Left Ischiocavernosus Muscle Tumor

1. Hricak H, Chang YCF and Thurnher S. (1998) Vagina: Evaluation with MR imaging. Part I. Normal anatomy and congenital anomalies. Radiology 169:169-174.

2. Chang YCF, Hricak H, Thurnher S and Lacey CG. (1988) Vagina: Evaluation with MR imaging. Part 2. Neoplasms. Radiology 169: 175179.

3. Siegelman ES, Outwater EK, Banner MP, Ramchandani P, Anderson TL and Schnall MD. (1997) High-resolution MR imaging of the vagina. Rodiographics 17:1183-1203. Beautifully illustrated article including normal anatomy, congenital anomalies and neoplasms.

4. Chang SD. (2002) Imaging of the vagina and vulva. Radiol. Clin. North Am. 40:637-658. Includes discussion of imaging in vaginal and vulval carcinoma.

5. Chyle V, Zagars GK, Wheeler JA, Wharton JT and Delclos L. (1996) Definitive radiotherapy for carcinoma of the vagina: outcome and prognostic features. Int. J. Radiat. Oncol. Biol. Phys. 35:891-905. A clinical review of 301 patients treated with radiotherapy.

6. Brown JJ, Guitierrez ED and Lee JK. (1992) MR appearance of the normal and abnormal vagina after hysterectomy. Am.J. Roentgenol. 158:95-99. A description of post-surgical appearances.

7. Van Hoe L, Vanbeckevoort D, Oyen R, Itzlinger U and Vergote I. (1999) Cervical Carcinoma: Optimized Local Staging with Intravaginal Contrast-enhanced MR Imaging—Preliminary Results. Radiology 213:608-611. A description of MR vaginography in cervical carcinoma.

Figure 7.1. Normal appearance of the vagina.

(a) Transaxial T2W1 through the lower vagina showing normal anatomy. The collapsed vagina is seen as a 'W-

shaped' structure with a low signal fibromuscular wall (black arrows). A thin layer of high signal within the vagina represents the vaginal mucosa and intraluminal mucus. The high signal of the paracolpol adventitia surrounding the vagina (asterisk) is due to slow flowing blood within the vaginal venous plexus. Urethra (Ur), Anal canal (AC).

(b) Sagittal T2W1 through the pelvis showing normal anatomy. The anterior (long arrows) and posterior (short arrows) fibromuscular walls of the vagina are of low signal. The vaginal mucosa and intraluminal mucus are visible as a thin layer of high signal. A small Nabothian cyst is seen in the anterior cervix as a well defined rounded area of high signal (Short black arrow).

Figure 7.2. T1 NO Vaginal carcinoma.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing a small tumour (arrow) in the left mid vagina. The tumour is constrained by the low signal vaginal wall.

Figure 7.3. T2 N0 Vaginal carcinoma (clear cell tumour).

(a) Transaxial T2W1 and (b) sagittal T2W1 showing a heterogenous soft tissue tumour (T) in the upper and mid vagina in a patient with previous hysterectomy. Tumour expands the vaginal lumen and breaches the low signal vaginal wall laterally to involve the paracolpol fat (small arrows). The sigmoid colon is tethered to the vaginal vault (black arrow in (b)), but this may be a normal post-operative finding. Anteriorly the tumour is fixed to the bladder muscle wall (white arrow in (b)).

Figure 7.4. T2 N1 Vaginal carcinoma.

Transaxial T2W1 of tumour (T) circumferentially thickening the lower vagina, but not extending to the pelvic floor nor involving the urethra (arrow). There is a small amount of fluid in the vaginal lumen (asterisk). There are bilateral inguinal lymph node metastases (N) of similar signal intensity to the primary tumour.

Figure 7.5. T2 N1 Vaginal carcinoma with posterior pelvic lymph node metastases.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing tumour (T) predominantly involving the posterior wall of the upper vagina but also within the anterior fornix (*). There are enlarged internal iliac (I), perirectal and obturator nodes (N) which show signal intensity similar to the primary tumour. The uterus is anteverted with a prominent junctional zone (J) and a small subserosal fibroid (F).

Figure 7.6. T2 N0 Vaginal carcinoma with ureteric obstruction and adherence to the posterior bladder wall.

