Female Pelvis Imaging
Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT
McGill University Health Center
Montreal General Hospital
May 28 – 30, 2015, Montréal, Québec
Disclosure Statement: No Conflict of Interest
I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical
device or communications organization.
I have no conflicts of interest to disclose ( i.e. no industry funding received or other
commercial relationships).
I have no financial relationship or advisory role with pharmaceutical or device-making
companies, or CME provider.
I will be discussing the results of ____ (“off-label” use), which is currently classified by
Health Canada as investigational for the intended use.
I will not discuss or describe in my presentation at the meeting the investigational or
unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is
classified by Health Canada as investigational for the intended use.
May 28 – 30, 2015, Montréal, Québec
Disclosure Statement: With a Conflict of Interest
I have/had an affiliation, financial or otherwise, with a pharmaceutical company, medical
device or communications organization, which could include:
Examples:
•having received a grant(s) or an honorarium from a commercial organization.
•holding a patent for a product referred to in the CME/CPD program or that is marketed by
a commercial organization.
•holding investments in a pharmaceutical organization, medical devices company or
communications firm.
•currently participating in or have participated in a clinical trial within the past two years.
I intend to make therapeutic recommendations for medications that have not received
regulatory approval (i.e. "off-label" use of medication).
May 28 – 30, 2015, Montréal, Québec
Outline
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Optimizing pelvic imaging
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Patient preparation
Surface coil and patient positioning
Artifacts
Routine pulse sequences
Pathology
Patient Preparation
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Screening
Pelvic questionnaire
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Pre/Postmenopausal
Date of LMP
Hormones/contraceptives
IUD’s /tampons
Surgery/XRT/Chemotherapy
Patient Preparation
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Pelvic questionnaire
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Pre/Postmenopausal
Date of LMP
Hormones/contraceptives
IUD’s /tampons
Surgery/XRT/Chemotherapy
Patient preparation
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Pelvic questionnaire
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Pre/Postmenopausal
Date of LMP
Hormones/contraceptives
IUD’s /tampons
Surgery/XRT/Chemotherapy
Patient on contraceptives
Endometrial hyperplasia
Patient Preparation
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Pelvic questionnaire
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Pre/Postmenopausal
Date of LMP
Hormones/contraceptives
IUD’s /tampons
Surgery/XRT/Chemotherapy
IUD
Tampon
Patient Preparation
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Pelvic questionnaire
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Pre/Postmenopausal
Date of LMP
Hormones/contraceptives
IUD’s /tampons
Surgery/XRT/Chemotherapy
I yr. post
Pre XRT
5 yrs. post
3 yrs. post
Patient Preparation
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Fasting 4-6 hours
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Avoid diuretics, caffeine
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Empty Bladder
Antiperistaltic Agents
• Hyoscine Butylbromide
(40 mg I.M.)
• Contra-indications:
• Glaucoma
• Angina, CHF, arrythmia
• BPH
No antispasmodic
• Glucagon ( 1 mg)
• Caution:
• Insulin dependent diabetic.
Antispasmodic
Surface Coil Technique
• Multichannel Surface Coil:
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Increased SNR
High Resolution Imaging (512x256)
Small FOV
(22-26cm)
Thin Slices
(3-4 mm)
Extended coverage when imaging
malignancies
Patient Positioning
Poor coil positioning
Imaging Techniques
FRFSE High Res.
512x256 matrix, 4mm , 4 NEX
SSFSE
320x192 matrix, 0.5 NEX
Artifacts
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Near-field artifact  greater SI at
the surface of the coil compared
to deeper structures
SI correction algorithm gives a
more uniform SI across the image
In FOV sat bands help to
minimize ghosting artifacts
Rafazand, Reinhold et al. JMRI
2007
Artifacts
Fibroid
No Intensity Correction
Fibroid
Intensity Correction
Rafazand, Reinhold
et al. JMRI 2007
In-FOV Sat Bands
Intensity Correction
In FOV Sat band
In FOV Sat Bands
Large endometrial cancer
Image Int. Corr.
