Cervical cancer response to neoadjuvant chemoradiotherapy: MRI assessment compared with surgery.

BACKGROUND: Imaging findings of residual cervical tumor after chemoradiotherapy can closely resemble those of post-irradiation inflammation. PURPOSE: To determine the diagnostic performance of magnetic resonance imaging (MRI) in evaluating residual disease after chemoradiotherapy in patients with locally advanced cervical carcinoma (LACC). MATERIAL AND METHODS: Retrospective analysis of prospectively collected data from 41 patients with histopathologically proven LACC (International Federation of Gynecology and Obstetrics stage ≥IB2) who underwent MRI before and after chemoradiotherapy. At each examination, a qualitative and semi-quantitative analysis of primary tumor, including tumor volume and signal intensity were assessed on T2-weighted (T2W) images. All patients had surgery after post-chemoradiotherapy MRI. MRI and histopathologic results were compared. RESULTS: All patients showed significant difference in tumor volume and signal intensity between pre- and post-chemoradiotherapy MRI (P < 0.0001). According to pathology, 27/41 (66%) patients had true negative and 2/41 (5%) had true positive post-chemoradiotherapy MRI. Eleven out of 41 (27%) patients showed inflammation with false positive post-chemoradiotherapy MRI and 1/41 (2%) had a false negative post-chemoradiotherapy MRI. Sensitivity, specificity, accuracy, positive predictive values, and negative predictive values of post-chemoradiotherapy MRI in predicting residual disease were 69%, 71%, 71%, 15%, and 96%, respectively. CONCLUSION: The differentiation of residual tumor from post-irradiation inflammation with early post- chemoradiotherapy MRI (within 28-60 days) is difficult with a high risk of false positive results. Combination of qualitative and semi-quantitative analysis does not improve the accuracy. Conversely, post-chemoradiotherapy MRI has a high negative predictive value with a low risk of false negative results. The role of conventional MRI combined with functional techniques should be evaluated.

Endometriosis-associated clear cell carcinoma arising in caesarean section scar: a case report and review of the literature.

BACKGROUND: Malignant transformation has been reported in approximately 1% of the endometriosis cases; herein, we report a case of clear cell endometrial carcinoma arising from endometriosis foci located within a caesarean section scar. CASE PRESENTATION: In November 2014, a Caucasian, 44-year-old woman was transferred to our institution because of severe respiratory failure due to massive lung embolism and rapid enlargement of a subcutaneous suprapubic mass. Abdomino-pelvic magnetic resonance showed a 10.5 × 5.0 × 5.0 cm subcutaneous solid mass involving the rectus abdominis muscle. Pelvic organs appeared normal, while right external iliac lymph nodes appeared enlarged (maximum diameter = 16 mm). A whole-body positron emission tomography/computed tomography scan showed irregular uptake of the radiotracer in the 22 cm mass of the abdominal wall, and in enlarged external iliac and inguinal lymph nodes. In December 2014, the patient underwent exploratory laparoscopy showing normal adnexae and pelvic organs; peritoneal as well as cervical, endometrial and vesical biopsies were negative. The patient was administered neo-adjuvant chemotherapy with carboplatin and paclitaxel, weekly, without benefit and then underwent wide resection of the abdominal mass, partial removal of rectus abdominis muscle and fascia, radical hysterectomy, bilateral salpingo-oophorectomy, and inguinal and pelvic lymphadenectomy. The muscular gap was repaired employing a gore-tex mesh while the external covering was made by a pedicled perforator fasciocutaneous anterolateral thigh flap. Final diagnosis was clear cell endometrial adenocarcinoma arising from endometriosis foci within the caesarean section scar. Pelvic and inguinal lymph nodes were metastatic. Tumor cells were positive for CK7 EMA, CKAE1/AE3, CD15, CA-125, while immunoreaction for Calretinin, WT1, estrogen, and progesterone receptors, cytokeratin 20, CD10, alpha fetoprotein, CDX2, TTF1, and thyroglobulin were all negative. Liver relapse occurred after 2 months; despite 3 cycles of pegylated liposomal doxorubicin (20 mg/m2, biweekly administration), the death of the patient disease occurred 1 month later. CONCLUSIONS: Attention should be focused on careful evaluation of patient history in terms of pelvic surgery, and symptoms suggestive of endometriosis such as repeated occurrence of endometriosis nodules at CS scar, or cyclic pain, or volume changes of the nodules.

