Publications by authors named "Benedetta Gui"

41 Publications

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

Radiol Med 2021 Aug 31;126(8):1055-1063. Epub 2021 May 31.

UOC Radiologia Generale ed Interventistica generale, Area Diagnostica per Immagini, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

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.
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http://dx.doi.org/10.1007/s11547-021-01377-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292245PMC
August 2021

Immunotherapy-Related Imaging Findings in Patients with Gynecological Malignancies: What Radiologists Need to Know.

Korean J Radiol 2021 08 20;22(8):1310-1322. Epub 2021 May 20.

UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Immunotherapy is an effective treatment option for gynecological malignancies. Radiologists dealing with gynecological patients undergoing treatment with immune checkpoint inhibitors should be aware of unconventional immune-related imaging features for the evaluation of tumor response and immune-related adverse events. In this paper, immune checkpoint inhibitors used for gynecological malignancies and their mechanisms of action are briefly presented. In the second part, patterns of pseudoprogression are illustrated, and different forms of immune-related adverse events are discussed.
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http://dx.doi.org/10.3348/kjr.2020.1299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316780PMC
August 2021

Validation of tumour-free distance as novel prognostic marker in early-stage cervical cancer: a retrospective, single-centre, cohort study.

Br J Cancer 2021 Aug 14;125(4):561-568. Epub 2021 Apr 14.

Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Rome, Italy.

Background: The aim of the present study was to assess the prognostic value of tumour-free distance (TFD), defined as the minimum distance of uninvolved stroma between the tumour and peri-cervical stromal ring, in early-stage cervical cancer.

Methods: Patients with pathologic FIGO 2009 stage IA1-IIA2 cervical cancer, treated by primary radical surgical treatment between 01/2000 and 11/2019, were retrospectively included. Adjuvant treatment was administered according to the presence of previously established pathologic risk factors. TFD was measured histologically on the hysterectomy specimen. Pre-operative TFD measured at MRI-scan from a cohort of patients was reviewed and compared with pathology TFD.

Results: 395 patients were included in the study. 93 (23.5%) patients had TFD ≤ 3.0 mm and 302 (76.5%) had TFD > 3.0 mm. TFD ≤ 3.0 mm together with lymph vascular space involvement represented the strongest predictor for lymph node metastasis at multivariate analysis. TFD ≤ 3.0 mm was associated with worse 5-year disease-free survival (DFS) and overall survival (OS), compared with TFD > 3.0 mm (p = 0.022 and p = 0.008, respectively). DFS difference was more evident in the subgroup of patients with low-risk factors who did not receive adjuvant treatment (p = 0.002). Cohen's kappa demonstrated an agreement between TFD measured at pre-operative MRI-scan and histology of 0.654.

Conclusions: Pathologic TFD ≤ 3.0 mm represents a poor prognostic factor significantly associated with lymph node metastasis and it may be considered a novel marker to select candidates for adjuvant treatment. The possibility to obtain this parameter by radiological imaging makes it a potential easy-measurable pre-operative marker to predict the presence of high-risk pathologic factors in early-stage cervical cancer.
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http://dx.doi.org/10.1038/s41416-021-01384-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368008PMC
August 2021

Staging, recurrence and follow-up of uterine cervical cancer using MRI: Updated Guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018.

Eur Radiol 2021 Apr 14. Epub 2021 Apr 14.

Department of Radiology, University of Montpellier, Montpellier, France.

Objectives: The recommendations cover indications for MRI examination including acquisition planes, patient preparation, imaging protocol including multi-parametric approaches such as diffusion-weighted imaging (DWI-MR),  dynamic contrast-enhanced imaging (DCE-MR) and standardised reporting. The document also underscores the value of whole-body 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) and highlights potential future methods.

Methods: In 2019, the ESUR female pelvic imaging working group reviewed the revised 2018 FIGO staging system, the up-to-date clinical management guidelines, and the recent imaging literature. The RAND-UCLA Appropriateness Method (RAM) was followed to develop the current ESUR consensus guidelines following methodological steps: literature research, questionnaire developments, panel selection, survey, data extraction and analysis.

Results: The updated ESUR guidelines are recommendations based on ≥ 80% consensus among experts. If ≥ 80% agreement was not reached, the action was indicated as optional.

Conclusions: The present ESUR guidelines focus on the main role of MRI in the initial staging, response monitoring and evaluation of disease recurrence. Whole-body FDG-PET plays an important role in the detection of lymph nodes (LNs) and distant metastases.

Key Points: • T2WI and DWI-MR are now recommended for initial staging, monitoring of response and evaluation of recurrence. • DCE-MR is optional; its primary role remains in the research setting. • T2WI, DWI-MRI and whole-body FDG-PET/CT enable comprehensive assessment of treatment response and recurrence.
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http://dx.doi.org/10.1007/s00330-020-07632-9DOI Listing
April 2021

Pretreatment MRI Radiomics Based Response Prediction Model in Locally Advanced Cervical Cancer.

Diagnostics (Basel) 2021 Mar 31;11(4). Epub 2021 Mar 31.

Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, 00168 Roma, Italy.

