Vagina Anatomy Imaging Appearance of the Vagina. Uta Zaspel and Bernd Hamm

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1 Vgin 275 Vgin 12 Ut Zspel nd Bernd Hmm CONTENTS 12.1 Antomy Imging Appernce of the Vgin Congenitl Mlformtions Benign Lesions Brtholin s Glnd Cysts Condylomt Acumint Grtner s Duct Cysts Inflmmtory Conditions of the Vgin Crohn s Disese Trum Benign Tumors of the Vgin Mlignnt Tumors of the Vgin Secondry Vginl Mlignncies Primry Vginl Mlignncies Bckground MR Imging Stging MR Appernce After Rdiotherpy MR Appernce After Surgery Residul nd Recurrent Tumor Lymph Nodes 290 References Antomy The vgin is firomusculr sheth-like structure connecting the externl genitls with the uterus. It is lined with nonkertinizing squmous epithelium nd is 8 12 cm long. The vgin protects the internl genitl orgns ginst scending infections, forms prt of the irth cnl, nd receives the penis in copultion. The proximl third of the vgin is t the level of the lterl vginl fornices, the middle third t the level of the urinry ldder se, nd the lower third t the level of the urethr. The nterior nd posterior wlls of the vgin re usully pressed together y the surrounding soft tissue, which ensures functionl mechnicl closure. On xil sections, this results in shpe tht resemles the letter H (see Fig. 12.3). The concertin rrier-like rrngement of the musculr lyer of the vginl wll nd n undnce of elstic fiers in the suepithelil nd dventitil connective tissue lyer enle extreme pssive extension nd ctive contrction. The squmous epithelium of the vgin is highly susceptile to hormonl effects. The epithelium consists of up to 30 cell lyers in women of reproductive ge ut of only few lyers in childhood nd fter menopuse. The vgin is supplied with lood through the descending rnch of the uterine rtery s well s through rnches from the rectl, vesicl, nd pudendl rteries. Lymph is drined from the vgin to the ilic, scrl, nd pr-ortic nodes from the upper two thirds nd to inguinl nd norectl nodes from the lower third nd vestiule. U. Zspel, MD Institut für Rdiologie (Cmpus Mitte), Chrité Universitätsmedizin Berlin, Chritépltz 1, Berlin, Germny B. Hmm, MD Professor nd Chirmn, Institut für Rdiologie (Cmpus Mitte), Klinik für Strhlenheilkunde (Cmpus Virchow-Klinikum und Cmpus Buch), Chrité Universitätsmedizin Berlin, Chritépltz 1, Berlin, Germny 12.2 Imging Appernce of the Vgin On xil CT scns, the vgin is difficult to differentite from the urethr (Fig. 12.1) nd it is not possile to distinguish the vginl epithelium/mucus from the lyers of the vginl wll.

2 276 U. Zspel nd B. Hmm c Fig c. CT ntomy of the norml vgin., CT. c Sgittl CT reconstruction. CT ntomy of the vgin middle third t the level of the urinry ldder () nd distl third t the level of the urethr (). The vgin hs the sme density s the wlls of the ldder, urethr, nd rectum nd cn e distinguished from these structures on CT y the presence of smll ft lyer. For differentition of the vgin, it is lso helpful if the ldder is filled with urine nd the rectum is filled with ir

