New MR techniques in gynecologic cancer.

OBJECTIVE: Functional MR techniques report on a variety of biologic features of tumors: dynamic contrast-enhanced, diffusion-weighted, and intrinsic susceptibility-weighted MRI and MR spectroscopy reflect, at a simplistic level, vascularity, cellularity, hypoxic status, and metabolism, respectively. This article reviews the evidence for each of the functional MR readouts to determine these clinical end points and thus influence the management of ovarian, endometrial, and cervical cancer. CONCLUSION: These techniques may be implemented in gynecologic malignancies to detect, characterize, and stage tumors as well as potentially to predict the outcome and measure response to treatment.

Metastatic ovarian and primary peritoneal cancer: assessing chemotherapy response with diffusion-weighted MR imaging--value of histogram analysis of apparent diffusion coefficients.

PURPOSE: To prospectively evaluate apparent diffusion coefficient (ADC) histograms in the prediction of chemotherapy response in patients with metastatic ovarian or primary peritoneal cancer. MATERIALS AND METHODS: Research ethics committee approval and patient written informed consent were obtained. Diffusion-weighted (DW) magnetic resonance (MR) imaging was performed through the abdomen and pelvis before and after one and three cycles of chemotherapy in 42 women (mean age, 63.0 years ± 11.4 [standard deviation]) with newly diagnosed or recurrent disease. Reproducibility and intra- and interobserver agreement of ADC calculations were assessed. Per-patient weighted ADC histograms were generated at each time point from pixel ADCs from five or fewer target lesions. Mean ADC, percentiles (10th, 25th, 50th, 75th, 90th), skew, kurtosis, and their change were analyzed according to histologic grade, primary versus recurrent disease status, and response, determined with integrated biochemical and morphologic criteria, with a linear mixed model. Areas under receiver operating characteristic curve (AUCs) for combinations of parameters were calculated with linear discriminant analysis. RESULTS: Coefficients of variation for repeat measurements and for within and between observers were 4.8%, 11.4%, and 13.7%, respectively. Grade and disease status did not significantly affect histogram parameters. Pretreatment ADCs were not predictive of response. In responders, all ADCs increased after the first and third cycle (P < .001), while skew and kurtosis decreased after the third (P < .001 and P = .006, respectively); however, in nonresponders, no parameter changed significantly. Percentage change of the 25th percentile performed best in identifying response (AUC = 0.82 and 0.83 after first and third cycle, respectively), whereas combination of parameters did not improve accuracy. CONCLUSION: An early increase of ADCs and later decrease of skew and kurtosis characterize chemotherapy response. Quantitative DW MR imaging can aid in early monitoring of treatment efficacy in patients with advanced ovarian cancer.

Optimising diffusion-weighted imaging in the abdomen and pelvis: comparison of image quality between monopolar and bipolar single-shot spin-echo echo-planar sequences.

OBJECTIVE: To compare geometric distortion, signal-to-noise ratio (SNR), apparent diffusion coefficient (ADC), efficacy of fat suppression and presence of artefact between monopolar (Stejskal and Tanner) and bipolar (twice-refocused, eddy-current-compensating) diffusion-weighted imaging (DWI) sequences in the abdomen and pelvis. MATERIALS AND METHODS: A semiquantitative distortion index (DI) was derived from the subtraction images with b = 0 and 1,000 s/mm(2) in a phantom and compared between the two sequences. Seven subjects were imaged with both sequences using four b values (0, 600, 900 and 1,050 s/mm(2)) and SNR, ADC for different organs and fat-to-muscle signal ratio (FMR) were compared. Image quality was evaluated by two radiologists on a 5-point scale. RESULTS: DI was improved in the bipolar sequence, indicating less geometric distortion. SNR was significantly lower for all tissues and b values in the bipolar images compared with the monopolar (p < 0.05), whereas FMR was not statistically different. ADC in liver, kidney and sacrum was higher in the bipolar scheme compared to the monopolar (p < 0.03), whereas in muscle it was lower (p = 0.018). Image quality scores were higher for the bipolar sequence (p ≤ 0.025). CONCLUSION: Artefact reduction makes the bipolar DWI sequence preferable in abdominopelvic applications, although the trade-off in SNR may compromise ADC measurements in muscle.

