Journal of Computer Assisted Tomography

Whole-Lesion Apparent Diffusion Coefficient Histogram Analysis for Assessing Normal-Sized Lymph Node Metastasis in Cervical Cancer: Comparison Between Readout-Segmented and Single-Shot Echo-Planar Diffusion-Weighted Imaging

Objective To compare the value of whole-lesion apparent diffusion coefficient (ADC) histogram analysis derived from readout-segmented echo-planar imaging (RS-EPI) and single-shot echo-planar imaging (SS-EPI) diffusion-weighted imaging (DWI) in evaluating normal-sized lymph node metastasis (LNM) in cervical cancer. Methods Seventy-six pathologically confirmed cervical cancer patients (stages IB and IIA) were enrolled, including 61 patients with non-LNM (group A) and 15 patients with normal-sized LNM (group B). The recorded tumor volume on T2-weighted imaging was the reference against which both DWIs were evaluated. Each ADC histogram parameter (including ADCmax, ADC90, ADCmedian, ADCmean, ADC10, ADCmin, ADCskewness, ADCkurtosis, and ADCentropy) was compared between SS-EPI and RS-EPI and between the 2 groups. Results There was no significant difference in tumor volume between the 2 DWIs and T2-weighted imaging (both P > 0.05). Higher ADCmax and ADCentropy but lower ADC10, ADCmin and ADCskewness were found in SS-EPI than those in RS-EPI (all P < 0.05). For SS-EPI, lower ADC90 and higher ADCkurtosis were found in group B than those in group A (both P < 0.05). For RS-EPI, lower ADC90 and higher ADCkurtosis and ADCentropy were found in group B than those in group A (all P < 0.05). Readout-segmented echo-planar imaging ADCkurtosis showed the highest area under the curve of 0.792 in the differentiation of the 2 groups (sensitivity, 80%; specificity, 73.77%). Conclusions Compared with SS-EPI, the ADC histogram parameters derived from RS-EPI were more accurate, and ADCkurtosis held great potential in differentiating normal-sized LNM in cervical cancer.

Endometrial Cancer, the Current International Federation of Gynecology and Obstetrics Staging System, and the Role of Imaging

Abstract Imaging plays a crucial role in the diagnosis, staging, and follow-up of endometrial cancer. Endometrial cancer is staged surgically using the International Federation of Gynecology and Obstetrics (FIGO) staging system. Preoperative imaging can complement surgical staging but is not yet considered a required component in the current FIGO staging system. Preoperative imaging can help identify some tumor characteristics and tumor spread, both locally and distally. More accurate assessment of endometrial cancers optimizes management and treatment plan, including degree of surgical intervention. In this article, we review the epidemiology, FIGO staging system, and the importance of imaging in the staging of endometrial cancer.

Assessment of Tamoxifen-Related Endometrial Changes in Premenopausal Female Patients With Diffusion-Weighted Magnetic Resonance Imaging

Purpose To evaluate tamoxifen-related endometrial changes in premenopausal female patients with diffusion-weighted magnetic resonance imaging (DWI). Methods This prospective study was performed on 71 premenopausal female patients (mean age, 41 years) who were receiving tamoxifen therapy. All patients underwent magnetic resonance imaging with DWI of the pelvis and hysteroscopic-guided endometrial biopsy. The apparent diffusion coefficient (ADC) values of the endometrial plate were calculated and correlated with pathological results. Results The mean ADCs of tamoxifen-related benign endometrial lesions (1.35 ± 0.19 and 1.32 ± 0.13 × 10−3 mm2/s) were significantly higher (P = 0.001) than those of normal endometrial plate (0.95 ± 0.11 and 0.93 ± 0.11 × 10−3 mm2/s) by both reviewers, respectively. The cutoff ADC values used to differentiate tamoxifen-related benign endometrial lesions from normal endometrium were 1.07 and 1.02 × 10−3 mm2/s with areas under the curve of 0.94 and 0.93 and accuracy of 94.4 and 95.8 by both reviewers, respectively. The mean ADC values of endometrial polyp (EP) (1.44 ± 0.19 and 1.42 ± 0.22 × 10−3 mm2/s) were significantly higher (P = 0.001) than those of endometrial hyperplasia (EH) (1.25 ± 0.19 and 1.23 ± 0.19 × 10−3 mm2/s) by both reviewers, respectively. The cutoff ADC values used to differentiate EP from EH were 1.38 × 10−3 and 1.36 × 10−3 mm2/s with areas under the curve of 0.81 and 0.77 and accuracy of 80% and 70% by both reviewers, respectively. There was an insignificant difference in ADC value between typical and atypical EH. The ADC values of endometrial cancer (0.80 and 0.78 × 10−3 mm2/s) were lower than those of tamoxifen-related benign endometrial lesions. The final diagnosis was normal endometrium (n = 36), benign endometrial lesions either EH (n = 17), or EP (n = 16), and endometrial cancer in only 2 patients. Conclusions We concluded that DWI helps in detection and characterization of different tamoxifen-related endometrial changes in the premenopausal female patients.

