Further Reading

1. Crowe PJ, Temple WJ, Lopez MJ andKetcham AS. (1999) Pelvic exenteration for advanced pelvic malignancy. Semin. Surg. Oncol. 17:152-160. Good review of exenteration.

2. Silverman JM and Krebs TL. (1997) MR imaging evaluation with a transrectal surface coil of local recurrence of prostatic cancer in men who have undergone radical prostatectomy. AJR 168(2): 379-385. Useful paper discussing the power ofMRI to identify local recurrence in this population.

3. Kinkel K, Tardivon AA etal. (1996) Dynamic contrast-enhanced subtraction versus T2-weighted spin-echo MR imaging in the follow-up of colorectal neoplasm: a prospective study of 41 patients. Radiology 200(2): 453-458. This paper discusses the advantages of dynamic MR imaging in recurrence.

4. Muller-Schimpfle M, BrixG, LayerG etal (1993) Recurrent rectal cancer: Diagnosis with dynamic MR imaging. Radiology 189: 881889. One of the original papers reporting the reliability of MR dynamic contrast enhancement in differentiating tumour recurrence from fibrosis and comparing it to standard T2-weighted imaging.

5. HawighorstH, KnapsteinPG etal. (1996). Pelvic lesions inpatients with treated cervical carcinoma: efficacy of pharmacokinetic analysis of dynamic MR images in distinguishing recurrent tumours from benign conditions. AJR 166(2): 401-408. In this paper, sophisticated analysis of dynamic contrast enhanced MRI improved the evaluation of treated cervical cancer patients with suspected recurrence.

6. PopovichMJ, Hricak H etal. (1993) The role of MR imaging in determining surgical eligibility for pelvic exenteration. AJR 160(3): 525531. One of the original papers covering this subject.

7. Robinson P, Carrington BM, Swindell R, Shanks JH and O'Dwyer ST (2002). Accuracy ofMRI in determining extent of recurrent pelvic bowel cancer prior to salvage surgery. Clin. Radiol. 57: 514-522. A comparison ofEUA and MRI assessment before attempted exenteration.

Figure 14.1. Residual tumour mass post radiotherapy.

Transaxial T2W1 demonstrating a residual bladder tumour (T) obstructing the left ureter (arrow) and associated with a left antero-lateral paravesical lymph node (small arrow).

Figure 14.2. Failure to develop normal post treatment appear-

Sagittal T2W1 of a patient who was treated for cervical cancer with radiotherapy. Six months after treatment the cervix still demonstrates heterogeneous signal intensity (arrows) instead of the uniform low signal intensity post treatment appearance. The patient went on to have salvage surgery after biopsy confirmation of residual tumour.

Figure 14.3. Recurrent cervical cancer.

Sagittal T2W1 demonstrating a recurrent tumour mass (T) in the anterior lip of the cervix, two years after finishing radiation therapy. Note the signal voids (arrows) from the metallic marker seeds placed in the vagina and the low signal intensity of the treated uterus, posterior lip of the cervix and upper vaginal canal.

Figure 14.4. Infiltrative bladder cancer recurrence.

Sagittal T2W1 demonstrating diffuse low signal intensity tumour (T) of the bladder wall with extension into the distal portion of the urachus (short arrow) and further diffuse soft tissue band-like stranding of the peritoneum anteriorly (arrowheads) and pre-sacral fascia (long arrows). The symmetrical nature of the abnormalities makes differentiation from radiotherapy treatment effect difficult.

Figure 14.5. Recurrent tumour in prostate bed after radical prostatectomy.

(a) Transaxial and (b) sagittal T2W1 demonstrating a small soft tissue mass (arrows) immediately above the anastomosis and adjacent to the bladder neck. Note that this mass is of low intermediate signal intensity, higher in signal than the bladder muscle layer (asterisks), anastomotic site (arrowheads) and muscle of the pelvic floor.

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Figure 14.6 Anterior pelvic clearance.

