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Tissue Characterization in the Female Pelvis by Means of MR Imaging¹

¹ From the Department of Radiology, University of Pennsylvania Medical Center, 1st Floor Silverstein, 3400 Spruce St, Philadelphia, PA 19104-4283 (E.S.S.), and the Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (E.K.O.). Received July 16, 1998; revision requested August 28; revision received October 13; accepted February 10, 1999. Address reprint requests to E.S.S. (e-mail: siegelm@oasis.rad.upenn.edu).

View larger version (106K): [in a new window]   Figure 1. MR urography demonstrates obstruction of the distal ureter in a 49-year-old woman with surgically proved cervical carcinoma with parametrial invasion. Coronal maximum intensity projection MR urogram (/100) shows a dilated right collecting system and ureter to the level of the right ureterovesical junction (large straight arrow). Other fluid-containing structures include spinal fluid (curved arrow) and bowel (small straight arrow).

View larger version (177K): [in a new window]   Figure 2. Blood within a subacute hematoma of rectus sheath and pelvis in a 76-year-old woman with atrial fibrillation who was being treated with oral anticoagulants. Axial fat-suppressed T1-weighted GRE image (300/1.7, 90° flip angle) shows typical left-sided rectus sheath and pelvic sidewall hematomas with a very high-signal-intensity outer rim (straight arrows) characteristic of methemoglobin. Magnetic susceptibility artifact (*) is present in the left femoral head from prior joint replacement. The unsuppressed fat (curved arrow) in the posterior acetabulum and deep gluteal soft tissues should not be interpreted as an additional site of hemorrhage.

View larger version (149K): [in a new window]   Figure 3a. Blood present within an adnexal mass in a 17-year-old girl with ovarian torsion. Hemorrhagic infarction of the left ovary was confirmed at surgery. (a) Axial T1-weighted, fat-suppressed, spoiled GRE image (280/1.7, 90° flip angle) shows a 10-cm left adnexal mass that has a high-signal-intensity rim (arrows), suspicious for subacute hemorrhage. (b) Axial fat-suppressed T2-weighted fast SE image (4,600/98) obtained slightly higher throughout the mass shows scattered subcentimeter cysts (arrowheads) representing ovarian follicles. The remainder of the ovary is composed of low- to intermediate-signal-intensity material, likely representing deoxyhemoglobin. (c) Axial gadopentetate dimeglumine–enhanced, T1-weighted, fat-saturated GRE image obtained with identical imaging parameters as in a shows only faint rim enhancement (arrows) of the ovary. The remainder of the ovary shows no perfusion.

View larger version (135K): [in a new window]   Figure 3b. Blood present within an adnexal mass in a 17-year-old girl with ovarian torsion. Hemorrhagic infarction of the left ovary was confirmed at surgery. (a) Axial T1-weighted, fat-suppressed, spoiled GRE image (280/1.7, 90° flip angle) shows a 10-cm left adnexal mass that has a high-signal-intensity rim (arrows), suspicious for subacute hemorrhage. (b) Axial fat-suppressed T2-weighted fast SE image (4,600/98) obtained slightly higher throughout the mass shows scattered subcentimeter cysts (arrowheads) representing ovarian follicles. The remainder of the ovary is composed of low- to intermediate-signal-intensity material, likely representing deoxyhemoglobin. (c) Axial gadopentetate dimeglumine–enhanced, T1-weighted, fat-saturated GRE image obtained with identical imaging parameters as in a shows only faint rim enhancement (arrows) of the ovary. The remainder of the ovary shows no perfusion.

View larger version (116K): [in a new window]   Figure 3c. Blood present within an adnexal mass in a 17-year-old girl with ovarian torsion. Hemorrhagic infarction of the left ovary was confirmed at surgery. (a) Axial T1-weighted, fat-suppressed, spoiled GRE image (280/1.7, 90° flip angle) shows a 10-cm left adnexal mass that has a high-signal-intensity rim (arrows), suspicious for subacute hemorrhage. (b) Axial fat-suppressed T2-weighted fast SE image (4,600/98) obtained slightly higher throughout the mass shows scattered subcentimeter cysts (arrowheads) representing ovarian follicles. The remainder of the ovary is composed of low- to intermediate-signal-intensity material, likely representing deoxyhemoglobin. (c) Axial gadopentetate dimeglumine–enhanced, T1-weighted, fat-saturated GRE image obtained with identical imaging parameters as in a shows only faint rim enhancement (arrows) of the ovary. The remainder of the ovary shows no perfusion.