The Role of Multiparametric Magnetic Resonance Imaging in the Study of Primary Tumor and Pelvic Lymph Node Metastasis in Stage IB1–IIA1 Cervical Cancer

Objective The aim of this study was to investigate the value of multiparametric magnetic resonance imaging (MRI) in demonstrating the metastatic potential of primary tumor and differentiating metastatic lymph nodes (MLNs) from nonmetastatic lymph nodes (non-MLNs) in stage IB1–IIA1 cervical cancer. Methods Fifty-seven stage IB1–IIA1 subjects were included. The apparent diffusion coefficient (ADC) values and dynamic contrast-enhanced MRI (DCE-MRI) parameters of primary tumors and lymph nodes and the conventional imaging features of the lymph nodes were measured and analyzed. Mann-Whitney test and χ2 test were used to analyze statistically significant parameters, logistic regression was used for multivariate analysis, and receiver operating characteristic analysis was used to compare the diagnostic performance of the MLNs. Results Nineteen subjects had lymph node metastasis. A total of 94 lymph nodes were evaluated, including 30 MLNs and 64 non-MLNs. There were no significant difference in ADC and DCE-MRI parameters between metastatic and nonmetastatic primary tumors. The heterogeneous signal was more commonly seen in MLNs than in non-MLNs (P = 0.001). The values of ADCmean, ADCmin, and ADCmax of MLNs were lower than those of non-MLNs (P < 0.001). The values of short-axis diameter, K trans, K ep, and V e of MLNs were higher than those of non-MLNs (P < 0.05). Compared with individual MRI parameters, the combined evaluation of short-axis diameter, ADCmean, and K trans showed the highest area under the curve of 0.930. Conclusions Diffusion-weighted imaging and DCE-MRI could not demonstrate the metastatic potential of primary tumor in stage IB1–IIA1 cervical cancer. Compared with individual MRI parameters, the combination of multiparametric MRI could improve the diagnostic performance of lymph node metastasis.

Diagnostic Accuracy of Magnetic Resonance Imaging for International Federation of Gynecology and Obstetrics 2018 IB to IIB Cervical Cancer Staging: Comparison Among Magnetic Resonance Sequences and Pathologies

Objective This study aimed to investigate the most accurate magnetic resonance (MR) sequence for tumor detection, maximal tumor diameter, and parametrial invasion compared with histopathologic diagnoses. Methods Fifty-one patients with International Federation of Gynecology and Obstetrics 2018 IB1 to IIB cervical cancer underwent preoperative MR imaging and surgical resection. Two radiologists independently evaluated the tumor detection, parametrial invasion, and tumor size in each of T2-weighted image, diffusion-weighted image, and contrast-enhanced T1-weighted image. Results obtained for squamous cell carcinoma (SCC) and adenocarcinoma were also compared. Results Neither the tumor detection rate nor parametrial invasion was found to be significantly different among sequences. Tumor size assessment using MR imaging with pathology showed good correlation: r = 0.63–0.72. The adenocarcinoma size tended to be more underestimated than SCC in comparison with the pathologic specimen. Conclusions Cervical cancer staging by MR images showed no significant difference among T2-weighted image, diffusion-weighted image, and contrast-enhanced T1-weighted image. Adenocarcinoma was prone to be measured as smaller than the pathologic specimen compared with SCC.

Uterine Cervical Carcinoma: Evaluation Using Non-Gaussian Diffusion Kurtosis Imaging and Its Correlation With Histopathological Findings

