Search

Figure S1. ACRIN 6695 plus RECIST CT scan schema; Figure S2. Kaplan-Meier PFS curve for patients who received bevacizumab and had increase vs. decrease in BF from T0 to T2.

Purpose: ACRIN 6695 was a feasibility study investigating whether CT perfusion (CTP) biomarkers are associated with progression-free survival (PFS) at 6 months (PFS-6) in patients with advanced ovarian cancer who were treated with carboplatin and either dose-dense (weekly) or conventional (3-weekly) paclitaxel, with optional bevacizumab in the prospective phase III GOG-0262 trial.Experimental Design: ACRIN 6695 recruited participants with residual disease after primary cytoreductive surgery or planned interval cytoreduction following neoadjuvant therapy, to undergo CTP studies before (T0), 3 weeks (T1), and 4 weeks (T2) after chemotherapy initiation. Tumor blood flow (BF) and blood volume (BV) were derived with commercial software. Fisher exact tests assessed the associations of CTP biomarkers changes from T0 to T2 dichotomized at zero with PFS-6 and overall radiographic response rate, while Cox regression assessed the associations between CTP biomarker changes and PFS and overall survival (OS). Bonferroni correction was used to account for multiple comparisons.Results: Seventy-six of 120 enrolled patients from 19 centers were evaluable with a median age of 61 years. BV increase was significantly associated with lower chance of PFS-6 (P = 0.028), while BF achieves borderline significance (P = 0.053). In addition, BF increase was associated with shorter PFS (HR 2.9, 95% CI, 1.3–6.4, P = 0.008) and remained significant after adjusting for age, change in tumor volume, and surgery status (P = 0.007). Neither BF nor BV changes were significantly associated with treatment response rate or OS.Conclusions: Early CTP biomarkers measurement may provide early prognostic information for PFS in newly diagnosed ovarian cancer. Clin Cancer Res; 23(14); 3684–91. ©2017 AACR.

Legends for the supplementary figures

Most pelvic tumors originate from the organs. Less commonly, tumors can arise from the various anatomic pelvic compartments and are comprised of mesenchymal tissue: muscles, connective tissue, vessels, lymphatics, and fat. Among some of the rarer entities are benign tumors (eg, angiomyxoma, cellular angiofibroma, and desmoid fibromatosis), malignant tumors (eg, sarcoma), and tumors that can manifest as benign or malignant (eg, solitary fibrous tumor or nerve sheath tumor). Because these tumors are uncommon and often manifest with nonspecific clinical features, imaging (usually MRI) is an initial step in the evaluation. Radiologists interpreting these images are asked to help narrow the differential diagnosis and assess the likelihood of malignancy for treatment planning. Thus, the MRI report should include the imaging features that would indicate the underlying tissue histology for pathologic diagnosis as well as a description of the anatomic extent and pattern of growth. The authors describe multiple locally aggressive benign and malignant mesenchymal tumors and highlight characteristic clinical and imaging features that enable the radiologist to narrow the differential diagnosis. The anatomic spaces of the pelvis are reviewed with illustrations to aid the radiologist in describing these tumors, which often span multiple pelvic compartments. Tumor appearance at T2-weighted, diffusion-weighted, and postcontrast MRI is summarized and illustrated with correlation at CT or fluorodeoxyglucose PET/CT, when available. MRI features that correspond to specific types of tissue (eg, myxoid, fibrous, or vascular) are highlighted and correlated with images from pathologic evaluation.

Objectives Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging. Methods Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms. Results An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific. Conclusions This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging. Key points • This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.

MR imaging shows high sensitivity and specificity for discriminating benign from malignant lesions, thereby aiding in cancer management from assessing the initial extent of disease to subsequent treatment response. Understanding the utility and application of advanced imaging techniques allows better lesion characterization. Subtypes of epithelial ovarian tumors are presented, along with characteristic imaging findings, and illustrated with examples. Select mimics of malignancy are also presented.

