Introduction

Magnetic resonance imaging (MRI) plays essential roles at every stage in the management of patients with gynecological cancer, from initial diagnosis and lesion characterization, to assessments of treatment effectiveness as well as for the determination of the activity of residual disease and the detection of recurrent active cancer. The limitations of morphological MRI assessments are well documented. For example, the detection of malignant lesions can be difficult particularly when disease burden is small or when disease is intermixed with normal or benign disease processes (e.g., detecting a small endometrial cancer in an endometrial polyp). Similarly, diagnostic accuracy of myometrial invasion by endometrial cancer is impaired particularly in patients with distortions of the endometrial cavity due to congenital abnormalities or fibroids or when there is scarring due to prior surgery. Coincident adenomyosis or a thinned/indistinct junctional zone can also impair assessments of depth of tumor invasion. Lesion characterization can be equally problematic, for example differentiating uterine sarcoma from degenerating leiomyomas or determining the nature of an adnexal mass. Detection and assessment of the activity of residual disease is also problematic for morphology-based imaging; for example, subtle serosal disease due to ovarian carcinoma is easily overlooked. Finally, determining relapsed disease in areas of therapy-induced scarring can be problematic requiring careful comparisons to be made with prior examinations (e.g., it is often difficult to differentiate tumor recurrence from post-surgical/post-radiotherapy fibrosis following pelvic surgery).