Objective The aim of the study was to assess non-Gaussian diffusion kurtosis imaging (DKI)'s usefulness as a noninvasive method to evaluate tumor invasion depth, histological grade, and lymph node metastasis in cervical carcinoma (CC) patients. Methods Twenty-two consecutive patients with histologically confirmed CC were examined by 1.5-T MRI and non-Gaussian DKI with 4 b values of 0, 500, 1000, and 2000 s/mm2. Kurtosis (K), diffusivity (D), and apparent diffusion coefficient (ADC) maps were compared with histopathological findings. Results Kurtosis maps revealed the fibrous stroma as a distinct high K zone (1.442 ± 0.373) that was significantly different from values of the cervical mucosa, outer stroma, and parametrium (0.648 ± 0.083, 0.715 ± 0.113, and 0.504 ± 0.060, respectively, P < 0.0001). Kurtosis (1.189 ± 0.228) and D (0.961 ± 0.198 × 10−3 mm2/s) values of all CCs were significantly different from those of all uterine cervical wall layers. Kurtosis and D values were significantly correlated with histological grades of CCs (r = 0.934, P < 0.0001, and r = −0.925, P < 0.0001, respectively), whereas no significant differences were found in ADC values between grades 2 and 3 CCs (P = 0.787). Metastatic and nonmetastatic lymph nodes showed significantly different K (P < 0.0001) and D (P < 0.0001) values; however, their ADC values did not show significant differences (P = 0.437). For differentiating grade 3 CCs from grade 1 or 2 CCs, the areas under the curve for K (0.991, P = 0.0375) and D (0.982, P = 0.0337) values were significantly higher than those for ADC values (0.759). For differentiating metastatic and nonmetastatic lymph nodes, the areas under the curve for K (0.974, P = 0.0028) and D (0.968, P = 0.0018) values were significantly higher than those for ADC (0.596). Conclusions Non-Gaussian DKI may be clinically useful for noninvasive evaluation of tumor invasion depth, histological grade, and lymph node metastasis in CC patients.

Imaging Biomarkers and Liquid Biopsy in Assessment of Cervical Cancer

Abstract The role of imaging has been increasing in pretherapy planning and response assessment in cervical cancer, particularly in high-resource settings that provide access to computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). In 2018, imaging was incorporated into the International Federation of Gynecology and Obstetrics staging system for cervical cancer. Magnetic resonance imaging is advantageous over CT for evaluation of the primary cervical cancer size and extent, because of superior contrast resolution. Furthermore, quantitative methods, including diffusion-weighted and dynamic contrast-enhanced MRI, show promise in improving treatment response and prognosis evaluation. Molecular imaging with fluorodeoxyglucose–PET/CT and PET/MRI can be particularly helpful in the detection of nodal disease and distant metastases. Semiautomated delineation of 3-dimensional tumor regions of interest has facilitated the development of novel PET-derived biomarkers that include metabolic volume and radiomics textural analysis features for prediction of outcomes. However, posttreatment inflammatory changes can be a confounder and lymph node evaluation is challenging, even with the use of PET/CT. Liquid biopsy has emerged as a promising tool that may be able to overcome some of the drawbacks inherent with imaging, such as limited ability to detect microscopic metastases or to distinguish between postchemoradiotherapy changes and residual tumor. Preliminary evidence suggests that liquid biopsy may be able to identify cervical cancer treatment response and resistance earlier than traditional methods. Future work should prioritize how to best synergize imaging and liquid biopsy as an integrated approach for optimal cervical cancer management.

Correlating Quantitative Para-Aortic Lymph Node Computed Tomography Parameters With Fluorodeoxyglucose Positron Emission Tomography for Cervical Cancer Staging: Possible Solution for Resource Constrained Countries

Abstract Objective The aim of the study was to determine the most accurate quantitative morphological parameters on computed tomography (CT) that correlate with fluorodeoxyglucose (FDG)-avid para-aortic nodes (PANs) in patients with cervical cancer. Methods A single-institution retrospective evaluation was performed of women with cervical cancer who underwent pretreatment positron emission tomography (PET)/CT and radiotherapy therapy planning CT between 2009 and 2020. A node-by-node correlation between pretreatment CT and PET/CT was performed for the reference standard of FDG avidity for short- and long-axis diameters, volume, and long-/short-axis ratio (L/S). The FDG-avid PANs were defined as PET-positive and non–FDG-avid PANs from patients without PET-determined PAN metastasis were defined as PET negative. Area under the receiver operator curve was calculated to access diagnostic accuracy of the different quantitative parameters. Results A total of 94 women (mean age ± standard deviation, 52 ± 13 years) with cervical cancer were included. Forty-seven patients had PET-positive PANs (181 PET-positive PANs) and 47 patients had no PET-positive PANs (141 PET-negative PANs). The area under the receiver operator curve for volume (0.945) was greater (P < 0.001) than that of short axis (0.895), long axis (0.885), and L/S (0.583). At a specificity set point of 0.90 (127/141 PANs), the cutoff for volume was 0.443 cm3 or greater (0.85 sensitivity [154/181 PANs]; 95% confidence interval, 0.83–0.93) and for short-axis diameter was 5.9 mm or greater (0.75 sensitivity [135/181 PANs]; 95% confidence interval, 0.68–0.81). Conclusions Para-aortic lymph node volume demonstrated that improved node-by-node correlation between CT and PET/CT compared with short-axis diameter, long-axis diameter, and L/S and is an alternative to improve detection of PAN suspicious of metastatic diseases in locations without access to PET/CT.

