Magnetic Resonance Imaging in Obstetrics and Gynaecology

Magnetic Resonance Imaging in Obstetrics and Gynaecology

Martin C. Powell, MD, MRCOG, FRCS(Ed)

Consultant in Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham, UK

Brian S. Worthington, BSc, FRCR

Professor of Diagnostic Radiology, University of Nottingham, UK

E. Malcolm Symonds, MD, FRCOG

Professor of Obstetrics and Gynaecology, University of Nottingham, UK

Table of Contents

Cover image

Title page

Dedication

Copyright

Preface

Chapter 1: Introduction

Publisher Summary

Historical background

Chapter 2: Principles of magnetic resonance imaging

Publisher Summary

Behaviour in an externally applied field

The quantum theory approach to NMR

Resonance

Relaxation

Image formation

Pulse sequences

NMR instrumentation

Chapter 3: Safety considerations

Publisher Summary

Introduction

Static magnetic fields

Biological effects

Gradient magnetic fields

Radiofrequency magnetic fields

Combined static magnetic fields, pulsed gradient magnetic fields, and radiofrequency magnetic fields

Acoustic noise

Contrast media

Conclusion

Appendix: Abstract from the recommended guidelines for clinical magnetic resonance imaging: National Radiological Protection Board (1991)

Supervision of exposed persons

Restrictions on exposure

Part I: Gynaecology

Chapter 4: The normal uterus and vagina

Publisher Summary

Introduction

The anatomy and signal characteristics of the normal uterus

The multiparous woman

The post-menopausal woman

The amenorrhoeic woman

The uterine low intensity band

Congenital anomalies

The normal vagina and vulva

Leiomyomas and adenomyosis

Chapter 5: Carcinoma of the uterine body

Publisher Summary

Introduction

Current imaging techniques of endometrial cancer

MRI and endometrial cancer

The signal characteristics and appearance of primary endometrial cancer

Stage II, III and IV tumours

Recurrent endometrial cancer

Chapter 6: Carcinoma of the cervix

Publisher Summary

Introduction

Current imaging techniques and cervical cancer

The signal characteristics of primary cervical carcinoma

The features of cervical carcinoma with MRI

MRI and recurrent cervical cancer

Chapter 7: Benign disease of the ovary

Publisher Summary

The normal ovary

The pathological ovary

The dermoid cyst

The endometriotic cyst

Simple cysts

Chapter 8: Carcinoma of the ovary

Publisher Summary

Introduction

Current imaging techniques and ovarian cancer

MRI and ovarian cancer

MRI characteristics of primary ovarian cancer

Primary and recurrent carcinoma of the rectum and colon

Retroperitoneal liposarcoma

MRI staging of ovarian cancer

Part II: Obstetrics

Chapter 9: The maternal anatomy and the placenta

Publisher Summary

The placenta

Imaging techniques and the placenta

Placenta praevia

Ultrasound and placenta praevia

MRI and placenta praevia

MRI and placental migration

Unexplained ante-partum haemorrhage

Chapter 10: Gestational trophoblastic neoplasia

Publisher Summary

Introduction

The MRI appearances of GTN

Chapter 11: The fetus

Publisher Summary

Introduction

The fetus: first and second trimesters

The normal fetus: third trimester

References

Appendix II: Technique for imaging the female pelvis

Index

Dedication

To our families

Copyright

Butterworth-Heinemann Ltd

Linacre House, Jordan Hill, Oxford OX2 8DP

A member of the Reed Elsevier group

OXFORD LONDON BOSTON

MUNICH NEW DELHI SINGAPORE SYDNEY

TOKYO TORONTO WELLINGTON

First published 1994

© Butterworth-Heinemann Ltd 1994

All rights reserved. No part of this publication may be reproduced in any material form (including photocopying or storing in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P 9HE. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publishers

British Library Cataloguing in Publication Data

Powell, Martin C.