Sagittal T2W1 in (a) a male, (b) a female patient and (c) a female patient. In (a) the bladder, prostate and seminal vesicles have been resected. A small postsurgical collection is seen (asterisk) in the bladder bed. Note the tethering of the recto-sigmoid to the posterior margin of collection. In (b) the bladder, urethra, uterus and vagina have been resected. Fat fills the surgical bed. This can be due to surgical placement of the omentum to prevent small bowel loops extending into the true pelvis. In (c) the patient has undergone anterior pelvic clearance but with preservation of the distal third of the vagina (arrows).

Figure 14.7. Posterior pelvic clearance.

Sagittal T2W1 in (a) a male and (b) a female. In (a) the patient has undergone an abdominoperineal resection with removal of the prostate and seminal vesicles and reanastomosis of the bladder (B) to the membranous urethra. In this patient note an incidental post-surgical haematoma (asterisk) in the pre-sacral space. In (b) the patient has undergone abdomino-perineal resection with removal of the uterus and vagina. Note the extensive band- like post-operative change in the pre-sacral space (arrows). The bladder and urethra demonstrate slight posterior prolapse with an increased angle between the symphysis pubis and the urethra (arrows).

Figure 14.8. Total pelvic clearance.

(a) Sagittal T2W1 demonstrating total pelvic clearance with preservation of the pelvic floor (arrows). Small bowel has entered the pelvic cavity (arrowheads). (b) Sagittal T2W1 in a patient who has undergone total pelvic clearance with resection of the pelvic floor muscles. Note multiple dependent loops of small bowel (arrowheads) within the true pelvis with minor herniation of small bowel into the perineum (arrows). There is a small post-surgical collection (asterisk). When the pelvic floor is resected, patients may develop large and troublesome perineal hernias post-operatively.

Figure 14.9. Tumour involving the bladder and sigmoid colon.

(a) and (b)Transaxial and (c) sagittal T2W1 demonstrating a tumour mass (T) arising at the vaginal vault in a patient with recurrent ovarian cancer. The tumour has infiltrated through the posterior wall of the bladder and lobulated tumour is identifiable within the bladder lumen (arrrows), the superior-most portion of disease is infiltrating into the sigmoid colon with the tumour mass reaching the lumen (arrowheads). An apparent separate nodule in the right pelvis in (a) is a lobular extension of disease underneath the recto-sigmoid junction. Note that the mid- and distal rectum are displaced by the tumour mass but there is no evidence of infiltration. Surgery required by MRI criteria: anterior exenteration and sigmoid colectomy

Figure 14.10. Tumour mass involving the sigmoid and left ureter.

(a) Transaxial and (b) coronal T2W1 in a patient with a pelvic soft tissue sarcoma tumour (T) which is displacing the rectosigmoid colon to the right of the midline (small arrows in (a)) with infiltration of the proximal sigmoid colon (long arrows in (a)) and with obstruction of the left ureter at the pelvic brim (asterisk in (b)).The bladder and recto-anal canal are clear of disease. Extent of surgery by MRI criteria: resection of the mass, sigmoid colectomy and left ureteric reimplantation. A psoas hitch of the bladder or a Boari bladder flap will be required to bridge the gap between the shortened ureter and the bladder.

Figure 14.11. Tumour recurrence involving the rectum, anal canal and vagina.

Sagittal T2W1 demonstrating a substantial tumour mass (T) involving the rectum and anal canal (arrows) with tumour extending into the vagina and involving the posterior wall superiorly (arrowheads) and both the anterior and posterior wall inferiorly. There is an air-containing fistula (asterisk) between the vault of the vagina and the rectum. The bladder is not involved but tumour is extending to the urethral meatus (small open arrow). Note that the tumour does not extend to the pre-sacral fascia (curved arrows) or sacrum proper. There is one small pre-sacral node (N) which is ofconcern for an early metastasis. Surgery required by MRI criteria: total exenteration. If the pre-sacral lymph node is positive then this would be a palliative exenteration performed to alleviate the disabling symptoms of pain, bleeding and discharge.

