Interactive Transcript
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,
0:29
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.
0:35
There's a few cervical cystic structures
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here, and you can see that the pelvic
0:40
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
0:50
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
0:58
most serious problems, but just giving
1:01
you an example of what we can see just on
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a quick overview of the sagittal images.
1:08
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
1:24
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
1:37
a normal looking right ovary here, so it's just
1:40
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,
2:39
and then bottom right is post-contrast.
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So you can see that there's some enhancement
2:45
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
2:59
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.
3:09
And we've got some more findings here.
3:12
So I'll just show you inversion
3:15
recovery, which I usually obtain
3:18
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.
4:04
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
4:17
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.
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