Imaging of Gynecological Disease 2.0

A special issue of Diagnostics (ISSN 2075-4418). This special issue belongs to the section "Medical Imaging and Theranostics".

Deadline for manuscript submissions: closed (31 January 2024) | Viewed by 15632

Special Issue Editor

Facoltà di Medicina e Chirurgia, Università Degli Studi dell'Aquila, Rome, Italy
Interests: ultrasound; ovarian cancer; cervical cancer; sonography; diagnosis; ultrasonography; gynecologic oncology; imaging; treatment
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Special Issue Information

Dear Colleagues,

The evaluation of a pelvic mass, detected at routine ultrasounds or in the context of having acute symptoms, requires certain methodical steps. It is necessary to diagnose the primary site or origin of the lesion; understand whether the lesion is an intra- or an extra-peritoneal lesion; attempt to discriminate between the benign or malignant nature of the lesion; formulate a specific diagnosis; and, furthermore, in the case of a possible malignant mass, define the stage of the disease process. Transvaginal ultrasonography is a dynamic and interactive examination and, in addition to an analysis of the echostructure and “elasticity” of a pelvic mass, it also permits an assessment of site-specific pain in different pelvic areas and an evaluation of the movement of the mass in relation to adjacent structures. All these “dynamic” features, together with morphological and vascular parameters, are essential for making a correct diagnosis.

Ovarian cancer is the seventh most common cancer among women in the developed world, and most women with ovarian cancer are diagnosed at an advanced stage of disease, when large intraperitoneal dissemination has already occurred. An accurate preoperative assessment of the tumor dissemination is pivotal for adequate counseling among risks and benefits of an aggressive surgical procedure, often required to achieve a complete cytoreduction. When performed by an experienced sonographer, ultrasound has an invaluable role in the primary diagnosis of gynecological cancer, in the assessment of tumor extent in the pelvis and abdominal cavity. Finally, ultrasound allows performing a biopsy in patients with peritoneal carcinomatosis, obtaining an adequate specimen for histologic diagnosis.

Intraoperative ultrasound techniques have been used for a long time in some surgical areas, especially in liver surgery, where some authors describe the role of intraoperative ultrasound during radiofrequency ablation or hepatic resection. However, in gynecology, these methods are not yet commonly employed.

An appropriate preoperative evaluation is required to obtain an optimal surgical procedure, and transvaginal ultrasound is the most used diagnostic method due to its feasibility and availability. However, and also in benign pathology, some fibroids are difficult to detect during surgery, especially when the palpation is not possible or limited, such as during laparoscopy or mini-laparotomy.

Recently, intraoperative ultrasound examination has been proposed in this setting as a useful method to guide the surgeon during myomectomy. Ultrasound examiners and surgeons should work together more often to guarantee the best therapeutic management for the patient in a gynecological setting.

The prevalence of pelvic urinary tract infiltration on transvaginal ultrasound examination in women with gynecologic malignancy was 10%. Pelvic urinary tract assessment plays a key role during transvaginal ultrasound examination, to plan the management of patients with gynecologic cancers.

Improvements in the treatment of cervical carcinoma have made it possible to offer optimal and personalized treatment. Cervical cancer staging is based on clinical examination and histological findings. Magnetic resonance imaging is considered the optimal method for staging cervical carcinoma because of its high accuracy in assessing local extension of disease and distant metastases. Ultrasound has gained increased attention in recent years; it is faster, cheaper, and more widely available than other imaging techniques and is highly accurate in detecting tumor presence and evaluating local extension of disease. Both are often used together with computed tomography or positron emission tomography, combined with computed tomography to assess the whole body, for a more accurate detection of pathological lymph nodes and metabolic information of the disease.

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women.

