the PET-CT. The T2WI score had the highest positive predictive value (PPV), while the negative predictive value (NPV) was consistent across modalities. The combined MR scores maintained high NPV, PPV, specificity, and sensitivity, and the PET/MR consensus scores showed superior diagnostic accuracy and specificity compared to the PET-CT score alone (p = 0.02926, p = 0.0083). The Kaplan-Meier analysis revealed significant differences in the PFS based on the T2WI (p < 0.001), DWI (p < 0.001), combined MR (p = 0.003), and PET-CT/MR consensus scores (p < 0.001) and in the OS for the T2WI (p < 0.001), DWI (p < 0.001), and combined MR scores (p = 0.031) between responders and non-responders.

CONCLUSION

Post-CRT response assessment using qualitative MR scoring and/or consensus PET-CT and MRI scoring was a better predictor of outcome compared to PET-CT assessment alone. This requires validation in a larger prospective study but offers the potential to help stratify patient follow-up in the future.

A computer-aided determining method for the myometrial infiltration depth of early endometrial cancer on MRI images

To classify early endometrial cancer (EC) on sagittal T2-weighted images (T2WI) by determining the depth of myometrial infiltration (MI) using a computer-aided diagnosis (CAD) method based on a multi-stage deep learning (DL) model. This study retrospectively investigated 154 patients with pathologically proven early EC at the institution between January 1, 2018, and December 31, 2020. Of these patients, 75 were in the International Federation of Gynecology and Obstetrics (FIGO) stage IA and 79 were in FIGO stage IB. An SSD-based detection model and an Attention U-net-based segmentation model were trained to select, crop, and segment magnetic resonance imaging (MRl) images. Then, an ellipse fitting algorithm was used to generate a uterine cavity line (UCL) to obtain MI depth for classification. In the independent test datasets, the uterus and tumor detection model achieves an average precision rate of 98.70% and 87.93%, respectively. Selecting the optimal MRI slices method yields an accuracy of 97.83%. The uterus and tumor segmentation model with mean IOU of 0.738 and 0.655, mean PA of 0.867 and 0.749, and mean DSC of 0.845 and 0.779, respectively. Finally, the CAD method based on the calculated MI depth reaches an accuracy of 86.9%, a sensitivity of 81.8%, and a specificity of 91.7% for early EC classification. In this study, the CAD method implements an end-to-end early EC classification and is found to be on par with radiologists in terms of performance. It is more intuitive and interpretable than previous DL-based CAD methods.

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.

Radiomics-based fertility-sparing treatment in endometrial carcinoma: a review

In recent years, with the increasing incidence of endometrial carcinoma in women of child-bearing age, to decision of whether to preserve patients' fertility during treatment has become increasingly complex, presenting a formidable challenge for both physicians and patients. Non-fertility-sparing treatment can remove lesions more thoroughly than fertility-sparing treatment. However, patients will permanently lose their fertility. In contrast, fertility-sparing treatment can treat tumors without impairing fertility, but the risk of disease progression is high as compared with non-fertility-sparing treatment. Therefore, it is extremely important to accurately identify patients who are suitable for fertility-sparing treatments. The evaluation of prognostic factors, including myometrial invasion, the presence of lymph node metastases, and histopathological type, is vital for determining whether a patient can receive fertility-sparing treatment. As a non-invasive and quantitative approach, radiomics has the potential to assist radiologists and other clinicians in determining more precise judgments with regard to the above factors by extracting imaging features and establishing predictive models. In this review, we summarized currently available fertility-sparing strategies and reviewed the performance of radiomics in predicting risk factors associated with fertility-sparing treatment. This review aims to assist clinicians in identifying patients suitable for fertility-sparing treatment more accurately and comprehensively and informs more appropriate and rigorous treatment decisions for endometrial cancer patients of child-bearing age.Critical relevance statement: Radiomics is a promising tool that may assist clinicians identify risk factors about fertility-sparing more accurately and comprehensively.

Preoperative staging of uterine cancer: can transvaginal ultrasonography play a role?

Introduction

Preoperative staging of uterine cancer has recently been implied as an important contribution to an accurate selection of low-risk cases, ultimately avoiding unnecessary lymph node debulking. The aim of this study was to evaluate the validity of transvaginal ultrasonography (TVS) in preoperative staging of uterine cancer in comparison to pelvic magnetic resonance imaging (MRI) and permanent section.

Methods

We conducted a prospective longitudinal multicenter trial between 2017 and 2018. Inclusion criteria comprised cases of endometrial neoplasia histologically confirmed or strong imaging suspicion, candidates for elective surgery as primary treatment. Proportions of Agreement (PA), kappa statistic (K), sensitivity, specificity and accuracy were calculated with 95% confidence intervals (95%CI).

Results

Eighty-two patients were eligible for the study, presenting a mean age of 68 years (standard deviation 11). In what concerns the TVS evaluation of myometrial invasion, the subjective and objective methods of Gordon and Karlsson presented a sensitivity of 79%, 79% and 67% [95%CI 63-91; 63-91; 50-81], a specificity of 65%, 58% and 79% [95%CI 49-79; 42-73; 64-89] and an overall accuracy of 72%, 68% and 73% [95%CI 61-81; 57-78; 63-82]. MRI presented respectively a sensitivity, specificity and overall accuracy of 92%, 70% and 82% [95%CI 77-98; 52-85; 71-90]. Regarding cervical involvement, the sensitivity was respectively 31%, 50% and 67% [95%CI 9-61; 21-79; 35-90] for the subjective method, objective TVS and MRI, and the specificity was 98%, 90% and 100% [95%CI 92-100; 77-97; 94;100]. Agreement between TVS and MRI was superior in the assessment of cervical invasion, with PA ranging from 0.82 to 0.93 and K from 0.45 to 0.58, in comparison to myometrial invasion with PA ranging from 0.68 to 0.73 and K from 0.31 to 0.50. Considering the assessment of cervical involvement, as MRI showed a specificity of 100% it is not possible to increase the specificity. However, it was possible to increase the sensitivity, considering the combination of TVS with objective approach and MRI.

Conclusion

TVS may have a promising role as a tool for preoperative staging of endometrial carcinoma, presenting a performance that approximates to MRI, with a higher agreement in the assessment of cervical invasion.

Diagnostic value of T2 and diffusion-weighted imaging (DWI) in local staging of endometrial cancer

BACKGROUND

Endometrial cancer (EC) is the eighth most prevalent cancer globally. T2-weighted magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) help anatomical localization and local staging of lesions. The present study was performed to assess the diagnostic value of the simultaneous use of T2 and DWI techniques in EC evaluation.

METHODS

Seventy-eight histopathological-proven EC cases were included in this study. Patients were assessed using a complete MRI exam, including T2 and DWI. The myometrial invasion, cervical, serosal or adnexal, vaginal or parametrial, and pelvic lymph node involvements and accuracy, sensitivity, specificity, and positive and negative predictive values were evaluated in each sequence distinctly and was compared with the pathology findings and full standard protocol using post-contrast multiphasic contrast-enhanced series.

