La radiologia medica

Ladies project: large database in endometrial cancers for a personalized treatment

Abstract Purpose To compare Italian use with current international guidelines and to evaluate oncological outcomes and toxicity patterns of adjuvant radiation therapy (RT) for endometrial cancer (EC) in Italian women. Materials and methods To conduct a retrospective multicentre Italian study a large database was set up. Inclusion criteria were: accrual between 2010 and 2020, treatment with surgery, post-operative external beam RT (EBRT) and/or interventional radiotherapy (IRT) associated or not with adjuvant chemotherapy. Oncological outcomes, acute and late toxicities were analysed according to RT schedule and risk group. Results A total of 1848 patients, from 16 Italian RT centres were enrolled (median age 65 years, range 27–88). All patients received post-operative RT associated with chemotherapy in 31%. Patients were stratified on the basis of standard risk factors (Bosse et al. in Eur J Cancer 51:1742–50, 2015). After merging intermediate and high-intermediate risk classes into one intermediate group and including advanced and oligometastatic disease in the high-risk group, the low-risk group encompassed 124 patients, the intermediate-risk 1140, and the high risk 576. No low-risk patient developed local relapse (LR). Multivariate analysis showed that intermediate risk patients had a 2.5-fold increased risk of LR if treated with IRT alone vs EBRT-IRT boost. RT schedule did not impact significantly on LR in high risk patients. All acute toxicity parameters were highest in patients who received EBRT with simultaneous integrated boost (EBRT-SIB) and lowest in patients who received only IRT (p < 0.0001). Late toxicity was highest patients who received EBRT-SIB and lowest in those who were given EBRT with sequential boost (p < 0.0001). Conclusions This retrospective study showed that Italian administration of adjuvant RT for EC is in accordance with current international guidelines. IRT alone for low-risk patients and EBRT associated with vaginal IRT remain standard adjuvant approaches for EC.

Multisequence magnetic resonance imaging-based radiomics models for the prediction of microsatellite instability in endometrial cancer

To evaluate the performance of multisequence magnetic resonance imaging (MRI)-based radiomics models in the assessment of microsatellite instability (MSI) status in endometrial cancer (EC). This retrospective multicentre study included 338 EC patients with available MSI status and preoperative MRI scans, divided into training (37 MSI, 123 microsatellite stability [MSS]), internal validation (15 MSI, 52 MSS), and external validation cohorts (30 MSI, 81 MSS). Radiomics features were extracted from T2-weighted images, diffusion-weighted images, and contrast-enhanced T1-weighted images. The ComBat harmonisation method was applied to remove intrascanner variability. The Boruta wrapper algorithm was used for key feature selection. Three classification algorithms, logistic regression (LR), random forest (RF), and support vector machine (SVM), were applied to build the radiomics models. The area under the receiver operating characteristic curve (AUC) was calculated to compare the diagnostic performance of the models. Decision curve analysis (DCA) was conducted to determine the clinical usefulness of the models. Among the 1980 features, Boruta finally selected nine radiomics features. A higher MSI prediction performance was achieved after running the ComBat harmonisation method. The SVM algorithm had the best performance, with AUCs of 0.921, 0.903, and 0.937 in the training, internal validation, and external validation cohorts, respectively. The DCA results showed that the SVM algorithm achieved higher net benefits than the other classifiers over a threshold range of 0.581-0.783. The multisequence MRI-based radiomics models showed promise in preoperatively predicting the MSI status in EC in this multicentre setting.

Radiological assessment of Peritoneal Cancer Index on preoperative CT in ovarian cancer is related to surgical outcome and survival

To evaluate whether Peritoneal Cancer Index (PCI) assessed on preoperative CT (CT-PCI) can be used as non-invasive preoperative tool to predict surgical outcome, disease-free survival (DFS) and overall survival (OS). This is a retrospective, observational cohort study performed in a single institution. We considered all patients with diagnosis of ovarian cancer and preoperative CT, who had undergone upfront cytoreductive surgery between 2008 and 2010 and had post-operative clinical follow-up to December 2015. Two radiologists reviewed CT scans and assessed CT-PCI using Sugarbaker's diagram. We assessed the discriminatory capacity of the CT-PCI score on the surgical outcome by ROC curve analysis. DFS and OS were assessed by Kaplan-Meier nonparametric curves and by multivariable Cox-regression analysis. A total of 297 patients were included in the present analysis. CT-PCI was positively correlated with post-operative residual disease [odds ratio (OR) 1.04, 95% CI 1.01-1.07, p = 0.003]. ROC curve analysis returned AUC = 0.64 for the prediction of total macroscopic tumour clearance. In multivariable analysis, patients with no peritoneal disease seen on CT had a significantly longer DFS [Hazard ratio (HR) 2.28, p = 0.007]. Radiological serosal small bowel involvement was an independent predictor for shorter OS (HR 3.01, p = 0.002). Radiological PCI assessed on preoperative CT is associated with the probability of residual disease after cytoreductive surgery; however, it has low performance as a triage test to reliably identify patients who are likely to have complete cytoreductive surgery. CT-PCI is positively correlated with both DFS and OS and may be used as an independent prognostic factor, for example in patients with high FIGO stages.