The aim of this study was to create a radiomics model for Locally Advanced Cervical Cancer (LACC) patients to predict pathological complete response (pCR) after neoadjuvant chemoradiotherapy (NACRT) analysing T2-weighted 1.5 T magnetic resonance imaging (MRI) acquired before treatment start. Patients with LACC and an International Federation of Gynecology and Obstetrics stage from IB2 to IVA at diagnosis were retrospectively enrolled for this study. All patients underwent NACRT, followed by radical surgery; pCR-assessed on surgical specimen-was defined as absence of any residual tumour. Finally, 1889 features were extracted from MR images; features showing statistical significance in predicting pCR at the univariate analysis were selected following an iterative method, which was ad-hoc developed for this study. Based on this method, 15 different classifiers were trained considering the most significant features selected. Model selection was carried out using the area under the receiver operating characteristic curve (AUC) as target metrics. One hundred eighty-three patients from two institutions were analysed. The model, showing the highest performance with an AUC of 0.80, was the random forest method initialised with default parameters. Radiomics appeared to be a reliable tool in pCR prediction for LACC patients undergoing NACRT, supporting the identification of patient risk groups, which paves treatment pathways tailored according to the predicted outcome.
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http://dx.doi.org/10.3390/diagnostics11040631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066099PMC
March 2021

Diagnostic performance of preoperative [F]FDG-PET/CT for lymph node staging in vulvar cancer: a large single-centre study.

Eur J Nucl Med Mol Imaging 2021 09 23;48(10):3303-3314. Epub 2021 Feb 23.

Unit of Nuclear Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Purpose: This retrospective study aimed to assess the diagnostic performance of preoperative [F]FDG-PET/CT in predicting the groin and pelvic lymph node (LN) status in a large single-centre series of vulvar cancer patients.

Methods: Between January 2013 and October 2018, among all consecutive women with proven vulvar cancer submitted to [F]FDG-PET/CT, 160 patients were included. LNs were analysed by two qualitative methods assessing PET information (defined as visual assessment) and a combination of PET and low-dose CT information (defined as overall assessment), respectively, as well as semi-quantitative analysis (LN-SUV). Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) in predicting the groin and pelvic LN status were calculated in the overall study population; a subset analysis of groin parameters in clinically/ultrasonography negative patients was also performed. Histopathology was the reference standard.

Results: All patients underwent vulvar and inguinofemoral LN surgery, and 35 pelvic LN surgery. Overall, 338 LN sites (296 groins and 42 pelvic sites) were histologically examined with 30.4% prevalence of metastatic groins and 28.6% for metastatic pelvic sites. In the overall study population, sensitivity (95% confidence interval, CI), specificity (95% CI), accuracy (95% CI), PPV (95% CI) and NPV (95% CI) at the groin level were 85.6% (78.3-92.8), 65.5% (59.0-72.0), 71.6% (66.5-76.8), 52.0% (44.0-60.1) and 91.2% (86.7-95.8) for visual assessment; 78.9% (70.5-87.3), 78.2% (72.5-83.8), 78.4% (73.7-83.1), 61.2% (52.3-70.1) and 89.4% (85.0-93.9) for overall assessment; and 73.3% (64.2-82.5), 85.0% (80.1-89.8), 81.4% (77.0-85.8), 68.0% (58.8-77.3) and 87.9% (83.4-92.5) for semi-quantitative analysis (SUV cut-off value 1.89 achieved by ROC analysis). Similar results were observed in the pelvis-based analysis.

Conclusion: In this large single-centre series of vulvar cancer patients, [F]FDG-PET/CT showed good values of sensitivity and NPV in discriminating metastatic from non-metastatic LNs. In routine clinical practice, qualitative analysis is a reliable interpretative criterion making unnecessary commonly used semi-quantitative methods such as SUV.
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http://dx.doi.org/10.1007/s00259-021-05257-8DOI Listing
September 2021

Imaging modalities in fertility preservation in patients with gynecologic cancers.

Int J Gynecol Cancer 2021 03 2;31(3):323-331. Epub 2020 Nov 2.

Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.

Fertility preservation is an integral component of clinical decision-making and treatment design. However, the selection criteria on imaging for patients eligible for fertility preservation is still unclear. The present review aimed to summarize the main findings reported in both the literature and international guidelines on the role of imaging in the selection of patients for fertility preservation. A search strategy was developed and applied to PubMed, Scopus, Web of Science, and EMBASE to identify previous citations reporting imaging and fertility preservation in patients with gynecological cancer. We also retrieved the published guidelines on the eligibility criteria for fertility-sparing treatment of gynecological neoplasms. A description of the internal multidisciplinary guidelines, clinically in use in our institution, is provided with representative clinical cases. The literature review revealed 1291 articles and 18 of these were selected for the analysis. Both ultrasound and MRI represented the primary imaging methods for selecting patients for fertility preservation in cervical and endometrial cancers. Eligibility criteria of fertility-sparing management in patients with cervical cancer were: tumor size <2 cm, tumor distance from the internal os >1 cm, and no parametrium invasion. For patients with endometrial cancer, these included no myometrial and cervical stroma invasion. Both ultrasound and MRI play a key role in characterizing adnexal masses. These modalities provide a useful tool in identifying small ovarian lesions, thus key in the surveillance of patients after fertility sparing surgery. However, efficacy in excluding disease beyond the ovary remains limited. This review provides an update of the literature and schematic outline for the counseling and management of patients with the desire for fertility preservation.
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http://dx.doi.org/10.1136/ijgc-2020-002109DOI Listing
March 2021

Neoadjuvant chemotherapy followed by conization in stage IB2-IIA1 cervical cancer larger than 2 cm: a pilot study.