View larger version (166K): [in a new window]   Figure 4a. Adnexal endometrial cysts in a 37-year-old woman with surgically confirmed endometriosis. (a) Axial fat-suppressed T1-weighted GRE image (120/2.6, 60° flip angle) shows bilateral high-signal-intensity adnexal lesions (arrows). (b) Axial T2-weighted fast SE image (5,000/108) shows that the lesions are of low-signal-intensity "shading" (arrows). Bilateral adnexal lesions with high signal intensity on T1-weighted images and low signal intensity on T2-weighted images have high specificity for endometriosis.

View larger version (167K): [in a new window]   Figure 4b. Adnexal endometrial cysts in a 37-year-old woman with surgically confirmed endometriosis. (a) Axial fat-suppressed T1-weighted GRE image (120/2.6, 60° flip angle) shows bilateral high-signal-intensity adnexal lesions (arrows). (b) Axial T2-weighted fast SE image (5,000/108) shows that the lesions are of low-signal-intensity "shading" (arrows). Bilateral adnexal lesions with high signal intensity on T1-weighted images and low signal intensity on T2-weighted images have high specificity for endometriosis.

View larger version (160K): [in a new window]   Figure 5a. Hemorrhagic corpus luteum cyst in a 41-year-old woman. (a) Axial T1-weighted SE image (500/16) shows a cyst with high signal intensity (arrow) in the left ovary. (b) Axial T2-weighted fast SE image (3,600/119) shows high signal intensity of the cyst. This combination of short T1 and long T2 is suggestive, but not diagnostic, of hemorrhagic functional cysts since some endometriomas can have a similar appearance (33). In our experience, the degree of T1 shortening is greater for endometriomas (Fig 4a) than for hemorrhagic functional cysts.

View larger version (172K): [in a new window]   Figure 5b. Hemorrhagic corpus luteum cyst in a 41-year-old woman. (a) Axial T1-weighted SE image (500/16) shows a cyst with high signal intensity (arrow) in the left ovary. (b) Axial T2-weighted fast SE image (3,600/119) shows high signal intensity of the cyst. This combination of short T1 and long T2 is suggestive, but not diagnostic, of hemorrhagic functional cysts since some endometriomas can have a similar appearance (33). In our experience, the degree of T1 shortening is greater for endometriomas (Fig 4a) than for hemorrhagic functional cysts.

View larger version (127K): [in a new window]   Figure 6a. MR imaging demonstration of blood within a distended vagina and endocervical and endometrial canal in a 12-year-old girl with primary amenorrhea, pelvic pain, and a palpable pelvic mass. An obstructing low transverse vaginal septum was confirmed surgically. (a) Sagittal T1-weighted, fat-suppressed, GRE image (250/7, 90° flip angle) shows distention of the endometrial (*), endocervical (black arrow), and vaginal (V) canals by very high-signal-intensity material representing subacute blood. The level of the obstruction lies below the symphysis pubis, near the introitus (white arrow). (b) Sagittal T2-weighted fast SE image (4,000/105) shows low-signal-intensity "shading" of the hematometrocolpos. It can be difficult to differentiate an imperforate hymen from a low transverse septum at MR imaging.

View larger version (124K): [in a new window]   Figure 6b. MR imaging demonstration of blood within a distended vagina and endocervical and endometrial canal in a 12-year-old girl with primary amenorrhea, pelvic pain, and a palpable pelvic mass. An obstructing low transverse vaginal septum was confirmed surgically. (a) Sagittal T1-weighted, fat-suppressed, GRE image (250/7, 90° flip angle) shows distention of the endometrial (*), endocervical (black arrow), and vaginal (V) canals by very high-signal-intensity material representing subacute blood. The level of the obstruction lies below the symphysis pubis, near the introitus (white arrow). (b) Sagittal T2-weighted fast SE image (4,000/105) shows low-signal-intensity "shading" of the hematometrocolpos. It can be difficult to differentiate an imperforate hymen from a low transverse septum at MR imaging.

