Effectiveness and safety of lenvatinib in a series of advanced well-differentiated thyroid carcinomas from a single tertiary cancer center and literature review.

BACKGROUND: Treatment of advanced differentiated thyroid carcinoma (DTC) remains a challenge as 25-50% of patients with locally invasive or distant metastatic disease become refractory to radioiodine (RAI) therapy. Tyrosine kinase inhibitors (TKI) are increasingly used in this setting. The SELECT trial demonstrated that lenvatinib, a multikinase inhibitor, significantly improved progression free survival (PFS) compared to placebo. Our aim was to report the effectiveness and safety of lenvatinib in our series of patients with advanced DTC. METHODS: A total of 25 patients with advanced DTC followed at a single tertiary center from January of 2016 to January of 2022 were retrospectively reviewed. RESULTS: Patients were treated with a mean daily dose of lenvatinib of 16.9 mg for a mean of 9.1 months. Median estimated PFS was 31.3 months. One patient achieved complete response. The objective response rate (ORR) was 40% and the disease control rate was 84%. The mean change in summed longest diameter of target lesions from baseline to nadir was -36.9%. Lenvatinib prolonged the tumor volume doubling time in 86.7% patients. Interestingly, we found that patients treated with a lower dose of lenvatinib (<16.9 mg daily) had a significantly higher PFS and ORR than patients treated with higher dosages (>16.9 mg). Adverse events were frequently reported. CONCLUSIONS: Our results confirm the effectiveness of lenvatinib in the management of patients with advanced DTC and support the need to adjust the dosage of lenvatinib to patient´s performance status and comorbidities.

Clinical and molecular characterisation of metastatic papillary thyroid cancer according to radioiodine therapy outcomes.

PURPOSE: Radioiodine (RAI) therapy remains the gold-standard approach for distant metastatic differentiated thyroid cancer (TC). The main objective of our work was to identify the clinical and molecular markers that may help to predict RAI avidity and RAI therapy response of metastatic lesions in a cohort of papillary thyroid cancer (PTC) patients. METHODS: We performed a retrospective analysis of 122 PTC patients submitted to RAI therapy due to distant metastatic disease. We also analysed, through next-generation sequencing, a custom panel of 78 genes and rearrangements, in a smaller cohort of 31 metastatic PTC, with complete follow-up, available RAI therapy data, and existing tumour sample at our centre. RESULTS: The most frequent outcome after RAI therapy was progression of disease in 59.0% of cases (n = 71), with median estimate progression-free survival of 30 months. RAI avidity was associated with PTC subtype, age and stimulated thyroglobulin at first RAI therapy for metastatic disease. The most frequently altered genes in the cohort of 31 PTC patients' primary tumours were RAS isoforms (54.8%) and TERT promoter (TERTp) (51.6%). The presence of BRAF p.V600E or RET/PTC alterations was associated with lower avidity (p = 0.012). TERTp mutations were not associated with avidity (p = 1.000) but portended a tendency for a higher rate of progression (p = 0.063); similar results were obtained when RAS and TERTp mutations coexisted (p = 1.000 and p = 0.073, respectively). CONCLUSIONS: Early identification of molecular markers in primary tumours may help to predict RAI therapy avidity, the response of metastatic lesions and to select the patients that may benefit the most from other systemic therapies.

The Role of High-Resolution Ultrasound in the Assessment of Surgical Candidates for Transoral Endoscopic Thyroidectomy Via Vestibular Approach (TOETVA).

The approach of surgical techniques has evolved significantly over the last decade, with natural orifice surgeries replacing traditional open approaches. In 2016, Angkoon Anuwong, in Thailand, demonstrated it was possible to perform thyroidectomies in a series of patients by a transoral endoscopic ap-proach - transoral endoscopy thyroidectomy vestibular approach (TOETVA) - with similar complication rates when compared to conventional surgeries. This transoral surgery has become a safe alternative with better cosmetic results, compared to conventional open-route procedures, like Kocher cervi-cotomy. Indeed, it is an option to surgically treat neoplastic and functional thyroid diseases. The technique is performed through a median incision in the oral vestibule, plus two bilateral incisions, followed by the insertion of three trocars, one centrally for a camera, and two laterally for working instruments. Although revolutionary, TOETVA has its technical limitations. Therefore, it is important to precisely define the preoperative eligibility criteria for this type of surgical approach. High-resolution ultrasound is the first imaging modality for the assessment of thyroid nodules, lymph node metastases and surgical field. The aim of this article is to outline the sonographic technique and the role of high-resolution ultrasound in the presurgical evaluation of TOETVA.

