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![Page 1: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/1.jpg)
May 28 – 30, 2015, Montréal, Québec
Female Pelvis Imaging
Laurian Rohoman, ACR,RT(MR),RT(R),FSMRTMcGill University Health CenterMontreal General Hospital
![Page 2: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/2.jpg)
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.
![Page 3: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/3.jpg)
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).
![Page 4: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/4.jpg)
Outline
Optimizing pelvic imaging Patient preparation Surface coil and patient positioning Artifacts
Routine pulse sequences Pathology
![Page 5: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/5.jpg)
Patient Preparation
Screening Pelvic questionnaire
Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy
![Page 6: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/6.jpg)
Patient Preparation
Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy
![Page 7: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/7.jpg)
Patient preparation
Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy
Patient on contraceptives
Endometrial hyperplasia
![Page 8: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/8.jpg)
Patient Preparation
Pelvic questionnaire Pre/Postmenopausal Date of LMP Hormones/contraceptives IUD’s /tampons Surgery/XRT/Chemotherapy
IUD
Tampon
![Page 9: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/9.jpg)
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
![Page 10: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/10.jpg)
Patient Preparation
Fasting 4-6 hours
Avoid diuretics, caffeine
Empty Bladder
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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
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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
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Patient Positioning
Poor coil positioning
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Imaging Techniques
FRFSE High Res.512x256 matrix, 4mm , 4 NEX
SSFSE 320x192 matrix, 0.5 NEX
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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
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Artifacts
No Intensity Correction Intensity Correction
Rafazand, Reinhold et al. JMRI 2007
FibroidFibroid
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In-FOV Sat Bands
Intensity Correction
Rafazand, Reinhold et al. JMRI 2007
In FOV Sat band
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In FOV Sat Bands
Image Int. Corr. Anterior Satband
Large endometrial cancer
![Page 19: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/19.jpg)
Other Artifacts
Susceptibility Artifact
No Fat sat Fat sat
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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
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Pulse Sequences - T2
T2-weighted sequences: Good for zonal anatomy Pathology
EJZMy
OS
FS
Bl
U
C
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Orthogonal Planes
Septate :flat fundus
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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
![Page 24: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/24.jpg)
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
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T1-weighted sequences: Characterization of ovarian/adnexal
masses Exclude the presence of blood or fat in
lesions Lymphadenopathy
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Benign ovarian/adnexal lesions
Opposed phase
Mature Cystic Teratoma or Dermoid
In phase
Fat saturation
Cy
Cy
Cy
Cy
T2
![Page 27: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/27.jpg)
T1 In phase
T1 FS
T1 Opposed phase
Lipid poor dermoid
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Endometrioma
T2
FS
OPIP
![Page 29: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/29.jpg)
Endometrioma
UU
U
In phaseOpposed phase
FatsatT2
![Page 30: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/30.jpg)
Benign uterine lesions
• Most common benign tumors of the uterus• Homogeneous, solid and well defined• Classified according to the location• Submucosal, intramural, subserosal
Leiomyomas
![Page 31: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/31.jpg)
Leiomyomas
Submucosal Intramural Subserosal
![Page 32: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/32.jpg)
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
![Page 33: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/33.jpg)
Diffuse Adenomyosis
![Page 34: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/34.jpg)
Adenomyoma
![Page 35: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/35.jpg)
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
![Page 36: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/36.jpg)
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
![Page 37: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/37.jpg)
Malignant lesions
• SSFSE or Haste of abdomen and pelvis• Axial T1-W sequence for node search• Dynamic contrast enhanced sequence • Diffusion weighted sequence
![Page 38: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/38.jpg)
Coronal SSFSE
Good overview of abdomen and pelvis
Detect liver lesions Hydronephrosis Lymphadenopathy
![Page 39: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/39.jpg)
Pulse Sequences - T1
Lymphadenopathy
FSPGR Breath Hold FSE/T1 Non Breath Hold
![Page 40: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/40.jpg)
Pulse Sequences - DWI Diffusion imaging:
Tissue cellularity Blood flow Lymph node detection Treatment response
![Page 41: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/41.jpg)
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
![Page 42: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/42.jpg)
Endometrial Ca Staging
Stage 1A
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Endometrial Ca Staging
Stage 1A
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Endometrial Ca Staging
Stage 2
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Endometrial Ca Staging
Contrast
Stage 3
![Page 46: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/46.jpg)
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
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Cervical Ca Staging
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Parametrial Invasion
![Page 49: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/49.jpg)
Parametrial Invasion
Contrast
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Bladder Involvement
![Page 51: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/51.jpg)
Ovarian Masses
A
B
C
D
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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
![Page 53: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/53.jpg)
Recurrent Ovarian Cancer
Perihepatic involvement
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Recurrent Ovarian Ca
Peritoneal Implants
![Page 55: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/55.jpg)
Recurrent Ovarian Ca
Serosal Implants
![Page 56: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/56.jpg)
Recurrent Ovarian Ca
Exudative Ascites: C+ images ≤ 5 mins
5 MIN 10 MIN
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Summary
• Antispasmodic agents improve
image quality
• Empty bladder to minimize
ghosting artifacts
• High resolution imaging to
increase diagnostic accuracy
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Summary
• Short axis plane for uterine and
cervical cancers
• Long axis plane for uterine
• anomaly
• I/O phase for characterizing
adnexal lesions
![Page 59: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/59.jpg)
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.
![Page 60: May 28 – 30, 2015, Montréal, Québec Female Pelvis Imaging Laurian Rohoman, ACR,RT(MR),RT(R),FSMRT McGill University Health Center Montreal General Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022062321/56649e245503460f94b12144/html5/thumbnails/60.jpg)
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