Interval Colorectal Cancer in Inflammatory Bowel Disease: A Review.

Inflammatory bowel disease (IBD) increases the risk of dysplasia and colorectal cancer (CRC). Moreover, colitis-associated CRC is responsible for a disproportionate number of CRC-related mortality. For this reason, societies recommend screening and surveillance colonoscopy as the standard of care for patients with ulcerative colitis and Crohn's colitis. Nonetheless, interval cancer defined as CRC detected within the appropriate surveillance interval might still occur despite following guideline recommendations. Even though there is limited data on risk factors associated with interval CRC in IBD, patient and disease-associated factors and technical aspects of the surveillance might play a role. This review aims to provide information on the epidemiology of interval CRC in IBD, the factors that might be associated with its occurrence, and the challenges of CRC screening and dysplasia management in patients with IBD.

Smooth muscle tumours of the uterus: MR imaging malignant predictive features-a 12-year analysis in a referral hospital in Portugal.

PURPOSE: To evaluate the magnetic resonance imaging (MRI) features that may help distinguish leiomyosarcomas from atypical leiomyomas (those presenting hyperintensity on T2-W images equal or superior to 50% compared to the myometrium). MATERIALS AND METHODS: The authors conducted a retrospective single-centre study that included a total of 57 women diagnosed with smooth muscle tumour of the uterus, who were evaluated with pelvic MRI, between January 2009 and March 2020. All cases had a histologically proven diagnosis (31 Atypical Leiomyomas-ALM; 26 Leiomyosarcomas-LMS). The MRI features evaluated in this study included: age at presentation, dimension, contours, intra-tumoral haemorrhagic areas, T2-WI heterogeneity, T2-WI dark areas, flow voids, cyst areas, necrosis, restriction on diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) values, signal intensity and heterogeneity after contrast administration in T1-WI, presence and location of unenhanced areas. The association between the MRI characteristics and the histological subtype was evaluated using Chi-Square and ANOVA tests. RESULTS: The MRI parameters that showed a statistically significance correlation with malignant histology and thus most strongly associated with LMS were found to be: irregular contours (p < 0.001), intra-tumoral haemorrhagic areas (p = 0.028), T2-WI dark areas (p = 0.016), high signal intensity after contrast administration (p = 0.005), necrosis (p = 0.001), central location for unenhanced areas (p = 0.026), and ADC value lower than 0.88 × 10-3 mm2/s (p = 0.002). CONCLUSION: With our work, we demonstrate the presence of seven MRI features that are statistically significant in differentiating between LMS and ALM.

Staging, recurrence and follow-up of uterine cervical cancer using MRI: Updated Guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018.

OBJECTIVES: The recommendations cover indications for MRI examination including acquisition planes, patient preparation, imaging protocol including multi-parametric approaches such as diffusion-weighted imaging (DWI-MR),  dynamic contrast-enhanced imaging (DCE-MR) and standardised reporting. The document also underscores the value of whole-body 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) and highlights potential future methods. METHODS: In 2019, the ESUR female pelvic imaging working group reviewed the revised 2018 FIGO staging system, the up-to-date clinical management guidelines, and the recent imaging literature. The RAND-UCLA Appropriateness Method (RAM) was followed to develop the current ESUR consensus guidelines following methodological steps: literature research, questionnaire developments, panel selection, survey, data extraction and analysis. RESULTS: The updated ESUR guidelines are recommendations based on ≥ 80% consensus among experts. If ≥ 80% agreement was not reached, the action was indicated as optional. CONCLUSIONS: The present ESUR guidelines focus on the main role of MRI in the initial staging, response monitoring and evaluation of disease recurrence. Whole-body FDG-PET plays an important role in the detection of lymph nodes (LNs) and distant metastases. KEY POINTS: • T2WI and DWI-MR are now recommended for initial staging, monitoring of response and evaluation of recurrence. • DCE-MR is optional; its primary role remains in the research setting. • T2WI, DWI-MRI and whole-body FDG-PET/CT enable comprehensive assessment of treatment response and recurrence.

Clinical Features of Asymptomatic SARS-CoV-2 Infection in Hemodialysis Patients.

