Fig. 20  (a) Axial T1WI, (b) sagittal T2WI, transverse (c) ADC map, and (d) subtracted DCE image show vulvar carcinoma in a 76-year-old woman. The tumor (arrow) appears isointense compared to surrounding muscles on T1WI, heterogeneous, mainly hyperintense on T2WI,

with restricted diffusion and heterogeneous contrast enhancement. Areas of necrosis within the mass have very high signal intensity on T2WI and reduced enhancement. A small amount of air is seen within the tumor

excisional tissue biopsy. Lymphoma is detected as a homogeneous solid vulvar mass, centrally located and strongly enhancing (Hosseinzadeh et al. 2012).

6.2.4\ Aggressive Angiomyxoma of the Vulva

Aggressive angiomyxoma is a rare tumor that affects the pelvis and perineum, usually seen in premenopausal women. It appears as a large, solid infiltrative mass that tends to displace rather than invade adjacent structures. It does not metastasize and is treated by wide local excision. There is a tendency for local recurrence if incompletely excised. Imaging is important to determine extent and, thus, the optimal surgical approach. High T2 signal is detected, probably reflecting the ­myxomatous stroma and high

water content (Fig. 22). Swirled or layered tissue within the tumor produces a distinctive appearance, with slightly lower signal intensity than the remainder of the tumor on T2WI and enhancement after gadolinium administration (Griffin et al. 2010).

7\ Vaginal Cuff Disease

The vaginal cuff represents the apex of the vagina, where the apposed upper walls are sutured together at hysterectomy. In cases where surgical history is unclear regarding total versus partial hysterectomy, imaging is important to define whether a cervical remnant is present. The vaginal cuff represents a common site of recurrent gynecologic malignancy

Fig. 21  Locally advanced vulvar carcinoma with bilateral inguinofemoral lymph node metastases. (a) Axial T2WI depicts large, heterogeneous vulvar carcinoma (arrow) invading the surrounding organs. The tumor (arrow) causes restricted diffusion and is detected hyper-

intense and hypointense on axial (b) DWI and (c) ADC map, respectively. (d) T2WI and (e) post-contrast T1WI with fat saturation show enlarged superficial inguinofemoral nodes (arrowhead), heterogeneously enhancing (Courtesy Dr. Forstner R, Salzburg, Austria)

after hysterectomy. Recurrence is usually seen in women with a history of cervical carcinoma, but also with endometrial carcinoma and, rarely, with ovarian carcinoma. Sometimes, on imaging the vaginal cuff appears bulky and/or asymmetric and

differentiation of a prominent cuff or cervical remnant from tumor recurrence can be difficult. The vaginal cuff and cervical remnant are well assessed at MRI, which is generally superior to CT (Walker et al. 2011; Brown et al. 1992).