Magnetic resonance imaging evaluation of gynecological mass lesions: A comprehensive analysis with histopathological correlation

MRI is the most effective method of detecting and characterizing adnexal and uterine lesions. Compared to other modalities MRI provides a substantial amount of information regarding uterine and adnexal masses and surrounding structures and has no radiation exposure hence it has carved a niche for being a superb diagnostic and follow-up modality. The extent of the lesion, and surrounding involvement also could be studied well and thus help in staging the lesion. Information regarding the secondary features such as ascites, pelvic lymphadenopathy, omental and pelvic metastases, and pelvic bone metastasis can be well evaluated. Further, the possible line of management and selection of treatment modality for the patient could be planned by using an MRI pelvis. Follow-up studies can suggest remission, residual, or recurrent tumors. Despite the valuable insights gained from MRI in evaluating gynecological masses, our study has several limitations that warrant consideration. Firstly, the study’s observational cross-sectional design limits our ability to establish causality between MRI findings and histopathological outcomes. While MRI provided detailed imaging characteristics, histopathological confirmation was not universally available for all cases, potentially introducing variability in diagnostic accuracy. Moreover, the study’s single-center nature may limit the generalizability of findings to broader populations or different healthcare settings with varying MRI equipment and expertise levels. Additionally, variations in MRI protocols, including sequences and parameters, could influence diagnostic outcomes, although efforts were made to standardize imaging procedures. Furthermore, the sample size, though adequate for a single-center study, may restrict the ability to detect rare gynecological conditions or to stratify findings across age groups or specific clinical presentations. Future prospective studies with larger, diverse patient cohorts and multicenter collaborations could address these limitations and further validate the utility of MRI in diagnosing and staging gynecological mass lesions.

Magnetic resonance imaging (MRI) has revolutionized the diagnostic approach to gynecological mass lesions, offering noninvasive and detailed visualization crucial for accurate diagnosis and treatment planning. [ 1 ] This imaging modality provides superior soft tissue contrast and multiplanar capability, making it indispensable in the evaluation of pelvic pathology. [ 2 ] Gynecological masses encompass a broad spectrum of benign and malignant lesions arising from various pelvic structures including the uterus, ovaries, fallopian tubes, and surrounding soft tissues. [ 3 ] Common benign lesions include fibroids, adenomyosis, and ovarian cysts, whereas malignant masses may originate from ovarian, endometrial, or cervical tissues. [ 4 ] Distinguishing between these entities is crucial for appropriate management decisions, with MRI playing a pivotal role in this differentiation. [ 5 ] The primary goal of MRI in evaluating gynecological masses is to characterize the lesion’s morphology, size, location, and its relationship with adjacent structures. [ 6 ] Tumor morphology on MRI, such as shape, margins, and internal characteristics (e.g., presence of septations, solid components, or cystic areas), can often suggest the nature of the lesion and guide further diagnostic and therapeutic interventions. [ 7 ] Furthermore, MRI provides valuable insights into the vascularity of gynecological masses through techniques such as dynamic contrast enhancement and diffusion-weighted imaging. [ 8 ] These functional imaging modalities enhance diagnostic accuracy by evaluating perfusion patterns and tissue cellularity, thereby aiding in the differentiation between benign and malignant lesions. [ 9 ] Histopathological correlation remains the gold standard for definitive diagnosis of gynecological masses. However, MRI serves as an indispensable adjunct by providing comprehensive preoperative assessment, enabling surgeons to plan optimal surgical approaches and interventions. [ 10 ] This study aims to provide a comprehensive analysis of the current role of MRI in the evaluation of gynecological mass lesions, emphasizing its strengths in correlation with histopathological findings. By synthesizing current literature and clinical evidence, this paper underscores the importance of MRI as a cornerstone in the management algorithm of gynecological malignancies and benign lesions alike.

Conceptualization: Syed Salman, Sajjad Ahmed Khan. Data curation: Sajjad Ahmed Khan. Formal analysis: Syed Salman, Nabeela Shireen. Investigation: Romana Riyaz. Methodology: Nabeela Shireen. Resources: Romana Riyaz. Software: Romana Riyaz. Supervision: Janender Pal Singh, Anuj Uttam. Writing – original draft: Syed Salman, Nabeela Shireen. Writing – review & editing: Sajjad Ahmed Khan, Janender Pal Singh, Anuj Uttam.

