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Figure 5.11. T4N1/Stage IVA endometrial cancer.

(a) Sagittal and (b) and (c) oblique transaxial T2WI showing an endometrial tumour (T) replacing the cervix (arrows) and extending into the left adenexal structures in (c) (asterisk), vagina in (a) (open arrows) and invading the posterior bladder wall in (a) and (b), the proximal urethra in (a) and the rectum in (b) (black and white arrowheads). The presence of bladder and rectal involvement makes the stage of this tumour T4NI/Stage IVA.There are bilateral metastatic surgical obturator nodes in (c) (N) and suspicious perirectal nodes (PN) in (a) and (b). A small volume of ascites (A) is present.

Figure 5.12. Central recurrence of endometrial cancer.

(a) Transaxial and (b) sagittal T2W1 demonstrating a large central pelvic tumour recurrence (T). The mass, which is arising exophytically from the vaginal vault, extends to involve the recto-sigmoid colon (arrows) without extension to the pelvic sidewall. One small bowel loop (S) is seen to be adherent to the superior surface of the mass in (b). The postero-superior bladder wall is abnormal (arrowheads) due to small volume tumour infiltrating the remnant of the uterovesical ligament (asterisk). (Figure courtesy of Dr. Carrington, Christie Hospital).

Uterus Without Ligaments
Figure 5.13. Pseudo invasion of cervix by endometrial cancer.

(a) Sagittal and (b) oblique transaxial T2W1 demonstrating an endometrial tumour (T) extending into and distending the cervical canal (asterisk). The resected specimen demonstrated tumour prolapse into the cervix without invasion of the cervical mucosa or stroma. Tumour prolapse can result in overstaging. Bladder (B).

Prolapse The Womb

(a) Sagittal and (b) Transaxial T2W1 demonstrating adenomyosis in a patient who also had a small T1a endometrial tumour (T). The adenomyosis mimics myometrial invasion (arrowhead). Bladder (B).

Figure 5.15. Endometrial polyp in a Tamoxifen uterus.

(a) Coronal and (b) sagittal T2W1, (c) contrast-enhanced coronal T1W1 and (d) contrast-enhanced sagittal

T1W1. The endometrial cavity is distended and there is high signal intensity material within it due to haemorrhage (also high signal on the T1W1). In the lower uterine cavity, a more ill defined abnormality (asterisk) is seen forming an irregular interface with the junctional zone (arrowheads). After intravenous Gd-DTPA, there was little enhancement of this region. At hysterectomy, the uterine cavity was distended with haemorrhage and a nonmalignant endometrial polyp was present at the site of the heterogeneous lesion. The junctional zone abnormalities correspond to the polyp's insertion. It is important to be aware that Tamoxifen treatment can predispose to an adenomyosis-like picture, endometrial polyps and endometrial carcinoma. (Figure courtesy of Dr. Carrington, Christie Hospital.)

Irregular Junctional Zone Uterus
Figure 5.16. Pseudomyometrial invasion due to fibroids.

(a) Sagittal and (b) oblique transaxial T2W1 demonstrating an endometrial tumour (T) infiltrating the anterior wall of the uterus (arrowhead). The intramural fibroids (F) incite high signal intensity within the adjacent myometrium (open arrows) which can result in difficulty in determining the true extent of tumour involvement of the myometrium. Intramural or submucosal fibroids can also distort the endometrial/myometrial interface adding to staging difficulty. Bladder (B).

Table 6.1. Epithelial tumours: make up 60-90% of all ovarian tumours; make up 90% of all malignant ovarian tumours

Serous

Mucinous

Endometrioid

Clear cell

Brenner

Incidence

20-50% of malignant tumours

10% of malignant tumours

20% of malignant tumours

6% of malignant tumours

1-2% of malignant tumours

Aggression

Benign 60% Malignant 25%

Benign 80% Malignant 10%

Almost always malignant

Almost always malignant but 75% Stage 1

Rarely malignant

Bilateral

25% of benign 65% of malignant

5% of benign 20% of malignant

40%

40%

6%

Age

Post-menopausal

Po st-menopausal

Post-menopausal

Post-menopausal

Any age, 50% over 50 yrs

Solid and homogenous. Occasionally cystic Usually small (1.0-2.0 cm). Extensive calcification

Typical features

Predominantly cystic. Malignant lesions have more solid components. Psammoma bodies in 30%

Multilocular cysts containing haemorrhage or cellular debris

Variable cystic/solid components. Associated with endometrial hyperplasia and carcinoma

Usually unilocular cyst with few mural nodules protruding into the lumen

Table 6.2. Sex cord stromal tumours: 5% of all ovarian malignanctes; 85-90% synthesise steroid

Fibroma

Thecoma

Granulosa cell

Sertoli-Leydig cell

Incidence

Rare

Commonest

5-10% of all ovarian malignancies

Less than 0.2% of all ovarian malignancies

Aggression

Benign

Benign

Malignant potential increases with size. 5yr survival is 90%

Aggressiveness depends on degree of differentiation. 5yr survival is 70%

Bilateral

Unilateral

Unilateral

Unilateral in >95%

Unilateral

Age

4th and 5th decades

Reproductive years

Any age but commonest in post-menopausal years

Reproductive years

Typical features

Solid. Associated with pleural effusion (Meigs syndrome)

Solid. Produces oestrogen and associated with abnormal vaginal bleeding, endometrial hyperplasia and carcinoma

Multi-cystic. May be haemorrhagic or necrotic. Can secrete oestrogen and is associated with abnormal vaginal bleeding, hyperplasia and carcinoma

Can be solid or cystic. Synthesise androgens resulting in masculinisation.

approximately 90% of patients doubling or halving of the CA-125 correlates with disease progression or regression respectively. In patients with treated early stage disease a rising CA-125 is predictive of recurrence regardless of imaging features. However, if the CA-125 falls to normal following treatment, this may not indicate complete response and up to 50% of patients will have residual disease discovered at laparotomy.

It is important to note that CA-125 is not exclusive to ovarian cancer and is also elevated in 40% of patients with advanced non-ovarian intra-abdominal malignancy, as well as other abdomino-pelvic conditions such as liver cirrhosis, pancreatitis, endometriosis, pelvic inflammatory disease, pregnancy and also in 1 % of healthy individuals.

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