Radiology
Genitourinary Yasuyuki Koji
MD #{149}Mutsumasa Hitoshi Okamura,
Yamashita,
Miyazaki,
MD
Carcinoma Dynamic
ofthe
magnetic
Takahashi, MD
#{149}
resonance
imaging was performed eight normal uteri and carcinomas. After rapid
(MR)
to evaluate 29 cervical injection
Cervix:
H
Takamine
Dynamic
been
to be
higher signal intensity than mat cervical tissue with this
the
quence.
plane.
In the
normal
uterus,
because
the
MR
tumor
in
imaging,
generates
a
does pulse
however,
norsecan-
initial slight enhancement of the junction between endometrium and
not demonstrate superficial carcinoma (including carcinoma in situ and mi-
myometrium
croinvasive
was
followed
by
hancement
of the uterine Cervical carcinoma
trium. readily distinguished from cal stroma and myometrium
en-
myomewas
the cernin the early dynamic phase (30-60 seconds). Tumor-cervix contrast in the early dynamic phase was significantly
more
marked
technique contrast weighted
with
the dynamic
SE
than with T2-weighted or material-enhanced Tiimaging (P < .01). For the
evaluation of parametrial invasion, the dynamic FLASH study showed better contrast than did T2-weighted images. derwent
Among surgery,
of the degree
18 patients accurate
who unassessment
of stromal
invasion and was possible with dyimages in i4 patients
tumor
size
namic
MR
(78%), (6i%), images
T2-weighted images in ii and postcontrast Ti-weighted in seven (39%).
Index
terms:
parative rapid
Magnetic Magnetic
studies
#{149}
imaging
854.32
Uterine
Uterine
neoplasms,
#{149}
diagnosis,
MR.
854.1214,
854.32
1992; 182:643-648
Radiology
I
From
MT.,
the Departments
T.S.)
and
of Radiology
Gynecology
(KM., HO.), Kumamoto Medicine, 1-1-1 Honjo,
From
the
ceived
16; final November (
1991
July
RSNA
1, 1991;
revision
scientific
received
School of 860, Japan.
assembly. requested
November reprint
(Y.Y.,
Obstetrics
University Kumamoto
revision
6. Address
RSNA, 1992
and
requests
ReAugust
5; accepted to Y.Y.
because
of
poor contrast between the cervical epithelium and tumor (4,5). Dynamic MR imaging with contrast enhancement obtained with gadopentetate dimegtumine is reported to be sensitive in the evaluation of hemodynamics (6) and in demonstrating small tumors (7). To enhance the detectabitity and accuracy of staging in cervical carcinoma, we prospectively performed dynamic MR imaging with
gadopentetate For this
dimeglumine. we evaluated
report,
hemodynamics vical carcinoma,
MR imaging findings,
ability imaging images
of the uterus correlated
with and
and
the and cerdynamic
histopathotogic
compared
accuracy
the
detect-
of dynamic
after
the
contrast
material.
administration
of
AND
METHODS
carcinoma
patients,
were
evaluated
within
nod of 7 days before operation, and roscopic and microscopic specimens obtained. The remaining 11 patients
therapy
(three
patients
classification
of the
International
Fed-
eration of Gynecology and Obstetrics and pathological classification of the tumor (TNM) (8). The depth of stromal invasion at the
midsagittal
as follows: sion (depth of the
level
was
no invasion, of invasion
stroma),
also
classified
superficial less than
or deep
invasion
invaone-half (greater
of the stroma). MR imaging was performed with a 1.5-T superconductive unit (Magnetom; Sicmens, Erlangen, Germany). Ti-weighted spin-echo (SE) 600/15 (repetition time msec/echo time msec) images were obtamed before and after contrast enhancement in the axial or sagittal plane with a than
one-half
192
x 256
matrix
two
and
excitations.