3 Vgin 277 On T1-weighted MR imges with ft sturtion, the vgin is of intermedite to low signl intensity nd the mucos, epithelium, nd musculr lyer cnnot e distinguished (Fig. 12.2). The individul lyers cn e pprecited much etter on T2-weighted imges nd contrst-enhnced T1- weighted imges (Figs ). T2-weighted imges depict the mucosl lyer nd the secretions within the vginl cnl with high signl intensity, which is thus clerly distinct from the lower-signl-intensity musculr wll nd the middle lyer. The prvginl tissue or dventiti with its dense venous plexus hs high signl intensity on T2-weighted imges [1]. The posterior vginl fornix cn e distinguished most redily from the cervix nd the nterior rectl wll in sgittl orienttion (Fig. 12.5). The smller nterior fornix is often more difficult to differentite from the cervix. Fig. 12.2,. MR ntomy of the norml vgin on FS T1-weighted imges., T1-weighted imges with ft st in xil nd sgittl orienttion. On T1-weighted imges, the vgin is of similr signl intensity s the wlls of the urinry ldder, urethr, nd rectum. Thus, the vgin cn only e loclized indirectly etween the filled ldder nd the ir-filled rectum Fig. 12.3,. MR ntomy of the norml vgin on T2-weighted imges., T2-weighted imges in xil nd sgittl orienttion. T2-weighted MR imges llow differentition of the three lyers forming the vginl wll (rrows). The innermost lyer, the vginl mucos, is of high signl intensity; the middle lyer, the musculris, is of low signl intensity; nd the outer lyer, consisting of prvginl ftty tissue nd the venous plexus, is of high signl intensity. On trnsverse imges, the vgin hs n H-shped ppernce (rrow). The vgin is locted etween the urethr nteriorly nd rectum posteriorly

4 278 U. Zspel nd B. Hmm Fig. 12.4,. MR ntomy of the norml vgin on contrst-enhnced imges., T1-weighted imges with ft st fter dministrtion of Gd-DTPA in xil nd sgittl orienttion. After contrst medium dministrtion, two lyers of the vginl wll (rrow) cn e distinguished, low-signl-intensity inner mucos with intrluminl secretion nd contrst-enhncing musculris nd the outer venous plexus, which re of high signl intensity Fig MR ntomy of the norml vginl fornices on T2- weighted imges. T2-weighted imge in sgittl orienttion. The uterine cervix protrudes into the vgin, forming the posterior vginl fornix (open rrow) nd the somewht smller nterior vginl fornix (rrow) Insertion of tmpon is not necessry for dequte evlution nd my even distort vginl ntomy (Fig. 12.6). Insted, evlution cn e improved y filling nd distending the vgin with ultrsound gel (Fig. 12.6). Hormone intke not only lters the thickness of the vginl epithelium nd the vginl mucus ut lso ffects the signl chrcteristics on MR imges. Before the onset of menstrution, the vgin hs lower signl intensity on T2-weighted imges nd very thin centrl epithelil/fluid lyer of high signl intensity. In women of reproductive ge, the contrst etween the vginl mucos nd the wll is highest during the erly prolifertive phse. In this phse, the vginl wll hs low signl intensity on T2-weighted imges with centrl stripe of high signl intensity (epithelium nd mucus) (Fig. 12.7, ). During the secretory phse, the centrl stripe shows moderte widening while there is simultneous increse in the signl of the vginl wll, which mkes it more difficult to distinguish these two lyers. In postmenopusl women without hormonl replcement, the vgin hs low signl intensity on T2-weighted imges nd the centrl stripe of high signl intensity is very thin (Fig. 12.7c, d). In postmenopusl women on estrogen sustitution, the vgin hs the sme ppernce s during the prolifertive phse in premenopusl women.

5 Vgin 279 Fig. 12.6,. Intrvginl tmpon nd gel filling of the vgin. T2-weighted imge in sgittl orienttion. Distortion of the vgin through n intrvginl tmpon (sterisk). The tmpon does not improve evlution of vginl morphology. T2-weighted imge in sgittl orienttion. Gel filling unfolds the vgin nd fornix (sterisk). The uterus is retroflexed c d Fig d. Pre- nd postmenopusl vginl ntomy. T2-weighted imges in sgittl nd xil orienttion. A premenopusl (,) nd postmenopusl (c,d) womn: Two-lyered ppernce of the wll of the vgin (open rrows) is demonstrted in the postmenopusl womn. The low-signl-intensity musculris lyer nd the high-signl-intensity prvginl ftty tissue cn e distinguished. Hypoplsi of the mucos, which is just rely visile s high-signl-intensity stripe in sgittl orienttion (c,d). Compre the thick high-signl-intensity vginl mucos in premenopusl ge (,) (rrows)