Dr. Manuela Ludovisi
Guest Editor

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Keywords

  • ultrasound
  • ovarian cancer
  • cervical cancer
  • gynecologic oncology
  • endometriosis
  • ultrasound biopsy
  • imaging
  • treatment

Published Papers (10 papers)

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Research

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15 pages, 10241 KiB  
Article
Ultrasound Features and Clinical Outcome of Patients with Ovarian Masses Diagnosed during Pregnancy: Experience of Single Gynecological Ultrasound Center
Diagnostics 2023, 13(20), 3247; https://doi.org/10.3390/diagnostics13203247 - 18 Oct 2023
Viewed by 837
Abstract
(1) Background: The number of adnexal masses detected during pregnancy has increased due to the use of first-trimester screening and increasingly advanced maternal age. Despite their low risk of malignancy, other risks associated with these masses include torsion, rupture and labor obstruction. Correct [...] Read more.
(1) Background: The number of adnexal masses detected during pregnancy has increased due to the use of first-trimester screening and increasingly advanced maternal age. Despite their low risk of malignancy, other risks associated with these masses include torsion, rupture and labor obstruction. Correct diagnosis and management are needed to guarantee both maternal and fetal safety. Adnexal masses may be troublesome to classify during pregnancy due to the increased volume of the uterus and pregnancy-related hormonal changes. Management should be based on ultrasound examination to provide the best treatment. The aim of this study was to describe the ultrasound features of ovarian masses detected during pregnancy and to optimize and personalize their management with the expertise of gynecologists, oncologists and sonographers. (2) Methods: Clinical, ultrasound, histological parameters and type of management (surveillance vs. surgery) were retrospectively retrieved. Patient management, perinatal outcomes and follow-up were also evaluated. (3) Results: according to the literature, these masses are most frequently benign, ultrasound follow-up is the best management, and obstetric outcomes are not considerably influenced by the presence of adnexal masses. (4) Conclusions: the management of patients with ovarian masses detected during pregnancy should be based on ultrasound examination, and a centralization in referral centers for ovarian masses should be considered. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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11 pages, 1077 KiB  
Article
Using Radiomics and Machine Learning Applied to MRI to Predict Response to Neoadjuvant Chemotherapy in Locally Advanced Cervical Cancer
Diagnostics 2023, 13(19), 3139; https://doi.org/10.3390/diagnostics13193139 - 06 Oct 2023
Cited by 1 | Viewed by 1032
Abstract
Neoadjuvant chemotherapy plus radical surgery could be a safe alternative to chemo-radiation in cervical cancer patients who are not willing to receive radiotherapy. The response to neoadjuvant chemotherapy is the main factor influencing the need for adjunctive treatments and survival. In the present [...] Read more.
Neoadjuvant chemotherapy plus radical surgery could be a safe alternative to chemo-radiation in cervical cancer patients who are not willing to receive radiotherapy. The response to neoadjuvant chemotherapy is the main factor influencing the need for adjunctive treatments and survival. In the present paper we aim to develop a machine learning model based on cervix magnetic resonance imaging (MRI) images to stratify the single-subject risk of cervical cancer. We collected MRI images from 72 subjects. Among these subjects, 28 patients (38.9%) belonged to the “Not completely responding” class and 44 patients (61.1%) belonged to the ’Completely responding‘ class according to their response to treatment. This image set was used for the training and cross-validation of different machine learning models. A robust radiomic approach was applied, under the hypothesis that the radiomic features could be able to capture the disease heterogeneity among the two groups. Three models consisting of three ensembles of machine learning classifiers (random forests, support vector machines, and k-nearest neighbor classifiers) were developed for the binary classification task of interest (“Not completely responding” vs. “Completely responding”), based on supervised learning, using response to treatment as the reference standard. The best model showed an ROC-AUC (%) of 83 (majority vote), 82.3 (mean) [79.9–84.6], an accuracy (%) of 74, 74.1 [72.1–76.1], a sensitivity (%) of 71, 73.8 [68.7–78.9], and a specificity (%) of 75, 74.2 [71–77.5]. In conclusion, our preliminary data support the adoption of a radiomic-based approach to predict the response to neoadjuvant chemotherapy. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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19 pages, 3288 KiB  
Article
Application of Ultrasound Scores (Subjective Assessment, Simple Rules Risk Assessment, ADNEX Model, O-RADS) to Adnexal Masses of Difficult Classification
Diagnostics 2023, 13(17), 2785; https://doi.org/10.3390/diagnostics13172785 - 28 Aug 2023
Viewed by 868
Abstract
Background: Ultrasound features help to differentiate benign from malignant masses, and some of them are included in the ultrasound (US) scores. The main aim of this work is to describe the ultrasound features of certain adnexal masses of difficult classification and to analyse [...] Read more.
