Background The 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer (EC) integrates histopathologic and molecular variables that may be inapparent at imaging. Purpose To evaluate the impact of the updated FIGO 2023 staging system on preoperative MRI assessment in patients with EC, and to assess its impact on patient outcomes. Materials and Methods In this dual-center retrospective study, women with biopsy-proven EC underwent abdominal MRI. Radiologic FIGO (rFIGO) 2009 stage was assigned from MRI and biopsy grade and histotype. Surgical specimens provided pathologic FIGO (pFIGO) 2009 and 2023 stages, incorporating molecular status. Concordance and causes of discordance were assessed. Potential impact on initial management was inferred using 2025 European Society of Gynaecological Oncology-European Society for Radiotherapy and Oncology-European Society of Pathology guidelines. Disease-free survival (DFS) and overall survival (OS) were assessed with Kaplan-Meier. Results A total of 231 women (median age, 63 years; IQR, 55-73 years) were evaluated. Major-stage agreement decreased from 86.6% (200 of 231) of patients for rFIGO 2009 versus pFIGO 2009 to 76.2% (176 of 231) for rFIGO 2023 versus pFIGO 2023 (P < .001); substage concordance declined from 74.0% (171 of 231) with FIGO 2009 to 56.3% (130 of 231) with FIGO 2023 (P < .001). Under FIGO 2023, the most common causes of discordance were minimal myometrial invasion (37 of 101 women, 36.6%), lymph node involvement (18 of 101 women, 17.8%), and histology-dependent factors such as lymphovascular space invasion (12 of 101 women, 11.9%) and histologic changes (19 of 101 women, 18.8%). Molecular data reclassified 35 of the 231 (15.2%) patients (18 patients were downstaged; 17 were upstaged). Discrepancies would have altered the initial approach in 22 of the 231 (9.5%) patients. Recurrence and death occurred in 18 (7.8%) and 16 (7.0%) of the 231 patients, respectively, with DFS and/or OS stratification across radiologic and pathologic 2009 and 2023 stages (all P < .001). Conclusion The 2023 FIGO update reduced substage concordance between preoperative pelvic MRI and final pathology, primarily due to the missed detection of minimal myometrial invasion and micrometastatic lymph node involvement. © RSNA, 2026 Supplemental material is available for this article. See also the editorial by Kataoka and Himoto in this issue.

Objective: This study aimed to explore the association between magnetic resonance imaging (MRI)-derived volumetric parameters and oncological outcomes, and to develop an exploratory predictive model based on these variables in patients treated with radio-chemotherapy followed by interventional radiotherapy (modern brachytherapy). Methods: Between 2021 and 2024, 300 patients with cervical cancer were included. Treatment was pelvic external beam radiotherapy with platinum-based chemotherapy followed by interventional radiotherapy boost. Volumetric MRI variables for each patient were collected. Time-to-event analyses were performed using Cox proportional hazards regression models. Model performance was assessed using Harrell's concordance index (C-index). Internal validation was performed using bootstrap resampling. Based on the final multivariable Cox models, an interactive web-based nomogram was developed as an exploratory tool to visualize model-derived associations. Results: Median tumor volume decreased from 69.4 cm3 at diagnosis to 2.2 cm3 at the time of pre-interventional radiotherapy MRI, with a median reduction rate of 96.5%. Tumor volume at diagnosis, pre-interventional radiotherapy residual tumor volume, and tumor volume reduction rate were significantly associated with loco-regional relapse and distant metastases in Cox regression analyses. These findings were consistent across univariate and multivariable models. Internal validation confirmed the stability of the model estimates. Conclusions: MRI-derived volumetric parameters are associated with oncological outcomes in patients with locally advanced cervical cancer and may contribute to early risk stratification. The proposed model should be considered exploratory and hypothesis-generating and requires external validation before any potential clinical application.

