textbook of radology and imaging vol2 [seven ed.] 6997039715

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SEVENTH E,DITION

TEXTBOOK OF

iltffiffiY

ANil WTI{ffi EDITEDBY DAVID

SUTTON

(Hon) FCan.AR FRcR, DMRD, MD,FRcB

C o n s u l t i n gR a d i o l o g i s t St Mary's Hospitaland Medical School,London Director, Radio Iog icaI Department (19 63 -'l9 84) ConsultingRadiologist,The National Hospitalfor Neurology and Neurosurgery,London, UK.

ASSOCUTEEDITORS NuclearMedicine FRCR PHltlP l.A. ROBINSON FRcP, MRI FRCR DMRD, IEREMY P.R.,ENKINS FRCB CT RICHARD W. WHITEHOUSE gSc,MBChB,MD,FRCR Ultrasound PAUI L. AttAN

FRCP(Ed) DMRD,FRCR, MSc,MBBS,

CardiacRadiology FRCR PETERWITDE BSc,MRCP, Neuroradiology FRCR DRACR, IOHN M. STEVENSMBBS,

)

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3 5 c m / s n o r m a l P S V< 2 5 c m / s a r t e r i a l insufficiency

Cavernosography Suspectedvenous leakage(where surgery considered) Young men with traumatic Arteriography a r t e r i a lo c c l u s i o n

D e c l i n i n gu s e

Anatomical information f o r s u r g i c a lp l a n n i n g

alprostadilor vacuumdevice)and in whom surgicalinterventionis c o n t e m p l a t e d l m a g i n g i s u s e d i n t h e a s s e s s m e not f s u s p e c t e d verscularabnormality (arterial or venous), believed to be the 819.32.46 Testicular torsion.Anteriorview ee.Tcpertechnetate study commonestcauseof organicerectiledysfunction. showsan intensely hyperaemic rim of tissue surrounding a photon-deficient Haemodynamic evaluation of these patients aims to detect areawhichrepresents the infarctedleft testis(arrows) arterialinsufficiencyand venousincompetence,for which surgical proceduresare available. Penile revascularisationand venous ligaTechnique The patient is positionedsupine,with the scrotumele- tion procedureshave given disappointinglong-term results,with vated by a towel placed between his legs, or better, a sling of rates of successfulreturn to intercourse of around 6OVoand 40Vo, adhesivetape placed acrossthe thighs. It is also helpful to place a respectively.Successfuloutcome dependson careful selectionof lead-rubber shield beneaththe sling and the scrotum in order to surgicalcandidates. block out activity fiom the patient's thighs. A rapid bolus injecFor many years assessmentwas based upon arteriography and tion of about 200 MBq of ee"'Tc-pertechnetate is given, and a cavernosography,which have now largely been replaced by duplex rapid sequenceof images of the scrotal region is obtained (e.g. ultrasonography (Table32.2). Duplex ultrasonography of the penis one frame per second tbr 40 seconds).After the initial dynamic and cavernosalarterieswas first describedin 1985 and has now s e r i e s ,o n e o r t w o f u r t h e r s p o t v i e w s w i t h h i g h c o u n t d e n s i t y emergedas the investigationof choice for penile arterial screening, should be obtained. but typically the most informative data are despite some debate regarding protocol and velocity thresholds those derived fiom summating the first-passframes to a single (particularly for moderate reductions in systolic velocity). It rmage. has a more limited role in demonstrating impaired venoocclusion. tnterpretdtion With torsion, the testis appears avascular or Arterial blood supply to the penis originatesfrom the internal severelyischaemic.This is manit'eston the images as a photoniliac arteriesvia the internal pudendalarteries,which divide and deficient area, which is ofien surroundedby a rim of increased a c t i v i t y r e p r e s e n t i n gs u r r o u n d i n gh y p e r a e m i a .T h e l i n e o f t h e form paired cavernosalarteriesat the base of the penis. It has been spermatic cord also often shows increasedactivity. With acute estimated that penile arterial inflow may increaseup to 30-fold e p i d i d y m o - o r c h i t i s .a c t i v i t y w i t h i n t h e t e s t i s i t s e l f i s u s u a l l y during tumescence. Tests of penile haemodynamics are performed following intranormal, but the inflammatoryresponsein the epididymis produces a C-shaped margin of markedly increasedactivity, and in some cavernosal injection of a vasoactiveagent to induce a pharmacocasesthis may appearto extendacrossthe testisas well. The con- logical erection. Alprostadil (5-20 pg) is more effective than tralateralnormal testis is usedas a benchmarkto indicatewhether papaverine,with a lower incidenceof priapism. The ultrasoundtransducer(7.5 or l0 MHz) is positioned on the the afl'ectedside shows increasedor reducedactivity. ventral surf'aceof the baseof the penis. Pairedcavernosalarteriesare Applicotton The main value of this test is as a supplement to fbund close to the septum.During the initial phaseof erection,both Doppler ultrasoundfor thosepatientspresentingacutely with uni- systolic and diastolic flow is increasedand continuous.The diastolic lateral testicularpain. Although the radionuclideprocedureitself wavefbrm decreasesat an intracavernosalpressureover 40 mmHg and takesjust a f'ew minutes, its value can be fully realisedonly when is reversedat an intracavemosalpressureover 80 mmHg. Above this, a rapidly respondingon-call service is provided, as the majority systolicflow is diminishedand flow ceasesif intracavemosalpressure of patientswith acute testicularproblems presentoutside normal approachessystolic blood pressure.Peak systolic velocity (PSV) and working hours. end-diastolicvelocity (EDV) are recordedevery 5 min for 30 min. It is now generally acceptedthat PSV>35 cm/s predicts normal arterial inflow and that PSV 7 . 5 m l

Normal size

Small

M o r e t h a n s e v e n2 - 5 m m f o l l i c l e s ; m a i n l y p e r i p h e r ad l istribution

S e v e r aflo l l i c l e so f 5 - 1 0 m m

No evidence of follicular activity

Increasedstroma

No increasedstroma

No increasedstroma

Large/normal uterus with thickendometrium

N o r m a l / s m a l lu t e r u sw i t h t h i n endometrium

S m a l lu t e r u sw i t h t h i n endometrium

G Y N A E C O L O C I C A LI M A G I N G

F19.34.12

l073

E V S P o l y c y s t i co v a r yw i t h p e r i p h e r a cl y s t s

( a r r o w s d) u e t o F I g . 3 4 . 1 5 T A S T h i c k e n e idr r e g u l aer n d o m e t r i u m endomeat the myometrial tamoxifenNote the smallcysts(arrowheads) trialinterface

Flg. 34.13

T A S P o l y c y s t i co v a r y C e n t r a la n d p e r i p h e r a cl y s t s

SequentiulHRT, i.e oestrogensfollowed by progesteronesfor at least I 2 days/month.are usually prescribedfor perimenopausaland but unpredictable patientswho havepersistent early postmenopausal ovarianfunction Most patientshaveregularmonthly bleedson such a regimenso should have an endometriumthat varies in thickness during the cycle. The maximum thicknessshould still be less than 8 rnm Any patientfbund to have a mildly thickenedendometrium on sequentialHRT shouldhavea repeatscanfollowing a withdrawal bleed. C o n t i r t u o t r st o m b i n e d h o r m o n e r e p l a c e m e n ti n v o l v e s t a k i n g togethercontinuouslyand shouldresult oestrogenand progesterone in endornetrialatrophywithin 6 months,i.e. endometrialthickness lessthan 4 mm.

Tomoxifen Tamoxif'en,used in the treatment of breastcancer,has both antioestrogenicand oestrogenic efl'ects and is associated with endometrial hyperplasia,an increasedincidence of polyps $S*' and endometrialcarcinoma.The uterus has a characteristic with mulFlg. 14.14 TAS.Multifollicular ovary(arrows)in a patientwith amenor- appearancewith increasedthicknessof the cavity echo t i p l e t i n y c y s t s ( F i g . 3 4 . 1 5 ) .T h e s ec y s t s w e r e o r i g i n a l l y t h o u g h t rhoeadueto anorexia nervosa to be part of the endometriumbut recently it has been suggested levelsof circulatingoestrogensand are seenin athletesand in assothat they are actually in the most superficial layer of the myociation with weight lossand anorexianervosa. metrium ratherthan the endometrium.Doppler studiesin patients Prirnuryovut iuu fuilure or prenruturetnenopouseis the onsetof with endometrialthickening due to tamoxifen show low impedthe menopausebefbre the age of 3-5years and is a rare causeof ance flow. i.e. low valuesfbr the RI and Pl. amenorrhoea Volue of ultrosound scrcening for potients on HRT Routine screeningis not indicatedfbr patientson HRT but should be perEffect of hormones furmed in thosewith abnormal vaginal bleeding. Comblned orol controceptlve pill The utelus and ovaries are s u p p r e s s e dT h e e n d o m e t r i u m s h o u l d b e t h i n a n d t h e o v a r i e s small with no evidenceof fbllicular activity. Progesterone-only pill The progesterone-only pill does not necessarilyinhibit fbllicular activity but the uterusshould look srnall. with u thin endornetrium. Hormone replocement theropy (HRT) The effect of HRT on the uterusand ovariesdependson the type of HRT taken Unopposedoe.\trollenudntinistntio,l causesthickening of the endometriumdue to endometrialhyperplasia. This is a precursorto endometrialcarcinoma.thereforeunopposedoestrogenregimens are only recommendedif the patienthas had a hysterectomy.

Intrauterine contracePtive devices (lUCDs) Conventionol IUCDs An IUCD is a common incidental finding . hey are easily visui n p a t i e n t su n d e r g o i n gp e l v i c u l t r a s o u n d T with shadowingand acoustic structures echogenic as highly alised should be entirely within the uterine cavity, not protruding into the rnyometrium or endocervical canal (Fig. 34.16). Large fibroids.particularlyif calcified,can occasionallycausedifhculty. E x p u l s i o n d u r i n g m e n s t r u a t i o nd o e s o c c u r b u t m o s t p a t i e n t s 'missing coil' will have the IUCD presentnormally ref'erredwith in the cavity, the threadshaving retractedinto the cervical canal. Cornplicationssuch as migration of the coil into or through the

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Fig,34.16

A TEXTBOOK OF RADIOLOGY AND IMAGING

T A S I U C D ( a r r o w ) i n t h e c e r v i c a cl a n a l

Fig. 34.17 TAS IUCD embedded i n t h e m y o m e t r i u m ( a r r o w ) ,w e l l o u t s i d et h e c a v i t y( a r r o w h e a d s ) .

F i g . 3 4 . 1 8 1 6 - y e a r - o l dg i r l w i t h c y c l i c a la b d o m i n a l p a i n f o u n d t o h a v e a d i d e l p h y su t e r u sw i t h a c o m p l e t ev a g i n a ls e p t u m a n d i m p e r f o r a t eh y m e n o n t h e l e f t . ( A ) L o n g i t u d i n a ls c a n d e m o n s t r a t e sa l a r g e h e t e r o g e n e o u sm a s s( a r r o w s )d u e t o b l o o d - f i l l e dd i s t e n d e dv a g i n a A s m a l l u t e r u sa n d c e r v i x( a r r o w h e a d s )c a n b e s e e na t t h e u p p e r m a r g i n o f t h e m a s s ( B ) L o n g i t u d i n a ls c a nt o t h e r i g h t o f ( A ) s h o w sa f u r t h e r u t e r u s( a r r o w h e a d sm a r k t h e p o s i t i o no f t h e e n d o m e t r i u m ) .T h e n o r m a l r i g h t v a g i n ai s c o m p r e s s e da n d h e n c e n o t v i s i b l e ( C ) T r a n s v e r ssec a nc o n f i r m i n gt w o u t e r i n eb o d i e s ( D ) I n t r a v e n o u su r o g r a m S o l i t a r yb u t d u p l e x k i d n e yo n t h e l e f t

G Y N A E C O L O G I C A TI M A G I N G

707 5

myometrium usually occur at the time of insertionand are associated with pain (Fig. 34.17). lt is rarely possibleto see an IUCD outside the uterus on ultrasound.so if there is doubt about the presenceof an IUCD on the ultrasounda plain abdominal X-ray should be pertbrmedto exclude uterinepertbration.Ultrasoundis also indicatedto look fbr causesof difficulty insertinga coil. e.g. large fibroid distorting the cavity or a severelyretroflexeduterus. The IUCD is associatedwith an increasedincidenceof pelvic infection In particularcolonisationwith Actinomycosismay occur with long-termuse and may well be asymptomatic. Mlreno coif The Mirena IUCD contains progestogensand is used tbr both contraceptionand to treat dysfunctionaluterinebleeding. Although similar in shapeto most other coils, the Mirena coil is less echogenicthan standardIUCDs and hence is harder to visualise on ultrasound,even when this is pertbrmedendovaginally.It is often seen by virtue of its acoustic shadow rather than direct visualisationof the coil itself.

Elg. 14.20 EVS Two endometrial echoes (arrows) within the uterus, sugg e s t i v eo f a u t e r i n es e p t u m .

