Cystic female pelvic lesions, whether of ovarian or non-ovarian origin, are prevalent in routine clinical practice, with the majority originating from gynaecological (ovarian) structures, ranging from functional cysts to malignant ovarian tumours. Despite the fact that we encounter these lesions in the course of our routine clinical work, arriving at an accurate diagnosis can often prove challenging due to the overlap of imaging appearances. Ultrasound is the primary imaging modality for the evaluation of most cystic female pelvic lesions, while MRI serves as a problem-solving tool. In cases that are more complex or equivocal, pelvic MRI proved to be particularly useful due to its superior soft tissue resolution, multiplanar imaging capability and non-invasive nature. In order to make an accurate diagnosis, it is crucial to have a comprehensive understanding of pelvic topographic anatomy, be familiar with possible differential diagnoses and include all relevant clinical data. The classification of ovarian cystic lesions was undertaken using the O-RADS MRI risk stratification system, which provides standardised language for communication between radiologists and clinicians. The objective of this review is to illustrate the spectrum of typical MRI characteristics of different cystic female lesions of both ovarian and non-ovarian origin, with the emphasis on differential diagnoses. The review includes tables with MRI appearances on T2, T1, DWI sequences and postcontrast tomograms. To facilitate the learning process, schematic representations of MRI appearances of ovarian lesions have been incorporated. MRI diagnosis of various ovarian and non-ovarian cystic female pelvic lesions and their differential diagnosis.

BACKGROUND/OBJECTIVES:Cytoreduction status is a critical prognostic factor in ovarian cancer, yet preoperative selection of patients suitable for primary debulking surgery and accurate prediction of surgical outcome remain challenging. This study aimed to evaluate the prognostic ability of MRI-based Fagotti score and Peritoneal Cancer Index (PCI) for predicting resectability of peritoneal disease in ovarian cancer patients. METHODS:This was a prospective single-center observational study. Patients with suspected primary ovarian cancer who underwent preoperative MRI of the abdomen and pelvis with a dedicated protocol were considered. MRI-based Fagotti score and PCI were determined by two readers independently, using a combination of T2W, Diffusion-Weighted Imaging (DWI), and contrast-enhanced T1W sequences. In cases of discordance, a third radiologist reviewed the scans and consensus was reached. ROC analysis and logistic regression were used to evaluate prognostic performance. The reference standard to predict resectability was optimal cytoreduction defined as residual disease ≤1 cm. RESULTS:Forty-six women with epithelial ovarian cancer (mean age 56.3 ± 2.6 years) who underwent preoperative MRI, followed by laparoscopy and/or laparotomy, were included in the study. Both MRI-based Fagotti score and PCI showed high predictive value for predicting resectability (AUC 0.92 and 0.94, respectively). Optimal cut-offs were ≤6 for Fagotti score and ≤20 for PCI. Patients with scores below these thresholds had >60-fold (Fagotti) and >100-fold (PCI) increased odds for successful primary cytoreduction (p < 0.001). CONCLUSIONS:MRI-based Fagotti score and PCI may serve as powerful noninvasive predictors of surgical outcome in ovarian cancer. MRI may reliably guide treatment decisions, reducing unnecessary laparotomies and optimizing patient selection.

Uterine rupture is rare but one of the most severe and fatal complications in obstetrics. Nonetheless, its presence in the second trimester is exceptionally rare, posing considerable difficulties for diagnosis and management. This case report demonstrates a 38-year-old woman with a history of a previous cesarean delivery who presented at 18 weeks of gestation at the emergency department with severe, acute onset abdominal pain at the right iliac fossa. The patient underwent surgery due to high suspicion, and incomplete uterine rupture was revealed and managed appropriately. Following the surgery, the patient was admitted to the hospital for close monitoring, and at 37 weeks, a successful cesarean delivery resulted in the birth of a live male infant. This case highlights that the obstetric team should remain alert to recognize early the signs and symptoms of this complication in patients with a history of uterine surgery and, as a result, to achieve an optimal perinatal outcome. Specific management and monitoring algorithms could aid the obstetric team in optimally treating these patients.