T2-
weighted 2,000/70 SE images were obtamed in sagittal and axial sections with a 256 x 256 matrix and one excitation. In 25 patients, dynamic MR imaging employed the SE technique in the sagittal plane with 200/15, a 128 x 256 rectangular matrix, and one excitation. In patients with large tumors suspected of parametrial or pelvic extension (n = 8; four patients underwent imaging with both techniques separately), dynamic MR imaging the
technique ifip angle
fast
low-angle
in the axial of 40#{176}, a 256
shot
plane x 256
(FLASH)
with 50/10, matrix, and
a
one excitation. Actual sampling time per image 25.6 seconds for the SE technique three planar
aged 33-88 (average, 59.8) years, with cervical carcinoma of the uterus, and eight healthy subjects (two in the proliferative phase, two in the secretory phase, one during menstruation, and three in menopause), aged 34-70 (average, 54.8) years, were prospectively evaluated with dynamic MR imaging. In all patients, cervical carcinoma was diagnosed with colposcopy and biopsy before MR imaging. Eighteen patients with cervical
ing
seconds
MATERIALS Twenty-nine
radiation
with stage IIB, five with stage IIIB, and three with stage IVA). Clinical staging was based on the stag-
employed
MR
with routine T2-weighted and with Ti-weighted images
obtained
resonance (MR), comresonance (MR), neoplasms,
#{149}
carcinoma),
Imaging’
derwent
useful
the evaluation of cervical carcinoma of the uterus. A T2-weighted pulse sequence has been reported to be optimal for imaging cervical carcinomas (1-3)
MD
MR
MR imaging
shown
gadopentetate dimeglumine, dynamic images were obtained every 30 seconds with the spin-echo (SE) technique in the sagittal plane or the fast low-angle shot (FLASH) technique in axial
Sawada,
#{149}
IGH-FIELD-STRENGTH
has of
MD
for
the
chosen for a sufficient
T2-weighted section
images.
with
all pulse
Two
were
thickness
The
to ratio.
obtained
with
to obtain
field
to
with a multithickness of 7
dynamic studies signal-to-noise
images
same
parable cm
technique.
sections were obtained technique. A section
mm was maintain the
FLASH
was and 10.2
of view
corn-
was
23
sequences.
Before the administration of gadopentetate dimeglumine (Magnevist; Nihon Shering, Osaka, Japan), axial or sagittal Ti-weighted and axial and sagittal T2weighted
images
were
obtained.
After
a
a pe-
macwere un-
Abbreviations: FLASH
=
C/N
fast low-angle
=
contrast-to-noise shot, SE = spin
ratio, echo.
643
rapid
hand
injection
opentetate
(2 rnL/sec)
dimeglurnine
dynamic
MR
images
were
each pulse sequence, for 4 minutes. After
routine obtained
of gad-
(0.1 rnmol/kg), obtained
every dynamic
with
30 seconds imaging,
TI-weighted in the same
weighted
utes after dimeglummne).
Image
SE images were plane as the T2and dynamic images (5-6 mminjection of gadopentetate
Analysis carcinoma
Cervical
that
surgery was evaluated T2-weighted images, images (obtained 0-I tion of gadopentetate phase dynamic images
utes
after
injection
dimeglumine),
undergone
dimeglummne), (obtained
late-
mm-
2-3
of gadopentetate
and
weighted
had
with nonenhanced early-phase dynamic minute after injec-
postcontrast
images.
The
TI-
MR imaging
find-
ings were analyzed by two of the radiologists (Y.Y., T.S.) in conference, and the findings were determined by consensus. MR imaging with each sequence was assessed
independently,
without
edge of pathologic (a) tumor visualization mor
delineation,
results,
These
macroscopic
(b)
(c) degree
and
witi
regard
(contrast),
invasion and tumor the imaging criteria
ble).
knowl-
with
to tu-
of stromal
volume (the details of are shown in the Ta-
findings
were and
then
microscopic
correlated find-
ings.