Target therapy for BRAF mutated anaplastic thyroid cancer: a clinical and molecular study.

OBJECTIVES: Anaplastic thyroid carcinoma (ATC) has a poor survival. The combination of Dabrafenib plus Trametinib (DT) had a significant impact in survival of BRAF p.V600E patients. However, durable responses may be compromised by resistance. We aim to present our experience with DT in BRAF positive ATC patients and compare the outcomes with usual therapy, and to study tumor molecular alterations in the DT group. METHODS: Patients treated between May 2018 and April 2022 in a tertiary referral center, assessed for BRAF status were included. Patients were divided in three groups: BRAF p.V600E treated with DT, BRAF wild type (WT) under multimodal therapy (MT), and BRAF WT under compassionate care (CC). Response was assessed monthly in the first 6 months and every 3 months afterwards, by RECIST 1.1. Overall survival (OS) and progression-free survival (PFS) were estimated with the Kaplan-Meier method and compared with the log-rank test. RESULTS: Twenty-seven ATC patients were included (DT = 9, MT = 8, and CC = 10). Median OS was 475 days for DT, 156 days for MT, and 39 days for CC (P < .001). At 12 months, only patients in the DT group were alive (71%). Median PFS was 270 days, in the DT group, compared with less than 32 days in BRAF WT (P < .001). No severe adverse events were reported. Molecular profiling showed that in one of the four clinical progressions, a pathogenic NRAS mutation was found. CONCLUSIONS: Our results show a significant real-world efficacy of Dabrafenib plus Trametinib in both survival and recurrence compared with standard treatment, with a good safety profile.

Entrectinib in the neoadjuvant setting of anaplastic thyroid cancer: a case report.

Background: Anaplastic thyroid carcinoma (ATC) is one of the most aggressive solid tumors. ATC is frequently diagnosed at advanced stages with unresectable disease and palliative care is often indicated. Recently, several patient-tailored therapies for ATC are emerging due to advances in molecular profiling of these tumors. Entrectinib is a potent oral selective inhibitor of neutrotrophic tropomyosin receptor kinase (NTRK), ROS1, and anaplastic lymphoma kinase fusions. The experience regarding ATC and other thyroid carcinomas, particularly in the neoadjuvant setting, is minimal. Case report: We present a case of a 51-year-old female patient presenting with a bulky mass of the left thyroid lobe measuring 100 × 108 × 80 mm that was considered surgically unresectable. While waiting for next-generation sequence (NGS) profiling, lenvatinib was initiated. There was an initial clinical and imagiologic response; however, progression occurred after 12 weeks, and at this time NGS identified an ETV6-NTRK3 fusion and entrectinib was started. After 12 weeks, tumor diameters reduced to a minimum of 68×60×49 mm, and the patient underwent total thyroidectomy plus central lymphadenectomy. Histological diagnosis confirmed an ATC (pT4a R2 N1a). Adjuvant radiotherapy (RT) (60 Grays) with weekly paclitaxel (45 mg/m2) was then administered followed by maintenance entrectinib 600 mg daily. Fluorodeoxyglucose positron emission tomography performed 3 months after completion of RT showed only non-specific uptake in the posterior wall of the hypopharynx and larynx, suggestive of inflammation. Conclusion: We report the first case of an ATC with a dramatic response to neoadjuvant therapy with entrectinib, which enabled surgical resection of an ab initio unresectable tumor.

Mucocele of the appendix: what to expect.

Mucoceles of the appendix are rare and can have quite variable imaging and clinical presentations, sometimes mimicking an adnexal mass. The underlying cause can be neoplastic or non-neoplastic. The typical imaging appearance of a mucocele of the appendix is that of a cystic structure with a tubular morphology. This structure is defined by having a blind-ending and being contiguous with the cecum. Radiologists should be familiar with key anatomical landmarks and with the various imaging features of mucoceles of the appendix, in order to provide a meaningful differential diagnosis of a lesion in the right lower abdominal quadrant. In addition, a neoplastic mucocele can rupture, resulting in pseudomyxoma peritonei, which will change the prognosis dramatically. Therefore, prompt diagnostic imaging is crucial.

