Gynecologic tumors: how to communicate imaging results to the surgeon

Imaging the post-treatment pelvis with gynecologic cancers

Gynecological malignancies, such as ovarian cancers, cervical cancers, and endometrial cancers, have a significant global impact. Women with gynecologic malignancies may receive a single or a combination of treatments, including surgery, chemotherapy, and radiation-based therapies. Radiologists utilize various diagnostic imaging modalities to provide the surgeon with relevant information about the diagnosis, prognosis, optimal surgical strategy, and prospective post-treatment imaging. Computerized Tomography (CT) and magnetic resonance imaging (MRI) may be used initially to evaluate and detect post-treatment complications. Although CT is primarily used for staging, MRI is commonly used for a more accurate evaluation of a tumor's size and detection of local invasion. Complications such as hematoma, abscess, inclusion cyst, seroma, tumor thrombosis, anorectovaginal fistula, and gossypiboma may occur after the three primary treatments, and systems such as the genitourinary, gastrointestinal, neurological, and musculoskeletal may be affected. In order to distinguish between early-onset and late-onset complications following gynecological treatment, radiological findings of the most common post-treatment complications will be presented in this review.

Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non-neoplastic causes

Contrary to traumatic and iatrogenic intraabdominal hemorrhages, spontaneous intraabdominal hemorrhage is a challenging clinical situation. A variety of neoplastic and non-neoplastic conditions may cause spontaneous intraabdominal bleeding. Imaging findings vary depending on the source of bleeding and the underlying cause. In this article, we aim to increase the awareness of imagers to the most common causes of spontaneous intraabdominal hemorrhage by using representative cases.

Comparison of magnetic resonance imaging and ultrasonography in tumor size: Evaluation of equality in advanced cervical cancer patients

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Imaging before cytoreductive surgery in advanced ovarian cancer patients

Appropriate and accurate pre-operative imaging in epithelial ovarian cancer patients may allow selection of patients that may mostly benefit either from primary cytoreductive surgery or from neoadjuvant chemotherapy. If the patient is considered suitable for upfront surgery, pre-operative imaging may help in planning the surgical approach, to forecast the operating time, and to estimate the need for other consulting specialists. Currently, computed tomography (CT) imaging is the standard of care for pre-operative evaluation of ovarian cancer patients; however, advanced magnetic resonance imaging (MRI) is emerging as a technique that may overcome the limitations of CT imaging, especially for small peritoneal deposits in difficult-to-resect sites. Positron emission tomography (PET)-CT imaging in the pre-operative setting is currently limited, whereas the use of the new hybrid technique PET-MRI is still under evaluation. Since criteria that may preclude optimal cytoreductive surgery may vary, depending on the aggressiveness of the surgical procedure and surgeon skill, multidisciplinary consensus conferences are the ideal platform to evaluate extent of the disease and surgical strategy.

Do DWI and quantitative DCE perfusion MR have a prognostic value in high-grade serous ovarian cancer?

PURPOSE

To evaluate whether perfusion and diffusion parameters from staging MR in ovarian cancer (OC) patients may predict the presence of residual tumor at surgery and the progression-free survival (PFS) in 12 months.

MATERIALS AND METHODS

Patients who are from a single institution, candidate for OC to cytoreductive surgery and undergoing MR for staging purposes were included in this study. Inclusion criteria were: preoperative MR including diffusion-weighted imaging (DWI) and perfusion dynamic contrast-enhanced (DCE) sequence; cytoreductive surgery performed within a month from MR; and minimum follow-up of 12 months. Patients' characteristics including the presence of residual tumor at surgery (R0 or R1) and relapse within 12 months from surgery were recorded. DWI parameters included apparent diffusion coefficient (ADC) of the largest ovarian mass (O-ADC) and normalized ovarian ADC as a ratio between ovarian ADC and muscle ADC (M-ADC). DCE quantitative parameters included were descriptors of tumor vascular properties such as forward and backward transfer constants, plasma volume and volume of extracellular space. Statistical analysis was performed, and p values < 0.05 were considered significant.

RESULTS

Forty-nine patients were included. M-ADC showed a slightly significant association with the presence of residual tumor at surgery. None of the other functional parameters showed either difference between R0 and R1 patients or association with PFS in the first 12 months.

CONCLUSIONS

This preliminary study demonstrated a slightly significant association between normalized ovarian ADC and the presence of residual tumor at surgery. The other perfusion and diffusion parameters were not significant for the endpoints of this study.

Cardiophrenic lymph node resection in cytoreduction for primary advanced or recurrent epithelial ovarian carcinoma: a cohort study

OBJECTIVES

To evaluate the clinical outcomes of epithelial ovarian carcinoma patients who underwent cardiophrenic lymph node resection.