RESULTS

Deep myometrial invasion in EC cases was detected in 38.5% by T2-DWI and 37.2% by pathology. The pathology diagnosed cervical, serosal, and vaginal involvements and pelvic lymph node metastases in 20.5%, 7.7%, 6.4% and 11.5% of cases respectively, while the numbers for T2-DWI were 26.9%, 7.7%, 7.7%, and 15.4%, respectively. The accuracy, sensitivity, specificity, PPV, and NPV of T2-DWI in the diagnosis of myometrial invasion were 93.5%, 93.1%, 93.8%, 90%, and 93.8%, respectively. A slightly higher Kappa coefficient of DWI (0.973) in the diagnosis of myometrial invasion was identified compared to T2 (0.946). The T2-DWI technique had a 52.6% intraclass correlation coefficient in the diagnosis of IA stage.

CONCLUSION

The simultaneous consideration of T2 and DWI technique may signify a noninvasive, rapid, safe, and accurate approach for precisely assessing myometrial invasion and EC staging. Elimination of intravenous contrast material result in prevention of contrast related side effects beside significant cost reduction for health care systems and patients with a comparable result to contrast enhanced MRI.

Imaging Recommendations for Diagnosis, Staging, and Management of Uterine Cancer

Uterine cancers are classified into cancers of the corpus uteri (uterine carcinomas and carcinosarcoma) and corpus uteri (sarcomas) by the AJCC staging system (eighth edition). Endometrial carcinoma is the most common amongst these with prolonged estrogen exposure being a well-known risk factor. The FIGO staging system for endometrial carcinoma is primarily surgical and includes total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Imaging is useful in the preoperative evaluation of tumor stage, especially assessment of myometrial invasion and cervical stromal extension. Dynamic contrast enhanced MRI with DWI has a high staging accuracy and is the preferred imaging modality for primary evaluation with contrast-enhanced CT abdomen being indicated for recurrent disease. PET/CT is considered superior in evaluation of lymph nodes and extra pelvic metastases.

Update on MRI in Evaluation and Treatment of Endometrial Cancer

Endometrial cancer is the second most common gynecologic cancer worldwide and the most common gynecologic cancer in the United States, with an increasing incidence in high-income countries. Although the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer is a surgical staging system, contemporary published evidence-based data and expert opinions recommend MRI for treatment planning as it provides critical diagnostic information on tumor size and depth, extent of myometrial and cervical invasion, extrauterine extent, and lymph node status, all of which are essential in choosing the most appropriate therapy. Multiparametric MRI using a combination of T2-weighted sequences, diffusion-weighted imaging, and multiphase contrast-enhanced imaging is the mainstay for imaging assessment of endometrial cancer. Identification of important prognostic factors at MRI improves both treatment selection and posttreatment follow-up. MRI also plays a crucial role for fertility-preserving strategies and in patients who are not surgical candidates by helping guide therapy and identify procedural complications. This review is a product of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel and reflects a multidisciplinary international collaborative effort to summarize updated information highlighting the role of MRI for endometrial cancer depiction and delineation, treatment planning, and follow-up. The article includes information regarding dedicated MRI protocols, tips for MRI reporting, imaging pitfalls, and strategies for image quality optimization. The roles of MRI-guided radiation therapy, hybrid PET/MRI, and advanced MRI techniques that are applicable to endometrial cancer imaging are also discussed. Online supplemental material is available for this article. ^©RSNA, 2022.

Characterizing the extracellular matrix transcriptome of cervical, endometrial, and uterine cancers

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The matrisome plays a critical role in the progression of cancer, but the matrisomes of gynecological cancers have not been well characterized.

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We built an in silico analysis pipeline to analyze publicly available bulk RNA-seq datasets of cervical, endometrial, and uterine cancers.

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Using a machine learning approach, we identified genes and gene networks that held inferential significance for cancer stage and patient survival.

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Cervical, endometrial, and uterine cancers are highly distinct from one another and should be analyzed separately.

Increasingly, the matrisome, a set of proteins that form the core of the extracellular matrix (ECM) or are closely associated with it, has been demonstrated to play a key role in tumor progression. However, in the context of gynecological cancers, the matrisome has not been well characterized. A holistic, yet targeted, exploration of the tumor microenvironment is critical for better understanding the progression of gynecological cancers, identifying key biomarkers for cancer progression, establishing the role of gene expression in patient survival, and for assisting in the development of new targeted therapies. In this work, we explored the matrisome gene expression profiles of cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC), uterine corpus endometrial carcinoma (UCEC), and uterine carcinosarcoma (UCS) using publicly available RNA-seq data from The Cancer Genome Atlas (TCGA) and The Genotype-Tissue Expression (GTEx) portal. We hypothesized that the matrisomal expression patterns of CESC, UCEC, and UCS would be highly distinct with respect to genes which are differentially expressed and hold inferential significance with respect to tumor progression, patient survival, or both. Through a combination of statistical and machine learning analysis techniques, we identified sets of genes and gene networks which characterized each of the gynecological cancer cohorts. Our findings demonstrate that the matrisome is critical for characterizing gynecological cancers and transcriptomic mechanisms of cancer progression and outcome. Furthermore, while the goal of pan-cancer transcriptional analyses is often to highlight the shared attributes of these cancer types, we demonstrate that they are highly distinct diseases which require separate analysis, modeling, and treatment approaches. In future studies, matrisome genes and gene ontology terms that were identified as holding inferential significance for cancer stage and patient survival can be evaluated as potential drug targets and incorporated into in vitro models of disease.

Magnetic resonance imaging pitfalls in determining myometrial invasion in stage I endometrial cancer: A case report and literature review

The degree of myometrial invasion (MI) is crucial in the preoperative diagnosis of endometrial cancer (EC) using MRI in terms of therapeutic and prognostic implications. However, several pitfalls should be kept in mind when using this modality. We report a case of EC on a 64-year-old woman, identified preoperatively without MI based on ultrasonography and MRI, implying a low risk of lymph node metastasis; surprisingly, the uterine incision showed the lesion had invaded <50% of the myometrium. Thus, a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed, and histopathologic analysis confirmed that the EC was on stage IA (cancer is in the endometrium only or less than halfway through the myometrium). In our case, thinning myometrium and uterine atrophy due to aging, multiple leiomyomas, previous curettage, and blood clots were all pitfalls for MRI in detecting MI. By detecting tiny or isointense tumors and depicting distinct vascularity of the malignancy in postmenopausal women, functional MRI techniques such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced MRI (DCE-MRI) can help reduce pitfalls when assessing MI. Clinicians can employ DWI preoperatively, which is more reliable and superior to DCE-MRI in determining tumor areas without contrast injection and perform a postoperative histopathological examination to confirm MI in EC.