Fertil Steril 2021 01 20;115(1):148-156. Epub 2020 Oct 20.

Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.

Objective: To evaluate feasibility of neoadjuvant chemotherapy (NACT) followed by cold-knife conization (CKC) in patients with 2018 FIGO stage IB2-IIA1 cervical cancer who desired to maintain fertility.

Design: Pilot study of conization after chemotherapy in stage IB2-IIA1 >2 cm cervical cancer.

Setting: University hospital.

Patient(s): From 2014 to 2018, 25 patients, <40 years of age, were enrolled.

Interventions(s): After laparoscopic pelvic lymph-node assessment, NACT with cisplatin/paclitaxel q21 was administered to eligible patients. Responsive patients were treated with CKC.

Main Outcome Measure(s): Obstetrical outcome: pregnancy rate. Oncologic outcome.

Result(s): Thirteen out of 25 patients were eligible for fertility-sparing treatment. Oncologic outcome: The clinical overall response rate was 84.5% (11 out of 13 patients). One patient achieved stable disease, was managed by radical surgery, and is still alive; another one experienced progression of disease and died after 15 months. The optimal pathologic response was 69.1%. In the setting of fertility preservation patients, the median follow-up was 37 months (range 18-76). In this group we registered one distant recurrence, 12 months after CKC, in the liver; the patient is still alive and without evidence of disease. Obstetrical outcome: Among the nine patients amenable, three tried to conceive, and two spontaneous pregnancy occurred a few months after the end of treatment, for a pregnancy rate of 66.7%.

Conclusion(s): This pilot study supports the feasibility of CKC after NACT as conservative treatment in stage IB2-IIA1 cervical cancer, with oncologic outcomes similar to those reported for trachelectomy in the same stage and with potential benefits in terms of obstetrical outcomes.

Clinical Trial Registration Number: NCT02323841.
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http://dx.doi.org/10.1016/j.fertnstert.2020.07.006DOI Listing
January 2021

Depiction of periprostatic nerve fibers by means of 1.5 T diffusion tensor imaging.

Abdom Radiol (NY) 2021 06 31;46(6):2760-2769. Epub 2020 Jul 31.

Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica del Sacro Cuore, Roma, Italy.

Purpose: The knowledge of periprostatic nerve fiber (pNF) is still incomplete by means of conventional MRI. The purpose of our study was to demonstrate if DTI imaging is able to depict anatomical features of pNF.

Methods: For this retrospective study, fifty-six patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including 32 directions DTI, were enrolled between October 2014 and December 2018. ANOVA test and Student's t-test were performed between the mean values of the number, FA values, and fiber length of pNF between base and mid-gland, mid-gland and apex, base and apex, right and left side, and anterior and posterior face of the prostate. A qualitative analysis was performed to detect the main orientation of pNF through a colorimetric 3D tractographic reconstruction.

Results: The number of pNF showed a decrease from the base (322) to mid-gland (248) and apex (75) (p < 0.05). The FA values were higher at base and mid-gland (0.435 and 0.456) compared to the apex (0.313) (p < 0.05). The length of pNF was higher at apex (13.4 mm) compared to base (11.5 mm) and mid-gland (11.7 mm) (p < 0.05). The number of pNF was higher on the posterior face compared to the anterior face at base (186 vs 137), (p < 0.001). The FA values were higher on the posterior face compared to the anterior face at base (0.452 vs 0.417), mid-gland (0.483 vs 0.429), and apex (0.42 vs 0.382), (p < 0.05). The length of the pNF was higher in the posterior (14.7 mm) than in the anterior face (12 mm) at apex (p < 0.001). The main orientation of pNF was longitudinal in all patients (56/56, 100%).

Conclusions: DTI imaging has been demonstrated able to depict anatomical features of pNF.
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http://dx.doi.org/10.1007/s00261-020-02682-5DOI Listing
June 2021

Molecular and biological profile may discriminate between synchronous or metachronous endometrial and ovarian cancer.

Int J Gynecol Cancer 2020 07 9;30(7):1071-1076. Epub 2020 Jun 9.

Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy, Rome, Italy

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http://dx.doi.org/10.1136/ijgc-2020-001545DOI Listing
July 2020

Multidisciplinary personalized approach in the management of vulvar cancer - the Vul.Can Team experience.

Int J Gynecol Cancer 2020 07 30;30(7):932-938. Epub 2020 May 30.

Unità Operativa di Radioterapia, Gemelli Molise Hospital, Campobasso, Molise, Italy.

Introduction: Multidisciplinary treatment strategy involving adjuvant radiotherapy for advanced vulvar cancer could be useful in offering the best personalized clinical approach. In 2013, the VULvar CANcer Multi-Disciplinary Team (Vul.Can MDT) was set up in our institution, in order to share knowledge and expertise, high-quality diagnosis, and evidence-based decision making in the context of personalized medicine. The aim of this observational study was to report on our series of vulvar cancer patients managed postoperatively with radiotherapy within the framework of a formal multidisciplinary tumor board.