EROS 2.0 study: evaluation of two interventional radiotherapy (brachytherapy) schedules for endometrial cancer: a comparison of late vaginal toxicity rates

Abstract Background To compare the late toxicity rates after two different high dose rate (HDR) adjuvant intravaginal interventional radiotherapy (IRT-brachytherapy) dose schedules in stage I-II endometrial cancer. Methods Stage I-II patients with endometrial cancer treated with surgery (with or without lymphadenectomy) and adjuvant HDR-IRT between 2014 and 2020 were included in this analysis. Patients were treated with two schedules. In the first cohort (C1), 21 Gy were delivered in three weekly fractions (7 Gy) prescribed 0.5 cm from the applicator surface. In the second cohort (C2), 24 Gy were delivered in four weekly fractions (6 Gy). The clinical target volume was the upper third of the vagina for C1 and the upper 3 cm for C2. HDR-IRT technique and point prescription (5 mm depth from the applicator surface) were the same for all patients. Vaginal toxicity was scored according to the CTCAE 5.0 scale in terms of the presence versus absence of any toxicity grade. The correlation among toxicity and clinical covariates (age, lymphadenectomy, fractionation, stage) was tested by Pearson correlation test (univariate) and by logistic regression (multivariable). Results 114 stage I and three stage II patients, median age 62 (range: 32–85) years, were included in this analysis. The mean follow-up was 56.3 months in C1 (40–76) and 20 months in C2 (8–42). Vaginal late toxicity was recorded in 40 and 15 patients in C1 and 2, respectively. Age, lymphadenectomy, and fractionation were significantly correlated with toxicity at univariate analysis (p value = 0.029, 0.006, and 0.002, respectively), while stepwise logistic regression confirmed only age and fractionation as significantly correlated parameters (p value = 0.02 and 0.001, respectively). Three-year local relapse-free, distant metastasis-free and cause-specific survival rates were 96.6%, 94.8%, and 99.1%, respectively. Conclusions This analysis showed lower vaginal late toxicity rate in C2 compared to C1.

Assessment of magnetic resonance image compilation (MAGiC) abilities of therapeutic selection and prediction on recurrence risk factors and short-term treatment efficacy in cervical cancer

Abstract Objectives To investigate the feasibility of MAGiC (hereafter, sy-T2WI; T1, T2, and PD maps) in determination of treatment plan and prediction of recurrence risk factors (RRF) and short-term treatment efficacy (STE) in patients with cervical cancer (CC) using hr-T2WI and DWI as reference standards. Methods 119 consecutive CC patients who underwent MAGiC, hr-T2WI and DWI were prospectively recruited from October 2021 to March 2024. The subjective evaluation of image quality and tumor staging using sy-T2WI and hr-T2WI was conducted. The accuracy, sensitivity and specificity of sy-T2WI were analyzed for selection of a treatment strategy (stage IB-IIA: surgical operation; stage IIB-IVA: CCRT). RRF and STE were evaluated in staging IB-IIA and IIB-IVA CC patients respectively. Then, the area under the curve (AUC) was used to objectively predict RRF and STE using the quantitative T1, T2, PD maps, their combinations, and apparent diffusion coefficient (ADC). Results There was no significant difference of image quality (all P > 0.05), but a strong agreement on tumor staging (Kappa value = 0.935; p < 0.001) between sy-T2WI and hr-T2WI. The accuracy, sensitivity, and specificity of sy-T2WI in deciding treatment strategies were 0.908, 0.908, and 0.999, respectively. Furthermore, the combination of T1 and T2 values was superior to ADC values for predicting RRF (AUC: 0.980 vs. 0.776; p = 0.005) in staging IB-IIA and STE (AUC: 0.982 vs. 0.737; p < 0.001) in IIB-IVA CC subjects. Conclusions MAGiC is a promising technique for determination on treatment selection, RRF prediction and STE prognosis in CC patients as its performance is equivalent and even superior to hr-T2WI and DWI.

