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Figure 14.22. Pelvic tumour mass involving the external iliac vessels.

(a) to (c) Coronal T2W1 demonstrating compression and displacement of the external iliac vein which is seen as a fine low signal intensity band at the margin of the large pelvic tumour (T) (arrows in (a)). Distal to the mass the vein demonstrates high signal intensity due to slow flow within its lumen (V in (a), (b) and (c)). The left common and external iliac artery are also markedly displaced and compressed by the tumour mass (arrowheads in (a) to (c)). Bladder (B). In these circumstances, it is often difficult to differentiate between adherence and involvement of the vessels. The pelvic surgeon should be warned that a vascular surgeon might be required to assist at the procedure.

Figure 14.23. Tumour involvement of S5.

(a) Transaxial and (b) sagittal T2W1 showing a small, recurrent rectal tumour (T) extending to involve S5

(arrows) and the bladder (B) and prostate (P). Extent of surgery required by MRI criteria: total pelvic clearance, resection of the pelvic floor and amputation of the sacrum below S3.

Figure 14.24. Tumour extension to the pelvic sidewall.

(a) Transaxial T1W1 and (b) T2W1 demonstrating a recurrent cervical tumour (T) extending to the right pelvic sidewall (arrows).The patient also has involvement of the rectum (arrowheads) and fluid in the vaginal vault (asterisk), which was due to a vesico-vaginal fistula. Pel vie sidewall disease is a contraindication to pelvic clearance.

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Figure 14.25. Extension of tumour into the sacrum.

(a) Sagittal T1W1 and (b) sagittal T2W1 demonstrating a recurrent ovarian tumour mass (T) involving the rectum (R) and extending through the pre-sacral fascia (arrowheads in (a) and (b)) to erode the periosteum of the sacrum at S2 and S3 levels (small arrows). This patient is ineligible for salvage surgery; she went on to have radiotherapy and is in remission after 5 years.

Figure 14.26. Involvement of sacral nerve roots by recurrent rectal tumour.

Coronal T2W1 demonstrating a large partially necrotic posterior recurrent rectal tumour (T) which is adherent to the left exiting sacral nerve roots (arrows) down to the proximal-most portion of the sciatic nerve (SN). Note how the nerve roots are retracted towards the mass and the asymmetrical swelling of the sciatic nerve compared to the normal right side, indicating oedema or early infiltration. S1 or S2 nerve root involvement renders the patient ineligible for complete pelvic clearance.

Figure 14.27. Tumour extension into the sciatic notch.

Figure 14.27. Tumour extension into the sciatic notch.

(a) Transaxial and (b) coronal T2W1 in a patient with a multilobulated synovial sarcoma tumour (T) with a component extending into the sciatic notch (arrows in (a) and (b)). Another component of the mass is indenting the pelvic floor (arrowheads in (b)). Additional tumour locules are present within the pelvis, one adjacent to the right external iliac vessels (asterisk in (a)) and another situated on the left posterior pelvic sidewall adjacent to the sacrum (open arrow in (a)). This tumour is unsuitable for exenteration because of extension into the sciatic notch and involvement of the pelvic sidewall.

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Figure 14.28. Involvement of the sacrum, sacral nerve roots, sciatic notch and sciatic nerve.

Coronal T2W1 in a patient with a chondrosarcoma demonstrating a huge pelvic tumour (T), with signal voids within it indicating hypervascularity or calcifications, which is infiltrating the sacrum (arrows) with encroachment into the right S1 foramen (arrowheads). The tumour is extending through the sciatic notch and both the right sacral roots and the proximal sciatic nerve are completely engulfed. Note that the distal sciatic nerve (SN) appears normally positioned. The patient had severe neurological symptoms of pain and weakness and the gluteal muscles are shown to be completely wasted on the right side.

Figure 14.29. Ascites, implants and lymph node metastasis in a patient being evaluated for pelvic clearance.

Transaxial T2W1 demonstrating a huge central pelvic tumour (T) with fluidfluid levels (arrowheads) likely to indicate haemorrhage within the mass. In the posterior pelvis, there is a small volume of ascites (A) and peritoneal implants (open arrows). Note an enlarged left internal iliac lymph node (long arrow), which has a similar signal intensity to the tumour proper making it likely to be a metastatic node. This patient is ineligible for curative pelvic clearance.

Figure 14.30. Bone metastases in a pelvic clearance candidate.

Coronal T1W1 in a patient with a fibrosarcoma tumour (T) for which radiotherapy had already been administered. The tumour is infiltrating the left S1 foramen (arrowheads). At the margin of the radiotherapy field there is high signal intensity within the marrow which has been irradiated and intermediate signal intensity in unradiated portions of the sacrum and iliac blades. A bone metastasis (arrow) has developed at the margin of the field.

Figure 14.31. Large pelvic mass simulating visceral involvement.

(a) Sagittal and (b) transaxial T2W1 in a patient with a large pelvic tumour (T) which is compressing both the rectum and the bladder (B). The posterior bladder wall demonstrates altered signal intensity on the sagittal images (arrows) but can be seen to be preserved on the transaxial image. This finding is explained by the plane of imaging, which is not perpendicular to the bladder wall on the sagittal sequence. On the transaxial image, the bladder wall is shown to be intact. Therefore, it is important to assess organ involvement in two planes. Note the bilateral hydroureter in (b) (arrowheads). This was not due to ureteric obstruction but to marked displacement of the ureters by the size of the central mass; they could be traced around the margins of the mass down to the vesico-ureteric junction.

Figure 14.32. Tumour compressing pelvic organs.

Transaxial T2W1 demonstrating a large recurrent ovarian tumour (T) compressing the bladder (B), which contains a urinary catheter. The mass is displacing the pelvic floor structures inferiorly. In these patients, it is often difficult to distinguish compression from adherence or infiltration.

Figure 14.33. Small volume peritoneal disease.

(a) and (b) Transaxial T2W1 in a patient with a recurrent ovarian tumour (T) which is adherent to the left abdominal wall (curved arrows). Additional small volume peritoneal deposits are seen adjacent to the bladder (arrow) and in the low pelvic peritoneum (arrowheads in (a) and (b)). Unusually, there is a retained right ovary (open arrow in (a)) with a small cyst within it.

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