An Analysis of Delta Apparent Diffusion Coefficient Values for Epithelial Ovarian Cancer Classification and Ki-67 Expression

Background: Ovarian cancer is one of the most common malignant tumors of the female reproductive system, characterized by high malignancy and poor prognosis. Epithelial ovarian cancer (EOC) accounts for 90% to 95% of all cases. This study aims to investigate the diagnostic value of delta apparent diffusion coefficient (dADC) values in distinguishing between type I and type II EOC and to explore its correlation with Ki-67 expression. Methods: A retrospective analysis included 95 patients (mean age: 51.6 ± 12.5 y; range: 17 to 73 y) diagnosed with EOC at our hospital from September 2021 to August 2023. Of these, 51 patients had type I EOC (low-grade serous carcinoma, clear cell carcinoma, endometrioid carcinoma, mucinous carcinoma, or borderline tumors), and 44 had type II EOC (high-grade serous carcinoma or high-grade endometrioid carcinoma). Bilateral lesions were observed in 16.8% of patients. Preoperative MRI, including diffusion-weighted imaging (DWI), serum CA125 levels, and postoperative immunohistochemical Ki-67 expression, were analyzed. Tumor staging was based on the 2021 FIGO criteria. Minimum ADC (minADC), maximum ADC (maxADC), and dADC values were calculated from the solid tumor components. Receiver operating characteristic (ROC) curves assessed diagnostic performance, and the correlation between dADC and Ki-67 expression was examined. Results: The maxADC and minADC of type II EOC were lower than those of type I, while dADC was higher than type I (P<0.05). ROC curve analysis showed that the efficacy of dADC in distinguishing between type I and type II EOC was higher than that of minADC and maxADC (P<0.05). When the dADC threshold was 0.31×10−3 mm2/s, the area under the curve (AUC) was 0.982, with a sensitivity of 95.3% and specificity of 97.3%. Pearson correlation analysis showed a positive correlation between dADC and Ki-67 expression. Conclusion: dADC has a certain value in accurately distinguishing between type I and type II EOC preoperatively, and it can reflect the proliferative activity of tumor cells.

Uterine Sarcoma or Degenerating Fibroid? Validating the New Consensus Magnetic Resonance Imaging Algorithm for Evaluating Atypical Uterine Masses

Objective The aim of the study is to assess the validity of a recently published consensus magnetic resonance imaging (MRI) diagnostic algorithm for differentiating degenerating leiomyomas from uterine sarcomas and other atypical appearing uterine malignancies. Methods Atypical uterine masses on pelvic MRI were identified using a radiology report search engine and teaching files with the keywords “atypical leiomyoma,” “atypical fibroid,” and “sarcoma.” All cases were pathology-proven. Two radiologists blinded to clinical, surgical, and pathologic reports retrospectively and independently reviewed 40 pelvic MRI examinations dated 1/2007–9/2022 to determine whether the masses appeared benign or malignant, using the 2022 consensus atypical uterine mass flow chart. Imaging features assessed included intermediate/high signal intensity (SI) at T2-weighted imaging, high diffusion weighted imaging SI (equal or higher SI than endometrium or lymph nodes on high b value imaging), apparent diffusion coefficient (ADC) value ≤0.905 × 10−3 mm2/s, peritoneal metastases, and abnormal lymph nodes. Results Among the 40 atypical uterine mass cases reviewed, 24 masses were benign (22 leiomyomas, 1 adenomyoma, and 1 borderline ovarian tumor) and 16 masses were malignant (6 leiomyosarcomas, 6 carcinosarcomas, 2 endometrial stromal sarcomas, 1 high-grade adenosarcoma, and 1 low-grade uterine sarcoma). Sensitivity, specificity, positive predictive value, and negative predictive value of whether a mass was benign or malignant were 75%, 95.8%, 92.3%, and 85% for reader 1, and 81.2%, 91.7%, 86.7%, and 88% for reader 2, respectively. Interrater agreement was strong, with a kappa statistic of 0.89. When excluding nonleiomyosarcoma uterine malignancies, sensitivity and negative predictive value improved to 100%. Conclusions The new consensus pelvic MRI algorithm for evaluating atypical uterine masses has good specificity, sensitivity, positive predictive value, and negative predictive value for determining malignancy, particularly for uterine sarcomas that are leiomyosarcomas. However, if ADC value is near but not below 0.905 × 10−3 mm2/s, the mass may still be malignant, especially if a b value lower than 1000 is used. If the atypical uterine mass is predominantly endometrial, morphological features on T2 and postgadolinium sequences should guide suspicion, as some atypical appearing nonleiomyosarcoma uterine malignancies may have an ADC value greater than 0.905 × 10−3 mm2/s.