Background: Ultrasound features help to differentiate benign from malignant masses, and some of them are included in the ultrasound (US) scores. The main aim of this work is to describe the ultrasound features of certain adnexal masses of difficult classification and to analyse them according to the most frequently used US scores. Methods: Retrospective studies of adnexal lesions are difficult to classify by US scores in women undergoing surgery. Ultrasound characteristics were analysed, and masses were classified according to the Subjective Assessment of the ultrasonographer (SA) and other US scores (IOTA Simple Rules Risk Assessment-SRRA, ADNEX model with and without CA125 and O-RADS). Results: A total of 133 adnexal masses were studied (benign: 66.2%, n:88; malignant: 33.8%, n:45) in a sample of women with mean age 56.5 ± 7.8 years. Malignant lesions were identified by SA in all cases. Borderline ovarian tumors (n:13) were not always detected by some US scores (SRRA: 76.9%, ADNEX model without and with CA125: 76.9% and 84.6%) nor were serous carcinoma (n:19) (SRRA: 89.5%), clear cell carcinoma (n:9) (SRRA: 66.7%) or endometrioid carcinoma (n:4) (ADNEX model without CA125: 75.0%). While most teratomas and serous cystadenomas have been correctly differentiated, other benign lesions were misclassified because of the presence of solid areas or papillae. Fibromas (n:13) were better identified by SA (23.1% malignancy), but worse with the other US scores (SRRA: 69.2%, ADNEX model without and with CA125: 84.6% and 69.2%, O-RADS: 53.8%). Cystoadenofibromas (n:10) were difficult to distinguish from malignant masses via all scores except SRRA (SA: 70.0%, SRRA: 20.0%, ADNEX model without and with CA125: 60.0% and 50.0%, O-RADS: 90.0%). Mucinous cystadenomas (n:12) were misdiagnosed as malignant in more than 15% of the cases in all US scores (SA: 33.3%, SRRA: 16.7%, ADNEX model without and with CA125: 16.7% and 16.7%, O-RADS:41.7%). Brenner tumors are also difficult to classify using all scores. Conclusion: Some malignant masses (borderline ovarian tumors, serous carcinoma, clear cell carcinoma, endometrioid carcinomas) are not always detected by US scores. Fibromas, cystoadenofibromas, some mucinous cystadenomas and Brenner tumors may present solid components/papillae that may induce confusion with malignant lesions. Most teratomas and serous cystadenomas are usually correctly classified. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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9 pages, 1117 KiB  
Article
Robotic Hysterectomy with Ureter Identification and Uterine Artery Ligation for Benign Gynecological Conditions: An Early-Year Single-Center Experience
Diagnostics 2023, 13(10), 1809; https://doi.org/10.3390/diagnostics13101809 - 20 May 2023
Viewed by 2193
Abstract
The use and application of robotic systems with a high-definition, three-dimensional vision system and advanced EndoWrist technology have become widespread. We sought to share our clinical experience with ureter identification and preventive uterine artery ligation in robotic hysterectomy. The records of patients undergoing [...] Read more.
The use and application of robotic systems with a high-definition, three-dimensional vision system and advanced EndoWrist technology have become widespread. We sought to share our clinical experience with ureter identification and preventive uterine artery ligation in robotic hysterectomy. The records of patients undergoing robotic hysterectomy between May 2014 and December 2015, including patient preoperative characteristics, operative time, and postoperative outcomes, were analyzed. We evaluated the feasibility and safety of using early ureteral identification and preventive uterine artery ligation in robotic hysterectomy in patients with benign gynecological conditions. Overall, 49 patients diagnosed with benign gynecological conditions were evaluated. The mean age of the patients and mean uterine weight were 46.2 ± 5.3 years and 348.7 ± 311.8 g, respectively. Robotic hysterectomy achieved satisfactory results, including a short postoperative hospital stay (2.7 ± 0.8 days), low conversion rate (n = 0), and low complication rate (n = 1; 2%). The average estimated blood loss was 109 ± 107.2 mL. Our results suggest that robotic hysterectomy using early ureteral identification and preventive uterine artery ligation is feasible and safe in patients with benign gynecological conditions. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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15 pages, 2440 KiB  
Article
Deep Infiltrating Endometriosis: Diagnostic Accuracy of Preoperative Magnetic Resonance Imaging with Respect to Morphological Criteria
Diagnostics 2023, 13(10), 1794; https://doi.org/10.3390/diagnostics13101794 - 19 May 2023
Cited by 3 | Viewed by 1853
Abstract
Several current guidelines recommend imaging in the diagnostic work-up of deep infiltrating endometriosis (DIE). The purpose of this retrospective diagnostic test study was to evaluate the diagnostic accuracy of MRI compared to laparoscopy for the identification of pelvic DIE, considering lesion morphology using [...] Read more.
Several current guidelines recommend imaging in the diagnostic work-up of deep infiltrating endometriosis (DIE). The purpose of this retrospective diagnostic test study was to evaluate the diagnostic accuracy of MRI compared to laparoscopy for the identification of pelvic DIE, considering lesion morphology using MRI. In all, 160 consecutive patients were included who received pelvic MRI for evaluation of endometriosis between October 2018 and December 2020 and underwent subsequent laparoscopy within 12 months of the MRI examination. MRI findings were categorized for suspected DIE using the Enzian classification and were additionally graded using a newly suggested deep infiltrating endometriosis morphology score (DEMS). Endometriosis was diagnosed in 108 patients (all types, i.e., purely superficial and DIE), of which 88 cases were diagnosed with DIE and 20 with solely superficial peritoneal endometriosis (i.e., not deep infiltrating endometriosis/DIE). The overall positive and negative predictive values of MRI for the diagnosis of DIE, including lesions with assumed low and medium certainty of DIE on MRI (DEMS 1–3), were 84.3% (95% CI: 75.3–90.4) and 67.8% (95% CI: 60.6–74.2), respectively, and 100.0% and 59.0% (95% CI: 54.6–63.3) when strict MRI diagnostic criteria were applied (DEMS 3). Overall sensitivity of MRI was 67.0% (95% CI: 56.2–76.7), specificity was 84.7% (95% CI: 74.3–92.1), accuracy was 75.0% (95% CI: 67.6–81.5), positive likelihood ratio (LR+) was 4.39 (95% CI: 2.50–7.71), negative likelihood ratio (LR-) was 0.39 (95% CI: 0.28–0.53), and Cohen’s kappa was 0.51 (95% CI: 0.38–0.64). When strict reporting criteria are applied, MRI can serve as a method to confirm clinically suspected DIE. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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8 pages, 1716 KiB  