Endometrial cancer is the second most common gynecologic cancer worldwide and the most common gynecologic cancer in the United States, with an increasing incidence in high-income countries. Although the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer is a surgical staging system, contemporary published evidence-based data and expert opinions recommend MRI for treatment planning as it provides critical diagnostic information on tumor size and depth, extent of myometrial and cervical invasion, extrauterine extent, and lymph node status, all of which are essential in choosing the most appropriate therapy. Multiparametric MRI using a combination of T2-weighted sequences, diffusion-weighted imaging, and multiphase contrast-enhanced imaging is the mainstay for imaging assessment of endometrial cancer. Identification of important prognostic factors at MRI improves both treatment selection and posttreatment follow-up. MRI also plays a crucial role for fertility-preserving strategies and in patients who are not surgical candidates by helping guide therapy and identify procedural complications. This review is a product of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel and reflects a multidisciplinary international collaborative effort to summarize updated information highlighting the role of MRI for endometrial cancer depiction and delineation, treatment planning, and follow-up. The article includes information regarding dedicated MRI protocols, tips for MRI reporting, imaging pitfalls, and strategies for image quality optimization. The roles of MRI-guided radiation therapy, hybrid PET/MRI, and advanced MRI techniques that are applicable to endometrial cancer imaging are also discussed.

Imaging plays an important role in the diagnosis and treatment of women with uterine cervical and endometrial cancers. Quantitative imaging, through MRI, PET/CT, and hybrid PET/MRI, allows for characterization of primary tumors beyond anatomic and qualitative descriptors. MRI diffusion-weighted imaging (DWI) yields an apparent diffusion coefficient (ADC), which can be applied in both the pre-and post-treatment assessment of uterine tumors. PET/CT assesses metabolic activity, and measurement of tumor standardized uptake value (SUV) is a useful metric in the staging of uterine malignancies. Hybrid PET/MRI is an emerging modality that combines the soft tissue contrast of MRI with the molecular imaging capability of PET. This review provides an overview of these quantitative imaging modalities, and their current and potential roles in the assessment of uterine cervical and cancer.

The role of positron emission tomography/magnetic resonance (PET/MR) in evaluating the local extent of rectal cancer remains uncertain. This study aimed to investigate the possible role of PET/MR versus magnetic resonance (MR) in clinically staging rectal cancer. This retrospective two-center cohort study of 62 patients with untreated rectal cancer investigated the possible role of baseline staging PET/MR versus stand-alone MR in determination of clinical stage. Two readers reviewed T and N stage, mesorectal fascia involvement, tumor length, distance from the anal verge, sphincter involvement, and extramural vascular invasion (EMVI). Sigmoidoscopy, digital rectal examination, and follow-up imaging, along with surgery when available, served as the reference standard. PET/MR outperformed MR in evaluating tumor size (42.5 ± 21.03 mm per the reference standard, 54 ± 20.45 mm by stand-alone MR, and 44 ± 20 mm by PET/MR, P = 0.004), and in identifying N status (correct by MR in 36/62 patients [58%] and by PET/MR in 49/62 cases [79%]; P = 0.02) and external sphincter infiltration (correct by MR in 6/10 and by PET/MR in 9/10; P = 0.003). No statistically significant differences were observed in relation to any other features. PET/MR provides a more precise assessment of the local extent of rectal cancers in evaluating cancer length, N status, and external sphincter involvement. PET/MR offers the opportunity to improve clinical decision-making, especially when evaluating low rectal tumors with possible external sphincter involvement.

OBJECTIVE 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) increases the sensitivity for preoperative detection of lymph nodes and distant metastases in endometrial cancer. The objective of this investigation was to determine the prognostic value of preoperative PET-CT compared with computed tomography (CT) alone for high-risk endometrial carcinoma. MATERIALS AND METHODS We performed a retrospective review of high-risk histology endometrial cancer from 2008 to 2015. Clinical variables including surgical procedure, preoperative imaging modality, and outcome were collected. Survival analysis was performed utilizing the Kaplan-Meier and Cox proportional hazards methodologies. RESULTS Of the 555 women treated for high-risk histology endometrial cancer, 88 (16%) had preoperative PET-CT, and 97 (17%) CT without PET available. PET-CT demonstrated positive findings in 37 women (42%) compared with 33 (30%) with preoperative CT alone. PET-CT had a positive predictive value of 96% for nodal metastasis compared with 60% for CT alone. The median follow-up time for the entire cohort was 59 months (range, 12 to 96 mo). Patients with a negative preoperative PET-CT (n=54) had a median progression-free survival (PFS) that was not reached, whereas the median PFS in the PET-CT positive group was 13 months (n=34). Women with a negative PET-CT had a longer median overall survival (OS) not yet reached compared with 34 months in the PET-CT positive cohort (hazard ratio, 2.4; P