Uterine fibroids (leiomyomas)

Fibroids are presentin up to 2o-50o/cof women. They are particul a r l y c o m m o n a n d p r e s e n ta t a y o u n g e r a g e i n b l a c k w o m e n . Congenital uterine abnormalities Although tiequently asymptomatic,they may presentwith abnorMinor duplicationabnormalitiesof the uterusare only of relevance mal bleeding,pain, abdominaldistension,subf'ertilityor recurrent in the investigationof subf'ertilityand recurrentmiscarriageand are m i s c a r r i a g et.h e s y m p t o m sd e p e n d i n gt o a c e r t a i ne x t e n t o n t h e discussedin more detail in the sectionon hysterosalpingography. location ancl size of the fibroids. Their location in the uterus is However,severeduplicationanomalieswith obstructedmenstruaand early adulthood.Typical presenting tion presentin adolescence s y m p t o m s a r e p r i m a r y a m e n o r r h o e ac, y c l i c a l a b d o m i n a l p a i n , pelvic massand severedysmenorrhoea. Ultrasoundrevealsa thickwalled cystic mass,owing either to an obstructedvagina(impertb. ith r a t e h y m e n ) o r a n o b s t r u c t e du t e r u s ( h a e m a t o m e t r i u m )w low-level internal echoesdue to blood. The correct diagnosiscan usuallybe reachedif the possibilityis consideredand care takento l o o k f o r a c c e s s o r yp e l v i c o r g a n s .T h e e x a m i n a t i o nm u s t a l s o includevisualisationofthe urinary tract as thereis a high incidence o f a s s o c i a t esdi n g l ek i d n e y s( F i g . 3 a . 1 8 ) . A non-obstructeddouble uterus(uterusdidelphys)may simulatea solid adnexalmasson pelvic examinationbut can be ditl'erentiatedon ultrasound due to the Dresenceof a central endometrial echo (Fig. 3a.19) The shapeof the endometrialecho, particularlyon a transversescan,can also help diagnosethe less severeduplication anomalies(Fig. 34.20). Diff'erentiationof a septatefrom a bicornuate uterusdependson identificationof a fundal notch and requiresvisualisation of the uterus en face. This can be difficult with conventional ultrasoundbut is more easily achievedwith 3D ultrasound. Recognitionof a unicornuateuterusis alsodifficult on ultrasound but can be inf-erredby its small sizeand abnormallateralposition.

describedas: o Submucous-arisingwithin the cavity Rarely they can form a tibroid polyp and protrudethroughthe os (Fig. 34.21)' o Mural-within the myometrium They may or may not abut or distort the shapeof the cavity,dependingon their precise location(Fie.34.22). o Subserosal-arisingdeepto the serosaand causinga bulge on the surfaceof the uterus (Fig 34.23) . Pedunculated-on a pedicle usually from the serosalsurface. o Cervical-rare. i.e. lessthan 5tlofibroids. increasingin size and becoming Fibroids are hormone-dependent, lessechogenicduring pregnancy,and decreasingin size following the menopause.However, regressionfollowing the menopausels preventedand may be reversedin patients taking HRT. On ultrasound,most fibroidsare round,well-definedhypoechoic masseswith a characteristicinternalarchitectureshowingrecurrent shadowing (Fig 34.24). They can be hyperechoic and may be calcitied, particularly in postmenopausalpatients' Degeneration within fibroidsappearsas either areasof increasedechogenicityor irregularcystic areas(Fig. 3a 25). Fibroidscan be very vascularso Doppler studiesmay show very low impedanceflow. Malignancy (leiomyosarcoma)is rare but should be suspectedif a fibroid sudof denly increasesin size.There are no specificultrasoundf-eatures malignancy. The role of ultrasoundis to confirm the diagnosisand determinethe number,size and locationof fibroids,as this will help determinetheir likely significanceand appropriatetreatment.See Table 34'2 for difterentialdiagnosisof libroids.

Adenomyosis

F l g . 3 4 . f 9 T A S . T w o s e p a r a t eu t e r i n e h o r n s i n d i c a t i v e o f b i c o r n u a t e u t e r u s .A r r o w h e a d si n d i c a t ep o s i t i o no f e n d o m e t r i u m

Adenomyosis or endometriosisinterna is the presenceof endometrial glands within the myometrium associatedwith adjacent myometrialhyperplasia.It is usuallya diffuseprocessbut may form a localisedmassor adenomyoma.Clinical findings are dysmenor-

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A T E X T B O O KO F R A D I O T O G YA N D I M A G I N G

Flg. 34.23 TAS. Two subserosalfibroids (arrows). Arrowheads indicate position of uterine cavity.

(A) TAS. Fibroid polyp (arrows) within the cervical canal. The Flg. 34.21 stalk of the polyp (arrowheads) can be seen in the uterine cavity. (B) TAS. S a m e p a t i e n t 6 m o n t h s e a r l i e r .T h e f i b r o i d p o l y p ( a r r o w s ) i s n o w s e e n within the uterine cavity.

F19.34.24

TAS. Fibroids.Typical recurrent shadowing (arrowheads).

Elg. 14.25 TAS.lrregularareaof increased reflectivityin the centreof a fibroiddueto degeneration. The ultrasound features of diffuse adenomyosisare poorly defined Elg,74.22 TAS.Typicalmuralfibroids(arrows)abuttingbut not displacing areas of decreased echogenicity and heterogeneity in the (arrowheads). the cavity Thelargerfibroidshowstypicalrecurrent shadowing myometrium, associatedin approximately 507o with small (2-5 mm) cystic spaces in the myometrium (Fig. 34.26) Using these criteria, rhoea and menorrhagia with a tender bulky uterus. Most cases are sensitivities and specificities of 80-907o have been achieved. diagnosed following pathological examination of hysterectomy Focal adenomyomascause focal bulges in the myometrium and specimens; however, endovaginal ultrasound and MRI have been may be hyper- or hypoechoic. They are generally less well defined shown to be of value. than fibroids but it is difficult to differentiatethe two.

MAGING G Y N A E C O L O G I C AI L Table 34.2

Differential of fibroids diaonosis

Locotion

Difterentiol dioonosis

Comments

Submucosal

Endometrialpolyps Retainedproducts of conception (RPC) E n d o m e t r i acl a r c i n o m a

U s u a l l yh y p e r e c h o i ci,. e s i m i l a rt o e n d o m e t r i u m H i s t o r yh e l p f u l .R P Cu s u a l l yo f m i x e d e c h o g e n i c i t y Postmenopausalpatients. Lesswell defined, possibly with myometrial invasion endometriumwith little masseffect. Heterogeneous Cavitymay containfluid (or gas if fistulapresent)

Endometritis/ fluid collection Mural/subserosal

Adenomyoma/ areaof adenomyosis Leiomyosarcoma Myometrialcontraction Metastaticdeposits

Pedunculated

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A n y c a u s eo f s o l i d a d n e x a lm a s s

Lesswell definedareaof heterogeneitywith no recurrent shadowingeffect Rapidgrowth but otherwiseimpossibleto differentiate. Very rare Poorlydefinedvirtuallyisoechoicmass;changeswith time-rarely a problem Veryrare,no distinguishingfeatures Usuallypossibleto see connection with uterus. Doppler of no value

. retainedproducts of conception . trophoblastic tumours-usually following a pregnancy. Fluid, including pus or blood, can also distend the cavity but should not be included in the endometrial measurement.A tiny amount of fluid (l-3 mm depth) is occasionally seen in a postmenopausal uterus and is of no significance; however, a cavity distended by fluid usually indicates an obstructed uterus. An attempt should be made to identify the underlying cause,e.g. cervical or uterine carcinoma, previous radiotherapyto the cervix, uterine synechiaedue to Asherman's syndrome, previous cervical surgery, etc. A pyometrium due to a uterocolic or uterovesicalfistula can cause a similar appearance. Endometrial polyps arecommon and typically measure5-15 mm llg. 14.26 E V S .A d e n o m y o s i s .C o a r s e m y o m e t r i a l t e x t u r e w i t h s m a l l cysts due to blood lakes Gig.3a.2'7). There is an increasedincidence in patients on tamoxifen or HRT. Most polyps are benign and cause intermenstrual bleeding,with or without pain. Endometrial abnormalities Endometrial hyperplasia is a precursor to endometrial carcinoma The endometrium is consideredabnormally thick if it measures so must be recognisedand endometrialsampling performed.Causes more than l4 mm in a premenopausalpatient and more than 4 mm of endometrial hyperplasia include polycystic ovaries, obesity, in a postmenopausalpatient. Causesof thickening of the cavity exogenoushormones,endogenousexcessoestrogenproduction, e.g. echo include: due to functioning ovarian tumours. . endometrial polyps Differentiation of endometrial polyps from hyperplasia can be . submucousfibroids difficult but can be helped by performing an endovaginalultra. endometrialhyperplasia sound examination during intrauterine injection of saline, so-called . endometrialcarcinoma sonohysterography(Figs 34.28, 34.29).

Flg. 34,27 EVS.Multiple endometrial polyps. Note the midline echoes due to the endometrial interface (arrows) are displaced by the polyps. This is a usefulfeature when trying to differentiate hyperplasiafrom polyps.

EVS.Endometrial thickening. This looks like hyperplasiabut Flg. 34.28 subsequentsalinehysterographydemonstrated it to be a polyp.

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A T E X T B O O KO F R A D I O L O G YA N D I M A G I N G than 507omyometrial invasion) and stage2 disease(more than 50% myometrial invasion); however, MRI is far better at looking for extrauterinespread,so this is the preferredtechnique. Doppler ultrasound of endometrial or intrauterine vesselsis of little value in premenopausalpatients becauseof cyclical changes and the effect of other uterine pathology,such as fibroids. However, measurementof Doppler indices may help in postmenopausal patients.It has been reported that malignancy is never found if the RI is greaterthan 0.83.

Cervix The cervix is most effectively examined by direct inspection, Papanicolausmearsand colposcopy,so the role of ultrasoundis very limited. It has no role in screeningor routine stagingof cervical carEig. 34.29 Salinehysterography. Endometrial polypoutlinedby saline. cinoma; however, occasionally patients present to the ultrasound Endometrial carcinoma occurs mainly in postmenopausal department prior to vaginal examination so the radiologist needs to women. The risk factors are the same as those described for be aware of the appearancesof cervical disease.Early tumours are endometrial hyperplasia,i.e. increasedoestrogenlevels, in addition undetectable but advanced tumours show an irregularly enlarged to hypertension, diabetes and nulliparity. The most common pre- cervix (Fig. 34 32), with or without an area of highly reflective senting symptom is abnormal uterine bleeding. echoesdue to necrosis.There may be an obstructed,distendeduterine Ultrasound appearancesvary from moderate endometrial thickcavity.Advanceddiseasemay also show invasionof the bladderwall ening, to an irregular hypoechoic intracavitary mass,to an enlarged and hydronephrosis due to ureteric involvement----eitherdue to nodal diffusely infiltrated uterus (Figs 34.30, 34.31). Endovaginal ultra- involvementor direct uretericinvasion(Fig. 34.33). sound is said to be good at differentiating between stage I (less Cervical polyps and cervical fibroids are also occasionallyseen.

Adnexal masses Simple ddnexdl cysts Simple adnexal cysts are most commonly functional in origin. They vary in size, reaching up to 7 cm in diameter, and yet still resolve spontaneously.Haemorrhage into

Fig. 34.3O carctnoma.

E V S .P o o r l y d e f i n e d i n t r a u t e r i n e m a s s d u e t o e n d o m e t r i a l

Elg.34.12 TAS.Carcinoma of cervix. Large irregular cervix (arrowheads) with a small tongue of tumour (arrow) extending towards the bladder.

Flg. 34.31 TAS. Obstructed uterus The cavity (arrows) is distended by blood with a polypoid mass just above the internal os due to endometrial carcrnoma.

F l g . 3 4 . 3 3 T A S .C e r v i c a lc a r c i n o m ai n v a d i n g b l a d d e r b a s e( a r r o w s )a n d causing an obstructed uterus (arrowheads).

MAGING G Y N A E C O L O G I C AI L

Elg. 14.14

E V S F i m b r i a lc y s t a d i a c e n tt o o v a r y .

IO79

high-level with diffusemoderately Elg. t4.76 EVS.Typicalendometrioma (arrows) echoes The dif'ferentialdiagnosis of a complex adnexal mass should in c l u d e : o Haerrorrhagiccyst-contains diffuse internalechoesor an irregularclump of echoesdue to clot Repeatscanshelpful to show change. . Rupturedcyst-typical history,irregularly-shaped cyst with

(arrows) adJacent to the ovary(arrowheads). Flg. 34.35 EVSHydrosalpinx the cyst may causepain and give rise to ditTuseinternalechoesor a c l u m p o f s o l i d e c h o e sw i t h i n t h e c y s t d u e t o c l o t . F o l l o w - u p u l t r a s o u n dw i l l s h o w a r e d u c t i o n i n t h e s i z e o f t h e c y s t a n d a change in the appearanceof the internal echoes contirming its benign nature. Small simple cysts ( l-3 cm) are also relativelycommon (3-5Vc) i n p o s t m e n o p a u s awl o r n e n D o p p l e r i n s o n a t i o ns h o u l d b e p e r fbrmed to confirm high impedanceflow and serum CA-12-5should are normal and the woman If both theseinvestigations be rneasured. i s a s y r n p t o r . n a t iict , i s r e a s o n a b l et o f b l l o w t h e c y s t w i t h s e r i a l ultrasound scans to confirm no growth rather than proceed to laparoscopy The diffbrentialdiagnosisof a sirnpleadnexalcyst includes: o Paraovarian cysts-may reachup to l0 cm, usuallyrecognisable by the fact they are close to, but can be separatedfiom, the ovary by gentlepressurewith the ultrasoundprobe(Fig. 34 34). o Endornetriomas (chocolatecysts)-usually containinternal echoesand havea thick wall but may look entirely simple. o Hydrosalpinx-a small hydrosalpinxmay mimic an ovariancyst but can be distinguishedby its ratherelongatedshape,its positionaroundor on the surfaceof the ovary and the presence of incompleteseptationsdue to mucosaltblds (Fig. 34.35). r Neoplasticcysts-particularly benigncystadenomas and some borderlinetumours. o Peritonealcystsor fluid trappedaroundthe ovary due to adhesions.Thesemay be asymptomaticor causecyclical pain (entruppedovary syttdntme).The patientsusuallygive a history of complicatedpelvic surgeryor infection. Complex adnexot mosses Complex adnexal massescan be due to complicated simple cysts; however,various inflammatory and neoplasticcauses must be considered in addition to some nongynaecologicalcauses.