The posterior reconstruction (PR) during robot-assisted radical prostatectomy (RARP)—as originally described by Rocco F and coworkers—has been introduced in 2006 aiming to restore anatomical disruption occurring after radical prostatectomy and to improve continence recovery. The original open technique has been adapted to laparoscopy and to robotics thereafter. The approximation achieved after PR may also reduce the anastomotic tension—while tying the suture – and thus enhance the anatomical alignment. The Rocco’s stitch was introduced by October 2024 at a tertiary robotic center previously unfamiliar to the technique; therefore, a comparative study to assess the impact of PR on the self-perceived quality and easiness of VUA of robotic surgeons was performed. This is a retrospective, single-center comparative study performed at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. The Rocco Stitch was introduced in October 2024 using the standardized two-layer technique. Cases before and after the introduction of PR were retrieved from a prospectively maintained database (Protocol ID 7314) and 271 patients undergoing RARP between November 2023 and February 2025 were evaluated. Post-operative cystogram was performed when deemed necessary (7–9 PO day), based on the surgeon’s ease of anastomosis execution and final perceived quality. The primary outcome of the study is the rate of cystogram use; the overall rate of urinary leakage and the need for additional imaging due to suspect urine extravasation are secondary endpoint. Multivariable logistic regression was performed to identify independent predictors of leakage. Overall, 87 patients received PR, 184 did not; PR group had significantly lower cystogram use (34.5

Malignant Bowel Obstruction (MBO) is an often preterminal complication of gastrointestinal and gynecological cancers. We tried to identify clinical and radiological parameters suggesting early providing of End of Life (EOL) care protocols in this kind of patients at Emergency Department (ED) presentation. We retrospectively analyzed 60 ED patients admitted for MBO in a one-year period, identifying a Bad Prognosis Group (BPG) (died or transferred to EOL care centers) and a Good Prognosis Group (GPG) (prosecution of treatment with curative intent). Predictors of bad prognosis were: time of onset of symptoms, Eastern Cooperative Oncology Group performance status (ECOG), Charlson Comorbidity Index (CCI), past intestinal obstruction, previous abdominal surgery and therapeutic strategy adopted. Computed tomography scan studies were reviewed by expert radiologists. CCI ≥ 4 (p=0,030), ECOG score ≥ 2 (p=0,016), no large bowel occlusion (p=0,045), mesenteric infiltration retraction (p=0,047) and extraperitoneal metastases (p=0,049) confirmed independent predictive value of bad prognosis at multivariate analysis. Identifying clinical and radiological criteria at ED evaluation can be useful to better identification of those MBO patients who may benefit from early providing EOL care protocols.

Uterine cancers include endometrial cancer (EC), cervical cancer (CC), and uterine sarcomas, with leiomyosarcoma being the most common subtype. Each tumour type has distinct biological behaviour, imaging features, and treatment approaches. Radiologists must be familiar with normal uterine anatomy and its variations, as well as key imaging characteristics and common patterns of tumour spread to ensure accurate staging and optimal treatment selection. MRI is the imaging modality of choice for evaluating uterine malignancies due to its excellent soft tissue contrast and multiplanar capabilities. Accurate assessment requires dedicated multiparametric protocols, as recommended by the European Society of Urogenital Radiology (ESUR), including high-resolution T2-weighted imaging, diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) sequences when appropriate. 18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) complements MRI in patients with CC by providing the highest accuracy for detecting lymph-node and distant metastases. CT is mainly used for systemic evaluation. This article presents a practical guide for radiologists, describing the main clinical indications, patient preparation, and tailored MRI protocols. It also highlights key imaging findings that should be evaluated and reported.

This study aimed to evaluate clinical outcomes in patients with vaginal recurrences treated with radiotherapy with or without chemotherapy, followed by image-guided interventional radiotherapy (IG-IRT). We retrospectively analyzed patients with vaginal recurrences treated with external beam radiotherapy (EBRT) ± chemotherapy followed by endovaginal high dose rate IG-IRT. The EBRT total dose was 45 Gy. The interventional radiotherapy boost delivered 28 Gy in four high-dose-rate fractions, achieving 85–95 Gy EQD2 (α/β 10) to the high-risk clinical target volume and 60 Gy EQD2 (α/β 10) to the intermediate-risk clinical target volume. The primary endpoint was local control. Secondary endpoints included metastasis-free survival, overall survival, cancer-specific survival, and acute and late toxicities. Thirty-two patients (median age, 54 years) were included. Two-year actuarial local control, metastasis-free survival, overall survival, and cancer-specific survival rates were 100

