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1. Sohaib S, Reznek R and Husband JES. (1997) Ovarian cancer. In: Imaging in Oncology (eds Janet ES Husband and R Reznek). Isis Medical Media Ltd, Oxford, pp.277-305. A chapter summarising the imaging features of malignant ovarian diseases for all commonly utilised modalities. Also provides a summary of epidemiology and pathology.

2. Forstner R, Hricak H, Occhipinti KA etal. (1995) Ovarian cancer: Staging with CT and MR Imaging. Radiology; 197:619-626. Study to evaluate ovarian cancer staging and tumour resectability with CT and MR. Results showed that while the staging accuracy of both modalities is only moderate, the prediction of resectability is excellent.

3. GhossainMA, Buy JN, Ligneres C etal. (1991) Epithelial Tumours of the Ovary: Comparison of MR and CT Findings. Radiology 81: 863-870. Retrospective study, looking at the characteristics of epithe-lial tumours on MR and CT. The accuracy for overall characterisation of benign as opposed to malignant tumours was better for MR than CT although no significant difference in sensitivity or specificity was identifed.

4. Semelka RC, Lawrence PH, Shoenut JP, etal. (1993) Primary Ovarian Cancer: Prospective Comparison of Contrast-enhanced CT and Pre- and Postcontrast, Fat-suppressed MR Imaging, with Histologic Correlation. J. Magn. Reson. Imaging 3:99-106. Prospective study comparing CT and MR staging of ovarian cancer. Results showed that MR is at least equivalent and may be superior to CT in the evaluation ofovarian cancer.

5. Prayer L, Kainz C, Kramer J et al (1993) CT and MR Accuracy in the Detection of Tumour Recurrence in Patients Treated for Ovarian Cancer. J. Comput. Assist Tomogr. 17(4): 626-632. Prospective study to evaluate the accuracy of clinical examination (including CA-125 level), CT and MR In the detection of tumour recurrence. Results showed that CA-125 is accurate in determining tumour recurrence and that CT is the primary imaging modality in the diagnosis of macroscopic disease. Neither CT nor MR can exclude microscopic disease.

6. Jeong YY, Outwater EK and Keun Kang H. (2000) From the RSNA Refresher Courses. Imaging Evaluation of Ovarian Masses. Radiographics 20:1445-1470. A review article summarising the features of both benign and malignant ovarian conditions on US, CT and MR.

7. Kurtz AB, Tsimikas JV, Tempany CM etal. (1999) Diagnosis and Staging of Ovarian Cancer: Comparative Values of Doppler and Conventional US, CT, and MR Imaging Correlated with Surgery and Histopathological Analysis—Report of the Radiology Diagnostic Oncology Group. Radiology 212:19-27. Large study aimed at determining the optimal imaging modality for diagnosis and staging of ovarian cancer. Conventional US, CT and MR were compared and results showed little variation between these modalities as regards staging ofovarian cancer but MR was shown to be superior for diagnosis.

Figure 6.1. Schematic drawing showing sites of origin of ovarian cancer.
Figure 6.2. Normal ovarian anatomy in a woman of reproductive age.

(a) Transaxial T1W1 and (b) transaxial T2W1 showing normal follicular cysts in the left ovary. These appear thin-walled and of low signal intensity on T1W1 and high signal intensity on T2W1 (arrows). The ovarian stroma is low-intermediate signal intensity on T1W1 and of higher signal intensity on T2W1 (arrowheads).

Figure 6.3. Post-menopausal ovaries.

Transaxial T2W1 showing normal appearances of the ovaries in a post-menopausal woman. They are of small volume and reduced signal intensity (arrowheads), as the ovarian stroma is replaced by fibrous tissue. Note the round ligament lying in close proximity to the ovaries (arrows). The left ovary contains a persistent small follicular cyst (Cy). The left ureter (U) is dilated due to a distal obstructing mass.

Figure 6.4. T1a Ovarian cancer.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing right ovarian endometrioid carcinoma. There is a cystic mass (T) with an irregularly thickened wall (arrows) and vegetations (arrowheads). The outer surface of the mass is smooth (open arrowheads) indicating an intact ovarian capsule. Note the primary endometrial tumour (E). 15-20% of endometrioid ovarian carcinomas have a synchronous endometrial carcinoma.