Diffusion-weighted imaging of peritoneal disease for noninvasive staging of advanced ovarian cancer.

Cross-sectional imaging of peritoneal carcinomatosis in patients with advanced ovarian cancer is important for appropriate management but can be compromised by the small size of cancer implants and the complexity of anatomic relationships. Diffusion-weighted imaging is a functional magnetic resonance (MR) imaging technique that exploits the restricted water mobility within hypercellular tumors to increase the contrast between these lesions and surrounding tissue. Its use improves the detection and delineation of peritoneal implants at both initial staging and follow-up. Moreover, diffusion-weighted imaging provides quantitative information about tissue cellularity that may be used to distinguish viable tumors from treatment-related changes. These data allow calculation of apparent diffusion coefficient (ADC) values, which, when considered in conjunction with biochemical and morphologic parameters, are helpful for assessing the effectiveness of treatment. The value of diffusion-weighted images is maximized when they are interpreted in comparison with anatomic MR images to avoid diagnostic pitfalls arising from normal hypercellular structures and neoplasms with low cellularity. When incorporating diffusion-weighted imaging into abdominal and pelvic MR studies, it is important to be aware of the strengths and limitations of the technique. Competence in data display methods and ADC calculations also helps improve the accuracy of image interpretation and may aid in the management of patients with advanced ovarian cancer.

A Ptolemaic mummy reveals evidence of invasive dentistry in ancient Egypt.

Over the last decades, it has been confirmed that computerized tomography (CT) is a valuable tool for studying mummies. In joint efforts put forth by the Mummy Research Project of the Hellenic Institute of Egyptology, the National Archaeological Museum, and the Athens Medical Center, a mummy was transported to the Radiology Department of the Athens Medical Center for study. Thus, a complete CT scanning was performed of this Ptolemaic mummy (AIG 3343: Sekhem, male, 150-30 BCE), belonging to the Egyptian Collection of the National Archaeological Museum of Athens. The most significant finding is an interproximal carious cavity packed with protective material. This is the second case of dental packing in the literature among ancient Egyptian mummies studied to date. Its remarkable resemblance to the previously published study may indicate a common dental intervention performed by ancient Egyptians. Despite the well-known early medical traditions of ancient Egypt, spanning from the Old Kingdom to the Ptolemaic and Roman Periods, little evidence remains of their practices in dentistry. Our finding represents a rare perspective on the origins of what remains today a major allied health field discipline.

Chronic maxillary atelectasis under the wrappings of an Egyptian mummy.

OBJECTIVES: In the context of a joint Mummy Research Project of the National Archaeological Museum, the Hellenic Institute of Egyptology and the Athens Medical Centre, an Egyptian mummy of the mid-Ptolemaic Period was transferred to our hospital and was thoroughly investigated with Computed Tomography. METHODS: The mummy was carefully removed from its coffin and scanned in a 64-detector row computed tomographic scanner. Multiplanar and anthropometric measurements were obtained using advanced software. RESULTS: The mummy appeared to be well-preserved and belonged to a young male adult. Among the findings, the most interesting and uncommon one was the asymmetry of the maxillary sinuses and the orbits. There were no signs of trauma. CONCLUSIONS: Computed Tomography revealed in a non-destructive way a rare, based on the published data, facial deformity in an Egyptian mummy attributed to chronic maxillary atelectasis.

Diffuse Calcifications of the Spleen in a Woman with Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, which affects a wide variety of organs including the spleen. Splenic involvement in SLE includes conditions such as splenomegaly, hyposplenism, infarction, and spontaneous rupture. However, only a few cases of splenic calcifications in patients with SLE have been reported. Herein, we present a case of a 24-year-old female diagnosed with SLE, in which we found diffuse splenic calcifications. The unique pattern of splenic calcifications in SLE contributes to the differential diagnosis from other conditions such as infections and other connective tissue diseases, which also cause calcifications in the spleen.