METHODS

We retrospectively reviewed the records of all surgically treated patients with advanced epithelial ovarian carcinoma (stages IIIC-IV) who underwent cardiophrenic lymph node resection between 2002 and 2018. Only those in whom cardiophrenic lymph node involvement was the only detectable extra-abdominal disease were included. Patients with suspected cardiophrenic lymph node metastasis on staging images underwent a transdiaphragmatic incision to access the para-cardiac space after complete abdominal cytoreduction achievement. Data on disease-free survival, overall survival, and surgical procedures performed concurrently with cardiophrenic lymph node resection were collected.

RESULTS

Of the total 456 patients, 29 underwent cardiophrenic lymph node resection; of these, 24 patients met the inclusion criteria. Twenty-two, one, and one patients had high grade serous epithelial ovarian carcinoma, low grade epithelial ovarian carcinoma, and ovarian carcinosarcoma, respectively. Ten patients had recurrent disease (recurrence group). Fourteen patients underwent cytoreduction during primary treatment (primary debulking group); four underwent cytoreduction after neoadjuvant chemotherapy. Cardiophrenic lymph node resection was performed on the right side in 19 patients, left side in three, and bilaterally in two. The average procedural duration was 28 minutes, with minimal blood loss and no severe complications. Twenty-one patients had cardiophrenic lymph node positivity. The median disease-free intervals were 17 and 12 months in the recurrent and primary debulking surgery groups, respectively. The mediastinum was the first recurrence site in 10 patients. Five patients developed brain metastases. Five patients had an overall survival beyond 50 months.

CONCLUSIONS

Although rare, the cardiophrenic lymph nodes may be a site of metastasis of ovarian cancer. Although their presence might indicate future recurrence, some patients may achieve long-term survival. Resection should be considered in cases of suspicious involvement to confirm extra-abdominal disease and achieve complete cytoreduction.

Endometrial cancer: an overview of novelties in treatment and related imaging keypoints for local staging

Endometrial cancer is the most common gynaecologic malignancy in developed countries and its incidence is increasing. First-level treatment, if no contraindicated, is based on surgery. Pre-operative imaging is needed for evaluation of local extent and detection of distant metastases in order to guide treatment planning. Radiological evaluation, based on transvaginal ultrasound, MR and CT, can make the difference in disease management, paying special attention to assessment of entity of myometrial invasion, cervical stromal extension, and assessment of lymph nodal involvement and distant metastases.

Radiomics of high-grade serous ovarian cancer: association between quantitative CT features, residual tumour and disease progression within 12 months

OBJECTIVES

To determine if radiomic features, alone or combined with clinical data, are associated with residual tumour (RT) at surgery, and predict the risk of disease progression within 12 months (PD12) in ovarian cancer (OC) patients.

METHODS

This retrospective study enrolled 101 patients according to the following inclusion parameters: cytoreductive surgery performed at our institution (9 May 2007-23 February 2016), assessment of BRCA mutational status, preoperative CT available. Radiomic features of the ovarian masses were extracted from 3D structures drawn on CT images. A phantom experiment was performed to assess the reproducibility of radiomic features. The final radiomic features included in the analysis (n = 516) were grouped into clusters using a hierarchical clustering procedure. The association of each cluster's representative radiomic feature with RT and PD12 was assessed by chi-square test. Multivariate analysis was performed using logistic regression models. P values < 0.05 were considered significant.

RESULTS

Patients with values of F2-Shape/Compactness1 below the median, of F1- GrayLevelCooccurenceMatrix25/0-1InformationMeasureCorr2 below the median and of F1-GrayLevelCooccurenceMatrix25/-333-1InverseVariance above the median showed higher risk of RT (36%, 36% and 35%, respectively, as opposed to 18%, 18% and 18%). Patients with values of F4-GrayLevelRunLengthMatrix25/-333RunPercentage above the median, of F2 shape/Max3DDiameter below the median and F1-GrayLevelCooccurenceMatrix25/45-1InverseVariance above the median showed higher risk of PD12 (22%, 24% and 23%, respectively, as opposed to 6%, 5% and 6%). At multivariate analysis F2-Shape/Max3DDiameter remained significant (odds ratio (95% CI) = 11.86 (1.41-99.88)). To predict PD12, a clinical radiomics model performed better than a base clinical model.

CONCLUSION

This study demonstrated significant associations between radiomic features and prognostic factors such as RT and PD12.

KEY POINTS

• No residual tumour (RT) at surgery is the most important prognostic factor in OC. • Radiomic features related to mass size, randomness and homogeneity were associated with RT. • Progression of disease within 12 months (PD12) indicates worse prognosis in OC. • A model including clinical and radiomic features performed better than only-clinical model to predict PD12.