The study enrolled female participants based on stringent criteria designed to comprehensively evaluate pelvic masses using MRI. Participants were selected if they presented with clinical suspicion of pelvic masses identified during physical examination and/or ultrasonography. This inclusion criterion ensured that the study captured a diverse range of pelvic pathologies that warranted further imaging investigation with MRI. Patients were included if they exhibited clinical suspicion of pelvic masses during initial assessment through physical examination or ultrasonography. This criterion aimed to encompass a broad spectrum of conditions, including benign and malignant masses, necessitating advanced imaging modalities like MRI for precise diagnosis and characterization. Exclusion criteria were applied to individuals with specific contraindications for MRI. This included patients with MRI-incompatible pacemakers or other implants/prostheses that could interfere with the imaging process. Additionally, individuals experiencing claustrophobia, which could compromise the quality of MRI scans due to patient discomfort or inability to remain still during the procedure, were also excluded from the study. The study was conducted over a period of 1 year, from June 2022 to July 2023. During this time frame, a total of 60 eligible patients were enrolled in the study. This duration was chosen to ensure an adequate representation of cases and to accommodate the logistical aspects of MRI scheduling and data collection at the tertiary care hospital. The sample size of 60 patients was determined based on statistical considerations aimed at achieving robust data analysis and reliable conclusions. This sample size was calculated to provide sufficient statistical power to detect differences in MRI findings between benign and malignant pelvic masses, ensuring the study’s validity and generalizability of findings to similar patient populations. MRI examinations were conducted using a 1.5 Tesla scanner equipped with dedicated pelvic surface coils. Patients underwent MRI scans in a supine position following a minimum 4-hour fasting period, which minimized potential artifacts and enhanced the clarity of imaging results. The MRI protocol included essential sequences such as T1-weighted, T2-weighted imaging (T2WI), and Short Tau Inversion Recovery sequences in axial, sagittal, and coronal planes. These sequences provided comprehensive anatomical and pathological information crucial for differential diagnosis of pelvic masses. Prior to participation, written informed consent was obtained from all study participants, ensuring their voluntary involvement and understanding of the study objectives and procedures. The study protocol was reviewed and approved by the institutional ethics committee, in accordance with ethical principles outlined in the Second Declaration of Helsinki. These measures ensured that the study was conducted ethically and with respect for participant rights and welfare. Imaging features obtained from MRI scans were systematically recorded in a master chart, facilitating organized data collection and subsequent analysis. This approach allowed for a detailed examination of MRI findings related to both benign and malignant pelvic masses. Statistical analysis of the collected data was performed to identify significant imaging characteristics and correlations with histopathological diagnoses, enhancing the understanding of pelvic mass pathologies and informing clinical decision-making. Histopathological diagnoses of pelvic masses were obtained through biopsy or fine needle aspiration cytology following MRI evaluation. These diagnostic procedures provided definitive pathological confirmation of MRI findings, validating the accuracy and diagnostic utility of MRI in characterizing pelvic mass lesions. Histopathological analysis contributed critical insights into the nature, composition, and malignant potential of identified masses, further guiding patient management and treatment strategies. The data obtained was coded and analyzed statistically by using Microsoft Excel 2019 and SPSS Microsoft version 21. The categorical data was expressed as rates, ratios, and proportions. The continuous data was expressed as mean + standard deviation. The chi-square test/Fischer exact test was used to find the significance of MRI findings. Diagnostic statistics such as sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to find the correlation of MRI with the final diagnosis.

