Clinical Imaging

Extra-uterine endometrial stromal sarcoma arising from deep infiltrating endometriosis

We present a compelling case of a 45-year-old female with a history of endometriosis and leiomyomas, who presented to her gynecologist with chronic pelvic pain complaints. Both a transvaginal ultrasound (US) and an MRI (magnetic resonance imaging) were ordered. The US demonstrated multiple uterine lesions, likely fibroids, and an endometrioma within the right ovary. The MRI of the pelvis with and without gadolinium identified a mass within the right ovary with homogenous intermediate T2-signal, restricted diffusion, and delayed enhancement relative to the myometrium. Several irregular-shaped lesions were also noted within the external myometrium, anterior pelvic wall, and the peritoneum, which were intermediate signal on T2-weighted images, restricted diffusion, and an enhancement pattern similar to the myometrium. The patient underwent a right adnexectomy. The histopathology findings were consistent with a low-grade endometrial stromal sarcoma (low grade-ESS) arising from the endometrial stroma of the right ovary. A debulking surgery confirmed the involvement of external myometrium, anterior pelvic wall, and the peritoneum secondary to a low-grade ESS without the endometrial cavity's involvement. The underlying hypothesis is that the endometriosis stroma from extra-uterine structures such as the right ovary, pelvic and anterior peritoneum, and external myometrium may have subsequently resulted in a low-grade ESS. Low-grade extra-uterine ESS without endometrial involvement is a rare entity. Based on our literature search, this is one of the few reports covering the radiological features of low-grade extra-uterine ESS arising outside the uterus with a concomitant deep infiltrating endometriosis, but without the involvement of the endometrial cavity.

Use of natural language processing to uncover racial bias in obstetrical documentation

Natural Language Processing (NLP), a form of Artificial Intelligence, allows free-text based clinical documentation to be integrated in ways that facilitate data analysis, data interpretation and formation of individualized medical and obstetrical care. In this cross-sectional study, we identified all births during the study period carrying the radiology-confirmed diagnosis of fibroid uterus in pregnancy (defined as size of largest diameter of >5 cm) by using an NLP platform and compared it to non-NLP derived data using ICD10 codes of the same diagnosis. We then compared the two sets of data and stratified documentation gaps by race. Using fibroid uterus in pregnancy as a marker, we found that Black patients were more likely to have the diagnosis entered late into the patient's chart or had missing documentation of the diagnosis. With appropriate algorithm definitions, cross referencing and thorough validation steps, NLP can contribute to identifying areas of documentation gaps and improve quality of care.

Pelvic effusion in patients with ovarian thecoma-fibroma associated with the tumor size and plaste CA-125 level: A retrospective magnetic resonance imaging study

To survey the occurrence rate of ascites in patients with thecoma-fibroma and its potential correlation with tumor MR imaging characteristics. A total of 40 patients with surgically proven thecoma-fibroma were enrolled in this retrospective study. We determined the tumor size, the components (solid or cystic) and their signal intensity features. Second, we identified ascites according to the fat-suppressed sagittal T (1) Among the 40 cases, 15 tumors were fibromas, 15 thecomas, and 10 fibrothecomas. Nine patients (26.47%) had elevated CA-125 levels (>35.0 U/ml). (2) Thirty-one patients had ascites (77.50%), 29 of which had a small amount of ascites. Nine cases had no ascites (22.50%). (3) MRI showed a solid mass in 22 cases (55.0%), cystic mass in five cases (12.5%) and mixed solid-cystic mass in 13 cases (32.5%). The χ Our data revealed that the incidence of ascites was 77.50% and was mainly correlated with tumor size and elevated CA-125 levels. These findings have potential value for improving the diagnosis and differential diagnosis of thecoma-fibroma.