fluid. surroLrnding o Torsion of cyst or ovary-heterogeneous enlargedovary with or without a thick-walledcyst with internalechoes.Presenceof colour flow within the ovary is said to indicateviability of the ovary, hence laparoscopyis worthwhile to try and preserve I'unction. o Endometriosis. . Acute / chronic tubo-ovarianabscess. r Dermoid cyst-complex masswith cystic and solid areas,fat and/orcalcification r Other neoplasticovariantumours,benignand malignant. o Pedunculatedfibroid-differentiation from an ovarian mass dependson identiticationof the ovariesseparately. . Ectopicpregnancy-should alwaysbe consideredin a patientof child-bearingage.Pregnancytest important. . Other inflammatorymasses-e.g. appendixor diverticularmass. r Other neoplasticmasses-e.g. arisingfrom the bowel or peritoneum(benignperitonealmesothelioma). Endotnetriosis is an incidental finding in up to 25Vo of laparoscopies.Symptoms are variable but the most common is dysmenorrhoea.The majority (up to 907c) of endometriotic(chocolate)cysts contain diffuse internalechoesdue to old blood. The echogenicityof these internal echoes varies from very low level, only discernable scanningendovaginally,to moderatelyhigh, which may causesome confusionwith a dermoid cyst (Fig. 34.36).The echoesmay show layeringcreatinga fluid-fluid level (Fig.34.37). gravity-dependent The wall thicknessof the cysts varies and highly reflective foci or flecksof calcificationmay be seenwithin the wall. Septations'creating multilocularcysts,are common, the variousloculescontaining echoesof ditfering densities,indicating haemorrhageof different ages(Fig. 34 38). Very large endometrioticcysts occasionallyoccur and may mirnic a solid mass;however,compressionof the masswith the probe will usually demonstratethe mass is deformable and the internal echoes move very slowly. Deposits are most easily recognisedon the ovary and in the broad ligament;however,endometriotic depositsdo occur anywhere in the pelvis or indeed outside the abdomen.Rarely nodules occur on the bowel, on the pleura and in the sofi tissues,particularly at the sites of scars(Figs 34.39' 34.40). Adhesions and difTuse small endometriotic deposits cannot be

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F i g . 1 4 . ? 7 T A S B i l a t e r ael n d o m e t r i o m a s .N o t e t h e f l u i d l e v e lo n t h e l e f t a n d t h e i r r e g u l a r l yt h i c k e n e dw a l l .

F i g . 3 4 . 3 8 T A S E n d o m e t r i o s i sC. o m p l e x o v a r i a nm a s sw i t h i n t e r n a ls e p t a t i o n sa n d e c h o e so f v a r y i n g d e n s i t y D i f f e r e n t i adl i a g n o s i sm u s t i n c l u d ea malignantumour.

F i g . 3 4 . 4 O T A S E n d o m e t r i o s iisn t h e b l a d d e r( c u r s o r s )A r r o w h e a d sm a r k D o s i t i o no f t h e u t e r u s .

Flg. 34.41 TAS. Acute pelvic infection with a thick-walled tubo-ovarian a b s c e s s( a r r o w )a n d f r e e p u s i n t h e p o u c h o f D o u g l a s( a r r o w h e a d ) .

Fig.34.42 EVSLargethin-walled chronichydrosalpinx. Pelvic inJfuntmator.t'cliseaseis becoming increasingly common as a causeof adnexalmasses,both in the acuteand chronic phases. The ultrasoundin acuteint'ectionmay show fiee fluid (pus)in assoFig. 34.39 Hugepleuraleffusionin a young girl Aspirationrevealed ciation with a complex adnexalmass,which comprisesthe ovary heavilyblood-stained fluid with multiplemacrophages typicalof pleural and thickened surroundingtube (Fig 34.4l) Doppler insonation endometriosis shows low impedance flow due to a surrounding inflammatory visuahsedwith ultrasoundso a normal ultrasoundexaminationdoes reaction. ln more chronic diseasethe ovary may be more easily not excludeendometriosis. Endometriosis normallyresolvesalier the definable(Fig. 34.3-5)with a thin-walledhydrosalpinxadjacentto menopausebut may be reactivatedif the patientis taking HRT. hence tne ovary. endometriosisshould still be consideredas part of the difl'erential The hydrosalpinxmay containinternalechoesdue to eitherblood diagnosisof a complex cyst in postmenopausalpatientstaking HRT. or pus (Fig. 34.42) zrndthe ovary may look like a polycystic ovary

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r Increased of ovulation,for example: numberof episodes -following treatmentwith ovulationinductionagents -the nulliparousstate. anduse Someprotectionis conferredby multiparity,breast-feeding of thecontraceptive Pill. Eptthettotovorlon tumours Eighty-five per cent of malignant ovariantumours are epithelialin origin and the commonest epithelialcarcinoma(60-80Vo)is a serouscystadenocarcinoma. They may show Seroustumoursarepredominantlycysticmasses. wall thickeningand nodularity,internalsolid areasand septations. Malignanttumourstend to havemore nodularityand solid areas (Figs 34-44-34-46). thantheir benigncounterparts are also large predominantly Mucinouscystadenocarcinomas with multiplethick cystic massesbut tend to be multiloculated internalseptationsand diffuse internalechoesdue to their high Jlg. 14.43 TAS Complexpelvicmassbehindthe uterus(arrowheads) and how Note multipleinternalseptations due to peritonealmesothelioma. the massconformsto the shapeof the pelvis. becauseof follicular fluid trapped by surface adhesions.Rarely patients present with right hypochondrial pain due to perihepatitis (Curtis-Fitz-Hugh syndrome). Adhesions around the liver have been described on ultrasound but it is rare to see any abnormality around the liver, and indeed the pelvic ultrasound may also be normal in even quite severepelvic inflammatory disease. Benign peritoneal mesotheliomais a slow-growing rare tumour that is difficult to treat becauseof its propensity to local recurrence

(Fie.3a.a3).

Ovarian tumours

TAS.Adnexal cyst with one solid area and some fine internal Flg. 34.4 echoes suggestiveof a serouscystadenocarcinoma.Histology confirmed a b o r d e r l i n em a l i g n a n tt u m o u r .

Ovarian tumours are classified into three main types, according to their cells of origin: epithelial (60-707o), sex cord stromal (5-107o) and germ cell (15-20Vo)tumours. In addition, approximately 57o of significant ovarian tumours are metastatic in origin. Primary tumours can be associatedwith the production of various hormones, including oestrogens,progestogensand androgens.Calcification is seen in cystadenomasand cystadenocarcinomas,fibromas and dermoid cysts/teratomas. In addition to classificationas benign or malignant, some ovarian tumours are classified as borderline malignant, indicating that they have a better prognosis,with a low risk of local recurrenceand even lower risk of metastaticdisease. Mollgnont ovorlon tumours Carcinoma of the ovary is responsible for about 5000 deaths/annumin the UK; 80Va of tumours occur in women over 50 years of age. Presentingsymptoms (pain, abdominal distension, vaginal bleeding, bowel and urinary dysfunction) usually occur late in the disease with two-thirds of patients having spread outside the pelvis at the time of diagnosis. This late presentationis responsible for the overall high mortality rate of approximately l}Vo at 5 years. Metastatic spread occurs most commonly to the peritoneum, with multiple peritoneal nodules, omental thickening and ascites.Lymphatic spread to the para-aortic nodes and liver metastasesare also seen. Risk factors for developmentof ovarian carcinoma include: o Family history of ovarian, breast,endometrial or colorectal carcinoma.Women with a pathogenicmutation in the BRCA 1 or BRCA2 geneshave a lifetime risk of 407aor 25Vo,respectively.

TAS. Malignant adnexal cyst with internal echoes and irreguFlg. !4.45 larlv thickened wall (arrowhead).

Flg. 14.46 TAS. Solid tumour mass (white arrowheads) surrounding the posterior aspect of the uterus (black arrows)'

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A T E X T B O O KO F R A D I O L O G YA N D I M A G I N G

]lg. 34.47 TAS.Benignmucinouscystadenoma showingthe typical multiloculatedappearance-impossible to differentiatefrom a malignant tumour. mucin content (Frg. 34.47). Benign mucinous cystadenomassimilarly contain thick irregular septationssuch that, in the absenceof ascitesor lymphadenopathy,it is impossible to distinguish a benign from a malignant mucinous tumour. However, in spite of their worrying appearance,only lUvo of mucinous tumours are actually malignant. Between 60 and 707oof seroustumours and 5 and 10% of mucinoustumoursare bilateral. Other rarer epithelial tumours include endometrioid carcinomas (these are associatedwith endometrial thickening due to endometrial hyperplasiaor carcinoma in approximately2O-307o),clear cell carcinomas and Brenner's tumours. Brenner's tumours are invariably benign, large at presentation and may be associatedwith a mucinous cystadenomaor dermoid cyst.

|19. 14.49 E V S .O v a r i a n f i b r o m a . H o m o g e n e o u s s o l i d m a s s ( a r r o w s ) arising from the ovary (arrowheads).

F l g . 3 4 . 5 O T A S .T y p i c a l d e r m o i d w i t h a f l o a t i n g e c h o g e n i c a r e a w i t h a c o u s t i cs h a d o w i n gd u e t o f a t , w i t h o r w i t h o u t c a l c i f i c a t i o n .

Sex cord tumours This group of tumours includeslbromas and the hormone-secreting tumours such as thecomas, granulosa cell tumours and Sertoli cell tumours (arrhenoblastomas). They are usually benign solid tumours. Patients with functioning tumours often present with the symptoms due to the excess hormone production, e.g. postmenopausalbleeding (Fig. 34.48). Fibromas are benign slow-growing tumours which when large may be associated with ascites and pleural effusions, a condition known as Meigs' syndrone. Fibromas can be heavily calcified (Fi5.34.49). Germ cell tumours Dermoid cysts (or benign cysric rcrotumas) are the commonest tumours in this group;95Vo are benignparticularly in patients aged between 20 and 50 years. Dermoid Flg. 34.51 TAS. Dermoid cyst in a pregnant patient. Note the echogenic nodule (arrows) and dense acoustic shadowing (arrowheads)

Eig. 14.44 TAS. Solid ovarian mass with a thickened endometrium (arrowheads) in a postmenopausal patient. Histology revealed a benign functioning thecoma.

cystsaretypicallycomplexadnexalmasseswith variableamounts of cystic and solid areas.They typically show areasof markedly increasedreflectivityand acousticshadowingdue to fat, calcificationor teeth.Fatcommonlyfloatsat the top of the cyst,obscuring deeperstructuresandthe true extentof the mass(Figs 34.5034.52).The echogenicnatureof the cystcan alsomakeit difficult to differentiate from bowel (Fig. 34.53), hence the size of a with ultrasound. dermoidcyst may be underestimated incidentally.Management Approximately25Voarediscovered of asymptomatic dermoidcystshaschangedover the last few years. Whereaspreviouslyall wouldhavebeenremoved,it is now consideredacceptable not to operateon small (lessthan5 cm), inciden-

MAGlNG G Y N A E C O T O G I C AI L

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Elg. 14.54 TAS.Bilateraladnexal massesdue to ovarian metastases.Note predominantly cystic masson the right and partly solid mass on the left.

Flg. 14.52 EVS. Solid-appearing dermoid cyst Note the thick septum and two nodules (arrows and arrowheads)casting shadows.

Flg. 34.55 TAS. Metastatic ovarian carcinoma causing omental thickening (arrows).

Flg. 34.53 EVS.Echogenicdermoidcyst (arrows).Note how the mass mimicsa loop of bowel The remainderof the ovary(arrowheads) is seen. tally discovereddermoid cysts providing the ultrasoundlindings are typical and there is no growth on follow-up scans.Between l0 and l57o of dermoidcystsare bilateral. Malignant germ cell tumours (dysgerminomas,immature teraIomas) occur predominantly in young women (mean age of approximately 20 years). They are usually large solid tumours but typically only stage I at presentation.They are associatedwith raisedlevelsof varioustumour markers,e.g hCG, AFP, CA- 125. Ovarlon metostoses (Kruckenberg's tumours) Ovarian secondary tumours most commonly arise from primary tumours of the stomach, colon, pancreasor breast.They may be solid, cystic or complex ovarian masses,frequently bilateral and usually associated with ascites.Secondarytumours are lesslikely to be multilocular than primary ovarian tumours but otherwise there are no specilicdistinguishingfeatures(Fig. 3a.54). Dlfferentlotlon of benrgn from mollgnont mosses A considerable amount has been written attempting to use ultrasound to differentiate benign from malignant adnexal masses with accuracy rates ranging fiom 50 to 987o1Clearly the presenceof metastatic disease (Figs 34.55, 34.56) indicates malignancy but in earlier diseaseit is difficult to be sure. Various scoring systems based on morphology and colour and spectral Doppler have been devised.A recent paper comparing the different schemeswas able to show that a combination of both morphology and Doppler indices is more accurate than either used alone but there is no agreementas to which Doppler index is best a n d a t w h i c h l e v e l t h e t h r e s h o l ds h o u l d b e s e t t o d i s t i n e u i s h

Flg. 34.56 TAS.Metastaticovariancarcinomashowingserosaltumour (arrowheads) arounda loop of bowel(arrow). between high and low impedanceflow. Current researchis investigating the use of ultrasound contrast media in associationwith 3D ultrasoundin the hope that assessmentof the pattern of vessels within a masswill help, but to date this is unproven. Featuressuggestiveof malignancy are: . Hypoechoic solid area within the mass (highly echogenicsolid areasdue to fat or calcification are typical ofdermoids). o Thick (more than 3 mm) nodularseptations. o Size of massgreaterthan 7 cm, although very large but simple cystsare usuallybenigncystadenomas. . Central rather than peripheral vascularity. o RI less than 0.6 (Fig. 3a.57). RI greaterthan 0.8 is suggestiveof benign diseasebut there is an indeterminaterange of 0.6-0.8;