Methods: Coupling surgical and oncological international guidelines with "case-by-case" discussions, a multi-specialist consensus was progressively reached and internal recommendations were developed and introduced in the daily routine. Data from vulvar cancer patients who underwent primary surgery and adjuvant radiotherapy throughout a 5-year period were retrospectively collected. Actuarial local control was the primary endpoint, while secondary end-points were acute and late toxicities, disease-free survival, and overall survival. Toxicity was evaluated according to the Common Toxicity Criteria Adverse Event v 4.0 scale.

Results: The analysis included 35 patients with squamous vulvar cancer treated with adjuvant radiotherapy±chemotherapy, from April 2013 to September 2017. Median age was 70 years (range 18-87), all patients underwent surgery followed by concomitant chemoradiation (45.7%) or radiotherapy alone (54.3%). The median prophylactic dose on lymphatic drainage was 45 Gy, while positive nodes and perineal area received 51.2 Gy and 52.6 Gy, respectively. Chemotherapy involved the cisplatin-based regimen (45.7%)±5-fluorouracil (37.1%). Median follow-up was 32 months (range 6-72): the 24-months local control, disease-free survival, and actuarial overall survival rates were 88.6%, 82.0%, and 91.0%, respectively. Low rates of severe acute (12%) and late (3%) toxicities occurred.

Discussion: The outcomes of this series support the benefit of a multidisciplinary personalized approach in the management of vulvar cancer.
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http://dx.doi.org/10.1136/ijgc-2020-001465DOI Listing
July 2020

Fusion imaging of ultrasound and MRI in the assessment of locally advanced cervical cancer: a prospective study.

Int J Gynecol Cancer 2020 04 18;30(4):456-465. Epub 2020 Mar 18.

Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.

Background: Fusion imaging is a new diagnostic method that integrates MRI and ultrasound. It may improve the detection and staging of locally advanced cervical cancer.

Objective: To evaluate the feasibility and accuracy of fusion imaging in patients with locally advanced cervical cancer.

Methods: Patients with suspicion of locally advanced cervical cancer at clinical examination and/or imaging, who were candidates for neoadjuvant treatment (chemotherapy or chemoradiation) followed by surgery, were prospectively enrolled between March and November 2018. MRI, ultrasound, and fusion images were obtained before and after neoadjuvant treatment. Feasibility, success of the fusion examination, and time needed to perform fusion studies were evaluated. The rates of concordance between MRI and ultrasound before and after performing fusion, using Cohen, Spearman, and McNemar tests were calculated. The agreement between MRI and ultrasound examination, and the agreement between radiologist and gynecologist during the fusion technique in assessing local extension of disease and the presence of residual disease after neoadjuvant therapy, were also analyzed. The rates of concordance between MRI and ultrasound examination before and after performing fusion imaging, using Cohen's kappa and Spearman's rank correlation coefficient were calculated. A McNemar test was used to assess if there were statistical significant differences in the parameters' agreement before and after performing fusion imaging.

Results: 40 patients were selected and of these, 33 were analyzed. A total of 52 fusion examinations were performed: 33 (63.5%) of 52 at the time of diagnosis and 19 (36.5%) of 52 after neoadjuvant treatment. Fusion imaging was feasible in 50 (96%) of 52 studies. The median overall time of fusion execution was 13 min (range 6-30) and the time spent in performing a fusion examination decreased from the first to the last examination (20 vs 6 min). The agreement between MRI and ultrasound parameters increased after performing fusion, particularly for parametrial infiltration (74% vs 86%, p=0.014 for the right posterior parametrium; 66% vs 80%, p=0.008 for the left posterior parametrium, 70% vs 82%, p=0.014 for the right lateral parametrium).

Conclusions: Fusion of MRI and ultrasound is feasible in patients with locally advanced cervical cancer and may increase the diagnostic accuracy of the single imaging methods. Fusion provides multiple diagnostic opportunities in gynecological oncology.
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http://dx.doi.org/10.1136/ijgc-2019-000902DOI Listing
April 2020

MRI in pregnant patients with suspected abdominal and pelvic cancer: a practical guide for radiologists.

Diagn Interv Radiol 2020 May;26(3):183-192

General Diagnostic and Interventional Radiology, Diagnostic Imaging Area, Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy;Institute of Radiology, Università Cattolica del Sacro Cuore, Roma, Italy.

The incidence of abdominal and pelvic cancer in pregnancy is low, but it is rising as the population of pregnant women gets older. Depending on disease stage, gestational age and patient's preference, active surveillance as well as surgery and chemotherapy are feasible options during pregnancy. Correct diagnosis and staging of the tumor is crucial for choosing the best therapeutic approach. Moreover, a reproducible modality to assess the treatment response is requested. Magnetic resonance imaging (MRI) is commonly used with good results for the local staging and treatment response evaluation of most abdominal and pelvic cancers in nonpregnant patients, and it is considered relatively safe during pregnancy. The purpose of this article is to analyze the most relevant topics regarding the use of MRI in pregnant women with abdominal and pelvic cancer. We discuss MRI safety during pregnancy, including the use of gadolinium-based contrast agents (GBCAs), how to prepare the patient for the exam and MRI technique. This will be followed by a brief review on the most common malignancies diagnosed during pregnancy and their MRI appearance.
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http://dx.doi.org/10.5152/dir.2019.19343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239363PMC
May 2020

Prognostic CT findings of malignant bowel obstruction in patients with advanced ovarian cancer.

Tumori 2020 Apr 18;106(2):149-154. Epub 2019 Nov 18.