Bilateral ovarian metastasis of clear-cell renal cell carcinoma: A case report

Renal cell carcinoma (RCC) accounts for 2-3% of all adult malignancies. Clear-cell type RCC is the most common type, accounting for approximately 75% of all renal cancer cases. The most common sites of metastasis include the lung, bone, and liver. Ovarian metastasis of RCC is an exceptionally rare occurrence with only 41 cases reported in the literature with only 11 of these cases involving the bilateral ovaries. Here we present a case of clear-cell RCC arising from the left kidney with metastatic involvement of bilateral ovaries in a 48-year-old woman.

Extramammary metastases to the breast: Radiologic and histologic review

Extramammary metastases to the breast are extremely rare and vary widely in their clinical and imaging features. Diagnosis may be challenging as lesions can mimic both primary breast cancer as well as benign breast lesions. The goal of this review is to describe the radiologic and pathologic features of the most common primary tumors that metastasize to the breast including lymphoma, melanoma, lung carcinoma, gynecologic carcinoma and sarcomas.

Primary peritoneal serous carcinoma: a primer for radiologists

Primary peritoneal serous carcinoma (PPSC) is a rare primary peritoneal tumor characterized by a unique range of clinical features and imaging findings. Though it shares many clinical, histologic, and imaging features with serous ovarian carcinoma, it remains a distinct clinical entity. Although less common than its primary ovarian counterpart, PPSC is characterized by a prognosis that is often equally poor with presentations common in late stages of disease. Key imaging modalities used in the evaluation of PPSC include ultrasound, CT, MRI, and PET/CT. For radiologists, an understanding of the pertinent imaging findings, pathologic correlations, and clinical features of PPSC is essential for arriving at the correct diagnosis and guiding the subsequent appropriate management of this complex malignancy.

Boba sign with a twist – A variant presentation of a mature cystic teratoma complicated by torsion and rupture

While mature cystic teratomas are relatively common ovarian neoplasms typically comprising of multiple embryologic cell types, a specific monodermal subtype involving thyroid tissue, struma ovarii, can rarely be seen. This case reviews typical imaging characteristics with MRI and ultrasound of struma ovarii and details possible complications from these masses with intraoperative and histologic correlation.

Clinical value of N-acetyl mucinous compounds and lipid peaks in differentiating benign and malignant ovarian mucinous tumors by MR spectroscopy

To retrospectively evaluate the clinical significance of the peaks of N-acetyl mucinous compounds (NAMC) at 2 ppm and lipid at 1.3 ppm in in-vivo proton magnetic resonance (MR) spectroscopy for distinguishing benign and malignant mucinous tumors in patients with ovarian masses. MR spectroscopy was performed in patients with pathologically diagnosed mucinous ovarian tumors at 3 T MRI system. The peaks of NAMC, lipid, and total choline compounds (tCho) were classified into three classes in comparison with the noise level by visual estimation. The NAMC concentration was quantified relative to unsuppressed water by using LCModel analysis. A total of 27 ovarian mucinous tumors in 27 patients were included in this study. The NAMC peak was observed in all 27 mucinous tumors, and the lipid peak was observed in 14 of 27 tumors: 1 of 9 benign tumors (11%), and 13 of 18 malignant tumors (11 borderline malignancies and 7 carcinomas) (72%). The presence of the lipid peak for the diagnosis of malignant mucinous tumor showed generally better diagnostic ability than MR imaging, with a sensitivity of 72%, specificity of 89%, accuracy of 78%, PPV of 93%, and NPV of 62%. The concentration of the NAMC in malignant mucinous tumors tended to be higher than that in benign mucinous tumors, but there was no statistically significant difference. The bimodal peaks of NAMC and lipid are suggestive of malignant mucinous tumors, and the presence of the lipid peak may be useful in distinguishing benign from malignant ovarian mucinous tumors.

