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Endometriosis on MRI Case 5

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

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The last couple cases are quick ones,

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

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Alright, so this is a 33-year-old

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

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So we scroll through on the sagittals again.

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Anterior compartment looks pretty okay.

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Our uterus is anteverted and retroflex again.

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Our posterior compartment,

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doesn't look too bad on the sagittals.

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There is a little bit of T1...

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oh, sorry, T2 hypointense tissue here

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is coming down, touching the torus uterinus and then

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

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

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So this is disease of the uterosacral ligament,

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

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But otherwise, the posterior compartment looks okay.

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When we scroll through on the axials,

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

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

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We see here that T2 hypointense

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thickening of the uterosacral ligaments on both sides,

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the proximal portions of them anyways.

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So that's that Chronic Stromal Fibrotic DIE.

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We have our right ovary here, looks pretty unremarkable.

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Our left ovary is right here.

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Little teeny tiny guy, looks okay.

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

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So we have this T2 hypointense mass

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that has some T2 bright cystic spaces within it.

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And then another similar looking finding right here

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along the posterior uterine wall.

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

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

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

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because it's just simple fluid.

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There is a little T1 bright

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little punctate foci here along the uterusacral ligament on the left

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here, as well as in the bilateral adnexa regions.

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So we have a little bit of superficial endometriosis there.

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

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

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So can we get the next question, please?

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

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Is this a fibroid, an adenomyoma?

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

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

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which is a reasonable guess because fibroids are

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

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But the other type of focal lesion that we

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

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

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

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

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So this is an adenomyoma, not a fibroid.

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

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

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

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

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So it's kind of T2 intermediate,

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

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It is different from the myometrium around that,

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

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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.

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And when we see these cystic spaces

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and lesions in a patient with endometriosis,

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

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Other important teaching points.

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So we talked about the torus uterinus,

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

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

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

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extend posterolaterally towards the sacrum on both sides.

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

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deep infiltrating endometriosis after the ovaries.

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

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

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

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

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

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Normal variant seen in 3% to 4%

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of the population has no impact on fertility at all.

Report

Faculty

Kristine S Burk, MD

Instructor in Radiology, Harvard Medical School

Brigham and Women's Hospital

Tags

Uterus

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

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