Immune checkpoint inhibitors (ICIs) have significantly improved outcomes in several solid malignancies but are associated with endocrine immune‐related adverse events (irAEs), particularly hypophysitis. This retrospective real‐world data study aimed to assess the magnetic resonance imaging (MRI) findings in cases with immune‐related (ir) hypophysitis. Sixty‐six cancer patients treated with ICIs at Laikon General Hospital between January 2016 and September 2024, presenting with anterior pituitary hormone deficiencies, were included. All patients underwent baseline pituitary MRI at the time of ir‐hypophysitis diagnosis (median time: 2 weeks post‐diagnosis). A follow‐up MRI was also available in 37 patients (median time: 1.6 years post‐diagnosis). All scans were centrally reviewed by radiologists blinded to clinical data. Baseline MRI abnormalities demonstrated pituitary enlargement (25%), reduced enhancement (10%), empty sella (8.3%), heterogeneous enhancement (5%), reduced size (3.3%), and stalk deviation (1.7%). Among 31 patients with both baseline and follow‐up MRIs, 45% showed imaging changes (partially empty sella, size alterations). No specific ICI regimen was associated with characteristic imaging patterns. Patients with multiple hormonal axis deficiencies had more frequent MRI abnormalities than those with isolated ACTH deficiency (68.4% vs. 46.3% initially; 71.3% vs. 56.4% at follow‐up). Pituitary MRI abnormalities are present in approximately half of patients with ir‐hypophysitis, with dynamic changes observed in follow‐up imaging. However, the absence of findings in a substantial proportion highlights the limited sensitivity of MRI in this irAE and underscores the importance of clinical and biochemical evaluation.

AIMS:Adrenal incidentalomas (AIs) encompass a wide range of clinical entities, from incidental benign neoplasms that need to be monitored to aggressive malignancies requiring urgent medical intervention and treatment. The incidence of adrenal tumors is steadily rising, reflecting a growing trend in their prevalence and highlighting the necessity for heightened awareness and advanced diagnostic strategies to address this escalating health concern. This retrospective study was undertaken in order to explore the possibility of developing a decision support system for classifying adrenal tumors as benign and malignant or suspicious for malignancy. METHODS:A powerful combination of 12 clinical, biochemical, epidemiological, and radiological features of 256 patients with adrenal tumors was analyzed to make predictions and various machine learning models were trained and compared to identify the model that consistently achieves the highest accuracy. RESULTS:An average accuracy of over 91% and a balanced accuracy surpassing 94% was achieved based on a small amount of data and a small number of patients, without using imaging radiomics. CONCLUSION:The present study provided a decision-making process in healthcare systems permitting reliable automated classification of adrenal tumors. This is a promising candidate for integration into an initial screening tool for adrenal cancer, offering clinicians a valuable resource for early detection and intervention.

The aim of this review is to provide an update on the imaging triage, safety considerations, and cancer-imaging features of common and uncommon gynecological tumors during pregnancy. Clinical examination can be inconclusive, especially for the evaluation of intra-abdominal diseases since symptoms related to cancer such as fatigue, vomiting, or nausea overlap with common pregnancy-associated symptoms. Delayed pregnancy, advanced maternal age, and improvements in diagnostic imaging in developed countries have increased the incidence of cancer diagnosis in gravid populations. Non-invasive diagnostic imaging has a central role in the initial diagnosis and management of pregnancy tumors. Sonography is the first modality for the abdominal evaluation of gravid patients because it is widely available, low cost, and lacks adverse effects on the mother and fetus. MR imaging is considered the imaging modality of choice for diagnosis and staging of gynecologic cancer during pregnancy due to its larger imaging field of view, better reproducibility, and excellent soft tissue contrast. Moreover, whole-body diffusion-weighted imaging (DWI) has been proposed for the oncologic staging of pregnant patients; however, large prospective studies are needed to support its clinical implementation. Gynecological cancer diagnosed during pregnancy requires accurate diagnosis and staging to determine optimal treatment based on gestational age, and therefore multidisciplinary team collaboration is pivotal.