Mucoceles do apêndice são raras e podem ter uma apresentação clínica e imagiológica bastante variável, por vezes mimetizando patologia anexial. As causas subjacentes podem ser neoplásicas ou não neoplásicas. O aspecto de imagem típico de mucoceles do apêndice é o de uma estrutura de natureza cística com morfologia tubular. Esta estrutura deverá terminar "em fundo cego" e ser contígua com o ceco. Os radiologistas devem estar familiarizados com os pontos anatômicos de referência e com as diferentes características imagiológicas de mucoceles do apêndice, de modo a fornecer um adequado diagnóstico diferencial de uma lesão localizada no quadrante abdominal inferior direito. Para além disso, uma mucocele neoplásica pode sofrer ruptura, resultando em pseudomixoma peritoneal, o que altera drasticamente o prognóstico. Assim, o diagnóstico por imagem em tempo útil é crucial.

Mucocele of the appendix: what to expect / Mucocele do apêndice: o que esperar

Abstract Mucoceles of the appendix are rare and can have quite variable imaging and clinical presentations, sometimes mimicking an adnexal mass. The underlying cause can be neoplastic or non-neoplastic. The typical imaging appearance of a mucocele of the appendix is that of a cystic structure with a tubular morphology. This structure is defined by having a blind-ending and being contiguous with the cecum. Radiologists should be familiar with key anatomical landmarks and with the various imaging features of mucoceles of the appendix, in order to provide a meaningful differential diagnosis of a lesion in the right lower abdominal quadrant. In addition, a neoplastic mucocele can rupture, resulting in pseudomyxoma peritonei, which will change the prognosis dramatically. Therefore, prompt diagnostic imaging is crucial.

Resumo Mucoceles do apêndice são raras e podem ter uma apresentação clínica e imagiológica bastante variável, por vezes mimetizando patologia anexial. As causas subjacentes podem ser neoplásicas ou não neoplásicas. O aspecto de imagem típico de mucoceles do apêndice é o de uma estrutura de natureza cística com morfologia tubular. Esta estrutura deverá terminar "em fundo cego" e ser contígua com o ceco. Os radiologistas devem estar familiarizados com os pontos anatômicos de referência e com as diferentes características imagiológicas de mucoceles do apêndice, de modo a fornecer um adequado diagnóstico diferencial de uma lesão localizada no quadrante abdominal inferior direito. Para além disso, uma mucocele neoplásica pode sofrer ruptura, resultando em pseudomixoma peritoneal, o que altera drasticamente o prognóstico. Assim, o diagnóstico por imagem em tempo útil é crucial.

Staging of Endometrial Cancer Using Fusion T2-Weighted Images with Diffusion-Weighted Images: A Way to Avoid Gadolinium?

Endometrial cancer is the eighth most common cancer worldwide, and its prognosis depends on various factors, with myometrial invasion having a major impact on prognosis. Optimizing MRI protocols is essential, and it would be useful to improve the diagnostic accuracy without the need for other sequences. We conducted a retrospective, single-center study, which included a total of 87 patients with surgically confirmed primary endometrial cancer, and who had undergone a pre-operative pelvic MRI. All exams were read by an experienced radiologist dedicated to urogenital radiology, and the depth of myometrial invasion was evaluated using T2-Weighted Images (T2WI) and fused T2WI with Diffusion-Weighted Images (DWI). Both results were compared to histopathological evaluations. When comparing both sets of imaging (T2WI and fused T2WI-DWI images) in diagnosing myometrial invasion, the fused images had better accuracy, and this difference was statistically significant (p < 0.001). T2WI analysis correctly diagnosed 82.1% (70.6-88.7) of cases, compared to 92.1% correctly diagnosed cases with fused images (79.5-97.2). The addition of fused images to a standard MRI protocol improves the diagnostic accuracy of myometrial invasion depth, encouraging its use, since it does not require more acquisition time.

High-Resolution Laryngeal US: Imaging Technique, Normal Anatomy, and Spectrum of Disease.

