Interactive Transcript
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Another diagnosis to consider in
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reproductive-age women is endometriosis.
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Endometriosis is defined as the presence of
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viable estrogen-sensitive endometrial glandular
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tissue and stroma outside of the uterus.
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Endometriosis is extremely common, affecting
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6 to 10 percent of reproductive-age women.
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And although many patients begin experiencing
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symptoms early in their lives, most patients
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are not diagnosed until they are 28 years old,
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with an average time from symptom onset
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to diagnosis of seven to eight years.
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And that's because the symptoms of
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endometriosis are vague and nonspecific.
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But most patients will experience
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some form of chronic pelvic pain
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and may also experience infertility.
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Endometrial implants are influenced by hormones.
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And so in the context of pregnancy,
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endometriosis symptoms may worsen.
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Patients with endometriosis who become
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pregnant are at increased risk of
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having a tubal ectopic pregnancy, a
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spontaneous miscarriage, and peripartum
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hemorrhage near the time of delivery.
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Specific pregnancy-related complications
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in patients with endometriosis include
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spontaneous hemoperitoneum, ovarian torsion,
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or rupture of an ovarian endometrioma, or
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uterine rupture near the time of delivery.
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There are two main sequences on MRI
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which may be useful in the identification
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and diagnosis of endometrial implants
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and endometriosis as a whole.
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T2-weighted imaging is especially important
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in the identification of ovarian lesions.
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Endometriomas, or ovarian endometrial implants,
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will demonstrate a classic T2 shading pattern,
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where the lesion will become progressively
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darker as you move from the anterolateral
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to the dependent portion of the lesion.
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On T2-weighted imaging, we can also visualize
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dilated or blood-filled fallopian tubes,
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which are hydrosalpinges and
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hematosalpinges, respectively.
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T2-weighted imaging may also be useful
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in identifying scarring in patients with
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deep infiltrative endometriosis, and
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this scar tissue will appear T2-dark.
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Fat-saturated pre-contrast T1-weighted images
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are the workhorse of identifying endometriosis.
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Classic powder-burn and implant
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lesions in endometriosis will appear
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intrinsically T1 hyperintense.
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Thanks again.
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And this imaging sequence, in particular,
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is key for distinguishing an endometriosis
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lesion from a fat-containing lesion,
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particularly ovarian teratomas.
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T1-weighted imaging can also be useful
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in identifying hemoperitoneum in patients
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who have spontaneous intra-abdominal
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hemorrhage in the context of endometriosis.
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This is an axial fat-saturated T2-weighted image
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of the abdomen in a patient who has a cystic,
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multi-septated right abdominal wall
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implant, in addition to a moderate
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volume of abdominal ascites.
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This is the T1 fat-saturated pre-contrast
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image, and we can see that this lesion in the
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right abdominal wall remains intrinsically
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T1 hyperintense, in addition to the
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ascites, which is actually hemoperitoneum.
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So, this is a patient who has an
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endometriotic implant in the abdominal
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wall in addition to spontaneous
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hemoperitoneum related to her endometriosis.
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Another important consideration in patients
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who are presenting with abdominal pelvic pain
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in reproductive age is intrauterine devices.
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Intrauterine devices are an extremely
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effective method of birth control.
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It's a foreign body, typically plastic or
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sometimes made of copper, which is inserted
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into the uterus and provides either hormonal
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and/or mechanical irritation of the uterine
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lining to prevent pregnancy from occurring.
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Most IUDs are T-shaped, although some of the
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older versions have more of a serpiginous
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stacked hairpin turn appearance to them.
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Ideal placement of an intrauterine
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device is with the top of the T, the
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arms or the crossbar near the uterine
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fundus, and then the stem within the
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endometrial cavity within the uterine body.
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Complications of intrauterine
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devices most commonly include
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malpositioning, which can be painful.
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The intrauterine devices can also become
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embedded within the uterine myometrium
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or occasionally perforate the uterus.
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This is most common at the site
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of a cesarean section scar.
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It's important to identify a malpositioned
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intrauterine device for two reasons.
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One, because a malpositioned IUD may not
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be providing effective birth control for
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the patient, and also, depending on the
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degree of embedment or malpositioning,
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it may require removal under anesthesia
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rather than in the gynecology office.
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As I said, IUDs are extremely
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effective, and so coexisting pregnancy
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in a patient with an IUD is rare.
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But the risk of a concomitant
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pregnancy happening is highest in
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the first year following placement.
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Patients who become pregnant with an IUD
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in place have a higher risk of preterm
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labor, spontaneous abortion, and infection.
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When an IUD is identified within the
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uterus in a pregnant patient, the
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management of the IUD really depends
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on the gestational age of the fetus.
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If the IUD is visualized in the first
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trimester of pregnancy, the provider may
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attempt to remove it in order to allow the
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pregnancy to progress as safely as possible.
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If the IUD is identified in the second or
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third trimester of pregnancy, the risks of
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removal may outweigh the benefits of removing
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it, and this may need to be a pregnancy
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that is just monitored more frequently.
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Localizing the intrauterine device by
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imaging is key in determining how and
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whether the IUD should be removed.
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One pearl that I want to share with
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you is that all intrauterine devices,
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whether they’re plastic or metallic,
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will be radiopaque on imaging.
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So these will look hyperdense
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on CT or plain radiographs.
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On ultrasound, because they are
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relatively dense structures, they’ll
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demonstrate posterior acoustic shadowing.
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And then, because of the filament
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within the plastic IUDs and the metallic
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component of the copper IUDs, these will
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be hypo intense or more apparent on T1
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weighted imaging and gradient echo MRI.
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Here are some examples of intrauterine
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devices across imaging modalities.
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This is an ultrasound image of the
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pelvis in a patient with an IUD.
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We can see echogenic components of the IUD,
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which demonstrate posterior acoustic shadowing.
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This is a 3D image of the uterus in a
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patient who has a malpositioned IUD.
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We can see that the arms are located
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appropriately at the uterine fundus, but the
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body of the IUD is exiting the endometrial
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canal and is embedded in the uterine myometrium.
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These are T1 weighted images of the pelvis.
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In a patient who was unable to
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locate her IUD strings, it was also
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unable to be located on ultrasound.
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And so again, on T1 weighted imaging or
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gradient echo imaging, the intrauterine
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device will become more apparent.
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And so we can see a portion of the arms
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here and here on MRI in this patient.
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And then finally, this is an
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appropriately positioned IUD on CT.
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This is a classic T-shaped IUD, which
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again looks radio dense on CT imaging.
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And it's appropriately positioned within the
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endometrial cavity near the uterine fundus.
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To summarize, there is a myriad of causes
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of abdominal pelvic pain and abdominal
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pelvic pathology during pregnancy.
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Using the clinical history and the
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patient's symptoms will help you
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guide your initial imaging approach.
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Ultrasound is the first-line imaging
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modality for evaluation of the
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uterus, the ovaries, and the fetus.
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Remember that appendicitis and renal stones are
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common causes of non-obstetric abdominal pain
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in pregnancy, and that MRI can serve as a useful
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adjunct if you need to further characterize or
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troubleshoot findings on your initial imaging.
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