e24087 Background: Immune checkpoint inhibitors (ICIs) have transformed the prognosis of many solid malignancies. However, their use has also been associated with distinct endocrine immune-related adverse events (irAEs), hypophysitis being among the most common. Purpose: To describe in a real-world patient cohort, how ICI-induced hypophysitis is depicted on pituitary MRI and how these imaging findings are evolved overtime. Methods: A retrospective analysis of pituitary MRIs was performed on ICI-treated cancer patients who developed biochemically confirmed pituitary insufficiency from January 2016 to September 2024.The initial MRI was performed at the time of diagnosis of ICI-induced hypophysitis, and the follow-up MRI was performed at the same center and assessed by the same radiologist. Both MRIs were evaluated by a central team of radiologists, blinded to the onset of ir-hypophysitis. Results: Sixty-six ICI-treated cancer patients (median age,67 years;35 males) were biochemically diagnosed with pituitary deficiency of one or multiple axis were eligible for inclusion in our analysis. The majority received immunotherapy(70% an anti-PD-1/anti-PD-L1 ICI, and 19% anti-PD-1/anti-PD-L1 and anti-CTLA-4 combinations) for melanoma (90.9%), whereas 4.5% of cases had lung cancer, 1.5% colon cancer and 3% hepatocellular carcinoma. The initial pituitary MRI was performed on 60 patients at a median time of 2 weeks post-diagnosis of ir-hypophysitis (6 excluded due to recently administered steroids for other irAE). Abnormalities were found in 32 patients (53.3%), including enlargement (25%) or reduced enhancement of pituitary gland (10%), empty sella turcica (8.3%), heterogeneous enhancement (5%), or reduced dimensions of pituitary gland (3.3%) and slight deviation of stalk (1.7%). A 2 nd pituitary MRI assessment, after a median follow-up of 1.6 years, was available in 37 patients; 45% of them presented alteration of their initial abnormal MRI findings. Abnormalities were described in 62.2% of cases, including reduced dimensions (18.9%), or enlargement of pituitary gland (16.2%), partially empty sella turcica (16.2%), heterogeneous (8.1%) and reduced (2.7%) enhancement of pituitary gland. No ICI-regimen was associated with a specific MRI abnormality; while subjects receiving an anti-PD-1 ICI or an ICI doublet continued to show abnormal imaging at follow up in similar rates (31.8%-31.5%). Patients with multiple axes deficiencies presented an increased frequency of MRI abnormalities compared to those with isolated corticotrope deficiency in both assessments. Conclusions: MRI pituitary abnormalities were found in approximately 50% of patients with ir-hypophysitis; were not specific to the underlying malignancy and the administered ICI and may persist overtime, transforming their abnormal imaging. The other half presented normal pituitary MRI in both assessments, keeping the challenge of imaging for this irAE.

Ovarian tumors are rare in the pediatric population, yet they are the most common type of malignancy in tumors of the female genital tract. Both non-neoplastic and neoplastic ovarian lesions are seen in children and adolescents. Most pediatric ovarian tumors are benign. Germ cell tumors constitute the majority of ovarian tumors in the pediatric cohort, and mature teratoma is the most prevalent histologic type. However, 3–8% % of ovarian tumors in children and adolescents are malignant. Accurate characterization of ovarian masses in the pediatric population is crucial to determine the appropriate treatment, which should be minimally invasive and focused on preserving fertility. Transabdominal US is the main imaging modality for the assessment of pediatric ovarian masses. MRI represents a valuable adjunct tool for the evaluation of sonographically indeterminate ovarian lesions. This technique is also recommended for tumor staging and follow-up. CT is often used in emergency situations or when there are contraindications for MRI. Imaging findings, along with clinical features and laboratory results, play a crucial role in the characterization of ovarian masses in the pediatric population. This narrative review was based on a comprehensive literature search of articles about imaging findings of ovarian masses in the pediatric population, published between 1977 and April 2025. Data were obtained from the PubMed database, using the following keywords: “imaging”, “ovarian tumors”, ovarian masses”, and “pediatric”. This article aims to provide an overview of the role of imaging in the assessment of ovarian masses in the pediatric age group.