6 280 U. Zspel nd B. Hmm Congenitl Mlformtions The upper third of the vgin develops from the müllerin ducts, which descend during emryonic life nd lso give rise to the uterus, uterine cervix, nd fllopin tues. This is why vginl mlformtions re typiclly ssocited with other developmentl nomlies of the müllerin ducts. The lower nd middle thirds of the vgin develop s result of emryologic interctions etween the müllerin ducts nd the urogenitl sinus. The close proximity to the wolffin duct (lso known s the mesonephric duct) explins the ssocition of vginl mlformtions with renl nomlies. Congenitl vginl mlformtions re genesis, dupliction, nd vginl sept. Congenitl sence (Fig. 12.8) nd hypoplsi of the vgin re rre nd re typiclly prt of the Myer-Rokitnsky-Küster-Huser (MRKH) syndrome. MRI shows rudimentry vgin, often with concurrent hypoplsi of the uterus. Becuse genesis of the vgin my e ssocited with renl genesis or ectopic kidneys, the kidneys should lwys e included in the exmintion. A longitudinl vginl septum (Fig. 12.9) occurs s consequence of incomplete fusion of the müllerin ducts or resorption filure of the vginl septum. This nomly is lso typiclly ssocited with other mlformtions of the müllerin ducts [septte uterus, icornute uterus, uterus didelphys (Fig. 12.9), cervicl dupliction] [2]. Firous horizontl vginl sept cn occur nywhere in the vgin s result of defective fusion of the descending müllerin ducts nd scending urogenitl sinus. A horizontl septum cuses primry menorrhe, dominl pin, n dominl mss, or dyspreuni. MR imging shows the vgin to e distended with retined secretion nd llows evlution of the loction nd thickness of the memrne for plnning the surgicl pproch. Ectopic ureters inserting into the vgin re nother nomly ut they re typiclly dignosed y excretory urogrphy. In generl, ptients with vginl mlformtions cn e exmined y hysteroslpingogrphy, ultrsonogrphy, or MRI [3]. MRI provides good overview of pelvic ntomy in ptients with suspected congenitl mlformtions of the vgin or other structures of the urogenitl trct nd is very helpful in plnning surgicl mesures for treting vginl mlformtions [4] Benign Lesions Brtholin s Glnd Cysts Brtholin s glnd cysts re mong the most common incidentl findings in the posterolterl portion of the lower vgin (Fig ). Fig. 12.8,. Agenesis of uterus nd vgin., T2-weighted imges in xil nd sgittl orienttion. (Reproduced with permission from [13])

7 Vgin 281 Fig c. Uterus didelphys. T2-weighted imges in trnsverse nd coronl orienttion. Good visuliztion of the duplicted uterus () nd the two fluid-filled vgins (,c) c The cysts develop when secretion is retined in the ducts of the vulvovginl glnds opening in the re of the vestiule. Brtholin s cysts re chrcterized on T2-weighted MR imges s cystic lesions of high signl intensity with delicte nd shrply delineted wll. On T1-weighted imges, they re of intermedite to high signl intensity, depending on the protein content. Lrge cysts cn cuse symptoms with wlking nd sitting. As compliction Brtholin s cysts my develop inflmmtion nd form n scess. As consequence those symptomtic cysts re treted y wide incision of the glndulr duct (mrsupiliztion) Condylomt Acumint Condylomt cumint re ppilloms cused y the humn ppillom virus nd re the most common enign tumors of the vulv ut rrely occur within the vgin. They re usully dignosed y inspection, which my e supplemented y colposcopy nd iopsy s required Grtner s Duct Cysts Grtner s duct cysts re nother mlformtion of the vgin [3]. They develop s retention cysts from remnnts of the wolffin duct system nd typiclly occur in the nterolterl portion of the vgin nd vulv (Fig ). Grtner s duct cysts vry in size from few millimeters to severl centimeters nd my occur in lrge numers. Smll Grtner s duct cysts re symptomtic nd my e detected incidentlly while lrger cysts cn compress the vgin or urethr. T1- nd T2-weighted MR imges depict cystic lesions with delicte wll nd high signl intensity due to their high protein content.

