MRI became more powerful in evaluation of gynecological diseases with popular use of functional sequences such as dynamic contrast enhancement (DCE) and diffusion-weighted imaging (DWI) in addition to fundamental T2-weighted imaging (T2WI). DCE and DWI became integral parts of gynecologic MRI that provide useful additional information in key elements of MRI evaluation of malignant diseases of the uterus and ovaries. This talk will include MRI features in evaluation of depth of myometrial invasion in endometrial carcinoma, parametrial invasion in uterine cervical carcinoma, and differentiation between benign and borderline malignancy in ovarian tumors. For endometrial carcinoma, assessing the depth of myometrial invasion has prognostic importance because it correlates well with the incidence of lymph node metastasis. An intact junctional zone at T2WI and an early enhancing subendometrial layer at DCE exclude deep myometrial invasion. Intact enhancing cervical mucosa excludes cervical stromal invasion. DWI has added value in demonstration of primary tumor, evaluation of depth of myometrial invasion, and depiction of unexpected extrauterine spread. It is difficult to assess depth of myometrial invasion if myometrium is thinned because of huge endometrial mass or hydrometra, or in case of associated uterine diseases such as leiomyoma, adenomyosis or congenital uterine anomalies. For uterine cervical carcinoma, parametrium is the most important part to be evaluated with MRI. Parametrium surrounds the uterine cervix in the form of cardinal ligaments on both sides, as uterovesical ligament anteriorly and as uterosacral ligament posteriolrly. Therefore assessment of parametrium all three planes (axial, coronal, sagittal) is important. MRI findings of parametrial invasion are, in addition to disruption of low-intensity cervical stromal ring at T2WI, irregular spiculated margin of cervical mass, nodular or irregular tumor extending into the parametrium, or tumor encasement of the periuterine vessels. Pitfalls in interpretation are partial volume effect by surrounding structures and secondary inflammatory changes around cervical tumor. One of the important area in MRI evaluation of ovarian tumors is differentiation between benign epithelial tumors and borderline malignancies. DWI findings are often very useful in the differentiation.

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References

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