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Figure 4.34. Central pelvic and subcutaneous haematoma complicating radical hysterectomy.

(a) Transaxial T1W1, (b) transaxial T2W1and (c) sagittal T2W1 in which a central haematoma (H) is seen with characteristic high signal intensity on the T1W1, and T2-weighted heterogeneous appearance with a low signal intensity rim and mixed high and intermediate signal intensity content. Compared to the central pelvic haematoma, the small subcutaneous haematoma (arrows) is of similar signal intensity. There is loculated ascites (A) above the haematoma in (c). (d) Sagittal T2W1 performed three months later demonstrates the small residuum of the haematoma (arrow) but persistent ascites (A). The appearance of haematomata varies with their age.

Figure 4.35 Unilocular lymphocoele after radical hysterectomy.

Transaxial (a) T1W1 and (b) T2W1 showing a small left-sided unilocular lymphocele (arrow) in a common position adjacent to the external iliac vessel. Lymphoceles are retroperitoneal collection of lymph fluid caused by surgical disruption of lymphatic trunks. They demonstrate signal intensity characteristics similar to water on T1WI and T2W1, are usually unilocualr and thinwalled and often resorb apontaneously.Occassionally septations may be seen within larger lymphocoeles.

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Figure 4.36. Post-surgical left pelvic sidewall haematoma and multiloculated right lymphocoele.

(a) Coronal T1W1 and (b) transaxial T2W1 demonstrating a left pelvic sidewall haematoma (H), whose nature is best elucidated on the T1W1, where there is a characteristic ring-within-ring appearance of a low to intermediate signal intensity thin margin, an inner high signal intensity ring and an inner intermediate signal intensity core. The bladder (B) is thick-walled and displaced to the left of the midline by a multiloculated lymphocoele (L) extending along the right pelvic sidewall and across the midline anteriorly. Lymphocoele are typically unilocular and thin-walled but may occasionally be multilocular.

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Figure 4.37. Response of cervical tumour of radiotherapy

Figure 4.37. Response of cervical tumour of radiotherapy

Sagittal T2W1 (a) at presentation, (b) 2 months and (c) 10 months after radiotherapy. The intermediate signal intensity cervical tumour (T) can be readily identified in (a). By 2 months there is only a small area of residual abnormal signal intensity (arrow in (b)) in the posterior lip of the cervix. The anterior lip of the cervix has reconstituted. The uterine body has lost its zonal differentiation but the outer myometrium (M) is still of normal signal intensity. Rapid tumour response to radiotherapy can often occur. By 10 months post radiotherapy the cervix and vagina are of intense low signal intensity indicating a good treatment response (arrows in (c)). The uterus has atrophied and the uterine body (U) is of low signal intensity with loss of zonal anatomy. There is now treatment-induced mural thickening of the posterior and superior bladder (arrowheads).

Figure 4.38. Response of the ovaries to radiotherapy.

Figure 4.38. Response of the ovaries to radiotherapy.

Off-axis transaxial T2W1 (a) before and (b) 4 months after radiotherapy. In (a) the ovaries (arrows) have multiple follicular cysts present with high signal intensity central stroma. In (b) 4 months after radiotherapy the ovaries (arrows) have shrunk, lost their follicular cysts and the signal intensity of the central stroma has started to decrease.

Figure 4.39. Post-radiotherapy cervical stenosis with hydrometria.

Sagittal T2W1 demonstrating a distended high signal intensity endometrial cavity with visualisation of the endometrium (arrowheads) and a stenotic internal os (arrow) with the cervix (C) demonstrating uniform low signal intensity after radiotherapy.

Figure 4.40. Post-radiotherapy haematometria.

Transaxial (a) T1W1, (b) T2W1and (c) sagittal T2W1. The uterus (arrow) is distended and contains altered blood (haematometria (H)) as shown by high signal intensity on T1W1and whorled intermediate and high signal intensity on T2W1. The apparent focal lesion (asterisk) in the left anterior uterine fundus represents haematoma of a different age to the rest of the uterine cavity. The patient went on to have a hysterectomy and altered blood filled the uterine cavity. The patient went on to have a hysterectomy and altered blood filled the uterine cavity. There was no evidence of malignancy.

Figure 4.41. Radiotherapy induced vesico-uterine fistula.

