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A 54-year-old woman was seen in the gynecologic oncology clinic because of a pelvic mass that was associated with urinary frequency and urgency, pelvic pain, fever, and weight loss. A large, central pelvic mass was noted on examination, and imaging studies showed a complex solid and cystic mass with ascites. The evaluation and management of malignant tumors of the ovaries and fallopian tubes are discussed by a multidisciplinary team.

Acute mesenteric ischemia, a frequently lethal disease, requires prompt diagnosis and intervention for favorable clinical outcomes. This goal remains elusive due, in part, to lack of a noninvasive and accurate imaging study. Traditional angiography is the diagnostic gold standard but is invasive and costly. Computed tomography (CT) is readily available and noninvasive but has shown variable success in diagnosing this disease. The faster scanning time of multidetector row CT (M.D.CT) greatly facilitates the use of CT angiography (CTA) in the clinical setting. We sought to determine whether M.D.CT-CTA could accurately demonstrate vascular anatomy and capture the earliest stages of mesenteric ischemia in a porcine model. Pigs underwent embolization of branches of the superior mesenteric artery, then imaging by M.D.CT-CTA with three-dimensional reconstruction protocols. After scanning, diseased bowel segments were surgically resected and pathologically examined. Multidetector row CT and CT angiography reliably defined normal and occluded mesenteric vessels in the pig. It detected early changes of ischemia including poor arterial enhancement and venous dilatation, which were seen in all ischemic animals. The radiographic findings--compared with pathologic diagnoses-- predicted ischemia, with a positive predictive value of 92%. These results indicate that M.D.CT-CTA holds great promise for the early detection necessary for successful treatment of acute mesenteric ischemia.

Nothing stirs the collective soul of primary debulking surgery (PDS) advocates like hard data suggesting equivalent outcomes of neoadjuvant chemotherapy (NAC). These opposing views have even metaphorically come to blows at the highly entertaining "SGO Fight Night" that took place during the 2008 Annual Meeting on Women's Cancer, replete with teams supporting each of the would-be gladiators. Decades of retrospective data supporting the clinical benefit of PDS has recently been challenged by the publication in 2010 of a randomized phase III trial conducted in Europe supporting the clinical efficacy of NAC. Naturally, a firestorm of criticism among believers ensued, yet practice patterns within the United States did slowly change, suggesting an emerging block of dissenters. Another randomized phase III European trial, as presented in abstract form in 2013, showed similar findings. Few other topics within the field of gynecologic oncology have participants so entrenched in the "corners" of their existing practice patterns. This review attempts to consolidate the current evidence supporting both sides so that the patient can be declared the winner.

Purpose Image-guided needle biopsy represents a minimally invasive method for pathologic diagnosis of a mass. This study evaluates the diagnostic yield, accuracy, and safety of ovarian mass biopsy with combined core and fine-needle technique. Materials and Methods Medical records of all women at least 18 years of age, referred from gynecologic oncology, who underwent image-guided ovarian mass biopsy from 2001 through 2011 were reviewed. Among 27 patients, ultrasound guidance was used in 13 (48%), six transabdominal and seven transvaginal; computed tomography guidance was used in 14 (52%), nine transabdominal and five transgluteal. Biopsy indications were suspected metastasis (n = 15; 56%), suspected ovarian cancer to be treated with neoadjuvant chemotherapy (n = 10; 37%), and relative contraindication to surgery (n = 2; 7%). Mean maximum lesion dimension was 9.9 cm (range, 2–23 cm), with solid composition in nine (33%), cystic in six (22%), and mixed in 12 (44%). Biopsy pathologic findings were compared versus those of the surgical specimen or, for masses that were not resected, versus the stability of benign masses and response to chemotherapy of malignant masses on follow-up. Results All biopsies yielded a diagnosis. No biopsy-related complications were noted. Eleven patients (41%) did not undergo lesion resection and were followed for an average of 28.8 months (range, 0.3–118.4 mo). In no patient did malignancy develop during clinical follow-up after a benign biopsy diagnosis. Sensitivity and specificity for diagnosis of malignancy were 100% ± 0 (19 of 19) and 88% ± 26 (seven of eight), respectively, for cancer detection. In nine patients (33%) with final pathologic diagnosis of epithelial ovarian cancer, tumor seeding was not observed during a mean follow-up of 44.6 months (range, 1.3–110.2 mo). Conclusions Image-guided ovarian mass core needle biopsy results in a pathologic diagnosis of benign and malignant masses with high yield, accuracy, and safety.