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A T E X T B O O KO F R A D I O L O G YA N D I M A G I N G

Management of infertility Ultrasound has a crucial diagnostic and therapeutic role in the managementof infertility. Its main usesare: . to confirm normal pelvic anatomy . to assessovarian morphology r to look tbr pelvic pathology such as endometriosisand hydrosalpinges . cycle monitoring -to confirm ovulation in natural cycles -to monitor the responseto ovulation induction agents,such as clomif'ene and Pergonal, and try and prevent ovarian hyperstimulation syndrome -to time hCG injections prior to assistedconception techniques such as IVF and donor insemination -to confirm developmentof the typical midcycle endometrium, as this has a bearing on conceptionrates o to guide for proceduressuch as cyst aspirationand oocyte collection. In some centres this initial ultrasoundexamination is combined with HyCoSy (hysterocontrastsonography)to conlirm tubal Elg. 34.57 TAS. Large malignant germ cell tumour in a 25-year-old. patency. D o p p l e r s h o w st y p i c a l l o w i m p e d a n c ef l o w w i t h R l o f 0 . 5 . Ovarian hyperstimulation syndrome (OHSS) results in very enlargedovaries (up to l0 cm in length) with multiple follicles. It is associatedwith ascitesand pleural effusions and, when severe,may lead to hypovolaemia, disseminatedintravascular coagulation, venous thrombosis and even death. Mild forms are common and usually self-limiting. HyCoSl- (hvsterocontrastsono+raphy) is performed by inserting a small balloon catheterthrough the cervix into the uterine cavity. An endovaginal scan is performed while the ultrasound contrast agent Echovist is injected via the catheter. Tubal patency is confirmed when contrast is seento flow along both fallopian tubes and around the ovary (Figs 34.59, 34.60). The technique is quite difficult to Flg. 34.58 EVS.Ovarian cyst w i t h n o d u l e i n a 6 5 - y e a r - o l d . learn but in experiencedhands accuracyrates of 80-90Vo for tubal Doppler shows low impedance patency can be achieved. Its obvious advantageover conventional flow (Rl 0.50) suggestiveof a hysterosalpingographyis the lack of ionising radiation. Early m a l i g n a n tt u m o u r . H i s t o l o g y reports claimed it was also less painful but this has not been subr e v e a l e d a b e n i g n c y s -!J.&J-&--,i&u, t& &,-ir!.. a r* t a d e n o f i b r o m a w i t h a B r e n n e r stantiatedand it has the disadvantageof not showing detailed tubal tumour. No evidence of malioanatomy. Therefore its precise role is still to be determined. It is nancv. probably justilied as a screening test for tubal patency in patients with a low orobabilitv of tubal disease. however,low impedanceflow can be seenwith benign disease (Fig. 34.58)and high impedanceflow with malignantdisease. Screening for ovarion concer The 5 year survival for stage I diseaseis over 807o,hence there has been considerableinterest in screeningfor early tumour. Serum CA-125 measurement,transabdominal and endovaginal ultrasound have all been investigated but found unreliable. CA-125 measurementsare normal in up to 5O7oof stage 1 tumours, and abnormally high results are found in healthy controls and patients with endometriosis,cirrhosis and other abdominal malignancies,The difficulties in distinguishing benign from malignant masseson ultrasound also lead to a considerable number of false positives and unnecessarylaparoscopies, Current recommendationsare therefore that whole population screening is not justified. However, most authors agree there is benefit in screening patients known to be at increasedrisk of the disease,particularly those thought to have hereditary ovarian Elg,14.59 HyCoSy.Contrast (Echovist)is seen outlining the cavity and cancer. e n t e r i n gt h e f a l l o p i a nt u b e ( a r r o w s )

G Y N A E C O L O G I C AI LM A G I N G

10E5

and sinogramsare all occasionIVUs, bariumstudies,cystograms ally necessaryin the investigationof gynaecologicalpatients by ultrasound,CT and MRI. but have been largely superseded vaginal are usedto demonstrate enemas and barium Cystograms for malignantdisease; fistulausuallydueto surgeryor radiotherapy of cyclicalrectalbleedingandpain may requirea the investigation barium enemato excludethe short smoothstricturetypical of andbariumstudiesof the smalland largebowelcan endometriosis of ovarian the typical serosalmetastases be usedto demonstrate carcinoma(Fie34.62).

Flg. 34.6O HyCoSy. Echovist outlines a fibroid polyp (arrows) in the uterine cavitv.

The role of the plain radiograph in current gynaecologicalpractice is very limited. However, it is clearly important to be able to recognise featuresof gynaecologicaldiseaseon plain films and it is still necessaryto perform a plain abdominal X-ray to look for an IUCD that cannot be found with ultrasound.Abdominal radiographsmay also be requested to assessbowel dilatation in postoperative patients and to exclude bowel obstruction as a cause of abdominal distension in patients with advancedovarian cancer. Rarely direct invasion by pelvic tumours may causebone destruction. Causesof pelvic calcification visible on a plain abdominal X-ray include: o fibroids-typically coarsepopcorn-typecalcification o dermoid cysts-the commonestovarian mass to calcify (teeth and/or a fat-fluid level pathognomonic;Fig. 34.61) . other ovarian masses-cystadenomas/carcinomas,fibromas o pseudomyxomaperitonei-from rupture of a mucinous tumour o fallopian tube calcification-rare, should suggesttuberculosis o uterine, i.e. endometrialossification from chronic endometritis.

Flg. 34.61 Dermoid cyst. Note calcification and teeth with a fat-fluid level (arrow).

Hysterosalpl ngography (HSG) remainsimportantin the investigaHysterosalpingography the uterine tion of infertility.It is an accuratemeansof assessing cavityand tubalpatencybut hasa low sensitivityfor the diagnosis The maincurrent so cannotreplacelaparoscopy. of pelvisadhesions Rare indicationsfor HSG are infertility and recurrentmiscarriage. indicationsincludecheckingthe efficacyof tubal sterilisationand reversalof sterilisation. of thetubesprior to attempted assessment TechnlqueThe procedureis performedin the first half of the menstrualcycle following cessationof bleeding.The patientis askedto refrain from unprotectedsexualintercoursefrom the date of her period until after the investigationto be certain there is no Examinationin the secondhalf of the cycle is risk of pregnancy. avoided becausethe thickened secretory-phaseendometrium and may causea falseincreases the risk of venousintravasation, positivediagnosisofcornual occlusion.Routineuseofantibiotics statementfrom the Royal is controversialbut a recentconsensus that all nonCollegeof Obstetricsand Gynaecologyrecommends pregnantwomenunder35 yearsof ageundergoinguterineinstrumentationshouldreceiveprophylacticantibioticsor be screened for relevantorganisms.The suggestedantibiotic regimencomprisesmetronidazoleI g rectallyat the time of the procedureplus doxycycline100mg twice daily for 7 days. Numerousdifferenttypesof cannulaare available.All possess somemeansof preventingreflux of contrastthroughthe cervix and ideallyshouldallow tractionon the uterus.Oncethe cannulais in place,water-soluble contrastmediumis injectedslowly under the tubes controluntil the uterinecavity is distended, fluoroscopic filled andcontrastis seento spill freely from the distalendsof the tubes.Spot films shouldbe takenduringthe early filling phaseto ensuresmall filling.defectsare not obliteratedby contrast,during earlytubalfilling beforethe isthmicportionsareobscuredby confree trast,and after completefilling of the tubesto demonstrate peritonealspill (Fig. 34.63).Additionalobliqueviews help to thepositionof the uterusandany fibroids.It is impordemonstrate tant that the uterinecavity is visualiseden face.This is usually it achievedby tractionon the cervix,but if theuterusis retroverted may be more effectiveto pushthe cervix so the uterinefundustips Nowadayswith back into the pelvis and is seenupside-down. unitsit is alsopossibleto anglethetuberather modernfluoroscopic the uterus. thanmanipulate Inadequate distensionof the uterus(dueto cervicalreflux) and diagnosisof cornual tubal spasmcan give rise to a false-positive occlusion.Intravenoushyoscinebutylbromide(Buscopan)or

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A TEXTBOOK OF RADIOLOGYAND IMAGINC

F i g . 7 4 . 6 2 B a r i u m e n e m a s .( A ) S e r o s a m l e t a s t a s e sf r o m o v a r i a nc a r c i n o m a ( B ) S h o r t s m o o t h s t r i c t u r ed u e t o e n d o m e t r i o s i s( a r r o w h e a d s ) N o t e t h e p u c k e r i n go f t h e s e r o s asl u r f a c ed u e t o a d h e s i o n s( a r r o w ) .

Fig, 74.61 HSC.NormalcavityBothtubesvisiblewith regularmucosal foldsandfreeperitoneal spill Notehowthe contrast flowsaroundloopsof bowel(arrows) glucagon have been suggestedas treatlrent for this but a World Health Olganization(WHO) study failed to confirm they wcrc ol' any value.lt is probably more importantto avoid rough manipulation of the cervix and allow time for spasrnto relax Gentletraction on the uterusand changein positionof thc patientcan also help. Il' there is doubt about the appearancesdistally, delayed films will h c l p d i s t i n g u i s hc o n t r a s tf l o w i n g i n t o a l a r g e h y d r o s a l p i n xf r o n r contrastspilling into the peritoneumand loculatedspill Cornplicationsof HSG include: o Pain-due to uterotubaldistensionor peritonealspill. Minirnisc by slow injectionof contrastand the use ol'isoslnolarcontrilst agents o Inf'ection-rare,but more fiequentin patientswith a pasthistoly of pelvic inflammatorydiseaseand hydrosalpinges.

plexusis shown The myometrial Eig. 74.& HSC Venousintravasation. Peritoneal spillis also with drainageinto the ovarianveins(arrowheads). seen o Vasovagalreactions-usually from Inanipulationof the cervix or inflationof an occlusionballoon in the cervicalcanal r Venousintravasation-of no clinical significancebut can make interpretationof the imagesdifficLrlt lt occursmore conrmonly in the prcsenceof libroids or tubal obstruction(Fig 34.64). r Aller-gicreaction to contrast media-very rare Congenitol uterine ohnormolitiei The uterus develops by fusion of the paired miillerian duct systems.Complete or partial failure of fusion is estimated to occur in 3-4Vo of the general p o p u l a t i o n .T h e r a n g e o f r e s u l t i n g a b n o r m a l i t i e si s s h o w n i n Fis. 34.6-5.

G Y N A E C O L O G I C AI LM A G I N G

(A) Uterus didelphys

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V

(B) Uterus bicornis bicollis

(C) Uterus bicornis unicollis

HSC. Bifid uterine cavity. lmpossible to be sure if this is bicortlg. !4.67 nuate or seDtate. (D) Septate and arcuate uterus

(E) Uterus unicornis unicollis with and without rudimentary opposite horn. Flg. 34.65

lmportant congenital abnormalitiesof the uterus.

Minor degrees of abnormality are of no clinical signilicance; however, there is an increased incidence of recurrent miscarriage in

patientswith a septateuterus,so differentiationfrom a bicornuate uterusis important.On HSG an angleof >90" betweenthehornsis from a suggestive of a bicornuateuterusbut definitedifferentiation septateuterusrequiresfurther investigationto look for a fundal notch. Truly unicornuate uteri arerare,so if an apparentlyunicornuate uterusis demonstrated on HSG careshouldbe takento look for a rudimentaryhornor secondcervix(Figs34.66-34.68).

Flg. 34.68

HSC Unicornuate uterus. No evidenceof a rudimentary horn.

Other uterlne obnomotttles causedby:

Filling defects in the uterus are

o fibroids(Figs34.69-34.71) o polyps/ endometrial hyperplasia o intrauterine causedby dilatationandcurettage adhesions, (D&C), tuberculosis or followingexposureto diethyloestradiol (DES) . pregnancy.

Elg. 14.66 HSC. Uterus bicornis bicollis. Note the completely separate cervicalcanalsand uterine horns, both of which have patent tubes.

The effect of fibroids on an HSG dependson their position of fibroidsmay causedisplacement within the uterus.Subserosal muralfibroidsenlargethe thecavitybut areotherwiseundetectable; cavity and may or may not causedistortion;submucousfibroids appearaspolypoidfilling defectswithin theuterinecavity,indistinguishablefrom endometrialpolyps.Early-fillingfilms are necessmallfibroidsandobliqueviewsarehelpfulin saryto demonstrate confirmingtheirexactlocation.

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A TEXTBOOK OF RADIOLOGY AND IMAGING

H S C F i l l i n gd e f e c td u e t o s u b m u c o u sf i b r o i d .

E i g . 1 4 . 7 0 H S G .C a v i t y a n d r i g h t f a l l o p i a nt u b e b e i n g d i s t o r t e db y l a r g e m u r a l f i b r o i d . N o t e s m a l lc a l c i f i e df i b r o i d o n t h e l e f t ( a r r o w s )

F i g . 3 4 . 7 2 H S C P o l y p o i de n d o m e t r i u m c a u s i n gm u l t i p l e f i l l i n g d e f e c t s ( a r r o w s )o n l y s e e no n t h e e a r l yf i l l i n g f i l m .

