Common Pelvic And Urinary MRI Flashcards by Lauren Knight

Zones of the prostate gland

Base, mid-gland, Apex

4 histological zones
- Anterior fibromuscular stromatolites
- Transitional zone (TZ) - surrounds the urethra (5% glandular tissue)
- central Zone (CZ =) - surrounds the ejactlatory ducts (20% glandular tissue)
-outer peripheral zone (PZ)(80% glandular tissue)

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What is Prostate cancer and its rates within the PZ and TZ zones?

Uncontrolled division of glandular cells:
70-75% PZ
20-25% - TZ

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Detection of Prostate cancer

Screening with PSA test - (PSA= prostate specific antigen)
DRE - rectal exam - hard irregular lumps in the prostate
Biopsy - Gleason score
Imaging to stage (NM, CT, MR)

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Indications for prostate MRI

PSA > 4 ng/l
Abnormal DRE
Surveillance

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What scale is used to grade prostate cancer?

Sequences assessed and each lesion graded on PI-RADs scale.
- 1 - 5 (1 very low to 5 very high likelihood of cancer)

PI - RADS = prostate imaging reporting and data system

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What are the Sequences used for Prostate cancer?

T2 w - sag, cor and ax
DWI
T1W ax
T1 FS dynamic with gad contrast ax

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How does a T2 prostate lesion appear?

Hypointesnse

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What is Buscopan?

Antispasmodic

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What are the Challenges of Prostate MRI?

Magnetic susceptibility - DWI
Motion artefact - peristalsis or respiration

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What are the 2 parts of the Cervix?

what types of cells do they contain?

Internal os/ endocervix - columnar epithelial cells

External os / ectocervix - squamous epithelial cells

Between the two is the transformational zone - squamocolumnar cells

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Where is cervical cancer usually found

Transformational zone

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Cervical cancer

Most common in women < 45
Associated with HPV

Screening 25 - 64 every 3-5 years
Colposcopy/ biopsy
HPV vaccination - 2008

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What are the Indications for cervix MRI?

Based on British gynaecological cancer society (BGCS) and RCR

cytogically proven cancer
response to chemo
reoccurance

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How many days post biopsy can we scan?

What are the cervix MRI protocol?

7-10 days post biopsy to allow for healing

T1W - to ashes para-aortic and pelvic lymph nodes - presence of hydronephrosis

T2w - assess size, position and local tissue invasion

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What are the specific challenges of cervical imaging?

Biopsy trauma can mimic Ca

Positioning of T2w axial coronal obliques - due to the nature of uterus positions

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What are the 3 layers of the Uterus ?

Perimetrium - double membrane continuous with abdominal peritoneum

Myometrium - thick layer of muscle, which expands during pregnancy

Endometrium - in a mucous membrane, most superficial layer is shed during menstruation

Endometrial cancer

uncontrolled proliferation of the endometrium
Most common, gynological cancer
Most common imposter, menopausal women
Increase prevalence due to obesity
Symptoms, post menopause, bleeding
symptomatic disease - no screening program

What are the indications for endometrial MRI?

Based on BGCS guidelines

PMB - post-menopausal, bleeding
confirmed endometrial cancer - to decide treatment options
- Staging to assess myometrial invasion and lymph nodes
- Advanced disease- avoid hysterectomy, if no possibility of cure

What are the protocols for Endometrial MRI?

T2W - to assess size position and local tissue invasion into myometrium, cervical stroma, parametric and Adnexa.
DWI - to asscess extent of myometrial invasion
T1FS - precontrast
T1FS - dynamic post contrast - to assess myometrium invasion
T1W ax - assess hilar abdominal and pelvic nodes

What are the Challenges of endometrial MRI?

Biopsy trauma mimic Ca
Position of T2w ax / coronal obliques due to position of uterus

What is Endometriosis?

Material tissue implants outside of the uterus, either with the female reproductive system or distant organs
: Such as bladder, bowel, lungs brain, skin

Most commonly on ovaries, where it forms endometriomas (chocolate cysts)

During the menstrual cycle, and the tissue breakdown and bleeds.
Patients experience , heavy bleeding, pelvic pain and infertility

What are the Indications for an MRI for Endometriosis?

NICE guidelines
Not used as a primary tool yet but to assess deep endometriosis involving bladder, bowel and ureter

Surgical planning

What are the protocols for endometriosis?

What are they assessing on the MRI?

T2w, T1W and T1FS

Asses for Adenomyosis, endometrial plaques/ foci, endometriomas, hydrosalpinx and hydronephrosis

What are the Specific challenges for diagnosing endometriosis?

Negative us and MRI can’t rule out endometriosis

Renal cancer

RCC - renal cell carcinoma - 9/10 cancers primary malignant adenocarcinoma Commonly from epithelium within the renal tubules of the medulla - 70% - 80% clear cell (proximal convoluted tubules) - 13% - 20% Papillary RCC (distal convoluted tubules)

How are Renal cancers diagnosed?

Usually by CT - lower cost and greater capacity compared to MRI MRI - marginally better than CT as it can indicate subtype and presence of thrombus in renal vein/ IVC - expensive and less available

What are the indications for an RCC MRI?

Staging of RCC with venous invasion When CT iodinated contrast can’t be used Pregnancy

What are the MRI protocols for RCC?

T1W Ax - to observe primary tumour, venous invasion, lymph nodes involvement T2w ax T1wFS ax T1FS ax post contrast ax - 20s, 50s, 80s (20s - arterial supply to inform partial nephrectomy , 80 sec - nephrogenic phase) T1W sag and cor

What are the Specific challenges of renal scanning?

Respiratory artefact Metal artefact Peristalsis

What are the causes of Renal artery stenosis? How do we diagnose RAS?

75% - atherosclerosis 20 % - fibromuscular dysplasia Diagnosis on MRI or CT

What is RAS - fibromuscular dysplasia?

The muscle and fibre tissues in the arteries thicken, causing the vessels to narrow- string of beads, appearances Causing stenosis, aneurysms and dissections to small, medium sized arteries Can lead to severe hypertension, ischaemic or haemorrhagic stroke

What are the Indications for renal artery MRI?

Hypertension that is resistant to medication or of late onset with no family history Poor renal function

What are the Renal artery MRI protocols?

T2w HASTE T1W FLASH 3D - pre and post con Or TWIST - 3D MRA with gad which acquires multiple images through the arterial mixed and venous phases which can be reconstructed into MIPS

What does MIP stand for?

Maximum intensity projection

Rectal cancer facts

2nd most common cancer in uK Affects males > females Most commonly affects 60-80 years old Screening program 60-74 Symptomatic - pain, blood in stools, change in bowel habit, anaemia

What is Rectal cancer?

Uncontrolled proliferation of epithelial cells (surface of mucosa) 98% adenocarcinomas which form from malignant transformation of polyps ( benign, adenomas) Malignant cells invade layers of rectum, and can invade beyond to lymph nodes and distant organs, such as liver and lungs.

What are the indications for Rectal cancer MRI?

Staging local disease in upper rectal and sigmoid cancers Surveillance

What are the Rectal cancer Protocols?

T2w sag - to measure distance from anal verge and length of tumour T2w axial - to look for pelvic disease outside of the mesorectum T2w ax oblique ( perpendicular to long axis of rectum) - to measure tumour and assess spread within the mesorectum( L5, S1) T2w coronal oblique ( parallel to the long axis of the rectum) - to measure tumour and spread within the mesorectum ( L5 - S1) Report to stage TNM