Faculty Bibliography

The prevalence of uterine sarcoma, typically leiomyosarcoma, is greater than previously believed, with current data indicating a risk as high as one in 770 women undergoing surgery for presumed leiomyomas (uterine fibroids). Presurgical detection of uterine sarcoma is an important clinical concern for gynecologists and gynecologic oncologists worldwide. Inadvertent minimally invasive treatment of unsuspected uterine leiomyosarcoma may delay definitive therapy or lead to disease dissemination. Contrast-enhanced MRI with diffusion-weighted imaging and apparent diffusion coefficient measurement provides high accuracy (88%-94.6%) in detecting uterine leiomyosarcoma, making radiologists valuable partners to gynecologists in risk assessment and disease management. The algorithm outlined in the Radiology 2023 MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma consensus statement has been preliminarily validated, and the authors present additional nuances to enhance its application in clinical practice.

BACKGROUND:Portomesenteric venous thrombosis (PMVT) is a rare complication of bariatric surgery that can lead to cavernous transformation of the portal vein. There are no established treatment algorithms regarding anticoagulation (AC) only vs. catheter-directed thrombolysis in this population. METHODS:Medical records at 4 urban bariatric surgery centers were queried for patients diagnosed with PMVT between 2012 and 2025. Patient characteristics, perioperative details, imaging at PMVT diagnosis, treatment course, and follow-up imaging were reviewed. Fisher's exact testing was conducted to identify correlations between extent of thrombosis, treatment course (anticoagulation vs. interventional radiology [IR] thrombolysis), and the outcome of cavernous transformation. RESULTS:71 patients were diagnosed with PMVT following bariatric surgery (68 LSG, 3 RYGB) at 4 centers between 2012 and 2025. Median time from surgery to PMVT diagnosis was 13 days. Three patients (4%) required reoperation for small bowel resection, of whom 2 underwent open thrombectomy and 1 underwent subsequent IR thrombolysis. Of the remaining patients, 6/68 (9%) underwent IR catheter-directed thrombolysis, and 62/68 (91%) received AC only. Of 53 patients with long-term data, 18 (34%) developed cavernous transformation. Among patients who had a main portal vein + intrahepatic portal vein + inflow (superior mesenteric vein or splenic vein) thrombosis, treatment with AC only was strongly associated with cavernous transformation (13/17, 76%) vs IR (1/5, 20%, p < 0.05). There were no deaths related to PMVT. CONCLUSIONS:In this largest known case series of postbariatric surgery PMVT treated with anticoagulation vs. IR, we found that the PMVT clot pattern with the highest risk of developing cavernous transformation was the extensive type involving the main portal vein, an intrahepatic portal vein, and an inflow vein, whether the main portal vein clot was occlusive or nonocclusive. Early IR intervention was associated with decreased cavernous transformation.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described. METHODS:Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible. RESULTS:. Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (n = 5) and intraoperative endoscopy (n = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1 year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to the gastric staple line. There were no gastric staple line leaks or bleeds. CONCLUSION/CONCLUSIONS:In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.

Ovarian cancer remains the sixth most common cause of cancer mortality in women in the United States and is a leading cause of mortality among patients with gynecologic malignancies. Imaging plays an important role in pretreatment staging of epithelial ovarian cancers, the evaluation of posttreatment response, and follow-up. Accurate pretreatment imaging is integral to determine appropriate first-line therapy. By delineating the extent of disease, imaging can assist decision making regarding the likelihood of optimal primary cytoreduction or need for neoadjuvant chemotherapy when optimal cytoreduction is not felt to be achievable. Contrast-enhanced CT serves as a mainstay modality for the pretreatment assessment of ovarian cancer, with MRI, PET/CT, and, in some instances, PET/MRI used in the pretreatment setting. CT and PET/CT are also integral to assessing response, including in the suspected recurrence setting, with MRI and PET/MRI being used in select cases. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Ovarian cancer remains low in prevalence but has the highest mortality of all gynecologic malignancies. Population-based screening for ovarian cancer remains a topic of interest in contemporary practice, given that the majority of cancers encountered are high-grade aggressive malignancies, for which favorable survival is encountered in the setting of early-stage disease. This document summarizes a review of the available data from randomized and observational trials that have evaluated the role of imaging for ovarian cancer screening in average-risk and high-risk patients. When considering screening using pelvic ultrasound in average-risk patients, we found insufficient published evidence to recommend ovarian cancer screening. Randomized controlled trials have not demonstrated a mortality benefit in this setting. Screening with pelvic ultrasound may be appropriate for select patients at high risk, although the existing data remain limited as large, randomized trials have not been performed in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

OBJECTIVE:The aim of the study is to evaluate the performance of the ovarian-adnexal reporting and data system magnetic resonance imaging (O-RADS MRI) score and perform individual MRI feature analysis for differentiating between benign and malignant ovarian teratomas. METHODS:In this institutional review board-approved retrospective study, consecutive patients with a pathology-proven fat-containing ovarian mass imaged with contrast-enhanced MRI (1.5T or 3T) from 2013 to 2022 were included. Two blinded radiologists independently evaluated masses per the O-RADS MRI lexicon, including having a "characteristic" or "large" Rokitansky nodule (RN). Additional features analyzed included the following: nodule size/percentage volume relative to total teratoma volume, presence of bulk/intravoxel fat in the nodule, diffusion restriction in the nodule, angular interface, nodule extension through the teratoma border, presence/type of nodule enhancement pattern (solid versus peripheral), and evidence for metastatic disease. An overall O-RADS MRI score was assigned. Patient and lesion features associated with malignancy were evaluated and used to create a malignant teratoma score. χ2, Fisher's exact tests, receiver operating characteristic curve, and κ analysis was performed. RESULTS:One hundred thirty-seven women (median age 34, range 9-84 years) with 123 benign and 14 malignant lesions were included. Mean teratoma size was 7.3 cm (malignant: 14.4 cm, benign: 6.5 cm). 18/123 (14.6%) of benign teratomas were assigned an O-RADS 4 based on the presence of a "large" (11/18) or "noncharacteristic" (12/18) RN. 12/14 malignant nodules occupied >25% of the total teratoma volume (P = 0.09). Features associated with malignancy included the following: age <18 years, an enhancing noncharacteristic RN, teratoma size >12 cm, irregular cystic border, and extralesional extension; these were incorporated into a malignant teratoma score, with a score of 2 or more associated with area under the curve of 0.991 for reviewer 1 and 0.993 for reviewer 2. Peripheral enhancement in a RN was never seen with malignancy (64/123 benign, 0/14 malignant) and would have appropriated downgraded 9/18 overcalled O-RADS 4 benign teratomas. CONCLUSIONS:O-RADS MRI overcalled 15% (18/123) benign teratomas as O-RADS 4 but correctly captured all malignant teratomas. We propose defining a "characteristic" RN as an intravoxel or bulk fat-containing nodule. Observation of a peripheral rim of enhancement in a noncharacteristic RN allowed more accurate prediction of benignity and should be added to the MRI lexicon for improved O-RADS performance.

Cervical cancer is a common gynecological malignancy worldwide. Cervical cancer is staged based on the International Federation of Gynecology and Obstetrics (FIGO) classification system, which was revised in 2018 to incorporate radiologic and pathologic data. Imaging plays an important role in pretreatment assessment including initial staging and treatment response assessment of cervical cancer. Accurate determination of tumor size, local extension, and nodal and distant metastases is important for treatment selection and for prognostication. Although local recurrence can be diagnosed by physical examination, imaging plays a critical role in detection and follow-up of local and distant recurrence and subsequent treatment selection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.