The gynecological masses on MRI had a broad differential diagnosis which included benign lesions like uterine fibroids, endometrial polyps, endometriosis, ovarian cysts, and adenomyosis and malignant lesions like Cervical, endometrial, ovarian, and vaginal carcinomas. Important considerations in arriving at the most probable diagnosis were the age of the patient, history, and findings on physical examination, routine biochemical laboratory tests, and the results of MRI. However, the final diagnosis was standardized after histopathological assessment wherever possible. In our study, the ratio of benign versus malignant disease was 1.60:1, as 37 were benign and 23 were malignant masses. The common benign masses seen were uterine fibroids (n = 14; 23.3%), followed by endometriosis (n = 8; 13.3%), and ovarian dermoid cysts (n = 4; 6.6%). Among malignant diseases, the most common was cervical cancer (n = 11; 18.3%), Followed by endometrial carcinoma (n = 7; 11.6%), carcinoma ovary (n = 3; 5%), carcinoma vagina (n = 2; 3%). Benign masses were most common in the 5th decade, with the average age of presentation of benign lesions being 45.6 years, followed by the 4th decade. In comparison, the malignant masses were most common in the 6th decade followed by the 7th decade with the average age for malignant masses being 60.2 years. The mean age of 50 patients with endometrial carcinoma was 62.7 years, and carcinoma cervix was 60.1 years in our study (Table 1 ). Distribution of adnexal masses according to age. In our study, benign gynecological masses were common among females in their reproductive age group and the most common presenting complaint was pain abdomen seen in 15 patients out of 37, followed by menstrual irregularity seen in 8 out of 37 patients, other presenting symptoms in cases of benign gynecological masses were infertility, abdomen distension and post-menopausal bleeding. There was incidental detection of the benign gynecological disease in 2 patients who presented for their routine annual health checkup. The most common presenting symptom in the cases of malignant gynecologic masses was postmenopausal bleeding seen in 11 out of 23 cases followed by menstrual irregularity in 4 out of 23 patients; other presenting complaints included abdominal pain, abdominal distension, and discharge per vagina (Table 2 ). Clinical presentation of patients in the study. The most common clinical finding in patients on physical examination was bulky uterus in 20 out of 60 patients, followed by adnexal mass and cervical growth seen in 12 and 11 patients respectively, other clinical findings were vaginal growth and palpable inguinal nodes seen in 2 patients each, There were total 13 patients out of 60 who did not have any abnormal findings on clinical examination. The majority of the patients in our study, who needed radiological evaluation were uterine masses (43.3%) followed by adnexal masses (33.3%), followed further by masses of cervical origin (18.3%) as shown in Figure 1 . Graphical representation of the pathologies of the study population. Fourteen patients were found to have uterine fibroids on MRI. MRI had an accuracy of 100% in detecting the number and size of fibroids. It was sensitive in picking the fatty, cystic, or hemorrhagic degeneration in the fibroids. The various fibroids that were detected in our study and correlated with histopathology examination are shown in Figure 2 . Pie chart representation of variants of uterine fibroids on MRI. MRI = magnetic resonance imaging. Eight patients were found to have endometriosis on MRI and endometriotic lesions were enough not to be detectable on any other modality. Endometriosis accounted for 13.3% of our study patients. The mean age of these patients was 40 years, with the age range being 23 to 52 years.MR had a sensitivity of 92% in diagnosing endometriosis, with a positive likelihood ratio of 0.93. T2–Shading was present in 7 out of 8 endometriotic cysts. The role of T2-shading in making a diagnosis of endometriosis in an endometriotic cyst has a specificity of 100%, with a sensitivity of 83%. Three of 8 patients with endometriosis also had dilated tubes which account for 37% of patients with endometriosis. In clinically suspected cases of endometrial carcinoma, MRI has a sensitivity and specificity of 87% and 91%, respectively, a positive predictive value (PPV) of 87% and a negative predictive value (NPV) of 91% for the identification of deep myometrial invasion. Histological types of carcinoma endometrium in the patients were endometrial adenocarcinoma (n = 4; 57.1%), papillary serous adenocarcinoma (n = 2; 28.5%), and undifferentiated endometrial carcinoma (n = 1; 14.2%). The depth of myometrial invasion on MRI versus histopathology examination is discussed in Table 3 . Radio-pathological correlation of evaluation of myometrial invasion (1/2 = deep). Among the 11 patients with cervical carcinomas, histopathologic examination established that 8 (72.7%) were squamous cell carcinoma and the remaining 3 patients were adenocarcinoma (27.2%). In our study, of 11 female patients with cervical carcinomas, histopathologic examination established that 8 (72.7%) were squamous cell carcinoma and