Interactive Transcript
0:01
And then we've got the third pattern,
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which is the deep or solid infiltrating type.
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And again, remember that in this subset,
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we've got endometrial deposits,
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which are more than five millimeters below
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the peritoneal surface, so typically
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not seen at the time of laparoscopy.
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So we talked a little bit about frozen cul-de-sac
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earlier, so now we can define what that is.
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So frozen cul-de-sac happens when there's
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lack of mobility of the uterus,
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which normally slides around it against
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adjacent structures.
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But because of adhesions along the posterior
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cul-de-sac, that mobility may no longer be visible.
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And this is again a dynamic finding,
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which typically is seen on transvaginal scanning.
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So if you've got experts in ventriculographic
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imaging at your institution, they're well
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aware of the different positions and the
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different compression that's required to
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assess for the presence of frozen cul-de-sac.
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So this is typically an ultrasound
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finding and not an MRI finding.
1:00
Torus uterinus involvement is definitely
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something that we can see on MRI,
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and I'll talk about that in more detail,
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what that is and what we look for.
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And then we can have organ and posterior
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compartment involvement as well.
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So we might have bladder involvement,
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typically the posterior wall, and in
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severe cases, patients might present
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with dysuria or even hematuria,
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depending on the depth of involvement.
1:25
Okay.
1:25
Thanks.
1:26
There may be involvement of the rectosigmoid
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colon or the posterior cul-de-sac, and
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then we might have involvement of the
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round ligament or surgical scars as well.
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So those are all manifestations
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of the deep infiltrating type.
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So what do you look for on MRI when
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you're evaluating pattern three?
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Well, one of the manifestations is the
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presence of a solid or a fibrotic mass.
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So these actually are quite common,
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but unless we're looking for
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them, we can easily overlook them.
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So if you didn't know to look behind the
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uterus, when evaluating a patient with
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endometriosis, you might miss this area of
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scarring or soft tissue thickening right in
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the midline along the posterior cul-de-sac.
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And it's quite challenging because you're
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looking for a structure with low T2 signal,
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which is the scarring that's adjacent to other
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structures with intermediate or low T2 signal.
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So very challenging to
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identify, certainly not easy.
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You really have to look for.
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A difference in shape or a little
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bit of distortion or indrawing of
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the structures towards the midline to
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find that particularly in this case.
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And again, just a reminder that with
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this deep endometriosis, we've got
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the deposits that are embedded within
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dense fibrous tissue and sometimes
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even smooth muscle, depending
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on which organs are involved.
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So remember to start your search with the
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ovaries and then sort of look superficially and
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then look deep posterior in all the organs.
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And then you're, you're doing
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due diligence to the case.
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So earlier I mentioned frozen cul-de-sac.
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So here's some images from AJR, just
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showing a 27-year-old woman who had
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posterior cul-de-sac endometriosis.
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And this was a dynamic examination that
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was done with transvaginal sonography.
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So here we can see some nice gut signature.
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So this is the rectum here with the variable
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layers in transverse and in longitudinal, and
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then we've got this structure that's annotated
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by the asterisk, it's got some flow around it.
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And that's preventing mobility
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of the uterus, which is anterior.
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So this is positioned between the anterior
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rectal wall and the posterior uterine
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wall, and then we're not seeing sliding
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of the uterus anterior to the rectum.
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So that's what the frozen cul-de-sac
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looks like on sonography.
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But again, it has to be done dynamically.
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