European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis.

Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence. KEY POINTS: • This report provides guidelines for MRI in endometriosis. • Minimal and optimal MRI acquisition protocols are provided. • Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.

Intra-individual randomised comparison of gadobutrol 1.0 M versus gadobenate dimeglumine 0.5 M in patients scheduled for preoperative breast MRI.

OBJECTIVE: To demonstrate non-inferiority of gadobutrol versus gadobenate dimeglumine by intra-individually comparing 0.1 mmol/kg body weight doses for contrast-enhanced breast magnetic resonance imaging (MRI) and prospectively evaluating lesion detection and characterisation in a multicentre trial. METHODS: Two identical breast MRI examinations were performed in 72 patients with biopsy-proven breast cancer, separated by 1-7 days. Gadobutrol 1.0 M or gadobenate 0.5 M were administered in a randomised order. Lesion detection and characterisation were performed by two independent blinded readers. Lesion tracking, which compared on-site readings and histology from surgery or biopsy, was performed by a third reader. Differences in lesion detection and characterisation were compared between the two contrast agents. RESULTS: Among 103 lesions, 96 were malignant and 7 were benign. No difference in lesion detection was identified between the contrast agents (82.33 % for gadobutrol, 81.60 % for gadobenate). Assessment of sensitivity in lesion characterisation and Breast Imaging Reporting and Data Systems showed no difference between gadobutrol (92.63 %) and gadobenate (90.53 %). Regarding morphology, there was more non-focal enhancement for gadobutrol than for gadobenate (P = 0.0057). CONCLUSION: Non-inferiority of gadobutrol compared with gadobenate was demonstrated for breast lesion detection and sensitivity in lesion characterisation in breast MRI.

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology.

OBJECTIVE: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. METHODS: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. RESULTS: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. CONCLUSIONS: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Mass detection on mammograms: influence of signal shape uncertainty on human and model observers.

We studied the influence of signal variability on human and model observers for detection tasks with realistic simulated masses superimposed on real patient mammographic backgrounds and synthesized mammographic backgrounds (clustered lumpy backgrounds, CLB). Results under the signal-known-exactly (SKE) paradigm were compared with signal-known-statistically (SKS) tasks for which the observers did not have prior knowledge of the shape or size of the signal. Human observers' performance did not vary significantly when benign masses were superimposed on real images or on CLB. Uncertainty and variability in signal shape did not degrade human performance significantly compared with the SKE task, while variability in signal size did. Implementation of appropriate internal noise components allowed the fit of model observers to human performance.

Staging of endometrial cancer with MRI: guidelines of the European Society of Urogenital Imaging.

The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2 min +/- 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.

Prospective study of 310 patients: can early CT predict the severity of acute pancreatitis?

BACKGROUND: This study was designed to determine the most important early CT parameters predictive of acute pancreatitis severity. METHODS: Three hundred and seventy-one consecutive patients with acute abdominal pain and hyperamylasemia were enrolled. Three hundred and ten of the 371 patients met our inclusion criteria. Acute pancreatitis severity was evaluated using the 1992 Atlanta criteria. Different CT parameters were reported from the admission abdominal CT by two radiologists blinded from any clinical parameter, but the patients' age and gender. These variables were fitted in a binary logistic regression model. RESULTS: Acute pancreatitis was mild in 80% cases, severe in 20% cases and lethal in 12.69% cases. The following CT parameters were significantly associated with the severity of acute pancreatitis: the objective size of the pancreas (P = 0.001), the peripancreatic fat abnormalities (P = 0.001) and the extent of necrosis (P = 0.007). Moreover, the age of the patient revealed itself a highly significant (P = 0.001) indicator of disease severity. The association of the four CT criteria eventually showed a sensitivity of 73% and a specificity of 81% to predict acute pancreatitis severity. CONCLUSION: Although these criteria correlated with disease severity, our study identified that morphological CT criteria cannot be used to triage patients with severe and mild acute pancreatitis.

Pitfalls in staging uterine neoplasm with imaging: a review.

This review analyzes current pitfalls in pretreatment staging of endometrial and cervical carcinoma with magnetic resonance imaging (MRI) based on a critical review of the literature. Technical, patient, and tumor-related characteristics were analyzed to improve further staging of uterine neoplasm with MRI. For endometrial carcinoma staging, contrast-enhanced dynamic imaging appears essential to avoid false-positive findings for deep myometrial invasion by better delineating tumor from normal myometrium. However, leiomyomas, adenomyosis, and grade 3 tumors provide difficulties in staging for pathologists and radiologists. Slice orientation perpendicular to the long axis of the cervical channel might improve false-negative findings for deep stromal invasion on T2-weighted images in endometrial and cervical cancer. Contrast-enhanced sequences do not improve diagnosis of parametrial or vaginal invasion in cervical cancer. Assessment of lymph node invasion by any imaging modality has limited sensitivity in detecting lymph node metastasis smaller than 5 mm. Knowledge of diagnostic criteria is critical to avoid false-negative findings for bladder wall invasion. Higher spatial resolution with dedicated multichannel pelvic phase array coils, smaller fields of view and section thickness, and careful comparison of T2-weighted and contrast-enhanced sequences are strategies that might avoid misinterpretation of pelvic MRI in staging uterine neoplasm.