The transformation of an adrenocortical adenoma (ACA) to an adrenocortical carcinoma (ACC) is extremely rare. Current guidelines suggest against further imaging studies and follow-up in patients with nonfunctional adrenal incidentalomas (NFAIs) with benign imaging characteristics. Herein, we present a 64-year-old male patient diagnosed initially with a NFAI of 3 cm in size with imaging characteristics consistent with an ACA. However, 13 years after initial diagnosis, this apparent ACA developed into a high-grade cortisol and androgen-secreting ACC with synchronous metastases. The literature review revealed a further 9 case reports of adrenal incidentalomas initially characterized as ACA that subsequently developed into ACC within a period ranging from 1 to 10 years. The pathogenesis of transformation of an initially denoted ACA to ACC is not fully delineated, although the existing literature focuses on the preexisting or changing genetic background of these lesions, highlighting the need to develop robust prognostic markers to identify patients at risk and individualize the follow-up of these unique cases.

RATIONALE AND OBJECTIVES:The aim of this study is to explore the utility of Inductive Decision Tree models (IDTs) in distinguishing between benign, malignant, and high-risk (B3) breast lesions. MATERIALS AND METHODS:We analyzed 124 histologically confirmed lesions in 114 patients who underwent breast MR with BI-RADS 4 or 5 assessment. The dataset comprised 10 imaging parameters and one clinical observation. Using the IDTs method (algorithm C5.0 boosted with AdaBoost algorithm) combined with the data balancing method SMOTE (Synthetic Minority Oversampling Technique) and a corresponding new method called LCC (Leveling of Cases per Class), we developed corresponding 3-class classification models (Benign, B3, or Malignant). The training set used for classification model development consists of 112 cases with 12 variables, and the model's performance was assessed using 10-fold Cross-Validation and Leave-One-Out methods (utilizing the training set) and the Use Test Set method (testing on an unknown (for the models) dataset of 12 cases with 12 variables). RESULTS:This preliminary study demonstrates the potential for IDTs to accurately distinguish between benign, B3 and Malignant lesions based on extracted data from breast MRI exams with a high classification accuracy (88.70 %), mean sensitivity of 97.18 % and specificity of 98.59 % achieved by the optimal classification model, derived from the combination of the IDTs method and the LCC data balancing method.

Placenta accreta spectrum (PAS) disorder is one of the leading causes of peripartum maternal morbidity and mortality; its early identification during pregnancy is of utmost importance to ensure the optimal clinical outcome. The aim of the present study is to investigate the possible association of the presence and type/location of placenta previa on MRI with PAS and maternal peripartum outcome. One hundred eighty-nine pregnant women (mean age: 35 years; mean gestational age: 32 weeks) at high risk for PAS underwent a dedicated placental MRI. All women underwent a C-section within 6 weeks from the MRI. All MRIs were evaluated by two experienced genitourinary radiologists for presence, type (complete/partial vs. marginal/low lying), and location (anterior vs. anterior-posterior vs. posterior) of placenta previa. Statistical analysis was performed for possible association of type/location of previa with placental invasiveness and peripartum outcomes. Intraoperative information was used as a reference standard. Complete/partial previa was detected in 143/189 (75.6%) and marginal/low lying previa in 33/189 (17.5%) women; in 88/189 (46.6%) women, the placenta had anterior-posterior, in 54/189 (28.6%) anterior and in 41/189 (21.7%) posterior. Complete/partial previa had an at least 3-fold probability of invasiveness and was more frequently associated with unfavorable peripartum events, including massive intraoperative blood loss or hysterectomy, compared to low-lying/marginal placenta. Posterior placental location was significantly associated with lower rates of PAS and better clinical outcomes. In conclusion, the type and location of placenta previa shown with MRI seems to be associated with severity of complications during delivery and should be carefully studied.