The optimal
assessment in sagittal
of stromal sections,
invasion and that
was of
parametrial invasion was optimal in axial sections. The depth of stromal invasion was interpreted as (a) no stromal invasion (the
cervical
stroma
thickness
of the
was
intact,
stroma
was
and
invasion
(abnormal
intensity
observed
in the
confined (c) deep sity
to the inner half invasion (abnormal
was
half
observed
signal outer
metrial
Figure
but
extending
to the
outer
was the
beyond stroma).
Para-
stroma,
there
was
diffuse
or localized
abnormal signal intensity in the parametrium. Involvement of the pelvic side wall or invasion of the bladder or rectum was defined
by
loss
of normal
signal
of these structures. A small (1-4-mm2)
region
placed
myometrium,
in the
tumor,
endometrium,
and
On sagittal SE dynamic trast material enhancement obtained for each region lows: (S - S,) x I00/S,,
the
tumor
and
644
#{149} Radiology
completely ratio
the
cervical
slight
enhancement
myometrium. with that
.s
postcontrast;
The
initially
junction
lower
between
(arrowheads),
The enhancement of myometrium.
of the
which
cervical
left,
J
the
endometrium
seconds
is followed
stroma
by
and
en-
endome-
fat
tissue.
studies, the conratio was of interest as fol-
where
S, mdi-
destroyed), (C/N)
stroma
ratio
U
normal
8).
Sequential dynamic
uteri
in the
Ranges
mean.
MR
sagittal
indicate
within
seconds
after
The en-
administration
dimeglumine. of
the
uterine
The
a) E a)
C a) U) ‘5
of
en-
myometrium
C
U C ‘5
myo-
of the junction between the and myometrium is marked
gadopentetate significant enhancement endometrium that of the
of
cervix,
and
#{149} = endometrium.
hancement
error =
of endometrium
0
for
plane
standard
metrium, hancement endometrium 60
enhanceimages
#{149} = myometrium,
junction
=
contrast
of SE
C 0
0
is
in the late dynamic phase. of the cervical stroma was gradual compared myometrium.
The and with
was
cervix,
cates signal intensity at each dynamic phase and S0, signal intensity on the image obtained before administration of contrast material. In patients with cervical carcinoma (except for those patients whose cervix had been the contrast-to-noise
shows
of the uterine slight compared
right, 30 postcontrast).
intensity
of interest
parametrial
2.
ment
the (z the
invasion was diagnosed when, in to the loss of low-intensity cervi-
addition cal
signal stroma,
of the stroma), signal inten-
intensity was observed stripe of the cervical
myometrium
hancement trium were
upper seconds
the
of the stroma, but the outer stripe or (it) serosal invasion (abnormal
intact),
and
left, precontrast; lower right, 210
uniform),
(b) superficial was
phase (upper postcontrast;
as follows: (S - S)/noise SD, S indicates signal intensity of the S, signal intensity of the cervical stroma; and noise SD, the standard deviation of the intensity of the background noise in the phase-encode direction (9). C/N between the tumor and parametrial fat
tissue
dynamic
ages
was obtained images and as follows: (S
ob-
-
for FLASH conventional S1)/noise SD,
and SE SE imwhere
Si indicates
signal intensity of the paramefat. The averages for the two pulse
trial sequences
between
was
tamed where tumor;
dent
t test.
were
compared
with
the
Stu-
RESULTS In normal the
endometrium
uteri,
the and
junction
between
myometrium
was
slightly enhanced initially; enhancement of the uterine myometrium followed. Initial enhancement of the junclion was not observed in two of eight healthy volunteers (one in the secretory phase and the other in menstruation). The endometrium and cervical epithelium showed little enhancement during the dynamic phase, regardless of the phase of the menstrual cycle or the age March
1992
of Pathologic
Summary
and MR Findings
in Operated-on
Carcinoma
of the Cervix Tumor
Case
Age
FIGO
No.