Ablation of symptomatic uterine fibroids with the Mirabilis system for rapid noninvasive ultrasound-guided high-intensity focused ultrasound (HIFU): a prospective observational clinical study

Abstract Objectives Uterine fibroids often lead to symptoms that negatively impact health-related quality of life (HRQOL). High-intensity focused ultrasound (HIFU) has emerged as a promising noninvasive treatment for reducing fibroid size and symptoms. The Mirabilis system for ultrasound (US)-guided HIFU introduces a novel technique known as ‘shell ablation’. This study evaluates the feasibility and efficacy of Mirabilis in a clinical setting, focusing on clinical outcomes. Materials and methods Sixteen patients with 23 uterine fibroids were treated with the Mirabilis system. Follow-up assessments included US and MRI at baseline, 6 weeks, 3, 6 and 9 months, and 1 year after HIFU. Changes in symptoms and QOL were evaluated using the Uterine Fibroid Symptom and HRQOL Questionnaire. Results A significant reduction in fibroid volume was observed after HIFU (baseline 182.1 ± 49.3 ml; 1 year: 76.0 ± 37.9 ml, p < 0.001). The symptom severity score significantly declined (baseline 57.2 ± 3.8; 1 year: 30.2 ± 4.9, p < 0.001), correlating with a significant improvement in HRQOL (baseline 47.0 ± 3.9, 1 year: 71.8 ± 5.3, p < 0.001). Conclusion HIFU with the portable Mirabilis system is a feasible and safe noninvasive treatment for symptomatic uterine fibroids in an outpatient setting. This approach allows efficient and rapid ablation even for large fibroids, significantly reducing fibroid volume and symptoms.

The performance of the node reporting and data system 1.0 (Node-RADS) and DWI–MRI in staging patients with cervical carcinoma according to the new FIGO classification (2018)

Abstract Purpose To evaluate the diagnostic accuracy of the Node-RADS score and the utility of apparent diffusion coefficient (ADC) values in predicting metastatic lymph nodes (LNs) involvement in cervical cancer (CC) patients using magnetic resonance imaging (MRI). The applicability of the Node RADS score across three readers with different years of experience in pelvic imaging was also assessed. Material and methods Among 140 patients, 68 underwent staging MRI, neoadjuvant chemotherapy and radical surgery, forming the study cohort. Node-RADS scores of the main pelvic stations were retrospectively determined to assess LN metastatic likelihood and compared with the histological findings. Mean ADC, relative ADC (rADC), and correct ADC (cADC) values of LNs classified as Node-RADS ≥ 3 were measured and compared with histological reports, considered as gold standard. Results Sensitivity, specificity, positive and negative predictive values (PPVs and NPVs), and accuracy were calculated for different Node-RADS thresholds. Node RADS ≥ 3 showed a sensitivity of 92.8% and specificity of 72.5%. Node RADS ≥ 4 yielded a sensitivity of 71.4% and specificity of 100%, while Node RADS 5 yielded 42.9% and 100%, respectively. The diagnostic performance of mean ADC, cADC and rADC values from 78 LNs with Node-RADS score ≥ 3 was assessed, with ADC demonstrating the highest area under the curve (AUC 0.820), compared to cADC and rADC values. Conclusion The Node-RADS score provides a standardized LNs assessment, enhancing diagnostic accuracy in CC patients. Its ease of use and high inter-observer concordance support its clinical utility. ADC measurement of LNs shows promise as an additional tool for optimizing patient diagnostic evaluation.

Combined dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging to predict neoadjuvant chemotherapy effect in FIGO stage IB2–IIA2 cervical cancers

To explore the value of histogram analysis of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) quantitative parameters and apparent diffusion coefficient (ADC) values in predicting the neoadjuvant chemotherapy (NACT) response for cervical cancers. Sixty-three patients with pathologically proved stage IB2-IIA2 cervical cancer from March 2013 to January 2017 were retrospectively analyzed. They were divided into two groups on the basis of therapeutic response: the significant response (SR) group, which contains complete response patients and partial response patients, and nonsignificant response (non-SR) group, which contains progressive diseases and stable diseases. Clinical characteristics, DCE-MRI parameters (K SR group and non-SR group were documented in 35 and 28 patients. The mean K Histogram analysis of DCE-MRI multi-parameters combined with ADC values may serve as sensitive indicators for predicting NACT effectiveness in cervical cancers.

Is there any correlation between HPV and early radioresponse before brachytherapy in cervix uteri carcinoma?