Magnetic Resonance Imaging in Obstetrics and Gynaecology

I. Title

618.1

ISBN 0 7506 1321 1

Library of Congress Cataloguing in Publication Data

Powell, Martin C.

Magnetic resonance imaging in obstetrics and gynaecology/Martin C. Powell, Brian S. Worthington, E. Malcolm Symonds.

p. cm.

Includes bibliographical references and index.

ISBN 0 7506 1321 1

1. Generative organs, Female—Magnetic resonance imaging.

2. Fetus—Magnetic resonance imaging. I. Worthington, B. S. (Brian S.) II. Symonds, E. M. (Edwin Malcolm) III. Title.

[DNLM: 1. Genital Neoplasms, Female—diagnosis. 2. Magnetic Resonance Imaging. WP 145 P885m 1993] RG107.5.M34P68 1993

618′.047548—dc20

DNLM/DLC

for Library of Congress 93-7115

CIP

Composition by Genesis Typesetting, Laser Quay, Rochester, Kent

Printed and bound in Great Britain by Bath Press, Avon

Preface

The development of a new imaging modality is an exciting and unpredictable event. The 1960s saw the introduction of ultrasound imaging and from a relatively crude collection of signals, it has been possible to develop a highly sophisticated method of imaging, both of the structure of the human fetus and of the pelvic organs. Furthermore, real-time imaging and the revelations of velocity profiles by pulsed Doppler ultrasound have opened up a window on the understanding of fetal physiology. The introduction of magnetic resonance imaging (MRI) has provided a further non-invasive technique without planar restriction, giving better tissue characterization than ultrasound.

Progress in the imaging of the human fetus has been slow. The first images of a human fetus were reported in 1983 by Smith et al. from Aberdeen. These images were obtained in the first trimester of pregnancies scheduled for termination. The following year, Johnson and the Nottingham group produced the first images of a full-term fetus (Johnson et al., 1984a). Since that time, progress in fetal imaging has been remarkably slow. Despite the fact that there is no firm evidence available, within the exposure conditions currently used in imaging-of any hazard to the fetus-there is a reluctance to use this technique in pregnancy.

Acting within the safety guidelines of the National Radiological Protection Board of Great Britain, and using a 0.15 T magnet, we have obtained images of remarkably high quality, despite the relatively long imaging time. The images reveal details of fetal anatomical structure to a remarkably high degree and emphasize the potential value of the technique in fetal and maternal imaging. For this reason, we believe that it is of value to collect the images into an atlas to outline what can currently be achieved with imaging in pregnancy and to encourage other investigators to pursue the field of fetal imaging and magnetic resonance spectroscopy, when this becomes more widely available.

The only significant factor to impair the quality of images is the movement of the fetus during relatively long imaging sequences. This does not apply to the uterus, the cervix and the placenta where the image will not be distorted by movement and placental localization can be accurately defined by the clear images of placental edge and the internal cervical os. Even at low field, remarkable detail of the placenta is obtained and there is every prospect of harnessing the technique to study placental perfusion in the foreseeable future.

Whatever problems may exist with fetal imaging, the excellent images obtained of various pathological conditions in the female pelvic organs have already established MRI as a major imaging modality in the field. Documentation of these images is therefore a matter of some importance and already has a practical value, particularly in the management of malignant disease in the pelvis.

The presence of a low intensity band in the subendometrial zone was noted early in MRI of the pelvis but the explanation, until recently, has been a matter for some debate. Whatever the mechanism of this phenomenon, it has been particularly useful in the assessment of invasion of endometrial carcinoma and of hydatidiform mole or choriocarcinoma.

Although the tissue densities may not differ greatly, it is possible to see clearly the invasion of tumour into surrounding tissue in cases of cervical carcinoma and several studies have now demonstrated the potential of MRI in the local staging of malignant disease of the cervix.

The anatomy of ovarian tumours, both benign and malignant, has been elucidated by various sequences and the clinical relevance of these findings is currently under evaluation. In endometriosis MRI can detect implants of disease within the pelvis as well as ovarian involvement and it is useful in monitoring its therapy.