Development and Validation of Multiparametric MRI-based Radiomics Models for Preoperative Risk Stratification of Endometrial Cancer

Background Stratifying high-risk histopathologic features in endometrial carcinoma is important for treatment planning. Radiomics analysis at preoperative MRI holds potential to identify high-risk phenotypes. Purpose To evaluate the performance of multiparametric MRI three-dimensional radiomics-based machine learning models for differentiating low- from high-risk histopathologic markers-deep myometrial invasion (MI), lymphovascular space invasion (LVSI), and high-grade status-and advanced-stage endometrial carcinoma. Materials and Methods This dual-center retrospective study included women with histologically proven endometrial carcinoma who underwent 1.5-T MRI before hysterectomy between January 2011 and July 2015. Exclusion criteria were tumor diameter less than 1 cm, missing MRI sequences or histopathology reports, neoadjuvant therapy, and malignant neoplasms other than endometrial carcinoma. Three-dimensional radiomics features were extracted after tumor segmentation at MRI (T2-weighted, diffusion-weighted, and dynamic contrast-enhanced MRI). Predictive features were selected in the training set with use of random forest (RF) models for each end point, and trained RF models were applied to the external test set. Five board-certified radiologists conducted MRI-based staging and deep MI assessment in the training set. Areas under the receiver operating characteristic curve (AUCs) were reported with balanced accuracies, and radiologists' readings were compared with radiomics with use of McNemar tests. Results In total, 157 women were included: 94 at the first institution (training set; mean age, 66 years ± 11 [SD]) and 63 at the second institution (test set; 67 years ± 12). RF models dichotomizing deep MI, LVSI, high grade, and International Federation of Gynecology and Obstetrics (FIGO) stage led to AUCs of 0.81 (95% CI: 0.68, 0.88), 0.80 (95% CI: 0.67, 0.93), 0.74 (95% CI: 0.61, 0.86), and 0.84 (95% CI: 0.72, 0.92), respectively, in the test set. In the training set, radiomics provided increased performance compared with radiologists' readings for identifying deep MI (balanced accuracy, 86% vs 79%; P = .03), while no evidence of a difference was observed in performance for advanced FIGO stage (80% vs 78%; P = .27). Conclusion Three-dimensional radiomics can stratify patients by using preoperative MRI according to high-risk histopathologic end points in endometrial carcinoma and provide nonsignificantly different or higher performance than radiologists in identifying advanced stage and deep myometrial invasion, respectively. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Kido and Nishio in this issue.

Review of the Standard and Advanced Screening, Staging Systems and Treatment Modalities for Cervical Cancer

Simple Summary

This review discusses the timeline and development of the recommended screening tests, diagnosis system, and therapeutics implemented in clinics for precancer and cancer of the uterine cervix. The incorporation of the latest automation, machine learning modules, and state-of-the-art technologies into these aspects are also discussed.

Abstract

Cancer arising from the uterine cervix is the fourth most common cause of cancer death among women worldwide. Almost 90% of cervical cancer mortality has occurred in low- and middle-income countries. One of the major aetiologies contributing to cervical cancer is the persistent infection by the cancer-causing types of the human papillomavirus. The disease is preventable if the premalignant lesion is detected early and managed effectively. In this review, we outlined the standard guidelines that have been introduced and implemented worldwide for decades, including the cytology, the HPV detection and genotyping, and the immunostaining of surrogate markers. In addition, the staging system used to classify the premalignancy and malignancy of the uterine cervix, as well as the safety and efficacy of the various treatment modalities in clinical trials for cervical cancers, are also discussed. In this millennial world, the advancements in computer-aided technology, including robotic modules and artificial intelligence (AI), are also incorporated into the screening, diagnostic, and treatment platforms. These innovations reduce the dependence on specialists and technologists, as well as the work burden and time incurred for sample processing. However, concerns over the practicality of these advancements remain, due to the high cost, lack of flexibility, and the judgment of a trained professional that is currently not replaceable by a machine.

A comparative analysis of MRI findings in endometrial cancer: differentiation between endometrioid adenocarcinoma, serous carcinoma, and clear cell carcinoma

OBJECTIVE

To assess the magnetic resonance imaging (MRI) findings of endometrial cancers and to reveal the differences between endometrioid carcinoma (EC), serous carcinoma (SC), and clear cell carcinoma (CCC).

METHODS

In this study, 274 consecutive patients with histopathologically confirmed endometrial cancer (231 ECs, 25 SCs, and 18 CCCs) who underwent MRI before hysterectomy were enrolled. MRI images were retrospectively reviewed and compared between the three pathologies.

RESULTS

The maximum diameters (55.6 ± 34.7 vs. 39.3 ± 21.6 vs. 39.4 ± 26.8 mm) (p < 0.05) and apparent diffusion coefficient (ADC) values (1.11 ± 0.21 vs. 0.84 ± 0.17 vs. 0.86 ± 0.16 × 10-3 mm2/s) (p < 0.01) were significantly greater in CCCs than in ECs and SCs, respectively. Infiltrative growth pattern (33% vs. 6%) (p < 0.01) was more frequent in CCCs than in ECs. Peritoneal dissemination (16% vs. 0%) (p < 0.01) and heterogeneous signal on diffusion-weighted (61% vs. 32%) (p < 0.05) images were more frequent in SCs than in ECs, respectively. Abnormal ascites (12% vs. 11% vs. 0%) and heterogeneous signal on T1-weighted (28% vs. 50% vs. 9%), T2-weighted (64% vs. 72% vs. 36%), and fat-suppressed gadolinium-enhanced T1-weighted (80% vs. 90% vs. 46%) images were more frequent in SCs and CCCs than in ECs, respectively (p < 0.05).

CONCLUSIONS

SCs frequently exhibited a heterogeneous signal with peritoneal dissemination and abnormal ascites. Alternatively, CCCs tended to have a larger tumor size and higher ADC values with an infiltrative growth pattern, heterogeneous signal, and abnormal ascites.

KEY POINTS

• SCs tend to have a heterogeneous signal intensity with peritoneal dissemination and abnormal ascites compared to ECs. • CCCs tend to have a heterogeneous signal intensity with an infiltrative growth pattern and abnormal ascites compared to ECs. • CCCs have a larger tumor size and higher ADC values compared to ECs and SCs.

Diffusion Weighted Imaging in the Assessment of Tumor Grade in Endometrial Cancer Based on Intravoxel Incoherent Motion MRI

The aim of this study is to investigate the possibility of predicting histological grade in patients with endometrial cancer on the basis of intravoxel incoherent motion (IVIM)-related histogram analysis parameters. This prospective study included 52 women with endometrial cancer (EC) who underwent MR imaging as initial staging in our hospital, allocated into low-grade (G1 and G2) and high-grade (G3) tumors according to the pathology reports. Regions of interest (ROIs) were drawn on the diffusion weighted images and apparent diffusion coefficient (ADC), true diffusivity (D), and perfusion fraction (f) using diffusion models were computed. Mean, median, skewness, kurtosis, and interquartile range (IQR) were calculated from the whole-tumor histogram. The IQR of the diffusion coefficient (D) was significantly lower in the low-grade tumors from that of the high-grade group with an adjusted p-value of less than 5% (0.048). The ROC curve analysis results of the statistically significant IQR of the D yielded an accuracy, sensitivity, and specificity of 74.5%, 70.1%, and 76.5% respectively, for discriminating low from high-grade tumors, with an optimal cutoff of 0.206 (×10⁻³ mm²/s) and an AUC of 75.4% (95% CI: 62.1 to 88.8). The IVIM modeling coupled with histogram analysis techniques is promising for preoperative differentiation between low- and high-grade EC tumors.