8 282 U. Zspel nd B. Hmm Fig ,. Brtholin s duct cyst. T2-weighted imge in sgittl orienttion. Thin wlled cyst (rrow) of the right wll t the vestiule of the vgin Fig ,. Grtner s duct cyst. T2-weighted imges in sgittl nd trnsverse orienttion. Depiction of Grtner s duct cyst (rrows) in the nterolterl portion of the right vgin Inflmmtory Conditions of the Vgin Infections of the vgin re frequent nd my e cused y wide vriety of pthogens (viruses, cteri, fungi). MRI is rrely needed to dignose vginl infection. There my e thickening of the vginl wll nd vginl secretion my e incresed. Vginl inflmmtion is ssocited with n incresed signl intensity of the vginl mucos or of the entire vginl wll on T2-weighted nd STIR imges. Contrst-enhnced T1-weighted imges show more mrked enhncement with higher signl of the vginl wll Crohn s Disese Crohn s disese is chronic inflmmtory condition tht my occur in ny prt of the gstrointestinl trct ut commonly involves the terminl ileum or right colon frme. Gynecologic involvement with inflmmtion of the orgns of the true pelvis or of the vulv is not uncommon. Another mnifesttion re fistuls etween the vgin nd the colon or rectum [5]. MRI is the method of choice for the dignostic evlution of pelvic fistuls.

9 Vgin Trum Trumtic injury to the vgin is usully cused y childirth nd is dignosed cliniclly in the mjority of cses. MRI hs dignostic role in excluding or evluting fistul formtion fter trum Benign Tumors of the Vgin Benign mesenchyml tumors re very rre nd include lipom, firom, nd neurofirom. They my e pedunculted nd protrude from the vgin Mlignnt Tumors of the Vgin Secondry Vginl Mlignncies Secondry tumors ccount for out 80% of ll vginl mlignncies. Direct tumor spred from djcent orgns such s the urinry ldder, vulv, uterine cervix (Fig ), or rectum is not uncommon. Moreover, the vgin is common site of recurrence fter surgicl resection of cervicl or ovrin cncer. Vginl metstses re typiclly from primry tumors of the genitl trct. Other mlignncies tht metstsize to the vgin re melnoms (Fig ). MRI does not llow etiologic or histologic clssifiction of secondry vginl mlignncies. Most secondry vginl tumors hve n intermedite signl intensity on T1-weighted imges nd high signl on T2-weighted imges Primry Vginl Mlignncies Bckground Most primry vginl mlignncies re crcinoms. Vginl crcinom is rre, ccounting for 1% 2 % of the mlignnt tumors of the femle genitl trct. Their incidence is 0.5/100,000 women. The mjor histologic type is squmous epithelil crcinom, which mkes up over 90% of ll primry vginl mlignncies. Vginl cncer typiclly occurs in women ged yers. Aout 4% of vginl cncers re denocrcinoms. This histologic type mostly ffects younger women from 17 to 32 yers of ge. Vginl srcom in the form of leiomyosrcom or firosrcom is rre [6]. Emryonl rhdomyosrcom (Fig ) is the Fig ,. Cervicl cncer invding the vgin. T2-weighted imges in xil nd sgittl orienttion. Cervicl cncer invding the proximl third of the posterior vginl wll (rrows)

10 284 U. Zspel nd B. Hmm Fig Vginl metstsis of mlignnt melnom. Contrst enhnced CT. An unspecific mss with inhomogeneous contrst enhncement in the vgin is shown. The right levtor ni muscle (rrow) cn not e well delineted suggesting tumor involvement. (Figure courtesy of Dr. Forstner) c Fig c. Botryoid srcom. Sgittl, trnsxil, nd coronl T2-weighted imges in 2-yer-old girl. A multiseptted mss with numerous thin septtions cuses extensive enlrgement of the vgin which extends up to the level of the promontorium