BACKGROUND: CKD is a risk factor for severe COVID-19. However, the clinical spectrum of COVID-19 in hemodialysis patients is still poorly characterized. OBJECTIVE: To analyze the clinical spectrum of COVID-19 on hemodialysis patients. METHOD: A retrospective observational study was conducted on 66 hemodialysis patients. Nasopharyngeal swab PCR and serology for SARS-CoV-2, blood analysis, chest radiography, treatment, and outcomes were assessed. RESULTS: COVID-19 was diagnosed in 50 patients: 38 (76%) were PCR-positive and 12 (24%) were PCR-negative but developed anti-SARS-CoV-2 antibodies. By contrast, 17% of PCR-positive patients failed to develop detectable antibodies against SARS-CoV-2. Among PCR-positive patients, 5/38 (13%) were asymptomatic, while among PCR-negative patients 7/12 (58%) were asymptomatic (p = 0.005) for a total of 12/50 (24%) asymptomatic patients. No other differences were found between PCR-positive and PCR-negative patients. No differences in potential predisposing factors were found between asymptomatic and symptomatic patients except for a lower use of ACE inhibitors among asymptomatic patients. Asymptomatic patients had laboratory evidence of milder disease such as higher lymphocyte counts and oxygen saturation and lower troponin I and interleukin-6 levels than symptomatic patients. Overall mortality was 7/50 (14%) and occurred only in symptomatic PCR-positive patients in whom mortality was 7/33 (21%). CONCLUSIONS: Asymptomatic SARS-CoV-2 infection is common in hemodialysis patients, especially among patients with initial negative PCR that later seroconvert. Thus COVID-19 mortality in hemodialysis patients may be lower than previously estimated based on PCR tests alone.

MRI of female genital tract congenital anomalies: European Society of Urogenital Radiology (ESUR) guidelines.

OBJECTIVE: To develop imaging guidelines for the MR work-up of female genital tract congenital anomalies (FGTCA). METHODS: These guidelines were prepared based on a questionnaire sent to all members of the European Society of Urogenital Radiology (ESUR) Female Pelvic Imaging Working Group (FPI-WG), critical review of the literature and expert consensus decision. RESULTS: The returned questionnaires from 17 different institutions have shown reasonable homogeneity of practice. Recommendations with focus on patient preparation and MR protocol are proposed, as these are key to optimised examinations. Details on MR sequences and planning of uterus-orientated sequences are provided. CONCLUSIONS: The multiplanar capabilities and soft tissue resolution of MRI provide superb characterisation of the wide spectrum of findings in FGTCA. A standardised imaging protocol and method of reporting ensures that the salient features are recognised, contributing to a correct diagnosis and classification of FGTCA, associated anomalies and complications. These imaging guidelines are based on current practice among expert radiologists in the field and incorporate up to date information regarding MR protocols and essentials of recently published classification systems. KEY POINTS: • MRI allows comprehensive evaluation of female genital tract congenital anomalies, in a single examination. • A dedicated MRI protocol comprises uterus-orientated sequences and vaginal and renal evaluation. • Integration of classification systems and structured reporting helps in successful communication of the imaging findings.

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.

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.

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.

ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update.

An update of the 2010 published ESUR recommendations of MRI of the sonographically indeterminate adnexal mass integrating functional techniques is provided. An algorithmic approach using sagittal T2 and a set of transaxial T1 and T2WI allows categorization of adnexal masses in one of the following three types according to its predominant signal characteristics. T1 'bright' masses due to fat or blood content can be simply and effectively determined using a combination of T1W, T2W and FST1W imaging. When there is concern for a solid component within such a mass, it requires additional assessment as for a complex cystic or cystic-solid mass. For low T2 solid adnexal masses, DWI is now recommended. Such masses with low DWI signal on high b value image (e.g. > b 1000 s/mm2) can be regarded as benign. Any other solid adnexal mass, displaying intermediate or high DWI signal, requires further assessment by contrast-enhanced (CE)T1W imaging, ideally with DCE MR, where a type 3 curve is highly predictive of malignancy. For complex cystic or cystic-solid masses, both DWI and CET1W-preferably DCE MRI-is recommended. Characteristic enhancement curves of solid components can discriminate between lesions that are highly likely malignant and highly likely benign. KEY POINTS: • MRI is a useful complementary imaging technique for assessing sonographically indeterminate masses. • Categorization allows confident diagnosis in the majority of adnexal masses. • Type 3 contrast enhancement curve is a strong indicator of malignancy. • In sonographically indeterminate masses, complementary MRI assists in triaging patient management.

The shading sign: is it exclusive of endometriomas?