The Association between Lower Uterine Segment Involvement in Corpus Located Endometrioid Adenocarcinoma with the (International Federation of Gynecology and Obstetrics) Grade and Stage

BACKGROUND: Although lower uterine segment (LUS) is regarded as an anatomically defined part that possess some histological differences, it is involvement by carcinoma have not been included in the criteria for definition in the staging system for endometrial carcinoma and there are few conflicting data focused on the effect of LUS involvement as a prognostic factor in endometrial cancer. AIM: To find the association between LUS involvement in corpus located endometrioid carcinoma with the grading and staging system established by the international federation of gynecology and obstetrics (FIGO). METHODS: This was a retrospective study involving data collected from achieves of histopathology departments of teaching laboratories within successive 4 years period in Medical City complex at Bagdad. Pathological analysis of 70 hysterectomy specimens of corpus located endometriod adenocarcinoma was done, histological sections from each case of endometrioid adenocarcinoma carcinoma were microscopically reviewed for appropriate grading and staging, in addition, meticulous search was applied for histological finding consistent with LUS involvement. The statistical comparison between the results was done using either independent sample t-test (for continuous data; mean ± SD) or Chi-square test at a significant p < 0.05. RESULTS: The study enrolled 70 histological samples of endometrioid adenocarcinoma, the majority of the samples were of low grade and stage at presentation. Of total sample, 46 (65.71%) showed LUS involvement by tumor cells. There was a significant statistical relationship between LUS involvement and FIGO stage while a non-significant statistical association with FIGO grade was found. CONCLUSION: LUS involvement by corpus located endometrioid adenocarcinoma is associated with an advanced FIGO stage at presentation while non-significant relationship was found between patient age and tumor grade.

Preoperative magnetic resonance imaging predicts clinicopathological parameters and stages of endometrial carcinomas

BACKGROUND

We investigated the agreement and accuracy of preoperative magnetic resonance imaging (MRI) with postoperative pathological characteristics and stages of endometrial endometrioid carcinoma (EEC).

METHODS

We recruited 527 women with EEC who underwent staging surgery at a single medical institution. The preoperative MRI, stages, and clinical and pathological parameters, including myometrial invasion (MI), cervical invasion (CI), adnexal metastasis (AM), intra-abdominal metastasis, and pelvic and/or para-aortic nodal metastasis, were recorded and analyzed. The agreement and accuracy between the preoperative MRI findings and these parameters and stages were assessed.

RESULTS

The rate of the preoperative MRI-based clinical stage matching the postoperative surgical stage was 85.2% in International Federation of Gynecology and Obstetrics stage IA, 51.9% in stage IB, 35.5% in stage II, 5.3% in stage IIIA, 33.3% in stage IIIB, 28.6% in stage IIIC1, 64.3% in stage IIIC2, and 93.8% in stage IVB. The consistency between radiologists and pathologists was 80.5% for deep MI, 91.5% for cervical invasion, 92.2% for adnexal metastasis, 98.9% for intra-abdominal metastasis, and 87.5% and 92.2% for pelvic and para-aortic nodal metastases, respectively. The negative predictive value of intra-abdominal metastasis was the highest with 99.8%.

CONCLUSIONS

Preoperative MRI could be an excellent tool for routine preoperative assessment to predict pathological parameters and stages of EEC, especially in excluding intra-abdominal metastatic disease.

Comparison of magnetic resonance imaging and ultrasonography in tumor size: Evaluation of equality in advanced cervical cancer patients

Background:

Methods:

Results:

Conclusion:

Role of MRI in diagnosing the primary site of origin in indeterminate cases of uterocervical carcinomas: a systematic review and meta-analysis

OBJECTIVE

To perform a literature review assessing role of MRI in predicting origin of indeterminate uterocervical carcinomas with emphasis on sequences and imaging parameters.

METHODS

Electronic literature search of PubMed was performed from its inception until May 2020 and PICO model used for study selection; population was female patients with known/clinical suspicion of uterocervical cancer, intervention was MRI, comparison was by histopathology and outcome was differentiation between primary endometrial and cervical cancers.

RESULTS

Eight out of nine reviewed articles reinforced role of MRI in uterocervical primary determination. T2 and Dynamic contrast were the most popular sequences determining tumor location, morphology, enhancement, and invasion patterns. Role of DWI and MR spectroscopy has been evaluated by even fewer studies with significant differences found in both apparent diffusion coefficient values and metabolite spectra. The four studies eligible for meta-analysis showed a pooled sensitivity of 88.4% (95% confidence interval 70.6 to 96.1%) and a pooled specificity of 39.5% (95% confidence interval 4.2 to 90.6%).

CONCLUSIONS

MRI plays a pivotal role in uterocervical primary determination with both conventional and newer sequences assessing important morphometric and functional parameters. Socioeconomic impact of both primaries, different management guidelines and paucity of existing studies warrants further research. Prospective multicenter trials will help bridge this gap. Meanwhile, individual patient database meta-analysis can help corroborate existing data.

ADVANCES IN KNOWLEDGE

MRI with its classical and functional sequences helps in differentiation of the uterine 'cancer gray zone' which is imperative as both primary endometrial and cervical tumors have different management protocols.

Role of Imaging in the Management of High-Risk Endometrial Cancer

Endometrial cancer (EC) is the second most frequent gynecological malignancy worldwide with an overall favorable prognosis. However, there is a subgroup of patients with a higher rate of recurrence and worse prognosis who benefit from a specific pre- and post-treatment radiological evaluation that allows the adjustment of the therapeutic attitude towards the biology of the tumor.

The main factors that determine high-risk disease are non-endometrioid tumor histology, histopathological grade 3, lymphovascular space invasion (LVSI), myometrial invasion ≥50%, and cervical stroma involvement. Radiological evaluation helps identify high-risk cases prior to surgical staging and is an important tool both in pre-treatment and in case of clinical recurrence suspicion.

As for imaging techniques, both transvaginal ultrasound and MRI can assess local tumor extent while CT and positron emission tomography/CT (PET/CT) help assess lymph nodes and distant metastases.

The central purpose of this article is to review the specific factors that determine high-risk endometrial cancer, and the main specificities in the pre-treatment and follow-up evaluation according to the most recent international guidelines.

MRI-based radiomics model for distinguishing endometrial carcinoma from benign mimics: A multicenter study

PURPOSE

To develop and validate an MRI-based radiomics model for preoperatively distinguishing endometrial carcinoma (EC) with benign mimics in a multicenter setting.

METHODS

Preoperative MRI scans of EC patients were retrospectively reviewed and divided into training set (158 patients from device 1 in center A), test set #1 (78 patients from device 2 in center A) and test set #2 (109 patients from device 3 in center B). Two radiologists performed manual delineation of tumor segmentation on the map of apparent diffusion coefficient (ADC), diffusion-weighted imaging (DWI) and T2-weighted imaging (T2WI). The features were extracted and firstly selected using Chi-square test, followed by refining using binary least absolute shrinkage and selection operator (LASSO) regression. The support vector machine (SVM) was employed to build the radiomics model, which is tuned in the training set using 10-fold cross-validation, and then assessed on the test set. Performance of the model was determined by area under the receiver-operating characteristic curve (AUC), accuracy, sensitivity, specificity and F1-score.

RESULTS

Five most informative features are selected from the extracted 3142 features. The SVM with linear kernel was employed to build the radiomics model. The AUCs of the model were 0.989 (95% confidence interval [CI]: 0.968-0.997) for the training set, 0.999 (95% CI: 0.991-1.000) for test set #1, 0.961 (95% CI: 0.902-0.983) for test set #2. Accuracies of the model were 0.937 for the training set (precision: 0.919, recall: 0.963, F1-score: 0.940), 0.974 for test set #1 (precision: 0.949, recall: 1.000, F1-score: 0.974) and 0.908 for test set #2 (precision: 0.899, recall: 0.954, F1-score: 0.925). These results confirmed the efficacy of this model in predicting EC in different centers.