Communication
Overlap of Suspicious and Non-Suspicious Features in the Ultrasound Evaluations of Leiomyosarcoma: A Single-Center Experience
Diagnostics 2023, 13(3), 543; https://doi.org/10.3390/diagnostics13030543 - 02 Feb 2023
Viewed by 3118
Abstract
Leiomyosarcoma (LMS) is a rare type of mesenchymal tumor. Suspecting LMS before surgery is crucial for proper patient management. Ultrasound is the primary method for assessing myometrial lesions. The overlapping of clinical, laboratory, as well as ultrasound features between fibroids and LMS makes [...] Read more.
Leiomyosarcoma (LMS) is a rare type of mesenchymal tumor. Suspecting LMS before surgery is crucial for proper patient management. Ultrasound is the primary method for assessing myometrial lesions. The overlapping of clinical, laboratory, as well as ultrasound features between fibroids and LMS makes differential diagnosis difficult. We report our single-center experience in ultrasound imaging assessment of LMS patients, highlighting that misleading findings such as shadowing and absent or minimal vascularization may also occur in LMS. To avoid mistakes, a comprehensive evaluation of potentially overlapping ultrasound features is necessary in preoperative ultrasound evaluations of all myometrial tumors. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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10 pages, 2808 KiB  
Article
Computed Tomography Indicators for Differentiating Stage 1 Borderline Ovarian Tumors from Stage I Malignant Epithelial Ovarian Tumors
Diagnostics 2023, 13(3), 480; https://doi.org/10.3390/diagnostics13030480 - 28 Jan 2023
Cited by 1 | Viewed by 952
Abstract
Preoperative diagnosis of borderline ovarian tumors (BOTs) is of increasing concern. This study aimed to determine computed tomography (CT) features in differentiating stage 1 BOTs from stage I malignant epithelial ovarian tumors (MEOTs). A total of 170 ovarian masses (97 BOTs and 73 [...] Read more.
Preoperative diagnosis of borderline ovarian tumors (BOTs) is of increasing concern. This study aimed to determine computed tomography (CT) features in differentiating stage 1 BOTs from stage I malignant epithelial ovarian tumors (MEOTs). A total of 170 ovarian masses (97 BOTs and 73 MEOTs) from 141 consecutive patients who underwent preoperative CT imaging were retrospectively analyzed. Two readers independently and retrospectively reviewed quantitative and qualitative CT features. Multivariate logistic analysis demonstrated that a larger tumor size (p = 0.0284 for reader 1, p = 0.0391 for reader 2) and a smaller solid component (p = 0.0007 for reader 1, p = 0.0003 for reader 2) were significantly associated with BOTs compared with MEOTs. In the subanalysis of cases with a solid component, smaller (p = 0.0092 for reader 1, p = 0.0014 for reader 2) and ill-defined (p = 0.0016 for reader 1, p = 0.0414 for reader 2) solid component was significantly associated with BOTs compared with MEOTs. Tumor size and the size and margin of the solid component were useful for differentiating stage 1 BOTs from stage 1 MEOTs on CT images. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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12 pages, 753 KiB  
Article
Texture Analysis in Uterine Cervix Carcinoma: Primary Tumour and Lymph Node Assessment
Diagnostics 2023, 13(3), 442; https://doi.org/10.3390/diagnostics13030442 - 26 Jan 2023
Cited by 2 | Viewed by 1406
Abstract
The conventional magnetic resonance imaging (MRI) evaluation and staging of cervical cancer encounters several pitfalls, partially due to subjective evaluations of medical images. Fifty-six patients with histologically proven cervical malignancies (squamous cell carcinomas, n = 42; adenocarcinomas, n = 14) who underwent pre-treatment [...] Read more.
The conventional magnetic resonance imaging (MRI) evaluation and staging of cervical cancer encounters several pitfalls, partially due to subjective evaluations of medical images. Fifty-six patients with histologically proven cervical malignancies (squamous cell carcinomas, n = 42; adenocarcinomas, n = 14) who underwent pre-treatment MRI examinations were retrospectively included. The lymph node status (non-metastatic lymph nodes, n = 39; metastatic lymph nodes, n = 17) was assessed using pathological and imaging findings. The texture analysis of primary tumours and lymph nodes was performed on T2-weighted images. Texture parameters with the highest ability to discriminate between the two histological types of primary tumours and metastatic and non-metastatic lymph nodes were selected based on Fisher coefficients (cut-off value > 3). The parameters’ discriminative ability was tested using an k nearest neighbour (KNN) classifier, and by comparing their absolute values through an univariate and receiver operating characteristic analysis. Results: The KNN classified metastatic and non-metastatic lymph nodes with 93.75% accuracy. Ten entropy variations were able to identify metastatic lymph nodes (sensitivity: 79.17–88%; specificity: 93.48–97.83%). No parameters exceeded the cut-off value when differentiating between histopathological entities. In conclusion, texture analysis can offer a superior non-invasive characterization of lymph node status, which can improve the staging accuracy of cervical cancers. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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Review