11 Vgin 285 commonest type of genitl rhdomyosrcom. It occurs in infncy nd is mostly locted t the vgin, vulv, nd perineum. When occurring in dolescence it more often ffects the cervix or corpus uteri. Due to good response to chemotherpy its prognosis hs improved. Chemotherpy is usully followed y n orgn preserving surgicl tretment [7]. The risk fctors for the occurrence of vginl cncer re similr to those for cervicl cncer nd include hving mny sexul prtners, chronic infection with high-risk types of HPV, immunosuppression, nd smoking. Vginl denocrcinom is ssocited with n incresed intruterine exposure to diethylstilestrol. Furthermore, it hs een shown tht there is n ssocition with tumors of the cervix or vulv nd sttus post hysterectomy [8]. Vginl cncer typiclly involves the proximl third nd the posterior wll of the vgin [6]. Erly vginl cncer is symptomtic. More dvnced tumors my cuse pinless vginl leeding or contct leeding, vginl dischrge, dysuri, nd dyspreuni. The growth pttern of vginl tumors includes the whole spectrum from exophytic nd ppillomtous, through infiltrting, to ulcerting forms. The tumor primrily extends y direct spred to the prcolpium, prmetri, vulv, uterine cervix, nd rectovginl nd vesicovginl sept. Fistuls re not infrequent when there is tumor invsion of the rectum nd ldder. Lymphtic spred of tumors involving the proximl two thirds of the vgin is to the lymph nodes long the externl nd common ilic rteries, nd the dominl ort. Vginl tumors in the lower third of the vgin drin into inguinl lymph nodes (Fig ), from where lymphtic spred continues to the lymph node sttions long the externl nd common ilic rteries nd to pr-ortic lymph nodes. Hemtogenous metsttic spred from vginl cncer is rre nd occurs lte in the disese. Orgn metstses primrily involve the liver, lung, or ones. Vginl cncer is stged using the FIGO nd TNM clssifictions (Tle 12.1). Tretment depends on the stge of cncer nd rnges from rdicl hysterectomy with widening of the vginl cuff to complete colpectomy with removl of the prcolpium. Vginl cncer with invsion of djcent orgns is treted y exentertion with djuvnt rdiotherpy. Ptients in whom distnt metstses outside the pelvis re present re treted y chemotherpy. Tle Stging of vginl cncer ccording to FIGO nd TNM criteri FIGO TNM 0 Tis Cis I T1 Tumor confined to vgin II T2 Tumor invdes prvginl tissues ut does not extend to pelvic wll III T3 Tumor extends to pelvic wll IV T4 Tumor invdes ldder nd rectum, tumor extends eyond the true pelvis IV M1 Distnt metstsis N1 Pelvic lymph node metstsis N2 Unilterl inguinl lymph node metstsis N3 Bilterl inguinl lymph node metstsis Fig ,. Regionl lymph node sttions. Vginl cncer of the proximl two thirds of the vgin drins into the pelvic lymph node sttions. The inguinl lymph nodes re the first lymph node sttions invded y vginl cncer of the distl third of the vgin. (Reproduced with permission from [14])

