Women's Imaging E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Current Clinical Imaging
• Sprache: Englisch

Seitenzahl: 397

Veröffentlichungsjahr: 2014

Beschreibung

The first complete reference dedicated to the full spectrum of women's imaging topics "Women's imaging" refers to the use of imaging modalities (X-ray, ultrasound, CT scan, and MRI) available for aiding in the diagnosis and care of such female-centric diseases as cancer of the breast, uterus, and ovaries. Currently, there is no single reference source that provides adequate discussions of MRI and its important role in the diagnosis of patients with women's health issues. Thoroughly illustrated with the highest-quality radiographic images available, Women's Imaging: MRI with Multimodality Correlation provides a concise overview of the topic and emphasizes practical image interpretation. It makes clear use of tables and diagrams, and offers careful examination of differential diagnosis with special notes on key learning points. Placing great emphasis on magnetic resonance imaging (MRI), while providing correlations to other important imaging modalities, the comprehensive book features the latest guidelines on imaging screening and includes in-depth chapter coverage of: * Pelvis MRI: Introduction and Technique * Imaging the Vagina and Urethra * Pelvic Floor Imaging * Imaging the Uterus * Imaging the Adnexa * Imaging Maternal Conditions in Pregnancy * Fetal Imaging * Breast MRI: Introduction and Technique * ACR Breast MRI Lexicon and Interpretation * Preoperative Breast Cancer Evaluation and Advanced Breast Cancer Imaging * Postsurgical Breast and Implant Imaging * MR-Guided Breast Interventions Providing up-to-date information on many of the health issues that affect women across the globe, Women's Imaging will appeal to all general radiologists - especially those specializing in body imaging, breast imaging, and women's imaging - as well as gynaecologists and obstetricians, breast surgeons, oncologists, radiation oncologists, and MRI technologists.

Leseprobe

Table of Contents

Title page

Copyright page

Contributors

Preface

Chapter 1: Pelvis MRI: introduction and technique

Imaging evaluation of the female pelvis

Indications for MRI

Patient preparation for MRI

Sequence protocols

Image optimization at 3T

Image interpretation

Chapter 2: Imaging the vagina and urethra

Vagina

Female urethra

Chapter 3: Pelvic floor imaging

Anatomy

Physiology

MR imaging of the pelvic floor

Pathology

Chapter 4: Imaging the uterus

Normal anatomy

Congenital uterine anomalies

Benign disease of the uterine corpus

Benign disease of the cervix

Malignant disease of the uterine corpus and cervix

Chapter 5: Imaging the adnexa

Normal anatomy

Benign disease of the adnexa

Malignant disease of the adnexa

Malignant disease of the fallopian tube

Adnexal mass characterization algorithm

Chapter 6: Imaging maternal conditions in pregnancy

Safety

Pain in pregnancy

Obstetrical complications

Postpartum uterus

Placental imaging

Chapter 7: Fetal imaging

Indications

Safety

Normal anatomy

Fetal anomalies

Chapter 8: Breast MRI: introduction and technique

Breast cancer

Rationale for the use of breast MR

Advancements in breast MRI

ACR appropriateness guidelines for the use of breast MRI

Screening

Adjunctive evaluation for extent of disease

Additional evaluation of clinical or physical finding

Technique

American College of Radiology accreditation [42]

Patient preparation and positioning

Safety (contraindications)

CAD for breast MRI

BI-RADS assessment

Difficulties in breast MR image interpretation

Chapter 9: ACR breast MRI lexicon and interpretation

Breast MR lexicon

Breast MR interpretation

Reporting breast MR

Breast MR lexicon lesion type

Associated findings

Extramammary findings

Kinetic assessment

BI-RADS Assessment categories

Common benign breast lesions

Chapter 10: Preoperative breast cancer evaluation and advanced breast cancer imaging

Preoperative breast cancer MR evaluation

Invasive ductal carcinoma (IDC)

Ductal carcinoma in situ (DCIS)