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14 pages, 2089 KiB  
Review
Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis: A Systematic Review and Meta-Analysis
Diagnostics 2023, 13(5), 948; https://doi.org/10.3390/diagnostics13050948 - 02 Mar 2023
Cited by 2 | Viewed by 1592
Abstract
Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. The aim of the present systematic review and meta-analysis is [...] Read more.
Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. The aim of the present systematic review and meta-analysis is to synthetize and report the current evidence on transvaginal sonography (TVS) accuracy to diagnose hydrosalpinx. Articles on the topic published between January 1990 and December 2022 were searched in five electronic databases. Data from the six selected studies, comprising 4144 adnexal masses in 3974 women, 118 of which were hydrosalpinxes, were analyzed as follows: overall, TVS had a pooled estimated sensitivity for hydrosalpinx of 84% (95% confidence interval (CI) = 76–89%), specificity of 99% (95% CI = 98–100%), positive likelihood ratio of 80.7 (95% CI = 33.7–193.0), and negative likelihood ratio of 0.16 (95% CI = 0.11–0.25) and DOR of 496 (95% CI = 178–1381). The mean prevalence of hydrosalpinx was 4%. The quality of the studies and their risk of bias were assessed using QUADAS-2, evidencing an overall acceptable quality of the selected articles. We concluded that TVS has a good specificity and sensitivity for diagnosing hydrosalpinx. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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Other