The aim of this study was to investigate the correlation between clinical and dosimetric factors and the incidence of pelvic insufficiency fractures (PIFs) in patients with cervical cancer treated with radical radiotherapy (RT), with or without chemotherapy, and to identify dose constraints that may reduce this risk. We reviewed data from cervical cancer patients treated with pelvic external-beam RT at our institution between 2020 and 2023. For each patient, pelvic bone marrow (BM) was contoured and divided into three subsites: lumbosacral spine (LSBM), ilium (IBM), and lower pelvis (LPBM). Data on the volume of each region receiving 10, 20, 30, and 40 Gy (V10, V20, V30, and V40, respectively) and Dmean were collected. A total of 202 patients were retrospectively analyzed. Of these, 36 patients (17.8

Gynaecological tumours present a broad spectrum of histological subtypes due to the diverse anatomical and tissue origin of the reproductive organs. Rare tumours affect less than 6 per 100 000 individuals annually, posing significant challenges in diagnosis and management due to limited clinical awareness. Indeed, treatment protocols rely on options developed for more common histotypes, which may have limited efficacy on these rare tumours. In recent years, collaborative international efforts have started to address these gaps, improving standards of care. A comprehensive understanding of rare tumours' clinical and imaging features is necessary for radiologists in order to provide clinicians with useful information for treatment planning. In this review, we adopted an organ-based outline, describing rare tumours of the uterine corpus (leiomyosarcoma, endometrial stromal sarcoma, carcinosarcoma), cervix (gastric-type adenocarcinoma), and ovary (cystadenofibroma, lipid-poor teratoma, struma ovarii, immature teratoma, dysgerminoma). Additionally, tumours occurring at multiple sites, including lymphoma, neuroendocrine tumours, aggressive angiomyxoma and metastases are discussed. The objective is to help radiologists become familiar with these uncommon entities, ultimately increasing awareness on this topic.

Decidual changes in deep pelvic endometriosis (DPE) are extremely rare. During pregnancy, endometriotic activity and symptoms diminish due to hormonal changes, whereas the endometrial lining undergoes decidualization in response to progesterone. In some cases, a significant hormonal boost can promote the decidualization of endometriotic implants, with endometriomas being the most common sites for such changes. Decidualized endometriosis at sites outside the ovaries is a rarer phenomenon, and the associated imaging features have been studied less. We present a case of non-pregnancy-related decidualization involving multiple sites of DPE. A 33-year-old woman exposed to ovarian stimulation before in vitro fertilization (IVF) presented with chronic pelvic pain and vaginal bleeding. Emergency CT demonstrated irregular solid tissue in the pouch of Douglas and along the bowel loops, raising concern for a neoplastic process. Tumor markers were negative. Transvaginal ultrasound showed a hypoechoic, irregular, hypervascular lesion, and ultrasound-guided biopsy demonstrated decidualized stromal endometriosis. MRI confirmed a solid mass centered in the posterior cul-de-sac with intermediate T2-weighted (W) signal intensity, hemorrhagic foci on fat-suppressed T1W images, marked diffusion restriction, and avid post-contrast enhancement. Similar solid components were also present at multiple pelvic sites, adjacent to DPE implants. Short-interval MRI follow-up showed size reduction; however, due to persistent pain, fertility-sparing surgery was performed, and histology confirmed decidualization of DPE at all sites. This rare case emphasizes that decidualization can also occur on DPE and outside pregnancy, potentially mimicking malignant transformation, highlighting the role of MRI in aiding diagnosis and guiding proper management for these patients.

