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