Interactive Transcript
0:00
All right, so this is a 36-year-old who presented with infertility.
0:06
I'm going to scroll through the sagittal
0:08
and the axial and then we're going to get our question done right off the bat.
0:12
So, scrolling through on the sagittal
0:17
we have a very a contracted bladder down here.
0:20
We have these extra kind of T2 bright structures
0:23
going on in the anterior compartment.
0:26
Looking at our middle compartment.
0:28
So our uterus is anteverted and not terribly flexed one way or another.
0:32
There are a couple of more homogeneous, very T2 dark structures in the uterus.
0:38
Notice these are a little bit T2 darker
0:40
than the lesion in the myometrium we saw in the last case.
0:47
And then our posterior compartment,
0:49
at least on this sagittal,
0:50
is a bit of a hot mess.
0:51
It's kind of hard to tell what's what.
0:52
So let's look at that on the axial and see
0:54
if we can get a better sense of what's going on.
1:01
Oh, boy.
1:02
Okay, so here's our uterus which is
1:05
in the midline and pushed fairly far anterior in the pelvis by this structure
1:12
and this structure here, which are our ovaries.
1:15
They are touching each other
1:17
in the midline in the back here, kind of displaced.
1:21
And then we have this tethering of the rectum forwards towards the
1:26
ovaries and the uterus by this T2 dark scar tissue here.
1:33
And then we have a little bit of...
1:36
We have another paraovarian or ovarian little cystic lesion down here.
1:41
Okay, so now that we have a lay of the land on the T2 non fat sat images,
1:46
let's pull up a T1 and look at these things side by side.
1:53
And there's a lot of bright stuff on the T1,
1:56
so we're going to have a lot to talk about here.
1:59
So, these adnexal structures are
2:03
T2 dark and T1 bright.
2:13
Okay.
2:14
And we also have a tubular structure in the right adnexa right here,
2:18
that is also T2 dark and T1 bright.
2:22
So we're going to talk a little bit about what that is.
2:29
And then we see little punctate foci of
2:31
T1 hyperintensity amongst all of this T2 dark stuff
2:35
that's happening in the center and causing all this tethering.
2:41
All right. So now that we've pointed out
2:43
all of the findings, but before talking about what all of these
2:46
things are, can we pull up the next question please?
2:49
So which feature of this case implies the highest severity of endometriosis?
2:55
The presence of kissing ovaries,
2:57
the presence of a hematosalpinx, the presence of both deep and superficial
3:01
morphologies or anterior compartment involvement?
3:05
All right, so I got a couple of votes for hematosalpinx
3:07
I got one vote for kissing ovaries
3:09
and one vote for both deep and superficial morphologies.
3:12
So we'll go through all of those answers
3:15
and talk about why one of them was correct.
3:18
So, kissing ovaries is the name given when
3:22
the ovaries are medialized and touching each other, they're kissing.
3:27
The examples that I've shown in this
3:29
lecture have been kissing posterior to the uterus, although they can also be
3:33
displaced anterior and be in a kissing morphology anterior to the uterus.
3:38
So the presence of endometriomas alone won't cause the ovaries to be moved
3:42
in location like this.
3:44
When they're medialized or kissing each other,
3:46
it actually implies that there's deep
3:48
infiltrating endometriosis and scarring of the ovaries together.
3:53
In this case, we also see that there's deep
3:54
infiltrating endometriosis involving the rectum and the uterus.
3:57
So there's kind of no question that there's DIE in this case.
4:01
But you can imagine, if we didn't have DIE
4:04
involving those other organs and all we saw were the medialization of the ovaries,
4:10
when the ovaries are kissing like that, it implies stage three or stage four.
4:16
And that's the surgical staging
4:19
that the gynecologist use, not a radiologic staging system,
4:22
but
4:24
it involves...
4:24
it implies surgical stage three or stage four endometriosis.
4:29
And in fact has an accuracy of 82%
4:32
for diagnosis of stage four endometriosis,
4:36
and a 79% specificity.
4:38
So kissing ovaries imply the highest degree...
4:42
the highest severity of disease because it implies that there is deep infiltrating
4:48
endometriosis obliterating the space between the ovaries.
4:51
Again, going to be very difficult for
4:53
the surgeon to get back into that area laparoscopically.
4:56
This case does feature a hematosalpinx,
4:58
so this tubular structure here in the right adnexa that's T1 bright
5:02
and T2 dark is a blood filled fallopian tube.
5:07
Hematosalpinx is highly suggestive of endometriosis, though is not specific
5:14
for it necessarily.
5:16
In the setting of endometriosis,
5:17
it implies that there is functional tissue
5:20
in the tube itself that is secreting that blood product.
5:23
Although we don't often see
5:25
nodular areas of glandular tissue, we just see the blood.
5:30
This case also shows
5:36
involvement of the round ligaments of the uterus on both sides.
5:41
So, the round ligaments extend from the kind of anterior lateral corners
5:47
of the uterus on both sides and then extend towards the inguinal canal.
6:00
They're a little bit stretched out because
6:03
of the displacement of the uterus,
6:09
although that is, in this case, subtle, but
6:12
example of anterior compartment involvement.
6:16
The round ligaments.
6:18
So here's the round ligament on one side and here's the round ligament on the other.
6:23
That thickened kind of triangular shape.
6:26
If you remember the case that we looked earlier, we were able to see the round
6:29
ligaments but they were very thin T2 hypointense structures.
6:32
That's what they should look like.
6:37
And then finally, we do have a little bit
6:40
of superficial endometriosis as well along the uterine serosa.
6:46
So in this case, we see all three morphologies of endometriosis.
6:51
Endometriomas,
6:52
deep infiltrating
6:53
endometriosis with obliteration of the rectouterine space and kissing
6:58
ovaries, as well as superficial endometriotic implants.
7:02
This is very, very severe disease.
7:07
Very overwhelming case to look at if you
7:09
don't break it down by compartment and by morphology when you dictate.
7:14
These T2 dark, homogeneously T2 dark structures in the uterus are fibroids.
7:19
And I think that was all I needed to say about this case.
7:22
So in the interest of time, I'm going to keep going.
© 2024 MRI Online. All Rights Reserved.