OBJECTIVES: To investigate if the shading sign is an exclusive MRI feature of endometriomas or endometrioid tumors, and to analyze its different patterns. METHODS: Three hundred and fourty six women with adnexal masses who underwent 1.5/3-T MRI were included in this retrospective, board-approved study. The shading sign was found in 56 patients, but five cases were excluded due to lack of imaging follow-up or histological correlation. The final sample included 51 women. The type of tumor and the pattern of shading were recorded for each case. RESULTS: Thirty endometriomas and five endometrioid carcinomas were found. The remaining 16 cases corresponded to other benign and malignant tumors. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 93%, 59%, and 96%, respectively. Restricting the analysis to cystic lesions without solid or fat component, sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 96%, 94%, and 80%. Five shading patterns were identified: layering (15.7%), liquid-liquid level (11.8%), homogenous (45.1%), heterogeneous (11.8%), and focal/multifocal shading within a complex mass (19.6%). No significant correlation was found between these patterns and the type of tumor. CONCLUSIONS: The shading sign is not exclusive of endometriomas or endometrioid tumors. Homogenous shading was the most prevalent pattern in endometriomas and half of the cases with focal/multifocal shading within a complex mass were endometrioid carcinomas.

Clear cell carcinoma of the ovary: Clues for radiologists to perform a correct diagnosis.

Ovarian clear cell carcinoma (OCCC) is an uncommon high-grade primary epithelial ovarian cancer, covering about 10-12 % of all ovarian malignancies. It has a strong association with endometriosis. OCCC diagnosis, at advanced stages, has an aggressive biological behaviour, and the therapeutic strategies for ovarian OCCC are somehow different from other ovarian carcinomas. Therefore, early diagnosis of these tumours is of extreme importance. As some ovarian tumours subtypes have distinguishing features, it is possible to differentiate them based on their imaging characteristics, which can guide patient management and help the clinicians and pathologists in their diagnosis. A large mass on one side of the ovary that is mostly cystic, with a focal or multifocal irregular eccentric growing solid mural nodules or projections protruding into the cystic space, may suggest clear cell carcinoma of the ovary diagnosis. The solid nodules usually have an intermediate signal on T2-weighted images. The cystic component can be either single or multilocular, and the contents may contain protein or blood. CT scanning is still the preferred method for preoperative staging and postoperative restaging, and radiologists are crucial in identifying this type of tumour. We reviewed the imaging files of patients with surgically proven clear cell carcinoma at the specimens, and our findings agree with previous studies. This paper aims to perform a comprehensive revision of OCCC's radiological and clinic-pathological features and assist radiologists in recognizing OCCC and narrowing down the possibilities of differential diagnosis.

Investigating the neural mechanisms of transcranial direct current stimulation effects on human cognition: current issues and potential solutions.

Transcranial direct current stimulation (tDCS) has been studied extensively for its potential to enhance human cognitive functions in healthy individuals and to treat cognitive impairment in various clinical populations. However, little is known about how tDCS modulates the neural networks supporting cognition and the complex interplay with mediating factors that may explain the frequently observed variability of stimulation effects within and between studies. Moreover, research in this field has been characterized by substantial methodological variability, frequent lack of rigorous experimental control and small sample sizes, thereby limiting the generalizability of findings and translational potential of tDCS. The present manuscript aims to delineate how these important issues can be addressed within a neuroimaging context, to reveal the neural underpinnings, predictors and mediators of tDCS-induced behavioral modulation. We will focus on functional magnetic resonance imaging (fMRI), because it allows the investigation of tDCS effects with excellent spatial precision and sufficient temporal resolution across the entire brain. Moreover, high resolution structural imaging data can be acquired for precise localization of stimulation effects, verification of electrode positions on the scalp and realistic current modeling based on individual head and brain anatomy. However, the general principles outlined in this review will also be applicable to other imaging modalities. Following an introduction to the overall state-of-the-art in this field, we will discuss in more detail the underlying causes of variability in previous tDCS studies. Moreover, we will elaborate on design considerations for tDCS-fMRI studies, optimization of tDCS and imaging protocols and how to assure high-level experimental control. Two additional sections address the pressing need for more systematic investigation of tDCS effects across the healthy human lifespan and implications for tDCS studies in age-associated disease, and potential benefits of establishing large-scale, multidisciplinary consortia for more coordinated tDCS research in the future. We hope that this review will contribute to more coordinated, methodologically sound, transparent and reproducible research in this field. Ultimately, our aim is to facilitate a better understanding of the underlying mechanisms by which tDCS modulates human cognitive functions and more effective and individually tailored translational and clinical applications of this technique in the future.

Adenomyosis at a Glance: An Integrated Review of Transvaginal Ultrasound and MR Imaging Findings.

