Signal Intensity

Figure 4.6. T2b cervical cancer with involvement of the uterovesical ligament, the anterior parametrium.

Sagittal T2W1 with tumour (T) arising from the anterior lip and involving the upper third of the vagina. The tumour extends anteriorly into the uterovesical ligament, normally of high signal intensity due to its fat content. Disease abuts the posterior wall of the bladder (B)—(arrows). A small volume of ascites (A) is present in the Pouch of Douglas.

Figure 4.7. T3a cervical cancer.

Sagittal T2W1 demonstrating tumour (T) extending down the anterior wall of the vagina (arrowheads) whose abnormal increased signal intensity contrasts with the normal low signal intensity of the submucosa and muscularis layers of the posterior vagina (arrow). There is also a small nodule of tumour extending into the uterovesical ligament, which is the anterior parametrium (open arrow).

Figure 4.8. T3b cervical tumour with hydronephrosis.

Transaxial (a) T1W1 and (b) high resolution T2W1 showing a tumour (T) completely replacing the cervix and demonstrating spiculated extension into the parametrium. The left ureter (long arrow) is dilated and partially surrounded by tumour. Disease has extended into the proximal portion of the right uterosacral ligament (short arrows) but has not reached the pelvic sidewall. The T1W1 often provide good soft tissue contrast between the tumour margin and adjacent parametrial fat.

Figure 4.9. T3b cervical tumour with uterosacral extension to the pelvic sidewall.

Transaxial T2W1 demonstrating tumour (T) involving the entire cervix, infiltrating the left uterosacral ligament (arrows) which is thickened, and extending to within a centimetre of the pelvic sidewall. Clinically this tumour was fixed to the sidewall.

Figure 4.10. T3b cervical tumour with uterosacral extension.

Transaxial T2W1 showing tumour extending along both uterosacral ligaments, to within 0.5cm of the sidewall on the right and to within a centimetre of the sidewall on the left. Note the lobular uterosacral tumour infiltration on the right side (arrow). Tumour extension to the pelvic sidewall is diagnosed differently by various authorities. Criteria include tumour extending to within I cm, tumour extending to within 0.5cm and tumour actually contacting the sidewall. Overall, however, early pelvic sidewall extension may be under-identified.

Figure 4.11. T3b cervical cancer with large volume uterosacral extension.

Transaxial (a) T1W1 and (b) T2W1 of a patient with substantial uterosacral tumour extending to the left pelvic sidewall (arrows) and infiltrating into the left piriformis muscle (P). The piriformis is tethered by the tumour at the site of infiltration and retracted away from the underlying gluteus maximus muscle (GM). However the tumour has not extended through the piriformis muscle. In (b) note increased T2-weighted signal intensity of the uninfiltrated portions of the piriformis muscle most likely due to reactive oedema.

Figure 4.12. T4a cervical cancer invading the bladder.

Sagittal T2W1 showing a large tumour (T) infiltrating the whole uterus and extending through the bladder into the mucosa (arrows). The mucosa should demonstrate the same signal intensity as the tumour proper to allow diagnosis of bladder infiltration. Note the normal low signal intensity muscle layer of the bladder inferiorly (asterisk) and the presence of overlying mucosal bullous oedema producing high signal intensity change within the mucosa (arrow-heads) which should not be diagnosed as tumour infiltration.

Figure 4.13. T4a cervical cancer invading the bladder.

Transaxcial (a) T2W1, (b) T2W fat suppressed and (c) sagittal T2W1. There is a large cervical tumour (T) invading the bladder in left posterior location with a mass of similar signal intensity to the tumour proper (arrow) seen within the bladder lumen. Note that there is bladder mucosal oedema (arrowheads) in (b) partially overlying the intravesical tumour but also extending over the posterior bladder wall. The central portion of bladder wall in (a) and (b) is also abnormal but signal intensity is higher than the tumour proper and represents oedema. In (b) a portion of the bladder wall is shown to be partially infiltrated but to retain an intact though oedematous inner muscle layer (small open arrow), bladder muscle layer (M). In (c) the abnormal signal intensity of the posterior bladder muscle layer and its retraction towards the tumour can be appreciated. Note the apparent abnormal signal intensity at the dome of the bladder in (c) (long arrow) This was due to artifact from adjacent peristalsing small bowel. To overcome this, hyoscine butylbromide (Buscopan) could be administered if necessary.