Krukenberg Tumors in Young Women: Computed Tomography and Magnetic Resonance Imaging Diagnosis

Introduction The purpose of this report was to present the computed tomography (CT) and magnetic resonance imaging (MRI) features of Krukenberg tumors and to review the pertinent clinical data about the rising incidence of this malignancy among young women. Material and Methods This series included 8 women who ranged in age from 24 to 44 years (mean, 36.3 years). They were diagnosed to have Krukenberg tumors during a 5-year period (2011–2016). All patients were evaluated by abdominal CT and pelvic or transvaginal sonography. Five of them also had MRI of the abdomen, and 3 had positron emission tomography scans. Results The primary cancer was located in the stomach of 7 patients and in the colon in 1. The initial presentation was due to large pelvic mass and abdominal distention by ascites in 3 patients, gastrointestinal symptoms in 4, and small bowel obstruction by carcinoma of the ascending colon in 1 woman. Ovarian metastases were demonstrated on the initial imaging examination of 5 patients and developed as metachronous lesion during follow-up in 3 cases. Six women died 3 to 23 months (mean, 11 months) after the diagnosis. One has survived for 6 years after extensive surgery, and 1 was lost to follow-up. Conclusions Krukenberg tumors are being diagnosed with an increasing frequency because of well-documented rising incidence of gastric and colorectal carcinomas among young women. Therefore, those presenting with gastrointestinal cancer should have careful imaging of their ovaries for possible metastases, and conversely, the clinical or sonographic detection of bilateral ovarian masses would require evaluation by CT or MRI of the abdomen in search for a potential primary gastrointestinal cancer. This report highlights the CT and MRI features of this neoplastic process and reviews the current concepts about its development and management.

Magnetic Resonance Imaging of Recurrent Adult Granulosa Cell Tumor of the Ovary: A Retrospective Analysis of 11 Cases

Objective The aim of the study was to characterize magnetic resonance imaging findings in patients with recurrent ovarian adult granulosa cell tumors (AGCTs). Methods Clinical and magnetic resonance imaging manifestations of recurrent AGCTs were evaluated in 11 patients. Results Initial recurrences of AGCT were diagnosed between 13 months and 30 years (mean, 11.3 years). Recurrent tumors were located in the pelvic peritoneum, the abdominal peritoneum, the retroperitoneum, and bone. The number of recurrent tumors varied from 1 to 5. Tumors varied in morphology and all margins were well circumscribed. The internal structures noted were as follows: multilocular cystic and solid and cystic. Furthermore, internal hemorrhage and sponge-like multicystic components were identified. Conclusions Ovarian AGCTs recurred in the pelvic peritoneum, abdominal peritoneum, and the retroperitoneal lymph nodes. Large recurrent AGCTs were commonly well circumscribed, round or lobulated, and multilocular cystic or solid and cystic. Moreover, they frequently included internal hemorrhage and sponge-like multicystic components.

Performance of O-RADS MRI Score in Differentiating Benign From Malignant Ovarian Teratomas: MR Feature Analysis for Differentiating O-RADS 4 From O-RADS 2

Objective The aim of the study is to evaluate the performance of the ovarian-adnexal reporting and data system magnetic resonance imaging (O-RADS MRI) score and perform individual MRI feature analysis for differentiating between benign and malignant ovarian teratomas. Methods In this institutional review board–approved retrospective study, consecutive patients with a pathology-proven fat-containing ovarian mass imaged with contrast-enhanced MRI (1.5T or 3T) from 2013 to 2022 were included. Two blinded radiologists independently evaluated masses per the O-RADS MRI lexicon, including having a “characteristic” or “large” Rokitansky nodule (RN). Additional features analyzed included the following: nodule size/percentage volume relative to total teratoma volume, presence of bulk/intravoxel fat in the nodule, diffusion restriction in the nodule, angular interface, nodule extension through the teratoma border, presence/type of nodule enhancement pattern (solid versus peripheral), and evidence for metastatic disease. An overall O-RADS MRI score was assigned. Patient and lesion features associated with malignancy were evaluated and used to create a malignant teratoma score. χ2, Fisher's exact tests, receiver operating characteristic curve, and κ analysis was performed. Results One hundred thirty-seven women (median age 34, range 9–84 years) with 123 benign and 14 malignant lesions were included. Mean teratoma size was 7.3 cm (malignant: 14.4 cm, benign: 6.5 cm). 18/123 (14.6%) of benign teratomas were assigned an O-RADS 4 based on the presence of a “large” (11/18) or “noncharacteristic” (12/18) RN. 12/14 malignant nodules occupied >25% of the total teratoma volume (P = 0.09). Features associated with malignancy included the following: age <18 years, an enhancing noncharacteristic RN, teratoma size >12 cm, irregular cystic border, and extralesional extension; these were incorporated into a malignant teratoma score, with a score of 2 or more associated with area under the curve of 0.991 for reviewer 1 and 0.993 for reviewer 2. Peripheral enhancement in a RN was never seen with malignancy (64/123 benign, 0/14 malignant) and would have appropriated downgraded 9/18 overcalled O-RADS 4 benign teratomas. Conclusions O-RADS MRI overcalled 15% (18/123) benign teratomas as O-RADS 4 but correctly captured all malignant teratomas. We propose defining a “characteristic” RN as an intravoxel or bulk fat-containing nodule. Observation of a peripheral rim of enhancement in a noncharacteristic RN allowed more accurate prediction of benignity and should be added to the MRI lexicon for improved O-RADS performance.