View larger version (136K): [in a new window]   Figure 7. Fat within a left adnexal mass in a 37-year-old woman with a surgically confirmed mature teratoma. Axial T2-weighted fast SE image (5,000/102) shows a complex mass with a meniscoid tissue–fluid level that is separated by a low-signal-intensity boundary (arrows). The latter likely represents a chemical shift in the frequency-encoding direction (anterior-to-posterior) at a fat-water interface. A spherical central portion of the mass is present. This sequence alone, while sufficient to establish a diagnosis of a teratoma, should be confirmed with either a fat saturation, water saturation, or chemical shift technique.

View larger version (164K): [in a new window]   Figure 8. Varying amounts of fat within a right-sided mature teratoma in a 41-year-old woman. A, Axial T1-weighted, in-phase, spoiled GRE image (120/4.2, 90° flip angle) shows a right adnexal mass with a very high-signal-intensity anterior component (straight arrow) and an intermediate- to high-signal-intensity posterior component (curved arrow). B, Axial T1-weighted, opposed-phase, spoiled GRE image (120/2.1, 90° flip angle) shows marked signal loss in the posterior portion of the mass, establishing the presence of microscopic lipid. While there is no signal loss of the anterior component of the mass, there is a subtle etching artifact at the border between the anterior aspect of the mass and the surrounding ovarian and paraovarian tissue (arrows). C, Axial T1-weighted, fat-saturated, opposed-phase, spoiled GRE image (120./2.1, 90o flip angle) shows marked loss of signal in the anterior portion of the mass, establishing the presence of macroscopic fat. Compared to the in-phase image in A, it is difficult to appreciate any change in signal intensity in the posterior portion of the mass. D, Axial T1-weighted, water-saturated spoiled GRE image (120/4.2, 90° flip angle) shows the macroscopic fat anteriorly and microscopic lipid posteriorly. This mature teratoma in a 41-year-old woman illustrates the complementary use of fat saturation and in-phase–opposed-phase chemical shift techniques in the characterization of lipid-containing masses.

View larger version (187K): [in a new window]   Figure 9. MR imaging demonstration of fibrotic bilateral adnexal masses and smooth-muscle myometrial masses in a 73-year-old woman with bilateral fibrothecomas, endometrial hyperplasia, and uterine leiomyomas. Axial T2-weighted fast SE image (5,000/136) shows bilateral adnexal masses (white *) whose signal intensity is lower than that of the outer myometrium and isointense to minimally hyperintense compared with the normal junctional zone and pelvic musculature. There is a widened endometrial complex (black *) and clear definition of the inner and outer myometrium, both of which are suggestive of hormonal production by the tumors in this postmenopausal woman. Three well-circumscribed, low-signal-intensity myometrial masses are present. One has a submucosal component (black arrow), another has a high-signal-intensity rim (solid white arrow), and the third has high signal intensity internally (open white arrow).

View larger version (162K): [in a new window]   Figure 10a. MR imaging demonstration of enhancing solid cancer with spread to the peritoneum in a 41-year-old woman with a surgically confirmed malignant epithelial ovarian neoplasm with peritoneal spread of disease. (a) Axial T2-weighted fast SE image (5,800/126) shows a large complex right adnexal mass with both cystic and solid components. The solid components are of higher signal intensity than that of the uterine myometrium. Solid projections of tissue (small arrows) within one of the intratumoral cysts and nodules of soft-tissue signal intensity (large arrow) are present in the cul-de-sac. (b) Axial gadopentetate dimeglumine–enhanced fat-saturated GRE image (400/2.9, 90° flip angle) shows enhancing intracystic solid tissue (small arrows) and peritoneal implants (large arrow).