Cervical Cancer
Figure 4.16. T4 cervical cancer involving the sigmoid colon.

Sagittal (a) and transaxial (b) T2W1 demonstrating a cervical tumour extending postero-superiorly into the sigmoid colon (arrows). The tumour extends through the uterovesical ligament to involve the supero-posterior bladder wall (asterisk). There is an air/fluid level in this centrally necrotic tumour (arrowheads).

Figure 4.17. Paracervical/parametrial lymph node metastases.

Off-axis transaxial (a) and off-axis coronal (b) T2W1 in two different patients illustrating paracervical/parametrial lymph node metastases (arrows) adjacent to the cervical tumour (T). These nodes are often small, but of similar signal intensity to the tumour proper, and appear separate from the primary tumour on all planes. They are infrequently seen because parametrial extension of the primary tumour often engulfs them. Note the right-sided ureterocoele (open arrow) in (a).

Figure 4.16. T4 cervical cancer involving the sigmoid colon.

Sagittal (a) and transaxial (b) T2W1 demonstrating a cervical tumour extending postero-superiorly into the sigmoid colon (arrows). The tumour extends through the uterovesical ligament to involve the supero-posterior bladder wall (asterisk). There is an air/fluid level in this centrally necrotic tumour (arrowheads).

Figure 4.17. Paracervical/parametrial lymph node metastases.

Off-axis transaxial (a) and off-axis coronal (b) T2W1 in two different patients illustrating paracervical/parametrial lymph node metastases (arrows) adjacent to the cervical tumour (T). These nodes are often small, but of similar signal intensity to the tumour proper, and appear separate from the primary tumour on all planes. They are infrequently seen because parametrial extension of the primary tumour often engulfs them. Note the right-sided ureterocoele (open arrow) in (a).

Figure 4.18. Bilateral obturator lymph nodes metastates.

Transaxial T1W1 (a) and T2W1 (b) demonstrating bilateral obturator lymph nodes (arrow) in a patient with a large cervical primary tumour (T). The nodes are situant adjacent to the obturator vessel (arrowhead) and positioned posterior to the external iliac vein (V), typically adjacent to the pelvic sidewall. These lymph nodes are highly likely to contain metastatic tumour because they are enlarged, rounded and of similar signal intensity to the primary tumour mass. Obturator nodes are the most frequently involved by metastatic tumour. It is important to evaluate both the T1W1 and T2W1 for nodal disease since node: fat contrast is optimal on T1W1 and lymph nodes may be overlooked occasionally on T2W1 if their signal intensity rises to approxmiate the signal intensity to fat.

Figure 4.19. Internal iliac and perirectal lymph node metastases.

Transaxial T2W1 demonstrating a high signal intensity primary cervical tumour (T) with metastatic spread to a right internal iliac (arrow) and two perirectal lymph nodes (open arrows). The right internal iliac lymph node has undergone central nodal necrosis as shown by irregular very high signal intensity within its centre.

Figure 4.20. Pre-sacral lymph node metastasis in cervical cancer.

Sagittal T2W1 demonstrating a pre-sacral node at S2 level (arrow) which has the same signal intensity as the tumour proper (T). It is likely to be involved by tumour. Pre-sacral lymph nodes may be excluded from the radiotherapy field if they are located below S2 level, since the posterior margin of the field is normally vertically aligned at the S2/3 junction.

Figure 4.21. Common iliac and external iliac metastatic lymph nodes in cervical cancer.