Anterior Satband
Other Artifacts
Susceptibility Artifact
No Fat sat
Fat sat
Routine Pulse Sequences
Endometrial/Cervical Ca
Ovarian/Adnexal Lesion
 Large FOV Coronal SSFSE
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Multiplanar T2-Wsequences
 Multiplanar T2-W sequences
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Axial GRE IP/OP
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Axial GRE T1 FS
 Dynamic CE (plane to be
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Axial dynamic CE fatsat
 determined by radiologist)
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Sagittal delayed fatsat
 Axial GRE T1 for nodes
 Axial DWI (B500, B1000)
 Delayed Orthogonal plane
Pulse Sequences - T2
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T2-weighted sequences:
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Good for zonal anatomy
Pathology
C
My
E
Bl
JZ
OS
FS
U
Orthogonal Planes
Septate :flat fundus
Pulse Sequences - T2 FS
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Not routinely used
Advantages:
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Disadvantage:
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Decreases motion artifacts
Improves dynamic range
Bowel edema post XRT
Difficult to see low SI lesions
Critical for f/u post surgery and/or chemoradiation therapy
Pulse Sequences - T2 FS
Endometrioma is difficult to
pick up on the T2 FS image
On this T2 no FS image
the lesion is clearly seen
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T1-weighted sequences:
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Characterization of ovarian/adnexal
masses
Exclude the presence of blood or fat in
lesions
Lymphadenopathy
Benign ovarian/adnexal lesions
Mature Cystic Teratoma or Dermoid
Cy
Cy
Cy
Opposed phase
Cy
In phase
Fat saturation
T2
Lipid poor dermoid
T1 In phase
T1 Opposed phase
T1 FS
Endometrioma
IP
OP
FS
T2
Endometrioma
U
U
U
In phase
Opposed phase
Fatsat
T2
Benign uterine lesions
Leiomyomas
• Most common benign tumors of the uterus
• Homogeneous, solid and well defined
• Classified according to the location
• Submucosal, intramural, subserosal
Leiomyomas
Submucosal
Intramural
Subserosal
Adenomyosis
• Migration of endometrial tissue and glands into
the adjacent myometrium causing hypertrophy
• Enlargement of uterus
• Widened junctional zone with small punctate
areas of high signal intensity
Diffuse Adenomyosis
Adenomyoma
Pulse Sequences - Gadolinium
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Standard dose of Gadolinium chelate
2ml/sec. with a 15 sec. delay
Three runs, arterial, venous and delayed phase
Fat saturation critical
Pulse Sequences - Gadolinium
• T1-weighted 2D or 3D with fatsat:
• To detect enhancement (mural nodules) in complex
cysts
• To determine the extent of invasion of uterine
tumors
• To exclude peritoneal and/or serosal metastasis in
ovarian cancer
Malignant lesions
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SSFSE or Haste of abdomen and pelvis
Axial T1-W sequence for node search
Dynamic contrast enhanced sequence
Diffusion weighted sequence
Coronal SSFSE
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Good overview of abdomen
and pelvis
Detect liver lesions
Hydronephrosis
Lymphadenopathy
Pulse Sequences - T1
Lymphadenopathy
FSPGR Breath Hold
FSE/T1 Non Breath Hold
Pulse Sequences - DWI
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Diffusion imaging:
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Tissue cellularity
Blood flow
Lymph node detection
Treatment response
Staging of Endometrial Cancer
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Fourth most common female cancer
Patients usually present with post menopausal
bleeding
Diagnosed by endometrial sampling
MRI is used for staging of the disease
Endometrial Ca Staging
Stage 1A
Endometrial Ca Staging
Stage 1A
Endometrial Ca Staging
Stage 2
Endometrial Ca Staging
Stage 3
Contrast
Staging of Cervical Cancer
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Uncommon in Western countries
Detected by screening (Pap smear) and
intermenstrual bleeding
Usually in premenopausal women
Diagnosed by core biopsy or smear
MRI is used for staging purposes
Cervical Ca Staging
Parametrial Invasion
Parametrial Invasion
Contrast
Bladder Involvement
Ovarian Masses
A
C
B
D
Recurrent Ovarian Cancer
Peritoneal Implants
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Patient Preparation
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Oral: 1.5 L dilute barium,
45 mins. before exam
Rectal: Ideally 0.5-1L of water
Usually: 240-300mL US gel mixed with water
Pelvis: T2-w high resolution imaging, axial/sag.
Abdomen: Axial T2 FS BH
I.V. Contrast: Axial and Cor. T1 FS abdo/pelvis
Recurrent Ovarian Cancer
Perihepatic involvement
Recurrent Ovarian Ca
Peritoneal Implants
Recurrent Ovarian Ca
Serosal Implants
Recurrent Ovarian Ca
Exudative Ascites: C+ images ≤ 5 mins
5 MIN
10 MIN
Summary
• Antispasmodic agents improve
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image quality
Empty bladder to minimize
ghosting artifacts
High resolution imaging to
increase diagnostic accuracy
Summary
• Short axis plane for uterine and
cervical cancers
• Long axis plane for uterine
• anomaly
• I/O phase for characterizing
adnexal lesions
Summary
• Dynamic CE scans to diagnose
depth of tumor invasion
• Fat sat is critical to determine the
extent of the mass and to improve
lesion conspicuity
• Exudative ascites, acquire
C+ images within 5 min.
Acknowledgements
I would like to thank Dr. Caroline Reinhold for her advice and
support in putting together this presentation
I would also like to thank the “MR Team” for their hard work
and dedication. Without them we would not have these great images.
Lyne Santello
Vanessa Petracupa
Kathy Mailly
Noha Tannous
Sandra Farkas
Tamara Smith
Marc Proulx