Transaxial T2W1 showing spiculated tumour (T) at the vaginal vault with low signal tumour extending into the parametrium (P), onto the posterior bladder wall (arrowheads) and onto the perirectal fascia (arrows). The left ureter (*) is obstructed by tumour but this, unlike the staging system for cervical carcinoma, does not increase the tumour stage to T3. Involvement of the bladder muscle wall is not sufficient to classify the tumour as T4, for this stage to apply tumour must extend to the bladder mucosa.

Figure 7.7. T3 NO Vaginal carcinoma involving the pelvic floor.

(a) Transaxial T2W1 showing tumour (T) extending through the right lateral vaginal wall to involve the levator ani muscle (arrows). (b) Transaxial T2W1 at the level of the vaginal introitus showing tumour (T) around the introitus and involving the urethral meatus (white arrow).

Figure 7.8. T3 N1 Vaginal carcinoma invading the perineal structures.

(a) Transaxial T2W1 at the level of the lower vagina (V) showing tumour (T) on the left side invading the left anterior pubo-rectalis muscle (P). There is circumferential involvement of the urethra (Ur) with loss of its normal zonal anatomy. There are left inguinal lymph node metastases (N) and a metastatic left anatomical obturator node (asterisk), these lymph nodes lie between the obturator externus and pectineus muscles and are not normally visible. Lower rectum (R).

(b) Transaxial T2W1 at a slightly lower level than (a) showing tumour extending through the left superficial perineal space (S) to involve the left ischiocavernosus muscle and crus of clitoris (arrows). The urethral meatus (Ur) and left bulbospongiosus muscle (B) are also invaded. There are left inguinal lymph node metastases (N).

Figure 7.9. T3 N0 Vaginal carcinoma involving the urethra and perineal body.

(a) Transaxial T2W1 showing circumferential tumour (T) involving the lower vagina with direct invasion of the urethra (arrow). Posteriorly, tumour involves the perineal body on the left (arrowhead). (b) Sagittal T2W1 showing tumour involving the anterior (arrow) and posterior (arrowhead) walls of the lower vagina. Anteriorly, tumour involves the urethral meatus (Ur). Note previous hysterectomy with fibrosis at the vaginal vault (V).

Figure 7.10. T4 N0 Vaginal carcinoma involving the posterior bladder wall.

(a) Transaxial T2W1 showing a large tumour (T) filling the lower vagina and breaching the left vaginal wall with involvement of the left levator ani muscle (white arrow). There is circumferential involvement of the urethra (Ur) (black arrow). (b) Sagittal T2W1 showing tumour (T) involving the entire length of the anterior vaginal wall. The low signal bladder muscle wall is destroyed and tumour involves the bladder mucosa (arrows).

Figure 7.11. T4 N0 Vaginal carcinoma involving the bladder muscle layer, rectum and sigmoid colon.

(a) Transaxial T2W1 showing an upper vaginal tumour (T) which infiltrates the paracolpol tissues and extends along the perirectal fascia bilaterally (arrows). In the midline there is breach of the perirectal fascia with tumour extension to the rectum (asterisk), including the rectal mucosa (short white arrows). (b) Sagittal T2W1 showing upper vaginal tumour (T) with invasion of the posterior bladder wall, the low signal bladder muscle wall is interrupted (asterisk) and there is bladder mucosal oedema (small black arrows). Superiorly, the tumour is invading loops of sigmoid colon (large white arrow).

Figure 7.12. T4 N0 Vaginal carcinoma involving the bladder, rectum and pelvic floor.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing a large tumour (T) with circumferential involvement of the entire length of the vagina. Tumour extends posteriorly to invade the rectum (asterisk) and laterally to invade the left levator ani muscle (large white arrow). Anteriorly, there is tumour invasion of the posterior bladder wall with tumour extension to the bladder mucosa (small black arrows).

Figure 7.13. T4 N0 Vaginal carcinoma invading the ischioanal fossa.

(a) Transaxial T2W1 showing lower right vaginal tumour (T) which extends into the paracolpol space and invades (asterisk) the lower rectum (R). Urethra (Ur), low signal vaginal muscular wall (V). (b) Transaxial T2W1 showing extensive tumour infiltration of the perineum with involvement of the right puborectalis muscle (arrow) and circumferential involvement of the lower urethra (Ur). The bulbospongiosus muscles (B) and right ischiocavernosus muscle (asterisk) are well seen.

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