Background Angiotensin-converting enzyme 2, a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury. Purpose To report abdominal imaging findings in patients with coronavirus disease 2019. Materials and Methods In this retrospective cross-sectional study, patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for SARS-CoV-2 were included. Abdominal imaging studies performed in these patients were reviewed, and salient findings were recorded. Medical records were reviewed for clinical data. Univariable analysis and logistic regression were performed. Results A total of 412 patients (average age, 57 years; range, 18 to >90 years; 241 men, 171 women) were evaluated. A total of 224 abdominal imaging studies were performed (radiography, n = 137; US, n = 44; CT, n = 42; MRI, n = 1) in 134 patients (33%). Abdominal imaging was associated with age (odds ratio [OR], 1.03 per year of increase; P = .001) and intensive care unit (ICU) admission (OR, 17.3; P < .001). Bowel-wall abnormalities were seen on 31% of CT images (13 of 42) and were associated with ICU admission (OR, 15.5; P = .01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT images obtained in patients in the ICU (four of 20). Surgical correlation (n = 4) revealed unusual yellow discoloration of the bowel (n = 3) and bowel infarction (n = 2). Pathologic findings revealed ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles (n = 2). Right upper quadrant US examinations were mostly performed because of liver laboratory findings (87%, 32 of 37), and 54% (20 of 37) revealed a dilated sludge-filled gallbladder, suggestive of bile stasis. Patients with a cholecystostomy tube placed (n = 4) had negative bacterial cultures. Conclusion Bowel abnormalities and gallbladder bile stasis were common findings on abdominal images of patients with coronavirus disease 2019. Patients who underwent laparotomy often had ischemia, possibly due to small-vessel thrombosis. © RSNA, 2020.

Uterine adenomyosis can be diagnosed on ultrasonography (US) and magnetic resonance imaging (MRI) with a high degree of accuracy. Adenomyosis is a myometrial process that can appear as diffuse or focal on imaging. Diffuse adenomyosis typically causes uterine enlargement, while focal adenomyosis can mimic other myometrial lesions, such as leiomyomas. Imaging features frequently seen on US include a heterogenous thickened myometrium and myometrial cysts. On MRI, widening of the junctional zone, whether focal or diffuse, and the presence of myometrial cysts, either simple or hemorrhagic, support the diagnosis of adenomyosis. Despite these characteristic imaging appearances, there are several gynecologic pathologies which can mimic adenomyosis and it is important to be vigilant of these when interpreting cross-sectional imaging exams. The decision to evaluate patients with US or MRI is contingent on multiple factors, including availability of the necessary technology and expertise for the latter. However, MRI appears to offer greater specificity and positive predictive value for the diagnosis of adenomyosis.

Endometriosis is often seen and sometimes initially diagnosed on hysterosalpingography (HSG), an imaging exam routinely performed on patients with infertility. Here we discuss the role of HSG in the evaluation of patients with infertility with a focus on patients with endometriosis. The HSG technique, including patient preparation as well as potential risks and complications, is detailed. Imaging findings in patients with endometriosis are illustrated and a template for exam reporting is presented. Common imaging pitfalls are described with examples.

To present recommendations for the use of imaging for evaluation and procedural guidance of brachytherapy for cervical cancer patients.An expert panel comprised of members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focused Panel and the American Brachytherapy Society jointly assessed the existing literature and provide data-driven guidance on imaging protocol development, interpretation, and reporting.Image-guidance during applicator implantation reduces rates of uterine perforation by the tandem. Postimplant images may be acquired with radiography, computed tomography (CT), or magnetic resonance imaging (MRI), and CT or MRI are preferred due to a decrease in severe complications. Pre-brachytherapy T2-weighted MRI may be used as a reference for contouring the high-risk clinical target volume (HR-CTV) when CT is used for treatment planning. Reference CT and MRI protocols are provided for reference.Image-guided brachytherapy in locally advanced cervical cancer is essential for optimal patient management. Various imaging modalities, including orthogonal radiographs, ultrasound, computed tomography, and magnetic resonance imaging, remain integral to the successful execution of image-guided brachytherapy.