CONCLUSION

The MRI-based radiomics model showed promising potential for distinguishing EC with benign mimics and might be useful for surgical management of EC.

Impact of incorporating Magnetic Resonance Imaging in FIGO Staging of Primary Carcinoma Cervix: Experience from a tertiary cancer center

BACKGROUND

International Federation of Gynaecology and Obstetrics (FIGO) staging of carcinoma cervix, although essentially clinical, acknowledges the benefits of MRI. The impact of incorporating MRI in staging of cervical cancer and the discordance between clinical-and MRI-based FIGO staging is not well studied, especially in low- and middle-income countries.

AIM

We aim to study the role and accuracy of MRI in staging carcinoma cervix, its correlation with clinical FIGO and histopathological staging with emphasis on how it can change treatment plan.

METHODS

Retrospective observational cohort study (n = 193) where MRI details of different staging parameters of the study subjects were compared with clinical FIGO staging and histopathology to assess correlation and agreement between them. Change of clinical FIGO stage and hence treatment plan brought about by incorporating MRI was assessed.

RESULTS

MRI had a tumor detection rate of 94.3%, overall staging accuracy of 78.3% and very strong correlation with histopathology (Spearman's coefficient of rank correlation, r = 0.886). Clinical FIGO and MRI had agreement only in 52.8% cases (r = 0.61). Incorporating MRI changed the clinical stage in 47.2% patients and subsequently modified primary treatment plan in 23.3%.

CONCLUSION

MRI is highly accurate in evaluating carcinoma cervix and has good correlation with histopathology. Our data shows low agreement between MRI and clinical FIGO staging. Thus, incorporating MRI in FIGO staging has considerable impact in altering treatment decisions and should be offered to all patients for staging carcinoma cervix.

Endometrial cancer from early to advanced-stage disease: an update for radiologists

The purpose of this article is to review the current molecular classification of endometrial cancer, the imaging findings in early and advanced disease, and the current management strategies, focusing on the new systemic therapies for advanced EC. In recent years, the management of endometrial cancer has significantly changed. The molecular characterization of endometrial cancer has shed new light into the biologic behavior of this disease, the International Federation of Gynecology and Obstetrics staging system was recently revised, and imaging was formally incorporated in the management of endometrial cancer. Recent genomic analysis of endometrial cancer led to the approval of new molecular-targeted therapies and immune checkpoint inhibitors. Imaging allows assessment of myometrial invasion, cervical stromal extension, lymph node involvement and distant metastases, and has a crucial role for treatment planning. Treatment strategies, which include surgery, radiation and systemic therapies are based on accurate staging and risk stratification.

Magnetic Resonance Imaging of Uterine Cervix: A Pictorial Essay

Uterine cervix is the lower constricted part of uterus which is best evaluated by magnetic resonance imaging (MRI) due to its higher soft tissue and contrast resolution. The cervical cancer is a common gynecological cancer causing much morbidity and mortality especially in developing countries. Cervical carcinomas mainly occurs in reproductive age group with prognosis mainly depending on the extent of disease at the time of diagnosis, hence it is important to identify these cancerous lesions early and stage them accurately for optimal treatment. In this article, we will review the following: (1) the normal MRI anatomy of uterine cervix; (2) MRI protocol and techniques in evaluation of cervical lesions; (3) imaging of spectrum of various congenital abnormalities and pathologies affecting uterine cervix which ranges from congenital abnormalities to various benign lesions of cervix like nabothian cysts, tunnel cysts, cervicitis, cervical fibroid, and, lastly, endometriosis which usually coexists with adenomyosis; the malignant lesions include carcinoma cervix, adenoma malignum or direct extension from carcinoma endometrium or from carcinoma of vagina; (4) Accurately stage carcinoma of cervix using FIGO classification (2018); and (5) posttreatment evaluation of cervical cancers. MRI is the most reliable imaging modality in evaluation of various cervical lesions, identification of cervical tumors, staging of the cervical malignancy, and stratifying patients for surgery and radiation therapy. It also plays an important role in detection of local disease recurrence.

[Uterine Cervical Cancer: Emphasis on Revised FIGO Staging 2018 and MRI]

Uterine cervical cancer is a common gynecological cancer prevalent in Korea. Early detection, precise diagnosis, and appropriate treatment can affect its prognosis. Imaging approaches play an important role in staging, treatment planning, and follow-up. MRI specifically provides the advantage of assessing tumor size and disease severity with high soft tissue contrast. The revised version of the International Federation of Gynecology and Obstetrics (FIGO) staging system has been introduced in 2018, which incorporates subdivided primary tumor size and lymph node metastasis. In this review, the staging of uterine cervical cancer based on previous studies, the recently revised FIGO staging, and various post-treatment images are primarily described using MRI.

PET Imaging for Gynecologic Malignancies

This review article summarizes the clinical applications of established and emerging PET tracers in the evaluation of the 5 most common gynecologic malignancies: endometrial, ovarian, cervical, vaginal, and vulvar cancers. Emphasis is given to 2-deoxy-2-[¹⁸F]fluoro-d-glucose as the most widely used and studied tracer, with additional clinical tracers also explored. The common imaging protocols are discussed, including standard dose ranges and uptake times, established roles, as well as the challenges and future directions of these imaging techniques. The key points are emphasized with images from selected cases.

MRI of the endometrium - from normal appearances to rare pathology

MRI was recently included as a standard pre-operative diagnostic tool for patients with endometrial cancer. MR findings allow a better risk assessment and ultimately guides the surgical planning. Therefore, it is vital that the radiological interpretation is as accurate as possible. This requires essential knowledge regarding the appropriate MRI protocol, as well as different appearances of the endometrium, ranging from normal peri- and post-menopausal changes, benign findings (e.g. endometrial hyperplasia, polyp, changes due to exogenous hormones) to common and rare endometrium-related malignancies. Furthermore, this review will emphasize the role of MRI in staging endometrial cancer patients and highlight pitfalls that could result in the underestimation or overestimation of the disease extent.

Predictive value of T2-weighted imaging and dynamic contrast-enhanced MRI for assessing cervical invasion in patients with endometrial cancer: a meta-analysis

PURPOSE

To obtain the diagnostic accuracy of T2-weighted imaging (T2WI), and dynamic contrast-enhanced MRI (DCE-MRI) in the preoperative assessment of cervical invasion in patients with endometrial cancer (EC).

METHODS

Databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials were searched for relevant articles published from January 2000 to August 2020. Pooled estimation data were obtained by statistical analysis.

RESULTS

In total, 24 articles were included. For assessing cervical invasion of EC, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) for T2WI were 0.70 (0.61-0.77), 0.92 (0.89-0.94), 8.7 (6.5-11.6), 0.33 (0.25-0.43), 26 (17-41), and 0.92 (0.89-0.94), respectively. For DCE-MRI, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.75 (0.60-0.85), 0.95 (0.89-0.98), 14.7 (6.6-32.9), 0.27 (0.16-0.44), 55 (18-165), and 0.92 (0.89-0.94), respectively; for T2WI combined with DCE-MRI, they were 0.58 (0.41-0.73), 0.98 (0.95-0.99), 28.1 (12.8-62.1), 0.43 (0.30-0.63), 65 (29-146), and 0.94 (0.91-0.96), respectively.