The prognostic effect of human papilloma virus (HPV) on early radioresponse before brachytherapy was evaluated in locally advanced cervix uteri carcinoma patients. Between 2015 and 2018, 150 patients with locally advanced carcinoma of the cervix uteri from University of Health Sciences Okmeydani Training and Research Hospital and Istanbul Oncology Hospital underwent chemotherapy concomitant with external radiotherapy and brachytherapy after performing fluorodeoxyglucose positron emission tomography (FDG PET) and magnetic resonance imaging (MRI) for purposes of staging and treatment planning. The treatment results of patients analyzed retrospectively. The median age of 57 patients was 53 years, and the initial tumor volume was 27 cm We could not determine the correlation between HPV contamination and patients who had early response intervention. But residual tumor of more than 2 cm in diameter after external radiotherapy may be a predictor of failed local control and development of metastasis within a short time.

Effect of granulocyte colony-stimulating factor on bone marrow: evaluation by intravoxel incoherent motion and dynamic contrast-enhanced magnetic resonance imaging

To report our experience with the use of intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI) and dynamic contrast-enhanced (DCE)-MRI in bone marrow before and after administration of granulocyte colony-stimulating factor (GCSF). Moreover, a small series of patients with bone metastases from breast cancer have been evaluated by IVIM DW-MRI and DCE-MRI before and after GCSF administration. We studied with IVIM-MRI and DCE-MRI 14 patients with rectal or uterine cervix cancer studied before and 4-18 days after administration of GCSF; the second MR examination was obtained after three chemotherapy courses. IVIM perfusion fraction (f), pseudo-diffusion coefficient (D*), true diffusion coefficient (D) and apparent diffusion coefficient (ADC) as well area under the curve at 60 s (AUC60) were calculated for bone marrow before and after GCSF administration. Moreover, two different IVIM parametric maps (i.e., ADC and ADC ADC, D, D*, f and AUC60 values were significantly higher in hyperplastic bone marrow than in untreated bone marrow (p values < 0.0001, < 0.0001, < 0.001, < 0.001, < 0.0001, respectively). All bone metastases were clearly differentiable from hyperplastic bone marrow on ADC MR functional imaging techniques, such as DW-, IVIM DW- and DCE-MRI are effective tools in assessing the response of bone marrow to the administration of growth factors. Although an overlap between signal of hyperplastic bone marrow and lytic bone metastases can occur on ADC maps and DCE-MRI, evaluation of ADCl

Observational multicenter Italian study on vulvar cancer adjuvant radiotherapy (OLDLADY 1.2): a cooperation among AIRO Gyn, MITO and MaNGO groups

Adjuvant radiotherapy (aRT) has been shown to reduce the risk of local relapse in vulvar cancer (VC). In this multicentre study (OLDLADY-1.2), several Institutions have combined their retrospective data on VC patients to produce a real-world dataset aimed at collecting data on efficacy and safety of aRT. The primary study end-point was the 2-year-local control, secondary end-points were the 2-year-metastasis free-survival, the 2-year-overall survival and the rate and severity of acute and late toxicities. Participating centres were required to fill data sets including age, stage, tumor diameter, type of surgery, margin status, depth of invasion, histology, grading as well technical/dosimetric details of radiotherapy. Data about response, local and regional recurrence, acute and late toxicities, follow-up and outcome measures were also collected. One hundred eighty-one patients with invasive VC from 9 Institutions were retrospectively identified. The majority of patients were stage III (63%), grade 2 (62.4%) squamous carcinoma (97.2%). Positive nodes were observed in 117 patients (64.6%), moreover tumor diameter > 4 cm, positive/close margins and depth of invasion deeper than 5 mm were found in 59.1%, 38.6%, 58% of patients, respectively. Sixty-one patients (33.7%) received adjuvant chemoradiation, and 120 (66.3%) received radiotherapy alone. aRT was started 3 months after surgery in 50.8% of patients. Prescribed volumes and doses heterogeneity was recorded according to margin status and nodal disease. Overall, 42.5% locoregional recurrences were recorded. With a median follow-up of 27 months (range 1-179), the 2-year actuarial local control rate, metastasis free and overall survival were 68.7%, 84.5%, and 67.5%, respectively. In term of safety, aRT leads to a prevalence of acute skin toxicity with a low incidence of severe toxicities. In the context of aRT for VC the present study reports a broad spectrum of approaches which would deserve greater standardization in terms of doses, volumes and drugs used.