View larger version (167K): [in a new window]   Figure 10b. MR imaging demonstration of enhancing solid cancer with spread to the peritoneum in a 41-year-old woman with a surgically confirmed malignant epithelial ovarian neoplasm with peritoneal spread of disease. (a) Axial T2-weighted fast SE image (5,800/126) shows a large complex right adnexal mass with both cystic and solid components. The solid components are of higher signal intensity than that of the uterine myometrium. Solid projections of tissue (small arrows) within one of the intratumoral cysts and nodules of soft-tissue signal intensity (large arrow) are present in the cul-de-sac. (b) Axial gadopentetate dimeglumine–enhanced fat-saturated GRE image (400/2.9, 90° flip angle) shows enhancing intracystic solid tissue (small arrows) and peritoneal implants (large arrow).

View larger version (127K): [in a new window]   Figure 11a. MR imaging demonstration of a focal myometrial contraction. (a, b) Sagittal T2-weighted half-Fourier RARE images (/96) obtained 25 minutes apart in a 32-year-old woman shows fetal head, chest, and abdominal contents to good advantage. A transient low-signal-intensity mass of the anterior uterine wall (*) represents a focal myometrial contraction. Half-Fourier RARE techniques have allowed one to obtain fetal MR images that are relatively free of motion artifacts (79,80).

View larger version (139K): [in a new window]   Figure 11b. MR imaging demonstration of a focal myometrial contraction. (a, b) Sagittal T2-weighted half-Fourier RARE images (/96) obtained 25 minutes apart in a 32-year-old woman shows fetal head, chest, and abdominal contents to good advantage. A transient low-signal-intensity mass of the anterior uterine wall (*) represents a focal myometrial contraction. Half-Fourier RARE techniques have allowed one to obtain fetal MR images that are relatively free of motion artifacts (79,80).

View larger version (187K): [in a new window]   Figure 12. MR imaging demonstration of diffuse smooth-muscle proliferation within the inner myometrium in a 36-year-old woman with adenomyosis. Sagittal T2-weighted fast SE image (4,200/108) shows diffuse asymmetric thickening of the inner myometrium by a relatively low-signal-intensity process (black arrows) compared to the outer myometrium. Punctate foci of high signal intensity (white arrows) are present. The diffuse area of low signal intensity within the myometrium represents reactive smooth-muscle proliferation. The ectopic intramyometrial endometrial glands have high signal intensity on this T2-weighted image.

View larger version (119K): [in a new window]   Figure 13a. Invasive squamous cell carcinoma of the cervix in a 64-year-old woman with vaginal bleeding . (a) Sagittal T2-weighted fast SE image (3,500/90) shows an infiltrative intermediate-signal-intensity cervical mass that invades the vagina (white arrow), posterior bladder wall (black arrow), and uterine body. Two low-signal-intensity leiomyomas (arrowheads) are clearly delineated. (b) Sagittal T2-weighted half-Fourier RARE image (/98) shows blurring of the margins of the cancer and the leiomyomas, secondary to T2 decay during the long echo train (83,84). An optimized fast SE sequence is preferred to a corresponding half-Fourier RARE sequence in the evaluation of normal uteri, because of the latter sequence's limitations on contrast and signal-to-noise ratio (85). However, a diagnosis of bladder invasion can still be established in this instance.

View larger version (117K): [in a new window]   Figure 13b. Invasive squamous cell carcinoma of the cervix in a 64-year-old woman with vaginal bleeding . (a) Sagittal T2-weighted fast SE image (3,500/90) shows an infiltrative intermediate-signal-intensity cervical mass that invades the vagina (white arrow), posterior bladder wall (black arrow), and uterine body. Two low-signal-intensity leiomyomas (arrowheads) are clearly delineated. (b) Sagittal T2-weighted half-Fourier RARE image (/98) shows blurring of the margins of the cancer and the leiomyomas, secondary to T2 decay during the long echo train (83,84). An optimized fast SE sequence is preferred to a corresponding half-Fourier RARE sequence in the evaluation of normal uteri, because of the latter sequence's limitations on contrast and signal-to-noise ratio (85). However, a diagnosis of bladder invasion can still be established in this instance.