This chapter covers cervical cancer, vulvar cancer, and vaginal cancer. It discusses the etiology, diagnosis, and pathologic features of all the different cancers in each category. Diagnosis and treatment of preinvasive in addition to invasive disease in all three categories are examined, including surgical therapy, radiation therapy, and chemotherapy. Recent studies and evidence in the diagnosis and treatment of these three very different cancers are reported.

Although most abnormal vaginal bleeding is caused by hormone imbalance, it can be indicative of disease, including endometrial polyps and hyperplasia, and cancers of the cervix and endometrium [1]. In postmenopausal women, the greatest concern is endometrial cancer, which is now the most common gynecologic cancer in the United States. Because this is curable if detected early, it is important to determine the cause of all cases of postmenopausal vaginal bleeding to avoid missed diagnoses of endometrial cancer. More than 90% of the cases of endometrial cancer occur in women older than 50 years of age, and this disease accounts for approximately5%ofthecasesofvag

We sought to develop quantitative methods to describe the use and results of imaging studies in emergency department patients.A computerized nonrelational database containing records of 3.5 million diagnostic reports generated by our radiology department from 1988 to 1997 was queried using Boolean and natural language search tools. Each record contained data fields for patient demographics, examination description and billing code, names of interpreting radiologists and referring physicians, patient history, report body, and report impression.Emergency department admissions and imaging studies were stable from 1991 to 1997, averaging 60,000 and 52,000 per year, respectively. Bone radiographs comprised 45.1% of examinations; chest radiographs, 44.6%; and abdominal radiographs, 10.4%. The percentages of radiographs interpreted as normal were 75.9% in 1992 and 75.3% in 1996, with cervical spine (88.7%), thoracic spine (86.3%), and knee (86.3%) yielding the highest proportion of studies with normal findings. The number of CT studies of the body increased from 1840 in 1993 to 3101 in 1997. Studies of the abdomen accounted for most of this increase (52.3% in 1993 to 66.0% in 1997). During evaluations for cervical spine injury, a mean of 6.5% of radiographic studies were followed by CT studies, and the findings of 89.0% of those CT studies were interpreted as normal.Radiology report databases represent a resource from which broad descriptions of the use and results of imaging studies can be obtained. Such descriptions may be useful in departmental and hospital administration, technology assessment, cost-effectiveness studies, and health policy formulation.

The educational objectives for this self-assessment module on adnexal masses are for the participant to exercise, self-assess, and improve his or her knowledge of the imaging evaluation of adnexal masses and to gain familiarity with the features of adnexal masses on sonography and MRI that characterize them as benign.

choosing the correct radiologic test , choosing the correct radiologic test , کتابخانه دیجیتالی دانشگاه علوم پزشکی و خدمات درمانی شهید بهشتی

OBJECTIVE. The purpose of this article is to review fetal radiation doses and associated risks resulting from CT performed during pregnancy. The scanning parameters that influence dose and the techniques for estimating and reducing dose are explained. CONCLUSION. Fetal radiation doses for CT examinations in which the fetus is not directly imaged???for example, head or chest CT???are minimal and need not figure in the risk-benefit analysis to perform the examination. In contrast, radiation dose should be considered with abdominopelvic CT because the fetus is likely to be exposed directly to the scanning beam. Safe implementation of CT in this setting requires an understanding of the factors influencing radiation dose. With this knowledge, when a risk-benefit analysis in a given clinical situation favors imaging using CT, the radiologist need not withhold or delay the examination and can achieve diagnostic-quality images while reducing radiation exposure.