Invasive lobular carcinoma (ILC)

Medullary carcinoma

Colloid carcinoma

Tubular carcinoma

Papillary carcinoma

Paget's disease

Locally advanced breast cancer

Chapter 11: Postsurgical breast and implant imaging

Introduction

Breast conservation surgery

Mastectomy

Reconstruction

Radiation therapy

Axillary node sampling/dissection

Benign procedural changes

Chapter 12: MR-guided breast interventions

Introduction

Percutaneous guided core biopsies

Imaging protocols

Equipment

Patient selection and preparation

Patient positioning

Lesion localization

Procedure

Complications

Pearls and pitfalls

What to expect

3T biopsy experience at UCSD

Index

Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, [phone], fax [phone], or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, [phone], fax [phone], or online at http://www.wiley.com/go/permissions.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at [phone], outside the United States at [phone] or fax [phone].

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic formats. For more information about Wiley products, visit our web site at www.wiley.com.

Library of Congress Cataloging-in-Publication Data:

Women's imaging : MRI with multimodality correlation / edited by Michele A. Brown, Haydee Ojeda-Fournier, Dragana Djilas, Mohamed El-Azzazi, Richard C. Semelka.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-48284-1 (cloth)

I. Brown, Michele A., editor of compilation. II. Ojeda-Fournier, Haydee, editor of compilation. III. Djilas, Dragana, editor of compilation. IV. El-Azzazi, Mohamed, editor of compilation. V. Semelka, Richard C., editor of compilation.

[DNLM: 1. Magnetic Resonance Imaging–methods. 2. Women's Health. WN 185]

RC386.6.M34

616.07′548–dc23

2013042717

Cover design by Wiley

Contributors

Chayanin Angthong, MD

Department of Radiology

University of North Carolina at Chapel HIll

Chapel Hill, NC, USA

Jasmina Boban, MD

Center for Diagnostic Imaging

Oncology Institute of Vojvodina

Novi Sad, Serbia

Dragana Bogdanovic-Stojanovic, MD, PhD

Assistant Professor of Radiology

Center for Diagnostic Imaging

Oncology Institute of Vojvodina

Novi Sad, Serbia

Michele A. Brown, MD

Professor of Clinical Radiology

UC San Diego Health System

San Diego, CA, USA

Julie Bykowski, MD

Assistant Professor of Clinical Radiology

Moores Cancer Center

UC San Diego Health System

La Jolla, CA, USA

Jade de Guzman, MD

Assistant Professor of Clinical Radiology

Moores Cancer Center

UC San Diego Health System

La Jolla, CA, USA

Dragana Djilas, MD, PhD

Associate Professor of Radiology

Center for Diagnostic Imaging

Oncology Institute of Vojvodina

Novi Sad, Serbia

Mohamed El-Azzazi MD, PhD

Clinical Research Scholar, MRI Section, Department of Radiology

University of North Carolina, Chapel Hill, NC, USA;

Professor of Radiology, Al-Azhar University

Cairo, Egypt;

Associate Professor of Radiology

Dammam University, Saudi Arabia;