the remaining 3 patients were adenocarcinoma (27.2%). Preoperative diagnosis of carcinoma cervix had an MRI done for staging. The staging was then correlated with postoperative histopathology reports in patients who were operated on directly. In the remaining cases, where radiotherapy/chemotherapy was initiated before the surgery, the MRI staging was correlated with clinical staging. The correlation of clinical, radiological & pathological staging is discussed in Table 4 . Clinico-radio-pathological correlation of staging of carcinoma cervix in terms of involvement of parametrium. Either staging was not done or the patient did not undergo surgery, or no viable tumor was detected due to preoperative radiotherapy/concurrent chemotherapy. Four patients (36.3%) had stage IVA disease, 3 patients (27.2%) had stage IIB disease, 2 patients (18.1%) had stage IIA disease, there was 1 patient (9%) each of Stage 3A and 3C disease For the determination of parametrial invasion MR had an accuracy of 91%, with a specificity of 100%, positive predictive value, negative predictive value and sensitivity of 100%, 75%, and 88% respectively. MRI examination of the 11 cases of cervical carcinoma confirmed that all 11 out of 11 (100%) were endocervical growth. Among these 5 of the patients had involvement of the anterior wall (45.4%) and 4 had involvement of both anterior and posterior cervical walls (36.3%), the remaining 2 patients had the involvement of posterior wall (18.1%) Intrauterine extension was detected in 3 out of 11 patients (27.2%), parametrial involvement in 8 (72.7%) patients, urinary bladder and rectum in 3 patients (27.0%) and extension to the pelvic side wall was detected in 2 patients (27.2%). MRI detected pelvic lymph node enlargement in 3 out of 11 patients (27.2%); they proved to be metastatic histopathologically in 2 patients and reactive hyperplasia in 1 patient. Among 12 cases of ovarian origin, 4 cases were mature cystic teratoma (33.3%), 3 cases were serous cystadenoma (25%), there were 2 cases each of mucinous cystadenoma (16.6%) and serous cystadenocarcinoma (16.6%), there was 1 case of mucinous cystadenocarcinoma (8.3%). In our study, MR was able to define the origin of gynecological masses to be ovarian in all 12 cases as shown in Figure 3 . The spectrum of histopathological types of ovarian masses. All the malignant ovarian masses were solid-cystic lesions. Among the benign masses, 5 lesions were cystic and 4 lesions were solid-cystic Among 4 cases of mature cystic teratoma in our study, all of them were solid cystic lesions; these dermoids had hyper-intense signal intensity on both T1-weighted and T2W with classical fat-fluid level, suppression on T1 fat sat sequence and presence of calcification. Other characteristics that allowed confident diagnosis like debris, palm tree-like protrusions, or rounded nodules (dermoid plugs). Among 3 cases of serous cystadenoma, 2 cases were unilocular adnexal cysts and 1 was a multilocular cyst with thin internal septae, no solid component/papillary projections were found to suggest malignant potential Both cases of mucinous cystadenoma were large multilocular cystic adnexal lesions with multiple thin internal septae, the lesions were predominantly T1 hypo intense and T2 hyperintense, few of the locules showed T1 hyperintensity and T2 hypo intensity suggesting the mucin content of the cyst. There were 2 cases of serous cystadenocarcinoma in our study which were confirmed on postoperative histopathological examination. Both of these lesions were solid cystic with a substantial solid component, the solid component was of T1/T2 intermediate signal intensity showing marked post-contrast enhancement. There was 1 case of mucinous cystadenocarcinoma in a 58-year-old female who presented with the complaint of lower abdominal pain and distension, The MRI showed a large multilocular solid cystic lesion in the right adnexa with thick septae and solid/nodular component. The solid component and thick septae showed post-contrast enhancement. There were 4 cases of endometrial polyps in our study, accounting for 6.6% of total cases in our study, 2 of these were pedunculated endometrial polyps and the remaining 2 cases were sessile endometrial polyps. Three of the patients with endometrial polyps were postmenopausal in the age group of 60 to 70 years, two of these women presented with post-menopausal bleeding, and one with vaginal discharge and lower abdominal pain. Another woman aged 40 years presented with the complaint of intermenstrual bleeding and had a pedunculated endometrial polyp prolapsed into the upper vagina. There were 2 cases of adenomyosis in our study, accounting for 3.3% of total cases in our study. The first case was of a 40-year-old female who presented with the complaint of dysmenorrhea and menorrhagia, The MRI showed an enlarged uterus with diffuse thickening of the junctional zone, displaying an intermediate signal on T1 and a low signal on T2. The intramural fundal uterine fibroid was a coexisting pathology in this case. The 2nd case was of a 49-year-old female who presented with dysmenorrhea and chronic pelvic pain and the diagnosis of adenomyosis was established based on MRI findings.