Although US is one of the most used modalities for head and neck imaging, its use in the diagnosis of laryngeal abnormalities is much less widespread. The standard assessment of laryngeal abnormalities currently involves direct laryngoscopy and cross-sectional imaging (either CT or MRI) but rarely US. US is readily available, noninvasive, and radiation free, and it allows real-time imaging (with video for dynamic assessment), higher resolution than that of cross-sectional imaging, and the performance of targeted fine needle aspiration cytology or biopsy. This modality, particularly with the advent of high-resolution US, has been found to be at least comparable to CT or MRI for diagnosis of malignant lesions and benign abnormalities such as vocal nodules, polyps, cysts, and Reinke edema. Furthermore, it has been found to be more sensitive for diagnosis of abnormalities such as small glottic tumors, and its dynamic capability can be used to identify functional abnormalities such as vocal cord palsy. The authors outline the technique of laryngeal US, which includes strategies to avoid calcified laryngeal cartilage by imaging through the thyrohyoid and cricothyroid membranes with a five-sweep strategy supplemented by cine film of the technique. They also provide US images of common laryngeal abnormalities such as tumors with and without extralaryngeal extension; vallecular, thyroglossal, and vocal cord cysts; laryngeal mucoceles; and vocal cord palsy. Online supplemental material is available for this article. ©RSNA, 2020.

State of the art in vulvar cancer imaging.

Vulvar carcinoma is an uncommon tumor that predominantly affects postmenopausal women. Currently, there is no screening procedure for vulvar carcinoma; in most cases, it is diagnosed only when symptoms appear. The most widely used staging system is that developed by the International Federation of Gynecology and Obstetrics. Lymph node status is the most important prognostic factor. We searched the PubMed/Medline database to identify relevant English-language articles on vulvar cancer, with a special focus on its imaging evaluation. Magnetic resonance imaging is useful for local and nodal staging, as well as facilitating the planning of surgical interventions and radiotherapy. Computed tomography or positron-emission tomography/computed tomography can play an important role in nodal and distant disease assessment, whereas ultrasound is often used for image-guided biopsies. Imaging is pivotal for staging and treatment planning in vulvar carcinoma.

O carcinoma da vulva é um tumor incomum que afeta predominantemente mulheres em menopausa. Atualmente, não existe um teste de rastreio para o carcinoma da vulva, e a maioria dos casos é diagnosticada com o aparecimento de sintomas. O sistema de estadiamento mais frequentemente utilizado é o da International Federation of Gynecology and Obstetrics. O fator prognóstico mais importante é o estadiamento ganglionar. Neste trabalho foram efetuadas pesquisas na base de dados PubMed/Medline, considerando-se textos pertinentes em língua inglesa sobre carcinoma da vulva, com especial ênfase na avaliação radiológica. A ressonância magnética é útil para a avaliação local e ganglionar e pode ajudar no planejamento cirúrgico e/ou de radioterapia; a tomografia computadorizada ou a tomografia com emissão de pósitrons/tomografia computadorizada pode ser importante na apreciação ganglionar e na doença a distância; e a ultrassonografia é, por vezes, utilizada para orientar procedimentos de intervenção, como a biópsia. A radiologia é fundamental no estadiamento e planejamento do tratamento do carcinoma da vulva.

State of the art in vulvar cancer imaging / Estado da arte na avaliação radiológica do carcinoma da vulva

Abstract Vulvar carcinoma is an uncommon tumor that predominantly affects postmenopausal women. Currently, there is no screening procedure for vulvar carcinoma; in most cases, it is diagnosed only when symptoms appear. The most widely used staging system is that developed by the International Federation of Gynecology and Obstetrics. Lymph node status is the most important prognostic factor. We searched the PubMed/Medline database to identify relevant English-language articles on vulvar cancer, with a special focus on its imaging evaluation. Magnetic resonance imaging is useful for local and nodal staging, as well as facilitating the planning of surgical interventions and radiotherapy. Computed tomography or positron-emission tomography/computed tomography can play an important role in nodal and distant disease assessment, whereas ultrasound is often used for image-guided biopsies. Imaging is pivotal for staging and treatment planning in vulvar carcinoma.