Flg,34.73 HSC.Linearfillingdefectsin the uterinecavitydueto adhesions

if extensive,they can completelyobliteratethe uterinecavity, causing Asherman'ssyndrome(Fig 34.14) Asherman'ssyndromels amenorrhoea due to intrauterinesynechiae,usually causedby dilatation and curettagefor postparturnhaemorrha-{e or retainedproductsof conception. Rarely it follows a normal pregnancy.Treatmentcompriseshysteroscopicresectionof the adhesionsand insertionof an intrauterine deviceto separatethe walls of the cavity. Intrauterine adhesionsand small irregularly-shapedcavities are also seenin patientswith chronic endometritisdue to tuberculosis (Fig. 34 15). Genitul tuberculosisprimarily aff'ectsthe fallopian tubes and 50c/cof patientswith tubal diseasewill have a uterine abnormality.Tubal tuberculosisleadsto a rigid abnormaltube with occlusionin the isthmus The endsare frequentlyclubbedand there are diverticula-like projections from the tubal surface. Tubal (and very rarely ovarian) calcification can be seen. 819.74.71 HSC.Cavityenlarged by fibroids A small irregular T-shapedcavity, with constrictions around the Multiple small filling defectscausingan irregularlobulatedoutline body, is also associatedwith exposureto DES. a drug that was used to the uterine cavity are also seen with endometrialhyperplasia,tbr fiom 1940 to 1960 to treat recurrentmiscarriage.It resultedin a example in patients with polycystic ovary syndrome (Fig. 34.'72) range of genital abnormalities in the daughtersof treated mothers Intrauterine synechiae/adhesions cause linear or irregularly-shaped and is associatedwith increasedincidenceof subfertility,ectopic Iilling defectsthat are not obliteratedby increasingamountsof con- pregnancyand pregnancyloss, as well as an increasedincidence of trast (Fig. 34.73).They are associatedwith recurrentmiscarriageand. c l e a rc e l l c a r c i n o m ao l ' t h e v a s i n a

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HSC. SevereAsherman's syndrome with complete obliteraElg. 14.74 tion of the uterine cavitv

endometritis leadingto an irregularTClg. 14.75 HSC Tuberculous shapeduterinecavity.

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Elg. 14,76 HSG Enlarged uterus with multiple diverticular-likeprojections of contrast into the myometrium typical of adenomyosis.

HSC. Normal right tube but a large left hydrosalpinx. Note Elg. t4.77 thi mucosal folds on the left have been obliterated and there is no distal soill.

Adenomyosis (endometriosisinterna) is a rare cause of subfertility; it can be recognisedby diverticula-like projectionsof contrast from the cavity into the myometrium, usually in association with an enlargeduterus (Fig. 34;76). Tubol dlseose Pelvic inflammatory disease is the most common causeof both distal and proximal tubal occlusion.Preservationof mucosal folds within a hydrosalpinxis said to be associatedwith a good responseto tubal surgery; however, nowadays patients are frequently referred directly for IVF rather than being considered for tubal surgery. Peritubal adhesionscannot be identified reliably on HSG but their presencecan be inferred if contrast remains loculated around the tube instead of spreading freely in the peritoneum, and if the tube looks angulated or distorted. Delayed images may be of value in determining this (Fig. 34.77). Other causesof tubal occlusion are endometriosis,postabortalor postpuerperalinfection and tuberculosis. Salpingitis isthmica nodosa (Fig. 3a.78) is characterisedby multiple diverticula-like collections of contrast projecting from the tubal lumen. It is usually due to pelvic inflammatory diseaseor endometriosisand is associatedwith an increasedincidence of subfertility and ectopic pregnancy.

isthmicanodosa(arrows).The right tube is Elg. t4,7a HSG.Salpingitis patentbut the left tube is very irregularand beadedand terminatesin a (arrowhead). hydrosalpinx Cornual ltolyp,sare occasionallyseenas tiny filling defectsat the cornua but they rarely cause obstruction and are of questionable clinical sisnificance.

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Selective follopion tube catheterlsotlon ond reconollsotlon Approximately 5O7o of proximal tubal occlusions have been shown to be due to spasm, amorphous debris and fine adhesions, rather than to a true histological occlusion, and these are amenable to treatment by selective fallopian tube catheterisation. Following a conventionalHSG a 5F catheteris manipulatedinto the origin of the tube. Contrastis injected to confirm tubal occlusion and then a guide-wire (0.35 in) is used to probe the tube and hopefully dislodge the obstruction.Successratesfor tubal recanalisation of 70-80% have been achieved, with subsequentpregnancy rates of l045Vo. This comparesfavourably with successrates achievedby IVF. The techniqueis popular in the USA but has been slow to gain acceptancein the UK, most gynaecologists preferring to send their patientswith tubal diseasedirectly for IVF (Figs 34.79, 34.80). Selectivetubal catheterisationalso allows measurementof tubal filling pressures.A pressure transducer is connected between the catheterand an injection pump. Once the cathetertip is positioned in the cornua, contrast is injected at a constant rate and the backpressuremonitored until tubal filling is achieved.Normal tubes fill with pressuresless than 200 cmH2O. A pressurerise of greaterthan

E19.34.79

HSC. Bilateralcornual occusions.

400 cmH2O before tubal filling has been associatedwith infertility and a poor response to tubal recanalisation.

The role of CT in the evaluation of gynaecological diseasesin the pelvis has declined since the advent of endovaginal scanning and MRI. As a general rule, benign diseaseshould be investigatedinitially by ultrasound and then MRI, rather than CT, which is used to solve specific problems. Staging of malignant diseaserequires CT or MRI, dependingon the site of the primary tumour. MRI is superior to CT for staging cervical and uterine carcinoma, particularly with respectto local disease,but CT still has a role in ovarian carcinoma becauseof its ability to detect peritoneal deposits. Currently CT and MRI have similar capabilities for detecting lymphadenopathy,although the use of different imaging planes and development of specific contrast suggestthat MRI will eventually prove to be more accurate. However, CT is frequently used as an imaging modality in patients with non-specific lower abdominal symptoms such as pain, or to determinethe site of origin of a mass, so it is clearly necessary to be aware of the CT appearancesof gynaecologicalconditions. CT of the pelvis is performed following opacification of the small bowel with oral contrast (given at least an hour before the scan) and with a moderately full bladder.Some institutions also use a vaginal tampon and rectal contrast.Intravenouscontrastenhancement helps to distinguish lymphadenopathyfrom pelvic vessels,so is mandatory when CT is performed as a staging investigation. CT onotomy of the pelvis The vagina is identified as a thin rectangular structure with a brightly enhancing mucosa. The cervix and uterus appear as soft-tissue masses,only distinguishable from each other by their shape, i.e. the cervix is round and the uterus oval or triangular in cross-section.The endometrium is not easily distinguished from the myometrium but distension of the cavity by fluid is discernible, particularly following enhancement with lntravenous contrast. The ovaries can usually be seen in adult premenopausalpatients as soft-tissue masses posterolateral to the uterus; however, their position is variable and their precise appearance depends on whether or not there are cysts/follicles present. The atrophic ovaries of postmenopausalpatients are frequently indistinguishable from surrounding structures. llterine flbroids Fibroids typically cause an enlarged lobulated uterus. They are usually isoechoic with the myometrium and show similar enhancement following intravenous contrast administration; however, they may contain calcification (up to l07o) or areas of reduced attenuation due to degeneration or necrosis. High-attenuation areas are also seen due to haemonhage. Pedunculated fibroids may be difficult to distinguish from an adnexal mass and submucous fibroids may expand the cavity, mimicking an endometrial carcinoma. There are no specific features to differentiate fibroids from adenomyomas or other rare myometrial tumours, such as metastases or leiomyosarcomas (Figs 34.8I, 34.82).

Flg. 3a.8O Selectivesalpingography. 5F catheter and wire manipulated into the right uterine cornua. Subsequentiniection of contrast shows tubal patency with free peritoneal spill.

Endometrlal corclnomo Endometrial carcinoma typically causes a hypodense, irregular mass expanding the uterine cavity, some-

G Y N A E C O L O G I C AI LM A G I N G

Flg. 34.81 CT. Bulky uterus with low-density areas due to fibroids. One small fleck of calcification

Flg. 34.82 CT. Bulkymildlyheterogeneous uteruswith posteriordisplacementof the cavitydue to adenomyosis ratherthanfibroids. times associatedwith blood, fluid or pus within the cavity. CT is good at determining the extent of extrauterine diseasebut cannot easily differentiate stage I from stage 2 disease,so formal staging is far better performed with MRL Cervlcol corclnomo Cervical carcinoma is suggestedby the presence of an enlarged irregular cervix. The tumour enhances less than the surrounding normal cervical stroma, forming a relatively hypodensearea fbllowing intravenouscontrast. Fluid may be seen within a distendeduterinecavity if the cervical canal is obstructed by tumour. Parametrial invasion is demonstratedby loss of clarity of the cervical margins, with an eccentric soft-tissuemass and stranding into the paracervical fat. However, minor soft-tissue stranding should be interpreted with caution as inflammatory changesand oedema following dilatation and curettageor cone biopsy can give similar appearances.Loss of the fat planes between the cervix and the ureters, rectum and/or bladder is indicative of advanceddisease(i.e. stage 3 or greater).There is also some correlation between cervical size and prognosis-a maximum anteroposterior depth greater than 4 cm is associated with a significantly higher incidence of nodal metastasesand a poor prognosls. Evaluationof a patientwith cervicalcarcinomamust also include assessmentof the iliac and para-aortic lymph nodes and both kidneys becauseof the propensity of the tumour to invade the

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CT. Small adnexal cyst (arrow) in postmenopausal patient Flg. 34.83 EVSconfirmed a small simple cvst.

CT. Complex mass in the pelvis typical of a dermoid cyst Elg. 34.a4 (arrows). The mass is of mixed attenuation but contains a large amount of f a t . l t h a s a c a l c i f i e dr i m a n d a d e n s e a r e a o f c a l c i f i c a t i o n( a r r o w h e a d s ) inferolaterallydue to a tooth.

of greaterthan 0.8 cm in the ureters.Short-axismeasurements commoniliac nodesis saidto indicatea high likelihoodof metastatic diseaseand this is particularlytrue if the nodesare relatively i.e. they possessthe hypoechoicfollowing contrastenhancement, astheprimarytumour. characteristics sameenhancement Adnexol mossesFunctionalovarian cysts are visible as thinmasseswithin the ovaries(Fig. 34.83). walled low-attenuation or torsion.On CT haemPaincanbe due to rupture,haemorrhage orrhagemay be recognisedby the presenceof high-attenuation fluid within a cyst.Acute torsioncausesseverepain and most patientsproceedto laparoscopywithout CT; however,subacute torsioncan be difficult to diagnoseclinically.CT findingsinclude deviationof the uterusto the sideof the torsionand engorgement mass(the of adjacentblood vesselsarounda non-enhancing cysts functional simple Apparently ovary). ischaemic enlarged should be further evaluatedwith ultrasoundto confirm their benignand transientnature. The causeof complex(i.e.partlycysticandpartlysolid)adnexal massesis difficult to determineon CT. A dermoid cyst can be areseenwithin it if fat andcalcification with confidence diagnosed (Fig.3a.84)(approximately 90Vo)but otherwiseit is difficult to The samecriteria from inflammatorymasses. distinguishneoplastic

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A TEXTBOOK OF RADIOLOGYAND IMACING i n o p e r a b l em e t a s t a t i cd i s e a s e .e . g l i v e r n r e t a s t a s e sf o. r w h o m surgery may have little to offer.

Angiogrophy Arteriography as a purely diagnostic procedure is rarely indicatednowadays.However.embolrsationof both uterine arteriescan be perfbrmed safely with a high successrate and low complication rate, hence it can be used to treat intractablebleeding, such as may occur fbllowing childbirth, frorn pelvic tumours, fbllowing radiothefapy,fbllowing trauma and tiom the very rare uterine arteriovenousmalformations. Arte riovenous malformutiotts are suspectedfrom a history of reculrent extremely heavy o r u t e r i n ei n t e r v e n t i o n . b l e e d sw h i c h u s u u l l yl i r l l o w u m i s c a r r i a g e Flg. 34.E5 CT Bilateral cysticadnexalmassesNotethe tiny gasbubble such as dilatationand curettageor evacuationof retainedproducts (arrow)seenin one of the masses. Laparoscopy confirmed bilateral hydro- of conception.Colour Doppler ultrasounddemonstratesan area salpinges with chronicinfection of abnormal vascularityin the uterus with high flow ratesand low are appliedto adnexalmasseson CT as lor Llltrasound, i.e. a cornplcx irnpedanceflow on spectralDoppler (Fig. 3a.87). masswith thick irregularseptationsand wall nodularityis strongly More reccntly transcatheter embolisationof the uterine arteries suggestive of a carcinoma.Rarelygas is seenwithin a massand indi- hiis been advocatedas a meansof treating large libroids in patients catesa pelvic abscess(Fig.34.8-5).Calcificationmay be secn in ir who wish to avoid hysterectomyEmbolisationof both uterinearterpedunculated fibroidor a solid ovariantumollr suchas a fibroma ies is perfbnned using polyvinyl alcohol (PVA) particles,with or Endometrioticcystshavea very variableappearance on CT. with without gel fbam Antibiotic cover is given,with sedationand analareasof high attenuationwithin them due to haemorrhageihow- gesiaas required Resultsto date show a reductionin uterinesizeof ever, both sensitivityand specificityfirr endometriosisare low on 40-l1c/c and a reduction in abnormal menstrualbleeding in 80-90o/o CT and quite extensiveperitonealimplantscan be missed. of patients.The complicationrate is low, the most common complication being pain due to ischaemic necrosis.Postproceduralinf'ection occurs in l-2a/c, There are reports of successfulpregnancy Ovarian carcinoma firllowing embolisation but amenorrhoea,thought to be due to CT does, howcver,retain a role in staging of ovarian clrcinonrr. ovarian failure. has also been reported, so the technique should be l a r g e l y b e c a u s eo f i t s a b i l i t y t o d c t e c t p e r i t o n e a la n d s e r o s a l consideredvery carefullyin patientswho are trying to conceive. depositsin additionto liver and nodal merasrases. Typically thereis Percutoneous ospirotion ond droinoge Follicular aspiration fbr diffuse thickeningof the omentum-so-called omentalcake-with Oocyteretrieval is routinely performed with ultrasoundguidance nodular thickening of the peritoneum and serosalsurface of the but there is reluctance to aspirate cysts becauseof f'earof seeding bowel (Fig. 34.86) Most ovariancarcinomasare alreadyadvanccd malignantcells in to the peritonealcavity. However,cysts that are at the time of presentationbut surgery is stilt helpful to reduce tumour bulk. Preoperative stagingof ovariancarcinomais therefirre perfbrmed to assesstumour bulk and detect those patients with

Fig.34.a6 CT Patientwith ovarian carcinoma, peritonealdeposits(white a r r o w h e a d s ) ,p a r a - a o r t i c l y m p h a d e n o p a t h y( b l a c k a r r o w h e a d s ) a n d 'omental c a k e ' ( b l a c ka r r o w s )

F i g . 1 4 . a 7 P a t i e n tw i t h a h i s t o r y o f r e c u r r e n tv e r y h e a v y v a g i n a l b l e e d i n g S e l e c t i v ien t e r n a il l i a ca r t e r yI n j e c t i o ns h o w sa n a b n o r m a ls t e l l a t ec o l l e c t i o no f v e s s e l so n t h e n g h t E m b o l i s a t i o w n a s p e r f o r m e d ,w i t h g o o d s y m p t o m a t i cr e l i e f

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likely to be benign can be saf'ely aspirated-either transabdominally acrossa distendedbladder or endovaginally.This is ef'fectivetreatment fbr pain caused by functional cysts or adhesion-relatedperitonealcysts,with a risk of recurrenceof l5-207o. may benefit Similarly patientswith largetubo-ovarianabscesses fiom aspiration or drainage of the pus, the pref-erredroute depending on the locationof the abscess. U l t r a s o u n dg u i d a n c ec a n a l s o h e l p t o g u i d e d r a i n a g eo f a n obstructeduterus.