Consultant in Radiology

King Fahad University Hospital, Saudi Arabia

Randy Fanous, MD, BHSc

Department of Radiology

UC San Diego Health System

San Diego, CA, USA

Michael J. Gabe, MD

Department of Radiology

UC San Diego Health System

San Diego, CA, USA

Vladimir Ivanovic, BSCEE

Center for Diagnostic Imaging

Oncology Institute of Vojvodina

Novi Sad, Serbia

Reena Malhotra

Department of Radiology

North Shore-LIJ Health System

New Hyde Park, NY, USA

Mary K. O′Boyle, MD

Clinical Professor of Radiology

Chief of Ultrasound

UC San Diego Health System

San Diego, CA, USA

Haydee Ojeda-Fournier, MD

Associate Professor of Clinical Radiology

Medical Director, Breast Imaging Section

Director Medical Student Education in Radiology

Moores Cancer Center

UC San Diego Health System

La Jolla, CA, USA

Dag Pavic, MD

Associate Professor of Radiology

Department of Radiology

Medical University of South Carolina

Charleston, SC, USA

Natasa Prvulovic Bunovic, MD

Consultant in Radiology

Center for Diagnostic Imaging

Oncology Institute of Vojvodina

Novi Sad, Serbia

Steven S. Raman, MD

Professor of Radiology, Surgery and Urology

David Geffen School of Medicine at UCLA

Los Angeles, CA, USA

Katherine M. Richman, MD

Clinical Professor of Radiology

UC San Diego Health System

La Jolla, CA, USA

Ryan C. Rockhill, MD

Body and Breast Imaging

Naval Medical Center San Diego

San Diego, CA, USA

Lorene E. Romine, MD

Assistant Clinical Professor of Radiology

UC San Diego Health System

San Diego, CA, USA

Laura E. Rueff, MD, MPH

Department of Radiology

University of California Los Angeles

Los Angeles, CA, USA

Richard C. Semelka, MD

Director, Magnetic Resonance Services

Professor, Vice Chairman of Clinical Research and

Vice Chairman of Quality and Safety

Department of Radiology

University of North Carolina at Chapel Hill

Chapel Hill, NC, USA

Shannon St Clair, MD

Department of Radiology

UC San Diego Health System

San Diego, CA, USA

Preface

Women's health issues consume a large portion of medical resources and healthcare dollars. Proper management requires a team of physicians from various specialties. Within the field of Radiology, there has been a trend toward developing a subspecialty dedicated to comprehensive imaging of women's healthcare needs, including gynecological, obstetric, genitourinary, and breast conditions. The term “Women's Imaging” is used differently in different contexts; for the purpose of this textbook, the term is used to describe imaging of the female reproductive system, including the pelvis and breast. An effective women's imager must work closely with clinical colleagues of various specialties and maintain a current understanding of diagnostic strategies, clinical implications of imaging findings, and the appropriate use of imaging tests to detect and monitor treatment.

The use of magnetic resonance imaging (MRI) for evaluation of gynecological, obstetric, and breast conditions has increased in recent years. MRI provides excellent tissue contrast resolution in the female pelvis and breast without ionizing radiation. Used together with complementary modalities, such as ultrasound and mammography, MRI has been shown to add important information to help guide patient care. The current text aims to provide the essentials of MRI in Women's Imaging, including indications, technique, and interpretation. For a number of entities, we illustrate the companion imaging studies of computed tomography, ultrasound, or mammography. Hopefully this text serves to redress the considerable underutilization of MRI in these settings. Used appropriately, MRI is cost-effective and singularly informative. There are other textbooks on the separate topics of pelvic and breast MRI; the goal of this text is to combine and update the essentials of Women's Imaging MRI into a comprehensive and succinct overview.

The present volume is separated into two main sections: female pelvis (chapters 1–7) and breast (chapters 8–12). The first chapter presents current common indications and sample protocols for female pelvis MRI. Chapters 2–5 address pathology and respective imaging findings of the vagina and female urethra, pelvic floor, uterus, and adnexa. Chapters 6 and 7 focus on issues specific to pregnancy. Chapter 8 discusses rationale and technique for MRI of the breast. Chapters 9–12 are dedicated to the imaging features of breast disease and the role of MRI-guided intervention in the care of women with abnormal breast imaging findings.

This text is the collective effort of many individuals. I would like to thank the co-editors and contributors for their hard work. In addition, I am indebted to my radiology colleagues at the University of California San Diego for their help and support, with special thanks to every member of the body imaging and breast imaging divisions.