With the advent of high-speed regimes such as echo-planar imaging, the problems of fetal movement will be overcome, and spectroscopy may come to assist in monitoring the efficacy of a chemotherapeutic regime in tumour management.

We have tried in this atlas to provide a basic almanac of images obtained by MRI in obstetrics and gynaecology.

At best, these images portray the underlying anatomical substrate with great clarity and we hope you will share our excitement in the discovery of the value of the technique in imaging the human fetus and reproductive tract.

Finally, we acknowledge our gratitude to the Nottingham physicists whose pioneering work enabled us to have access to this technology at an early stage of its development, and to Mr Nick Bullimore who worked for many long hours to produce the photographs which illustrate this text.

1

Introduction

Publisher Summary

This chapter discusses that the discipline of radiology which exists today is because of the discovery of radiation bands in the electromagnetic spectrum, which penetrates human tissue, and thus is exploited for imaging. Magnetic resonance employs radiofrequency radiation and almost certainly represents the final window in the electromagnetic spectrum for imaging. It is similar to computer tomography in providing a cross-sectional display of body anatomy with excellent resolution of soft tissue detail. The images are essentially a map of the distribution density of hydrogen nuclei and parameters reflecting their motion, in cellular water and lipids. The total avoidance of ionizing radiation, its lack of known hazards, and the penetration of bone and air without attenuation make it a particularly attractive non-invasive imaging technique.

The discipline of radiology only exists today because of the discovery of bands of radiation in the electromagnetic spectrum, which can penetrate human tissue, and thus can be exploited for imaging. Magnetic resonance employs radiofrequency radiation and almost certainly represents the final such window in the electromagnetic spectrum for imaging. It is similar to computer tomography (CT) in providing a cross-sectional display of body anatomy with excellent resolution of soft tissue detail. The images are essentially a map of the distribution density of hydrogen nuclei and parameters reflecting their motion, in cellular water and lipids. The total avoidance of ionizing radiation, its lack of known hazards and the penetration of bone and air without attenuation make it a particularly attractive non-invasive imaging technique.

Historical background

The first demonstrations of the physical phenomenon of nuclear magnetic resonance (NMR) were described in 1946 by two independent groups, working on opposite sides of the USA. Each described their experiments in quite different physical terms. In Harvard, the emphasis had been on transitions of magnetic nuclei between quantized states in a magnetic field, and on resonance absorption of radiofrequency energy (Purcell et al., 1946). Whilst at Stanford Bloch described the precession of nuclear magnetization in a magnetic field, inducing an electromotive force in a surrounding radiofrequency coil (Bloch et al., 1946). These two descriptions of NMR were later shown to be quantitatively equivalent (Andrew, 1955). Felix Bloch of Stanford University and Edward Purcell at Harvard were subsequently awarded the Nobel Prize for Physics in 1952 for their pioneering work leading to the discovery of NMR.

The cost of a modern commercial magnetic resonance imaging (MRI) system today can be over a million pounds. It is a sobering thought to consider that the early experiments of Bloch and Purcell were carried out on second-hand equipment. The Harvard group borrowed a large electromagnet previously converted from a discarded generator from the Boston elevated railway. At Stanford an electromagnet was borrowed from the physics lecture theatre, and only a few hundred dollars were spent to obtain an oscilloscope. Following the discovery of NMR using hydrogen, other groups were able to demonstrate the phenomenon of NMR in almost all magnetic nuclei in the periodic table of elements.