Persistent Urogenital Sinus: Diagnostic Imaging for Clinical Management. What Does the Radiologist Need to Know?

BACKGROUND: Persistent urogenital sinus (PUGS) is a congenital pathological condition characterized by an abnormal communication between the urethra and vagina. It may be a part of a complex syndrome and can be more often associated with congenital malformations affecting the genitourinary tract system (33%) such as intersex, rectovaginal communication, bladder agenesis, absence of vagina, and hydrocolpos. The correct radiological assessment of PUGS is especially useful for clinicians since the exact anatomical evaluation of this abnormality is a crucial factor for surgical planning. The imaging study modalities, which are essentially based on ultrasonography, voiding cystourethrography, and magnetic resonance imaging, could be misinterpreted if not correctly performed. AIM: The aim of this article is to highlight this rare pathological condition and to help general radiologists in achieving the correct technical approach for the diagnosis. Special attention will be paid in discussing the role of different imaging modalities and their contribution to the diagnosis and clinical management of patients.

Deep pelvic endometriosis: don't forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features.

Deep infiltrating endometriosis is an important gynecologic disease that may develop during the reproductive years and is responsible for severe pelvic pain. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligament, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic sites. Surgery remains the best therapeutic treatment for affected patients and an accurate preoperative evaluation of the extension of endometriotic lesions is essential for a successful outcome. However, many atypical locations for deep pelvic endometriosis exist although still lesser known to both gynecologists and radiologists such as endometriosis of the round ligaments of the uterus (RLUs). In this article, we review embryology and anatomy of the RLUs as well clinical characteristics associated with these endometriotic locations. In addition, we describe magnetic resonance (MR) imaging protocol, normal MR imaging appearances of the RLUs and the most common abnormal findings of endometriotic involvement of these ligaments at MR imaging. Radiologists should always keep in mind the RLUs as a possible site of deep pelvic endometriosis localization and should not forget to carefully look for them on MR images.

How to improve MRI accuracy in detecting deep infiltrating colorectal endometriosis: MRI findings vs. laparoscopy and histopathology.

OBJECTIVE: To verify whether the capability of magnetic resonance imaging (MRI) in diagnosing deep infiltrating colorectal endometriosis (DICE) is improved using an association of MRI findings. METHODS AND MATERIALS: The imaging database of our Institute of Radiology was retrospectively reviewed to identify patients subjected to MRI for a suspicion of deep infiltrating endometriosis. Medical history was then investigated and only patients who were also subjected to laparoscopy (LA) were included. Absence of LA represented the exclusion criterion. Images were evaluated twice by two radiologists using two different diagnostic criteria for an abnormal result: the contemporary presence of nodules or hypointense plaque-like lesions in the adjacent fat plane and bowel wall thickness, without (first criterion) or with (second criterion) semicircular shape (i.e. "radial and retracting shape"). Radiologists worked in consensus evaluating images in two separate sessions, using the first criterion in the first section and the second criterion in the second one. MRI results were compared with LA or histopathology as the gold standard by 2 × 2 tables and statistically analyzed (k statistics). Likelihood-ratio test was also performed, being independent from the prevalence of the disease. RESULTS: By consulting case sheets, 33/50 females (ranging age 24-39 years, mean age 32.2 years) who were subjected to MRI also underwent LA. Intestinal resection for DICE was performed in 11/33 patients; in 22/33 superficial intestinal foci, adhesions/nodules in the fat plane were simply removed. When the first criterion was applied, MRI agreement with histopathology or LA was poor (51.5 %) (k value = 0.20; p < 0.055), while it was improved (96.9 %) when using the second diagnostic criterion (k value = 0.93; p < 0.0000). Likelihood ratio was 1.375 (95 % CI 0.69-2.72) using the first and 22 (95 % CI 20.08-24.1) using the second criterion. CONCLUSION: The second criterion, or the joint presence of nodules or hypointense plaque-like lesions in the adjacent fat plane and bowel wall thickness showing "radial and retracting shape", improves MRI capability in DICE diagnosis. It can be considered an effective indicator of DICE on T2-weighted images at 1.5-T MRI, and can ensure the correct preoperative assessment of the disease for the best therapeutic procedure and treatment planning.

Early-stage cervical cancer: tumor delineation by magnetic resonance imaging and ultrasound - a European multicenter trial.

