Revised FIGO staging for carcinoma of the cervix uteri

Advances in MR imaging techniques, along with the growing role of the radiologist as part of a multidisciplinary treatment-planning team, have become central in tailoring treatment options and frequently lead to modifications in the therapeutic approach in patients with gynecologic malignancies.

The Added Role of MR Imaging in Treatment Stratification of Patients with Gynecologic Malignancies: What the Radiologist Needs to Know

Cancers of the uterine corpus and cervix are the most common gynecologic malignancies worldwide. The International Federation of Gynecology and Obstetrics (FIGO) staging system was first established in 1958, when it was recognized that the recurrence rate and patient outcomes were directly related to the degree of tumor spread at the patient's initial presentation. Changes in understanding of tumor biology led to a recent update in the FIGO staging system that reflects the variation in treatment strategies between endometrial and cervical cancer. Patients with endometrial cancer are primarily treated with hysterectomy; thus, staging is done at surgery and histologic analysis. Magnetic resonance (MR) imaging may accurately depict the extent of endometrial cancer at diagnosis and, in conjunction with the tumor grade and histologic subtype, help stratify risk, which determines the therapeutic course. Cervical carcinoma is staged at clinical examination because many tumors are inoperable at the time of patient presentation. Preoperative MR imaging criteria are not formally included in the revised FIGO staging system because cervical carcinoma is most prevalent in developing countries, where imaging resources are limited. However, MR imaging is highly sensitive and specific for depicting important prognostic factors and, when available, is recommended as an adjunct to clinical examination. The MR imaging findings of uterine carcinoma should be discussed in a multidisciplinary setting in conjunction with clinical and histologic findings, an approach that provides accurate staging and risk stratification and allows for individualized treatment.

https://pubs.rsna.org/doi/pdf/10.1148/rg.326125519

The Revised FIGO Staging System for Uterine Malignancies: Implications for MR Imaging

In this study, the authors evaluated MR volumetry as a tool for the initial staging of endometrial cancer; when it was used as a quantitative biomarker, tumor volume allowed accurate prediction of deep myometrial invasion, tumor grade, and lymphovascular invasion.

Endometrial Cancer: Combined MR Volumetry and Diffusion-weighted Imaging for Assessment of Myometrial and Lymphovascular Invasion and Tumor Grade.

With the genomic revolution in the early 1990s, medical research has been driven to study the basis of human disease on a genomic level and to devise precise cancer therapies tailored to the specific genetic makeup of a tumor. To match novel therapeutic concepts conceived in the era of precision medicine, diagnostic tests must be equally sufficient, multilayered, and complex to identify the relevant genetic alterations that render cancers susceptible to treatment. With significant advances in training and medical imaging techniques, image analysis and the development of high-throughput methods to extract and correlate multiple imaging parameters with genomic data, a new direction in medical research has emerged. This novel approach has been termed radiogenomics. Radiogenomics aims to correlate imaging characteristics (ie, the imaging phenotype) with gene expression patterns, gene mutations, and other genome-related characteristics and is designed to facilitate a deeper understanding of tumor biology and capture the intrinsic tumor heterogeneity. Ultimately, the goal of radiogenomics is to develop imaging biomarkers for outcome that incorporate both phenotypic and genotypic metrics. Due to the noninvasive nature of medical imaging and its ubiquitous use in clinical practice, the field of radiogenomics is rapidly evolving and initial results are encouraging. In this article, we briefly discuss the background and then summarize the current role and the potential of radiogenomics in brain, liver, prostate, gynecological, and breast tumors. Level of evidence 5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;47:604-620.

Background, current role, and potential applications of radiogenomics.

Objective: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. Methods: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. Results: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. Conclusions: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

/pdf/staging-of-uterine-cervical-cancer-with-mri-guidelines-of-528vka9ewa.pdf

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

Primary sclerosing cholangitis is a disease affecting around 0.006–0.016% of the population. Of these, around 75% have concomitant inflammatory bowel disease (IBD) according to the most recent epidemiological studies. Several theories have been proposed regarding the pathogenesis of primary sclerosing cholangitis (PSC). These include changes in the function of cholangiocytes, effects of the gut microbiome, association with specific human leukocyte antigen haplotypes and dysregulation of the immune system. However, these do not explain the observed association with IBD. Moreover, there are considerable differences in the frequency and outcomes between patients with PSC and ulcerative colitis compared with PSC and Crohn’s disease. The aim of this review is to appraise the most recent studies that have contributed to the epidemiology, advances in the pathophysiology, and characterization of important clinical aspects of the association of PSC and IBD.

https://publinestorage.blob.core.windows.net/journals/JCTH.2022.0(0).0.00344.pdf

Primary Sclerosing Cholangitis and Inflammatory Bowel Disease: A Review

Immune checkpoint inhibitors (ICIs) suppress the function of immune checkpoints, which are involved in downregulating immune responses. These lead to an increased activation of the function of T cells, increased release of cytokines, and decreased activity of regulatory T cells. This allows for a more significant and less regulated immune response and subsequent enhanced cytotoxic activity against cancer cells. A number of cancers are now being treated with these agents and this increased use has resulted in more reports of toxicity. While almost every organ can be affected, the skin, gastrointestinal tract, liver, and endocrine glands are most commonly involved. It is necessary that gastroenterologists and hepatologists familiarize themselves with diagnostic steps and management plan in patients with these undesirable outcomes. When assessing for possible ICIs induced hepatotoxicity, it is of utmost importance to use a formal scoring system such as the Roussel Uclaf causality assessment method (RUCAM) to assess for risk factors, alternative causes, and response to cessation and re-exposure of a given drug. While this review is based on studies with and without RUCAM, the conclusions were carefully established mainly from studies that used RUCAM. The aim of this review is to provide information on the epidemiology, risk factors, clinical presentation, diagnostic tools, and management plan based on the most recent studies of immunotherapy-induced hepatotoxicity.

https://publinestorage.blob.core.windows.net/journals/JCTH.2022.0(0).0.00105.pdf

Immunotherapy-induced Hepatotoxicity: A Review

Colitis and Intestinal Granulomas in Acquired Immunodeficiency Syndrome

Infection with Epstein-Barr virus (EBV) is common and associated with a high seroprevalence. It is often asymptomatic, but infectious mononucleosis (IM) is the clinical hallmark of this disease especially among teens. Hepatic involvement during primary EBV infection often results in mild self-resolving elevation of liver enzymes, typically in association with IM. However, cholestatic hepatitis might sporadically occur. EBV reactivation is rare, especially among immunocompetent patients. Moreover, reactivation of EBV causing isolated cholestatic hepatitis is extremely rare and only reported in patients who are immunocompromised. Here we present a unique case of EBV reactivation causing cholestatic hepatitis in an otherwise healthy and immunocompetent female and we review the epidemiology, clinical presentation, diagnosis, and treatment of EBV induced cholestatic hepatitis.

/pdf/epstein-barr-virus-reactivation-causing-cholestatic-1bc4p09b.pdf

T. Da Cunha

Papers

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

Primary Sclerosing Cholangitis and Inflammatory Bowel Disease: A Review

Immunotherapy-induced Hepatotoxicity: A Review

Colitis and Intestinal Granulomas in Acquired Immunodeficiency Syndrome

Epstein-Barr Virus Reactivation Causing Cholestatic Hepatitis