(y)
Stage
Visualization*/
Delineationt/Interpretation*
.
Histologic
Pathologic
Findings
Stage
Stromal Invasion
T2WSE
Dynamic
Post-CE
pTis
Insitu
-/N/N
pTla
Superficial
-/N/N
-IN/N +/C/+
-IN/N -/N/N
Adenocarcinoma SCCK SCCKS
pTib pT2b pTlb
Superficial Serosa Superficial
pTlb pI2a
Superficial
++/C/+ ++/C/+ ++/R/+ ++/C/+
+/U/+ ++/C/+ +/U/+/U/-
lID
SCC NK L SCC NK L
+/U/+ ++/C/+ +/U/+ -/N/N
Deep
+ +/C/+
+ +/R/+
+
CIS
N/A
pus
In situ
-IN/N
-/N/N
1113
5CC NK L SCCKS
pT2b
Deep
++/C/+
++/R/+
+ +/C/+
SCCNKL
pT2a pT2a
Deep Deep
+/U/++/C/+
#{247}+/R/+ ++/R/+
++/U/+ ++/U/+
N/A
pus
Superficial
-/N/N
-/N/N
SCCNKL
pTla
Superficial
-/N/N
+/U/-
lB
5CC NK L
pTib
IIB
SCCNKL
pTib
Deep Deep
++/C/+ ++/C/+
+#{247}/R/+ ++/C/+
66
IIB
pT2b pub
++/C/+
++/R/+
+/U/-
lB lB
SCC NK L SCC K S
Deep
34 73
Superficial
+/C/+
+ +/R/+
-/N/N
SCC
pTlb
Superficial
+/C/+
++/C/+
+/U/-
I
40
lB
2
51
hA
3 4 5 6
58 62 36 78
IIA IIB
7
70
8 9 10
33 55 36
11 12
49 50
hA 1113 CIS
13
36
IA
14
59
15
68
16 17 18
SCCNKL Verrucose carcinoma
lB lB
NK L
Note-Dynamic = SE dynamic image, FIGO = International Federation ofGynecology NK = nonkeratinizing, post-CE = postcontrast Ti-weighted SE image, S = small, SCC = *Tumor visualization on MR images: + + = tumor was excellently demonstrated with observed with fairly good contrast; = tumor was not visualized, or the contrast between Tumor delineation on MR images: R = tumor was clearly delineated with a rim, c = delineated, N = tumor was not visualized. 1Thterpretation of the stromal invasion and the tumor size on MR images: + = stromal defined, but degree of stromal invasion or tumor size was not correctly interpreted, N =
and Obstetrics,
K
keratinizing,
L
=
+/C/+ -/N/N
-/N/N -IN/N ++/C/+ +/U/-
large cell, N/A
=
not available,
squamous cell carcinoma, T2WSE = 12-weighted SE image. remarkable constrast between the tumor and stroma; + = tumor was the tumor and the stroma was poor. tumor was dearly delineated without a rim, U = tumor was unclearly invasion and tumor size was correctly tumor was not visible.
interpreted,
-
=
tumor
was
Figure 3. Case 15. MR images and contrast enhancement ratios obtamed in a 68-year-old woman with a cervical carcinoma. (a) SE dynamic MR images (200/15) (upper left, precontrast; upper right, 30 seconds postcontrast; lower left, 90 seconds postcontrast; lower right, 210 seconds postcontrast). (b) Sequential contrast enhancement ratio of SE dynamic MR images. 0 = tumor, #{149} = myometrium, 0 = cervix, U = junction of endometrium and myometrium, #{149} = endometrium. (c) T2-weighted SE image (2,000/70). (d) Postcontrast Ti-weighted image (600/15). (a, b) In the early dynamic phase, the tumor is seen as a well-enhanced mass in the cervix. The enhancement of the junction of uterine endometrium and myometrium is seen (arrowheads). In the late dynamic phase, the tumor became isointense with myometrium. Gadopentetate dimeglumine is observed in the bladder at 210 seconds (arrow). (c) T2-weighted image obtained at the same sagittal plane demonstrates a hypenntense mass corresponding to the enhanced area on dynamic MR images. (d) Postcontrast Ti-weighted image also shows a hypenntense that on dynamic and
mass, but T2-weighted
the
contrast images.