Figure 6.5. T1b Ovarian cancer.

Coronal T2W1 showing bilateral ovarian cystic tumours (T). The capsules of the ovaries are intact (arrows). Note the absence of ascites. Uterus (U).

Figure 6.6. T1c Ovarian cancer.

(a) Transaxial T2W1 (b) coronal T2W1 and (c) sagittal T2W1 showing bilateral mixed composition ovarian masses (T).The lesions are lobulated and incompletely encapsulated, with tumour on the medial ovarian surface of the right sided mass and the superior ovarian surface of the left sided mass (arrows). There is a small volume of malignant ascites (arrowheads).

Figure 6.7. T2a Ovarian cancer.

(a) Transaxial T2W1 and (b) coronal T2W1 showing a large mixed composition tumour mass (T) filling the pelvis.The uterus (U) is displaced anteriorly and to the right and is inseparable from the tumour (arrows).The mass effect has resulted in bilateral hydronephrosis (H). Ureter (asterisk).

Figure 6.8. T2b Ovarian cancer.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing a locally extensive ovarian tumour (T) which has spread posteriorly to penetrate the perirectal fascia and fat and adhere to the rectum (arrows).Anteriorly tumour extends to abut and infiltrate the posterior surface of the rectus sheath (arrowheads) and involve the bladder (B). Note the fluid/fluid level in part of the tumour mass representing layering of proteinaceous secretions and haemorrhage (open arrowheads) and the absence of ascites.

Perirectal Sheath Tumor
Figure 6.9. T2c Ovarian cancer.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing mixed cystic and solid tumour mass (T) filling the central pelvis and extending to the pelvic sidewalls (arrowheads). The bladder (B) is displaced inferiorly by the mass. Malignant ascites (A) is present with a number of tumour nodules adherent to the peritoneum (open arrowheads).

Bladder Cancer Images T3b
Figure 6.10. T3b Ovarian cancer.

(a) Coronal T1W1 and (b) transaxial T2W1 showing mixed solid and cystic central pelvic tumour mass (T).

There are metastatic deposits (arrowheads) in the omentum. Note the presence of ascites (arrows).

Figure 6.11. T3c Ovarian cancer.

(a) Transaxial T1W1, (b) coronal T1W1, (c) transaxial T2W1 and (d) sagittal T2W1.There is a large mixed composition pelvic mass (T) involving the vaginal vault (arrows). A metastatic deposit (M) greater than 2.0 cm in diameter is present in the left mid abdomen.

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Ovarian Mass
Figure 6.12. N1 Ovarian cancer.

(a) Transaxial T2W1 (b) coronal T1W1 (c) coronal T2W1 showing lymph node metastases in various locations (arrows): (a) right obturator and left external iliac (b) interaortocaval and (c) right superficial inguinal sites. Tumour mass (T); ascites (A).

Figure 6.13. Ml Ovarian cancer.

(a) Transaxial T1W1 and (b) coronal T1W1 showing a metastatic deposit (M) centred on the left ilium. The tumour has crossed the sacro-iliac joint to invade the sacral ala (arrows) and extended into the soft tissues of the buttock breaching the low signal intensity line of the bone cortex (arrowheads). Bone metastases from epithelial ovarian cancer are rare; when they occur the diagnosis should be reconfirmed.

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Figure 6.14. Haemorrhagic follicular cyst.

(a) Transaxial T1W1 and (b) transaxial T2W1, (c) transaxial T1W1 and (d) transaxial T2W1. (a) and (b)

demonstrating the right ovary enlarged by a thin-walled follicular cyst containing subacute (greater than 1 week old) haematoma which appears high signal on T1W1 and mixed high signal on T2W1 (arrows). This signal pattern termed "shading" is due to the presence of intracellular methaemoglobin and is a finding more commonly seen in endometriomas (see Figure 6.17), (c) and (d) were obtained 3 months later and show resolution of the haematoma and a normal pattern of follicular cysts (arrowheads). Neoplasia cannot be excluded from an apparently haemorrhagic follicular cyst so that imaging after a 2-3 month interval using ultrasound or MRI is required.