Vaginal cancer: Why should we care? Anatomy, staging and in-depth imaging-based review of vaginal malignancies focusing on MRI and PET/CT

Vaginal cancer often poses a challenge for clinical and radiological diagnosis, and its risk factors, progression, and treatment are still poorly established. Although vaginal malignancies are rare, even globally, their rates have increased due to the increased access to healthcare and the evolution of screening measures and diagnostic methods. Because the vaginal cavity is a virtual space, it can harbor lesions that often go unnoticed and, not infrequently, diagnosed belatedly. MRI and, more recently, PET/CT are part of the imaging armamentarium that have already been incorporated into the clinical staging and management of gynecological tumors, allowing excellent morphological characterization of the lesion, its topography and relationship with adjacent structures for the investigation of disease dissemination, overcoming limitations of clinical methods, such as speculum examination, usually restricted to observation only of the superficial characteristics of these lesions. Some vaginal neoplasms have characteristic MRI patterns, which, combined with expert knowledge of anatomy, allow identification of local macroscopic details (such as the mucosal, submucosal, and muscle layers). Furthermore, the application of PET/CT, already well established for identifying systemic disease, has a large impact on patient prognosis. The objective of this work is to review the epidemiological aspects of primary vaginal cancers and the imaging patterns of their main histological subtypes based on MRI and PET/CT, with a brief discussion of the local anatomy, oncological staging, and treatment.

Assessment of the O-RADS scoring system for the differentiation of different types of ovarian neoplasms: A modified approach with non-DCE-MRI

The O-RADS MRI score stratifies adnexal mass risk with characteristics of T1-weighted, T2-weighed and dynamic contrast-enhanced (DCE) images. We explored a modified approach to evaluate the value of incorporation DWI/ADC with non-DCE-MRI in ORADS scoring system, and to assess the diagnostic performance and interreader consistency in differentiating ovarian neoplasm with different types. This retrospective study included 218 women who underwent pelvic MRI with 221 ovarian tumors between January 2017 and December 2021. Two radiologists independently assessed each lesion using the original and modified O-RADS approach (incorporating DWI/ADC with non-DCE). Cohen's weighted-kappa and ROC analyses were employed to assess interreader consistency and diagnostic efficiency across all lesions and three ovarian neoplasms categories. The area under the ROC curve (AUC) of the original protocol was 0.945 for all lesions and 0.947, 0.992, and 0.758 for the epithelial cell, germ cell and sex cord-stromal neoplasms. The modified approach achieved AUCs of 0.959 for all lesions and 0.962, 0.997, and 0.837 for the three categories. The interreader agreement was 'excellent' for all lesions and 'good' for the subgroups with the original protocol, improving to 'excellent' for all categories with the modified approach. A modified O-RADS incorporating DWI/ADC with non-DCE MRI yields high diagnostic performance in differentiation of different types of ovarian neoplasms. It further improves consistency in subgroup interpretation. The modified approach can serve as an effective diagnostic tool without DCE, further promoting its adoption in primary hospitals.

Diffusion-weighted imaging versus dynamic contrast-enhanced imaging for pre-operative diagnosis of deep myometrial invasion in endometrial cancer: A meta-analysis

This study investigates the differences in diagnostic performance between diffuse-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE), either alone or in combination with T2-weighted imaging (T2WI), for diagnosing deep myometrial invasion (dMI) of endometrial cancers (EC). We performed a comprehensive search for published studies comparing DWI and DCE for preoperatively diagnosing dMI of EC. The overall diagnostic accuracy of each test was calculated using the areas under the summary receiver operating characteristic curves (AUCs). The sensitivities and specificities were compared using bivariate meta-regression. Pooled analysis of nineteen studies with 961 patients (main group) showed that DWI had a larger AUC (0.943, 95% confidence interval (CI) = 0.921-0.967) than DCE (0.922, 95% CI = 0.893-0.953). For the subgroup comprising 7 studies, DWI combined with T2WI and DCE combined with T2WI showed AUCs of 0.959 (95% CI, 0.932-0.986) and 0.929 (95% CI, 0.847-1.000), respectively. None of the differences in AUCs were statistically significant. All comparisons of the sensitivities and specificities of the main group and subgroup also showed no significant differences. This meta-analysis found no significant difference in diagnostic performance between DWI and DCE for diagnosis of dMI in EC. DWI may be preferred for its ease of use in clinical practice.

