Background Magnetic resonance spectroscopy (MRS) uses the same hardware as MR imaging and allows us to analyse the biochemistry of tissues in vivo. Published data for gynaecological lesions are limited and are largely based on MRS carried out at the lower magnetic field strength of 1.5 Tesla (T).Objective The purpose of this study was to determine whether in vivo proton MRS could be performed at the higher magnetic field strength of 3 T to characterise the spectra of a variety of benign and malignant gynaecological lesions.Design Prospective, non-randomised study.Setting MRI department within a tertiary referral centre for gynaecological cancers.Sample All women with a pelvic mass under going 3T MRI.Methods We carried out MRS on nonrandomised women undergoing routine 3 T MRI within our MRI department during investigation for gynaecological lesions from February 2006 to April 2008. Only those women for whom histopathological data were available were included.Main outcome measures The presence of choline detected by in vivo 3T MRS.Results Eighty-seven women underwent MRS, 57 of whom had newly diagnosed neoplasms. MRS data for 39 of these new women (18 were excluded because of technical errors or missing data) were used to detect the presence of choline, an indicator of basement membrane turnover. Overall, choline was present in 13 of the 14 ovarian cancers, 8 of the 11 cervical tumours and all 4 of the uterine cancers. There was no statistical significant difference between choline levels in various lesion types (P = 0.735) or between benign and malignant disease (P = 0.550).Conclusions In vivo MRS can be performed at 3 T to provide biochemical information on pelvic lesions. The way in which this information can be utilised is less clear but may be incorporated into monitoring tissue response in cancer treatments.

Boerhaave's syndrome can present inidaily as a case of tension pneumothorax. Mortality rate with delayed treatment is very high, therefore diagnosis should be made rapidly in the emergency department. Multidisciplinary cooperation, immediate radiological confirmation, prompt aggressive resuscitation, and surgical intervention offer the best chance of survival. (7AccidEmergMed 1999;16:235-236) Keywords: Boerhaave's syndrome; tension pneumothorax; multidisciplinary cooperationCase report A 72 year old women was brought to the accident and emergency department of the Chelsea and Westminster Hospital by ambulance in respiratory distress. The previous night she had experienced epigastric pain for about four hours; this culminated in an episode of vomiting 10 hours before presentation that exacerbated her epigastric and retrosternal pain. She became alarmed and called an ambulance when increasing dyspnoea supervened. She was quickly assessed in the resuscitation room and found to be in profound respiratory distress and peripheral vascular collapse. Her respiratory rate was 30 breaths/min, pulse rate 120 beats/min, thready but regular, temperature 36°C, oxygen saturation on 15 1/min via a rebreathing mask 93.2%, and blood pressure 90/50 mm Hg. Chest examination, arterial blood gas analysis, and electrocardiography were done simultaneously revealing left tracheal deviation, surgical emphysema in the neck, hyper-resonant percussion note, absent breath sounds on the right hemithorax, metabolic acidosis, and sinus tachycardia.A diagnosis of tension pneumothorax was made and the right hemithorax decompressed immediately with a size 1 4G special chest aspiration trochar inserted into the second intercostal space mid-clavicular line. This was followed by aspiration via a three way stopcock that yielded about 500 ml of air. Consequently, her dyspnoea improved significantly allowing a quick mobile post-aspiration chest radiograph (fig 1), which showed 50% right hydropneumothorax, pneumomediastinum, and surgical emphysema in the neck.The diagnosis of spontaneous rupture of the oesophagus (Boerhaave's syndrome), complicated by tension pneumothorax, was then made.Her resuscitation was continued with intravenous infusion of colloids and under water seal pleural drainage with a size 28 ch (9.3 mm in diameter) tube inserted into the fifth intercostal space mid-axillary line. This instantly drained about 200 ml of bile stained fluid containing food debris with a pH of 6.0. At this stage the surgeons, radiologists, and anaesthetists were immediately involved. She was fasted, had nasogastric intubation with suction, intravenous antibiotics (cefuroxime 1500 mg and metronidazole 500 mg), and urethral catheterisation. Central venous pressure monitoring was started and an arterial line inserted.

Objectives The aim of the study was to determine whether staging primary ovarian cancer using 3.0 Tesla (3T) magnetic resonance imaging (MRI) is comparable to surgical staging of the disease.Design A retrospective study consisting of a search of the pathology database to identify women with ovarian pathology from May 2004 to January 2007.Setting All women treated for suspected ovarian cancer in our cancer centre region.Sample All women suspected of ovarian pathology who underwent 3T MRI prior to primary surgical intervention between May 2004 and January 2007.Methods All women found to have ovarian pathology, both benign and malignant, were then cross checked with the magnetic resonance (MR) database to identify those who had undergone 3T MRI prior to surgery. The resulting group of women underwent comparison of the MR, surgical and histopathological findings for each individual including diagnosis of benign or malignant disease and International Federation of Gynecology and Obstetrics (FIGO) staging where appropriate.Main outcome measures Comparisons were made between the staging accuracy of 3T MRI and surgical staging compared with histopathological findings and FIGO stage using weighted kappa. Sensitivity, specificity and accuracy were calculated for diagnosing malignant ovarian disease with 3T MRI.Results A total of 191 women identified as having ovarian pathology underwent imaging with 3T MR and primary surgical intervention. In 19 of these women, the ovarian disease was an incidental finding. The group for which staging methods were compared consisted of 77 women of primary ovarian malignancy (20 of whom had borderline tumours). 3T MRI was able to detect ovarian malignancy with a sensitivity of 92% and a specificity of 76%. The overall accuracy in detecting malignancy with 3T MRI was 84%, with a positive predictive value of 80% and negative predictive value of 90%. Statistical analysis of the two methods of staging using weighted kappa, gave a K value of 0.926 (SE ±0.121) for surgical staging and 0.866 (SE ±0.119) for MR staging. A further analysis of the staging data for ovarian cancers alone, excluding borderline tumours resulted in a K value of 0.931 (SE ±0.136) for histopathological staging versus MR staging and 0.958 (±0.140) for histopathological stage versus surgical staging.Conclusion Our study has shown that MRI can achieve staging of ovarian cancer comparable with the accuracy seen with surgical staging. No previous studies comparing different modalities have used the higher field strength 3T MRI. In addition, all other studies comparing radiological assessment of ovarian cancer have grouped the stages into I, II, III and IV rather than the more clinically appropriate a, b and c subgroups.Keywords 3.0T MRI, ovarian cancer, staging.Please cite this paper as: Booth S, Turnbull L, Poole D, Richmond I. The accurate staging of ovarian cancer using 3T magnetic resonance imaging -a realistic option. BJOG 2008;115:894-901.