Integrative deep learning and radiomics analysis for ovarian tumor classification and diagnosis: a multicenter large-sample comparative study

This study aims to evaluate the effectiveness of combining transvaginal ultrasound (US)-based radiomics and deep learning model for the accurate differentiation between benign and malignant ovarian tumors in large-scale studies. A multicenter retrospective study collected grayscale and color US images of ovarian tumors. Patients were divided into training, internal, and external validation groups. Models including a convolutional neural networks (CNN), optimal radiomics, and a combined model were constructed and evaluated for predictive performance using area under curve (AUC), sensitivity, and specificity. The DeLong test compared model AUCs with O-RADS and expert assessments. 3193 images from 2078 patients were analyzed. The CNN achieved AUCs of 0.970 (internal) and 0.959 (external), respectively. Optimal radiomic model achieved AUCs of 0.949 (internal) and 0.954 (external), respectively. The combined CNN-radiomics model attained the highest AUC of 0.977 (internal) and 0.972 (external), respectively, outperforming individual models, O-RADS, and expert methods (p < 0.05). The combined CNN-radiomics model using transvaginal US images provides more accurate and reliable ovarian tumor diagnosis, enhancing malignancy prediction and offering clinicians a more precise diagnostic tool.

Polyethylene Glycol microspheres for uterine artery embolization for the treatment of symptomatic uterine fibroids

Uterine fibroids are prevalent benign pelvic tumors, often causing debilitating symptoms that impair quality of life. Uterine fibroid embolization (UFE) is a consolidated minimally invasive treatment option. The purpose of this study is to report our experience with polyethylene glycol microspheres (HydroPearl) in UFE for symptomatic patients. This single-center retrospective study evaluated 37 consecutive patients with symptomatic uterine fibroids referred to our institution since November 2016 to February 2020 for UFE with HydroPearl microspheres. All patients included completed a comprehensive pre-UFE clinical assessment and underwent a magnetic resonance imaging (MRI) pre- and post-procedure. Technical success, procedure-related complications, clinical outcomes, follow-up MRI findings, and patient satisfaction were evaluated. A technical success rate of 97% with complete bilateral uterine artery embolization was achieved. Significant improvements were observed in menorrhagia, bulk-type symptoms, abdominal pain, and urinary dysfunctions after UFE. Post-procedural MRI assessments demonstrated reductions in uterine and dominant fibroid volumes, indicating successful devascularization. No immediate procedural complications were reported. Symptoms interfering with everyday activities significantly improved after the procedure. Patient satisfaction was high, with 89% expressing satisfaction with the treatment and 84% indicating purpose to repeat the procedure if necessary. Uterine artery embolization with HydroPearl is a safe and effective treatment option for symptomatic uterine fibroids. A significant improvement in menorrhagia and bulk-type symptoms after the procedure was observed correlated by a reduction in diameters and volumes of both the uterus and the main fibroid in post-procedural MRI.

Application of magnetic resonance imaging radiomics in endometrial cancer: a systematic review and meta-analysis

We aimed to systematically assess the methodological quality and clinical potential application of published magnetic resonance imaging (MRI)-based radiomics studies about endometrial cancer (EC). Studies of EC radiomics analyses published between 1 January 2000 and 19 March 2023 were extracted, and their methodological quality was evaluated using the radiomics quality score (RQS) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Pairwise correlation analyses and separate meta-analyses of studies exploring differential diagnoses and risk prediction were also performed. Forty-five studies involving 3 aims were included. The mean RQS was 13.77 (range: 9-22.5); publication bias was observed in the areas of 'index test' and 'flow and timing'. A high RQS was significantly associated with therapy selection-aimed studies, low QUADAS-2 risk, recent publication year, and high-performance metrics. Raw data from 6 differential diagnosis and 34 risk prediction models were subjected to meta-analysis, revealing diagnostic odds ratios of 23.81 (95% confidence interval [CI] 8.48-66.83) and 18.23 (95% CI 13.68-24.29), respectively. The methodological quality of radiomics studies involving patients with EC is unsatisfactory. However, MRI-based radiomics analyses showed promising utility in terms of differential diagnosis and risk prediction.