Radiologia Diagnostica e Interventistica Generale, Area Diagnostica per Immagini, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Objective: To evaluate computed tomography (CT) findings able to predict outcome in patients with ovarian cancer (OC) and concomitant bowel occlusion.

Methods: This institutional review board-approved retrospective study included 31 patients with OC and clinical evidence of bowel occlusion who underwent CT at presentation between February 2013 and June 2015. Two radiologists recorded various qualitative CT features. Correlations between CT and survival data were made with Mann-Whitney test, Wilcoxon test, and χ test, as appropriate. Receiver operating characteristic curves were generated for statistically significant CT findings using logistic regression model.

Results: Two of 31 patients (6.5%) were alive at the end of this study; 29 patients (93.5%) died of disease. Median overall survival was 90 days. CT features associated with short life expectancy were bowel mural thinning (=0.03), mesenteric tumor deposits (=0.009), mesenteric infiltration (=0.02), and ascites (=0.04). Area under the curve was 0.728 (=0.03) for mesenteric tumor deposits in predicting malignant bowel obstruction.

Conclusions: Accurate interpretation of CT features may guide decisions in care of women with OC and bowel obstruction.
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http://dx.doi.org/10.1177/0300891619886657DOI Listing
April 2020

The role of F-FDG-PET/CT in predicting the histopathological response in locally advanced cervical carcinoma treated by chemo-radiotherapy followed by radical surgery: a prospective study.

Eur J Nucl Med Mol Imaging 2020 05 14;47(5):1228-1238. Epub 2019 Aug 14.

Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.

Purpose: This prospective study aimed to evaluate whether F-FDG-PET/CT performed before, during and after neoadjuvant chemo-radiotherapy (CRT) could predict histopathological response in patients with locally advanced cervical cancer (LACC) treated with CRT followed by radical surgery.

Methods: Between October 2010 and June 2014, 88 patients with LACC were enrolled. For each patient, three F-FDG-PET/CT scans (baseline, early and final) were acquired and evaluated by qualitative and quantitative analysis. Maximum standardized uptake value (SUV), SUV, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were measured as absolute values and their percentage variation (delta) (early vs. baseline and final vs. baseline). The role of F-FDG-PET/CT in predicting lymph node (LN) residual disease was evaluated by qualitative analysis only. Histopathology was the reference standard.

Results: At histopathology, 40 patients had complete response (CR, pR0), 48 had partial response (PR: 21 microscopic [pR1] and 27 macroscopic [pR2]). At baseline, SUV and SUV were significantly higher in pR0 than in pR1-pR2 patients. At early evaluation, MTV and TLG were significantly higher in pR1-pR2 than in pR0 patients. At final evaluation, SUV, SUV and TLG were significantly higher in pR1-pR2 than in pR0 patients. Delta SUV parameters and delta TLG were significantly lower in PR group both during and after CRT. Delta MTV was significantly lower in patients with PR in the early phase only. In receiver operating characteristic (ROC) curve analysis, baseline SUV, early delta TLG, and final delta SUV better discriminated PR, providing 83.3%, 67.6% and 85% positive predictive value (PPV) and 60.3%, 90% and 70.8% negative predictive value (NPV), respectively. For LN assessment, high NPV was observed at early and final F-FDG-PET/CT (93.5% and 92.3%, respectively).

Conclusion: In LACC patients treated with CRT followed by surgery, early variations in metabolic parameters effectively discriminate histopathological PR of the primary tumor, suggesting the potential role of F-FDG-PET/CT in early personalized treatment. The high NPV of early and final PET/CT could enable "tailored surgery" by avoiding lymphadenectomy in selected patients.
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http://dx.doi.org/10.1007/s00259-019-04436-yDOI Listing
May 2020

Multidetector CT appearance of the pelvis after vaginal delivery: normal appearances and abnormal acute findings.

Diagn Interv Radiol 2019 May;25(3):210-218

Department of Radiological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences, Università Cattolica del Sacro Cuore, Roma, Italy.

Vaginal delivery is the most commonly performed delivery in the world and accounts for nearly two-thirds of all deliveries in the United States. It is a secure method but may be associated with some acute complications, especially in the immediate postpartum days, which can potentially be fatal for the mother. The most frequent acute complications are hemorrhages/hematomas, uterine rupture, endometritis, retained product of conception (RPOC), ovarian thrombosis and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). A first evaluation of the clinical status of the patients is executed by the clinicians who, depending on their experience, perform ultrasonography by themselves and eventually may request further radiologic exams in doubtful cases. Radiologists may play an important role recognizing early postpartum complications and differentiating them from physiologic postoperative findings. In this setting, the use of multidetector computed tomography (MDCT) is important for diagnosis of suspected postpartum complications. The aim of this article is to review the normal and abnormal post vaginal delivery MDCT aspects in order to help the clinical management by preventing misdiagnoses and tailoring the best medical treatments.
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http://dx.doi.org/10.5152/dir.2019.18127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521907PMC
May 2019

CT findings after pelvic exenteration: review of normal appearances and most common complications.

Radiol Med 2019 Jul 26;124(7):693-703. Epub 2019 Feb 26.

Radiologia Diagnostica e Interventistica Generale, Area Diagnostica per Immagini, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.