12 286 U. Zspel nd B. Hmm MR Imging MRI hs its most importnt dignostic role in stging vginl cncer tht hs een confirmed y colposcopy nd iopsy. Stging y MRI serves to determine locl tumor extent nd to clssify the cncer ccording to TNM nd FIGO criteri [9]. In ddition, MRI llows ssessment of inguinl nd pelvic lymph nodes. Becuse the signl intensity of vginl tumors, except for vginl melnom, is unspecific, MRI does not llow differentition of the different primry nd secondry mlignncies involving the vgin nd thus cnnot replce histologic dignosis [10]. The protocol recommended for MR imging of vginl cncer is summrized in Tle Tle MRI sequences recommended for imging of vginl cncer Sequence T2w TSE PD TSE T1w TSE Contrstenhnced T1w TSE Are imged Sgittl Trnsverse Uterus to pelvic floor Trnsverse Aortic ifurction to groin Sgittl Trnsverse Uterus to pelvic floor Sgittl Trnsverse Uterus to pelvic floor Prior to MR imging, ptients re dministered spsmolytic gent to reduce intestinl motility, e.g. 2 ml Buscopn R (40 mg utylscopolmine). Distention of the vgin, e.g. y filling with ultrsound gel, my improve dignostic ssessment. In women with n olique orienttion of the vgin, ngultion of the trnsverse T2- weighted sequence perpendiculr to the xis of the vgin will improve evlution of ntomy nd tumor extent. On T2-weighted imges, vginl tumors hve n intermedite to high signl intensity, enling their differentition from the low-signl-intensity musculr vginl wll (Fig ). On T1-weighted imges, vginl tumor is identified s contour deformity of the vgin nd not y difference in signl intensity. Following dministrtion of contrst medium, most vginl tumors disply more mrked signl enhncement thn the vginl wll (Fig c,d). Becuse vginl tumors my show mrginl inflmmtory rection, their extent my e overestimted [9]. Moreover, it my e difficult to differentite cervicl cncer nd tumors of the proximl vgin when there is invsion of oth orgns. In such cses, the tumor often rises from the orgn contining the lrgest tumor mss. However, only iopsy enles relile differentition in such cses nd etween primry nd secondry vginl tumors in generl. An exception re vginl melnoms which show distinct signl ehvior tht depends on their composition such s presence of intrlesionl hemorrhge or pigments. Melnin is prmgnetic nd shortens relxtion times, resulting in higher signl on T1-weighted imges nd lower signl on T2-weighted imges. There is no prmgnetic effect melnotic melnoms Stging Stge T1 vginl cncer is confined to the vgin (Fig ). T2-weighted imges show hyperintense disruption of the low-signl-intensity musculr vginl wll. To exclude cncer growth eyond the vgin, it is importnt to differentite the tumor from the ftty lyer surrounding the vgin. The differentition of tumor nd ft my e esier on T1-weighted imges ecuse there is superior contrst etween low-signl-intensity tumor nd high-signl-intensity ft. On T2-weighted imges, on the other hnd, oth tumor nd prvginl ft with its rich venous network hve high signl intensity. However, this is not relile criterion ecuse the ftty lyer surrounding the vgin is very thin. Stge II tumors re chrcterized y invsion of prvginl ftty tissue, which is seen s lurred nd irregulr delinetion of the vginl wll (Figs , 12.18, 12.19). Lrger tumors extending eyond the vgin re seen s low-signl-intensity lesions surrounded y hyperintense prvginl tissue on T1- weighted imges. On T2-weighted imges oth the vginl tumor nd the prvginl tissue hve high signl intensity nd re difficult to distinguish. In stge III disese with tumor extension to the pelvic sidewll (Fig ), musculr infiltrtion of the pelvic wll is est pprecited on T2-weighted imges. Muscle is of lower signl intensity nd cn thus e differentited from the high-signl-intensity tumor. Other importnt muscles tht need to e evluted re the levtor ni, piriform, nd internl oturtor muscles. Invsion of the internl nl sphincter muscle cn e evluted on coronl T2-weighted imges. Stge IV vginl cncer is chrcterized y invsion of the ldder nd rectum (Fig ), which is identified s disruption of the low-signl-intensity musculr lyer of these orgns on T2-weighted imges. Fistuls cn e identified on contrst-enhnced T1-weighted imges. They re chrcterized y more pronounced contrst enhncement nd there my e centrl signl void in the fistul cnl.