JeremyP R. Jenkins MRI is an importanttechniquein the evaluationof pelvic pathology due to its ability to obtain imageswith a high soft-tissuecontrast r e s o l u t i o na n d d i s c r i m i n a t i o ni n m u l t i p l e p l a n e s .l t i s n o w t h e primary techniqueof choice in the staging of pelvic malignancy, with the exceptionof stagingovarianmalignancy,where CT is the preferredtechnique Advantagesof MRI in the pelvis have been Flg. 34.E9 Normal zonal anatomy of the cervix on a transverse (TSE3500/100)image.b = bladder;s = cervical spin-echo Tr-weighted discussedin Chapter3 | . mucusandepithelium. stroma;straightarrow= cervical

Uterus, cerv:x and vag:na Both sagittal and transverseimaging planes are required when sity of the three zones in the uterus occur during the menstrual assessingthe uterine body, cervix and vagina.T,-weighted scans cycle, with an increasein volume and signalof the myometriumin the display the characteristiczonal anatomy,with three distinct areas the secretoryphase.Following intravenousgadolinium-chelate within the uterittebodv (Fig.34.88).There is a hyperintense central endometriumand myometrium enhance,with the junctional zone zone representing the endometriumcombinedwith secretionsin the remaininglow-signalon T'-weightedimages. The t'ervi.r is a cylindrical-shapedstructure measuring2-4 cm in e n d o m e t r i a lc a n a l , a n o u t e r a r e a o f i n t e r m e d i a t es i g n a l d u e t o myometrium, and a low-signal junctional zone between.from a length,connectingwith the body of the uterusat the isthmus.The layerof compressedmyometrium.Changesin sizeand signalinten- level of the isthmusis approximatelyat the peritonealreflectionon the bladder. The cervix has two distinct layers: a hyperintense central zone representingcervical mucus and epithelium,with an outer zone of low signal,similar to the uterinejunctional zone,due to the fibrostromal wall (Fig. 34.89). A turther peripheral layer of intermediatesignal may be seencontinuouswith the myometrium' The pununetn mr has an intermediatesignal on Tr-weighted images, with increasein signal on T"-weighted scans.After intravenous gadolinium-chelatethe compact cervical stroma retains its low of the paracervicaltissueand inner cervisignal.with enhancement cal epitheliumon T,-weightedimages.There are numerousglands lining the cervicalcanal and the ducts of theseglandscan become blocked.producingretention(nabothian)cysts (Fig. 34.90) These are commonly seenon MRI of the femalepelvis. The t,ugittttcan be identified as a high-signal central zone of mucus and epithelium surroundedby a low-signal muscularwall (Fig. 3a.88).The vaginacan be divided into threeregions:an upper third is characterisedby the lateral vaginal fornices, a middle third is at the level of the bladderbase,and a lower third is at the level of the urethra.There is a high-signalvenous plexus surroundingthe cervix and vagina, best seen on transverseTr-weighted images (Fig.3a.90). Intrauterinecontraceptivedevices (lUCDs) are safely imaged with MRI, with no adverseheatingor torque effectsdemonstrated. Normal uterus on a sagittal Tr-weighted spin-echo (TSE Flg. 34.88 All IUCDs show a signal void, the extentdependingon the type of 3500/100) image with normal zonal anatomy of central high-signal in situ, on all pulse sequences(Fig.3a.9l). A contraceptive device e n d o m e t r i u m ( e ) , t h e j u n c t i o n a lz o n e ( j ) a n d t h e o u t e r m y o m e t r i u m ( m ) b = urinejilledbladder. diaphragm will, however,produce a significant signal artefact.

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llg. 34.9O Nabothian cysts (curved arrow) within the cervix on a fatsuppressedtransverseT2-weightedspin-echo (FSE3500/100) image.

Flg. 34.91 An IUCD (arrow) within the uterus (u) on a transversefatsuppressedT2-weighted spin-echo (FSE3500/1 00) image. f = free fluid in the sacralcul de sac.

Congenital uterlne anomalles The upper two-thirds of the vagina, cervix, uterus and fallopian tubes develop from fusion and descent of paired milllerian ducts. The lower third of the vagina is derived from the urogenital sinus. Partial or complete failure of the ducts to fuse results in a spectrum of complex abnormalities.MRI is the techniqueof choice in assessment and evaluation of these congenital lesions. MRI can demonstrate unicornuate, bicornuate and septate uteri, and uterine didelphys (Fig. 3a.92). A uterine didelphys is one in which two separateuteri and cervicesare visualized.A septateuterus is one in which the uterine septum fails to resorb, which results in failure of correct placental implantation and subsequentmiscarriage.MRI is able, unlike other imaging techniques,to differentiate a septate from a bicornuateuterus.The importanceof making this distinction is that the surgical approach for treating the two anomalies is dif-

Flg. 14.92 (A,B)Uterinedidelphysshowingtwo separateuteri and Tr-weightedspin-echo cervices(arrows)are demonstratedon transverse (FSE3500/100)images.Notethe normalleft ovary(o). ferent: a bicornuate uterus requires abdominal surgery,whereasthe septateuteruscan be repairedhysteroscopically.MRI, as with other imaging methods, can be used to assessany renal tract abnormalities coexistentwith thesemiillerian duct anomalies.

Uterine tumours LelomyomoThis is the mostcommonsoliduterinetumour,being single or multiple. These tumours are composedof smooth muscle with varying amountsof fibrous tissue,and occur in women.They are locatedin the sub20-307oof premenopausal mucosal,intramuraland subserosalspacesof the uterus.Rarely they can occur along the broad ligamentor be entirely separate from the uterus.Submucosal tumoursprojectinto the endometrial

G Y N A E C O L O G I C AI LM A G I N G

Multiple leiomyomas (l) on (A) sagittal and (B) Tlweighted Flg. 34.93 s p i n - e c h o( F S E3 5 0 0 / 10 0 ) i m a g e sw i t h a l a r g e c e r v i c a li n t r a m u r a ll e i o m y oma (c) and smaller intramural tumours (e). There is a degenerating serosal leiomyoma (d) and a smaller serosalleiomyoma (s) adlacent to a loculated cystic collection due to an associatedhydrosalpinx (h). b = bladder.

cavity, and intramural lesions arise within the myometrium. Subserosalleiomyomas occur along the serosal surface of the uterus. As the tumours are oestrogen-dependentthey can grow rapidly during pregnancy, and tend to regress following the menopause. MRI provides an accurate assessmentof the site, size and number of uterine leiomyomas, with lesions as small as 3 mm diameter being detected. Leiomyomas are classified according to their position-submucosal, intramural, subserosalor cervical (Fig. 3a.93). Non-degeneratingleiomyomas have a characteristic uniform signal intensity, being indistinguishablefrom myometrium on T,-weighted images,with a lower signal on Tr-weightedscans (Fig. 3a.93A). Occasionally calcification within these tumours producesa low signal on all pulse sequences.Degeneratingtumours show a variable and non-specific signal appearancewith an intermediate-high signal on T,-weighted and a high signal on T2weighted images (Fig. 3a.93B). Malignant transformationcannot be differentiated from benign degenerating tumours. The use of intravenousgadolinium-chelatedoes not improve the detection rate or characterisationof leiomyomas. W h i l e t h e a s s e s s m e not f l e i o m y o m a s i s u s u a l l y b y c l i n i c a l examination and ultrasound, these techniquescan be limited in the

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deposit(arrow)within the bladderwall on Flg. 34.94 Endometrioma spin-echo (Aj coronalT,-weighted(SE650/25)and (B)coronalT2-weighted (TSE35OO/lOO) images.Note the areasof high signalwithin the superficial in (A),and the low signalon the marginof the depositdue to haemorrhage Tr-weightedin (B).b = bladder;u = uterus.

presenceof a retrovertedor displaced uterus. In addition, difficulty can be encounteredin discriminating between a uterine and an adnexal mass. False-negativerates of up to 207o for the detection of leiomyomas by ultrasound have been reported. Precise delineation of uterine leiomyomas can determine appropriatetreatment. The relationship of these tumours to the endometrium and junctional zone is important in patients being considered for selective myomectomy. MRI is useful in demonstrating subserosaltumours and those submucosallesions on a pedicle or stalk, as the presence of either of these precludes the use of uterine artery ablation as a treatment. Endometrlosls This is a condition of unknown cause in which endometrial glands and stroma (functioning endometrium) are found outside the uterine cavity and musculature. This ectopic endometrium, being influenced by circulating hormones, undergoes repeat haemorrhage and develops into blood-filled cysts (termed endometriomas). These haemorrhagic cysts are associated with adhesions and scarring. They can occur on any retroperitoneal surface, and have been found at distant sites (lymph nodes,lung and bone).

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F i g . 3 4 . 9 5 E n d o m e t r i o s i so n a t r a n s v e r s eT r - w e i g h t e d s p i n - e c h o( T S E 3 5 0 0 / 1 0 0 ) i m a g e s h o w i n g m u l t i p l e f l u i d - f l u i d l e v e l sf r o m h a e m o r r h a g i c contents within multiloculated cysts filling the pelvis.There is dilatation ol the right ureter (arrow).

on sagittalTr-weightedspin-echo(TSE Eig. t4.97 Diffuseadenomyosis thickeningof the 3500/100)imageshowingdiffuseirregularlow-signal iunctional zone.b = bladder. detection of these lesions can be achieved using high-resolution fat-suppressedT'-weighted imaging. MRI cannot be used for routine screeningor staging becauseof limitations in sensitivity and specificity, and laparoscopyis still required. MRI is, however, useful in the assessmentof patients with adnexal and other masses following a non-diagnostic ultrasound examination. The characteristic appearanceof endometriosis is of multiple, multiloculated cysts with thick walls and haemorrhagic fluid contents.On MRI the haemorrhagiccomponentappearsof high and low signal on Tr- and Tr-weighted images,respectively(Fig. 34.95). The low signal on the T2-weightedscansis due to the profound T, shortening from the haemorrhagic component. A less specific appearance,which is not uncommon in endometriomas,is of a high signal on both T'- and T2-weightedscans,and this is similar to haemorrhagic functional cysts of the ovary as well as malignant tumours. Some endometriomasare solid masseswith low signal on Tr-weighted images due to fibrosis (Fig. 34.944), which can enhancefollowing gadolinium-chelateinjection. Small foci of haemorrhage may be seen in these masses.Solid endometriomas may invade deeply into bladder and bowel (Fig.34.94).