Imaging plays a pivotal role in the diagnostic approach of women with suspected ovarian cancer. MRI is widely used for preoperative characterization and risk stratification of adnexal masses. While epithelial ovarian cancer (EOC) has typical findings on MRI; there are several benign and malignant pelvic conditions that may mimic its appearance on imaging. Knowledge of the origin and imaging characteristics of a pelvic mass will help radiologists diagnose ovarian cancer promptly and accurately. Finally, in special subgroups, including adolescents and gravid population, the prevalence of various ovarian tumors differs from that of the general population and there are conditions which uniquely manifest during these periods of life.

Purpose: Tumor heterogeneity may be responsible for poor response to treatment and adverse prognosis in women with HGOEC. The purpose of this study is to propose an automated classification system that allows medical experts to automatically identify intratumoral areas of different cellularity indicative of tumor heterogeneity. Methods: Twenty-two patients underwent dedicated pelvic MRI, and a database of 11,095 images was created. After image processing techniques were applied to align and assess the cancerous regions, two specific imaging series were used to extract quantitative features (radiomics). These features were employed to create, through artificial intelligence, an estimator of the highly cellular intratumoral area as defined by arbitrarily selected apparent diffusion coefficient (ADC) cut-off values (ADC < 0.85 × 10−3 mm2/s). Results: The average recorded accuracy of the proposed automated classification system was equal to 0.86. Conclusion: The proposed classification system for assessing highly cellular intratumoral areas, based on radiomics, may be used as a tool for assessing tumor heterogeneity.

Background An imaging-based predictor of response could provide prognostic information early during treatment course in patients with multiple myeloma (MM). Purpose To investigate if very early changes in bone marrow relative fat fraction (rFF) and apparent diffusion coefficient (ADC) histogram metrics, occurring after one cycle of induction therapy in participants with newly diagnosed MM, could help predict overall best response status. Materials and Methods This prospective study included participants with MM who were enrolled between August 2014 and December 2017. Histogram metrics were extracted from ADC and rFF maps from MRI examinations performed before treatment and after the first treatment cycle. Participants were categorized into the very good partial response (VGPR) or better group and the less than VGPR group per the International Myeloma Working Group response criteria. ADC and rFF map metrics for predicting treatment response were compared using the Wilcoxon rank test, and the false discovery rate (FDR) was used to correct for multiple comparisons. Results A total of 23 participants (mean age, 65 years ± 11 [SD]; 13 men) were evaluated. There was no evidence of a difference in ADC metrics between the two responder groups after correcting for multiple comparisons. The rFF histogram changes between pretreatment MRI and MRI after the first treatment cycle (ΔrFF) that provided significant differences between the VGPR or better and less than VGPR groups were as follows: ΔrFF_10th Percentile (median, 0.5 [95% CI: 0, 1] vs -2.5 [95% CI: -5.1, 0.1], respectively), ΔrFF_90th Percentile (median, 2 [95% CI: 1, 6.8] vs -0.5 [95% CI: -1, 0]), ΔrFF_Mean (median, 3.4 [95% CI: 0.3, 7.6] vs -1.1 [95% CI: -1.8, -0.7]), and ΔrFF_Root Mean Squared (median, 3.2 [95% CI: 0.3, 6.1] vs -0.7 [95% CI: -1.3, -0.4]) (FDR-adjusted P = .03 for all), and the latter two also presented mean group increases in the VGPR or better group that were above the upper 95% CI limit for repeatability. Conclusion Very early changes in bone marrow relative fat fraction histogram metrics, calculated from MRI examination at baseline and after only one cycle of induction therapy, may help to predict very good partial response or better in participants with newly diagnosed multiple myeloma. © RSNA, 2022 Online supplemental material is available for this article.

