Endometriosis: A multimodal imaging review.

Endometriosis is a chronic inflammatory disorder characterized endometrial-like tissue present outside of the uterus, affecting approximately 10% of reproductive age women. It is associated with abdomino-pelvic pain, infertility and other non - gynecologic symptoms, making it a challenging diagnosis. Several guidelines have been developed by different international societies to diagnose and classify endometriosis, yet areas of controversy and uncertainty remains. Transvaginal ultrasound (TV-US) is the first-line imaging modality used to identify endometriosis due to its accessibility and cost-efficacy. Enhanced sonographic techniques are emerging as a dedicated technique to evaluate deep infiltrating endometriosis (DIE), depending on the expertise of the sonographer as well as the location of the lesions. MRI is an ideal complementary modality to ultrasonography for pre-operative planning as it allows for a larger field-of-view when required and it has high levels of reproducibility and tolerability. Typically, endometriotic lesions appear hypoechoic on ultrasonography. On MRI, classical features include DIE T2 hypointensity, endometrioma T2 hypointensity and T1 hyperintensity, while superficial peritoneal endometriosis (SPE) is described as a small focus of T1 hyperintensity. Imaging has become a critical tool in the diagnosis, surveillance and surgical planning of endometriosis. This literature review is based mostly on studies from the last two decades and aims to provide a detailed overview of the imaging features of endometriosis as well as the advances and usefulness of different imaging modalities for this condition.

Computer-aided diagnosis through medical image retrieval in radiology.

Currently, radiologists face an excessive workload, which leads to high levels of fatigue, and consequently, to undesired diagnosis mistakes. Decision support systems can be used to prioritize and help radiologists making quicker decisions. In this sense, medical content-based image retrieval systems can be of extreme utility by providing well-curated similar examples. Nonetheless, most medical content-based image retrieval systems work by finding the most similar image, which is not equivalent to finding the most similar image in terms of disease and its severity. Here, we propose an interpretability-driven and an attention-driven medical image retrieval system. We conducted experiments in a large and publicly available dataset of chest radiographs with structured labels derived from free-text radiology reports (MIMIC-CXR-JPG). We evaluated the methods on two common conditions: pleural effusion and (potential) pneumonia. As ground-truth to perform the evaluation, query/test and catalogue images were classified and ordered by an experienced board-certified radiologist. For a profound and complete evaluation, additional radiologists also provided their rankings, which allowed us to infer inter-rater variability, and yield qualitative performance levels. Based on our ground-truth ranking, we also quantitatively evaluated the proposed approaches by computing the normalized Discounted Cumulative Gain (nDCG). We found that the Interpretability-guided approach outperforms the other state-of-the-art approaches and shows the best agreement with the most experienced radiologist. Furthermore, its performance lies within the observed inter-rater variability.

Predictive Factors for Voiding Dysfunction after Surgery for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To evaluate the prognostic value of pre- and perioperative factors for voiding dysfunction after surgery for deep infiltrating endometriosis (DIE). DESIGN: Single-center retrospective cohort study. SETTING: University hospital. PATIENTS: A total of 198 women with DIE in the posterior compartment who underwent surgery and a postoperative bladder scan. INTERVENTIONS: Surgical resection of the DIE nodule from the dorsal compartment. MEASUREMENTS AND MAIN RESULTS: After surgery, 41% of the patients initially experienced voiding dysfunction (defined as >100 mL postvoid residual urine volume at second bladder scan). The number decreased to 11% by the time of hospital discharge. Among those with a need for self-catheterization after discharge (n = 17), voiding dysfunction lasted for a median of 41 days before a return to normal bladder function, with a residual urine volume of <100 mL. The preoperative presence of DIE nodules in the ENZIAN compartment B was associated with postoperative voiding dysfunction (p = .001). The hazard ratio for elevated residual urine volume was highest when the disease stage was B3 (hazard ratio 6.43; CI, 2.3-18.2; p <.001), describing a nodule diameter of >3 cm in lateral distension. Receiver operating characteristic curve analyses showed that a first residual urine volume >220 mL has a good predictive value for the risk of intermittent self-catheterization (area under the receiver operating characteristic curve 0.893; p <.001). CONCLUSION: Postoperative voiding dysfunction is frequent; of note, in most cases the problem is temporary. When DIE with an ENZIAN classification B is noted intraoperatively and, most of all, when the diameter of the lesion is >3 cm, a higher risk of postoperative voiding dysfunction is to be expected.

Cloverleaf Sign in Pelvic Magnetic Resonance Imaging for Deep Infiltrating Endometriosis: Association With Longer Operation Times, Greater Blood Loss, and Higher Rates of Bowel Resection.

