0:00

Alright, so we're going to move on to case five.

0:03

The last couple cases are quick ones,

0:05

so I'm trying to spend more time on these heavier cases upfront.

0:10

Alright, so this is a 33-year-old

0:12

who presented with infertility and chronic pelvic pain, and pain with intercourse.

0:17

So we scroll through on the sagittals again.

0:20

Anterior compartment looks pretty okay.

0:22

Our uterus is anteverted and retroflex again.

0:28

Our posterior compartment,

0:33

doesn't look too bad on the sagittals.

0:36

There is a little bit of T1...

0:39

oh, sorry, T2 hypointense tissue here

0:43

is coming down, touching the torus uterinus and then

0:46

extending posterolaterally as I scroll off to the side in that side.

0:50

And posterolaterally as I scroll off to the side on this side.

0:54

So this is disease of the uterosacral ligament,

0:58

so we'll take a look at what that looks like on the axial in a second.

1:01

But otherwise, the posterior compartment looks okay.

1:06

When we scroll through on the axials,

1:09

which I'll try and produce slowly so that it doesn't skip,

1:15

we see a little bit of free fluid in the pelvis.

1:19

We see here that T2 hypointense

1:23

thickening of the uterosacral ligaments on both sides,

1:26

the proximal portions of them anyways.

1:29

So that's that Chronic Stromal Fibrotic DIE.

1:35

We have our right ovary here, looks pretty unremarkable.

1:39

Our left ovary is right here.

1:41

Little teeny tiny guy, looks okay.

1:44

And then we have a couple of findings in the uterus itself.

1:46

So we have this T2 hypointense mass

1:50

that has some T2 bright cystic spaces within it.

1:53

And then another similar looking finding right here

1:55

along the posterior uterine wall.

1:58

So let's take a look at the T1 pre next to the axial T2.

2:06

So we can put together the T1 and T2 signal characteristics of these findings.

2:11

So the fluid in the pelvis is bright on T2, dark on T1

2:14

because it's just simple fluid.

2:19

There is a little T1 bright

2:22

little punctate foci here along the uterusacral ligament on the left

2:29

here, as well as in the bilateral adnexa regions.

2:32

So we have a little bit of superficial endometriosis there.

2:36

We don't really see any bright T1 signal involving this uterine lesion

2:41

and I don't see any bright T1 signal in either ovary.

2:47

So can we get the next question, please?

2:51

So what is this pathology that we're seeing in the uterus?

2:55

Is this a fibroid, an adenomyoma?

2:58

Are we seeing a mass in the endometrium or are we seeing a septate uterus?

3:04

Alright, so people have answered that this is a fibroid,

3:08

which is a reasonable guess because fibroids are

3:11

by far the most common lesion seen, focal lesion seen in the myometrium.

3:17

But the other type of focal lesion that we

3:19

can see in the myometrium, and one that we always need to be thinking about

3:22

in patients with endometriosis, is what's called an adenomyoma,

3:26

which is a focal area of adenomyosis, that instead of involving the junctional zone

3:32

diffusely along one or both walls, involves a focal area of the myometrium.

3:39

So this is an adenomyoma, not a fibroid.

3:44

The reasons why are because it contains little tiny cystic spaces.

3:49

So if we think about what the junctional zone looked like in that original case

3:52

that we saw, where it was kind of T2 intermediate signal

3:57

and not super well-defined, we're seeing similar findings here.

4:03

So it's kind of T2 intermediate,

4:04

there are these tiny cystic spaces in it, which are pretty classic for adenomyosis.

4:11

It is different from the myometrium around that,

4:14

but doesn't have a really discreet capsule like fibroids often do.

4:21

You can see here in this more posterior lesion

4:23

I think a little bit better, that it is not super well-circumscribed.

4:28

And when we see these cystic spaces

4:31

and lesions in a patient with endometriosis,

4:34

that's what kind of pushes us over to calling these adenomyomas.

4:39

Other important teaching points.

4:41

So we talked about the torus uterinus,

4:44

which again is, by definition, the point along the posterior cervicals or

4:50

the posterior uterine serosa where the uterine body meets the cervical body.

4:55

That is where the uterosacral ligaments insert and then the uterosacral ligaments

5:00

extend posterolaterally towards the sacrum on both sides.

5:07

The uterosacral ligaments are the second most common area to be involved with deep endome...

5:12

deep infiltrating endometriosis after the ovaries.

5:16

So it's a really important place to look because you'll often find disease there.

5:23

And then this was not a septate uterus, but this was an arcuate uterus.

5:29

So there is kind of a pronounced curve of the contour of the endometrial cavity

5:35

at the fundus, but it doesn't quite indent more than a centimeter.

5:45

So it's just a kind of bonus arcuate uterus.

5:49

Normal variant seen in 3% to 4%

5:52

of the population has no impact on fertility at all.