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Pattern 3 – Deep/Solid Infiltrating Type

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0:01

And then we've got the third pattern,

0:02

which is the deep or solid infiltrating type.

0:05

And again, remember that in this subset,

0:08

we've got endometrial deposits,

0:10

which are more than five millimeters below

0:12

the peritoneal surface, so typically

0:15

not seen at the time of laparoscopy.

0:17

So we talked a little bit about frozen cul-de-sac

0:19

earlier, so now we can define what that is.

0:23

So frozen cul-de-sac happens when there's

0:26

lack of mobility of the uterus,

0:28

which normally slides around it against

0:31

adjacent structures.

0:32

But because of adhesions along the posterior

0:36

cul-de-sac, that mobility may no longer be visible.

0:39

And this is again a dynamic finding,

0:42

which typically is seen on transvaginal scanning.

0:44

So if you've got experts in ventriculographic

0:47

imaging at your institution, they're well

0:50

aware of the different positions and the

0:51

different compression that's required to

0:54

assess for the presence of frozen cul-de-sac.

0:57

So this is typically an ultrasound

0:58

finding and not an MRI finding.

1:00

Torus uterinus involvement is definitely

1:04

something that we can see on MRI,

1:06

and I'll talk about that in more detail,

1:07

what that is and what we look for.

1:10

And then we can have organ and posterior

1:12

compartment involvement as well.

1:14

So we might have bladder involvement,

1:17

typically the posterior wall, and in

1:19

severe cases, patients might present

1:21

with dysuria or even hematuria,

1:23

depending on the depth of involvement.

1:25

Okay.

1:25

Thanks.

1:26

There may be involvement of the rectosigmoid

1:27

colon or the posterior cul-de-sac, and

1:30

then we might have involvement of the

1:31

round ligament or surgical scars as well.

1:34

So those are all manifestations

1:36

of the deep infiltrating type.

1:39

So what do you look for on MRI when

1:41

you're evaluating pattern three?

1:43

Well, one of the manifestations is the

1:46

presence of a solid or a fibrotic mass.

1:49

So these actually are quite common,

1:51

but unless we're looking for

1:53

them, we can easily overlook them.

1:55

So if you didn't know to look behind the

1:57

uterus, when evaluating a patient with

2:00

endometriosis, you might miss this area of

2:03

scarring or soft tissue thickening right in

2:06

the midline along the posterior cul-de-sac.

2:09

And it's quite challenging because you're

2:10

looking for a structure with low T2 signal,

2:14

which is the scarring that's adjacent to other

2:17

structures with intermediate or low T2 signal.

2:20

So very challenging to

2:23

identify, certainly not easy.

2:25

You really have to look for.

2:27

A difference in shape or a little

2:28

bit of distortion or indrawing of

2:31

the structures towards the midline to

2:34

find that particularly in this case.

2:36

And again, just a reminder that with

2:38

this deep endometriosis, we've got

2:41

the deposits that are embedded within

2:43

dense fibrous tissue and sometimes

2:45

even smooth muscle, depending

2:46

on which organs are involved.

2:48

So remember to start your search with the

2:50

ovaries and then sort of look superficially and

2:53

then look deep posterior in all the organs.

2:55

And then you're, you're doing

2:57

due diligence to the case.

2:59

So earlier I mentioned frozen cul-de-sac.

3:02

So here's some images from AJR, just

3:05

showing a 27-year-old woman who had

3:07

posterior cul-de-sac endometriosis.

3:10

And this was a dynamic examination that

3:13

was done with transvaginal sonography.

3:16

So here we can see some nice gut signature.

3:18

So this is the rectum here with the variable

3:21

layers in transverse and in longitudinal, and

3:24

then we've got this structure that's annotated

3:26

by the asterisk, it's got some flow around it.

3:30

And that's preventing mobility

3:32

of the uterus, which is anterior.

3:34

So this is positioned between the anterior

3:36

rectal wall and the posterior uterine

3:38

wall, and then we're not seeing sliding

3:40

of the uterus anterior to the rectum.

3:43

So that's what the frozen cul-de-sac

3:44

looks like on sonography.

3:47

But again, it has to be done dynamically.

Report

Faculty

Zahra Kassam, MD, FRCPC

Associate Professor of Medical Imaging, Division Head of Body Imaging

Western University

Tags

Uterus

Pelvic Wall and Floor

Ovaries

Non-infectious Inflammatory

Neoplastic

MRI

Idiopathic

Gynecologic (GYN)

Body

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