Resumo O carcinoma da vulva é um tumor incomum que afeta predominantemente mulheres em menopausa. Atualmente, não existe um teste de rastreio para o carcinoma da vulva, e a maioria dos casos é diagnosticada com o aparecimento de sintomas. O sistema de estadiamento mais frequentemente utilizado é o da International Federation of Gynecology and Obstetrics. O fator prognóstico mais importante é o estadiamento ganglionar. Neste trabalho foram efetuadas pesquisas na base de dados PubMed/Medline, considerando-se textos pertinentes em língua inglesa sobre carcinoma da vulva, com especial ênfase na avaliação radiológica. A ressonância magnética é útil para a avaliação local e ganglionar e pode ajudar no planejamento cirúrgico e/ou de radioterapia; a tomografia computadorizada ou a tomografia com emissão de pósitrons/tomografia computadorizada pode ser importante na apreciação ganglionar e na doença a distância; e a ultrassonografia é, por vezes, utilizada para orientar procedimentos de intervenção, como a biópsia. A radiologia é fundamental no estadiamento e planejamento do tratamento do carcinoma da vulva.

The added value of diffusion-weighted imaging in the preoperative assessment of endometrial cancer.

OBJECTIVE: To evaluate the added value of diffusion-weighted imaging (DWI) in the preoperative assessment of myometrial invasion in endometrial cancer, in comparison with T2-weighted imaging (T2WI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). MATERIALS AND METHODS: This was a retrospective study involving 44 women with endometrial cancer who underwent preoperative 1.5 T MRI. Two radiologists, both of whom were blinded to the histopathology reports, performed a consensus interpretation of the depth of myometrial invasion and of the stage of the cancer, considering three sets of sequences: T2WI, DCE-MRI+T2WI, and DWI+T2WI. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each set. The accuracy was compared with p-value adjustment by the Benjamini-Hochberg procedure. RESULTS: Among the 44 patients evaluated, DWI+T2WI demonstrated better diagnostic performance in assessing deep myometrial invasion and correctly staged more patients (n = 41) than did DCE-MRI+T2WI (n = 34) and T2WI (n = 22). The superior diagnostic accuracy of DWI+T2WI was statistically significant in comparison with T2WI (p < 0.05) but not in comparison with DCE-MRI+T2WI (p > 0.05). CONCLUSION: The addition of DWI apparently improves the diagnostic accuracy of MRI in the preoperative assessment of the depth of myometrial invasion in endometrial cancer, which may be particularly helpful in patients for whom contrast agents are contraindicated.

OBJETIVO: Determinar o valor adicional da difusão (DWI) em ressonância magnética (RM) na avaliação pré-operatória da invasão miometrial do câncer do endométrio, em comparação com sequências T2 e com o estudo dinâmico após contraste paramagnético (dynamic contrast-enhanced - DCE). MATERIAIS E MÉTODOS: Estudo retrospectivo incluindo 44 mulheres com câncer do endométrio que realizaram RM 1,5 T pré-operatória. Dois radiologistas desconhecendo a histopatologia final realizaram interpretação consensual sobre a profundidade de invasão miometrial e o estádio da doença considerando três conjuntos de sequências: T2, DCE+T2 e DWI+T2. Para cada conjunto foram calculadas acuidade, sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. A acuidade diagnóstica foi comparada com ajuste do valor de p utilizando o procedimento Benjamini-Hochberg. RESULTADOS: DWI+T2 apresentou melhor performance diagnóstica na avaliação da invasão miometrial e permitiu estadiar corretamente mais pacientes (41/44) do que DCE+T2 (34/44) e T2 (22/44). A superior acuidade diagnóstica da DWI+T2 foi estatisticamente significativa quando comparada com T2 (p < 0,05), mas não quando comparada com DCE+T2 (p > 0,05). CONCLUSÃO: A interpretação da DWI+T2 melhorou a acuidade diagnóstica da RM na avaliação pré-operatória da invasão miometrial do câncer de endométrio, o que poderá ser particularmente útil em pacientes com contraindicação para contraste paramagnético.

The added value of diffusion-weighted imaging in the preoperative assessment of endometrial cancer / A acurácia do estudo de difusão na avaliação pré-operatória do carcinoma do endométrio

