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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

PurposeThis retrospective study aimed to assess the diagnostic performance of preoperative [18F]FDG-PET/CT in predicting the groin and pelvic lymph node (LN) status in a large single-centre series of vulvar cancer patients.MethodsBetween January 2013 and October 2018, among all consecutive women with proven vulvar cancer submitted to [18F]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-SUVmax). 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.ResultsAll 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 (SUVmax cut-off value 1.89 achieved by ROC analysis). Similar results were observed in the pelvis-based analysis.ConclusionIn this large single-centre series of vulvar cancer patients, [18F]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 SUVmax.

PurposeThis prospective study aimed to evaluate whether 18F-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.MethodsBetween October 2010 and June 2014, 88 patients with LACC were enrolled. For each patient, three 18F-FDG-PET/CT scans (baseline, early and final) were acquired and evaluated by qualitative and quantitative analysis. Maximum standardized uptake value (SUVmax), SUVmean, 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 18F-FDG-PET/CT in predicting lymph node (LN) residual disease was evaluated by qualitative analysis only. Histopathology was the reference standard.ResultsAt histopathology, 40 patients had complete response (CR, pR0), 48 had partial response (PR: 21 microscopic [pR1] and 27 macroscopic [pR2]). At baseline, SUVmax and SUVmean 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, SUVmax, SUVmean 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 SUVmean, early delta TLG, and final delta SUVmax 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 18F-FDG-PET/CT (93.5% and 92.3%, respectively).ConclusionIn 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 18F-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.

Correct staging of cervical cancer is essential to establish the best therapeutic procedure and prognosis for the patient. MRI is the best imaging modality for local staging and follow-up. According to the latest ESUR guidelines, T2WI and DWI-MR sequences are fundamental in these settings, and CE-MRI remains optional. This systematic review, according to the PRISMA 2020 checklist, aims to give an overview of the literature regarding the use of contrast in MRI in cervical cancer and provide more specific indications of when it may be helpful. Systematic searches on PubMed and Web Of Science (WOS) were performed, and 97 papers were included; 1 paper was added considering the references of included articles. From our literature review, it emerged that many papers about the use of contrast in cervical cancer are dated, especially about staging and detection of tumor recurrence. We did not find strong evidence suggesting that CE-MRI is helpful in any clinical setting for cervical cancer staging and detection of tumor recurrence. There is growing evidence that perfusion parameters and perfusion-derived radiomics models might have a role as prognostic and predictive biomarkers, but the lack of standardization and validation limits their use in a research setting.

A Correction to this paper has been published: 10.1007/s00330-021-08066-7

The integration of diagnostic imaging with radiation therapy (RT) is evolving into a continuous workflow, significantly advancing personalised oncology care. Recent technological innovations, particularly the incorporation of real-time magnetic resonance imaging (MRI) with linear accelerators, have markedly enhanced RT precision, improving target coverage and reducing radiation exposure to surrounding healthy tissues. Furthermore, real-time MRI enables the collection of quantitative imaging data during each treatment fraction, potentially leading to the identification of quantitative imaging biomarkers. These biomarkers can capture dynamic biological changes during RT, offering unprecedented insights into treatment response. The integration of these imaging biomarkers with clinical, genomic, and pathological data into artificial intelligence (AI)-supported clinical decision support systems promises to further refine therapeutic personalisation. In this context, AI plays a central role by automating labour-intensive tasks, extracting quantitative metrics, and integrating multidimensional data into clinically meaningful predictive models. This review outlines a vision for the future of RT, highlighting how the synergy of advanced imaging, AI, and multidomain data through three logical steps: (1) rethinking and reorganising the patient care journey; (2) from imaging “for” to imaging “with” RT; and (3) incorporation into clinical decision support systems. This integration will support the development of personalised, biologically driven treatment strategies. Relevance statement The longitudinal integration of diagnostic imaging and RT, facilitated by AI, could significantly enhance clinical workflow efficiency and therapeutic accuracy in oncology. Key Points Oncological care is transitioning from disease-centred to patient-centred, with tumour boards representing the junction for shared multidisciplinary decisions. Integrating advanced imaging with RT enables quantitative imaging biomarkers extraction that captures tumour changes throughout the course of treatment. Artificial intelligence plays a central role in automating resource-intensive processes and integrating large-scale multidomain data towards personalised medicine. Graphical Abstract

Incidental findings on female pelvic MRI present diagnostic challenges and may have significant clinical implications. Defined as abnormalities unrelated to the primary imaging indication, these findings have become increasingly prevalent with the expanded use of MRI in gynaecological practice. Standard gynaecological MRI protocols, incorporating T1- and T2-weighted sequences, diffusion-weighted imaging, and contrast-enhanced sequences, facilitate the characterisation of numerous extra-gynaecological abnormalities, ranging from benign to critical lesions. This review proposes a compartment-based approach for identifying extra-gynaecological findings, discussing their imaging characteristics and differential diagnoses. This approach may help radiologists systematically assess incidental findings, potentially improving the recognition of clinically relevant abnormalities and supporting timely clinical decision-making. Critical relevance statement Incidental extra-gynaecological findings on pelvic MRI can present significant diagnostic challenges. Systematic evaluation of incidental extra-gynaecological findings on pelvic MRI can improve radiologists’ awareness of clinically relevant abnormalities. Key Points Extra-gynaecological incidental findings on pelvic MRI are common and range from benign to malignant conditions. A compartment-based classification—dividing the female pelvis into anterior, lateral, posterior, musculoskeletal, and miscellaneous compartments—provides a systematic framework for interpretation. Thorough assessment of all MRI sequences, including large field-of-view images, may help identify clinically relevant incidental findings. Graphical Abstract

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.

Ovarian cystadenofibroma is a benign ovarian tumor that is characterized by a consistent percentage of masses, which remain indeterminate in ultrasonography and require magnetic resonance (MR) investigation; they may mimic borderline or malignant lesions. Three main morphologic patterns, resembling different ovarian neoplasms, can be identified in cystadenofibromas: multilocular solid lesions, unilocular cystic lesions with parietal thickening, and purely cystic masses. However, a cystoadenofibroma has typical features, such as T2-weighted hypointensity associated with no restrictions in diffusion-weighted imaging (the so-called “dark-dark appearance”) and progressive post-contrast enhancement (type I perfusion curve). The purpose of this study was to review the features of ovarian cystadenofibromas in MR imaging and to suggest pearls and pitfalls regarding their correct diagnosis.

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.