The aim of this review is to illustrate normal computed tomography (CT) findings and the most common complications in patients who underwent pelvic exenteration (PE) for advanced, persistent or recurrent gynecological cancers. We review the various surgical techniques used in PE, discuss optimal CT protocols for postsurgical evaluation and describe cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications. The interpretation of abdominopelvic CT imaging after PE is very challenging due to remarkable modifications of normal anatomy. After this radical pelvic surgery, the familiarity with expected CT appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent PE.
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http://dx.doi.org/10.1007/s11547-019-01009-9DOI Listing
July 2019

EROS study: evaluation between high-dose-rate and low-dose-rate vaginal interventional radiotherapy (brachytherapy) in terms of overall survival and rate of stenosis.

J Contemp Brachytherapy 2018 Aug 31;10(4):315-320. Epub 2018 Aug 31.

Radioterapia Oncologica, Area Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.

Purpose: To compare the survival and toxicity outcomes in patients with endometrial cancer treated with either high-dose-rate (HDR) or low-dose-rate (LDR) vaginal brachytherapy (VBT) following external beam radiotherapy (EBRT).

Material And Methods: From January 2000 to December 2014, patients with endometrial cancer after radical hysterectomy with/without pelvic and/or para-aortic lymphadenectomy were treated with adjuvant EBRT (45 Gy, 1.8 Gy/day to the whole pelvis) and subsequent VBT boost (HDR dose of 7 Gy in one fraction or LDR VBT dose of 25 Gy). The dose was prescribed at 0.5 cm from the surface of the applicator and the proximal half to two-thirds of the vagina was irradiated. The outcomes of patients were evaluated in terms of local control (LC), overall survival (OS), and rates of adverse events.

Results: We analyzed data of 200 patients treated with EBRT followed by HDR VBT boost in 78 patients and LDR VBT boost in 122 patients. With a median follow-up of 25 months (range, 6-163), 5-year OS was 98% and 97% in the LDR and HDR groups, respectively ( = 0.37). The 5-year LC was similar (93% in both groups) ( = 0.81). In multivariate analyses, none of the factors assessed (age, stage, grade) impacted OS ( = 0.37) or LC ( = 0.81). Patients treated with LDR VBT after EBRT had higher rates of acute gastrointestinal toxicity. No differences were found in acute genitourinary or hematological toxicities. Late toxicity such as vaginal stenosis was registered during regular follow-up visits and was similar in the two groups ( = 0.67).

Conclusions: In our analysis, there were no differences in terms of OS and late toxicity outcomes for patients receiving LDR or HDR VBT. HDR VBT is a safe technique in comparison to LDR VBT.
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http://dx.doi.org/10.5114/jcb.2018.77953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142651PMC
August 2018

Neo-adjuvant platinum-based chemotherapy followed by chemoradiation and radical surgery in locally advanced cervical cancer (Lacc) patients: A phase II study.

Eur J Surg Oncol 2018 07 3;44(7):1062-1068. Epub 2018 May 3.

Department of Women's and Children's Health, "Fondazione Policlinico Universitario A. Gemelli", Università Cattolica del Sacro Cuore, Rome, Italy; Division of Gynecologic Oncology, "Fondazione di ricerca e cura Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy.

Purpose: The aim of this Phase II, non-randomized study was to assess activity and safety of neoadjuvant chemotherapy (NACT) before chemoradiation (CT/RT) followed by radical surgery (RS) in locally advanced cervical cancer (LACC) patients.

Methods And Materials: The primary end point was rate of pathologic complete response (pCR). FIGO Stage IB2-IVA patients were administered NACT chemotherapy (paclitaxel 80 mg/m, carboplatin AUC 2), for 6 weeks, followed by Intensity Modulated Radiotherapy plus simultaneous boost (total dose of 50.4 Gy to CTV1, and 39.6 Gy to CTV2). Clinical response was assessed according to RECIST criteria. Responsive patients were triaged to RS. The regimen would be considered active if >20 pCRs were registered in 39 patients.

Results: 45 patients were enrolled into the study; 25 patients (55.5%) were FIGO stage IIB, 9 cases (20.0%) had stage III disease. At work up, pelvic lymph node involvement was documented in 38 (84.4%) patients; pCR was documented in 18 out of 40 patients (45.0%). Grade 3-4 hematological toxicity after NACT occurred in 4 patients; CT/RT associated grade 3 toxicity was found in 7 patients. Early and late postoperative complications were detected in 16, and 11 cases, respectively. Three-year PFS and OS were 66.0% and 86.0%, respectively.

Conclusions: NACT followed by CT/RT by IMRT and RS, is feasible and safe; failure to achieve the primary endpoint has to be recognized; however, enrollment of a higher rate of poor prognosis patients compared to historical data used to calculate sample size, could have resulted in reduced activity.
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http://dx.doi.org/10.1016/j.ejso.2018.04.019DOI Listing
July 2018

Author's Reply.

Authors:
Benedetta Gui

Diagn Interv Radiol 2018 Jan-Feb;24(1):60-61

Institute of Radiology, Diagnostic Area, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.

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http://dx.doi.org/10.5152/dir.2017.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765933PMC
April 2018

Shining light in a dark landscape: MRI evaluation of unusual localization of endometriosis.

Diagn Interv Radiol 2017 Jul-Aug;23(4):272-281

Institute of Radiology, Diagnostic Area, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.