13 Vgin 287 c d Fig d. Vginl cncer., T2-weighted imges in sgittl nd xil orienttion. FIGO stge II vginl cncer of intermedite signl intensity (sttus post hysterectomy). There is tumor throughout the nterior wll of the distl vgin (rrows). Tumor extension to the urethr (open rrow). c,d T1-weighted imges with ft st fter dministrtion of Gd-DTPA in xil nd sgittl orienttion. Contrst medium dministrtion does not improve delinetion of the cncer MR Appernce After Rdiotherpy Edemtous nd inflmmtory rections of the vgin tht persist for up to out 6 months fter rdiotherpy re ssocited with n incresed signl intensity of the vginl wll on T2-weighted imges. The oserved increse in signl intensity is directly proportion to the totl rdition dose dministered nd lwys occurs ove threshold dose of 45 Gy. The mode of dministrtion (percutneous rdition, rchytherpy) ppers not to ffect the degree of signl chnge. Irrdited tissue lso shows incresed enhncement fter contrst medium dministrtion. Aout 6 months fter completion of rdiotherpy, firosis leds to decresed signl intensity of the vgin on T1- nd T2-weighted imges nd there is gin less pronounced contrst medium enhncement [11]. A rre compliction of rdiotherpy is vginl stenosis with susequent development of serometr or hemtometr (Fig ).

14 288 U. Zspel nd B. Hmm Fig FIGO stge I. Vginl cncer is limited to the vgin. (Reproduced with permission from [14]) Fig FIGO stge II. Tumour involves the prvginl tissue ut does not extend to the pelvic wll. (Reproduced with permission from [14] ) c Fig c. Vginl cncer. T2-weighted imge in sgittl orienttion. T2-weighted imge with ft st in xil orienttion. c T1-weighted imge with ft st fter dministrtion of Gd-DTPA in xil orienttion. Sttus post hysterectomy for leiomyoms of the uterus. Vginl cncer (rrows) of in the proximl two thirds of the vgin with infiltrtion of the vginl wll. Accessory finding: ir inclusion in the urinry ldder fter ctheteriztion.,c Firly good differentition of the solid tumor (rrows) from the high-signl-intensity venous plexus. There is no ovious infiltrtion of the prcolpl ft. (Figure courtesy of Dr. Forstner)

15 Vgin 289 Fig FIGO stge III. Cncer extends to the pelvic wll. (Reproduced with permission from [14]) Fig FIGO stge IV. Tumour involves the mucos of the ldder or rectum or extends eyond the true pelvis. (Reproduced with permission from [14]) Fig ,. Vginl stenosis. T2-weighted imges in xil nd sgittl orienttion. Vginl stenosis in the proximl third of the vgin fter rdiotherpy. There is hemtometr () nd hemtoslpinx () (short rrows). (Reproduced with permission from [13])