View larger version (162K): [in a new window]   Figure 14a. MR imaging demonstration of fibrous tissue and mucin within a complex left adnexal mass in a 51-year-old woman. At surgery, the fibrous mass was a Brenner tumor and the mucin-containing mass was a borderline mucinous tumor. (a) Axial T1-weighted SE (400/10) and (b) T2-weighted fast SE (4,700/85) images show a large pelvic mass that displaces the uterus (curved arrow in b) posteriorly. The mass has two components. Anteriorly and laterally, there is a well-circumscribed, 6.5-cm mass (white *) that has low signal intensity on both the T1- and T2-weighted images. The remainder of the mass has low-, intermediate-, and high- (black * in a) signal-intensity components relative to muscle on the T1-weighted image and intermediate- to high-signal-intensity components on the T2-weighted image. (MR images courtesy of Bohyun Kim, MD, Samsung Medical Center, Seoul, Korea.)

View larger version (168K): [in a new window]   Figure 14b. MR imaging demonstration of fibrous tissue and mucin within a complex left adnexal mass in a 51-year-old woman. At surgery, the fibrous mass was a Brenner tumor and the mucin-containing mass was a borderline mucinous tumor. (a) Axial T1-weighted SE (400/10) and (b) T2-weighted fast SE (4,700/85) images show a large pelvic mass that displaces the uterus (curved arrow in b) posteriorly. The mass has two components. Anteriorly and laterally, there is a well-circumscribed, 6.5-cm mass (white *) that has low signal intensity on both the T1- and T2-weighted images. The remainder of the mass has low-, intermediate-, and high- (black * in a) signal-intensity components relative to muscle on the T1-weighted image and intermediate- to high-signal-intensity components on the T2-weighted image. (MR images courtesy of Bohyun Kim, MD, Samsung Medical Center, Seoul, Korea.)

View larger version (146K): [in a new window]   Figure 15a. MR imaging demonstration of various concentrations of mucin within a mucinous neoplasm of low malignant potential of the right ovary in a 37-year-old woman. (a) Axial T1-weighted SE image (600/12) demonstrates a large multilocular cystic mass with varying signal intensities that are hypointense (large white *), minimally hyperintense (small white *), and markedly hyperintense (black *) relative to muscle. (b) Axial T2-weighted fast SE image (6,000/126) shows that the majority of the locules are moderately hyperintense to muscle. The lack of solid components, ascites, or peritoneal implants suggests a benign diagnosis.

View larger version (120K): [in a new window]   Figure 15b. MR imaging demonstration of various concentrations of mucin within a mucinous neoplasm of low malignant potential of the right ovary in a 37-year-old woman. (a) Axial T1-weighted SE image (600/12) demonstrates a large multilocular cystic mass with varying signal intensities that are hypointense (large white *), minimally hyperintense (small white *), and markedly hyperintense (black *) relative to muscle. (b) Axial T2-weighted fast SE image (6,000/126) shows that the majority of the locules are moderately hyperintense to muscle. The lack of solid components, ascites, or peritoneal implants suggests a benign diagnosis.

View larger version (160K): [in a new window]   Figure 16a. MR imaging demonstration of mucin within recurrent mucinous adenocarcinoma of the rectum in a 65-year-old woman. (a) Axial fat-suppressed T2-weighted fast SE (3,000/99) and (b) gadopentetate dimeglumine–enhanced fat-saturated GRE (200/2.9, 90° flip angle) images show an infiltrative heterogeneous mass that has high signal intensity on the T2-weighted image; the center of the mass is in the rectal bed. There is a fistula to the left vaginal fornix (*). There is heterogeneous peripheral enhancement and patchy internal enhancement that distinguishes this process from a postprocedural fluid collection. Both the high signal intensity of the rectal tumor on the T2-weighted image and the irregular rim enhancement are very suggestive of a mucinous subtype of rectal carcinoma (110). (c) Histologic section of the mass shows glandular epithelium (arrow) with abundant extracellular mucin (*). (Hematoxylin-eosin stain; original magnification, x20.)