Abstract Objective: To evaluate the added value of diffusion-weighted imaging (DWI) in the preoperative assessment of myometrial invasion in endometrial cancer, in comparison with T2-weighted imaging (T2WI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Materials and Methods: This was a retrospective study involving 44 women with endometrial cancer who underwent preoperative 1.5 T MRI. Two radiologists, both of whom were blinded to the histopathology reports, performed a consensus interpretation of the depth of myometrial invasion and of the stage of the cancer, considering three sets of sequences: T2WI, DCE-MRI+T2WI, and DWI+T2WI. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each set. The accuracy was compared with p-value adjustment by the Benjamini-Hochberg procedure. Results: Among the 44 patients evaluated, DWI+T2WI demonstrated better diagnostic performance in assessing deep myometrial invasion and correctly staged more patients (n = 41) than did DCE-MRI+T2WI (n = 34) and T2WI (n = 22). The superior diagnostic accuracy of DWI+T2WI was statistically significant in comparison with T2WI (p < 0.05) but not in comparison with DCE-MRI+T2WI (p > 0.05). Conclusion: The addition of DWI apparently improves the diagnostic accuracy of MRI in the preoperative assessment of the depth of myometrial invasion in endometrial cancer, which may be particularly helpful in patients for whom contrast agents are contraindicated.

Resumo Objetivo: Determinar o valor adicional da difusão (DWI) em ressonância magnética (RM) na avaliação pré-operatória da invasão miometrial do câncer do endométrio, em comparação com sequências T2 e com o estudo dinâmico após contraste paramagnético (dynamic contrast-enhanced - DCE). Materiais e Métodos: Estudo retrospectivo incluindo 44 mulheres com câncer do endométrio que realizaram RM 1,5 T pré-operatória. Dois radiologistas desconhecendo a histopatologia final realizaram interpretação consensual sobre a profundidade de invasão miometrial e o estádio da doença considerando três conjuntos de sequências: T2, DCE+T2 e DWI+T2. Para cada conjunto foram calculadas acuidade, sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. A acuidade diagnóstica foi comparada com ajuste do valor de p utilizando o procedimento Benjamini-Hochberg. Resultados: DWI+T2 apresentou melhor performance diagnóstica na avaliação da invasão miometrial e permitiu estadiar corretamente mais pacientes (41/44) do que DCE+T2 (34/44) e T2 (22/44). A superior acuidade diagnóstica da DWI+T2 foi estatisticamente significativa quando comparada com T2 (p < 0,05), mas não quando comparada com DCE+T2 (p > 0,05). Conclusão: A interpretação da DWI+T2 melhorou a acuidade diagnóstica da RM na avaliação pré-operatória da invasão miometrial do câncer de endométrio, o que poderá ser particularmente útil em pacientes com contraindicação para contraste paramagnético.

T2 hyperintense myometrial tumors: can MRI features differentiate leiomyomas from leiomyosarcomas?

PURPOSE: To establish MRI features that help differentiate atypical leiomyomas and leiomyomas with degeneration that show hyperintensity on T2WI from leiomyosarcomas. METHODS AND MATERIALS: This retrospective study evaluated 41 women who performed MRI before undergoing hysterectomy and had histologically proven atypical leiomyomas, leiomyomas with degeneration or leiomyosarcomas (21 leiomyomas; 20 leiomyosarcomas); only patients with T2 hyperintense myometrial tumors were included. The association between MRI features (contours; free pelvic fluid; intra-tumoral hemorrhagic areas, T2 heterogeneity; T2 dark areas; flow voids; restriction on diffusion-weighted images; signal intensity and heterogeneity after contrast administration; unenhanced areas, localization of unenhanced areas; necrosis; cystic areas) and the histology (leiomyoma vs. leiomyosarcoma) were calculated using Fisher's exact test. For those features that showed a significant association, a univariate linear regression was performed. RESULTS: Five MRI features demonstrated a significant correlation with malignant histology: irregular borders (p = 0.03); "T2 dark" areas (p = 0.02); presence of central necrosis (p = 0.01); presence of high signal on b1000 DWI (p < 0.001); ADC value lower than 0.82 × 10-3 mm2/s; hyperenhancement of the tumor relative to the myometrium on post-contrast images (p = 0.02); and type 3 enhancing curve on DCE. Two of these features demonstrated a significant result predicting a malignant histology: lobulated contours and central necrosis [F(3;34) = 8,95; p < 0.001; R2 = 0.506]. CONCLUSION: The presence of lobulated borders, T2 dark areas, necrosis, hyperintensity relative to the myometrium after contrast administration, central necrosis, presence of high signal on b1000 DWI, ADC value lower than 0.82 × 10-3 mm2/s and type 3 enhancing curve on DCE can help distinguish between leiomyoma and leiomyosarcoma. The association of lobulated borders and central necrosis can help predict a malignant histology.

Benign ovarian lesions with restricted diffusion.

