Interactive Transcript
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
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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.
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