OBJECTIVE: To compare the diagnostic accuracy of ultrasound (US) and magnetic resonance imaging (MRI) in the preoperative assessment of early-stage cervical cancer using pathologic findings as the reference standard. PATIENTS AND METHODS: Prospective multi-center trial enrolling 209 consecutive women with early-stage cervical cancer (FIGO IA2-IIA) scheduled for surgery. The following parameters were assessed on US and MRI and compared to pathology: remaining tumor, size, tumor stromal invasion<2/3 (superficial) or ≥2/3 (deep), and parametrial invasion. RESULTS: Complete data were available for 182 patients. The agreement between US and pathology was excellent for detecting tumors, correctly classifying bulky tumors (>4cm), and detecting deep stromal invasion (kappa values 0.84, 0.82, and 0.81 respectively); and good for classifying small tumors (<2cm) and detecting parametrial invasion (kappa values 0.78 and 0.75, respectively). The agreement between MRI and histology was good for classifying tumors as <2cm, or >4cm, and detecting deep stromal invasion (kappa values 0.71, 0.76, and 0.77, respectively). It was moderately accurate in tumor detection, and in assessing parametrial invasion (kappa values 0.52 and 0.45, respectively). The agreement between histology and US was significantly better in assessing residual tumor (p<0.001) and parametrial invasion (p<0.001) than the results obtained by MRI. Imaging methods were not significantly influenced by previous cone biopsy. CONCLUSION: US and MRI are highly accurate for the preoperative assessment of women with early-stage cervical cancer, although US may be more accurate in detecting residual tumors and assessing parametrial invasion.

A case of unusual acute coronary syndrome.

Pheochromocytoma is a rare tumor that usually develops ahead of the neuroectodermal chromaffin cells of the adrenal medulla, but it may arise anywhere within plexus of sympathetic adrenergic nerves. Headache, palpitations, tremor, excessive sweating, abdominal pain, and hypertensive paroxysm are the common clinical presentations of the tumor, but it has also been reported several cardiac symptoms.

Imaging of gynecologic malignancies with FDG PET-CT: case examples, physiologic activity, and pitfalls.

The utilization of 2-[fluorine 18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in combination with computed tomography (CT) in the assessment of gynecologic malignancies has been rapidly growing in recent years; however, its role in clinical practice has yet to be established. A number of pitfalls are commonly encountered, including normal physiologic activity in bowel loops and blood vessels, or focal retained activity in ureters and urinary bladder. Increased uptake has also been reported in many benign pelvic processes and in premenopausal patients; endometrial activity changes cyclically, whereas increased ovarian uptake may be functional. FDG PET-CT has an emerging role in staging nodal disease and in the evaluation of local recurrence or peritoneal spread of gynecologic malignancies and is also useful in monitoring response to therapy and in long-term follow-up. FDG PET-CT is most suitable in patients with high tumor markers and negative or uncertain conventional imaging data. Patient preparation, proper scanning protocol, combined assessment of PET and CT data, and the evaluation of conventional imaging findings are essential to define disease and to avoid diagnostic pitfalls.

Multidetector CT appearance of the pelvis after vaginal delivery: normal appearances and abnormal acute findings.

Vaginal delivery is the most commonly performed delivery in the world and accounts for nearly two-thirds of all deliveries in the United States. It is a secure method but may be associated with some acute complications, especially in the immediate postpartum days, which can potentially be fatal for the mother. The most frequent acute complications are hemorrhages/hematomas, uterine rupture, endometritis, retained product of conception (RPOC), ovarian thrombosis and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). A first evaluation of the clinical status of the patients is executed by the clinicians who, depending on their experience, perform ultrasonography by themselves and eventually may request further radiologic exams in doubtful cases. Radiologists may play an important role recognizing early postpartum complications and differentiating them from physiologic postoperative findings. In this setting, the use of multidetector computed tomography (MDCT) is important for diagnosis of suspected postpartum complications. The aim of this article is to review the normal and abnormal post vaginal delivery MDCT aspects in order to help the clinical management by preventing misdiagnoses and tailoring the best medical treatments.

Imaging after treatment in uterine malignancies: Spectrum of normal findings and most common complications.