Diagnostic accuracy of MRI for evaluating myometrial invasion in endometrial cancer: a comparison of MUSE-DWI, rFOV-DWI, and DCE-MRI

Abstract Objectives To compare the image quality of high-resolution diffusion-weighted imaging (DWI) using multiplexed sensitivity encoding (MUSE) versus reduced field-of-view (rFOV) techniques in endometrial cancer (EC) and to compare the diagnostic performance of these techniques with that of dynamic contrast-enhanced (DCE) MRI for assessing myometrial invasion of EC. Methods MUSE-DWI and rFOV-DWI were obtained preoperatively in 58 women with EC. Three radiologists assessed the image quality of MUSE-DWI and rFOV-DWI. For 55 women who underwent DCE-MRI, the same radiologists assessed the superficial and deep myometrial invasion using MUSE-DWI, rFOV-DWI, and DCE-MRI. Qualitative scores were compared using the Wilcoxon signed-rank test. Receiver operating characteristic analysis was performed to compare the diagnostic performance. Results Artifacts, sharpness, lesion conspicuity, and overall quality were significantly better with MUSE-DWI than with rFOV-DWI (p &lt; 0.05). The area under the curve (AUC) of MUSE-DWI, rFOV-DWI, and DCE-MRI for the assessment of myometrial invasion were not significantly different except for significantly higher AUC of MUSE-DWI than that of DCE-MRI for superficial myometrial invasion (0.76 for MUSE-DWI and 0.64 for DCE-MRI, p = 0.049) and for deep myometrial invasion (0.92 for MUSE-DWI and 0.80 for DCE-MRI, p = 0.022) in one observer, and that of rFOV-DWI for deep myometrial invasion in another observer (0.96 for MUSE-DWI and 0.89 for rFOV-MRI, p = 0.048). Conclusion MUSE-DWI exhibits better image quality than rFOV-DWI. MUSE-DWI and rFOV-DWI shows almost equivalent diagnostic performance compared to DCE-MRI for assessing superficial and deep myometrial invasion in EC although MUSE-DWI may be helpful for some radiologists.

Preoperative identification from occult leiomyosarcomas in laparoscopic hysterectomy and laparoscopic myomectomy: accuracy of the ultrasound scoring system (PRESS-US)

To assess the diagnostic performance and inter-observer agreement of a PREoperative sarcoma scoring based on ultrasound (PRESS-US) in differentiating uterine leiomyosarcoma (uLMS) from leiomyoma (LM). We conducted a retrospective evaluation of patients who underwent surgery and received standardized ultrasound examinations due to the presence of uterine myoma-like masses. Histological diagnosis was used as the reference standard. The masses were analyzed using morphological uterus sonographic assessment criteria, and the diagnostic accuracy of PRESS-US was evaluated using ROC curve analysis. Kappa (κ) statistics were used to assess the inter-observer agreement between a less experienced and an expert radiologist. Among the 646 patients, 632 (97.8%) were diagnosed with LM, and 14 (2.2%) had uLMS. The malignancy rates for low-risk and high-risk patients were 0.35% and 13.48%, respectively. The optimal PRESS-US cutoff was 17.5, resulting in an AUC of 89.7% (95% CI, 0.79-1.00), with a sensitivity of 85.7% and a specificity of 87.8%. The inter-observer agreement between a less experienced and an expert radiologist was excellent (κ = 0.811, P < 0.001). PRESS-US provides effective risk stratification for uLMS for radiologists with different levels of experience, with high reliability. Subgrouping high-risk patients helps in better risk stratification.

External beam radiotherapy followed by image-guided adaptive brachytherapy in locally advanced cervical cancer: a multicenter retrospective analysis

To evaluate oncological outcomes and toxicities in patients with locally advanced cervical cancer (LACC) treated with concurrent chemoradiotherapy followed by image-guided adaptive brachytherapy at two Italian centres. A retrospective analysis was conducted on 122 patients with LACC treated between 2010 and 2022. Primary endpoints were local control (LC), pelvic control (PC), and nodal control (NC). Secondary endpoints included disease-free survival (DFS), metastasis-free survival (MFS), overall survival (OS), and late toxicity. Correlations between patient characteristics and oncological outcomes were conducted. Brachytherapy planning was CT and MRI-based in 88 (72.1%) and 34 patients (27.9%), respectively. The mean total dose (EQD2) delivered to high-risk clinical target volume was 82 Gy. Overall treatment time was ≤ 50 days and > 50 days in 48 (39.3%) and 74 patients (60.7%), respectively. At a mean follow up of 101 months, 3 and 5-year LC rates were 87% and 85%, respectively. Five-year PC and NC rates were 77% and 85.1%. Five-year DFS and OS were 61% and 65.4%, respectively, with significant correlations between these outcomes and FIGO stage and nodal status at diagnosis. Gastrointestinal, genitourinary and vaginal adverse effects were the most reported late toxicities and 8 (6.5%) grade 3-5 events were observed. 32 patients (26.2%) had vaginal stenosis and it was significantly related to 3D imaging used for brachytherapy planning. The study confirmed the efficacy and safety of chemoradiotherapy and IGABT for LACC. Full implementation of MRI treatment planning and interstitial techniques could further enhance personalized treatment and outcomes.