Adenomyosls Adenomyosis, which represents heterotopic stratum basale of the endometrium interdigitating with the myometrium, cannot be distinguished from leiomyomas on clinical findings or by ultrasound.Each producessimilar symptoms of pelvic pain and menorrhagia with uterine enlargement. Distinction between the two pathologies is important as treatment options are different: hysterectomy for adenomyosis versus myomectomy for leiomyoma. Adenomyosis can be focal, diffuse or microscopic. There is debate as to the normal thickness of the junctional zone, with the maximum limit suggestedto be up to 12 mm, rather than 5 mm as (arrow)on (A) coronaland (B) sagittalTr- indicated in earlier studies. 819.34.96 Focaladenomyosis weightedspin-echo thickAdenomyosis can be diagnosed,and usually differentiated from OSE3500/100) imagesshowingfocallow-signal (arrowedin leiomyomas, on MRI as a diffuse or focal thickening of the junczonein (A) undergoing haemorrhage eningof the junctional (B))a yearlater.b = bladder; e = intramural leiomyoma. tional zone, with or without focal areas of high signal on T2MRI has been used in the detection of endometriomas weighted images (Figs 34.96, 34.97). On T2-weightedimages focal (Fig. 34.94), with reported high levels of accuracy.However, small adenomyosis appears as a poorly marginated low-signal mass ( 3 - 5 m m ; w i d t h 3 7 m m T 1b C l i n i c a l lvyi s i b l eo r m i c r o s c o p>y l A 2 Tl bl C l i n i c a l ly 4 c m T2 Beyondcervixbut not to pelvicwall f 2a I n v o l v e m e not f v a g i n ab u t n o t l o w e rt h i r d f 2b b u t n o t t o p e l v i cs i d e - w a l l Parametrie a xl t e n s i o n E x t e n s i otno p e l v i cw a l l / l o w etrh i r d v a g i n a / h y d r o n e p h r o s iTs3 T3a L o w e rt h i r d v a g i n a T3b E x t e n s i otno p e l v i cw a l l / h y d r o n e p h r o s i s T4 Extensionbeyondtrue pelvis/bladder/rectum 14 Involvementof bladder/rectum M1 to other organs Spreadoutsidetrue pelvis/metastases

fiom leiomyomas,althoughsmall leiomyomascan have ill-defined marginsas well, which can lead to misdiagnoses

Cervical carcinoma A stagingclassificationfor tenicul carcinomcthas beendescribedby the Committee of the InternationalFederationof Gynaecology and Obstetrics(FIGO), basedprimarily on clinical findings and recently revisedin 1995(Box 34.I. which alsogivesthe TNM classification) of ditTerThis stagingsystemwas devisedto assistin the assessment ent institutionsand to aid in the evaluationof treatmentplanning and results lt should be noted that MRI and CT were not includedas part of the stagingclassitication,and nor was lymph node status,as these were not widely available.The FICO staging methodsof assessment of cervical carcinoma. classilicationis usedin the assessment FIGO stageI diseaseis tumour confinedto the cervix and is subdivided accordingto the depth of stromal invasion.Current MRI of this stageof disease. usageis limited in its role in assessment The use of pelvic phased-arrayand/or endorectal/endovaginalcoil techniquewith resultantimprovedresolution,possiblywith contrast

Elg. t4.99 Largecervicalcarcinoma(arrow)infiltratinginto the bladder on a tumour nodulein the posteriorfornix(arrowhead) (b) with a separate (FSE3000/100)image.Notethe endomespin-echo T2-weighted sagrttal triil oUstiuction(e). (Courtesyof Dr i. M. Hawnaur,Departmentof of Manchester University Radiology, ) Diagnostic

enhancement,should allow greaterprecision in measuringthe depth of penetrationof tumour into the cervical wall. Carcinoma confined within the cervix but with >5 mm depth of invasionor >7 mm in breadth(FIGO stageIB) can be demonstratedon MRI. StageIB diseasehas recently been further subdivided into clinical tumours not exceeding4 cm in diameter(stageIBI), and more bulky disease larger than 4 cm (stage IB2) (Fig. 34.98). Tumour volume is an important prognostic factor in stage I disease.Patients with early stage lB disease may have a survival of >907o, which reduces to 50-60c/cor less for those with bulky disease'This invasive cervical carcinoma is better demonstratedon MRI than CT and appearsas an area of high signal contrastedagainst the low-signal cervical stroma on T,-weighted images. The presence of a low-signal stromal ring around the high-signal tumour is good evidence (93-10(Yh sensitivity) of a confined tumour. The absenceof a lowsignal stromal band, however,is not certain evidenceof parametrial spreaddue to limitation in spatial resolution using current MRI techniques.The use of high-resolutionMRI, as indicatedabove,is likely to overcomethis limitation.The cervix may enlarge,leading to obstructionof the endometrialcanal with distensionof the uterus fiorn retainedsecretions(Fig. 3a.99). In FIGO stage II diseasethe tumour extends beyond the cervtx' In stage IIA the tumour extendsinto the upper two-thirds of the vagina but not into the parametrium(Fig.34.100)' and stageIIB diseaseextendsinto the parametriumbut not to the pelvic side-wall (Fig.34 l0l). This distinctionis critical' as most institutionstreat lesions above stage IIA diseaseby radiation therapy' The reported accuracyof MRI in the demonstrationof parametrialor vaginal spread is approximately 7O-90Vo.On MRI Tt-weighted images extension into the parametrium is identified by the high-signal tumour breaching the low-signal cervical stromal wall on transFlg. 34.9E Carcinoma of the cervix (stage l82) showing exophytic verse, or transverse-obliquesections parallelling the short axis of t u m o u r ( a r r o w s )w i t h i n t h e v a g i n a lc a n a lo n s a g i t t a lT r - w e i g h t e ds p i n - e c h o = the cervix. False-positiveresults on MRI are due to surrounding w a l l b l a d d e r b ( T S E3 5 0 0 / 1 0 0 ) i m a g e N o t e t h e i n t a c t l o w - s i g n avl a g i n a l

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F l g . 3 4 . l O O B u l k y e x o p h y t i c c e r v i c a lc a r c i n o m a c o n f i n e d w i t h i n t h e c e r v i xo n a s a g i t t a lT r - w e i g h t e ds p i n - e c h o( T S E5 0 4 1/ 1 3 2 ) i m a g e T h e l o w s i g n a lv a g i n a lw a l l r e m a i n si n t a c t a p a r t f r o m a n a r e a o f t u m o u r i n f i l t r a t i o n p o s t e r i o r l y( a r r o w ) .W i t h i n t h e t u m o u r i n t h e a n t e r i o rf o r n i x t h e r e i s a n a r e a o f n e c r o s i sb = b l a d d e r .( C o u r t e s yo f D r R . J J o h n s o n C , h r i s t i eH o s p i t a l . )

F l g . 3 4 , 1 O 2 B u l k y c a r c i n o m ao f t h e c e r v i x e x t e n d i n g i n t o t h e b o d y o f the uterus,lower third of the vagina (small arrows) and bladder (open a r r o w ) o n a s a g i t t a l T r - w e i g h t e d s p i n - e c h o ( T S E 5 0 4 1 / 13 2 ) i m a g e . ( C o u r t e s yo f D r R . j . l o h n s o n ,C h r i s t i eH o s p i t a l . )

F i g . 3 4 . 1 O 3 T u m o u r( t ) i n f i l t r a t i ntgh e p a r a m e t r i u m and leftiliacus muscle(i), with left-sided involvedlymph nodes(n) and a right ovarian (o) on a transverse metastasis T2-weighted spin-echo(TSE3500/100) image.b = bladder. Flg. 34.lOl Carcinomaof the cervix(stagellB) showingtumour (t) other cause (stage IIIB) (Fig. 34.103). MRI criteria for pelvic sidewithin the parametrium(arrows)on transverse Tr-weightedspin-echo (FSE3500/100)image.Note the lossof the normallow signalfrom the wall invasion includes tumour within I cm of the musclesof the pelvic wall, vascularencasementor high-signaltumour replacement cervical stroma.b = bladder. of low-signal adjacentmuscles (levator ani, piriformis, obturator interoedema, vascular parametrium or an inflammatory reaction to the nus) (Figs 34.103, 34.104). Overstagingof tumour can again occur tumour. Vaginal extension is indicated on MRI by high-signal due to surroundingoedemaor inflammatorychange tumour replacingthe normal low-signalvaginal wall (Fig. 34. 100). In stage IV diseasethe tumour extends outside the reproductive Overstagingof diseaseoccurs particularly from large exophytic tract, with tumour involvement of the mucosa of the rectum or tumoursin the region of the anteriorfornix. As direct inspectionof bladder (stageIVA) (Fig. 34.105), or diseaseoutside the true pelvis vaginal infiltration can be easily performed, this assessmenton or distantmetastases (stageIVB). Sagittaland transverseTr-weighted MRI is not critical. scansallow assessmentof tumour infiltration into the lower uterine In FIGO stageIII diseasethere is extensioninto the lower third of segment, bladder, rectum and vagina, where high-signal tumour the vagina(stageIIIA) (Fig. 34. 102),or to the pelvic side-wallwith or replacesthe normal low-signal structures(Figs 34.106, 34.107).The without hydronephrosis, or a non-functioningkidney due to no known use of dynamic contrastenhancementallows a clearer assessmentof

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Flg. 34.tO6 Carcinomaof the cervix(t) infiltratingthroughthe bladder spin-echo(TSE3500/100)image. T2-weighted wall (arrow)on a transverse b = bladder. will increasethe accuracyin the detectionof nodal diseaseirrespective of size or anatomicaldistribution. The treatment and prognosis of invasive cervical carcinoma is Flg, 34.1O4 Cervicalcarcinoma (t) extending into the parametrium proon tumour volume, extent of disease,histological grade, ( s t r a i g h t dependent p o s t e r i o r l y ducing left hydronephrosis arrow) and extending through the perirectal fascia into the rectal mucosa (curved arrow) on a depth of invasion and vascular and lymphatic involvement. t r a n s v e r s eT r - w e i g h t e d s p i n - e c h o ( T S E 5 0 4 1 / 1 3 2 ) i m a g e . b = b l a d d e r Following histological diagnosis accurate staging is important in (Courtesyof Dr R.J.Johnson,Christie Hospital.) order to optimise treatment-demonstration of parametrial extension often precludes surgery and requires radiotherapy (Fig.34.108). Clinical staging is often inaccurate,particularly in those with more advanced disease-two-thirds of these patients may be incorrectly staged.Imprecision in clinical staging is due to errors in assessmentof size of endophytic tumours, uterine body extension, infiltration of parametria and pelvic side-wall and lymphadenopathy.X-ray, CT and ultrasound (including transrectal ultrasound) are used for staging and assessmentof tumour volume but are limited due to poor tissue discrimination and difficulty in delineating adjacent organ involvement. MRI has an overall accuracy range in staging of approximately 78-927o, with imProved accuracy in more advanced tumours. The accuracy of MRI for demonstratingextent of tumour invasion of the pelvic side-wall is over 90Vo,with a similar value for detectingbladder and rectal wall involvement. Good concordance has been achieved with tumour volume measurementson MRI when compared with data obtained by histological review. The advantagesthat MRI has over other Flg. 34.1O5 Recurrentcarcinomaof the cervix(t) infiltratinginto the imaging techniquesinclude an improved tissue resolution and disparametriumand right levatorani on a transverse Tr-weightedspin-echo facility, particularly with (TSE5041/132) image.Notethe low-signal vaginalwall(arrow).b = bladder, crimination combined with a multiplanar sequenceswith facilphased-array coils, fast acquisition the use of r = rectum.(Courtesy of Dr R.l. lohnson,ChristieHospital.) ity for fat suppression,and dynamic contrastenhancementmethods. tumour extension into the bladder or rectal wall, compared with An advantageof dynamic contrast enhancementis in the assessTr-weightedimages. ment of neoangiogenesisof the tumour, which has a direct relationAlthough lymph node status is not part of the FIGO staging, the ship to tumour growth rate and necrosis,but is not routinely used in presence and extent of lymphadenopathy has important implicastaging tumours.T2-weightedimagesremain superiorin the evaluations in treatmentand prognosis.The presenceor absenceof pelvic tion of parametrialspreadas the normal Parametriumis well vasculymphadenopathy is assessedon T'-weighted images, with nodes larised. The detailed imaging technique is outlined in the Royal 'A Guide to the Practical Use of greater than 7-10 mm in diameter being consideredabnormal (see College of Radiologists' booklet Ch. 3l) (Fig. 34.103). Similar signal intensity appearancesare, MRI in Oncology'. however, obtained from hyperplastic and metastatic nodes.A new MRI is indicatedin patientswith tumours greaterthan 2 cm diamMRI lymphographic contrast is now availableusing ultrasmall iron eter on clinical examination, when the tumour is primarily in the oxide particles (USIOP), which accumulatesin normal nodes,pro- endocervicalcanal, or if it is of an infiltrative type. MRI can be of ducing a signal void while sparing metastaticnodes, which retain particular value in assessingpregnantpatientswith invasivecervical their abnormal signal (see Chapters 2, 59). The use of this agent carcinomaand in detectingconcomitantuterinedisease,e.g. leiomy-

11 0 0

A T E X T B O O KO F R A D I O L O G YA N D I M A G I N C

119.34.107 Extensiverecurrent cervical carcinoma (t) following a hysterectomy on (A) selected transverseT2-weighted spin-echo (TSE 3500/100) i m a g e s ,a n d ( B ) c o r o n a lT r - w e i g h t e ds p i n - e c h o( T S E3 5 0 0 / 1 0 0 ) f a t - s u p p r e s s e idm a g e . T h e r e i s a l a r g e t u m o u r r e c u r r e n c ei n f i l t r a t i n gt h r o u g h t h e l o w e r t w o - t h i r d so f t h e v a g i n a i n t o t h e p e l v i cf l o o r a n d i n t h e b l a d d e rw a l l ( o p e n a r r o w ) , w i t h s e p a r a t et u m o u r n o d u l e si n t h e r i g h t i s c h i a lr e c t a lf o s s a( s t r a i g h t a r r o w ) a n d l e f t p a r a m e t r i u m .T h e r e i s b i l a t e r a li n g u i n a ll y m p h a d e n o p a t h y( s m a l la r r o w s ) .N o t e t h e m a s so f h i g h e r s i g n a lt h a n t u m o u r i n t h e l e f t a d n e x a from the native ovary. b = bladder.