Figure 14.12. Tumour mass involving the bladder, seminal vesicles, rectum, and pelvic floor.

(a) and (b) Transaxial and (c) coronal T2W1 in which a large soft tissue sarcoma tumour (T) can be seen to displace and infiltrate the rectum (arrows) with high signal oedema or haemorrhage of the rectal mucosa best seen on the coronal view (arrowheads). The tumour mass is displacing the lower rectum and anal canal, infiltrating the pelvic floor on the right side with extension into the right ischioanal fossa (IAF).The right seminal vesicle and the medial left seminal vesicle (SV) are totally engulfed by tumour which is also involving the right lateral bladder wall (open arrows in (a)). Extent of surgery required by MRI criteria: total pelvic clearance with resection of the pelvic floor.

Figure 14.13. Tumour involving the seminal vesicles and pre-sacral fascia.

(a) Transaxial and (b) sagittal T2W1 demonstrating a recurrent rectal tumour (T) involving the seminal vesicles and extending posteriorly to involve the presacral fascia (arrows in (b)). One small left internal iliac node is seen (arrowhead in (a)) which is not significant by size criteria but whose signal intensity is similar to that of the tumour proper. Note that the sacrum is not involved and that the prostate (P) is also free from tumour infiltration. The tumour abuts the posterior wall of the bladder (B) to which it may be adherent but there is no evidence of tumour extension into or through the wall, with preservation of the normal low signal intensity of the bladder wall. Extent of the surgery required by MRI criteria: posterior exenteration, prostatectomy and possible cystectomy since the tumour may be adherent to the posterior bladder wall. Although the prostate is not involved, it has to be removed with the seminal vesicles.

Figure 14.14. Tumour involving the pelvic floor.

(a) Transaxial and (b) coronal T2W1 demonstrating a recurrent vaginal tumour (T) infiltrating the right anterior pubococcygeal portion of the levator ani muscle with extension of tumour into the anterior ischioanal fossa (IAF) (arrow) and infiltration of the anterior wall of the anal canal (asterisk). Note the normal signal intensity left pelvic floor (arrowheads). in (b) the craniocaudal extent of the tumour recurrence is appreciated and extension into the perineum (open arrows) can be identified. Extent of surgery required by MRI criteria: total pelvic clearance with resection of the pelvic floor.

Figure 14.15. Recurrent rectal cancer involving the pelvic floor.

(a) Transaxial T2W1 demonstrating the normal post-surgical appearances after abdominoperineal resection when the perineal scar (arrow) becomes continuous with the oversewn inferior portion of the levator ani muscles (arrowheads). Note the low signal intensity of both the scar and the pelvic floor. (b) Transaxial T2W1 at a more cranial level than (a) demonstrates a small lobular soft tissue recurrent tumour (T) which is of higher signal intensity than the levator and apex of the surgical scar. It is involving the vaginal vault (V) which is of low signal intensity due to post hysterectomy fibrosis. Extent of surgery required by MRI criteria: vaginectomy and resection of the pelvic floor.

Figure 14.16. Perineal involvement by recurrent vaginal cancer.

(a) to (d) Transaxial T2W1 demonstrating a recurrent vaginal tumour with the tumour mass (T) involving the urethra (Ur) in (a) where there is contiguous tumour extending from the left vagina to the left lateral margin of the urethra. Note the abnormal signal intensity of the urethra proper with intermediate to low signal intensity tumour within it (asterisk) and loss of its normal target appearance. In (b) and (c) the mass can be seen to have extended posteriorly to involve the anterior anal canal (small arrow), and anteriorly to involve the antero-inferior recess of the ischioanal fossa (open arrow in (b)). The mass abuts the left crus of the clitoris (arrowheads in (c)), and directly abuts the periosteum of the inferior pubic ramus (curved arrows in (b)). The tumour is involving the perineal body (short arrows in (d)). Also note the left inguinal nodes (N) in (b) and (c) which are not enlarged by size criteria but have a signal intensity similar to the signal intensity of the tumour. A similar signal, small left anatomical obturator node (ON) is seen between obturator externus (OE) and pectineus (P) on the left side in (a) (small curved arrow). Extent of surgery required by MRI criteria: total pelvic clearance, resection of the pelvic floor and perineum, local resection of the left inferior pubic ramus and insertion of a myocutaneous flap. A left inguinal lymph node dissection could be performed also but the left anatomical obturator lymph node would not be dissected routinely.