T2w1 Images Mri

Figure 6.15. Polycystic ovary disease.

Normal Ovaries Mri

Figure 6.15. Polycystic ovary disease.

(a) Transaxial T2W1 and (b) coronal T2W1 showing enlarged ovaries with characteristically distributed multiple small peripheral cysts (arrowheads) with an hypertrophied low signal intensity central stroma (arrow). This condition should be recognised and distinguished from the normal appearance of follicular cysts seen in Figures 62 and 6.14d above.

Figure 6.16. Hydrosalpinx.

(a) Coronal T2W1 (b) transaxial T2W1 (c) and (d) parasagittal T2W images showing bilateral hydrosalpinges. On initial inspection the coronal and transaxial images give the erroneous impression of bilateral adenexal cystic masses. Review of the parasagittal images confirms the presence of dilated Fallopian tubes (F) represented as thin-walled (arrows) convoluted tubular structures with mucosal folds (arrowheads).

Figure 6.17. Endometrioma.

(a) Transaxial T1W1 and (b) transaxial T2W1 showing an endometrioma of the right ovary. Endometriomas typically have a uniformly thick low signal intensity rim (arrows) indicating a fibrous capsule and variable signal intensity contents on T1W1 and T2W1 due to haemoglobin breakdown products (arrowheads).A characteristic pattern is of high signal on T1W1 and loss of signal on T2W1 termed "shading" a finding indicating the presence of intracellular methaemoglobin.

Figure 6.18. Benign cystic teratoma.

(a) Coronal T1W1 and (b) coronal STIR image showing a left ovarian benign cystic teratoma

(teratodermoid).The diagnostic feature of these tumours is fat (arrows) contained within a well-circumscribed wall (arrowheads) from which ectodermal elements (open arrowheads) with varying degrees of differentiation arise. Fat suppressed imaging usually differentiates between haemorrhagic cysts and benign cystic teratomas as the signal from fat in teratomas is suppressed as in (b). Note the metastasis (M) in the left femoral head from a facial rhabdomyosarcoma.

Figure 6.19. Peritoneal inclusion cysts.

Figure 6.19. Peritoneal inclusion cysts.

(a) Transaxial T1W1 and (b) transaxial T2W1 in a 41-year-old woman with Crohn's disease. The left ovary (arrows) is partially surrounded by fluid-filled locules (L). These are derived from non-neoplastic mesothelial proliferation caused by retained ovarian fluid in patients with peritoneal adhesions. The extra-ovarian location of the cysts differentiates them from benign or malignant ovarian tumours. The shape and location remote from the peritoneal cul-de-sac differentiates the cysts from ascites.

Figure 6.20. Post-operative swelling of round ligaments.

Transaxial T2W1 demonstrating bilateral bulbous swelling (arrowheads) of the proximal ends of the transected round ligaments (arrows) 4 months following total abdominal hysterectomy and bilateral salpingo-oophorectomy for ovarian cancer. These changes usually resolve by 12 months after surgery. They should be recognised and differentiated from tumour masses. Note the residual tumour (T) arising from the vaginal vault and involving the rectum (R) with several perirectal tumour nodules (open arrowheads) likely in lymph nodes.

Figure 6.21. Recurrent ovarian cancer; suitable for surgical resection.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing a large mixed composition pelvic tumour mass (T). The encapsulated nature of the mass (arrows) and the absence of metastases makes it suitable for surgical resection. Note the mass effect has caused descent of the pelvic floor and prolapse of the pelvic viscera with bladder (B) outlet obstruction due to compression of its neck. Anal canal (AC); vagina (V); urethra (U).

Figure 6.22. Recurrent ovarian cancer; unsuitable for surgical resection.

(a) Transaxial T2W1, (b) and (c ) coronal T2W1 following total abdominal hysterectomy and bilateral salpingo-oophorectomy for borderline ovarian tumour. There is a mixed composition pelvic tumour mass (T). In addition there is a small volume of ascites (arrows) outlining a serosal tumour nodule adherent to the sigmoid colon (arrowheads).The presence of serosal and peritoneal disease precludes curative surgery.

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