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9 pages, 2617 KiB  
Interesting Images
Successful Implementation of HITOC and HIPEC in the Management of Advanced Ovarian Carcinoma with Pleural and Peritoneal Carcinomatosis
Diagnostics 2024, 14(5), 455; https://doi.org/10.3390/diagnostics14050455 - 20 Feb 2024
Viewed by 1131
Abstract
This case report details the application and outcomes of a novel therapeutic approach involving hyperthermic intraperitoneal chemotherapy (HIPEC) and hyperthermic intrathoracic chemotherapy (HITOC) in a single patient diagnosed with advanced ovarian neoplasm. The treatment protocol included pleural cytoreductive surgery (CRS) and HITOC followed [...] Read more.
This case report details the application and outcomes of a novel therapeutic approach involving hyperthermic intraperitoneal chemotherapy (HIPEC) and hyperthermic intrathoracic chemotherapy (HITOC) in a single patient diagnosed with advanced ovarian neoplasm. The treatment protocol included pleural cytoreductive surgery (CRS) and HITOC followed by a second surgical intervention consisting of peritoneal CRS and HIPEC. HIPEC targeted the intraperitoneal space with heated chemotherapy, while HITOC extended the thermal perfusion to the thoracic cavity. The patient has shown significant progression in disease-free survival over one year and eight months of observation, demonstrating lower recurrence rates and an overall survival outcome exceeding expectations based on conventional therapy outcomes. The combined modality demonstrated a manageable toxicity profile, with no significant increase in peri- or postoperative complications observed. Full article
(This article belongs to the Special Issue Imaging of Gynecological Disease 2.0)
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