CONCLUSIONS

DCE-MRI demonstrated higher diagnostic performance than T2WI in the prediction of cervical invasion in patients with EC. T2WI combined with DCE-MRI improved the pooled specificity, PLR, DOR, and AUC compared to T2WI alone or DCE-MRI alone.

Diagnostic Accuracy of 18F-FDG-PET/CT and MRI in Predicting the Tumor Response in Locally Advanced Cervical Carcinoma Treated by Chemoradiotherapy: A Meta-Analysis

Objective

The aim of this meta-analysis was to compare the diagnostic accuracy of 18F-FDG-PET/CT and MRI in predicting the tumor response in locally advanced cervical carcinoma (LACC) treated by chemoradiotherapy (CRT).

Method

This meta-analysis has been performed according to PRISMA guidelines. Systematic searches were conducted using PubMed and Embase databases for articles published from January 1, 2010, to January 1, 2020. By using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool, the reviewers assessed the methodological quality scores of the selected studies. We analyzed the sensitivity, specificity, and accuracy of two diagnostic methods using Meta-DiSc 1.4 and Stata 15.

Results

An overall of 15 studies including 1132 patients were included. Sensitivities of PET/CT and MRI were 83.5% and 82.7%, while the corresponding rates for specificities were 77.8% and 68.4%, respectively. The DOR, PLR, and NLR for MRI were 15.140, 2.92, and 22.6. PET/CT had a DOR of 25.21. The PLR and NLR for PET/CT were 4.13 and 0.215, respectively. The diagnostic sensitivity and specificity of PET/CT for the detection of residual tumor were 86% and 95%, respectively. The corresponding rates for MRI were 73% and 96%, respectively. The diagnostic sensitivity and specificity of PET/CT for the detection of tumor metastases were 97% and 99%, while the corresponding rates for MRI were 31% and 98%, respectively.

Conclusion

18F-FDG PET/CT seemed to have a better overall diagnostic accuracy in the evaluation of treatment response to chemoradiotherapy in LACC patients. MRI showed a really poor sensitivity in the detection of metastases, and PET/CT performed significantly better. However, the difference between these two methods in the detection of residual disease was not significant. More studies are needed to be conducted in order to approve that 18F-FDG PET/CT can be a standard option to assess the treatment response.

Magnetic resonance imaging findings in 11 cases of dedifferentiated endometrial carcinoma of the uterus

Purpose

We evaluated magnetic resonance imaging (MRI) findings of dedifferentiated endometrial carcinoma (DEC), comprising undifferentiated carcinoma and low-grade endometrioid carcinoma.

Materials and methods

We recruited 11 patients with pathologically proven DEC treated at our institute. We evaluated primary lesion size, location and signal intensity on MRI, and prognosis. MRI and pathological findings were compared in eight resected patients.

Results

Primary tumors ranged from 16 to 206 mm in diameter. DEC was located at the endometrium in 9 of the 11 patients; the remaining two patients showed diffuse involvement of the enlarged myometrium. These two patients with diffuse involvement type died within 4 months. Of the eight patients who underwent resection, seven had macroscopic intratumoral hemorrhage and six showed a high signal on T1-weighted images or low signal on T2-weighted images. Of the eight resected patients, four had tumor necrosis > 25% and tumor size > 5 cm. In these patients, necrosis appeared as nonenhanced areas on contrast-enhanced MRI.

Conclusion

MRI findings of DEC showed two patterns: mass-forming type and diffuse myometrial type with poor prognosis. Most patients with DEC had intratumoral hemorrhage, and large tumors (> 5 cm) had gross necrosis, which appeared as nonenhanced areas on contrast-enhanced MRI.

MRI Findings and Differential Diagnosis of Benign and Malignant Tumors of the Uterine Corpus

자궁은 크게 자궁체부와 자궁경부로 나뉜다. 이 중 자궁내막과 자궁근층으로 이루어진 자궁체부에는 양성에서 악성 종양까지 다양한 질환이 발생한다. 비침습적인 일차적 평가로 초음파와 컴퓨터단층촬영이 있으나 비특이적인 영상 소견으로 감별이 어려운 경우가 있다. 반면높은 해상도와 병리학적 특성 파악이 가능한 자기공명영상은 병변의 위치 확인뿐만 아니라 조직학적 특징, 그 리고 악성 종양의 병기 설정에도 도움을 준다. 이 종설에서는 영상의학과의사들이 알아야 할 자궁체부에서 볼 수 있는 다양한 양성과 악성 종양들의 특징적인 자기공명영상 소견들과 이들의 감별점에 대해 정리했다.

Diagnostic Accuracy of MRI for Detecting Cervical Invasion in Patients with Endometrial Carcinoma: A Meta-Analysis

Objectives: To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) in the preoperative assessment of cervical invasion and to analyse the influence of different imaging protocols in patients with endometrial carcinoma.

Methods: An extensive search of articles about MRI for assessing cervical invasion in patients with endometrial carcinoma was performed on PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials from January 2000 to July 2020. Two reviewers independently evaluated the methodological quality of each study by using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Diagnostic accuracy results and additional useful information were extracted. The pooled estimation data was obtained by statistical analysis.

Results: A total of 42 eligible studies were included in the meta-analysis. Significant evidence of heterogeneity was found for detecting cervical invasion (I² = 74.1%, P = 0.00 for sensitivity and I² = 56.2%, P = 0.00 for specificity). The pooled sensitivity and specificity of MRI were 0.58 and 0.95 respectively. The use of higher field strength (3.0 T) demonstrated higher pooled sensitivity (0.74). Using diffusion weighted imaging (DWI) alone presented higher pooled sensitivity (0.86) than using other sequences. The studies that used dynamic contrast-enhanced MRI (DCE-MRI) alone showed higher sensitivity (0.80) and specificity (0.96) than those that used T2-weighted imaging (T2WI) alone.

Conclusions: MRI shows high specificity for detecting cervical infiltration in endometrial carcinoma. Using DWI or a 3.0-T device may improve the pooled sensitivity. DCE-MRI demonstrates higher pooled sensitivity and specificity than T2WI.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations.

METHODS

This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted.

RESULTS

When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively).

CONCLUSIONS

Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Diagnostic performance of intraoperative assessment in grade 2 endometrioid endometrial carcinoma

Abstract

Background

Endometrial carcinoma is the most common gynecologic malignancy in developed countries. Grade 2 carcinoma is associated with pelvic lymph-node metastasis, depending on selected risk factors. Intraoperative assessment (IOA) can identify patients at risk for lymph node metastasis who should undergo staging surgery. Our objective was to establish the diagnostic precision of IOA in determining the need for surgical staging in grade 2 endometrioid endometrial carcinoma.

Methods

Two hundred twenty-two patients underwent IOA. Results were compared to the final pathology report. The accuracy of the IOA parameters was calculated. Variables were evaluated in patients with positive versus negative IOA. Overall and disease-free survivals were calculated according to IOA, lymphadenectomy, and nodal metastasis.