Michele A. Brown, MD

Chapter 1

Pelvis MRI: introduction and technique

Michele A. Brown & Richard C. Semelka

Imaging evaluation of the female pelvis

Imaging plays an important role in the management of gynecological diseaseUltrasound is often the initial imaging testPoor tissue contrast of CT limits gynecologic applicationsMRI benefits from excellent tissue contrast and lack of ionizing radiationIncreased experience and availability have led to increased role of MRIMRI deemed appropriate by American College of Radiology for gynecological conditions, especially pre-treatment assessment of endometrial and cervical cancer, work-up of suspected adnexal mass, and evaluation of acute pelvic pain in reproductive-aged women in the setting of indeterminate ultrasound [1–4]Numerous gynecological and obstetric conditions are depicted by MRI, which may provide initial imaging (e.g., suspected urethral diverticulum) or problem-solving after ultrasound

Indications for MRI

(Table 1.1)

Table 1.1. Indications for MRI of the female pelvis

IndicationProtocolNotesPelvic painGeneralFS T1WI for endometriosisUrethral diverticulmUrethraContrast if known/visualized massVaginal massUrethraContrast if known/visualized massPelvic floor symptomsPelvic floorSagittal images with ValsalvaUterine anomalyUterine anomalyTrue coronal to uterine fundusAdenomyosisGeneralBright myometrial foci on T2WIFibroidsGeneralAdd contrast if pre-embolizationFibroid versus adnexal massGeneralVessels extending from uterus to mass suggest uterine originEndometrial cancerUterine malignancyHigh resolution T2WI and T1WI + contrast oblique to endometrium for tumor invasionCervical cancerUterine malignancyHigh resolution T2WI oblique to cervix for parametrial invasionAdnexal mass characterizationGeneralFS T1WI for dermoid, endometriomaAbdominal pain in pregnancyMaternal abdominal painSS-ETSE (+ FS), and steady-state GE for appendix, monitor if possibleFetal anomalyFetalSS-ETSE oriented to region of interest, monitor if possible

FS = fat saturated; T1WI = T1-weighted images; T2WI = T2-weighted images; SS = single shot; ETSE = echo-train spin-echo; GE = gradient echo

Benign uterine conditionsAnomalies MRI considered imaging modality of choiceInforms management decisions (e.g., septate versus bicornuate uterus)Acquired disease Problem solving for indeterminate ultrasoundMRI allows definitive diagnosis for conditions such as urethral diverticulum, leiomyoma, adenomyosis, endometriosis, and dermoidUterine malignancyEndometrial cancer Preoperative staging: deep myometrial invasion correlated with lymph node invasion [5, 6]MRI shown to aid management for advanced and high grade cancer [7]Cervical carcinoma Depth of stromal and parametrial invasion [8, 9]MRI particularly aids management for Tumors larger than 2 cmEndocervical tumors [10]Biopsy-proved adenocarcinoma (cervical versus endometrial origin)Coexistent pelvic mass(es)New diagnosis of cervical cancer during pregnancyPrior radiation therapy [11–15]Adnexal massDetermine origin of massTissue characterization aids specific diagnosis (e.g., endometrioma, dermoid)MRI helps predict likelihood of malignancy to direct proper management and limit surgical intervention for benign disease [16, 17]For known ovarian cancer, CT typically used for staging; MRI if CT contraindicatedMRI may yield definitive diagnosis for adnexal disease that is indeterminate on ultrasound, obviating need for follow-up imagingAbdominal pain in pregnancyAccurate evaluation for appendicitis (and other acute diseases) without ionizing radiation [18, 19]Increasing availability of MRI in acute settingFetal anomaliesProblem solving for indeterminate ultrasoundUsefulness of MRI has increased with ultrafast sequences

Patient preparation for MRI

Empty bladderFasting 4 hoursOptional Antispasmotic (e.g., glucagon 1 mg)Intra-vaginal gel [20]Supine position, or decubitus in late pregnancyPhased-array coil positioned over pelvisTo reduce artifact, may utilize Saturation band over anterior abdominal wall for non-fat-saturated sagittalSupplemental anteroposterior frequency-encoding direction for axial imagesIntrauterine contraceptive devices are safely imaged [21]