Flg. 34,lOa Carcinoma of the cervix (straight arrows) on sagittal Tr-weighted spin echo (SE 1500/80) (A) before treatment, (B) 6 weeks, and (C) 6 m o n t h s a f t e r r a d i o t h e r a p yN . o t e t h e r a p i d r e d u c t i o ni n s i z eo f t h e t u m o u r b e t w e e n( A ) a n d ( B ) . T h e s m a l l a r e ao f h i g h s i g n a li n t h e c e r v i x i n ( C ) i s d u e t o e i t h e r r e s i d u a tl u m o u r o r p o s t - t r e a t m e n ct h a n g e . N o t e t h e l o w - s i g n a la r e a i n t h e u t e r u sd u e t o a n o n - d e g e n e r a t i n gl e i o m y o m a( c u r v e da r r o w ) , a n d t h e h i g h m u c o s a ls i g n a li n t h e p o s t e r i o rw a l l o f t h e b l a d d e r( b ) f r o m r a d i o t h e r a p yc h a n g e i n ( B ) a n d ( C ) .

omas (Fig. 34.108). MRI can be used in the diagnosisof recurrent disease and in aiding the distinction of tumour from post-treatment change(Fig. 34.109).Tumour recurrenceis indicatedby the presence of a soft-tissuemass which, on Tr-weighted images,exhibits a high signal compared with muscle and fat. Improved conspicuity of diseasecan be achieved using fat-suppressedsequences.Although longstandingpost-treatmentfibrosis can be of low signal on all pulse sequences,signal appearancesotherwise may overlap with those obtained from tumour. Less than 6 months after radiotherapy both recurrent tumour and fibrosis exhibit hyperintensityon Tr-weighted

images, making distinction diflicult. Six to l2 months post-radiotherapy the radiation fibrosis becomeslower in signal. The use of dynamic contrast enhancement with integration of signal intensity-time curves may allow separation of post-treatment fibrosis from recurrenttumour-the tumour neoangiogenesisallows a more rapid contrastuptake than in radiation fibrosis. Significant overlap in measuredT' values has been demonstrated between normal cervical tissue and tumour, although a reduction in tumour T' has been noted in cervical carcinomas following radiotherapy.

GYNAECOLOGICALIMAGING

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Endometrial carcinoma Endometrialcarcinoma is a common gynaecologicalmalignancy, being the most prevalentinvasive malignancy of the female genital tract in the USA. In 1998,36 100 new casesof endometrialcarcinoma were diagnosed,with approximatelya sixth of patientsdying from their disease.There has been a threefold increasein the incidence of endometrial carcinoma over the last 30 years, with a strong link to long-term oestrogenexposurewithout opposed progesterone.Risk tactors include obesity, diabetes mellitus, hypertension, multiparity,late-onsetmenopause,polycysticovaries,and the long-term use of tamoxifen for the treatment of breast cancer. In the UK this tumour is secondin prevalenceto ovarianmalignancy. Endometrial carcinoma may be localised or diffuse and mainly occurs in postmenopausalwomen. Over 907a presentwith postmenopausalbleeding.Approximately 90Voof tumours are well difarising within the uterine epithelium. adenocarcinomas f'erentiated Localised tumours are polypoidal with a superficial attachment to the endometrium, whereas diffuse lesions infiltrate the entire endometriumand invade the myometrium, spreadingbeyond the uterusand cervix to involve adjacentorgans.The depth of infiltration of the myometriumrelatesto the presenceof nodal metastases' Only a few per cent of patients have nodal involvement with superficial invasion, increasing to approximately 40Vo for deep myometrialinfiltration. The detailedimaging techniqueis outlined in the Royal College of Radiologists' booklet A Guide to the Practical Use of MRI in Oncologv.On MRI endometrialcarcinomashowsa signalintensity appearancesimilar to normal endometrium, which can cause F l g . 3 4 . 1 O 9 E x t e n s i v er a d i a t i o n c h a n g e i n v o l v i n g t h e b l a d d e r ,v a g i n a , difficulty in defining small lesions. Large lesions expand the r e c t u m a n d b o w e l l o o p s o n ( A ) s a g i t t a lT 2 - w e i g h t e d( S E 1 5 0 0 / 8 0 ) a n d ( B ) endometrialcavity (Figs 34 I 10, 34.1I l) and can havea low signal t r a n s v e r s eT r - w e i g h t e d ( S E 8 0 0 / 4 0 ) i m a g e s . I n ( A ) t h e b l a d d e r ( b ) h a s a y u c o s a a r o u n d t h e p o s t e r i o r on T,-weighted images.Widening or signal heterogeneityon Trt h i c k e n e d w a l l w i t h a h i g h - s i g n a l - i n t e n s i tm w a l l . T h e u t e r u s ( u ) i s e n l a r g e da n d t h e v a g i n a ( a r r o w s ) ,r e c t o s i g m o i d( r ) , weighted images within the endometrial canal may be the only a n d a d j a c e n ts m a l l b o w e l l o o p s ( l ) s h o w t h i c k e n e dw a l l s w i t h h i g h s i g n a l . abnormal finding in early-stagedisease(Fig. 34.1l6). Blood clot' N o e v i d e n c eo f r e c u r r e n c eo f c e r v i c a lc a r c i n o m a ,w h i c h w a s c o n f i r m e d o n adenomatoushyperplasiaand degeneratingsubmucosalleiomyoma h i s t o l o g i c arl e v i e w T h e h i g h s i g n a lf r o m t h e s a c r u ma n d L 5 v e r t e b r ai s d u e can producesimilar changes,making histologicalreview essential. t o r a d i a t i o n - i n d u c e df a t t y i n f i l t r a t i o no f t h e m a r r o w s p a c e s .T h e a r e a o f s i g n a lv o i d w i t h i n t h e v a g i n a i n ( A ) i s d u e t o a t a m p o n i n s i t u The most reliablecriterionfor the diagnosisof myometrialinvasion is disruption of the junctional zone. Difficulty can occur in this

111 * ''it";

Flg. 34.llO Stage lC endometrial carcinoma (e) on a sagittal T2w e i g h t e d s p i n - e c h o( T S E3 5 0 0 / 1 0 0 ) i m a g e . b = b l a d d e r

F l g . 3 4 . 1 1 1 E n d o m e t r i a cl a r c i n o m a( e ) o n a s a g i t t a lT 2 - w e i g h t e ds p i n e c h o ( T S E 3 5 0 0 / 1 0 0 ) i m a g e w i t h a s s o c i a t e dl y m p h n o d e i n v o l v e m e n t ( d e m o n s t r a t e do n o t h e r s e c t i o n s )m a k i n g t h i s a s t a g e l l l C t u m o u r . b = bladder.

110.2 Box 14.2

A T E X T B O O KO F R A D I O L O G YA N D I M A G I N G FIGO/TNM staging for uterine corpus

FICO lA lB lC llA llB lllA lllB lllc IVA IVB

Tumourconfinedto endometrium Invasion < h a l fd e p t h o f m y o m e t r i u m Invasion> half depth of myometrium Extensionto cervix,endocervicalglandsonly Invasionof cervicalstroma Invasionof uterineserosa/adnexae/+ve peritonealcytology Vaginalinvolvement(directspreador metastasis) Pelvicand/or para-aorticlymph node metastases Invasionof bladder/bower Distanm t e t a s t a s eisn,c l u d i n ge x t r a p e l v inco d a ld i s e a s e

Tl a T 1b Tl c f2a f 2b T3a T3b N1 f4 M1

The vast majority of small ovarian cysts visualised on MRI are ovarian folLicLesin various stagesof development.In women of reproductive years a cyst > I cm is usually a corpus luteum cyst, brl/. on occasionswill be a follicular cyst. These simple ovarian cysts are thinwalled and tend to have a low-intermediate signal on T,-weighted imagesand a high signal on Tr-weighted scans(Fig. 34.112).Simple ovarian cysts are not uncommon in postmenopausalwomen. The ovaries lie in the adnexa lateral to the uterus, maintaining a constantrelationship with the pelvic ureter.The ureter coursesposterior or lateral to the ovary, this relationship remaining constant irrespective of the position of an ovarian mass in the pelvis. Thus an ovarian mass will displace the ureter posteriorly or laterally

assessmentas the junctional zone may not be visible in some postmenopausalwomen. Following intravenousgadolinium-chelatethe endometrial carcinoma enhances, increasing the contrast difference between tumour and normal endometrium and improving the conspicuity of smaller lesions.In addition, viable rumour can be differentiated from non-enhancingnecrosis and blood clot. Dynamic contrast enhancement with integration of signal intensity-time curves allows separationof viable from necrotic tumour. Staging of endometrial carcinoma is important in defining appropriate treatment, which is primarily surgical with or without pelvic radiotherapy (Box34.2). Clinical staging is inaccurare:one-fifth of patients are understaged.As with the other imaging techniques, MRI cannot provide a histological diagnosis and is not indicated unless a positive histology has been obtained.The overall reported accuracyfor MRI in staging is 85-92Vo; it has particular advantagein defining the depth of myometrial invasion and in demonstrating extrauterine extension. MRI is indicated in those patients in whom physical examination is difficult and there is a clinical suspicion of advanced disease,those who are unsuitable for surgical staging, or if the tumour is of high grade.

Ovaries The normal-sized ovaries are best demonstrated on transverseor coronal scans,and can be identifiedtn96Voofwomen ofreproductive age.They measure 1.5-3 cm in diameter and have a variable signal on T1- and Tr-weighted images. The premenopausalovary shows a low-intermediate signal, similar to muscle, on T,-weighted images. This appearanceis altered if there is haemonhage present. On T2weighted scansthe ovary is usually oflow signal, but it can be ofhigh signal in some individuals. The cause of this high signal is unknown but is probably due to a looser vascular and connective tissue in the medulla of the ovary. A low-signal rim, in keeping with fibrous cortical tissue, can be observed on the Tr-weighted images. On high-resolution Tr-weighted imaging, numerous small peripheral cysts (follicles) are seen (Fig. 34.1l2), with a more inrermediate-high signal from the central stroma of the ovary. This appearancemust be distinguished from that of polycystic ovarian disease. The postmenopausalovary demonstratesa low signal on Tr-weighted images, with few if any peripheral follicular cysts. On T,-weighted images, difficulty can occur in identifying the ovaries separatefrom adjacent bowel and uterus. The use ofbowel-specific oral contrast agents can be of help in this regard. After intravenous gadolinium-chelate the normal ovaries enhance,allowing improved detection of non-enhancing follicular cysts.

Elg. 14.112 Bilateralcystic ovaries (o) in a 25-year-old on a coronal fats a t u r a t i o nT r - w e i g h t e d s p i n - e c h o( T S E3 5 0 0 / 1 0 0 ) i m a g e s h o w i n g a l o w s i g n a l h a e m o r r h a g i cr i g h t o v a r i a n c y s t ( l a r g e a r r o w - p r o b a b l y a c o r p u s luteum cyst) with some surrounding free intraperitonealfluid (small arrows). r = rectum; u = uterus.

F l g . 3 4 . f 1 3 M u l t i l o c u l a t e dt h i n - w a l l e d h a e m o r r h a g i cb e n i g n o v a r i a n cysts (c) showing fluid-fluid levels on a transverseTr-weighted spin-echo (SE2000/1 20) image. There is a coincidental uterine leiomyoma (l).

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D e r m o i d c y s t ( a r r o w s ) s h o w i n g a u n i l o c u l a rm a s s w i t h a Flg. 34.115 n o d u l e w i t h i n h i g h - s i g n a lf a t o n ( A ) c o r o n a l T r - w e i g h t e d s p i n - e c h o( T S E 7 0 0 1 1 2 ) i m a g e a n d ( B ) s a g i t t a l T 2 - w e i g h t e ds p i n - e c h o ( T S E 3 5 0 0 / 1 0 0 ) i m a g e A f a t - s u p p r e s s e ds e q u e n c e( n o t s h o w n ) w a s a l s o p e r f o r m e d t o confirm the fat contents of the cvst. b = bladder.

F l g . 3 4 . 1 1 4 L a r g e l e f t a d n e x a lm a s s( d ) d u e t o a n o v a r i a nd e r m o i d d i s p l a c i n gt h e u t e r u sw h i c h c o n t a i n sa c o i n c i d e n ts u b s e r o s al e l i o m y o m a( l ) o n ( A ) c o r o n a l T , - w e i g h t e d ( S E 7 2 0 1 2 5 )a n d ( B ) t r a n s v e r s eT r - w e i g h t e ds p i n e c h o ( T S E2 0 0 0 / 8 0 ) i m a g e s .T h e d e r m o i d c y s t h a s s o l i d a n d c y s t i cc o m p o n e n t sw i t h s o m e a r e a so f i n t e r m e d i a t e - h i g hs i g n a ln o t e d i n ( A )

Dermoidcystr (maturecystic teratomas)Theseoccurmostcommonly during the reproductiveyears,and accountfor 20Voof all ovariantumours.Approximatelyl2%oarebilateral,with malignant degenerationin less than 2Vo.Typically they presentas a unilocularcysticmass,with a few showingseptawithin thecystic are5- l5 cm in diameter component.The majorityat presentation (Fig. 34.1 l7B), in contradistinction to pelvic lymphadenopathy When confirmationor diagnosed on ultrasound. and are usually which lies on the pelvic side-wall lateral to the ureter. additionalinformationis required,CT or MRI can be helpful Benign ovorlon cpfr These tend ro be small (3 months) show a high Fluid-fluid levels can be seen as a result of the haematoma, and there is marked enhancementwith gadolinium-chelateinjection as a consequence of the marked vascularity of this condition (Fig.45.22). In the subsequent2 weeks amorphous densities develop in the mass, possibly with periosteal reaction. During this initial 4-week period the process histologically resembles a parosteal osteosarcoma,and the MRI features are non-specific; however,there is usually a thin line of separationbetween the ossification and adjacent bone, which aids in the differentiation. One characteristic feature of myositis ossificans in its acute and intermediate stages ( 0 . 5 t o > 1 . 0 p e r 10 0 0 >0.75

< 1. 0

3 . T o m a x i m i s et h e n u m b e r o f s m a l l i n v a s i v ec a n c e r s

The rate of invasivecancers 'l l e s st h a n 5 m m i n d i a m e t e r detected in eligible women invited and screened

Prevalentscreen>1 .5 Per 1000 Incident screen>1 .65 per 1000

Prevalentscreen>2.0 Per 1000 lncident screen>2.2 per 1000

4 . T o a c h i e v eo p t i m u m imagequality

a

H i g h c o n t r a s ts p a t i a l resolution b. Minimaldetectable contrast (approx.) 5-6 mm detail 0.5 mm detail c . S t a n d a r df i l m d e n s i t y

>lOp/mm

5 To limit radiation

M e a n g l a n d u l a rd o s e p e r f i l m to standard breast using a grid