Developments in magnetic resonance imaging have expanded its role in the assessment of the female pelvis, including the diagnosis of ovarian lesions. In this setting, diffusion-weighted imaging has proven its diagnostic value, which is particularly important in differentiating between benign and malignant ovarian tumors. In general, the latter show restricted diffusion, whereas the former do not. Exceptions include teratomas, endometriomas, hemorrhagic cysts, ovarian abscesses, ovarian infarction, and some benign stromal tumors. The aim of this review is to draw attention to benign ovarian lesions with restricted diffusion, with a special focus on diffusion-weighted imaging pearls and pitfalls.

Os recentes desenvolvimentos nas técnicas de ressonância magnética aumentaram o seu papel na avaliação da pelve em mulheres, incluindo o diagnóstico de lesões ovarianas. A imagem ponderada em difusão comprovou ter um valor diagnóstico indiscutível, fato particularmente importante na diferenciação entre tumores ovarianos benignos e malignos. Em geral, os últimos têm restrição na difusão, enquanto os primeiros não. As exceções incluem teratomas, endometriomas, cistos hemorrágicos, abcessos ovarianos, enfarte ovariano e alguns tumores benignos do estroma ovariano. Esta revisão tem como objetivo expor lesões ovarianas benignas com restrição na difusão, com especial enfoque nas pérolas e armadilhas da imagem ponderada em difusão.

Primary vaginal malignancies: a single oncology centre experience.

Primary vaginal malignancies constitute a rare entity. The aim of this study was to review all primary vaginal malignancies diagnosed in an oncologic referral centre over 11 years. A total of 35 cases were retrospectively analysed, including clinical and MRI features. Squamous cell carcinoma (SCC) was the most frequent histologic subtype (77.1%), followed by adenocarcinoma (14.3%). There was no statistically significant difference for the mean age at diagnosis or for the mean largest diameter of the tumour. Most SCCs (95%) were homogeneous on T2-weighted imaging, while all adenocarcinomas were heterogeneous (p = .0001). Concerning location, both SCCs (59.3%) and adenocarcinomas (80%) occurred more often on the upper third. However, regarding the wall of origin, all adenocarcinomas originated on the anterior vaginal wall (p = .0002), while SCCs (62.5%) had a predisposition for the posterior wall (p = .017). Regarding the history of previous hysterectomy, in the SCC group, 73.3% of patients with previous hysterectomies had cervical dysplasia (p = .018). Impact statement What is already known on this subject? MRI plays an important role in the initial approach of primary vaginal malignancies. In previous studies, it is said that SCCs usually appear homogeneous on T2WI, with the intermediate-high signal, while adenocarcinomas are often homogeneously hyperintense. Regarding location, it is known that SCCs usually arise from the posterior wall of the upper third, while adenocarcinomas often originate on the anterior wall of the proximal third. What do the results of this study add? In this study, we found that all of our cases of adenocarcinomas were heterogeneous on T2WI, with high-signal intensity areas, while SCCs were predominantly homogeneous, and this association was statistically significant. We could also confirm the data in the literature regarding the most common location of these tumours. This study also showed an association between vaginal SCC and a previous hysterectomy with cervical dysplasia. What are the implications of these findings for clinical practice and/or further research? The histologic type of vaginal malignancy has clinical and management impact. Although MRI is usually performed after histologic characterisation, this is not always the case. We think that this study can constitute a starting point to better understand the MRI features of these rare tumours. Although this technique will obviously never preclude histologic characterisation, it may provide some initial hint on the type of tumour and its aggressiveness.

Benign ovarian lesions with restricted diffusion / Lesões ovarianas benignas com restrição na difusão

Abstract Developments in magnetic resonance imaging have expanded its role in the assessment of the female pelvis, including the diagnosis of ovarian lesions. In this setting, diffusion-weighted imaging has proven its diagnostic value, which is particularly important in differentiating between benign and malignant ovarian tumors. In general, the latter show restricted diffusion, whereas the former do not. Exceptions include teratomas, endometriomas, hemorrhagic cysts, ovarian abscesses, ovarian infarction, and some benign stromal tumors. The aim of this review is to draw attention to benign ovarian lesions with restricted diffusion, with a special focus on diffusion-weighted imaging pearls and pitfalls.