Uterine malignancies account for the majority of gynaecologic cancers. Different treatment options are available depending on histology, disease grade and stage. Hysterectomy is the most frequent surgical procedure. Chemotherapy and radiation therapy (CRT) represents the preferred therapeutic choice for locally advanced uterine and cervical malignancies. Imaging of the female pelvis following these treatments is particularly challenging due to alteration of the normal anatomy. Radiologists should be familiar with both the expected post-treatment imaging findings and the imaging features of possible complications to make the correct interpretation and avoid possible pitfalls. The purpose of this review is to show the expected computed tomography (CT) and Magnetic Resonance Imaging (MRI) appearances of the female pelvis following surgery and CRT for uterine and cervical cancer, to illustrate the imaging findings of early and delayed most common complications after surgery and CRT, describing the suitable imaging modalities and protocols for evaluation of patients treated for gynaecologic malignancies.

Shining light in a dark landscape: MRI evaluation of unusual localization of endometriosis.

Endometriosis is a disease distinguished by the presence of endometrial tissue outside the uterine cavity with intralesional recurrent bleeding and resulting fibrosis. The most common locations for endometriosis are the ovaries, pelvic peritoneum, uterosacral ligaments, and torus uterinus. Typical symptoms are secondary dysmenorrhea and cyclic or chronic pelvic pain. Unusual sites of endometriosis may be associated with specific symptoms depending on the localization. Atypical pelvic endometriosis localizations can occur in the cervix, vagina, round ligaments, ureter, and nerves. Moreover, rare extrapelvic endometriosis implants can be localized in the upper abdomen, subphrenic fold, or in the abdominal wall. Magnetic resonance imaging (MRI) represents a problem-solving tool among other imaging modalities. MRI is an advantageous technique, because of its multiplanarity, high contrast resolution, and lack of ionizing radiation. Our purpose is to remind the radiologists the possibility of atypical pelvic and extrapelvic endometriosis localizations and to illustrate the specific MRI findings. Endometriotic tissue with hemorrhagic content can be distinguished from adherences and fibrosis on MRI imaging. Radiologists should keep in mind these atypical localizations in patients with suspected endometriosis, in order to achieve the diagnosis and to help the clinicians in planning a correct and complete treatment strategy.

The morbidly adherent placenta: when and what association of signs can improve MRI diagnosis? Our experience.

PURPOSE: We aimed to verify whether combination of specific signs improves magnetic resonance imaging (MRI) accuracy in morbidly adherent placenta (MAP). METHODS: MRI findings for MAP were retrospectively evaluated in 27 women. Histopathology was the reference standard, showing MAP in eight of 27 cases. Specificity, sensitivity, positive predictive value, and negative predictive value were calculated for all MRI signs. Two skilled radiologists analyzed MRI findings, resolving discrepancies by consensus, using three alternative diagnostic criteria during three consecutive sections. First criterion: at least one of reported MRI signs indicates MAP and the absence of any sign is normal; second criterion: at least one statistically significant sign indicates MAP and no sign or nonsignificant sign is normal; third criterion: at least two statistically significant signs indicate MAP and no sign, nonsignificant sign, or only one significant sign is normal. RESULTS: Using the first criterion yielded an unacceptable rate of false positive results (78.9%). Using the second criterion there were less false positive results (31.5%), and diagnostic accuracy of the second criterion was significantly higher than the first; the third criterion correctly classified 100% of cases. CONCLUSION: Only specific MRI signs can correctly predict MAP at histopathology, particularly when multiple (at least two) specific signs are observed together.

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings.

Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.

MRI anatomy of parametrial extension to better identify local pathways of disease spread in cervical cancer.

This paper highlights an updated anatomy of parametrial extension with emphasis on magnetic resonance imaging (MRI) assessment of disease spread in the parametrium in patients with locally advanced cervical cancer. Pelvic landmarks were identified to assess the anterior and posterior extensions of the parametria, besides the lateral extension, as defined in a previous anatomical study. A series of schematic drawings and MRI images are shown to document the anatomical delineation of disease on MRI, which is crucial not only for correct image-based three-dimensional radiotherapy but also for the surgical oncologist, since neoadjuvant chemoradiotherapy followed by radical surgery is emerging in Europe as a valid alternative to standard chemoradiation.

Posterior urethral valves.