OBJECTIVES: The aim of this study was to evaluate the significance of a new imaging sign, the "cloverleaf sign," in diagnosing deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI) in concordance to intraoperative findings. MATERIALS AND METHODS: This retrospective study included 103 patients operated during the January 2016 to June 2018 period with preoperative 1.5 T and 3 T MRI, with or without vaginal and rectal gel filling. Magnetic resonance imaging scans were read blinded to intraoperative findings by a specialized gynecologic radiologist and a junior radiologist, and then compared with intraoperative findings by looking at the operation report, postoperative diagnosis, and intraoperative images and videos by an experienced gynecologist surgeon specialized in endometriosis surgery. All endometriosis lesions were confirmed by pathology. The "cloverleaf sign" was defined as a cloverleaf-like figure in imaging morphology; the "leaves" formed by at least 3 different organs come together in the center of the figure formed by constrictive adhesions including T2-weighted (T2W) hypointense DIE. Operation times, intraoperative blood loss, and the frequency of DIE and bowel resections were analyzed in cloverleaf and noncloverleaf groups. The 2-sample Wilcoxon rank-sum (Mann-Whitney U) test and multivariate analysis of variance were used to calculate the significance of an overall impact of cloverleaf sign on operation time, blood loss, and the amount of the bowel resection rate. P < 0.05 was considered statistically significant. RESULTS: The prevalence of DIE in the study population was 79.6%. A total of 11.5% of the patients had no endometriosis, 32.6% had rASRM I and II, and 55.9% had rASRM III and IV. Forty-six patients (45%) had received rectal and vaginal gel opacification before scanning, 57 (55%) did not. A cloverleaf sign on MRI was detected in 34 patients (15 in gel filling and 19 in nonfilling group). The interreader agreement was almost perfect 0.91 (κ). The median operation time in the cloverleaf group was 248 minutes (interquartile range [IQR], 165-330) compared with 145 minutes in the noncloverleaf group (IQR, 90-210), that is, significantly higher (P < 0.001). Intraoperative blood loss was also significantly higher in the conglomerate group (125 vs 50 mL; IQR, 100-300 vs 50-100; P < 0.001). Of the bowel resections in our study population, 41% (14/34) were performed on patients with a cloverleaf sign in the MRI, compared with 13% (9/69) in patients without the cloverleaf sign. CONCLUSIONS: The "cloverleaf" MRI sign was associated with significantly longer operation time, increased intraoperative blood loss, and higher rates of bowel resection in DIE patients.

A survey on the future of radiology among radiologists, medical students and surgeons: Students and surgeons tend to be more skeptical about artificial intelligence and radiologists may fear that other disciplines take over.

PURPOSE: To evaluate the opinion and assessment of radiologists, surgeons and medical students on a number of important topics regarding the future of radiology, such as artificial intelligence (AI), turf battles, teleradiology and 3D-printing. METHOD: An online questionnaire was created using the SurveyMonkey platform targeting radiologists, students and surgeons throughout the German speaking part of Switzerland. A total of 170 people participated in the survey (59 radiologists, 56 surgeons and 55 students). Statistical analysis was carried out using the Kruskal-Wallis test with Dunn's multiple comparison post-hoc tests. RESULTS: While the majority of participants agreed that AI should be included as a support system in radiology (Likert scale 0-10: Median value 8), surgeons were less supportive than radiologists (p = 0.001). Students saw a potential threat of AI as more likely than radiologists did (p = 0.041). When asked whether they were concerned about "turf losses" from radiology to other disciplines, radiologists were much more likely to agree than students (p < 0.001). Of the students that do not intend to specialize in radiology, 26 % stated that AI was one of the reasons. Surgeons advocate the use of teleradiology. CONCLUSIONS: With regard to AI, radiologists expect their workflow to become more efficient and tend to support the use of AI, whereas medical students and surgeons tend to be more skeptical towards this technology. Medical students see AI as a potential threat to diagnostic radiologists, while radiologists themselves are rather afraid of turf losses.

Comparison of PSMA-ligand PET/CT and multiparametric MRI for the detection of recurrent prostate cancer in the pelvis.

PURPOSE: So far, there have been very few studies which provide a direct comparison between MRI and PSMA-ligand PET/CT for the detection of recurrent prostate cancer (rPC). This present study therefore aims to provide further clinical data in order to resolve this urgent clinical question, and thereby strengthen clinical recommendations. METHODS: A retrospective analysis was performed for patients who were scanned at our institution with whole-body PSMA-PET/CT (tracer: 68Ga-PSMA-11) between January 2017 and September 2018 in order to detect rPC. Amongst them, 43 underwent an additional pelvic MRI within 2 months. Both modalities were compared as follows: a consensus read of the PET data was performed by two nuclear physicians. All lesions were recorded with respect to their type and localization. The same process was conducted by two radiologists for pelvic MRI. Thereafter, both modalities were directly compared for every patient and lesion. RESULTS: Overall, 30/43 patients (69.8%) presented with a pathologic MRI and 38/43 (88.4%) with a pathologic PSMA-PET/CT of the pelvis. MRI detected 53 pelvic rPC lesions (13 of them classified as "uncertain") and PSMA-PET/CT detected 75 pelvic lesions (three classified as "uncertain"). The superiority of PSMA-PET/CT was statistically significant only if uncertain lesions were classified as false-positive. CONCLUSIONS: PSMA-PET/CT detected more pelvic lesions characteristic for rPC when compared to MRI. In order to detect rPC, a potential future scenario could be conducting first a PSMA-PET/CT. Combining the advantages of both modalities in hybrid PET/MRI scanners would be an ideal future scenario.