MRI offers a high contrast resolution, provides a good tissue characterization, and has the capability of multiplanar imaging, delineates and characterizes normal uterine anatomy better, along with focal and diffuse uterine conditions. Because it is noninvasive, carries no risk of radiation, requires no anesthesia, and is less operator-dependent, it is becoming a useful modality for evaluating gynecological pathology. A total of 60 cases of gynecological masses that underwent MRI were included in the study. The ages of these patients ranged from 21 to 83 years. The mean age of patients with gynecological masses was 51.25 years, which was comparable with the results of the study by Moideen et al [ 11 ] where the mean age of the patients with gynecological masses was 47.5 years with a range of 11 to 73 years. In our study, benign masses were most common during the 5th decade, with the mean age of diagnosis being 45.6 years followed by the 4th decade. In contrast, the malignant masses were most common in the 6th decade followed by the 7th decade with a mean age of 60.2 years. This is quite similar to the study by Mathew et al [ 12 ] which states that patients presenting in the 6th decade or above had maximum chances of malignancy. Uterine leiomyomas (fibroid) are the most common pelvic tumors in women with gynecological mass lesions as per the results of the study by Wilde and Scott-Barrett [ 13 ] and similar results were obtained in our study, with the uterine fibroids (n = 14; 23.3%) being the most common benign gynecological masses followed by endometriosis (n = 8; 13.3%). Carcinoma cervix (n = 11; 18.3%) was the most common malignant gynecological mass, followed by endometrial carcinoma (n = 7; 11.6%), carcinoma ovary (n = 3; 5%), and carcinoma vagina (n = 2; 3%), in that order. This finding aligns with the study by Agarwal et al, [ 14 ] which reports that carcinoma cervix constitutes 70% of the most common gynecological cancers observed in their research, highlighting notable differences and similarities compared to international data over the past decade. In our study, the most common clinical presentation for the benign gynecological masses was lower abdominal pain, while the patients with malignant masses presented most commonly with postmenstrual bleeding. This is following the results of the study by Wasim et al, [ 15 ] where the most common presenting symptom in benign lesions was pain in the lower abdomen, it being present in 66% of the patients. This however is not in concordance with the results of Zacharia and O’Neill [ 16 ] who observed in a retrospective study that the most common indications for MRI evaluation are menstrual irregularities (like dysmenorrhea, and menorrhagia) (45%). For the ovarian masses, abdominal pain was the common presentation in patients with benign or malignant ovarian masses. This is similar to the study by Wasim et al, [ 15 ] in which abdominal pain was the most common presenting symptom (66% in benign and 76% in malignant). Recent studies have highlighted consistent trends in the demographics and clinical presentations of gynecological masses evaluated by MRI. Our findings align closely with those reported by Moideen and Anitha, [ 17 ] who explored the demographics and clinical presentations of gynecological masses using MRI. Similarly, Mathew and colleagues [ 18 ] observed age-related trends in malignancy among gynecological masses detected by MRI. These observations reinforce the demographic distribution observed in our study, with benign masses predominantly affecting patients in their 40s and 50s, while malignant masses are more prevalent in those over 60 years of age. Additionally, the predominance of uterine fibroids as the most common benign gynecological mass is consistent with studies by Wilde et al, [ 19 ] and the high incidence of cervical carcinoma as the leading malignant entity, as reported by Agarwal et al, [ 20 ] further corroborates our findings. Clinical presentations, such as lower abdominal pain in benign cases and postmenstrual bleeding in malignancies, mirror those reported by Wasim et al. [ 21 ] However, variations exist, as Zacharia and O’Neill [ 22 ] highlighted menstrual irregularities as the most common indication for MRI evaluation, contrasting with our findings. These comparisons underscore the utility of MRI in diagnosing and characterizing gynecological masses across diverse patient populations and clinical settings. Ultrasound is the first-line imaging modality because it is a cost-effective portable real-time examination that provides good anatomic details without the use of radiation. MRI, however, is the most accurate and desirable tool for pretreatment planning. MR was specific enough in determining the number, size, and location of the fibroids in our study (Fig. 4 ). MRI could pick up fatty, cystic & hemorrhagic degeneration in fibroids very well. This is in concordance with a study by Schwartz et al [ 23 ] who studied the value of MRI in differentiating leiomyoma variants & concluded that MRI is better at differentiating the non-cellular variants (i.e., cystic, fatty, and hemorrhagic degeneration) from normal leiomyoma. Axial MRI scan of the pelvis demonstrated a large well defined enhancing T1WI and T2WI hypointense lesions with multiple T2WI hyper intense internal foci seen in the left adnexa, adjacent to the lateral wall of the uterus, reported as left broad ligament fibroid. MRI = magnetic resonance imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging. Of all the 3 morphological subtypes of endometriosis, the superficial peritoneal lesion is not detectable on MRI. Ovarian and deep pelvic infiltrating endometriosis can be characterized by imaging. Among 8 cases of endometriosis, 3 patients had deep pelvic endometriosis in the form of involvement of urinary bladder, rectum & recto-sigmoid. These lesions could not be picked up on ultrasound. In our study, the endometriotic cysts were well differentiated from the hemorrhagic cysts since endometrioma had T2-shortening owing to the presence of different stages of blood and protein contents (Fig. 5 ). Hemorrhagic cysts on the other hand had high T2 SI and lower T1 SI. This is in concordance with the conclusions drawn by Outwater et al [ 24 ] who compared the MR imaging features of endometriomas and hemorrhagic cysts and concluded that endometriomas tended to have higher T1 and lower T2 signal intensities than hemorrhagic cysts. In our study, T2 Shading was present in 7 out of 8 endometriotic cysts. The role of T2- shading in making a diagnosis of endometriosis in an endometriotic cyst was found to have a specificity of 100%, with a sensitivity of 83%. Axial MRI pelvis scan demonstrating bulky left ovary with multi-locular cystic lesion with enhancing walls demonstrating variable T2WI Hypo and hyper-intense signal (shading sign), the lesion is infiltrating into the recto-uterine pouch and involving the anterior border of rectosigmoid—suggestive of deep endometriosis. MRI = magnetic resonance imaging, T2WI = T2-weighted imaging. MRI has an established role in identifying deep myometrial invasion and this can help in making a preoperative decision of the need for pelvic lymphadenectomy. We studied 8 patients having a histopathological diagnosis of carcinoma endometrium, who underwent MRI for staging. The FIGO staging system is commonly used for treatment planning. The average age of these patients was found to be 62.7 years. This is similar to the recent review study by Arora who noted that the peak incidence of endometrial cancer is after the sixth decade. [ 25 ] In our study, MRI has a sensitivity and specificity of 87% and 91%, respectively, a PPV of 87%, and a NPV of 91% for the identification of deep myometrial invasion. Peungjesada et al [ 26 ] and Wu et al studied the accuracy of MRI in assessing the myometrial invasion in carcinoma endometrium and concluded that T2WI has a pooled sensitivity and specificity of 87% and 58%, respectively, in the assessment of myometrial invasion with the accuracy of dynamic contrast-enhanced images and T2WI together being 98% for assessing myometrial invasion. In our study, the staging accuracy was 84%, which is similar to the previous several studies were done by Dodamapahala et al, Park et al, and Xu-Wellier et al, [ 27 – 29 ] who observed the overall staging accuracy of MRI to be between 85% and 93%. The accuracy of the assessment of the depth of myometrial invasion was better with dynamic contrast-enhanced imaging (55–77% for T2-weighted images vs 85–91%). The sensitivity and specificity of MRI in the assessment of the depth of myometrial invasion range from 69% to 94% and from 64% to 100%, respectively; which are similar to the results obtained in our study. Manfredi et al [ 30 ] assessed the role of MRI in the detection of cervical invasion and supported our results with sensitivity, specificity, PPV, and NPV of 80%, 96%, 89%, and 93%, respectively. Conclusively, MRI was consistent in predicting the depth of myometrial invasion and cervical extension, which correlates with the risk of lymph node metastases (Fig. 6 ). Although MRI is not incorporated in the FIGO staging system, it has a key role in staging, patient selection for treatment, and detection of disease recurrence. A sagittal MRI pelvis scan revealed a distended uterine cavity with a large ill-defined T1WI Iso intense and T2WI heterogeneously hyperintense signal lesion with a thin streak of endometrial fluid in the anterior aspect of the lesion. The lesion is infiltrating into less than half of the myometrium, and the outer band of the myometrium is intact suggestive of stage IA endometrial carcinoma. MRI = magnetic