Endometriosis is a chronic oestrogen-dependent condition characterised by the presence of endometrial-like tissue outside the uterus. Although benign, the associated chronic inflammation and fibrosis can result in substantial symptomatic burden, including chronic pelvic pain, menorrhagia, dysmenorrhoea and dyspareunia. Adenomyosis, which commonly co-exists with endometriosis, is defined by endometrial glands within the myometrium, causing chronic inflammation and fibrosis. Symptoms overlap with endometriosis, including heavy menstrual bleeding, dysmenorrhoea and chronic pelvic pain.Historically, laparoscopy with histological confirmation was considered the diagnostic gold standard for endometriosis. However, imaging now plays an essential role in non-invasive diagnosis and pre- operative planning.Transvaginal ultrasound remains the first-line imaging modality in the diagnosis of endometriosis due to its accessibility, cost-effectiveness and real-time dynamic assessment. Certain forms of deep endometriosis, particularly rectal and bladder involvement, are more readily detected with ultrasound when performed by an expert operator using a structured approach that includes assessment of sliding signs and detailed evaluation of each pelvic compartment. Similarly, the MUSA consensus provides a standardised ultrasound approach for the diagnosis of adenomyosis, incorporating both direct and indirect signs.MRI offers excellent soft tissue contrast and multiplanar capability, enabling assessment of the entire pelvis and characterisation of indeterminate lesions. MRI allows the comprehensive evaluation of the parametria, ureters, nerves and bowel muscle invasive lesions beyond the reach of ultrasound.Standardised reporting systems, including the #Enzian classification, now enable a unified language between radiologists and the multidisciplinary team. Comprehensive compartment-based disease mapping is essential for accurate surgical planning and improving patient outcomes. This review illustrates the typical US and MRI appearances of endometriosis and adenomyosis, using a compartment-based approach.

Numerous conditions can mimic ovarian malignancy. Identifying the origin of a pelvic mass or disseminated peritoneal abnormality on imaging is important to ensure that the patient receives optimal management by the appropriate clinical team.Ovarian cancer mimics include infections and other neoplastic processes, for example actinomycosis, lymphoma and sarcoma. We will illustrate intraperitoneal and extraperitoneal ovarian and non-ovarian mimics.Primary peritoneal carcinomatosis mimics include processes such as deep infiltrating endometriosis and rare causes such as gliomatosis peritonei and diffuse peritoneal leiomyomatosis.We aim to illustrate the multimodality key imaging appearances of common and rarer types of mimics.

Radiology plays an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilized to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.

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Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET1T2ER Check! to help identify key features more suggestive of a uterine sarcoma.

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET1T2ER Check! to help identify key features more suggestive of a uterine sarcoma.

Objective: To assess the value of non-contrast MRI features for characterisation of uterine leiomyosarcoma (LMS) and differentiation from atypical benign leiomyomas Methods: This study included 57 atypical leiomyomas and 16 LMS which were referred pre-operatively for management review to the specialist gynaeoncology multidisciplinary team meeting. Non-contrast MRIs were retrospectively reviewed by five independent readers (three senior, two junior) and a 5-level Likert score (1-low/5-high) was assigned to each mass for likelihood of LMS. Evaluation of qualitative and quantitative MRI features was done using uni- and multivariable regression analysis. Inter-reader reliability for the assessment of MRI features was calculated by using Cohen’s κ values. Results: In the univariate analysis, interruption of the endometrial interface and irregular tumour shape had the highest odds ratios (ORs) (64.00, p < 0.001 and 12.00, p = 0.002, respectively) for prediction of LMS. Likert score of the mass was significant in prediction (OR, 3.14; p < 0.001) with excellent reliability between readers (ICC 0.86; 95% CI, 0.76–0.92). The post-menopausal status, interruption of endometrial interface and thickened endometrial stripe were the most predictive independent variables in multivariable estimation of the risk of leiomyosarcoma with an accuracy of 0.88 (95%CI, 0.78–0.94). Conclusion: At any level of expertise as a radiologist reader, the loss of the normal endometrial stripe (either thickened or not seen) in a post-menopausal patient with a myometrial mass was highly likely to be LMS. Advances in knowledge: This study demonstrates the potential utility of non-contrast MRI features in characterisation of LMS over atypical leiomyomas, and therefore influence on optimal management of these cases.

