Impact of incorporating Magnetic Resonance Imaging in FIGO Staging of Primary Carcinoma Cervix: Experience from a tertiary cancer center.

BACKGROUND: International Federation of Gynaecology and Obstetrics (FIGO) staging of carcinoma cervix, although essentially clinical, acknowledges the benefits of MRI. The impact of incorporating MRI in staging of cervical cancer and the discordance between clinical-and MRI-based FIGO staging is not well studied, especially in low- and middle-income countries. AIM: We aim to study the role and accuracy of MRI in staging carcinoma cervix, its correlation with clinical FIGO and histopathological staging with emphasis on how it can change treatment plan. METHODS: Retrospective observational cohort study (n = 193) where MRI details of different staging parameters of the study subjects were compared with clinical FIGO staging and histopathology to assess correlation and agreement between them. Change of clinical FIGO stage and hence treatment plan brought about by incorporating MRI was assessed. RESULTS: MRI had a tumor detection rate of 94.3%, overall staging accuracy of 78.3% and very strong correlation with histopathology (Spearman's coefficient of rank correlation, r = 0.886). Clinical FIGO and MRI had agreement only in 52.8% cases (r = 0.61). Incorporating MRI changed the clinical stage in 47.2% patients and subsequently modified primary treatment plan in 23.3%. CONCLUSION: MRI is highly accurate in evaluating carcinoma cervix and has good correlation with histopathology. Our data shows low agreement between MRI and clinical FIGO staging. Thus, incorporating MRI in FIGO staging has considerable impact in altering treatment decisions and should be offered to all patients for staging carcinoma cervix.

Evaluation of Computed Tomography Scan and CA 125 Response in Predicting Operability in Advanced Ovarian Cancer and Assessing Survival Outcome in Interval Cytoreductive Surgery.

The study aims at the prediction of optimal cytoreduction (OCR) in patients undergoing interval cytoreduction (ICR) in advanced epithelial ovarian cancer (AEOC) based on CT imaging and CA 125 values and assessing the survival pattern of these patients after ICR. This is a prospective observational study of patients with stage III C ovarian cancer who underwent ICR in our institution after neoadjuvant chemotherapy (NACT). All consecutive patients operated from April 2016 to October 2017 were included in the study. From their medical records, their demographic details and clinical variables were recorded. The CA 125 value and CT scan findings before and after chemotherapy were documented. A Bristow's predictive score (BS) was calculated based on the radiological parameters. After ICR, the outcome of the surgery was documented. Optimal cytoreduction (OCR) was defined as no gross residual disease after surgery. The surgical outcome was correlated with the CA 125 difference pre and post chemotherapy and Bristow's predictive score pre and post chemotherapy. The patients were followed up and their survival at 6 and 12 months was assessed. Univariate and multivariate analysis was done to identify factors predicting OCR. 51 patients were included in the study. Age group of the women ranged from 31 to 74 years with a mean of 52 years. Majority of the patients (70.6%) were postmenopausal. Of the 51 women, OCR could be achieved in 31 patients (60.8%). Post-chemotherapy, 36 patients had elevated CA125 above baseline of which 50% attained OCR. Forty six patients had CA 125 response post chemotherapy of which 67.4% attained OCR. Forty five patients had reduction in Bristow Score compared to the pre chemo values of which 64.4% attained OCR which was not found to be statistically significant. Overall survival was 100% survival at 6 months and 92.8% at 12 months in those who achieved OCR. Those with residual disease 0.1-1 cm had survival of 74.1% at 6 and 12 months. Those with residual disease > 1 cm had a survival of 50% at 6 and 12 months. CA125 response has a significant role in predicting OCR while CT evaluation using the BS was not useful in predicting OCR during ICR for AEOC.

Atypical PRES with diffusion restriction or neurotoxicity- ? part of same spectrum-after oxaliplatin (FOLFOX-4 regimen) for colonic cancer.

Atypical features of Posterior reversible encephalopathy syndrome (PRES) (diffusion restriction, involvement of corpus callosum & white matter tracts along posterior limbs of internal capsule) were seen in a patient after oxaliplatin administration (FOLFOX- 4 regimen). Findings were most obvious on diffusion weighted images, similar to acute methotrexate neurotoxicity, and resolved completely on follow up.

Ifosfamide-Induced Malignancy of Ureter and Bladder.

Cyclophosphamide-induced bladder malignancy is a well-known entity mediated by its metabolic product, acrolein. There is a significant association between the incidence of hemorrhagic cystitis during treatment and the later development of malignancies. We report a case of multifocal urothelial carcinoma occurring in a patient treated with ifosfamide 19 years ago. No case report of ifosfamide-induced malignancy could be identified in the literature. A brief review of the literature on the relative risks of ifosfamide therapy, the mechanism of bladder toxicity, and suggestions to minimize the deleterious effects of the drug have been done. Ifosfamide should be used in the lowest possible dose and that patients receiving more than 20 grams of the drug should undergo a routine urinalysis for microscopic hematuria. Prophylactic measures such as high fluid intake, frequent voiding, day time administration of the drug, and concomitant use of mesna may decrease the contact time and the concentrations of toxic metabolites on the bladder urothelium.

Unusual continuous intra-abdominal spread of primary testicular lymphoma along the spermatic cord and gonadal vessels: Report of 2 cases.

Primary testicular lymphoma (PTL) is an uncommon neoplasm (<5% of all testicular tumors). Testicular lymphoma presents with homogeneous mass, hyperintense on T1-weighted images, and iso-to-hypointense on T2-weighted images with strong diffusion restriction and homogeneous contrast enhancement. Seminoma testis, a close differential due to T2 hypointensity and homogeneousity, can be differentiated by its lower diffusion restriction and younger age group. Involvement of spermatic cord and epididymis is rare with seminoma. Intra-abdominal extension along the gonadal vein is not reported. PTL disseminates to extranodal sites. However, extension of PTL along the spermatic cord and gonadal vein up to the inferior vena cava is a rare phenomenon. We report 2 cases of PTL with involvement of epididymis and spermatic cord and further continuous extension along the gonadal vein up to the inferior vena cava. These findings are very rare and when present may help to differentiate testicular lymphoma from other testicular tumors.

Osmotic myelinolysis: Does extrapontine myelinolysis precede central pontine myelinolysis? Report of two cases and review of literature.

Osmotic myelinolysis is an acute, rare, demyelinating process. After the initial description of the condition by Adam and colleagues in 1959, many case series have been published describing the central and extrapontine myelinolysis. Imaging has a definitive role in establishing the diagnosis of osmotic myelinolysis in vivo and diffusion-weighted imaging reveals earliest changes in affected brain parenchyma. We report two cases of patients with proven malignancy who developed extrapontine myelinolysis after treatment for hyponatremia and progressed to central pontine myelinolysis within a week. This was confirmed with magnetic resonance (MR) imaging and clinical assessment. This temporal progression of MR features, especially on diffusion-weighted imaging, from extrapontine to central pontine myelinolysis in osmotic injury has not been described in literature to the best of our knowledge. An early MRI of the brain in suspected/high-risk cases of osmotic myelinolysis may show features of extrapontine myelinolysis in the form of restricted diffusion in bilateral basal ganglia and may serve as a guide for predicting progression, prognosticating and deciding further treatment of pontine myelinolysis. We propose that in a significant number of cases, central pontine myelinolysis may be predicted by doing an early MRI of the brain with diffusion-weighted imaging, when extrapontine symptoms start to develop. This can potentially increase the window period and possibilities for therapeutic intervention and may even help in prevention.