The Added Value of Apparent Diffusion Coefficient and Histogram Analysis in Assessing Treatment Response of Locally Advanced Cervical Cancer

Objective The aim of the study is to assess the diagnostic performance of quantitative analysis of diffusion-weighted imaging in assessing treatment response in cervical cancer patients. Methods A retrospective analysis was done for 50 patients with locally advanced cervical cancer who received concurrent chemoradiotherapy and underwent magnetic resonance imaging and diffusion-weighted imaging. Treatment response was classified into 4 categories according to RECIST criteria 6 months after therapy completion. Apparent diffusion coefficient (ADC) values were measured using both region of interest (ROI) ADC and whole lesion (WL) ADC histogram for all cases at both baseline pretreatment and posttreatment Magnetic resonance imaging studies. Changes in ADC values were calculated and compared between groups. Results The percentage change of ROI-ADCmean at a cutoff value of >20 had excellent discrimination of responders versus nonresponders, while the percentage change of WL-ADCmean, ADCmin, and ADCmax at cutoff values of >12.5, >35.8, and > 19.6 had acceptable discrimination of responders versus nonresponders. Logistic regression analysis revealed that only baseline WL ADCmin was a statistically significant independent predictor of response. Cancer cervix patients with baseline ADCmin < or equal to 0.73 have 12.1 times higher odds of exhibiting a response. Conclusions The percentage change of ROI-ADCmean and WL histogram ADCmean values after concurrent chemoradiotherapy can predict response. Pretreatment WL histogram ADCmin was a statistically significant independent predictor of posttherapy response.

Evaluation of Amide Proton Transfer Imaging Combined With Serum Squamous Cell Carcinoma Antigen for Grading Cervical Cancer

Objective: The aim of the study is to investigate the efficacy of amide proton transfer-weighted (APT) imaging combined with serum squamous cell carcinoma antigen (SCC-Ag) in grading cervical cancer. Methods: Sixty-three patients with surgically confirmed cervical SCC were enrolled and categorized into 3 groups: highly differentiated (G1), moderately differentiated (G2), and poorly differentiated (G3). The diagnostic efficacies of APT imaging and serum SCC-Ag, alone or in combination, for grading cervical SCC were compared. Results: The APT values measured by the 2 observers were in excellent agreement (intraclass correlation coefficient >0.75). Mean (± standard deviation) APT values for the high, moderate, and poor differentiation groups were 2.542 ± 0.215% (95% confidence interval [CI]: 2.423–2.677), 2.784 ± 0.175% (95% CI: 2.701–2.856), and 3.120 ± 0.221% (95% CI: 2.950–3.250), respectively. APT values for groups G2 and G3 were significantly higher than those for G1 (P < 0.05). APT values for identifying cervical SCC in groups G1 and G2, G2 and G3, and G1 and G3, had areas under the receiver operating characteristic curve, sensitivities, and specificities of 0.815 (95% confidence interval [CI]: 0.674–0.914), 82.1%, and 72.2%, 0.882 (95% CI: 0.751–0.959), 70.6%, and 92.7%, and 0.961 (95% CI: 0.835–0.998), 94.1%, and 94.4%, respectively. APT values were significantly and positively correlated with the histological grade of cervical SCC (Spearman's correlation [r s] = 0.731, P < 0.01). Serum SCC-Ag levels for the high, moderate, and poor differentiation groups were 1.60 (0.88–4.63) ng/mL, 4.10 (1.85–6.98) ng/mL, and 26.10 (9.65–70.00) ng/mL, respectively. The differences were statistically significant only between groups G1 and G3 and G2 and G3 (P < 0.05), whereas the differences between groups G1 and G2 were not statistically significant (P > 0.05). Spearman's analysis revealed a positive correlation between SCC-Ag levels and the histological grade of cervical SCC (r s = 0.573, P < 0.01). The diagnostic efficacy of APT imaging for the histological grading of cervical SCC was better than that of serum SCC-Ag, and the discriminatory efficacy of the combination of the 2 parameters was better than that of either alone. Conclusions: The diagnostic efficacy of APT imaging was better than that of serum SCC-Ag, and the combined diagnostic utility of APT and SCC-Ag was better than that of the individual parameters.

