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DOI: 10.1148/rg.281075134
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Ovarian, Cervical, and Endometrial Cancer1

Akila N. Viswanathan, MD, MPH, Barbara M. Buttin, MD, and Anne M. Kennedy, MD

1 From the Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute and Harvard Medical School, 75 Francis St, Boston, MA 02115 (A.N.V.); the Division of Gynecologic Oncology, Northwestern University Feinberg School of Medicine, Chicago, Ill (B.M.B.); and the Department of Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah (A.M.K.). From the Oncodiagnosis Panel at the 2006 RSNA Annual Meeting. Received June 4, 2007; revision requested July 23; final revision received September 21; accepted September 24. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Ovarian cancer. Endovaginal US image shows a large (>9 cm), mixed cystic-solid mass with irregular vessels running in thick septa. The sonographic features are suggestive of a malignant neoplasm.

 

Figure 2
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  		Figure 2.  Staging of ovarian cancer. Contrast-enhanced CT scan shows an extensive omental "cake," mesenteric nodularity, and ascites. In addition, there is diffuse enhancement of the entire mesenteric root (arrows). The mesenteric root involvement makes this case inoperable; therefore, the patient should receive chemotherapy as first-line treatment.

 

Figure 3
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  		Figure 3.  Photograph shows the left paraaortic lymph nodes. (Courtesy of Julian Schink, MD, Northwestern University Feinberg School of Medicine, Chicago, Ill.)

 

Figure 4
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  		Figure 4.  Photograph shows use of an argon beam coagulator for desiccation of tumor implants. (Courtesy of Julian Schink, MD.)

 

Figure 5
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  		Figure 5.  Photograph of a patient’s abdomen shows proper placement of an intraperitoneal catheter.

 

Figure 6
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  		Figure 6.  Ovarian cancer in a patient with an elevated CA-125 level. Contrast-enhanced CT scan obtained for postoperative surveillance shows mesenteric nodules, retroperitoneal adenopathy (arrow), and metastases to the bowel serosa (arrowhead).

 

Figure 7
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  		Figure 7.  Complications of treatment for ovarian cancer. Contrast-enhanced CT scan shows postoperative bowel perforation and peritonitis. There is oral contrast material (arrowhead) in the peritoneal space mixed with fluid bowel contents and gas. Note the large air-fluid level (arrow) in the peritoneal cavity. The perforation was repaired. An abscess formed subsequently and was treated with percutaneous drainage; ultimately, the patient recovered completely.

 

Figure 8A
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  		Figure 8a.  Correct imaging plane for evaluation of cervical cancer with MR imaging. (a) Sagittal T2-weighted image, obtained to localize the cervix, shows an imaging plane (dashed lines) that is axial to the cervix. (b) MR image obtained in the plane indicated by the dashed lines in a shows the cervix as a "doughnut" with the endocervical canal in the center. Normal cervical stroma is dark on T2-weighted images.

 

Figure 8B
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  		Figure 8b.  Correct imaging plane for evaluation of cervical cancer with MR imaging. (a) Sagittal T2-weighted image, obtained to localize the cervix, shows an imaging plane (dashed lines) that is axial to the cervix. (b) MR image obtained in the plane indicated by the dashed lines in a shows the cervix as a "doughnut" with the endocervical canal in the center. Normal cervical stroma is dark on T2-weighted images.

 

Figure 9
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  		Figure 9.  Parametrial extension of cervical cancer. T2-weighted MR image shows that an intermediate-signal-intensity tumor has replaced all of the normal low-signal-intensity cervical stroma. Fingerlike projections of the tumor (arrows) extend into the parametrial fat.

 

Figure 10
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  		Figure 10.  Standard four-field plan for external-beam radiation therapy to the pelvis. The plan was developed after CT simulation to depict the contours of the nodal regions, the central uterine cervix, and the vagina.

 

Figure 11
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  		Figure 11.  Photograph shows a Fletcher-Suit-Delclos tandem and ovoid applicator for low-dose-rate radiation therapy.

 

Figure 12
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  		Figure 12.  Photograph shows a tandem and ring applicator for high-dose-rate radiation therapy.

 

Figure 13A
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  		Figure 13a.  Improper placement of a radiation therapy applicator. (a) US image shows an intrauterine tandem that is displaced into the posterior myometrium but does not perforate the serosa. The applicator was removed and repositioned with US guidance. (b) US image shows proper positioning of the applicator.