Uncinate fasciculus microstructure and verbal episodic memory in amyotrophic lateral sclerosis: a diffusion tensor imaging and neuropsychological study.

The present study evaluates the integrity of uncinate fasciculus (UF) and the association between UF microstructure and verbal episodic memory (as one of the cognitive functions linked to UF) in non-demented patients with amyotrophic lateral sclerosis (ALS) using diffusion tensor imaging (DTI). We studied 21 patients with ALS and 11 healthy, demographically-comparable volunteers. Fractional anisotropy, apparent diffusion coefficient, axial and radial diffusivity were the DTI metrics examined. Episodic memory was evaluated with Babcock Story Recall Test and Rey Auditory Verbal Learning Test (RAVLT) for patients; measures of immediate and delayed recall and retention for both tests and sum of words recalled through five learning trials for RAVLT were considered. Patients with ALS showed significant bilateral reduction of axial diffusivity in the UF as compared to controls. Furthermore, there were several significant relations between various DTI metrics (mostly in left hemisphere) and memory measures (specifically for the RAVLT). UF microstructural changes may contribute to ALS-related memory impairment, with word-list learning performance relying more upon the integrity of frontal and temporal connections than memory components associated with story recall.

Imaging ovarian cancer and peritoneal metastases--current and emerging techniques.

Peritoneal metastases are often the first presentation of ovarian malignancy. Evaluating the extent of disease critically determines tumor resectability and can also predict outcome. Standard CT, however, frequently fails to identify small sites of peritoneal spread. Moreover, it does not provide a quantitative index of disease response to cytotoxic therapy as it relies on macroscopic morphological changes in tumor volume, and does not reflect preceding molecular events in the microenvironment of the tumor. We describe the emerging role of functional imaging techniques, such as radioimmunoscintigraphy, PET/CT, diffusion-weighted MRI, dynamic contrast-enhanced MRI, and magnetic resonance spectroscopy in staging ovarian cancer and assessing treatment response. The combination of functional information with conventional anatomical visualization holds promise to accurately characterize peritoneal disease, and provides noninvasive biomarkers of therapeutic performance and patient prognosis.

Value of diffusion-weighted imaging for assessing site-specific response of advanced ovarian cancer to neoadjuvant chemotherapy: correlation of apparent diffusion coefficients with epithelial and stromal densities on histology.

This study correlates apparent diffusion coefficients (ADCs) from Diffusion-weighted Imaging (DWI) in primary ovarian tumours and their omental metastases following neoadjuvant chemotherapy with epithelial and stromal densities in order to relate them to histological composition. Eight patients underwent DWI at 1.5 T with four b-values (0, 600, 900, and 1,050 s/mm(2))at baseline and after one and three cycles of platinum-based chemotherapy. Mean ADCs were calculated at each timepoint from solid tumour at ovarian and omental sites. Specimens from 15 corresponding lesions (8 ovarian, 7 omental), obtained at interval debulking surgery, were stained immunohistochemically to quantify epithelial and stromal components. End-of-treatment ADC was correlated with epithelial and stromal densities. Longitudinal changes in ADC with treatment were compared between primary and metastatic lesions using parametric tests. No baseline differences in ADC between primary and metastatic sites were seen. Mean ADC increased significantly from baseline after both first and third cycle (P < 0.001) in both ovarian and omental lesions. ADC and total epithelial plus stromal density (lesion cellularity) were negatively correlated in ovarian lesions (r= -0.79, P=0.02) but not in omental metastases or when both sites were considered together. However, ADC and epithelial density were negatively correlated in ovarian (r=- 0.78, P=0.02) and omental lesions (r=-0.75, P=0.04) and when both sites were considered together (r=-0.77, P< 0.001). There was no significant correlation between ADC and stromal density. Thus ADC reflects mainly epithelial content in advanced ovarian cancer and is not solely a function of lesion cellularity.