View larger version (173K): [in a new window]   Figure 16b. MR imaging demonstration of mucin within recurrent mucinous adenocarcinoma of the rectum in a 65-year-old woman. (a) Axial fat-suppressed T2-weighted fast SE (3,000/99) and (b) gadopentetate dimeglumine–enhanced fat-saturated GRE (200/2.9, 90° flip angle) images show an infiltrative heterogeneous mass that has high signal intensity on the T2-weighted image; the center of the mass is in the rectal bed. There is a fistula to the left vaginal fornix (*). There is heterogeneous peripheral enhancement and patchy internal enhancement that distinguishes this process from a postprocedural fluid collection. Both the high signal intensity of the rectal tumor on the T2-weighted image and the irregular rim enhancement are very suggestive of a mucinous subtype of rectal carcinoma (110). (c) Histologic section of the mass shows glandular epithelium (arrow) with abundant extracellular mucin (*). (Hematoxylin-eosin stain; original magnification, x20.)

View larger version (181K): [in a new window]   Figure 16c. MR imaging demonstration of mucin within recurrent mucinous adenocarcinoma of the rectum in a 65-year-old woman. (a) Axial fat-suppressed T2-weighted fast SE (3,000/99) and (b) gadopentetate dimeglumine–enhanced fat-saturated GRE (200/2.9, 90° flip angle) images show an infiltrative heterogeneous mass that has high signal intensity on the T2-weighted image; the center of the mass is in the rectal bed. There is a fistula to the left vaginal fornix (*). There is heterogeneous peripheral enhancement and patchy internal enhancement that distinguishes this process from a postprocedural fluid collection. Both the high signal intensity of the rectal tumor on the T2-weighted image and the irregular rim enhancement are very suggestive of a mucinous subtype of rectal carcinoma (110). (c) Histologic section of the mass shows glandular epithelium (arrow) with abundant extracellular mucin (*). (Hematoxylin-eosin stain; original magnification, x20.)

View larger version (180K): [in a new window]   Figure 17a. Myxoid tissue in a degenerated leiomyoma in a 49-year-old woman. (a) Sagittal and (b) axial T2-weighted fast SE images (5,300/126) show a well-circumscribed mass of the anterior uterus that has both low- (white * in b) and high- (black * in b) signal-intensity components compared to the outer myometrium. (c) Gadopentetate dimeglumine–enhanced fat-saturated GRE image (500/3.3, 90° flip angle) obtained at the same level as b shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image enhances, indicating that it does not represent intratumoral cysts or necrosis. (d) Histologic section of a different myxoid leiomyoma shows the loose, water-laden myxoid tissue (*) contrasted with the denser smooth-muscle bundles of the leiomyomas (thick arrow). Myxoid degeneration is not necrosis; several vessels (thin arrows) still course through the myxoid tissue. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (171K): [in a new window]   Figure 17b. Myxoid tissue in a degenerated leiomyoma in a 49-year-old woman. (a) Sagittal and (b) axial T2-weighted fast SE images (5,300/126) show a well-circumscribed mass of the anterior uterus that has both low- (white * in b) and high- (black * in b) signal-intensity components compared to the outer myometrium. (c) Gadopentetate dimeglumine–enhanced fat-saturated GRE image (500/3.3, 90° flip angle) obtained at the same level as b shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image enhances, indicating that it does not represent intratumoral cysts or necrosis. (d) Histologic section of a different myxoid leiomyoma shows the loose, water-laden myxoid tissue (*) contrasted with the denser smooth-muscle bundles of the leiomyomas (thick arrow). Myxoid degeneration is not necrosis; several vessels (thin arrows) still course through the myxoid tissue. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (176K): [in a new window]   Figure 17c. Myxoid tissue in a degenerated leiomyoma in a 49-year-old woman. (a) Sagittal and (b) axial T2-weighted fast SE images (5,300/126) show a well-circumscribed mass of the anterior uterus that has both low- (white * in b) and high- (black * in b) signal-intensity components compared to the outer myometrium. (c) Gadopentetate dimeglumine–enhanced fat-saturated GRE image (500/3.3, 90° flip angle) obtained at the same level as b shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image enhances, indicating that it does not represent intratumoral cysts or necrosis. (d) Histologic section of a different myxoid leiomyoma shows the loose, water-laden myxoid tissue (*) contrasted with the denser smooth-muscle bundles of the leiomyomas (thick arrow). Myxoid degeneration is not necrosis; several vessels (thin arrows) still course through the myxoid tissue. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (187K): [in a new window]   Figure 17d. Myxoid tissue in a degenerated leiomyoma in a 49-year-old woman. (a) Sagittal and (b) axial T2-weighted fast SE images (5,300/126) show a well-circumscribed mass of the anterior uterus that has both low- (white * in b) and high- (black * in b) signal-intensity components compared to the outer myometrium. (c) Gadopentetate dimeglumine–enhanced fat-saturated GRE image (500/3.3, 90° flip angle) obtained at the same level as b shows that some of the intratumoral tissue with high signal intensity on the T2-weighted image enhances, indicating that it does not represent intratumoral cysts or necrosis. (d) Histologic section of a different myxoid leiomyoma shows the loose, water-laden myxoid tissue (*) contrasted with the denser smooth-muscle bundles of the leiomyomas (thick arrow). Myxoid degeneration is not necrosis; several vessels (thin arrows) still course through the myxoid tissue. (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (148K): [in a new window]   Figure 18a. MR imaging appearance of ovarian edema without hemorrhage in a 16-year-old girl with pelvic pain. At subsequent surgery, a partially twisted, viable left ovary (massive ovarian edema) was present. (a) Fat-suppressed, T2-weighted fast SE image (4,600/133) shows a large left adnexal mass that contains multiple follicles (black arrows), identifying it as the left ovary. A prominent right ovary (white arrow) is also present. (b) Gadopentetate dimeglumine–enhanced axial fat-suppressed T1-weighted spoiled GRE image (150/2.9, 90° flip angle) shows enhancing follicles within both ovaries (arrows). No high signal intensity was present on the T1-weighted images before administration of contrast material (not shown) to suggest hemorrhagic infarction (see Fig 3).