is not
so remarkable
as
a. 0 Ia) C 0
E 0 0 C C 0 I0 Ia)
C 0
0 30
60
90
120
Time after administration
150
180
210
of Gd-DTPA(seconds)
b. Volume
182
#{149} Number
3
Radiology
#{149} 645
of
the
vical that
patient. of
(Figs In
the
of
slight
was
the
compared
myometrium
in
surgery are shown in the Table. On T2weighted SE images, dynamic images, and postcontrast Ti-weighted images, tumors demonstrated high signal intensity compared with the low signal intensity of the surrounding cervical stroma. Abnormal signal intensity was not observed in two patients with carcinoma in situ and one with superficial stromal invasion on T2-weighted SE and dynamic images. In three patients, only dynamic MR images depicted the tumor, and in five patients, tumors were seen more clearly on dynamic MR images than on T2-weighted images. In
cer-
with
most
cases
1, 2). patients
tumors
than
Enhancement
stroma
with
showed
carcinoma, earlier
myometrium and cervical earlier than did the junction between the endometrium and myometrium (Fig 3). The C/N between the tumor and the cervical stroma could be evaluated on SE dynamic studies obtamed in 17 patients. Contrast was stroma
did
cervical enhancement
the
slightly
and
marked
in
the
early
dynamic
phase
seconds), but decreased with time (Fig 4). The MR imaging and histopathologic (30-60
findings
in patients
who
these
eight
tween was
underwent
patients,
the not
the
tumor
and
contrast
cervical
remarkable
on
S a
Time after administration
Figure
be-
T2-weighted
seconds)
a. Figure trast;
upper
2. right,
Cervical 30
carcinoma
seconds
of the
postcontrast;
verrucose lower
left,
Sequential the cervical
and
b. 5. Case
of Gd-DTPA(seconds)
C/Ns between the tumor and stroma on SE dynamic MR images. There are various degrees and patterns of enhancement in dynamic MR imaging. In most patients, the contrast between the tumor and the cervical stroma was substantial in the early dynamic phase (30-60
stroma
4.
decreased
with
time.
C.
type
in a 51-year-old
90 seconds
postcontrast;
woman. lower
(a) SE dynamic right,
210
MR
images
seconds
(200/15)
postcontrast).
(upper (b)
Surgical
left,
precon-
specimen
of
the uterus. (c) Histologic specimen of the uterus (hematoxylin-eosin stain; original magnification, x 1). (a) Dynamic MR images obtained in the early dynamic phase show early enhancement of the tumor in the anterior and posterior cervical lips (arrowheads). Enhancement of the endocervix is also seen. (b) Tumor is located from the anterior lip through the lateral wall to the posterior lip on the surgical specimen (arrowheads). (c) Microscopic observation shows a papillary tumor extending into two-thirds of the cervical stroma, correlating very well with dynamic MR images. The depth of invasion was less than 5 mm (arrowheads). The tumor was not visualized on T2-weighted images.
a. Figure onds
b. 6. Case
5.
postcontrast;
Cervical lower
carcinoma left,
90
in
seconds
c.
a 36-year-old
woman.
postcontrast;
lower
(a) right,
SE 210
dynamic seconds
MR
images
postcontrast).