Objective: To predict short-term outcomes in hospitalized COVID-19 patients using a model incorporating clinical variables with automated convolutional neural network (CNN) chest radiograph analysis. Methods: A retrospective single center study was performed on patients consecutively admitted with COVID-19 between March 14 and April 21 2020. Demographic, clinical and laboratory data were collected, and automated CNN scoring of the admission chest radiograph was performed. The two outcomes of disease progression were intubation or death within 7 days and death within 14 days following admission. Multiple imputation was performed for missing predictor variables and, for each imputed data set, a penalized logistic regression model was constructed to identify predictors and their functional relationship to each outcome. Cross-validated area under the characteristic (AUC) curves were estimated to quantify the discriminative ability of each model. Results: 801 patients (median age 59; interquartile range 46–73 years, 469 men) were evaluated. 36 patients were deceased and 207 were intubated at 7 days and 65 were deceased at 14 days. Cross-validated AUC values for predictive models were 0.82 (95% CI, 0.79–0.86) for death or intubation within 7 days and 0.82 (0.78–0.87) for death within 14 days. Automated CNN chest radiograph score was an important variable in predicting both outcomes. Conclusion: Automated CNN chest radiograph analysis, in combination with clinical variables, predicts short-term intubation and death in patients hospitalized for COVID-19 infection. Chest radiograph scoring of more severe disease was associated with a greater probability of adverse short-term outcome. Advances in knowledge: Model-based predictions of intubation and death in COVID-19 can be performed with high discriminative performance using admission clinical data and convolutional neural network-based scoring of chest radiograph severity.

Imaging plays an important role in the diagnosis and treatment of women with uterine cervical and endometrial cancers. Quantitative imaging, through MRI, PET/CT, and hybrid PET/MRI, allows for characterization of primary tumors beyond anatomic and qualitative descriptors. MRI diffusion-weighted imaging (DWI) yields an apparent diffusion coefficient (ADC), which can be applied in both the pre-and post-treatment assessment of uterine tumors. PET/CT assesses metabolic activity, and measurement of tumor standardized uptake value (SUV) is a useful metric in the staging of uterine malignancies. Hybrid PET/MRI is an emerging modality that combines the soft tissue contrast of MRI with the molecular imaging capability of PET. This review provides an overview of these quantitative imaging modalities, and their current and potential roles in the assessment of uterine cervical and cancer.

Imaging plays a central role in the 2018 International Federation of Gynecology and Obstetrics staging system for uterine cervical cancer. The revision calls for a more precise measurement of primary tumor size, best assessed with imaging. Evaluation for abdominopelvic retroperitoneal lymphadenopathy, either with imaging alone or with pathologic analysis, is now also part of staging. Choice of modality depends on the technology available within the practice setting. In high-resource settings, pelvic MRI (to assess tumor size and central pelvic spread) and torso fluorodeoxyglucose PET/CT (to assess lymphadenopathy and distant metastases) are used to assign stage and to plan therapy. In lower-resource settings, analogous modalities are pelvic US and chest radiography. Although imaging is already a part of pretreatment planning in some high-resource settings, its incorporation into assigning stage is a new development.

Objective A scoring system has been proposed to predict gross residual disease at primary debulking surgery (PDS) for advanced epithelial ovarian cancer. This scoring system has not been assessed in patients undergoing neoadjuvant chemotherapy (NACT). The aim of this study is to assess the reproducibility and prognostic significance of the scoring system when applied to women undergoing NACT followed by interval debulking surgery (IDS). Methods A retrospective cohort study was conducted of patients with advanced ovarian cancer who underwent NACT and IDS between 2005 and 2014. Change in tumor burden using computed tomography (CT) at diagnosis (T0) and after initiation of NACT but before IDS (T1) was independently assessed by two radiologists blinded to outcomes using two read criteria: a scoring system utilizing clinical and radiologic criteria and RECIST 1.1. Relationship between CT assessments to surgical outcome, progression free survival (PFS) and overall survival (OS) were evaluated. Reader agreement was measured using Fleiss's kappa (ĸ). Results 76 patients were analyzed. Optimal surgical outcome was achieved in 69 (91%) of patients. Median progression free survival was 13.2 months and overall survival was 32.6 months, respectively. Predictive score change from T0 to T1 of >1 (denoting an improvement in disease burden) was associated with optimal cytoreduction (p = 0.02 and 0.01 for readers 1 and 2, respectively). Neither predictive score nor RECIST 1.1 assessment was predictive of OS or PFS. Reader agreement was substantial for predictive score (κ = 0.77) and moderate for RECIST (κ = 0.51) assessments. Conclusions A change in score before and after neoadjuvant chemotherapy minimizes reader variability and predicts surgical outcome.

