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Ovarian Malignancy – Unspecified – Case

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0:01

All right, so I'm going to show you

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another case of a complex ovarian lesion.

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So again, I'll start on the

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sagittal T2-weighted images here.

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So this is an older patient in her 60s.

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So right away on the sagittal images,

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again, they're really good to just get

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a quick overview of what's going on. So

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we can see that the uterus is kind of

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anteverted or just midline in location.

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We can see that there's a low T2 signal mass,

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which is protruding into the endometrium.

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This is probably a subendometrial

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fibroid, just based on the low T2 signal.

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There's a few cervical cystic structures

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here, and you can see that the pelvic

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floor is sagging on this image.

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So instead of being flat

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or concave, it's convex.

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So this patient has a rectocele

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and a cystocele already.

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So the bladder is sagging, the rectum is

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sagging, and the pelvic floor is sagging.

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So obviously these are not the patient's

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most serious problems, but just giving

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you an example of what we can see just on

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a quick overview of the sagittal images.

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So we know that there's obviously some

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really heterogeneous, bizarre-looking mass,

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which we have to now characterize further.

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So now we're going to look at the ovaries.

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So can we find a right ovary?

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Well, I think we can start to see the

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shape of the right ovary here, but

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again, this is a postmenopausal woman,

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so we're not going to see ovaries, but.

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Just based on the location and the size and the

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shape, I think we can safely say that we have

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a normal looking right ovary here, so it's just

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anterior to the external iliac vessels here.

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And here we've got the uterus.

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Now can we see a normal left ovary?

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Let's look, let's just follow the

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ovarian vessels, follow them, follow

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them, follow them, and they kind of

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terminate in this big heterogeneous mass.

1:59

Okay, so I think we can safely say that the left

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ovary is abnormal and enlarged due to this mass.

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So what are the characteristics of this mass?

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Well, it's got very heterogeneous T2 signal.

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We have an area that's low

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T2 signal on the ADC map.

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Also, pretty low signal on the T2-weighted

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images, but kind of intermediate signal on

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the high B-value diffusion-weighted images.

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So that may represent an area of restriction.

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So that's a bit concerning for high cellularity.

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All right, so now I will show you the

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pre- and post-contrast weighted images.

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So bottom left, this is pre-contrast,

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and then bottom right is post-contrast.

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So you can see that there's some enhancement

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of the small locules, and a particular concern

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is the presence of nodular enhancement.

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So that's concerning for an ORADS5 lesion.

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This low T2 signal area that's persistent

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on the multiple sequences may represent

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an area of calcification, but this

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nodular enhancement is pretty worrisome.

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And we've got some more findings here.

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So I'll just show you inversion

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recovery, which I usually obtain

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routinely for my pelvic patients.

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And again, it's very useful to look for

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edema and lymphadenopathy and fluid.

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And then in this case, it's also helpful

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to look at the bone marrow because in this

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patient, we've got some abnormal marrow

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signal here in the right pubic tubercle.

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And then as we scroll more superiorly,

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it looks like there's probably a

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fracture here of the pubic ramus.

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And then we've got some high T2 signal of the

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left sacral ala and the right sacral ala here.

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So let's go back to those post-contrast

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images and take a look at those areas.

4:00

So look at that enhancement of

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the sacral ala bilaterally.

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So probably due to insufficiency

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fractures in this patient, or if she

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had previous radiation therapy, that

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could account for what we're seeing.

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But the pubic ramus, it looks like there's

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definitely a fracture there extending to the

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tubercle, and there's a lot of high signal

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and enhancement of the adjacent musculature.

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So superior and inferior

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pubic rami are both fractured.

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So in this case, we're not sure if this is due

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to metastatic disease with pathologic fractures

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or another etiology, but you definitely have

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your guard up seeing those findings in this

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patient with presumed ovarian malignancy.

Report

Faculty

Zahra Kassam, MD, FRCPC

Associate Professor of Medical Imaging, Division Head of Body Imaging

Western University

Tags

Ovaries

Neoplastic

MRI

Gynecologic (GYN)

Body

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