To determine the accuracy of interpretation of a non-contrast MRI protocol in characterizing adnexal masses. Two hundred ninety-one patients (350 adnexal masses) who underwent gynecological MRI at our institution between the 1st of January 2008 and the 31st of December 2018 were reviewed. A random subset (102 patients with 121 masses) was chosen to evaluate the reproducibility and repeatability of readers’ assessments. Readers evaluated non-contrast MRI scans retrospectively, assigned a 5-point score for the risk of malignancy and gave a specific diagnosis. The reference standard for the diagnosis was histopathology or at least one-year imaging follow-up. Diagnostic accuracy of the non-contrast MRI score was calculated. Inter- and intra-reader agreement was analyzed with Cohen’s kappa statistics. There were 53/350 (15.1%) malignant lesions in the whole cohort and 20/121 (16.5%) malignant lesions in the random subset. Good agreement between readers was found for the non-contrast MRI score (к = 0.73, 95% confidence interval [CI] 0.58–0.86) whilst the intra-reader agreement was excellent (к = 0.81, 95% CI 0.70–0.88). The non-contrast MRI score value of ≥ 4 was associated with malignancy with a sensitivity of 84.9%, a specificity of 95.9%, an accuracy of 94.2% and a positive likelihood ratio of 21 (area under the receiver operating curve 0.93, 95% CI 0.90–0.96). Adnexal mass characterization on MRI without the administration of contrast medium has a high accuracy and excellent inter- and intra-reader agreement. Our results suggest that non-contrast studies may offer a reasonable diagnostic alternative when the administration of intravenous contrast medium is not possible. • A non-contrast pelvic MRI protocol may allow the characterization of adnexal masses with high accuracy. • The non-contrast MRI score may be used in clinical practice for differentiating benign from malignant adnexal lesions when the lack of intravenous contrast medium precludes analysis with the O–RADS MRI score.

Leiomyomas are the most common benign tumors of the uterus. On the opposite side, leiomyosarcomas are rare malignant uterine tumors that account for a significant proportion of uterine cancer deaths. Especially when large and degenerated, leiomyomas and leiomyoma variants can have overlapping imaging characteristics with those of leiomyosarcomas. Although not always possible, it is paramount to be able to differentiate between leiomyomas and leiomyosarcomas on imaging, as the therapeutic management can differ. This pictorial review aims to familiarize radiologists with imaging features of leiomyomas and various types of leiomyoma degeneration and variants, together with their pathology correlates.

Serous borderline ovarian tumours (SBOTs) are an intermediate group of neoplasms, which have features between benign and malignant ovarian tumours and for which, fertility-sparing surgery can be offered. MRI in imaging of SBOTs is, therefore, crucial in raising the possibility of the diagnosis, in order to present the patient with the most appropriate treatment options. There are characteristic MRI features that SBOTs demonstrate. In addition, recent advanced techniques, and further classification into subtypes within the borderline group have been developed. The aim of this article is to review the MRI features of SBOT and provide the reporter with an awareness of the imaging tips and tricks in the differential diagnosis of SBOT.

MRI was recently included as a standard pre-operative diagnostic tool for patients with endometrial cancer. MR findings allow a better risk assessment and ultimately guides the surgical planning. Therefore, it is vital that the radiological interpretation is as accurate as possible. This requires essential knowledge regarding the appropriate MRI protocol, as well as different appearances of the endometrium, ranging from normal peri- and post-menopausal changes, benign findings (e.g. endometrial hyperplasia, polyp, changes due to exogenous hormones) to common and rare endometrium-related malignancies. Furthermore, this review will emphasize the role of MRI in staging endometrial cancer patients and highlight pitfalls that could result in the underestimation or overestimation of the disease extent.

Radiology plays an essential role in the management of benign gynaecological conditions and includes: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities, their recommended roles in the imaging and imaging findings of common female pelvic pathology.

Intestinal transplant is considered in a small number of patients with intestinal failure or locally invasive benign abdominal tumours to improve both quality of life and survival. The complexity of the underlying diseases and postoperative findings are reflected in the imaging undertaken to support this patient group. Increasing numbers of patients are undergoing these procedures. Radiologists are increasingly likely to encounter these patients before and after surgery. This article will discuss the imaging findings that may prompt referral for transplantation assessment. It will also describe surgical anatomy and postoperative complications. Intestinal transplant is considered in a small number of patients with intestinal failure or locally invasive benign abdominal tumours to improve both quality of life and survival. The complexity of the underlying diseases and postoperative findings are reflected in the imaging undertaken to support this patient group. Increasing numbers of patients are undergoing these procedures. Radiologists are increasingly likely to encounter these patients before and after surgery. This article will discuss the imaging findings that may prompt referral for transplantation assessment. It will also describe surgical anatomy and postoperative complications.