(200/15) (b)
(upper T2-weighted
logic specimen (hematoxylmn-eosin stain; original magnification, x40). (a) In the dynamic phase, enhancement the peripheral portion of the tumor (arrowheads). The junction of uterine endometrium and myometrium row). (b) T2-weighted image in the same sagittal plane shows slight hypermntensity of the tumor compared margin of the tumor is unclear. (c) Microscopic observation shows well-demarcated squamous cell carcinoma. served
646
at
the
#{149} Radiology
margin
of
the
tumor
left,
precontrast; SE
image
upper (2,000/70).
right, (c)
30
5cc-
Histo-
of the tumor is seen especially at is slightly seen at 90 seconds (arwith the surrounding tissue, but the Infiltration of lymphocytes is ob-
(arrowheads).
March
1992
images.
This
contrast was due to of fibrous tissue in patients and a relaextension of the tumor
lack
in
six
with well-demarcated tumors and were usually consistent with compression of normal tissue or an inflammatory reaction (Fig 6). In 18 patients who underwent surgery, accurate assessment of the degree of stromal invasion and tumor size was possible in ii patients (61%) with T2-weighted images, 14 patients (78%) with dynamic MR images, and seven patients (39%) with postcontrast Ti-weighted images. When C/Ns were compared by testing various pulse sequences, the earlyphase SE dynamic images elicited a better C/N (P < .01) than did T2-weighted images and late-phase dynamic images. Ti-weighted images obtained after the administration of contrast material showed poor contrast (Fig 7). FLASH axial images showed parametrial extension more clearly than did T2-weighted images in all patients (Fig 8). Dynamic FLASH images showed hyperintensity in the tumor and relative hypointensity in the parametrial fat (Fig 9). C/N between the tumor and parametrial fat was better on Ti-weighted images with or without contrast enhancement and on postcontrast FLASH images than on T2-weighted or precontrast FLASH images (Fig 10). Contrast on Ti-weighted images obtained with or without contrast enhancement was much superior to that on other images (negative contrast), but there was little contrast between the tumor and normal tissue. FLASH images showed good contrast between the tumor and parametriat fat tissue or the surrounding organs (Figs 8, 9).
of
the predominance the tumor in two tively superficial patients.
With dynamic MR imaging, carcinoma in situ was not visualized, but even a preclinical invasive tumor less than 5 mm in depth demonstrated high signal intensity, which correlated well with histologic findings (Fig 5). In large tumors, any extension to the vagina and uterine body was more clearly demonstrated with dynamic MR imaging. Sharp demarcation of the margin of the tumor was demonstrated in 14 patients (78%) on the dynamic images, nine (50%) on T2-weighted images, and four (22%) on postcontrast Ti-weighted images.
Hyperintense
rims
were
ob-
served around the tumor on dynamic MR images in eight patients (44%). Histologically, the rims were correlated
0
0
0 0
7.
Figure vical
Contrast
stroma
between
with
each
tumor
pulse
and
sequence
cer(the
averages in 18 measurable cases). The contrast on FLASH dynamic images was not available because the cervix was almost destroyed in patients who were imaged with those ages
pulse in
sequences.
the
early
phase
The
SE
dynamic
had
the
best
ages
(TIWSE)
Figure
8. radiation
right,
30
therapy.
seconds
(c)
ment. Invasion clearly than on (b). These areas internal
Volume
poor
MR images
went
(2,000/70).
showed
182
obtained in a 51-year-old (a) Dynamic MR images lower TI-weighted
to the left internal the T2-weighted probably represent
obturator
muscle
Number
#{149}
High-field-strength, imaging of invasive
T2-weighted cervical carcinoma
supply
of the uterus
is de-
at dynamic MR imaging. The contrast resolution of MR im-
aging demonstrates the tumor definitely better than do other imaging techniques. Dynamic MR imaging reveals the hemodynamics of the uterus in vivo. Patterns of enhancement at dynamic MR imaging reflect the vascularity of each part of the uterus. In the normal uterus, enhancement occurred initially at the junction between the endometrium and myometrium, followed by enhancement of the uterine myometnum. Initial enhancement of the junction, however,
MR
contrast.
