0:00

Really good. Great. So that was a nice case and we'll move on

0:04

now for our next case, which, this is rather a relatively recent case.

0:13

It's an MRI of the pelvis. And so this patient

0:19

actually got an ultrasound. I do forget what the ultrasound was for.

0:22

I presume it's pelvic pain. They saw something in the ultrasound that they

0:27

wanted to get a MRI for to further evaluate it. And so I'll

0:32

start off with the T2 images, non fat saturated. I'll have the T2 fat

0:37

side images side by side. And we can see ovaries over here.

0:42

These are nice, normal looking ovaries. This patient I think is 24,

0:45

25 years old. And so this is the finding on the ultrasound that

0:53

was queried and they weren't sure what it was.

0:56

I'll show it to you on the T2 image, T2 fat saturated image.

1:01

Observe it's sort of internal contents. What does it sort of look like

1:04

over there? For completion sake, I'll just show that to you on the

1:08

sagittal T2 weighted images, you get another sense of what this looks like.

1:12

I think one of the key findings here will also be determining where

1:16

is this located? What does it contain? What are the internal contents?

1:24

And the in and out of phase, this is the out of phase

1:27

image over here. And the in phase image over here. Right signal is

1:35

a loose signal on the out of phase image.

1:40

And finally I'll show you the post contrast sequences. T1 fat side post

1:45

contrast. Lesion over here looks like it had a lot of bright signals so

1:49

I'm gonna skip ahead and show you the subtraction images which removes any

1:52

T1 hyperintense signal to give you a sense of there's any internal nodular

1:56

enhancement associated with it. And so that's the lesion over there.

2:04

Okay, so I'll just recap real quick. You can see this lesion on

2:12

the T2 fat saturated image. T1 pres and T1 posts. And then

2:26

another look at it on another sequence here T2 L image. So let's pull

2:32

up the question for this question number eight.

2:34

For this one, we're gonna go back to our

2:37

usual questions. What is the most likely diagnosis here?

2:41

Four options. Tubo ovarian abscess patient has some pain and we see this

2:46

sort of somewhat complex looking lesion or some complex internal contents.

2:51

Is this a cystic adenomyoma? Is this a cellular leiomyoma? Could this be

2:58

a hematosalpinx? For taking into account location, internal contents, this

3:05

lesion. What do we think is the best diagnosis here? Pull up the answers.

3:10

Yeah, cystic adenomyoma got four points. The most hematosalpinx and wanting

3:15

to do tubo ovarian abscess and cellular leiomyoma. So I must admit...

3:19

I like this case because it was actually shown a very...

3:22

Well I'll tell you a story. So what happened was we saw a

3:25

case with my colleagues maybe two years ago and somebody asked us what

3:29

it was and we weren't really sure what it was and that was

3:31

that we were sort of indeterminate and didn't really

3:34

know what to say. And then I went to another conference,

3:36

they're showing unknown cases and they showed a case that was so similar

3:39

to the case that I saw and turned out to be something called

3:43

a cystic adenomyoma. And maybe it looks like perhaps a lot of you

3:47

on the audience have heard of that. I have something I hadn't actually

3:49

heard of and so I went back and I looked at the case

3:52

like, "Oh my goodness that's exactly what it looks like." And then we

3:54

came across this case and this is what it looks like we called

3:57

it and this was actually prospectively this was a path proven cystic adenomyoma.

4:02

And in fact recently, we've had another case where it just looks exactly

4:05

like this and now we're very confident that we can call this lesion.

4:08

So what is this? So this is a cystic adenomyoma. It's certainly form

4:13

of this adenomyoma adenomyosis, which I'm sure many on the caller familiar

4:17

with, where you have endometrial glands or stroma that start to appear in

4:22

the myometrium. You get junctional zone thickness typically with this adenomyosis

4:26

of more than 12 mm. If you look at the junctional zone here

4:29

in adenomyoma adenomyosis, it will be more than 12 mm. You'll see foci

4:33

of glandular tissue with cysts and andro hemorrhage within it.

4:39

So that stuff we see not uncommonly. Now a cystic adenomyoma, cystic adenomyosis

4:44

is sort of this rare variant, where you see

4:49

a focal cystic space in the myometrium that's sort of filled with hemorrhage

4:53

and it's thought to be just a focal area that undergoes repeated hemorrhage

4:57

over a period of time. And so the imaging appearance is that it's

5:00

sort of this intramural mass within the myometrium and round to oval in

5:06

shape. The wall is generally thickened and the outside of it is sort

5:09

of T2 hypointense. Pretty well defined and internally, it will contain hemorrhage

5:14

and in fact internally, you often will see layering hemorrhage. Just like

5:18

you see the endometriomas because these are areas we have

5:21

repeatedly focal areas, a focal area of hemorrhage over a time.

5:26

This is undergoing lots of hemorrhage and so

5:29

it's a benign finding. This was... I'm not sure why this was resected, potentially

5:35

a patient had some issues that were thought to be attributed to this

5:39

but in and of itself it's a benign finding

5:43

and not something one needs to worry about. I think in hematosalpinx was

5:46

not a bad thought particularly the fact that it contained hemorrhagic content.

5:50

But certainly they're often not as round as this, they're often a tubular

5:53

in shape so we don't quite see that over here. A cellular leiomyoma doesn't

5:58

really have this sort of cystic appearance. It's more intermediate T2 signal

6:02

and it enhances as opposed to this which demonstrates no enhancement.

6:07

And I'm not sure if anyone has a tubo ovarian abscess. But again

6:09

with tubo ovarian abscess you expect to see a lot of edema

6:13

in that particular location. Lots of intermediate T2 signal and here we

6:16

just see a really well defined mass that contains hemorrhage.