Tina PW Lam Radiology

QMH

Correlative imaging of gynecological

diseases

Correlative imaging

* Structural imaging

* Tissue characterization

* Cancer staging

* Functional imaging

Structural imaging

* Detail anatomy

* Accurate lesion size, location and extent

* Delineate complex anomaly

Patient 1 14 year-old girl Menarchy at 11 years old Regular monthly cycle

Dysmenorhoea Progressive abdominal distension

TT1W axial

T2W axial

T2W

T2W sagittal

T2W coronal Uterine didelphys Cervical atresia Endometriotic cyst

Tissue Characterization

* Differentiate gas, fat, fluid, soft tissue, blood, tumour and calcification

Mature Teratoma

Leiolipoma

Calcified leiomyoma

T1W

T1W FS+C

Mature teratoma

T2W

Adenomhyosis Endometriotic cyst

2010

2012

2012

Patient 2 A 50 year-old perimenopausal lady uterine leiomyoma for several years

Recent enlargement with heterogeneous signal

MRI 2012

T2W

T1W FS +C

Red degeneration of leiomyoma

T2W

T1W FS

T1W FS +C

US in 10/2013

Cancer staging

Cancer of cervix uteri

*  Differentiate operable early disease (stages Ia, Ib & IIa) from advanced disease

*  Delineate extent of advanced disease extent to define the radiotherapy fields

*  Clinical staging inaccurate, assessment difficulties:

parametrial, pelvic sidewall invasions

bladder & rectal invasions

endocervical tumour size

lymph node & distant metastases

Patient 3 A 16 year-old girl Menorrhagia since menarchy

Progressive weight loss P/E: vagina filled with tumour

Clear cell carcinoma of cervix & vagina

Hypoplastic uterus, T-shaped cavity – suspected DES exposure

Cancer of cervix uteri

Cancer of cervix uteri

Cancer of corpus uteri

* Depth of myometrial invasion correlates with tumor grade, cervical extension, and prevalence of LN metastases

* Incidence of LN metastases increases from 3% with superficial myometrial invasion (stage IB) to 46% with deep myometrial invasion (stage IC)

* The sensitivity and specificity of MRI for depth of myometrial invasion range from 69-94% and 64-100% respectively

Berman ML, Ballon SC, Lagasse LD, Watring WG. Am J Obstet Gynecol 1980; 136:679 –688 Boronow RC, Morrow CP, Creasman WT, et al. Obstet Gynecol 1984; 63:825–832

Cancer of corpus uteri

Patient 4 56 yr-old menopausal lady Post menopausal bleeding P/E: tumor protruded from cervix MRI: stage IIIC2 aggressive tumor Histology: MMMT

Cancer of ovary

* The use of MR in evaluation of sonographically indeterminate adnexal lesions resulted in fewer surgical procedures, better patient triage, and net cost savings

Schwartz PE. Gynecologic Oncology. 1997;64(1):1–3.

Cancer of Ovary

Patient 5 A 49 year-old lady Long standing endometriotic cyst Developed vascular mural nodules

PET/CT

PET-CT

Clear cell carcinoma with omental and peritoneal deposits

Functional imaging

Omental & peritoneal

deposits

PPE

No residual disease after chemotherapy

PET/CT in 4/13

PET/CT in 9/13

Staging & follow-up of ovarian cancer

* PET/CT & CT alone are 100% specific

* PET/CT marginally better than CT alone at 97% sensitivity.

* MRI is comparable to CT

http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/StagingAndFollowUpOvarianCancer.pdf

PET/CT in cancers of cervix & corpus uteri

* Highest accuracy in LN metastasis detection (95-98%)*

* 45% endometrial cancers are grade I and not FDG-avid*

* Poor spatial resolution, inefficient detection of parametrial or adjacent organs invasion in cervical cancer

*Antonsen SL et al. Gynecol Oncol. 2013 Feb;128(2):300-8

Recent advances

* Hybrid MRI/PET * Functional MRI – Dynamic contrast enhanced - Diffusion weighted imaging * MR spectroscopy

Thank you!