MRI Versus CT in Planning Primary Debulking Surgery for Epithelial Ovarian Cancer

Objective: To assess the performance of whole-abdomen diffusion-weighted imaging (DWI) combined with conventional MRI compared with CT in preoperative planning of the primary debulking surgery (PDS) in epithelial ovarian cancer (EOC) patients. Methods: Fifty-seven patients with EOC who underwent preoperative whole-abdomen MRI and CT were recruited for this study. During a multidisciplinary treatment (MDT) discussion, anatomical sites were allocated to specialized surgeons and the surgical plan, including assistant and backup surgeons, was finalized. According to the surgical records and pathological diagnoses, the χ 2 test was used to compare the consistency rates of CT and MRI for planning PDS. Diagnostic efficiencies of MRI and CT for planning PDS were compared using a 2-tailed McNemar test. Results: For the hepatobiliary sites, MRI demonstrated significantly higher sensitivity (0.947 vs. 0.632, P =0.022), specificity (0.842 vs. 0.684, P =0.039), and accuracy (0.912 vs. 0.649, P =0.041) than CT. For gastrointestinal sites, MRI showed a significantly higher sensitivity (0.750 vs. 0.450, P =0.021), specificity (0.941 vs. 0.882, P =0.031), and accuracy (0.807 vs. 0.579, P =0.027) than CT. No significant differences in sensitivity (0.769 vs. 0.385, P =0.289), specificity (0.909 vs. 0.909, P =0.453), or accuracy (0.877 vs. 0.789, P =0.227) were found between MRI and CT for the urological sites. In addition, MRI demonstrated a significantly higher consistency rate with the surgical plans and records (0.667 vs. 0.281, P <0.001) than CT. Conclusions: MRI offers superior diagnostic efficiency over CT for evaluating sites relevant to hepatobiliary and gastrointestinal surgeons, enhancing the accuracy of surgical planning and potentially becoming the preferred imaging modality for preoperative PDS planning.

Ovarian Masses in Patients With Breast Cancer

Purpose The aim of the study was to investigate the characteristic findings of computed tomography (CT) or magnetic resonance imaging (MRI) to discriminate metastasis from primary ovarian tumors in patients with a history of breast cancer. Methods This retrospective study enrolled consecutive 72 patients with a history of breast cancer who underwent surgical confirmation of an ovarian mass detected on CT or MRI (primary ovarian tumors, n = 66; metastases, n = 6). Two independent readers analyzed the grade of solid portions of the ovarian mass using a 5-point scale on CT or MRI. A predominantly cystic mass was defined as a solid grade of 1 to 2. Cancer antigen 125 (CA 125) and the initial stage of breast cancer were also investigated. Results The proportions of predominantly cystic masses were significantly different between metastases (0% for both readers) and primary ovarian tumors (59% for reader 1 and 53% for reader 2, P < 0.05). For masses of solid portion grades 3 to 5, CA 125 was significantly higher for malignant epithelial tumors than for the other tumors (P < 0.001), and the initial stage of breast cancer was significantly higher for metastases than for the other tumors (P < 0.001), respectively. Conclusions In patients with a history of breast cancer, predominantly cystic masses detected on CT or MRI seem to be primary ovarian tumors. For the other masses, knowledge of CA 125 and initial breast cancer stage may help in the differential diagnosis.

Radiogenomics: A Valuable Tool for the Clinical Assessment and Research of Ovarian Cancer

Abstract A new interdisciplinary approach based on medical imaging phenotypes, gene expression patterns, and clinical parameters, referred to as radiogenomics, has recently been developed for biomarker identification and clinical risk stratification in oncology, including for the assessment of ovarian cancer. Some radiological phenotypes (implant distribution, lymphadenopathy, and texture-derived features) are related to specific genetic landscapes (BRCA, BRAF, SULF1, the Classification of Ovarian Cancer), and integrated models can improve the efficiency for predicting clinical outcomes. The establishment of databases in medical images and gene expression profile with large sample size and the improvement of artificial intelligence algorithm will further promote the application of radiogenomics in ovarian cancer.