Seeing beyond the tumor: computed tomography image-based radiomic analysis helps identify ovarian clear cell carcinoma subtype in epithelial ovarian cancer

To develop and validate a model that can preoperatively identify the ovarian clear cell carcinoma (OCCC) subtype in epithelial ovarian cancer (EOC) using CT imaging radiomics and clinical data. We retrospectively analyzed data from 282 patients with EOC (training set = 225, testing set = 57) who underwent pre-surgery CT examinations. Patients were categorized into OCCC or other EOC subtypes based on postoperative pathology. Seven clinical characteristics (age, cancer antigen [CA]-125, CA-199, endometriosis, venous thromboembolism, hypercalcemia, stage) were collected. Primary tumors were manually delineated on portal venous-phase images, and 1218 radiomic features were extracted. The F-test-based feature selection method and logistic regression algorithm were used to build the radiomic signature, clinical model, and integrated model. To explore the effects of integrated model-assisted diagnosis, five radiologists independently interpreted images in the testing set and reevaluated cases two weeks later with knowledge of the integrated model's output. The diagnostic performances of the predictive models, radiologists, and radiologists aided by the integrated model were evaluated. The integrated model containing the radiomic signature (constructed by four wavelet radiomic features) and three clinical characteristics (CA-125, endometriosis, and hypercalcinemia), showed better diagnostic performance (AUC = 0.863 [0.762-0.964]) than the clinical model (AUC = 0.792 [0.630-0.953], p = 0.295) and the radiomic signature alone (AUC = 0.781 [0.636-0.926], p = 0.185). The diagnostic sensitivities of the radiologists were significantly improved when using the integrated model (p = 0.023-0.041), while the specificities and accuracies were maintained (p = 0.074-1.000). Our integrated model shows great potential to facilitate the early identification of the OCCC subtype in EOC, which may enhance subtype-specific therapy and clinical management.

Locally advanced cervical cancer: how the improvement in techniques in external beam radiotherapy and brachytherapy impacts on survival outcomes and long-term toxicities

Platinum-based chemoradiotherapy and brachytherapy are the standard treatment for locally advanced cervical cancer. Reported long-term outcomes for treated with both IMRT and 3D-Image-guided-adaptive brachytherapy are lacking. This retrospective study included 165 patients with FIGO Stage IB-IVB cervical cancer, treated with chemoradiotherapy in combination with brachytherapy. External beam radiotherapy was delivered as IMRT/VMAT/TOMO helical or 3DCRT. The intracavitary brachytherapy treatment (ICBT) was performed using two different planning system (with or without optimization). Among the patient subgroups, comprising those who received IMRT/VMAT/Tomo helical and 3DCRT, as well as those who underwent ICBT planning optimization and those who did not, homogeneity was observed in terms of age, performance status, T stage, N status, TNM stage, and histology. With a median follow-up time of 60.5 months, the 5-year overall survival (OS) in the 3DCRT and IMRT groups was 74.9% and 92.8%, respectively (p = 0.033). The 5-year OS in the ICBT planning optimization group was 93.7%, compared to 75% in the non-optimization group (p = 0.014). Regarding late radiation toxicities, patients in the IMRT group had a lower incidence of chronic rectal toxicity compared to those in the 3DCRT group (6.5% vs. 34.1%, p = 0.001). The group with ICBT planning optimization had a lower incidence of late urinary toxicities (10.4%) compared to the non-optimized ICBT planning group (18.2%, p = 0.012). Similarly, the ICBT planning optimization group had a lower incidence of late rectal toxicity (6.5% with 80% grade 1 and 20% grade 2) compared to the non-optimized ICBT planning group (34.1%, p = 0.001). In this series, the group of patients receiving optimized ICBT had an advantage in terms of OS and CSS suggesting that the use of new Treatment Planning Systems associated with 3D imaging, improves the long-term survival. Additionally, a significant reduction in late rectal and urinary toxicity has been observed.