[Practice guidelines: conservative treatment of fibroids]. / Traitement conservateur des fibromes: recommandations pour la pratique.

The conservative treatment of uterine fibroids is essentially based on symptomatology and patient's choice of treatment. The gynaecologist must develop a clear therapeutic protocol based on clinical examination, available test results and consideration of patient preference. The therapeutic options include close surveillance, hormonal treatments, conservative operative endoscopy and arterial embolization.

[Using BI-RADS in French]. / Le système BI-RADS en imagerie mammaire: initiation à son utilisation en version française.

BI-RADStrade mark is the referral lexicon in the United States for the classification of terms which are used for reporting breast imaging. The purpose of this chapter is to present and summarize the French version.

Comparison of magnetic resonance imaging and transvaginal ultrasonography in diagnosing bladder endometriosis.

STUDY OBJECTIVE: To take recent progress in magnetic resonance imaging (MRI) into account to determine its accuracy compared with that of transvaginal ultrasonography (TVUS) in diagnosing bladder endometriosis. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Twelve women with histologically proved bladder endometriosis. INTERVENTION: Magnetic resonance imaging with body and endocavitary coils and TVUS. MEASUREMENTS AND MAIN RESULTS: Although TVUS was normal in four patients, MRI enabled endometriotic lesions to be detected in all patients. Magnetic resonance imaging with endocavitary coil established the existence of deep infiltration in three patients when muscularis involvement was not visible with the body coil. In seven women MRI determined how far deep posterior endometriotic lesions extended, whereas with TVUS this was impossible to see. Conclusion. MRI had advantages over TVUS in diagnosing small lesions of associated posterior deep endometriotic lesions. The endocavitary coil gave better results than the phased-array coil for diagnosing deep infiltration. These results are important in that they help guide surgical management.

MR imaging: breast cancer staging and screening.

This review describes the current knowledge and challenges of breast cancer staging and screening with MRI of the breast. Assessment of local disease extent, including tumor size, multicentricity, and chest wall invasion, can be obtained more accurately with MRI than with mammography. Moreover, international experts have established standardized reporting of MRI staging results, taking into account tumor size measurements and the number of breast quadrants involved. Results from MRI assessment of the axilla and skin are promising, but need further refinement. Preliminary results of the use of breast MRI in patients at high risk for breast cancer demonstrated a superiority of breast MRI over the combined use of mammography and high-frequency ultrasound. The role of MRI in this subset of patients may be confirmed by ongoing larger multicenter trials. Strict protocol conditions are mandatory to maintain a high standard of quality. Confirming the nature of "MRI-only" lesions with MRI-guided biopsy systems will allow changes in treatment planning. More accurate tumor diagnosis and tumor volume evaluation may allow minimally invasive treatment strategies.

Challenges to interpretation of breast MRI.

This review describes the current knowledge and challenges of lesion interpretation with MRI of the breast according to different image interpretation strategies. Particular emphasis is given to patient- and tumor-related factors that influence image interpretation. The impacts of the menstrual cycle, prior surgery, radiation therapy, and chemotherapy are summarized. Particular enhancement features of ductal carcinoma in situ (DCIS) or invasive lobular carcinoma are described. Finally, an adequate diagnosis at MRI of the breast should take into account the results of the patient's history, physical examination, and all imaging tests performed before MRI. J. Magn. Reson. Imaging 2001;13:821-829.

Staging endometrial cancer: role of magnetic resonance imaging.

This review article summarizes and comments the role of magnetic resonance imaging (MRI) in the management of endometrial cancer. The MRI technique, appearance, and diagnostic criteria of endometrial carcinoma are discussed. The value of MRI in the preoperative staging of endometrial cancer is compared to alternative strategies. Contrast-enhanced MRI performs best in the pretreatment evaluation of myometrial or cervical invasion, compared to ultrasonography (US), computed tomography (CT), or nonenhanced MRI. The overall costs and accuracy are similar to those of the current methods of staging, including intraoperative gross dissection of the uterus. In addition, results of MRI might decrease the number of unnecessary lymph node dissections. J. Magn. Reson. Imaging 2001;13:850-855.

Development, standardization, and testing of a lexicon for reporting contrast-enhanced breast magnetic resonance imaging studies.