Results

IOA was positive in 80 patients. It showed an accuracy of 76.13% when compared with the postoperative assessment. The best individual parameter was myometrial invasion. Nodal metastasis was observed in 16 patients in the positive IOA group and 7 patients in the negative group. Patients with lymph node metastasis had a 5-year overall survival rate of 80.9%, whereas patients without metastasis had a 5-year overall survival rate of 97.9%.

Conclusions

IOA is an adequate tool to identify high-risk patients in grade 2 endometrial carcinoma. Myometrial invasion is the individual parameter that yields the highest diagnostic precision.

Exploring the Inter-voxel Information in Pharmacokinetic Maps for Cervical Carcinoma Prediction

Physiological parameters can be estimated from dynamic contrast enhanced magnetic resonance imaging (DCEMRI) data using pharmacokinetic models. This work evaluates the performance of various pharmacokinetic models through a retrospective study on cervix cancer, including two generalized kinetic models and three 2-compartment exchange models (2CXMs). In the current clinical practice, region of interest (ROI) is treated as a whole and the models are assessed by their top pharmacokinetic parameters. We explore the intervoxel relationship in the pharmacokinetic parameter maps and demonstrate that, for those insignificant parameters, texture descriptors can largely improve their discriminative power. Multi-parametric classifiers are developed to fuse the information carried by physiological parameters and the descriptors. Assessed merely by the top parameter, the DP (distributed parameter) model is the best one with an area under the ROC (receiver operating characteristic) curve (AUC) of 0.80; by combining multiple pharmacokinetic parameters, the ExTofts model is the winner with an AUC of 0.837. Finally, the classifier of the AATH (adiabatic approximation to the tissue homogeneity) model build on combined features achieves an AUC of 0.92.Clinical Relevance - Using data from 36 cervical cancer patients and 17 normal subjects, this work quantitatively compared the various pharmacokinetic models and provided recommendations for model selection in cervical cancer diagnosis.

A preoperative radiomics model for the identification of lymph node metastasis in patients with early-stage cervical squamous cell carcinoma

OBJECTIVES

To develop and validate a radiomics model for preoperative identification of lymph node metastasis (LNM) in patients with early-stage cervical squamous cell carcinoma (CSCC).

METHODS

Total of 190 eligible patients were randomly divided into training (n = 100) and validation (n = 90) cohorts. Handcrafted features and deep-learning features were extracted from T2W fat suppression images. The minimum redundancy maximum relevance algorithm and LASSO regression with 10-fold cross-validation were used for key features selection. A radiomics model that incorporated the handcrafted-signature, deep-signature, and squamous cell carcinoma antigen (SCC-Ag) levels was developed by logistic regression. The model performance was assessed and validated with respect to its calibration, discrimination, and clinical usefulness.

RESULTS

Three handcrafted features and three deep-learning features were selected and used to build handcrafted- and deep-signature. The model, which incorporated the handcrafted-signature, deep-signature, and SCC-Ag, showed satisfactory calibration and discrimination in the training cohort (AUC: 0.852, 95% CI: 0.761-0.943) and the validation cohort (AUC: 0.815, 95% CI: 0.711-0.919). Decision curve analysis indicated the clinical usefulness of the radiomics model. The radiomics model yielded greater AUCs than either the radiomics signature (AUC = 0.806 and 0.779, respectively) or the SCC-Ag (AUC = 0.735 and 0.688, respectively) alone in both the training and validation cohorts.

CONCLUSION

The presented radiomics model can be used for preoperative identification of LNM in patients with early-stage CSCC. Its performance outperforms that of SCC-Ag level analysis alone.

ADVANCES IN KNOWLEDGE

A radiomics model incorporated radiomics signature and SCC-Ag levels demonstrated good performance in identifying LNM in patients with early-stage CSCC.

Neuroendocrine carcinoma of uterine cervix findings shown by MRI for staging and survival analysis - Japan multicenter study

Objectives: To investigate neuroendocrine carcinoma (NEC) of the uterine cervix cases for MRI features and staging, as well as pathological correlations and survival.

Results: FIGO was I in 42, II in 14, III in 1, and IV in 5 patients. T2-weighted MRI showed homogeneous slightly high signal intensity and obvious restricted diffusion (ADC map, low intensity; DWI, high intensity) throughout the tumor in most cases, and mild enhancement in two-thirds. In 50 patients who underwent a radical hysterectomy and lymphadenectomy without neoadjuvant chemotherapy (NAC), intrapelvic T staging by MRI overall accuracy was 88.0% with reference to pathology staging, while patient-based sensitivity, specificity, and accuracy for metastatic pelvic lymph node detection was 38.5%, 100%, and 83.3%, respectively. During a mean follow-up period of 45.6 months (range 4.3–151.0 months), 28 patients (45.2%) experienced recurrence and 24 (38.7%) died. Three-year progression-free and overall survival rates for FIGO I, II, III, and IV were 64.3% and 80.9%, 50% and 64.3%, 0% and 0%, and 0% and 0%, respectively.

Materials and Methods: Sixty-two patients with histologically surgery-proven uterine cervical NEC were enrolled. Twelve received NAC. Clinical data, pathological findings, and pretreatment pelvic MRI findings were retrospectively reviewed. Thirty-two tumors were pure NEC and 30 mixed with other histotypes. The NECs were small cell type (41), large cell type (18), or a mixture of both (3).

Conclusions: Homogeneous lesion texture with obvious restricted diffusion throughout the tumor are features suggestive of cervical NEC. Our findings show that MRI is reliable for T staging of cervical NEC.

Rare Case Report of an Endometrial Adenocarcinoma Arising in a Complete Septate Uterus With a Double Cervix and Vagina

Endometrial adenocarcinomas arising in a complete septate uterus with cervical and vaginal duplication are rare. Here, we report a case of stage III endometrioid endometrial adenocarcinoma arising in a complete septate uterus with a double cervix and vagina coupled with a left serous ovarian cystadenoma in a 35-year-old-female patient. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and was addressed to the oncologist for adjuvant radio-chemotherapy. We highlight the symptoms, diagnosis, and therapeutic management, and compare them to the recent literature. 

Interpreting body MRI cases: classic findings in pelvic MRI

The high contrast resolution provided by magnetic resonance imaging (MRI) compared to all other modalities allows the interpreting radiologist to make a specific diagnosis for many common and uncommon findings. In some cases, the diagnosis can be so certain that there is no differential diagnosis. In this article, we review the most classically recognized findings when interpreting MRI of the pelvis including the following: Ovaries: Simple cyst, hemorrhagic cyst, corpus luteum, dermoid, fibroma/fibrothecoma. Uterus: C-section scar, adenomyosis, endometriosis, fibroid, congenital uterine anomalies. Cervix: nabothian cyst, cervical cancer. Vagina/Vulva: Gardener's duct cyst, Bartholin's gland cyst. Urethra: skene gland cyst, urethral diverticulum. Prostate: utricle cyst, Mullerian duct cyst, benign prostatic hyperplasia, prostate cancer.

Uterine Carcinosarcoma: A Case Report and Literature Review

Uterine carcinosarcomas are rare and extremely aggressive undifferentiated carcinomas which include both carcinomatous and sarcomatous elements. A 52-year-old female presented with heavy irregular menstrual bleeding for several years and new right elbow pain and swelling. Ultrasound and computed tomography showed a large uterine mass with regional and distant metastatic lymphadenopathy and suspicious findings of osseous metastasis to the right elbow. A biopsy confirmed uterine carcinosarcoma, and the patient underwent chemotherapy and then surgical resection of the uterine mass with palliative radiotherapy of the right elbow. The postoperative imaging showed new metastasis, and the patient was scheduled to start on immunotherapy. Considering the highly invasive nature of uterine carcinosarcomas, timely detection of this cancer using characteristic imaging and pathology findings is of extreme importance to improve the patient's survival.

