may 28 – 30, 2015, montréal, québec female pelvis imaging laurian rohoman,...

May 28 – 30, 2015, Montréal, Québec

Female Pelvis Imaging

Laurian Rohoman, ACR,RT(MR),RT(R),FSMRTMcGill University Health CenterMontreal General Hospital

Disclosure Statement: No Conflict of Interest

May 28 – 30, 2015, Montréal, Québec

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).

Outline

Optimizing pelvic imaging Patient preparation Surface coil and patient positioning Artifacts

Routine pulse sequences Pathology

Patient Preparation

Screening Pelvic questionnaire

Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy

Patient Preparation

Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy

Patient preparation

Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy

Patient on contraceptives

Endometrial hyperplasia

Patient Preparation

Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy

IUD

Tampon

Patient Preparation

Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy

I yr. post

3 yrs. post

5 yrs. post

Pre XRT

Patient Preparation

Fasting 4-6 hours

Avoid diuretics, caffeine

Empty Bladder

Antiperistaltic Agents

• Hyoscine Butylbromide (40 mg I.M.)

• Contra-indications:• Glaucoma• Angina, CHF, arrythmia• BPH

• Glucagon ( 1 mg)• Caution:

• Insulin dependent diabetic.

No antispasmodic

Antispasmodic

Surface Coil Technique

• Multichannel Surface Coil:• 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

• 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

Artifacts

No Intensity Correction Intensity Correction

Rafazand, Reinhold et al. JMRI 2007

FibroidFibroid

In-FOV Sat Bands

Intensity Correction

Rafazand, Reinhold et al. JMRI 2007

In FOV Sat band

In FOV Sat Bands

Image Int. Corr. Anterior Satband

Large endometrial cancer

Other Artifacts

Susceptibility Artifact

No Fat sat Fat sat

Routine Pulse Sequences

Large FOV Coronal SSFSE Multiplanar T2-W sequences Axial GRE T1 for nodes Axial DWI (B500, B1000) Dynamic CE (plane to be determined by radiologist) Delayed Orthogonal plane

Multiplanar T2-Wsequences

Axial GRE IP/OP

Axial GRE T1 FS

Axial dynamic CE fatsat

Sagittal delayed fatsat

Endometrial/Cervical Ca Ovarian/Adnexal Lesion

Pulse Sequences - T2

T2-weighted sequences: Good for zonal anatomy Pathology

EJZMy

OS

FS

Bl

U

C

Orthogonal Planes

Septate :flat fundus

Pulse Sequences - T2 FS

Not routinely used Advantages:

Decreases motion artifacts Improves dynamic range Bowel edema post XRT

Disadvantage: Difficult to see low SI lesions

Critical for f/u post surgery and/or chemo-radiation therapy

Pulse Sequences - T2 FS

Endometrioma is difficult topick up on the T2 FS image

On this T2 no FS image the lesion is clearly seen

T1-weighted sequences: Characterization of ovarian/adnexal

masses Exclude the presence of blood or fat in

lesions Lymphadenopathy

Benign ovarian/adnexal lesions

Opposed phase

Mature Cystic Teratoma or Dermoid

In phase

Fat saturation

Cy

Cy

Cy

Cy

T2

T1 In phase

T1 FS

T1 Opposed phase

Lipid poor dermoid

Endometrioma

T2

FS

OPIP

Endometrioma

UU

U

In phaseOpposed phase

FatsatT2

Benign uterine lesions

• Most common benign tumors of the uterus• Homogeneous, solid and well defined• Classified according to the location• Submucosal, intramural, subserosal

Leiomyomas

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

• 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

• SSFSE or Haste of abdomen and pelvis• Axial T1-W sequence for node search• Dynamic contrast enhanced sequence • Diffusion weighted sequence

Coronal SSFSE

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 Diffusion imaging:

Tissue cellularity Blood flow Lymph node detection Treatment response

Staging of Endometrial Cancer

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

Contrast

Stage 3

Staging of Cervical Cancer

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

B

C

D

Recurrent Ovarian Cancer

Patient Preparation 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

Peritoneal Implants

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

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 Tamara Smith

Noha Tannous Marc Proulx

Sandra Farkas