Computed Tomography and Magnetic Resonance Imaging Appearances of Malignant Vaginal Tumors in Children: Endodermal Sinus Tumor and Rhabdomyosarcoma

Purpose The aim of this study is to analyze retrospectively the computed tomography and magnetic resonance imaging (MRI) features of pediatric vaginal endodermal sinus tumor (EST) and rhabdomyosarcoma (RMS) in a case series. Methods Seven children with vaginal EST and 2 children with vaginal RMS underwent MRI and/or computed tomography examination before the biopsy and treatment. Images were evaluated by 2 observers for the following features: (a) tumor extent; (b) margin; (c) tumor shape; (d) tumor size; (e) architecture (solid, cystic, or mixed cystic-solid); (f) hemorrhage, necrosis, and calcification; (g) magnetic resonance T2 signal intensity; (h) pattern of the enhancement; and (i) signal intensity on diffusion-weighted imaging and apparent diffusion coefficient (ADC) value. Results All of the 7 ESTs showed as a round-shaped solid mass with a location limited to the vagina without vulva and bladder invasion, whereas RMSs have an irregular grape-like appearance filling the whole vagina with vulva and bladder invasion. The invasion to the cervix was not observed in EST or RMS. Both EST and RMS were heterogeneously hyperintense on T2-weighted magnetic resonance images and enhanced remarkably and heterogeneously. Heterogeneous high signal on diffusion-weighted imaging were observed in vaginal EST and RMS. The ESTs showed a lower ADC value (mean, 1.04×10−3 mm2/s), while RMSs showed a relatively high ADC value (mean, 1.51 × 10−3 mm2/s). Conclusions Computed tomography and MRI may be useful tools in diagnosing the vaginal RMS and EST.

Diffusion-Tensor Imaging of Uterine Cervical Carcinoma: Correlation With Histopathologic Findings

AbstractThe authors investigated the usefulness of diffusion-tensor imaging (DTI) for evaluating tumor invasion depth, histologic grade, and lymph node metastasis in patients with cervical carcinoma (CC). Fifteen consecutive patients with histologically confirmed CC underwent 1.5-T magnetic resonance imaging and DTI. The CCs were clearly depicted as hypointense areas on all DTI maps. Fractional anisotropy, mean diffusivity, and axial diffusivity showed significantly inverse correlations with CC histologic grades and were significantly different between metastatic and nonmetastatic lymph nodes.

Assessment of the Effectiveness of the Vaginal Contrast Media in Magnetic Resonance Imaging for Detection of Pelvic Pathologies: A Meta-analysis

ObjectiveMagnetic resonance imaging (MRI) is an excellent modality for pelvic imaging. The anatomy of uterine cavity and vagina is optimally evaluated when the walls, which may spontaneously be collapsed, are distended. Distension of these cavities during pelvic MRI for evaluation of gynecologic diseases has been conducted with vagina, filled with ultrasound gel or saline solution. In this meta-analysis, we aim to assess the effectiveness of vaginal contrast media in MRI for improving the detection of pelvic pathologies.MethodsThe PubMed, MEDLINE, EMBASE, Web of Science, Google Scholar, Science Citation Index, and Cochrane Library databases were systematically searched through March 2019 for studies of the accuracy of MRI using vaginal contrast media in the diagnosis and staging of pelvic pathologies. Four eligible studies of a total of 120 patients were included in the meta-analysis. The sensitivity rates and relative risk for MRI, before and after vaginal contrast medium administration, were pooled, and their 95% confidence intervals (CIs) were determined.ResultsThe pooled sensitivity rate for MRI before administering intravaginal contrast medium in detecting pelvic pathologies was 63% (95% CI, 54%–72%), and that after was 89% (95% CI, 83%–93%). The interstudy heterogeneity rate (assessed using theI2statistic) was relatively low: 13% (P= 0.33) and 0% (P= 0.45) before and after vaginal contrast medium use, respectively. The average relative risk was 1.54 (SD, 0.22; 95% CI, 1.18–1.89; median, 1.50; range, 1.34–1.80). This demonstrated that, on average, the sensitivity rate for MRI in detecting pelvic disorders increased by 54% after the use of a vaginal contrast medium.ConclusionsUse of vaginal contrast media improved the diagnostic ability of MRI in identifying pelvic pathologies.

Benign and Malignant Ovarian Teratomas: Multimodality Imaging Findings With Histopathologic Correlation

Abstract The purpose of this article is to provide a comprehensive review of the imaging findings along with histopathologic correlation of mature (benign) teratomas and malignant ovarian teratomas, which include both immature teratomas and malignant degeneration of mature teratomas. The radiologist's ability to provide an accurate diagnosis plays an essential role in guiding the interdisciplinary care of patients with malignant teratomas and improving their outcomes.