(a) Coronal T1W1 showing multiple enlarged right pelvic sidewall lymph nodes (arrow). (b) Coronal and (c) transaxial T1W1 in adifferent patient. There are left common iliac lymph node metastates (open arrows) producing the filled in fat sign compared to the contralateral side. This site for lymph nodes metastases can be overlooked easily. In (c) maglignant bone infiltration can be seen within the right medial ilium and in the left sacrum directly underlying the metastatic lymph node mass. Bone infiltration can be due to haematogeneous spread or direct bone erosion by lymph node disease. Note the asymmetry of the iliopsoas muscles with increase in size on the left side. This is most likely to be due to oedema arising from imparied lymphatic drainage.

Figure 4.22. Pelvic metastatic lymph nodes.

(a) Transaxial T2W1 demonstrating a primary tumour (T) with ahuge left external iliac lymph node mass showing central necrosis (N) and encasing the left external iliac artery (arrowhead). The bladder (B) is displaced to the right. The patient also has bilateral adnexal cysts (asterisks). It is unusual to have such a large lymph node metastasis at presentation. (b) Transaxial T2W1 showing a small right obturator lymph node (arrow) with central nodal necrosis exhibiting high signal intensity greater than pelvic fat. Histopathological analyisis confirmed metastatic tumour in this node. In squamous cell carcinoma. T2-weighted central nodal necrosis is highly accurate predictor of metastatic nodal infiltration even if the lymph node is not enlarged by size criteria. If there is uncertainity whether T2-weighted high signal intensity in a node is a fat or central nodal necrosis, then fat suppressed imaging (fat saturation or STIR sequences) may help.(c) Off-axis transaxial T2W1 demonstrating a large cervical primary tumour (T) with parameterial extension and a left obturator lymph node (arrow) which is of normal size but of similar signal intensity to the tumour proper. This finding indicates likely metastatic infiltration.

Figure 4.23. T2b MI cervical cancer with metastasis to the lower vagina.

Sagittal T2W1 showing a bulky cervical tumour (T) and a metastasis to the lower third of the vagina (M). The two lesions were separate on all imaging planes.

Figure 4.24. Upper retroperitoneal lymph node metastases.

Coronal T1W1 demonstrating left pelvic sidewall lymph node metastases (arrow) and upper retroperitoneal lymph node metastases (arrowheads).

Figure 4.25. Liver metastases in cervical cancer.

(a) Sagittal T2W1 demonstrating a large cervical tumour (T) extending into the parametrium, body of uterus and upper two thirds of the vagina. (b) Off axis coronal dynamic enhanced gradient recalled echo image of the liver demonstrating a large necrotic metastasis (M) with a satellite lesion (arrow).

Figure 4.26. Bone metastasis in cervical cancer.

Transaxial T1W1 showing an intermediate signal intensity metastasis (arrow) in the right superior pubic ramus and acetabulum. The lesion has breached the cortex anteriorly. Bone metastases contrast best with marrow fat on T1W1. (See also Figures 4.21(b) and (c)).

Figure 4.27. Small tumours and post biopsy change.

Sagittal T2W1 demonstrating subtly altered signal intensity in and slight expansion of the posterior lip of the cervix (arrows) after biopsy. Pathological examination of the hysterectomy specimen revealed inflammatory change after biopsy but no residual tumour.

Figure 4.28. Nabothian cysts.

(a) Transaxial and (b) coronal T2W1 demonstrating a well demarcated thin-walled high signal intensity lesion in the cervix (arrows). Nabothian cysts are mucus retention cysts formed by occlusion of the endocervical crypts by squamous metaplasia.

Figure 4.29. Loss of cervical fibrous stroma.

Transaxial T2W1 demonstrating a tumour (T) with complete loss of the low signal intensity fibrous stroma but a smooth margin with the parametrial fat. Absence of the low signal intensity fibrous stromal ring is not an absolute indicator of tumour extension into the parametrium (see text).

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