Key Points Question In men invited to undergo screening for prostate cancer with magnetic resonance imaging (MRI), ultrasonography, and prostate-specific antigen testing, what is the prevalence of positive test results, rates of biopsy, and detection of prostate cancer? Findings In this cohort study in which 408 men underwent 3 screening tests, an MRI score of 4 or 5 was associated with improved detection of clinically significant prostate cancer without an increase in the number of men who underwent biopsy or were overdiagnosed with clinically insignificant prostate cancer if prostate-specific antigen testing alone was used. Ultrasonography was not associated with improved screening performance. Meaning These findings suggest that a short, noncontrast MRI may have favorable performance characteristics as a community-based screening test., Importance Screening for prostate cancer using prostate-specific antigen (PSA) testing can lead to problems of underdiagnosis and overdiagnosis. Short, noncontrast magnetic resonance imaging (MRI) or transrectal ultrasonography might overcome these limitations. Objective To compare the performance of PSA testing, MRI, and ultrasonography as screening tests for prostate cancer. Design, Setting, and Participants This prospective, population-based, blinded cohort study was conducted at 7 primary care practices and 2 imaging centers in the United Kingdom. Men 50 to 69 years of age were invited for prostate cancer screening from October 10, 2018, to May 15, 2019. Interventions All participants underwent screening with a PSA test, MRI (T2 weighted and diffusion), and ultrasonography (B-mode and shear wave elastography). The tests were independently interpreted without knowledge of other results. Both imaging tests were reported on a validated 5-point scale of suspicion. If any test result was positive, a systematic 12-core biopsy was performed. Additional image fusion–targeted biopsies were performed if the MRI or ultrasonography results were positive. Main Outcomes and Measures The main outcome was the proportion of men with positive MRI or ultrasonography (defined as a score of 3-5 or 4-5) or PSA test (defined as PSA ≥3 μg/L) results. Key secondary outcomes were the number of clinically significant and clinically insignificant cancers detected if each test was used exclusively. Clinically significant cancer was defined as any Gleason score of 3+4 or higher. Results A total of 2034 men were invited to participate; of 411 who attended screening, 408 consented to receive all screening tests. The proportion with positive MRI results (score, 3-5) was higher than the proportion with positive PSA test results (72 [17.7%; 95% CI, 14.3%-21.8%] vs 40 [9.9%; 95% CI, 7.3%-13.2%]; P, This cohort study of men undergoing prostate cancer testing compares the performance of prostate-specific antigen testing, magnetic resonance imaging, and ultrasonography as screening tests for prostate cancer.

Imaging is central to the diagnosis and management of Pancreatic Ductal Adenocarcinoma (PDAC). This study evaluated if positron emission tomography (PET)/magnetic resonance imaging (MRI) elicited treatment modifications in PDAC when compared to standard of care imaging (SCI). This retrospective study included consecutive patients with PDAC who underwent 2-deoxy-2-[18F]fluoro-d-glucose ([18F]F-FDG) PET/MRI and SCI from May 2017 to January 2019. SCI included abdominal computed tomography (CT), MRI, and/or PET/CT. For patients who had more than one pair of PET/MRI and SCI, each management decision was independently evaluated. Treatment strategies based on each modality were extracted from electronic medical records. Follow-up was evaluated until January 2020. Twenty-five patients underwent 37 PET/MRI’s, mean age was 65 ± 9 years and 13 (13/25, 52 %) were men. 49 % (18/37, 95 % CI 33–64 %) of the PET/MRI scans changed clinical management. Whether the SCI included a PET/CT or not did not significantly modify the probability of management change (OR = 0.9, 95 % CI 0.2–4, p = 1). One hundred percent (33/33) of the available follow-up data confirmed PET/MRI findings. PET/MRI significantly changed PDAC management, consistently across the different SCI modalities it was compared to. These findings suggest a role for PET/MRI in the management of PDAC.