Figure 14.17. Pelvic sarcoma involving the uterus, cervix and bladder.

(a) Transaxial and (b) sagittal T2W1 demonstrating a large central pelvic tumour (T) infiltrating into the uterus (U) with tumour extending through the anterior uterine body to infiltrate the inner junctional zone (small arrows in (a)). The tumour also infiltrates the cervix, best appreciated on the sagittal view (curved arrows). There is extensive tumour infiltration of the posterior wall of the bladder (arrows in (a)). Note a small but likely involved left paravesical lymph node (arrowhead in (a)) and an enlarged and likely metastatic right internal iliac lymph node (open arrow in (a)). A small air bubble is present in the anterior aspect of the bladder (B). This was due to recent cystoscopy. Ascites (A) is also present. Extent of surgery required by MRI criteria: anterior pelvic clearance. If there is malignant ascites, then the procedure becomes palliative.

Figure 14.18. Recurrent sarcoma involving small bowel.

Figure 14.18. Recurrent sarcoma involving small bowel.

(a) Transaxial and (b) sagittal T2W1 demonstrating a large central pelvic tumour (T) with fluid-fluid levels in the mass due to haemorrhage. The antero-superior surface of the mass is infiltrating around lower signal intensity small bowel loops (arrows in (a) and (b)). Posteriorly the tumour is also infiltrating into the rectosigmoid (arrowheads in (a)). A component of the mass is displacing the rectus abdominis muscles anteriorly (open arrows in (a)) but there is no evidence of tumour infiltrating into the rectus abdominis muscles as their signal intensity is preserved. The bladder (B) is compressed but not involved by the mass. Note incidental arachnoid cysts (Cy) in the sacral spine in (b). Extent of surgery required by MRI criteria: local resection, recto-sigmoid colectomy and small bowel resection.

Figure 14.19. Tumour involvement of the caecum and small bowel.

Transaxial T2W1 demonstrating a small bowel loop (arrows) being enveloped in the superior-most extent of a recurrent rectal tumour (T). The patient had subacute obstruction and a dilated loop of small bowel (SI) is seen in the left iliac fossa. The recurrent tumour mass is also extending antero-laterally to involve the caecum (Ca). Note the dilated left ureter (asterisk) due to entrapment at the pelvic brim. The tumour is also directly adjacent to the posterior wall of the bladder (B) which has altered high signal intensity of its outer muscle layer (arrowheads) indicating likely infiltration. Extent of surgery required by MRI criteria: total pelvic clearance with small bowel loop and caecal resection.

Figure 14.20. Anterior abdominal wall involvement by tumour.

Figure 14.20. Anterior abdominal wall involvement by tumour.

(a) Transaxial and (b) sagittal T2W1 demonstrating a recurrent pelvic leiomyosarcoma (T) with multiple fluid-fluid levels filling the pelvis and extending anteriorly into the right rectus abdominis muscle (arrows), with scalloping of the muscle: tumour interface. The tumour is compressing the bladder (B) and infiltrating the dome (arrowheads). There is some reactive oedema of the bladder mucosa (asterisk). Note the depression of the pelvic floor by the sheer size of the mass. Extent of surgery by MRI criteria: total pelvic clearance and localised abdominal wall resection.

Figure 14.21. Vascular pelvic tumour.

Transaxial T2W1 demonstrating a large pelvic tumour mass with multiple collateral vessels (arrowheads)

identified as signal voids in and around the periphery of the mass. Note additional similar collateral vessels around the bladder (B).This finding should make the surgical team consider pre-operative angiog-raphy with a view to tumour embolisation. Intralesional signal voids can also be due to dystrophic calcification.

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