Purpose: Accurate antenatal diagnosis of placenta accreta spectrum (PAS) is important for optimal management. The purpose of this study was to compare the respective capabilities of 1.5-T and 3.0-T MRI in the diagnosis of PAS. Materials and methods: Between March 2016-March 2021, 190 pregnant women at high risk for PAS underwent dedicated prenatal MRI with either 1.5-T or 3.0-T units at a tertiary imaging center. Cesarian section and MRI were performed less than 6 weeks from each other. Prospectively collected data were evaluated by two experienced genitourinary radiologists for presence and extent of PAS. A comparative study was designed to investigate differences in predictive ability between 1.5-T and 3.0-T MRI groups. Sensitivity, specificity, accuracy, negative and positive prognostic values relative to intraoperative/histological findings, were computed for both groups and were compared with chi-square (chi 2) test. Interobserver agreement was estimated using Kappa test. Results: One hundred-eighty-two gravid women were included in the study; of these, 91/182 (50%) women were evaluated with 1.5-T (mean age, 35 +/- 5.1 [SD] years; mean gestational age: 32.5 weeks) and 91/182 (50%) with 3.0-T MRI (mean age, 34.9 +/- 4.9 [SD] years; mean gestational age, 32.1 weeks). 1.5-T MRI yielded 95.7% sensitivity (95% CI: 87.8-99.1) and 81.8% specificity (95% CI: 59.8) and 3.0-T MRI 93.8% sensitivity (95% CI: 86.0-97.9) and 83.3% specificity (95% CI: 48.2-97.7) for PAS identification, with no differences between the two groups (P = 0.725 and P > 0.999, respectively). MRI showed excellent predictive ability for detecting extrauterine placental spread with 100% sensitivity (95% CI: 89.4-100.0), 96.7% specificity (95% CI: 88.1-99.6) for 1.5-T and 97% sensitivity (95% CI: 84.2-99.9), 96.7% specificity (95% CI: 88.1-99.6) for 3.0-T without differences between the two groups (P > 0.999). Interobserver agreement was excellent for both groups. The most frequently detected MRI signs of PAS for both 1.5-T and 3.0-T groups were placental heterogeneity (n = 85, 93.5% vs. n = 90, 98.9%; P = 0.413), and intraplacental fetal vessels (n = 64, 70.3% vs. n = 65, 71.4%; P = 0.870). Conclusion: This study suggests that 3.0-T MRI and 1.5-T MRI are equivalent for the diagnosis of PAS. (C) 2022 Societe francaise de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Introduction/Aim: Placenta accreta spectrum (PAS) is the leading cause of emergency peri-partum hysterectomy and can be fatal in up to 7% of the cases, due to massive hemorrhage. The objective of this study is to evaluate the usefulness of Intraoperative Cell Salvage (ICS) and autologous transfusion in gravid women with prenatal MRI positive for extensive placental invasiveness. Methods: Between March 2019-March 2021, 23 gravid women (mean age, 37 years; mean gestational age, 35.2 weeks) suspicious for PAS were treated. All women had placenta previa in the second trimester ultrasound and underwent dedicated prenatal MRI for placental evaluation between 30 and 34 weeks of gestation. All MRI examinations were prospectively reviewed by two experienced radiologists for PAS presence, depth of invasion and extrauterine placental spread. All 23 women underwent C-section within 6 weeks (mean, 4 weeks) from MRI. In 16 women with MRI diagnosis of PAS, ICS was used during the delivery. No placenta in situ approach, methotrexate or endovascular- assisted hemostasis were applied. Intraoperative and pathologic findings were the standard of reference. Results: In 11/16 women with PAS, percreta with extrauterine spread (n=8 bladder, n= 6, parametrial involvement) was diagnosed on both MRI and surgery; 6/11 treated with hysterectomy. ICS was used in all 11 cases. All 11 women suffered massive hemorrhage during the delivery and required a total of 28958 ml blood transfusion (range: 970 ml- 6367 ml). ICS provided 16515 ml (range: 970 ml -3750 ml), which corresponds to 57% of the total blood volume required. In all cases, postoperative course was uneventful. Conclusion: The use of ICS in women with extensive PAS may optimize surgical treatment and improve clinical outcome. Prenatal placental MRI may help the obstetricians to identify the appropriate candidates for ICS application.