To compare biparametric MRI (bpMRI) and multiparametric MRI (mpMRI) for detecting clinically significant prostate cancer (csPCa), and to assess the impact of artificial intelligence (AI)–assisted bpMRI on diagnostic performance and biopsy-related outcomes in readers with different expertise. In this retrospective multi-reader study, 173 men referred for prostate mpMRI were evaluated by five radiologists (two experts, three basic readers) who scored bpMRI and mpMRI using PI-RADS v2.1. After a 45-day wash-out, the same readers reinterpreted bpMRI with concurrent AI decision support (available for 127 cases). Diagnostic performance for csPCa (ISUP ≥ 2) and benefit-to-harm ratios were compared across protocols and reader groups. Mean area under the receiver operating characteristic curve was 0.820 for bpMRI and 0.819 for mpMRI (difference 0.001), indicating comparable diagnostic performance. In the AI subset, AI increased mean specificity from 59.7

Vulvar and vaginal cancers represent rare malignancies for which high-quality evidence remains scarce, largely due to their low incidence and biological heterogeneity. Therefore, the clinical management of these tumors poses significant challenges for multidisciplinary teams. To address this unmet need, an interdisciplinary expert panel developed the present position paper based on the best available evidence regarding surgical, locoregional and systemic treatment strategies. In addition, considerations relevant to the care of transgender and gender-diverse individuals are incorporated. This document aims to support multidisciplinary clinical decision-making in vulvar and vaginal cancers by synthesising current evidence, identifying areas of uncertainty, and outlining available resources to promote the implementation of structured, evidence-informed, and patient-centered treatment approaches.

Endometrial cancer (EC) is the most common gynaecologic malignancy in developed countries, and its diagnostic and prognostic framework has evolved substantially following the introduction of the 2023 FIGO staging system, which integrates molecular classification with clinicopathologic features. Both histopathologic features, such as lymphovascular space invasion (LVSI) and molecular subtype, including POLE mutation status, mismatch-repair deficiency, and p53-abnormal phenotype, are incorporated into the updated staging system, highlighting the importance of tumour biology in risk stratification. Accordingly, the value and contribution of MRI to patient management must extend beyond macroscopic assessment to support a more biologically driven approach. This narrative review synthesizes recent advances in MRI for EC, highlighting developments that improve diagnostic accuracy and align imaging with the molecular paradigm. Multiparametric MRI remains the reference standard for local staging, while emerging quantitative diffusion techniques provide microstructural biomarkers associated with tumor aggressiveness and prognostic features. The consistency of nodal staging has been enhanced by Node-RADS, a structured reporting system that integrates nodal morphology and configuration, with the goal of improving reproducibility and diagnostic performance over size-based assessment alone. Radiomics and artificial intelligence (AI) represent the most transformative frontier, enabling MRI to infer biological behaviours previously accessible only via histopathologic assessment. Radiomics and deep-learning models have demonstrated high accuracy in predicting LVSI, DMI, nodal metastasis, and molecular subtypes, offering non-invasive biomarkers aligned with FIGO 2023 prognostic categories. Together, these advances position MRI as a quantitatively enriched, biologically relevant tool that supports precision oncology in endometrial cancer.

To evaluate the impact of MRI-defined bladder wall invasion from uterine cervical cancer (CC) on disease recurrence and overall survival. IRB-approved multicenter retrospective study including women who underwent staging MRI for histologically confirmed CC (Jan 2015–Dec 2020). Image analysis was independently performed by two radiologists. Bladder wall invasion was diagnosed if ≥ 3 of the following criteria were met: loss of the cervix-bladder fat plane, bladder wall thickening, loss of bladder wall T2-hypointensity, and presence of endoluminal tumor growth. MRI findings were compared with endoscopy/cytology. The impact of MRI-defined bladder wall invasion on tumor recurrence and survival was assessed using logistic regression. Survival curves were compared using the log-rank test. We included 214 women with a median age of 55 (IQR 47–65) years. MRI-defined bladder wall invasion was observed in 21.5