The prognosis of cervical cancer is linked to lymph node involvement, and this is predicted clinically and pathologically by the stage of the disease, as well as the volume and grade of the tumor. Staging of cervical cancer based on International Federation of Gynecology and Obstetrics (FIGO) staging uses physical examination, cystoscopy, proctoscopy, intravenous urography, and barium enema. It does not include CT or MRI. Evaluation of the parametrium is limited in FIGO staging, and lymph node metastasis, an important prognostic factor, is not included in FIGO staging. The most important role for imaging is to distinguish stages Ia, Ib, and IIa disease treated with surgery from advanced disease treated with radiation therapy with or without chemotherapy. This article reviews the current role of imaging in pretreatment planning of invasive cervical cancer. The ACR Appropriateness Criteria ® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

OBJECTIVE. The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. A twisted pedicle, although not often detected on imaging, is pathognomonic when seen. Subacute ovarian hemorrhage and abnormal enhancement is usually seen, and both features show characteristic patterns on CT and MRI. Ipsilateral uterine deviation can also be seen. CONCLUSION. Diagnostic pitfalls that may mimic ovarian torsion and observations for discriminating them are discussed.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Endometrial cancer is one of the common malignancies in the female genital tract. Imaging in pretreatment evaluation may play an important role in an assessment of morphological prognostic factors including tumor size, depth of myometrial invasion, endocervical extent, and lymph node status. Imaging is also useful in posttreatment evaluation of patients with clinically suspected recurrence. Various modalities including MRI, CT ultrasound and FDG PET-CT-CT have been used for evaluation of the endometrial cancer in both before and after treatment settings. Literature on the indications and usefulness of these imaging studies for endometrial cancer is reviewed.

Purpose The aims of this study were to define the magnitude of frequent body CT scanning of young adults and to determine associated patient diagnoses, examination indications, short-term outcomes, and estimated radiation-induced cancer risk. Methods Patients aged 18 to 35 years who underwent chest or abdominopelvic CT between 2003 and 2007 at any of 3 hospitals were identified and categorized by total number of scans per body part as rarely ( 5 and 15) scanned. Medical records of the frequently scanned were reviewed. Cumulative radiation exposure, calculated from typical effective doses, was used to estimate cancer risk. Cancer incidence and mortality were estimated using the Biological Effects of Ionizing Radiation method. Results A total of 25,104 patients underwent 45,632 scans, of whom 23,851 (95%) and 70 (0.3%) were rarely and frequently scanned, respectively. Among frequently scanned patients, the most common diagnoses were cancer (19 of 36 [52.8%]) and cystic fibrosis with lung transplantation (11 of 36 [30.5%]) for chest CT and cancer (25 of 34 [73.5%]) for abdominopelvic CT. During the mean 5.4 years (range, 0.9-7.6 years) of follow-up, 46% of frequently scanned patients (32 of 70) died. Of the 47 cancers predicted in the entire cohort, 36 (77%) and 2 (3%) were expected in the rarely and frequently scanned. Conclusions The majority of CT-induced cancers are predicted to result from sporadic rather than frequent scanning. Frequent scanning confers a significant cancer risk but occurs in severely ill patients, a large proportion of who die before any radiation-induced cancer would be a factor in their health.

The majority of women with ovarian cancer have advanced stage disease at the time of diagnosis and a poor 5 year survival rate. Hence, screening has been investigated in the hopes of improving survival by diagnosing ovarian cancer at an earlier stage. Most screening methods thus far have included ultrasound and/or serum tumor markers. However, low prevalence of the disease, high false positive rate of current screening methods, and the probable rapid growth of most ovarian carcinomas from no defined precursor lesion, all contribute to difficulty in screening for ovarian cancer. While screening may be able to detect ovarian cancer at an earlier stage, adequate data is presently lacking on whether screening improves survival. The results of ongoing large clinical trials will be available in a few years and should provide critical information regarding the usefulness of screening. Pending results of those large clinical trials, screening is not currently recommended for women at average risk for ovarian cancer. Screening is most likely to be performed in women with an increased familial risk of ovarian cancer, but patients should be aware that even with this risk factor, there is currently insufficient evidence to know if screening is effective. New screening methods, including new or multiple serum markers and proteomics, are also being investigated.

The Gynaecological Cancer InterGroup conducts collaborative trials in gynecologic cancer and also aims to develop standards that can be used to strengthen all aspects of study methodology. There is an urgent need to develop more refined imaging end points that can be used as early treatment response biomarkers in ovarian cancer. Therefore, the Gynaecological Cancer InterGroup commissioned an expert position paper on the role of functional imaging as an end point in clinical trials in ovarian cancer. In this position paper, we state the limitation of current anatomical imaging methods used in clinical trials, highlight the potential of functional imaging, and provide key recommendations on the use of functional imaging as an end point in ovarian cancer clinical trials.