Sequence protocols

Many protocol optionsAppropriate choice depends on Specific clinical questionAvailable equipment and expertiseFor known or suspected uterine disease/anomalies, T2-weighted sequences are obtained in an oblique plane oriented to uterus (Figure 1.1)

Figure 1.1. Imaging planes oriented to the uterus. Multiple T2-weighted images in a patient with septate uterus. Large field-of-view single-shot sequence (a) is obtained first and is used to plan an oblique sagittal T2-weighted sequence (b) obtained parallel to the endometrium (line, a). The oblique sagittal is used to plan an oblique axial (c) obtained perpendicular to the endometrium (line, b). The oblique axial may then be used to plan a true coronal of the uterus (d) obtained parallel to the endometrium (line, c). In the absence of 3D T2-weighted imaging, this process assures appropriate imaging planes regardless of angle/tilt of the uterus.

Individual sequence parameters may vary based on manufacturer, etc.Sequences may include Single-shot (SS) echo-train spin echo (ETSE) For example, HASTE or SSFSESensitive to fluid, resistant to motion and susceptibilityLarge field of view Localization, evaluation of coil positionCoronal: evaluation of renal anomalies/obstructionAxial: prescribe true sagittal view of uterusT2-weighted Breathhold may be sufficient for benign diseaseNon-breathhold (high-resolution) for uterine malignancyWith or without fat saturationMay be done as 3D ETSEBest sequence for uterine zonal anatomyT1-weighted Breathhold in- and out-of-phase dual echo Differentiates fat- and blood-containing lesionsSensitive to small foci of fat within adnexal massNon-breathhold (high-resolution) for uterine cancerChemically selective fat saturation for endometriosisT2/T1-weighted steady-state free precession gradient echo (GE) For example, TruFISP or FIESTARapid, resistant to motionDifferentiates vessels from bowel (e.g., appendix)Useful for fetal and maternal imagingT1-weighted 3D GE pre- and post-contrast Fat-suppressed GE, repeated for dynamic imagingProvides enhancement informationMay use MRA parameters (e.g., vascular malformation)Diffusion-weighted imaging (DWI) (optional) B values of 0 and at least one other value up to 1000Apparent diffusion coefficient (ADC) map createdDWI sequence and ADC map interpreted togetherAids detection of tumor, inflammationAdditional functional techniques may have increasing role [7]Oblique planes oriented to the endometrium or cervix important for cancer [22]Protocol tailored to clinical question (Table 1.2, Table 1.3, Table 1.4, Table 1.5, Table 1.6, Table 1.7, Table 1.8)

Table 1.2. General female pelvis

Table 1.3. Urethra

Table 1.4. Pelvic floor

Table 1.5. Uterine anomaly

Table 1.6. Uterine malignancy

Table 1.7. Maternal abdominal pain

Table 1.8. Fetal

Image optimization at 3T

Potential advantages Increase in signal-to-noise ratio (SNR), orSimilar SNR at a faster speedChallenges Signal shading magnified by dielectric effectsIncreased specific absorption rates (SARs)Changes in optimal TR and TEIncreased signal inhomogeneities Greater shimming challenge for extrinsic magnetic fieldIntrinsic field distortion due to increased susceptibility/chemical shiftSolutions [23–28] Dialectric effect: dialectric pad (= radiofrequency cushion) placed between patient and surface coilSusceptibility: use shorter TE/higher receiver bandwidth, higher spatial resolution3D GE and ETSE sequences may benefit from higher field strengthConsider individual patient Pregnant patients less suitable for 3T due to standing wave effects from amniotic fluid and safety concerns [26]Non-pregnant patients may be imaged safely and effectively at 3T using optimized parameters [28]

Image interpretation

Large volume data acquisitionMay be useful to employ a systematic checklist (Table 1.9) Several gynecological conditions have MRI features that allow definitive diagnosis