Adenomyosis is a benign uterine disorder increasingly recognized in premenopausal women. Given its significant clinical burden, an accurate noninvasive diagnosis is paramount. Both transvaginal ultrasound (TVUS) and magnetic resonance (MR) provide an adequate assessment of adenomyosis, the former being recommended for first-line imaging evaluation and the latter being mainly used as a problem-solving technique. In this article, the authors review the TVUS and MR imaging findings of adenomyosis while referring to their histopathological background. Whereas direct signs correlate directly to ectopic endometrial tissue and are highly specific to adenomyosis, indirect signs result from myometrial hypertrophy and increase diagnostic sensitivity. Potential pitfalls, differential diagnoses, and frequently associated estrogen-dependent conditions are also discussed.

Ovarian dysgerminoma: clues to the radiological diagnosis.

Ovarian dysgerminoma (OD) is a rare germ cell tumor accounting for 1%-2% of all malignant ovarian tumors and is generally associated with a good prognosis. The condition is more frequent in young women and can arise in dysgenetic gonads that contain gonadoblastomas. While the definitive diagnosis of OD is only possible histologically, certain radiological features can provide facilitating clues. A large, unilateral, solid, lobulated ovarian tumor with markedly enhancing septa should raise the suspicion of OD in young women. Serum lactate dehydrogenase is characteristically elevated in this tumor type and can complement its diagnosis and postoperative follow-up; however, it is a nonspecific marker. Moreover, knowing the mimickers of OD is essential to optimizing the radiological image interpretation and allowing for adequate management and timely treatment. Therefore, in this article, the radiological and clinical-pathologic features of ODs were reviewed to allow radiologists to become familiarized with them and narrow the diagnostic possibilities when facing this type of tumor.

Breast cancer metastasizing to the upper gastrointestinal tract (the esophagus and the stomach): A comprehensive review of the literature.

Breast cancer can infrequently metastasize to the upper gastrointestinal (GI) tract but the exact incidence is not well established-there is considerable variation between incidence reported from clinical studies and incidence noted in autopsy series. Clinical presentation can be very non-specific and often mimics primary gastrointestinal conditions. Endoscopy alone may not be sufficient to make a diagnosis and misdiagnosis is also common. A high degree of awareness and clinical suspicion is required to establish metastases to the upper GI tract. We undertook a comprehensive review of the available literature on breast cancer metastases to the esophagus and stomach including the clinical symptoms and presentation, endoscopic features, additional diagnostic imaging modalities, treatment and outcomes.

Abdominal splenosis mimicking peritoneal carcinomatosis of ovarian cancer.

We present the clinical case of a 53-year-old woman referred for suspicion of recurrence of a mesonephric-like adenocarcinoma of the ovary. Abdominal and pelvic CT revealed multiple round/oval solid nodules with similar density scattered throughout the abdomen and pelvis, the biggest ones appearing in the left hypochondrium; no normal-appearing spleen or ascites were observed. These radiological findings and the absence of significant elevation of CA 125 levels made the radiologists hypothesize that these aspects were related to abdominal splenosis. They asked the patient about previous medical history of splenic injury, which she confirmed, referring it was a consequence of a remote major trauma. A 99mTc-labeled heat-denatured erythrocytes (99mTc-DRBC) scintigraphy/ hybrid SPECT/CT was then performed for definitive diagnosis; it showed spleen remnants as foci of increased radiopharmaceutical uptake in the same locations as the nodules appearing in the CT. This diagnostic work-up was consistent with abdominal splenosis, mimicking peritoneal carcinomatosis of ovarian cancer.

Malignant peripheral nerve sheath tumor mimicking an adnexal mass: a radio-pathologic correlation.

We report the case of a pelvic malignant peripheral nerve sheath tumor mimicking an adnexal mass. A 59-year-old postmenopausal woman presented with a 3-month history of diffuse abdominal bloating and urinary frequency. Laboratory tests revealed an increased CA 125. Radiologic evaluation depicted a large, heterogeneous solid mass located right to the uterus, pushing it to the left. After a multidisciplinary board discussion, the diagnosis of a right adnexal lesion was assumed, and the patient was referred to surgery. The final diagnosis was only achieved after pathology examination, which prove to be a malignant peripheral nerve sheath tumor. This paper highlights some clinical, radiologic and pathological features of malignant peripheral nerve sheath tumors, a rare entity that should be considered as a differential in patients presenting with pelvic tumors of uncertain origin.