Diffusion-Weighted Genitourinary Imaging.

This review article aims to provide an overview on of diffusion-weighted MR imaging (DW-MR imaging) in the urogenital tract. Compared with conventional cross-sectional imaging methods, the additional value of DW-MR imaging in the detection and further characterization of benign and malignant lesions of the kidneys, bladder, prostate, and pelvic lymph nodes is discussed as well as the role of DW-MR imaging in the evaluation of treatment response.

Intestinal differentiated mucinous adenocarcinoma of the endometrium with sporadic MSI high status: a case report.

BACKGROUND: Intestinal differentiation of primary mucinous adenocarcinoma of the uterine corpus is exceedingly rare in comparison to the approximately 25% rate in endocervical and ovarian mucinous carcinoma. Additionally, little is known about the related genetic and epigenetic alterations, even though large-scale molecular characterisation of the different types of endometrial cancer took place in the TCGA project along the entities defined by the recent WHO classification. CASE PRESENTATION: We present a 62-year-old patient harbouring a primary mucinous carcinoma of the uterine corpus with a morphological resemblance to mucinous colorectal adenocarcinoma. The intestinal differentiation was substantiated by CDX2 and CK20 positivity in the absence of PAX8, p16, WT1, p53, ER, PgR, AFP, SALL4 and Glypican3. A high MSI status with MLH1 hypermethylation was revealed by molecular testing. CONCLUSION: Intestinal differentiation of mucinous adenocarcinoma of the endometrium is a unique observation. Besides morphology, it obviously can share molecular features of sporadic MSI colorectal cancers. It can be speculated that either CDX2 positive morula formation or intestinal metaplasia of the endometrium as rare conditions might be the origin of carcinogenesis for this type II endometrial cancer. Both conditions were not detectable in this case. Of note, categorising endometrial cancers in genetic subgroups like MSI high cancers alone might lead to the integration of likewise morphologically different tumours like the case presented here with intestinal differentiation. Hence, careful genotype-phenotype correlations are warranted for studies of mucinous adenocarcinoma of the endometrium.

Primary and metastatic ovarian cancer: Characterization by 3.0T diffusion-weighted MRI.

OBJECTIVES: We aimed to investigate whether apparent diffusion coefficients (ADCs) measured by 3.0T diffusion-weighted magnetic resonance imaging (DWI) associate with histological aggressiveness of ovarian cancer (OC) or predict the clinical outcome. This prospective study enrolled 40 patients with primary OC, treated 2011-2014. METHODS: DWI was performed prior to surgery. Two observers used whole lesion single plane region of interest (WLsp-ROI) and five small ROIs (S-ROI) to analyze ADCs. Samples from tumours and metastases were collected during surgery. Immunohistochemistry and quantitative reverse transcription polymerase chain reaction (qRT-PCR) were used to measure the expression of vascular endothelial growth factor (VEGF) and its receptors. RESULTS: The interobserver reliability of ADC measurements was excellent for primary tumours ICC 0.912 (WLsp-ROI). Low ADCs significantly associated with poorly differentiated OC (WLsp-ROI P = 0.035). In primary tumours, lower ADCs significantly associated with high Ki-67 (P = 0.001) and low VEGF (P = 0.001) expression. In metastases, lower ADCs (WLsp-ROI) significantly correlated with low VEGF receptors mRNA levels. ADCs had predictive value; 3-year overall survival was poorer in patients with lower ADCs (WLsp-ROI P = 0.023, S-ROI P = 0.038). CONCLUSION: Reduced ADCs are associated with histological severity and worse outcome in OC. ADCs measured with WLsp-ROI may serve as a prognostic biomarker of OC. KEY POINTS: • Reduced ADCs correlate with prognostic markers: poor differentiation and high Ki-67 expression • ADCs also significantly correlated with VEGF protein expression in primary tumours • Lower ADC values are associated with poorer survival in ovarian cancer • Whole lesion single plane-ROI ADCs may be used as a prognostic biomarker in OC.

Diffusion-Weighted Genitourinary Imaging.

This review article aims to provide an overview on of diffusion-weighted MR imaging (DW-MR imaging) in the urogenital tract. Compared with conventional cross-sectional imaging methods, the additional value of DW-MR imaging in the detection and further characterization of benign and malignant lesions of the kidneys, bladder, prostate, and pelvic lymph nodes is discussed as well as the role of DW-MR imaging in the evaluation of treatment response.

Effects of continuous combined hormone replacement therapy and clodronate on bone mineral density in osteoporotic postmenopausal women: a 5-year follow-up.

OBJECTIVE: To determine the effects of HRT with or without clodronate on bone mineral density (BMD) change and bone turnover markers. DESIGN: Prospective, partly randomized trial. SETTING: Kuopio University Hospital, Finland. POPULATION: 167 osteoporotic women (61+/-2.7 years; T-score