Characteristics of MR Imaging for Staging and Survival Analysis of Neuroendocrine Carcinoma of the Endometrium: A Multicenter Study in Japan

Purpose:

This study aimed to examine MRI features and staging of neuroendocrine carcinoma (NEC) of the endometrium and evaluate survival.

Methods:

Clinical data, pathological, and preoperative pelvic MRI findings in 22 patients with histologically surgery-proven endometrial NEC were retrospectively reviewed. Tumors were pure NEC (n = 10) or mixed histotype (n = 12), with 13 large and nine small cell type.

Results:

International Federation of Gynecology and Obstetrics (FIGO) staging was I, II, III, and IV in 6, 2, 12, and 2 patients, respectively. In 13 (76.4%) of 17 patients with pathological deep myometrial invasion, MRI showed abnormal diffusely infiltrative high T₂ signal intensity throughout the myometrium with loss of normal uterine architecture. All tumors had restricted diffusion (apparent diffusion coefficient map low signal intensity, diffusion weighted imaging high signal intensity). Accuracy of T staging by MRI for all cases was 81.8%, with reference to pathology staging, while patient-based sensitivity, specificity, and accuracy for detecting metastatic pelvic lymph nodes was 60.0%, 100%, and 77.8%, respectively. Two intrapelvic peritoneal dissemination cases were detected by MRI. During follow-up (mean 30.4, range 3.3–138.4 months), 16 patients (72.7%) experienced recurrence and 12 (54.5%) died of disease. Two-year disease-free and overall survival rates for FIGO I, II, III, and IV were 66.7% and 83.3%, 50% and 100%, 10% and 33.3%, and 0% and 0%, respectively.

Conclusion:

Abnormal diffusely infiltrative high T₂ signal intensity throughout the myometrium with normal uterine architecture loss and obvious restricted diffusion throughout the tumor are suggestive features of endometrial NEC. Pelvic MRI is reliable for intrapelvic staging of affected patients.

Comparison of pain and proper sample status according to usage of tenaculum and analgesia: a randomized clinical trial

Objective

Colposcopic biopsy is a discomfortable procedure. Additionally, it creates negative influence on sexuality. This study aimed to investigate the relationships among tenaculum, pain perception, and biopsy size during colposcopy.

Methods

In total, 228 patients who underwent colposcopy-directed biopsy were included, and randomized into 4 groups based on whether analgesic and tenaculum were used and replaced (tenaculum with n=58/without analgesic n=56, no tenaculum replacement with n=57/without analgesic n=57). Lidocaine hydrochloride (40 mg) plus adrenaline (0.025 mg) was administered in the analgesic groups. The pain was assessed using a linear visual analog scale. The biopsy specimen size was measured in millimeters.

Results

The mean age of the patients was 42.85±8.88 years. The most frequent colposcopy indications were atypical squamous cells of undetermined significance and human papilloma virus-positive results on cervical cytology (30.2%; n=69). Low- and high-grade intraepithelial lesions were noted in 14.91% (n=34) and 10.96% (n=25) women through colposcopy-directed biopsy results, respectively. Tenaculum replacement increased pain perception in the without analgesic group; however, no statistically significant differences were noted between of the groups with and without tenaculum replacement with analgesic. The size and number of biopsy specimens were not associated with tenaculum replacement and analgesic use.

Conclusion

Administration of analgesics decreased discomfort and pain in patients. Tenaculum replacement aided colposcopists in manipulating the cervix. Additionally, administration of analgesics relieved pain in the tenaculum replacement group.

Trial Registration

ClinicalTrials.gov Identifier: NCT03279666

Multimodality Imaging of Uterine Cervical Malignancies

OBJECTIVE. In this article, we provide an updated review on the role of imaging in initial staging, treatment monitoring, and follow-up of cervical cancer with a focus on the role of MRI and FDG PET/CT. In addition, the 2018 International Federation of Gynecology and Obstetrics staging system and its implication on management of cervical cancer are explored. CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases.

Metastatic clear cell endometrial carcinoma: an unusual cause of a common clinical presentation

A 60-year-old woman presented with melena for 2 weeks. She had undergone hysterectomy and bilateral salpingo-oophorectomy to treat clear cell endometrial carcinoma 10 months before the presentation. She was anaemic and tachycardic; abdominal CT scan revealed a large duodenal mass. Her gastrointestinal bleed was not amenable to endoscopic intervention, so she had emergent laparotomy, pancreaticoduodenectomy with duodenal mass excision. Histopathology confirmed that the duodenal mass was a metastatic deposit from her clear cell endometrial cancer. Postoperatively, she was frail and chose hospice care and she died 90 days postoperatively. Clear cell endometrial cancer is a rare subtype of endometrial cancer, that has a worse prognosis compared with the more common endometrioid subtype. The duodenum is a rare site for metastatic endometrial cancer, and we report this case to alert clinicians to the possibility of metastases to the small intestine in patients with clear cell endometrial cancer.

Diagnosis of Cervical Cancer With Parametrial Invasion on Whole-Tumor Dynamic Contrast-Enhanced Magnetic Resonance Imaging Combined With Whole-Lesion Texture Analysis Based on T2- Weighted Images

Purpose: To evaluate the diagnostic value of the combination of whole-tumor dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and whole-lesion texture features based on T2-weighted images for cervical cancer with parametrial invasion. Materials and Methods: Sixty-two patients with cervical cancer (27 with parametrial invasion and 35 without invasion) preoperatively underwent routine MRI and DCE-MRI examinations. DCE-MRI parameters (K^trans, K_ep, and V_e) and texture features (mean, skewness, kurtosis, uniformity, energy, and entropy) based on T2-weighted images were acquired by two observers. All parameters of parametrial invasion and non-invasion were analyzed by one-way analysis of variance. The diagnostic efficiency of significant variables was assessed using receiver operating characteristic analysis. Results: The invasion group of cervical cancer demonstrated significantly higher K^trans (0.335 ± 0.050 vs. 0.269 ± 0.079; p < 0.001), lower energy values (0.503 ± 0.093 vs. 0.602 ± 0.087; p < 0.001), and higher entropy values (1.391 ± 0.193 vs. 1.24 ± 0.129; p < 0.001) than those in the non-invasion group. Optimal diagnostic performance [area under curve [AUC], 0.925; sensitivity, 0.935; specificity, 0.829] could be obtained by the combination of K^trans, energy, and entropy values. The AUC values of K^trans (0.788), energy (0.761), entropy (0.749), the combination of K^trans and energy (0.814), the combination of K^trans and entropy (0.727), and the combination of energy and entropy (0.619) were lower than those of the combination of K^trans, energy, and entropy values. Conclusion: The combination of DCE-MRI and texture analysis is a promising method for diagnosis cervical cancer with parametrial infiltration. Moreover, the combination of K^trans, energy, and entropy is more valuable than any one alone, especially in improving diagnostic sensitivity.