 

Figure 13B
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  		Figure 13b.  Improper placement of a radiation therapy applicator. (a) US image shows an intrauterine tandem that is displaced into the posterior myometrium but does not perforate the serosa. The applicator was removed and repositioned with US guidance. (b) US image shows proper positioning of the applicator.

 

Figure 14
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  		Figure 14.  PET image shows uptake in the supraclavicular region (arrow), a known site of skip metastases from cervical cancer. PET depicts distant nodal disease that would not be evident at clinical examination.

 

Figure 15
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  		Figure 15.  Isodose curves around an interstitial implant for brachytherapy of cervical cancer.

 

Figure 16A
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  		Figure 16a.  Fusion of a CT simulation image (a) with a PET image (b) allows contouring of involved lymph nodes (arrow).

 

Figure 16B
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  		Figure 16b.  Fusion of a CT simulation image (a) with a PET image (b) allows contouring of involved lymph nodes (arrow).

 

Figure 17
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  		Figure 17.  Radiation enteritis in a patient who was treated for cervical cancer. Contrast-enhanced CT scan shows thick-walled small bowel loops of increased permeability, hence the ascites.

 

Figure 18
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  		Figure 18.  Local recurrence after hysterectomy for cervical cancer. T2-weighted MR image shows a mass in the anterior vaginal wall (arrow), a finding that represents a local recurrence of cervical cancer. The vagina is distended with surgical lubricant, which allows better delineation of the walls.

 

Figure 19A
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  		Figure 19a.  Complications of external-beam radiation therapy for cervical cancer. (a) CT scan shows avascular necrosis of the right femoral head (arrowhead) and a soft-tissue mass along the right pelvic sidewall (arrow). (b) MR image shows abnormal signal intensity in the presacral space and piriformis muscle. Biopsy results were negative, and the signal intensity changes were attributed to inflammatory changes after radiation therapy.

 

Figure 19B
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  		Figure 19b.  Complications of external-beam radiation therapy for cervical cancer. (a) CT scan shows avascular necrosis of the right femoral head (arrowhead) and a soft-tissue mass along the right pelvic sidewall (arrow). (b) MR image shows abnormal signal intensity in the presacral space and piriformis muscle. Biopsy results were negative, and the signal intensity changes were attributed to inflammatory changes after radiation therapy.

 

Figure 20A
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  		Figure 20a.  Pelvic US of endometrial cancer. (a) Gray-scale US image shows focal thickening of the endometrium (arrow), which has heterogeneous echogenicity. (b) Color Doppler image shows irregular vessels (arrow) within the area of endometrial thickening.

 

Figure 20B
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  		Figure 20b.  Pelvic US of endometrial cancer. (a) Gray-scale US image shows focal thickening of the endometrium (arrow), which has heterogeneous echogenicity. (b) Color Doppler image shows irregular vessels (arrow) within the area of endometrial thickening.

 

Figure 21A
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  		Figure 21a.  (a) Photograph shows the left pelvic retroperitoneum after lymph node sampling. The view is from the right side looking toward the feet. (b) Photograph shows the vena cava after the removal of lymph nodes. (Case courtesy of Julian Schink, MD.)

 

Figure 21B
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  		Figure 21b.  (a) Photograph shows the left pelvic retroperitoneum after lymph node sampling. The view is from the right side looking toward the feet. (b) Photograph shows the vena cava after the removal of lymph nodes. (Case courtesy of Julian Schink, MD.)

 

Figure 22
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  		Figure 22.  Treatment planning in endometrial cancer. Anterior (left) and lateral (right) simulation images of the postoperative pelvis show the radiation fields for external-beam radiation therapy. The contoured volumes include the pelvic lymph nodes and the vagina.

 

Figure 23
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  		Figure 23.  MR imaging–guided interstitial brachytherapy of a recurrent endometrial cancer of the vaginal cuff, which was treated with curative radiation therapy. The addition of imaging-guided interstitial brachytherapy after external-beam therapy results in sparing of the bladder, rectum, and sigmoid colon.

 

Figure 24
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  		Figure 24.  Tumor recurrence in a patient who underwent hysterectomy for endometrial cancer. The patient experienced pelvic pain for several months after surgery; because palpation was compromised by body habitus, MR imaging was performed to evaluate for recurrence. Sagittal MR image shows implantation of endometrial cancer (arrowhead) in the hysterectomy scar. The large abdominal wall mass was successfully resected with resolution of the patient’s pain.

 




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