Predictive value of T2-weighted imaging and dynamic contrast-enhanced MRI for assessing cervical invasion in patients with endometrial cancer: a meta-analysis

To obtain the diagnostic accuracy of T2-weighted imaging (T2WI), and dynamic contrast-enhanced MRI (DCE-MRI) in the preoperative assessment of cervical invasion in patients with endometrial cancer (EC). Databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials were searched for relevant articles published from January 2000 to August 2020. Pooled estimation data were obtained by statistical analysis. In total, 24 articles were included. For assessing cervical invasion of EC, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) for T2WI were 0.70 (0.61-0.77), 0.92 (0.89-0.94), 8.7 (6.5-11.6), 0.33 (0.25-0.43), 26 (17-41), and 0.92 (0.89-0.94), respectively. For DCE-MRI, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.75 (0.60-0.85), 0.95 (0.89-0.98), 14.7 (6.6-32.9), 0.27 (0.16-0.44), 55 (18-165), and 0.92 (0.89-0.94), respectively; for T2WI combined with DCE-MRI, they were 0.58 (0.41-0.73), 0.98 (0.95-0.99), 28.1 (12.8-62.1), 0.43 (0.30-0.63), 65 (29-146), and 0.94 (0.91-0.96), respectively. DCE-MRI demonstrated higher diagnostic performance than T2WI in the prediction of cervical invasion in patients with EC. T2WI combined with DCE-MRI improved the pooled specificity, PLR, DOR, and AUC compared to T2WI alone or DCE-MRI alone.

I saw the “sea anemone” sign: Puffy face of borderline ovarian tumors

The sea anemone sign is a radiologic sign seen on magnetic resonance imaging (MRI) studies that indicates the morphological development of serous borderline ovarian tumors (SBOTs), as papillary projections originating from the wall of the cystic lesion. The presence of T2 hypointense fibrous stroma in the center of the papilla is a helpful tip in the diagnosis of SBOTs. Those projections might also be assumed to have a frond-like appearance which can be seen as branching papillary projections, especially on T2-weighted imaging. The term "sea anemone" sign is described by Tanaka et al. who deemed it as a "hallmark" feature of surface SBOTs.

I saw the Venetian blind sign

The Venetian blind sign is a radiologic sign seen on pelvic ultrasound. It is classically associated with adenomyosis and, less commonly, uterine fibroids. It appears as alternating vertical stripes of hyperechoic and hypoechoic bands, resembling the horizontal slatted window blinds for which it is named.

Outcome prediction for symptomatic patients with fibroids who underwent uterine artery embolization

To predict the clinical outcome of symptomatic patients with uterine leiomyomas who underwent uterine artery embolization (UAE), based on clinical and radiological features. Patients with symptomatic uterine leiomyomas who underwent UAE from March 2010 to September 2019 were consecutively included in this retrospective study. Patients with persistent or recurrent symptoms and those who needed repeated UAE, myomectomy, or hysterectomy following the initial treatment were considered to have a poor outcome after UAE. The total and enhancing volume of the dominant leiomyoma in each location and uterine volume were obtained before and after UAE. Univariate and multivariate Cox proportional hazard analyses were used to evaluate the parameters that could predict poor outcome. A total of 116 patients (mean age, 45 ± 5 years) were included. Forty-six patients (46/116, 39.7%) showed poor outcome. Cox regression analysis showed higher hazard of poor outcome for younger patients vs. older patients (HR: 0.92, p-value: 0.01), patients with adenomyosis vs. patients without adenomyosis (HR: 2.47, p-value  2.5 cm before UAE vs. patients without adenomyosis (HR: 4.2, p-value  440 cm Pretreatment clinical and MRI features could identify patients with a higher risk for poor outcome after UAE.