Endometriosis is a disease distinguished by the presence of endometrial tissue outside the uterine cavity with intralesional recurrent bleeding and resulting fibrosis. The most common locations for endometriosis are the ovaries, pelvic peritoneum, uterosacral ligaments, and torus uterinus. Typical symptoms are secondary dysmenorrhea and cyclic or chronic pelvic pain. Unusual sites of endometriosis may be associated with specific symptoms depending on the localization. Atypical pelvic endometriosis localizations can occur in the cervix, vagina, round ligaments, ureter, and nerves. Moreover, rare extrapelvic endometriosis implants can be localized in the upper abdomen, subphrenic fold, or in the abdominal wall. Magnetic resonance imaging (MRI) represents a problem-solving tool among other imaging modalities. MRI is an advantageous technique, because of its multiplanarity, high contrast resolution, and lack of ionizing radiation. Our purpose is to remind the radiologists the possibility of atypical pelvic and extrapelvic endometriosis localizations and to illustrate the specific MRI findings. Endometriotic tissue with hemorrhagic content can be distinguished from adherences and fibrosis on MRI imaging. Radiologists should keep in mind these atypical localizations in patients with suspected endometriosis, in order to achieve the diagnosis and to help the clinicians in planning a correct and complete treatment strategy.
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http://dx.doi.org/10.5152/dir.2017.16364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508950PMC
February 2018

Erratum to: Persistent Urogenital Sinus: Diagnostic Imaging for Clinical Management. What Does the Radiologist Need to Know?

Am J Perinatol 2016 04 21;33(5):e1. Epub 2017 Jun 21.

Department of Radiological Sciences, Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy.

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http://dx.doi.org/10.1055/s-0037-1604062DOI Listing
April 2016

Early detection of recurrence or progression disease in patients with ovarian cancer after primary debulking surgery. Correlation between CT findings and CA 125 levels.

Minerva Ginecol 2017 Dec 9;69(6):538-547. Epub 2017 Jun 9.

Diagnostic Imaging Area, Sacro Cuore Catholic University, Rome, Italy.

Background: There are no standard approaches for follow up in advanced ovarian cancer (AOC) patients; the aim of this study is to evaluate correlation between computed tomography (CT) and CA 125 levels to assess early detection of recurrence or progression disease (PD).

Methods: We included 76 patients with AOC, who had prior debulking surgery, starting first or second line of chemotherapy and underwent follow-up CT examinations. Evaluation of tumor response to treatment by imaging was assessed using RECIST 1.1. Site of relapse was classified as: abdomen, chest and neck (observed in the upper chest scans).

Results: Change in CA 125 levels was calculated in respect previous evaluation at the end of treatment for each patient. The most suitable cut-offs could be identified in an increase in CA 125 levels >10.5% (sensitivity: 67.9%; specificity: 83.6%; LR+: 4.1; LR-: 0.4) in order to predict PD and in a change of -0.5% in order to exclude PD (sensitivity 83.0%; specificity: 69.6%; LR+: 2.7; LR-: 0.2). Site of relapse was abdomen (58.5%), abdomen and chest (33.9%), chest (3.8%), chest and neck (1.9%), and abdomen, chest and neck (1.9%).

Conclusions: Increase in CA 125 levels >10.5% could be sufficiently predictive of PD requiring CT examination. Change of -0.5% is sufficiently predictive of absence of PD. Increase <10.5% and >0.5% needs clinical correlation to establish correct timing and extension of CT examination. Attention must be played in reducing number and extent of CT examinations to reduce exposure dose.
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http://dx.doi.org/10.23736/S0026-4784.17.04062-XDOI Listing
December 2017

Imaging after treatment in uterine malignancies: Spectrum of normal findings and most common complications.

J Med Imaging Radiat Oncol 2017 Dec 18;61(6):777-790. Epub 2017 May 18.

Department of Radiological Sciences, Fondazione Policlinico Agostino Gemelli, Rome, Italy.

Uterine malignancies account for the majority of gynaecologic cancers. Different treatment options are available depending on histology, disease grade and stage. Hysterectomy is the most frequent surgical procedure. Chemotherapy and radiation therapy (CRT) represents the preferred therapeutic choice for locally advanced uterine and cervical malignancies. Imaging of the female pelvis following these treatments is particularly challenging due to alteration of the normal anatomy. Radiologists should be familiar with both the expected post-treatment imaging findings and the imaging features of possible complications to make the correct interpretation and avoid possible pitfalls. The purpose of this review is to show the expected computed tomography (CT) and Magnetic Resonance Imaging (MRI) appearances of the female pelvis following surgery and CRT for uterine and cervical cancer, to illustrate the imaging findings of early and delayed most common complications after surgery and CRT, describing the suitable imaging modalities and protocols for evaluation of patients treated for gynaecologic malignancies.
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http://dx.doi.org/10.1111/1754-9485.12624DOI Listing
December 2017

The morbidly adherent placenta: when and what association of signs can improve MRI diagnosis? Our experience.

Diagn Interv Radiol 2017 May-Jun;23(3):180-186

Department of Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.

Purpose: We aimed to verify whether combination of specific signs improves magnetic resonance imaging (MRI) accuracy in morbidly adherent placenta (MAP).