postcontrast; Postcontrast
markable excellent
DISCUSSION
(T2WSE) images images (P < .01). CE) Ti-weighted SE im-
(Post
The blood
rived from the uterine and ovarian arteries anastomosing with each other to form a uteroovarian vascular arch with many arterial branches supplying the uterine wall (10). As shown with histologic and microangiographic observation, all parts of the myometrium of the uterus are vascularized, especially at the junction of the stratum basale of the endometnum and subjacent myometrium, while vessels of the cervical stroma and endometrium are relatively sparse (1 1 ,i2,13). Cervical carcinoma had been considered to be hypovascutar at angiography (14); the degree of contrast enhancement of the cervical carcinoma, however, was shown to be re-
imcontrast,
followed by T2-weighted and late-phase dynamic Postcontrast
has been shown to have an accuracy rate as high as 9i% (3) and 95% (5). Superficial lesions were underestimated, however, because of poor contrast between the high signal intensity of the tumor and that of the cervical epithehum and because of the presence of surface blood clotting (4,5). Although our study is preliminary, the early phase of dynamic imaging demonstrated significantly better contrast than did T2weighted images.
with
3
left,
woman obtained
90 seconds image
postcontrast;
(600/15).
obturator muscle (right image (b). Unenhanced cystic necrosis in the good
contrast,
but
with cervical carcinoma extending to adjacent with the FLASH technique (50/10; flip angle,
there
(a, b)
lower Images
right,
210
of dynamic
seconds study
postcontrast). show
invasive
organs (stage IVA). The patient under40#{176}) (upper left, precontrast; upper (b) tumor
T2-weighted with
marked
spin-echo
image
contrast
enhance-
arrowhead), bladder (left arrowhead), and rectum (arrow) is visualized more areas in the tumor in a correspond to hypenntense areas on the T2-weighted tumor. (c) Postcontrast Ti-weighted image also shows invasion to the rectum is no
contrast
between
the
tumor
and
the
image and left
bladder.
Radiology
#{149} 647
was
not
always
observed.
The
zone
of
initial enhancement the junction of the
probably reflects stratum basale of the
endometrium
subjacent
and
myome-
trium. There may be some relationship between the hormonal change and pattern of enhancement. Further study is required to clarify this point. Enhancement of the cervical stroma appeared slight and gradual compared with that of the myometrium. On the other hand, cervical carcinoma demonstrated enhancement earlier and more intensely
than
uterus. therefore, visual
The
any
tissue
in the
dynamic MR images, the best contrast at
analysis,
as
before
any
of C/N
other
early provided
well
as quantification
enhancement
cervical
stroma
curred.
On
postcontrast
and
images,
the
contrast
of the
myometrium
oc-
TI-weighted between
the
tumor
and stroma was decreased because of the delay that followed administration of gadopentetate dimeglumine. Our histologic correlation showed that the early enhanced lesions were consistent
with
the
presence
prove
or tissue.
to be
tion
of the
invasive
sign
degree
well demarrim was the tumors, with reac-
compression This rim might
a useful
in
the
of
evalua-
of infiltration
of the
tumor.
both the tumor fat show hyperintensity dynamic SE and T2-weighted
and
Because
trial
niques,
it is difficult
trial
invasion.
ters
of 50/10
showed
to
tumor
tensity
in
addition, nor
to the
two
averages
and
shorter
paramewith the SE tech-
evaluate
low
signal
displayed the
early
this
FLASH
signal
in-
phase.
In
dynamic technique
is supe-
SE parameters 600/15 in signal-to-noise time.
On
technique
for
tumors
will
be
gas
SE
usefulness
required
of the
parametrial
We ity
weighted
imaging,
648
to
FLASH
have
(15).
and
but
#{149} Radiology
MR
First,
evaluating
that
of the
this
enhanced
shows
parametrial
the
3.