Resumo Os recentes desenvolvimentos nas técnicas de ressonância magnética aumentaram o seu papel na avaliação da pelve em mulheres, incluindo o diagnóstico de lesões ovarianas. A imagem ponderada em difusão comprovou ter um valor diagnóstico indiscutível, fato particularmente importante na diferenciação entre tumores ovarianos benignos e malignos. Em geral, os últimos têm restrição na difusão, enquanto os primeiros não. As exceções incluem teratomas, endometriomas, cistos hemorrágicos, abcessos ovarianos, enfarte ovariano e alguns tumores benignos do estroma ovariano. Esta revisão tem como objetivo expor lesões ovarianas benignas com restrição na difusão, com especial enfoque nas pérolas e armadilhas da imagem ponderada em difusão.

Endometrial Cancer MRI staging: Updated Guidelines of the European Society of Urogenital Radiology.

OBJECTIVES: To update the 2009 ESUR endometrial cancer guidelines and propose strategies to standardize image acquisition, interpretation and reporting for endometrial cancer staging with MRI. METHODS: The published evidence-based data and the opinion of experts were combined using the RAND-UCLA Appropriateness Method and formed the basis for these consensus guidelines. The responses of the experts to 81 questions regarding the details of patient preparation, MR imaging protocol, image interpretation and reporting were collected, analysed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (if at least 80% consensus among experts) or uncertain (if less than 80% consensus among experts). RESULTS: Consensus regarding patient preparation, MR image acquisition, interpretation and reporting was determined using the RAND-UCLA Appropriateness Method. A tailored MR imaging protocol and a standardized report were recommended. CONCLUSIONS: These consensus recommendations should be used as a guide for endometrial cancer staging with MRI. KEY POINTS: • MRI is recommended for initial staging of endometrial cancer. • MR imaging protocol should be tailored based on the risk of lymph node metastases. • Myometrial invasion is best assessed using combined axial-oblique T2WI, DWI and contrast-enhanced imaging. • The mnemonic "Clinical and MRI Critical TEAM" summarizes key elements of the standardized report.

Endometrial cancer after radiation therapy for cervical carcinoma: A radiological approach.

Clinical and pathological aspects of endometrial cancers that develop after radiation therapy for cervical carcinoma have been studied for years but their imaging features have not yet been described. To determine these features, we performed a retrospective study that included all patients of our institution that were diagnosed with an endometrial cancer after being submitted to radiation therapy for cervical cancer and that performed computed tomography (CT) or magnetic resonance (MR) imaging at the time of the diagnosis, in a period of 11 years. We found 13 patients meeting these inclusion criteria. A wide range of morphologies were observed: single solid tumors (46%); single mixed tumors (15%); large heterogeneous multifocal tumors (15%) and multifocal small polypoid tumors (15%). Large tumors were frequent at presentation, with 65% of the lesions measuring more than 5 cm (mean, 7.4 cm; range, 1.2-14.9 cm). Hematometra was a striking feature that was present in 85% of the cases, with a mean volume of 318 mL and was associated in 91% of the cases with cervical stenosis, a known complication of pelvic radiotherapy that could justify a delay in symptoms presentation. Post-radiotherapy changes and hematometra limited the utility of MR imaging in local staging. Distant metastases could be promptly diagnosed with CT or MR imaging and were observed in 42% of the patients. These rare heterogeneous tumors should be considered after radiotherapy for cervical carcinoma, especially when hematometra is observed. Aggressive histological presentations and delayed symptoms due to cervical stenosis are responsible for an unfavorable prognosis.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas.

OBJECTIVE: The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas. METHODS: Guidelines for imaging uterine leiomyomas were defined based on a survey distributed to all members of the working group, an expert consensus meeting at European Congress of Radiology (ECR) 2017 and a critical review of the literature. RESULTS: The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed. CONCLUSIONS: MRI offers an outstanding and reproducible map of the size, site and distribution of leiomyomas. A standardised imaging protocol and method of reporting ensures that the salient features are recognised. These imaging guidelines are based on the current practice among expert radiologists in the field of female pelvic imaging and also incorporate essentials of the current published MR literature of uterine leiomyomas. KEY POINTS: • MRI allows comprehensive mapping of size and distribution of leiomyomas. • Basic MRI comprise T2W and T1W sequences centered to the uterus. • Standardized reporting ensures pivotal information on leiomyomas, the uterus and differential diagnosis. • MRI aids in differentiation of leiomyomas from other benign and malignant entities, including leiomyosarcoma.