Methods: MRI findings for MAP were retrospectively evaluated in 27 women. Histopathology was the reference standard, showing MAP in eight of 27 cases. Specificity, sensitivity, positive predictive value, and negative predictive value were calculated for all MRI signs. Two skilled radiologists analyzed MRI findings, resolving discrepancies by consensus, using three alternative diagnostic criteria during three consecutive sections. First criterion: at least one of reported MRI signs indicates MAP and the absence of any sign is normal; second criterion: at least one statistically significant sign indicates MAP and no sign or nonsignificant sign is normal; third criterion: at least two statistically significant signs indicate MAP and no sign, nonsignificant sign, or only one significant sign is normal.

Results: Using the first criterion yielded an unacceptable rate of false positive results (78.9%). Using the second criterion there were less false positive results (31.5%), and diagnostic accuracy of the second criterion was significantly higher than the first; the third criterion correctly classified 100% of cases.

Conclusion: Only specific MRI signs can correctly predict MAP at histopathology, particularly when multiple (at least two) specific signs are observed together.
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http://dx.doi.org/10.5152/dir.2017.16275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5410997PMC
January 2018

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings.

Diagn Interv Radiol 2016 Nov-Dec;22(6):534-541

Department of Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.

Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.
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http://dx.doi.org/10.5152/dir.2016.15593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098948PMC
May 2017

MRI anatomy of parametrial extension to better identify local pathways of disease spread in cervical cancer.

Diagn Interv Radiol 2016 Jul-Aug;22(4):319-25

Department of Radiological Sciences, Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy.

This paper highlights an updated anatomy of parametrial extension with emphasis on magnetic resonance imaging (MRI) assessment of disease spread in the parametrium in patients with locally advanced cervical cancer. Pelvic landmarks were identified to assess the anterior and posterior extensions of the parametria, besides the lateral extension, as defined in a previous anatomical study. A series of schematic drawings and MRI images are shown to document the anatomical delineation of disease on MRI, which is crucial not only for correct image-based three-dimensional radiotherapy but also for the surgical oncologist, since neoadjuvant chemoradiotherapy followed by radical surgery is emerging in Europe as a valid alternative to standard chemoradiation.
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http://dx.doi.org/10.5152/dir.2015.15282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956016PMC
May 2017

Cervical cancer response to neoadjuvant chemoradiotherapy: MRI assessment compared with surgery.

Acta Radiol 2016 Sep 29;57(9):1123-31. Epub 2015 Nov 29.

Department of Bioimaging and Radiological Sciences, Catholic University of the Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.

Background: Imaging findings of residual cervical tumor after chemoradiotherapy can closely resemble those of post-irradiation inflammation.

Purpose: To determine the diagnostic performance of magnetic resonance imaging (MRI) in evaluating residual disease after chemoradiotherapy in patients with locally advanced cervical carcinoma (LACC).

Material And Methods: Retrospective analysis of prospectively collected data from 41 patients with histopathologically proven LACC (International Federation of Gynecology and Obstetrics stage ≥IB2) who underwent MRI before and after chemoradiotherapy. At each examination, a qualitative and semi-quantitative analysis of primary tumor, including tumor volume and signal intensity were assessed on T2-weighted (T2W) images. All patients had surgery after post-chemoradiotherapy MRI. MRI and histopathologic results were compared.

Results: All patients showed significant difference in tumor volume and signal intensity between pre- and post-chemoradiotherapy MRI (P < 0.0001). According to pathology, 27/41 (66%) patients had true negative and 2/41 (5%) had true positive post-chemoradiotherapy MRI. Eleven out of 41 (27%) patients showed inflammation with false positive post-chemoradiotherapy MRI and 1/41 (2%) had a false negative post-chemoradiotherapy MRI. Sensitivity, specificity, accuracy, positive predictive values, and negative predictive values of post-chemoradiotherapy MRI in predicting residual disease were 69%, 71%, 71%, 15%, and 96%, respectively.

Conclusion: The differentiation of residual tumor from post-irradiation inflammation with early post- chemoradiotherapy MRI (within 28-60 days) is difficult with a high risk of false positive results. Combination of qualitative and semi-quantitative analysis does not improve the accuracy. Conversely, post-chemoradiotherapy MRI has a high negative predictive value with a low risk of false negative results. The role of conventional MRI combined with functional techniques should be evaluated.
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http://dx.doi.org/10.1177/0284185115617346DOI Listing
September 2016

Persistent Urogenital Sinus: Diagnostic Imaging for Clinical Management. What Does the Radiologist Need to Know?

Am J Perinatol 2016 04 21;33(5):425-32. Epub 2015 Oct 21.

Department of Radiological Sciences, Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy.

Background: Persistent urogenital sinus (PUGS) is a congenital pathological condition characterized by an abnormal communication between the urethra and vagina. It may be a part of a complex syndrome and can be more often associated with congenital malformations affecting the genitourinary tract system (33%) such as intersex, rectovaginal communication, bladder agenesis, absence of vagina, and hydrocolpos. The correct radiological assessment of PUGS is especially useful for clinicians since the exact anatomical evaluation of this abnormality is a crucial factor for surgical planning. The imaging study modalities, which are essentially based on ultrasonography, voiding cystourethrography, and magnetic resonance imaging, could be misinterpreted if not correctly performed.

Aim: The aim of this article is to highlight this rare pathological condition and to help general radiologists in achieving the correct technical approach for the diagnosis. Special attention will be paid in discussing the role of different imaging modalities and their contribution to the diagnosis and clinical management of patients.
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http://dx.doi.org/10.1055/s-0035-1565996DOI Listing
April 2016
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