resonance imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging. The most common gynecological malignancy with significant cancer-specific mortality of up to 30%, the early detection of cervical carcinoma, correct staging, and appropriate treatment strategies are of great importance. We included 11 patients who underwent MRI to stage a histopathological diagnosis of carcinoma cervix. In our study cervical carcinoma was the most common malignancy and the average age of the patients with cervical malignancy was 60.1 (range 46-73) years. This is in concordance with the results of the study done by Shweel et al [ 31 ] and Mahajan et al where the patients were 40 - 65 years of age and their average age was 45 years. The exophytic mass, which is more common in younger females, is easily diagnosed early. But in older women, endocervical masses are common leading to the delay in diagnosis. T2W images play a crucial role in the identification of the primary tumor and its extent. These masses show intermediate to high signals on T2W images. Early tumors can be identified on dynamic contrast-enhanced images with low apparent diffusion coefficient value as compared to non-tumor tissue. [ 31 ] MRI tells us the exact volume, shape, and direction of the primary lesion, the local extent of the disease, and nodal status accurately, which helps the clinician in treatment planning (Fig. 7 ). Tumor response to chemo-radiation is also better evaluated with MRI. Our results are in concordance with the study by Kim et al [ 32 ] who found that the accuracy of 3 methods (MRI, CT, and clinical examination) in cervical cancer staging was 92% accuracy for MRI compared with 78% for clinical examination, and 70% for CT. MRI is the preferred imaging modality because of its ability to assess soft tissue in detail, permitting thereby better identification of stromal and parametrial invasion. In our study, MR was found to have an accuracy of 91%, with specificity of 100%, positive predictive value, negative predictive value, and sensitivity of 100%,75% &88% respectively, for the determination of parametrial invasion. The results are fairly similar to the study by Shweel et al [ 31 ] who observed that the MRI has a sensitivity of 100% and specificity of 85.7% in the detection of parametrial infiltration and a sensitivity of 100% and specificity of 90% in the detection of vaginal infiltration. It is sensitive (100%) and specific (100%) in detecting tumor extension to the stroma, urinary bladder, and rectum. Although pelvic lymph node metastasis is not included in FIGO staging, it is one of the important prognostic factors as positive nodes indicate poor prognosis irrespective of the stage of the tumor. In our study, 3 out of 12 patient’s carcinoma cervix had pelvic lymph node involvement, among which paracervical lymph nodes were present in one patient while 2 patients had iliac lymphadenopathy nodes. Yang et al [ 33 ] compared dynamic helical CT and dynamic MR imaging in the evaluation of pelvic lymph nodes in cervical carcinoma and observed the sensitivity, specificity, positive and negative predictive values, and accuracy of MRI in the diagnosis of lymph node metastasis to be 70.6%, 89.8%, 66.7%, 91.4%, and 85.5%, respectively. In our study, the accuracy was 100%, results were affected by the small sample size. A sagittal scan of the MRI pelvis scan showed an enhancing T1WI hypo intense T2WI hyperintense lesion involving both the anterior and posterior wall of the cervix and infiltrating into the lower uterine segment, representing Stage II B cervical carcinoma. MRI = magnetic resonance imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging. An ultrasound examination is the most valuable diagnostic study in the evaluation of an adnexal or pelvic mass. But is not specific for the detection of benign and malignant lesions, where MRI would serve the purpose like in our study. Dwivedi et al studied the role of MRI in determining the organ of origin, nature (benign vs malignant) and characteristics of adnexal masses. The sensitivity of MRI for the mass of ovarian origin was (97.7%) and the specificity was (73.1%). The diagnostic accuracy was (92.1%). [ 34 ] In our study, MRI was able to successfully differentiate benign from malignant adnexal lesions. 