The role of MRI in cervical cancer &gt; 2 cm (FIGO stage IB2-IIA1) conservatively treated with neoadjuvant chemotherapy followed by conization: a pilot study

Abstract Introduction MRI is very accurate in selecting young women with cervical cancer for fertility-sparing surgery (FSS), in particular radical hysterectomy (RH). In order to improve obstetrical outcomes, neoadjuvant chemotherapy (NACT) followed by cold knife conization (CKC) has been proposed as alternative technique. Objective To investigate the role of MRI in evaluation of response to treatment after neoadjuvant chemotherapy (NACT), followed by CKC, in patients with cervical cancer FIGO stage IB2-IIA1 with tumor size 2 – 4 cm, desiring to preserve their fertility. Methods 13 young women (23–36 years old) with cervical cancer stage IB2-IIA1 desiring to preserve their fertility were included. Tumor diameter at baseline and after treatment was detected on 1.5 T MRI. Treatment response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and then compared to histopathology result. Results MRI correctly assessed 11 out of 13 cases, according to RECIST 1.1, compared to histopathology. Among these 7 patients with partial response (PR), 2 cases of CR, 1 SD and 1 PD with persistence or enlargement of primary tumor. Conclusion Our pilot study supports the usefulness of MRI in assessment of treatment response after NACT, followed by CKC. Trial registration number ClinicalTrials.gov: NCT02323841

Definitive chemoradiation in vulvar squamous cell carcinoma: outcome and toxicity from an observational multicenter Italian study on vulvar cancer (OLDLADY 1.1)

Abstract Background Vulvar carcinoma is a rather uncommon gynecological malignancy affecting elderly women and the treatment of loco-regional advanced carcinoma of the vulva (LAVC) is a challenge for both gynecologic and radiation oncologists. Definitive chemoradiation (CRT) is the treatment of choice, but with disappointing results. In this multicenter study (OLDLADY-1.1), several institutions have combined their retrospective data on LAVC patients to produce a real-world dataset aimed at collecting data on efficacy and safety of CRT. Methods The primary study end-point was 2-year-local control (LC), secondary end-points were 2-year-metastasis free-survival (MFS), 2-year-overall survival (OS) and the rate and severity of acute and late toxicities. Participating centers were required to fill data sets including age, stage, histology, grading as well as technical/dosimetric details of CRT. Data about response, local and regional recurrence, acute and late toxicities, follow-up and outcome measures were also collected. The toxicity was a posteriori documented through the Common Terminology Criteria for Adverse Events version 5 scale. Results Retrospective analysis was performed on 65 patients with primary or recurrent LAVC treated at five different radiation oncology institutions covering 11-year time interval (February 2010–November 2021). Median age at diagnosis was 72 years (range 32–89). With a median follow-up of 19 months (range 1–114 months), 2-year actuarial LC, MFS and OS rate were 43.2%, 84.9% and 59.7%, respectively. In 29 patients (44%), CRT was temporarily stopped (median 5 days, range 1–53 days) due to toxicity. The treatment interruption was statistically significant at univariate analysis of factors predicting LC (p: 0.05) and OS rate (p: 0.011), and it was confirmed at the multivariate analysis for LC rate (p: 0.032). In terms of toxicity profile, no G4 event was recorded. Most adverse events were reported as grade 1 or 2. Only 14 acute G3 toxicities, all cutaneous, and 7 late G3 events (3 genitourinary, 3 cutaneous, and 1 vaginal stenosis) were recorded. Conclusion In the context of CRT for LAVC, the present study reports encouraging results even if there is clearly room for further improvements, in terms of both treatment outcomes, toxicity and treatment interruption management.

Radiomics-based prediction of two-year clinical outcome in locally advanced cervical cancer patients undergoing neoadjuvant chemoradiotherapy

Abstract Purpose The aim of this study is to determine if radiomics features extracted from staging magnetic resonance (MR) images could predict 2-year long-term clinical outcome in patients with locally advanced cervical cancer (LACC) after neoadjuvant chemoradiotherapy (NACRT). Materials and methods We retrospectively enrolled patients with LACC diagnosis who underwent NACRT followed by radical surgery in two different institutions. Radiomics features were extracted from pre-treatment 1.5 T T2w MR images. The predictive performance of each feature was quantified in terms of Wilcoxon–Mann–Whitney test. Among the significant features, Pearson correlation coefficient (PCC) was calculated to quantify the correlation among the different predictors. A logistic regression model was calculated considering the two most significant features at the univariate analysis showing the lowest PCC value. The predictive performance of the model created was quantified out using the area under the receiver operating characteristic curve (AUC). Results A total of 175 patients were retrospectively enrolled (142 for the training cohort and 33 for the validation one). 1896 radiomic feature were extracted, 91 of which showed significance (p &lt; 0.05) at the univariate analysis. The radiomic model showing the highest predictive value combined the features calculated starting from the gray level co-occurrence-based features. This model achieved an AUC of 0.73 in the training set and 0.91 in the validation set. Conclusions The proposed radiomic model showed promising performances in predicting 2-year overall survival before NACRT. Nevertheless, the observed results should be tested in larger studies with consistent external validation cohorts, to confirm their potential clinical use.