View larger version (158K): [in a new window]   Figure 18b. MR imaging appearance of ovarian edema without hemorrhage in a 16-year-old girl with pelvic pain. At subsequent surgery, a partially twisted, viable left ovary (massive ovarian edema) was present. (a) Fat-suppressed, T2-weighted fast SE image (4,600/133) shows a large left adnexal mass that contains multiple follicles (black arrows), identifying it as the left ovary. A prominent right ovary (white arrow) is also present. (b) Gadopentetate dimeglumine–enhanced axial fat-suppressed T1-weighted spoiled GRE image (150/2.9, 90° flip angle) shows enhancing follicles within both ovaries (arrows). No high signal intensity was present on the T1-weighted images before administration of contrast material (not shown) to suggest hemorrhagic infarction (see Fig 3).

View larger version (141K): [in a new window]   Figure 19a. MR imaging demonstration of papillary projections in a papillary serous borderline tumor in a 19-year-old woman. (a) Axial T2-weighted fast SE image (4,000/126) shows a complex multiloculated pelvic mass that contains multiple papillary projections. The projections in the left cyst are composed of a central fibrous core (long black arrow) surrounded by edematous stroma (short black arrows). The right-sided mass (curved white arrow) is a cyst filled entirely with papillary projections. (b) Corresponding axial gadopentetate dimeglumine–enhanced fat-saturated GRE image (250/2.9, 90° flip angle) shows enhancement of the cyst wall (arrow) and papillary projections. The fluid that makes up the remainder of the tumor does not enhance.

View larger version (151K): [in a new window]   Figure 19b. MR imaging demonstration of papillary projections in a papillary serous borderline tumor in a 19-year-old woman. (a) Axial T2-weighted fast SE image (4,000/126) shows a complex multiloculated pelvic mass that contains multiple papillary projections. The projections in the left cyst are composed of a central fibrous core (long black arrow) surrounded by edematous stroma (short black arrows). The right-sided mass (curved white arrow) is a cyst filled entirely with papillary projections. (b) Corresponding axial gadopentetate dimeglumine–enhanced fat-saturated GRE image (250/2.9, 90° flip angle) shows enhancement of the cyst wall (arrow) and papillary projections. The fluid that makes up the remainder of the tumor does not enhance.