4 patients with adnexal masses were found to have dermoid cysts (mature teratoma) on MRI. These desmoids had hyperintense signal intensity on both T1W and T2W with classical fat-fluid level, suppression on T1 Fat SAT sequence, and presence of calcification. This was similar to the study by Togashi et al, who concluded that the fat within a dermoid demonstrates the characteristic SI similar to that of the subcutaneous fat, suppression on FatSat images, or pathognomonic pattern of chemical shift artifact. In addition to fat, MRI of ovarian teratomas had several other characteristics that allowed confident diagnoses like debris, palm tree-like protrusions or rounded nodules (dermoid plugs), and occasionally fat fluid levels and globular calcification. [ 35 ] Therefore, MRI is the state-of-the-art imaging modality for the evaluation of adnexal masses with an overall high diagnostic value due to its accuracy in identifying the origin of adnexal mass and characterizing the solid, hemorrhagic, fatty, and fibrous content which may obviate surgery or significantly contribute to preoperative planning (Fig. 8 ). Both the cases of serous cystadenocarcinoma presented in 6th and 7th decade of their life, this is in concordance with observation by Pablo et al who stated that the peak age of incidence for serous cystadenocarcinomas is in 6 to 7th decade of life In our study the serous and mucinous cystadenomas were well differentiated from each other, the serous cystadenomas were unilocular/multilocular thin walled cystic adnexal lesions with homogenous T1 hypo intense and T2 hyper intense signal, the mucinous cystadenomas were largest at presentation as compared to the serous cystadenomas with multilocular cysts containing fluid of varied viscosity as a result showing variable T1/T2 signal depending upon on mucin content within these cysts Benign serous/mucinous cystadenonomas were thin walled cystic lesions without any enhancing solid components, papillary projection or thick internal septations differentiating them from serous/mucinous cystadenocarcinomas. The findings in our study were in concordance with observation made by Seung Eun Jung et al who stated that Serous cystadenoma is a thin-walled, unilocular or multilocular tumor filled with serous fluid and the mucinous cystadenoma is almost always multilocular, and may be large & the MR imaging and CT appearance of the individual locules may vary as a result of differences in degree of hemorrhage or protein content. According to this study the features that are suggestive of malignancy were large soft tissue mass with necrosis, thick walled cysts, papillary projections and presence of ascites, peritoneal implants, pelvic wall invasion and adenopathy. Axial MRI pelvis scan revealed a well-defined solid-cystic lesion in the left adnexa with a solid component showing heterogeneous T1WI and T2WI hyperintense signals. The focal T1WI hyperintense area which is getting suppressed on FAT SAT images is seen within the lesion-suggestive of the Fatty component, with few tiny foci of T1WI and T2WI hypo intensities noted within solid component suggestive of calcification, suggestive of mature cystic teratoma. MRI = magnetic resonance imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging. There were 4 cases of endometrial polyps in our study, accounting for 6.6% of total cases in our study, 2 of these were pedunculated endometrial polyps and the remaining 2 cases were sessile endometrial polyps. Endometrial polyps appear as intermediate signal on T1 WI and heterogeneous high signal intensity on T2 WI with the larger lesions distending the endometrial cavity. Smaller polyps blending with the surrounding endometrium are difficult to distinguish. The endometrial polyps can be distinguished from the endometrial carcinomas as the endometrial polyp’s have high T2 signal intensity when compared to the endometrial carcinomas which appear as relatively homogenous intermediate T2 signal intensity masses. [ 36 ] There were 2 cases of adenomyosis in our study. In patients with dysmenorrhea and menorrhagia from adenomyosis, MRI shows the characteristic diffuse bar focal low signal lenticular-shaped junctional zone thickening > 12 mm that distinguishes this condition from fibroids on T2-W images. Also, there is the presence of tiny T1 hyperintense cystic lesions indicating the presence of ectopic endometrial glands within the myometrium. MRI was successful in our study in making the diagnosis of adenomyosis in all these cases mentioned above, as was correlated with histopathology. The observation in the study by Taran et al [ 37 ] that sometimes adenomyosis may coexist with uterine fibroid, or with endometriosis is similar to observations in our study in that we had 1 patient of adenomyosis having coexisting pathology which was a fundal uterine fibroid. The coexisting pathologies were differentiated well from one another with the help of MRI in these patients and were correlated with the histopathology. This is similar to the study by Togashi et al, [ 35 ] who found that MRI is also useful in distinguishing adenomyosis from a leiomyoma in cases of an enlarged uterus, which is perhaps the most clinically important distinction.

We express our gratitude to the department of obstetrics and gynecology for providing the needful information. ChatGPT was used for language polishing and grammatical corrections.