OBJECTIVE. The purpose of this article is to describe the role of MR, CT, and PET/CT in the detection of ovarian cancer and the evaluation of adnexal lesions.CONCLUSION. The goal of imaging in ovarian cancer detection is to expeditiously distinguish benign adnexal lesions from those requiring further pathologic evaluation for malignancy. For lesions indeterminate on ultrasound, MRI increases the specificity of imaging evaluation, thus decreasing benign resections. CT is useful in diagnosis and treatment planning of advanced cancer. Although 18F-FDG-avid ovarian lesions in postmenopausal women are considered suspicious for malignancy, PET/CT is not recommended for primary cancer detection because of high false-positive rates.

The aim of this study was to relate the early use of advanced imaging to length of hospital stay.Among all 33,226 admissions to an urban tertiary care hospital in 2005, the authors identified the 10,005 admissions (30.1%) that includedor=1 advanced imaging study (CT, MRI, or nuclear scintigraphy) during the period from 1 day before admission (day -1) through discharge. The length of stay was calculated, and using the date of the first advanced imaging study performed relative to date of admission (date of service), the residual length of stay (length of stay minus date of service) of each admission was also calculated. For admissions ofor=3 days in duration, the mean length of stay of patients with early imaging (on day -1 or 0) was compared using t test to that of patients with later imaging (on day 1 or 2). For all admissions with advanced imaging, linear regression analysis was applied to length of stay and residual length of stay as a function of date of service. Similar analysis was performed on subgroups classified by examination type (modality and body part) and International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code.The mean length of stay was significantly shorter for those imaged on day -1 or 0 compared with day 1 or 2 for all admissions ofor=3 days (8.6 vs 9.0 days, P = .015) and for the following specific subgroups: abdominal CT (8.4 vs 9.7 days, P = .003) and neurologic MR examination types (7.6 vs 8.7 days, P = .03) and abdominal ICD-9 codes (7.5 vs 8.8 days, P = .007). A statistically significant positive correlation was noted between length of stay and date of service for all admissions (slope, 0.27; P.001) and for the following subgroups: neurologic CT, chest CT, abdominal CT, and nuclear scintigraphy examination types and abdominal ICD-9 codes.Early imaging with CT, MRI, or nuclear scintigraphy, particularly on the day before or the day of admission, was associated with significantly shorter lengths of stay of inpatients compared with patients who underwent advanced imaging later.

Ultrasound, sonohysterography (SHG), magnetic resonance imaging, computed tomography (CT), and positron emission tomography (PET) are tools available for diagnosis and for post-treatment surveillance. The transvaginal ultrasound has a well-defined role in women presenting with postmenopausal bleeding. Magnetic resonance imaging (MRI) provides the most accurate modality for preoperative staging in patients with early disease; CT and PET are helpful in the detection of distant meta­stases; sonohysterography is a less-invasive alternative to hysteroscopy.

The educational objectives for this self-assessment module on endovaginal sonography and sonohysterography are for the participant to exercise, self-assess, and improve his or her understanding of the imaging evaluation of abnormal vaginal bleeding and to gain familiarity with the algorithm for the workup for endometrial disorders.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

To compare fusion, positron emission tomography–computed tomography (PET–CT) with CT alone in detecting ovarian carcinoma recurrence. Fifty-one consecutive patients underwent 53 restaging PET–CT scans with a concurrent diagnostic quality CT scan. Two body imaging radiologists independently assessed the CT’s; each then teamed with a nuclear medicine specialist to review the PET–CT’s. Two teams conferred for consensus on the presence of disease in the chest, abdomen, and body overall with CT alone and with PET–CT, using a six-point reader confidence metric to determine accuracy and receiver operating characteristic (ROC) curves. Reader agreement was compared using kappa. Recurrence was determined by two gynecologic oncologists reviewing clinical records from time of presentation to at least 13 months (mean 22.7) after imaging. Recurrence was based on histopathology in 17% (9/53). Seventy-two percent (38/53) cases had recurrence, with two cases showing isolated chest recurrence. PET–CT accuracy exceeded CT for body 92% (49/53) vs. 83% (44/53), chest 96% (51/53) vs. 89% (47/53), and abdomen 91% (48/53) vs. 79% (42/53). ROC curves for PET–CT dominated that for CT alone; this difference was statistically significant for abdomen and for body overall (P