(a) and (b) Sagittal T2W1. In (a) there is a large necrotic cervical tumour (T) involving the uterine body and extending through the bladder wall to involve the mucosa (arrows). In (b) 3 months post treatment a fistula (arrow) can be seen and the cervical cavity and vagina are fluid filled (open arrows). The uterus has decreased in size and the endometrial cavity (E) is visualised. The posterior cervix has reconstituted (arrowheads).

Figure 4.42. Evolution of complex post radiation fistula.

(i) 12 months after therapy, (a) Sagittal, (b) and (c) transaxial T2W1. There is high signal intensity within the cervix (asterisk) due to oedema and hypervascularity. The anorectum demonstrates treatment effect with high signal intensity of the mucosa (arrow) and a high signal intensity thickened lamina propria (open arrow in (b)). An extraluminal air-containing cavity (C) is present between the uterus and the proximal rectum in (a). A small tract (arrowhead) is seen extending through the posterior vaginal wall in (b) but no fistulous connection is identified with the rectum. In (c) there is a further tract (arrowheads) which extends through the posterior vaginal wall without involving the rectal wall.

(ii) 18 months after therapy, (d) Sagittal and (e) transaxial T2W1. There is complete necrosis of the cervix and a double fistula between the cervix/ vagina and the proximal and mid rectum (arrows), whose anterior wall has largely necrosed with a small residual portion superiorly (asterisk). There is also a fistula between the vagina and the bladder (open arrow).The mucosa and muscle layers of the bladder wall are markedly thickened with increased signal intensity of portions of the muscle layer (arrowheads in (e)). Fluid is seen extending down the vagina and there is high signal intensity material (black arrows in (d)) on the patient's perineal skin because of the fistulous discharge per vaginum. On all transaxial images the obturator internus muscles (O) demonstrate high signal intensity due to radiation therapy.

Figure 4.43. Residual cervical cancer.

Sagittal T2W1 (a) pretreatment, (b) 6 months post-radiotherapy. A cavitating high signal intensity tumour (T) is present. Two metallic marker seeds (arrows) have been placed in the anterior and posterior lips of the cervix at examination under anaesthesia to guide the external beam radiotherapy. These clips demonstrate the bloom susceptibility artifact associated with metal. After treatment there remains a high signal intensity mass (M) in the cervix, which shows no evidence of reconstituting. The rest of the uterus has atrophied. One marker seed remains in the posterior lip. The patient underwent salvage hysterectomy with cystectomy (anterior pelvic clearance) and residual adenocarcinoma was confirmed. Residual high signal intensity within the cervix more than 6 months after radiotherapy warrants investigation. The abnormality may be due to tumour or occasionally radiation-induced oedema and telangiectasia. Dynamic contrast enhanced MR imaging may help differentiate between the two conditions.

Figure 4.44. Recurrent cervical cancer.

(a) Sagittal and (b) transaxial T2W1 demonstrating a central high signal intensity partially necrotic recurrent tumour (T) and necrotic left external iliac lymph node metastasis (N) invading the left anterior abdominal wall (arrows). There is abnormal high signal intensity of the obturator internus muscles (O) and portions of the piriformis muscles (P) which reflects oedema and hyperaemia, either due to local inflammation or the effect of radiation therapy.

Figure 4.45. Recurrent common iliac lymph node metastasis.

(a) Coronal and (b) transaxial T1W1 showing a small left common iliac nodal mass (arrows) which was producing back pain. The patient had undergone radiotherapy to the primary tumour and pelvic nodal stations two years before. In these circumstances, nodal recurrences are often at or above the margin of the field, here at L5/S1 level. The metastatic nodes may erode into adjacent bone, and produce severe pain. Note the high signal intensity of the pelvic marrow due to fat replacement, but preservation of haemopoietic marrow in L5 vertebral body.

Figure 4.46. Recurrent pelvic sidewall and upper retroperitoneal lymph node metastases.

Coronal T1W1 showing a small left external iliac nodal mass (arrows) and upper retroperitoneal lymph node metastases in a para-aortic (open arrows) and interaortocaval (asterisk) distribution. The IVC (arrowheads) is displaced laterally.

Sagittal T2W1. The bladder, urethra, uterus and vagina have been removed and the levator ani muscles oversewn (arrows). The omentum (Om) has been placed in the surgical bed to prevent small bowel prolapsing inferiorly.

Figure 4.48. Anterior pelvic clearance with neovagina formation.

(a) Sagittal and (b) transaxial T2W1 demonstrating absence of the anterior pelvic organs, retention of the rectum (R) and formation of a neovagina (V) from colon. Omentum (Om) has been placed in the surgical bed.

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