Table 1.9. Diagnostic checklist for female pelvis MRI

StructureMRI features evaluatedGynecologicalUterine corpusSize and positionPresence of myometrial massEndometrium thicknessJunctional zone thicknessCervixPresence of cystic massPresence of solid tumor   Size of lesion   Parametrial involvementVaginaPresence of cystic massPresence of wall thickening/solid tumorAdnexaOvarian sizePresence of ovarian mass   Cystic or solid   Fat containing   Blood containing   Enhancement features   Unilateral or bilateralParaovarian cystic or solid massNon-gynecologicalBladderPresence of solid massPresence of cystoceleUrethraPresence of diverticulum   Size and configuration   Solid/enhancing componentsPresence of hypermobilityBowelCaliberPresence of rectoceleMusculoskeletalBone marrow signalDegenerative changesTraumatic injuryLymphaticEnlarged lymph nodes

References

1. Lee, J.H., Dubinsky, T., Andreotti, R.F., et al. ACR Appropriateness Criteria(R) pretreatment evaluation and follow-up of endometrial cancer of the uterus. Ultrasound Quarterly 2011; 27(2):139–45.

2. Siegel, C.L., Andreotti, R.F., Cardenes, H.R., et al. ACR Appropriateness Criteria(R) pretreatment planning of invasive cancer of the cervix. Journal of the American College of Radiology 2012; 9(6):395–402.

3. Harris, R.D., Javitt, M.C., Glanc, P., et al. ACR Appropriateness Criteria(R) clinically suspected adnexal mass. Ultrasound Quarterly 2013; 29(1):79–86.

4. Andreotti, R.F., Lee, S.I., Dejesus Allison, S.O., et al. ACR Appropriateness Criteria(R) acute pelvic pain in the reproductive age group. Ultrasound Quarterly 2011; 27(3):205–10.

5. Kinkel, K., Kaji, Y., Yu, K.K., et al. Radiologic staging in patients with endometrial cancer: a meta-analysis. Radiology 1999; 212(3):711–18.

6. Wakefield, J.C., Downey, K., Kyriazi, S., deSouza, N.M. New MR techniques in gynecologic cancer. AJR. American Journal of Roentgenology 2013; 200(2):249–60

7. Frei, K.A., Kinkel, K., Bonél, H.M., et al. Prediction of deep myometrial invasion in patients with endometrial cancer: clinical utility of contrast-enhanced MR imaging – a meta-analysis and Bayesian analysis. Radiology 2000; 216(2):444–9.

8. Sironi, S., De Cobelli, F., Scarfone, G., et al. Carcinoma of the cervix: value of plain and gadolinium-enhanced MR imaging in assessing degree of invasiveness. Radiology 1993; 188(3):780–97.

9. Subak, L.L., Hricak, H., Powell, C.B., Azizi, L., Stern, J.L. Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging. Obstetrics and Gynecology 1995; 86(1):43–50.

10. Hricak, H., Powell, C.B., Yu, K.K., et al. Invasive cervical carcinoma: role of MR imaging in pretreatment work-up – cost minimization and diagnostic efficacy analysis. Radiology 1996; 198(2):403–9.

11. Flueckiger, F., Ebner, F., Poschauko, H., et al. Cervical cancer: serial MR imaging before and after primary radiation therapy – a 2-year follow-up study. Radiology 1992; 184(1):89–93.

12. Hricak, H., Swift, P.S., Campos, Z., et al. Irradiation of the cervix uteri: value of unenhanced and contrast-enhanced MR imaging. Radiology 1993; 189(2):381–8.

13. Weber, T.M., Sostman, H.D., Spritzer, C.E., et al. Cervical carcinoma: determination of recurrent tumor extent versus radiation changes with MR imaging. Radiology 1995; 194(1):135–9.

14. Yamashita, Y., Harada, M., Torashima, M., et al. Dynamic MR imaging of recurrent postoperative cervical cancer. Journal of Magnetic Resonance Imaging 1996; 6(1):167–71.