NMR was initially employed as a technique for the non-destructive analysis of small samples. Several workers had observed that the NMR frequency was dependent on the chemical form in which the element was present. The magnetic field around nuclei in a complex chemical environment is altered due to shielding currents that are associated with the electron distribution around adjacent atoms. These changes in the magnetic field cause small alterations in the resonant frequency which are known as chemical shifts and these allow a distinction to be made between the nuclei in different chemical environments. NMR spectroscopy relies on information derived from chemical shifts, providing a fingerprint of the chemical compound. The method is now one of the chemist’s most valuable structural and analytical tools and today no chemistry research laboratory is properly equipped without its high-resolution NMR spectrometer. To be able to perform NMR spectroscopy, a very high uniform magnetic field is required to give satisfactory resolution of the signals deriving from different molecular species.

One of the other applications for NMR was to provide a method for measuring the strength of a magnetic field, as the resonance frequency and the magnetic field are directly proportional to each other. Portable magnetometers have become useful in civil engineering projects, in archaeological surveys for buried magnetic artefacts and are now employed for magnetic field measurements in satellites and space vehicles.

In 1971 Damadian reported that implanted tumours in experimental animals displayed differences in their magnetic resonance properties. The fundamental insight required in harnessing magnetic resonance as an imaging technique was provided by both Mansfield and Lauterbur in 1973; they demonstrated that spatial localization of an NMR signal could be achieved by applying a linearly varying magnetic field.

Human in vivo images were first published in 1976 by Mansfield and Maudsley and Hinshaw et al. (1978). The technical problems involved in scaling up the method to whole body were not trivial but eventually a series of laboratory prototype systems were built which were the forerunners of today’s commercial systems. The multiplanar capability of MRI was first demonstrated on such a system by Hawkes et al. in 1980; this group went on to report the first demonstration of intracranial pathology with MRI in the same year.

An early paper to suggest a potential role for NMR in obstetrics came from the Aberdeen group. This study, published in the Lancet, involved 6 patients within the first trimester of pregnancy who were imaged prior to an elective termination (Smith et al., 1983). The placenta was demonstrated and measurements taken from the images obtained were suggested to approach those of ultrasound. The results were displayed as proton density, T1, or a combination of both. A subsequent paper from Nottingham demonstrated images of the fetus and maternal anatomy in the final trimester of pregnancy (Johnson et al., 1984a). Both uterus and placenta were displayed, and the dimensions and configuration of the pelvis could be assessed. Because of the long scan time this involved, images of the fetus in the first trimester were poor, but were found to be better in the final trimester when fetal movement is more restricted. The Aberdeen study was limited to transverse axial images only with no T2-weighted sequences. Although the Nottingham group had additional sagittal and coronal planes available for study, they were limited by the use of only one pulse sequence, the steady state free precession (SSFP). The initial images produced by both these groups were exciting in the potential they offered, but their usefulness was restricted by poor resolution capacity and the limited range of pulse sequences available on these prototype NMR systems.

Initially two research groups based in the USA and two in the UK (Nottingham and Aberdeen) began evaluating the potential role of MRI in assessing pathology within the male and female pelvis. Few examples of pathology were included in these early papers, but the ability of MRI to differentiate different tissue types within the pelvis was clearly demonstrated (Hricak et al., 1983; Butler et al., 1984). Johnson et al. (1984b) at the University Hospital Nottingham published the first paper on pathological changes observed with NMR in ovarian cancer, using a clinical prototype imaging system. The early published papers, although limited in their scope, were able to suggest the potential MRI may have in clinical gynaecology.

The female pelvis is suitable for examination by MRI, because of the minimal effect on the pelvic organs from respiratory movement. Movement during the course of MRI, however slight, has a significant effect on the final image quality, and is found to be most prominent in images of the upper abdomen and lungs. Since the first publications on mainly prototype systems, there have now been a substantial number of reports regarding the application of MRI to the female pelvis. They have in the main concentrated on its application to gynaecological oncology where a role for MRI in cervical and endometrial cancer has been established (Lee, 1988; Hricak et al., 1991). The role for MRI however in primary and recurrent ovarian cancer is still to be determined (Powell et al., 1987a).

MRI in obstetrics has been more problematical; fetal movement is a major drawback to its usefulness (McCarthy