The purpose of this study was to develop, standardize, and test reproducibility of a lexicon for reporting contrast-enhanced breast magnetic resonance imaging (MRI) examinations. To standardize breast MRI lesion description and reporting, seven radiologists with extensive breast MRI experience developed consensus on technical detail, clinical history, and terminology reporting to describe kinetic and architectural features of lesions detected on contrast-enhanced breast MR images. This lexicon adapted American College of Radiology Breast Imaging and Data Reporting System terminology for breast MRI reporting, including recommendations for reporting clinical history, technical parameters for breast MRI, descriptions for general breast composition, morphologic and kinetic characteristics of mass lesions or regions of abnormal enhancement, and overall impression and management recommendations. To test morphology reproducibility, seven radiologists assessed morphology characteristics of 85 contrast-enhanced breast MRI studies. Data from each independent reader were used to compute weighted and unweighted kappa (kappa) statistics for interobserver agreement among readers. The MR lexicon differentiates two lesion types, mass and non-mass-like enhancement based on morphology and geographical distribution, with descriptors of shape, margin, and internal enhancement. Lexicon testing showed substantial agreement for breast density (kappa = 0.63) and moderate agreement for lesion type (kappa = 0.57), mass margins (kappa = 0.55), and mass shape (kappa = 0.42). Agreement was fair for internal enhancement characteristics. Unweighted kappa statistics showed highest agreement for the terms dense in the breast composition category, mass in lesion type, spiculated and smooth in mass margins, irregular in mass shape, and both dark septations and rim enhancement for internal enhancement characteristics within a mass. The newly developed breast MR lexicon demonstrated moderate interobserver agreement. While breast density and lesion type appear reproducible, other terms require further refinement and testing to lead to a uniform standard language and reporting system for breast MRI. J. Magn. Reson. Imaging 2001;13:889-895.

US characterization of ovarian masses: a meta-analysis.

PURPOSE: To compare the effectiveness of current ultrasonographic (US) techniques for characterizing ovarian masses. MATERIALS AND METHODS: Through a MEDLINE literature search, articles with imaging-histopathologic correlation and data that allowed calculation of contingency tables were identified. Results of morphologic assessment, Doppler US, color Doppler flow imaging, and combined techniques were compared. RESULTS: Among 89 data sets from 46 included studies (5,159 subjects), 35 sets used morphologic information, 36 measured Doppler US indexes, 10 assessed tumor vascularity with color Doppler flow imaging, and eight used combined techniques. Summary receiver operating characteristic curves revealed significantly higher performance for combined techniques than for morphologic information (P: =.003), Doppler US indexes (P: =.003), or color Doppler flow imaging alone (P: =.001). The Q* point (and 95% CI) for combined techniques was 0.92 (0.87, 0.96) versus 0. 85 (0.83, 0.88) for morphology, 0.82 (0.78, 0.86) for Doppler US, and 0.73 (0.58, 0.87) for color Doppler flow imaging. Morphologic assessment showed a trend toward better performance than color Doppler flow imaging (P: =.09) or Doppler US indexes (P: =.07). Doppler US index results were better in earlier studies (P: =.005). CONCLUSION: Combined US techniques and a diagnostic algorithm perform significantly better than morphologic assessment, color Doppler flow imaging, or Doppler US indexes alone in characterizing ovarian masses.

MR imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and MR imaging.

OBJECTIVE: Postsurgical contrast enhancement resulting from inflammatory changes at the site of surgery limits the accuracy of MR imaging of the breast in diagnosing residual breast cancer. This study was undertaken to evaluate the influence of the time interval between lumpectomy and MR imaging on the diagnosis of residual breast cancer. MATERIALS AND METHODS: Sixty-eight patients who had undergone excisional biopsy with positive resection margins underwent MR imaging for evaluation of residual breast cancer and possible breast conservation. Patients were retrospectively stratified according to the time interval between lumpectomy and MR imaging. Dynamic and morphologic enhancement features were used for lesion characterization. Imaging findings were correlated with results of histopathology. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for patients waiting 7, 14, 21, 28, 35, and 42 days after initial surgery before undergoing MR imaging of the breast. RESULTS: The time interval between lumpectomy and MR imaging of the breast had the greatest influence on the specificity and negative predictive value of MR imaging, increasing progressively over time. A plateau of highest values of 75% specificity and 86% negative predictive value was reached at 28 and 35 days after surgery, respectively. Although the sensitivity and positive predictive value showed smaller variations over time, peak values of 95% sensitivity and 92% positive predictive value were obtained at 35 and 28 days after surgery, respectively. CONCLUSION: We recommend scheduling patients with positive resection margins no earlier than 28 days after initial surgery for evaluation of residual cancer using MR imaging of the breast.