15. Hertel, H., Köhler, C., Grund, D., et al. Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic lymphadenectomy: prospective multicenter study of 100 patients with early cervical cancer. Gynecologic Oncology 2006; 103(2): 506–11.

16. Hricak, H., Chen, M., Coakley, F.V., et al. Complex adnexal masses: detection and characterization with MR imaging – multivariate analysis. Radiology 2000; 214(1):39–46.

17. Sohaib, S.A., Sahdev, A., Van Trappen, P., Jacobs, I.J., Reznek, R.H. Characterization of adnexal mass lesions on MR imaging. AJR. American Journal of Roentgenology 2003; 180(5):1297–304.

18. Birchard, K.R., Brown, M.A., Hyslop, W.B., Firat, Z., Semelka, R.C. MRI of acute abdominal and pelvic pain in pregnant patients. AJR. American Journal of Roentgenology 2005; 184(2):452–8.

19. Oto, A., Ernst, R.D., Shah, R., et al. Right-lower-quadrant pain and suspected appendicitis in pregnant women: evaluation with MR imaging – initial experience. Radiology 2005; 234(2):445–51.

20. Brown, M.A., Mattrey, R.F., Stamato, S., Sirlin, C.B. MRI of the female pelvis using vaginal gel. AJR. American Journal of Roentgenology 2005; 185(5):1221–7.

21. Pasquale, S.A., Russer, T.J., Foldesy, R., Mezrich, R.S. Lack of interaction between magnetic resonance imaging and the copper-T380A IUD. Contraception 1997; 55(3): 169–73.

22. Shiraiwa, M., Joja, I., Asakawa, T., et al. Cervical carcinoma: efficacy of thin-section oblique axial T2-weighted images for evaluating parametrial invasion. Abdominal Imaging 1999; 24(5): 514–19.

23. Kataoka, M., Kido, A., Koyama, T., et al. MRI of the female pelvis at 3T compared to 1.5T: evaluation on high-resolution T2-weighted and HASTE images. Journal of Magnetic Resonance Imaging 2007; 25(3): 527–34.

24. Martin, D.R., Friel, H.T., Danrad, R., De Becker, J., Hussain, S.M. Approach to abdominal imaging at 1.5 Tesla and optimization at 3 Tesla. Magnetic Resonance Imaging Clinics of North America 2005; 13(2):241–54.

25. Hussain, S.M., van den Bos, I.C., Oliveto, J.M., Martin, D.R. MR imaging of the female pelvis at 3T. Magnetic Resonance Imaging Clinics of North America 2006; 14(4):537–44.

26. Merkle, E.M., Dale, B.M. Abdominal MRI at 3.0 T: the basics revisited. AJR. American Journal of Roentgenology 2006; 186(6):1524–32.

27. Cornfeld, D., Weinreb, J. Simple changes to 1.5-T MRI abdomen and pelvis protocols to optimize resuts at 3T. AJR. American Journal of Roentgenology 2008; 190(2):W140–50.

28. Morakkabati-Spitz, N., Schild, H.H., Kuhl, C.K., et al. Female pelvis: MR imaging at 3.0 T with sensitivity encoding and flip-angle sweep technique. Radiology 2006; 241(2):538–45.

Chapter 2

Imaging the vagina and urethra

Shannon St. Clair, Randy Fanous, Mohamed El-Azzazi, Richard C. Semelka, & Michele A. Brown

Vagina

Normal anatomy

Key facts

Fibromuscular tube between bladder and rectum, 7–9 cm long (Figure 2.1) Embryological origin [1] Upper one-third = Müllerian ductLower two-thirds = urogenital sinusLayers [2] Inner = mucosaMiddle = submucosa and muscularisOuter = adventitia, containing vaginal venous plexusFornices: anterior, posterior, lateral Portion of vagina that surrounds the cervixBest visualized on sagittal and transverse imagesFor descriptive purposes, vagina may be divided into thirds