4.
pulse
tumor.
a relatively
sequence,
Invasion
to the
hyperintense
mass
with
fat.
6.
can
be
per-
routine
SE
techniques
With improvement and acquisition will
become
carcinomas
are
em-
of the
useful
7.
in
superiorT2-
draw-
0
0 0#{149}
T2WSE
Figure
10.
averages trast
in
cervix.
U
FLASH
p..
Contrast
parametrial
of spatial time, this more
025
fat
in five
Ti-weighted
FLASH
CE
between
with
each
TIWSE
tumor
pulse
CE
PS1
dy”*#{232}
and
sequence
(the
measurable
cases). PreconSE (T1WSE) images, images, and postcontrast
FLASH dynamic weighted (Post CE T1WSE) contrast, while precontrast and T2 weighted (T2WSE) poor contrast (P < .01).
10.
images
had
Ti good
(pre CE) FLASH images
Togashi K, Nishimura K, Sagoh T, et al. Carcinoma of the cervix: staging with MR imaging. Radiology 1989; 171:245-251. Choyke PL, Frank JA, Girton ME, et al. Dynamic Gd-DTPA-enhanced MR imaging of the kidney: experimental results. Radiology 1989; Sakamoto Y, Takahashi M, Korogi Y, Bussaka H, Ushio Y. Normal and abnormal pituitary glands: gadopentetate dimeglumine-enhanced MR imaging. Radiology 1991; 178:441445. American Joint Committee on Cancer. Gynecologic sites. In: Beahrs OH, Henson DE, Mutter RVP, Myes MH, eds. Manual for staging of cancer. 3rd ed. Philadelphia: Lippin-
Pritchard JA, MacDonald the female reproductive stetncs.
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Ti-weighted
several
study
150:135-138.
the
over
a dynamic
References
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after
ployed. resolution
8.
are
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image
formed only in limited imaging planes. In our system, the number of sections available per study is limited to three at present. Second, the spatial resolution is inferior to that of routine SE sequences. Therefore, we believe this technique should be limited to selected patients with a carcinoma with superficial extension, invasion to the other organs, or poor visualization on T2-weighted im-
5.
parametrial images
postcontrast
there
backs.
intensity
With
with
1986; 159:725-730.
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demonstrated
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T2-weighted
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invasion.
of dynamic
the
(b)
enhancement.
compared
2.
reported to be useful in the evaluation of parametrial invasion (3), but they cannot aid in differentiating the tumor from normal parametrial tissue. Further study
almost
SE dynamic techand the FLASH with
Ti-weighted
is speculated.
dark
the
induced
invasion.
parametrium
contrast
relatively
Worthington JL, Balfe DM, Lee JKT, et al. Uterine neoplasms: MR imaging. Radiology
facts
intestinal
inhomogeneous
1.
hand, the SE dynamic images superior in tissue contrast benormal uterine tissue and the and were less susceptible to artiby
with
fat appears
with ratio
other were tween tumor
therefore selected the nique for small tumors
tumor
parametrial
technique
intensity,
high
sampling
invasive
ages
parame-
With the FLASH parameand a flip angle of 40#{176}, fat
relatively
while
b.
9. Case 7. MR images obtained in a 70-year-old woman with a cervical carcinoma with parametrial invasion (stage IIB). She underwent radiation therapy. (a) Dynamic MR images obtained with the FLASH technique (50/10; flip angle, 40#{176}) (upper left, precontrast; upper right, 30 seconds postcontrast; lower left, 90 seconds postcontrast; lower right, 210 seconds postcontrast). (b) T2-weighted SE image (2,000/70). (a) Images of the dynamic study show an
Figure
of tumors
in all cases. In histologically cated lesions, a hyperintense frequently observed around which was usually consistent tive inflammation surrounding
a.
is.
Hendrickson
M, Kempson
R.
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March
1992