The goal is to investigate the best time point for assessing radiological complete response after exclusive chemoradiation in locally advanced cervical cancer (LACC). This is a retrospective single-center study. Seventy-nine patients with LACC, stage IB3-IVA FIGO 2018 treated between January and December 2020 were retrospectively analyzed. All patients received external beam radiotherapy (45 Gy in 25 daily fractions ± simultaneous boost to lymph nodes), and interventional radiotherapy (IRT, 28 Gy/twice/weekly) with concurrent chemotherapy. The radiological complete response evaluation was examined using magnetic resonance imaging (MRI) at three timepoints: (i) before IRT, at the end of external beam radiotherapy, (ii) 3 months following the completion of IRT and (iii) 6 months after IRT. Seventy-nine patients were included. At the three timepoints, the complete response rate increased with 21, 53, and 59 patients reporting a complete response at MRI scan, respectively. Seven patients with partial response at the second assessment had complete response 6 months after treatment completion, overall resulting in 80

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. The longitudinal integration of diagnostic imaging and RT, facilitated by AI, could significantly enhance clinical workflow efficiency and therapeutic accuracy in oncology.

Cervical cancer treatment involves multidisciplinary care teams composed of gynecologic surgeons, gynecologic oncologists, radiation oncologists, pathologists, and radiologists. The 2018 update of the FIGO cervical cancer staging system incorporated imaging as a source of staging information, reflecting the critical role of imaging in evaluating patients with cervical cancer before and after therapy. However, the lack of standardized terminology has led to challenges in the updated system's application, including ambiguity in management decisions. This collaborative project between the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel, the European Society of Urogenital Radiology Female Pelvic Imaging Working Group, and the Asian Society of Abdominal Radiology aimed to develop a list of standardized consensus-based terms and definitions for reporting imaging findings in the initial staging, follow-up, and treatment planning of cervical cancer, as well as a report template leveraging the lexicon terms. The lexicon and report template were developed by 20 committee members (17 radiologists, two gynecologic oncologic surgeons, and one radiation oncologist), representing 19 institutions from North America, Europe, and Asia. These tools are intended to improve consistency in the reporting of cervical cancer imaging, to enhance communication among care teams and optimize patient management.

PURPOSE:To assess the incidence of pelvic insufficiency fractures (PIFs) after concurrent chemoradiotherapy (CCRT) in patients with locally advanced cervical cancer (LACC), their time of onset and risk factors. We also analysed the inter-observer agreement between gynaecologic radiologists (GYN readers) and radiologists expert in musculoskeletal imaging (MSK reader) in detecting PIFs in our tertiary care centre. METHODS:Patients with confirmed LACC who underwent concurrent chemoradiation (CCRT) at our institution from June 2019 to November 2022 were retrospectively included. These patients underwent follow-up pelvic MRI every 3-6 months after CCRT. Cohen's kappa statistics was employed to assess the inter-observer agreement between GYN and MSK readers.Logistic regression analysis was performed calculating odds ratios (OR) to identify risk factors for PIFs, such as age, body mass index (BMI), diabetes, smoking, hypertension, renal function and tumour size. RESULTS:Eighty-seven patients were included. PIFs were diagnosed in 21/87 (24.1 %) patients with a median onset time of 7.4 months from the end of EBRT. Among risk factors, age was statistically associated with PIFs (OR = 1.057, 95 % CI: 1.005-1.118, p = 0.033) with median age in the fracture group of 61.1 years (range: 52.0-71.5) and 53.8 years (range: 43.8-63.3). BMI was a significant predictor of PIFs (OR = 1.134; 95 % CI: 1.013-1.285; p = 0.027), with a higher median BMI among patients with PIFs (26.5; range: 21.5-31.2) compared to non-fractured patients (23.1; range: 20.2-25.1). Also patients with reduced renal function (eGFR < 60 mL/min) had 3.437 times higher odds of experiencing fractures compared to those with normal eGFR. The GYN readers correctly identified PIFs in 2/21 cases and agreed with the MSK reader in 68/87 cases. The interobserver agreement was poor to fair (K = 0.138; 95 % CI: 0-0.311). CONCLUSIONS:PIFs are a common complication of CCRT. Their identification on post-CCRT MRI may decrease the need for further targeted investigations and invasive treatments.