16 290 U. Zspel nd B. Hmm MR Appernce After Surgery The postopertive ppernce vries with the type of surgery performed. Shortly fter surgery, scrs re chrcterized y high signl intensity on T2- weighted imges nd there is normlly incresed contrst enhncement on T1-weighted imges due to postopertive edem formtion nd neovsculriztion. These rective chnges re difficult to distinguish from residul or recurrent tumor in the erly postopertive phse [12] Residul nd Recurrent Tumor With its intrinsic high soft-tissue contrst, MRI is the method of choice for demonstrting residul tumor or tumor recurrence. Moreover, MRI llows identifiction of rdition-induced chnges of the orgns of the true pelvis. Postopertive scrs or postctinic chnges cn e differentited from recurrent or residul tumor on MR imges on condition tht the exmintion is performed t lest 6 months fter the end of therpy. This intervl is necessry ecuse cute rective increses in signl due to edem nd inflmmtion immeditely fter irrdition or surgery cnnot e differentited from vitl tumor tissue. After out 6 months, the vgin hs returned to its norml low signl intensity on T2-weighted imges nd residul or recurrent tumor cn e identified s high-signl-intensity disruption of the vginl wll [12]. Recurrent tumor hs n incresed signl intensity on T2-weighted imges nd typiclly shows n inhomogeneous structure. On contrst-enhnced imges, recurrent tumor is chrcterized y higher signl enhncement compred with surrounding tissue. However, the exminer must e wre tht even fter 6 months following rdition or surgery, incresed signl intensities my e due to posttherpeutic rective chnges. In such cses, dynmic contrst-enhnced fst GRE study my e helpful. Here, recurrent or residul tumor will show significntly erlier nd more pronounced contrst enhncement thn scr tissue. As in pretherpeutic stging, contrst-enhnced T1-weighted imges re helpful to identify possile invsion of the ldder or rectum y recurrent or residul tumor. Tumor invsion of these orgns is indicted y circumscried res of normlly incresed contrst enhncement in the wll. As in preopertive stging, musculr infiltrtion is est seen on T2-weighted imges. Ultrsonogrphy nd CT hve only limited role in detecting recurrent or residul vginl tumor ecuse they rely on the configurtion of the lesion s the only criterion. The sensitivity of oth modlities is too low for differentition of tumor from posttherpeutic chnges nd for the detection of smll tumors. The ccurcy of the clinicl exmintion is lso limited, in prticulr when postopertive scr tissue is present Lymph Nodes Imging of the inguinl, pelvic, nd, where necessry, pr-ortic lymph node stges y mens of MRI/ CT my provide dditionl informtion for primry therpeutic decision mking. Although the inguinl lymph nodes re esily ccessile to plption, plption hs poor sensitivity in detecting inguinl lymph node metstsis. Evlution for lymph node metstsis is cliniclly relevnt efore surgery nd efore primry or djuvnt rdiotherpy. Moreover, considerle proportion of recurrent vginl tumors rise from lymph node metstses. The criteri for lymph node imging re descried in Chpter 14. References 1. Hrick H, Chng YC, Thurnher S (1988) Vgin: evlution with MR imging. Prt I. Norml ntomy nd congenitl nomlies. Rdiology 169: Hddd B, Louis-Sylvestre C, Poitout P, Pniel BJ (1997) Longitudinl vginl septum: retrospective study of 202 cses. Eur J Ostet Gynecol Reprod Biol 74: Crrington BM, Hrick H, Nuruddin RN, Secf E, Lros RK, Jr., Hill EC (1990) Mullerin duct nomlies: MR imging evlution. Rdiology 176: Pellerito JS, McCrthy SM, Doyle MB, Glickmn MG, DeCherney AH (1992) Dignosis of uterine nomlies: reltive ccurcy of MR imging, endovginl sonogrphy, nd hysteroslpingogrphy. Rdiology 183: Feller ER, Riudo S, Jckson ND (2001) Gynecologic spects of Crohn s disese. Am Fm Physicin 64: Cresmn WT (2005) Vginl cncers. Curr Opin Ostet Gynecol 17: Piur B, Rinovich A, Yni-Inr I (2002) Primry mlignnt melnom of the vgin: cse report nd review of literture. Eur J Gynecol Oncol 23: Merino MJ (1991) Vginl cncer: the role of infectious nd environmentl fctors. Am J Ostet Gynecol 165: Lopez C, Blogun M, Gnesn R, Olliff JF (2005) MRI of vginl conditions. Clin Rdiol 60:

17 Vgin Siegelmn ES, Outwter EK, Bnner MP, Rmchndni P, Anderson TL, Schnll MD (1997) High-resolution MR imging of the vgin. Rdiogrphics 17: Sugimur K, Crrington BM, Quivey JM, Hrick H (1990) Postirrdition chnges in the pelvis: ssessment with MR imging. Rdiology 175: Chng YC, Hrick H, Thurnher S, Lcey CG (1988) Vgin: evlution with MR imging. Prt II. Neoplsms. Rdiology 169: Hmm B et l. (2006) MRT von Adomen und Becken. 2. Edition. Thieme, Stuttgrt 14. Wittekind C, Greene FL, Hutter RVP, Klimpfinger M, Soin LH (eds) (2005) TNM Atls Illustrted Guide to the TNM/pTNM Clssifiction of Mlignnt Tumours. Springer, Berlin Heidelerg New York