Posterior urethral valves represent the most common post-vesical obstructive malformation. They affect the male gender and appear as intraluminal folds located immediately proximal to the verumontanum. One of the most credited pathogenetic theories considers them an anomalous insertion of mesonephric duct into the cloaca or an incomplete involution of plicae colliculi. At present, the diagnosis of posterior urethral valves is prenatal and the pattern is characterized by detrusor hypertrophy and more or less marked hydroureteronephrosis. Urinary tract disorders that accompany posterior urethral valves include moderate hydroureteronephrosis to severe functional impairment of the entire urinary tract with consequent renal failure. Treatment of posterior urethral valves consists in their resection. At present, with miniaturized endoscopes, valve fulguration is feasible also in newborn infants. In low-weight patients or in case of poor general condition, temporary external urinary bypass (e.g. cystostomy) is feasible.

The neurogenic bladder: anatomy and neurophysiology.

Micturition disorders secondary to alterations of complex neural controls do not represent a separate, typified condition but frequently they are symptoms of more complex diseases. Unfortunately, they are often misunderstood leading to severe damages to the patient. In diagnostic imaging of neural alterations of micturition, a major role is played by voiding cystourethrography for its contribution to both the morphologic and functional aspects. The dynamics of micturition is documented by voiding cystourethrography and with the integration between radiologic morphofunctional imaging and urodynamic pressure values the type and level of the neural lesion can be better defined. Therefore, subsequent neuroradiologic study can be specifically planned. Modern diagnostic imaging allows ready detection of the frequent complications of neurogenic bladder as diverticula, lithiasis, inflammation, that, especially in some patients, if misunderstood, can be particularly severe.

Diagnostic imaging of neurogenic bladder.

Correct radiologic diagnosis of neurogenic bladder is mainly based on morphofunctional information derived from voiding cystourethrography. This examination allows the evaluation of the bladder morphology, the degree of filling, and the validity of muscular contraction. Indications on the bladder neck, striated sphincter function and urethral morphology are also provided. Presence of ureterovesical reflux is detected with its possible precise classification. Abnormal amount of residual urine is identified and often early diagnosis of most common complications of neurogenic bladder as vesical lithiasis, diverticula and infections, can be established.

Combined diagnostic imaging of transitional cell carcinoma of the upper urinary tract.

The case of a female patient with recurrent macroscopic hematuria and negative vesical and renal ultrasonography, is discussed. On urography a gross pyelocaliceal filling defect was visualized. Urographic findings were suggestive of the diagnosis of transitional cell carcinoma of the upper urinary. CT was performed to confirm the diagnosis and stage the tumor: it showed the presence of an advanced lesion. At histology the diagnosis of transitional cell carcinoma of the upper urinary tract was confirmed.

Locally advanced prostate cancer: three-dimensional magnetic resonance spectroscopy to monitor prostate response to therapy.

PURPOSE: To correlate results of three-dimensional magnetic resonance spectroscopic imaging (MRSI) with prostate-specific antigen (PSA) levels and time since external beam irradiation (EBRT) in patients treated with long-term hormone therapy (HT) and EBRT for locally advanced disease to verify successful treatment by documenting the achievement of metabolic atrophy (MA). METHODS AND MATERIALS: Between 2006 and 2008, 109 patients were consecutively enrolled. MA was assessed by choline and citrate peak area-to-noise-ratio <5:1. Cancerous metabolism (CM) was defined by choline-to-creatine ratio >1.5:1 or choline signal-to-noise-ratio >5:1. To test the strength of association between MRSI results and the time elapsed since EBRT (TEFRT), PSA levels, Gleason score (GS), and stage, logistic regression (LR) was performed. p value <0.05 was statistically significant. The patients' outcomes were verified in 2011. RESULTS: MRSI documented MA in 84 of 109 and CM in 25 of 109 cases. LR showed that age, GS, stage, and initial and recent PSA had no significant impact on MRSI results which were significantly related to PSA values at the time of MRSI and to TEFRT. Patients were divided into three groups according to TEFRT: <1 year, 1-2 years, and >2 years. MA was detected in 54.1% of patients of group 1, 88.9% of group 2, and in 94.5% of group 3 (100% when PSA nadir was reached). CM was detected in 50% of patients with reached PSA nadir in group 1. Local relapse was found in 3 patients previously showing CM at long TEFRT. CONCLUSION: MA detection, indicative of successful treatment because growth of normal or abnormal cells cannot occur without metabolism, increases with decreasing PSA levels and increasing time on HT after EBRT. This supports long-term HT in advanced prostate cancer. Larger study series are needed to assess whether MRSI could predict local relapse by detecting CM at long TEFRT.